we in a health care crisis?
certainly are in a health care crisis. If we had set out to design
the worst system that we could imagine, we couldn't have imagined
on as bad as we have. Here's a system in which we spend over twice
what the next most expensive country spends on health care -- that's
Switzerland. We spend roughly $4500 for every American, whether
they have insurance or not. Switzerland spends maybe $2500 for every
citizen. Canada spends maybe $2,000. Great Britain, poor little
Great Britain, spends about $1,000 for every British citizen. And
what do we get for it? What do we get for that $4500? Well, we certainly
don't get our money's worth. We have roughly 43 million people with
no insurance whatsoever, and among the rest of us, many of us are
underinsured. That is, we have shrinking packages. This might be
covered, but that won't be covered.
life expectancy is shorter. Our infant mortality is higher. Our
childhood immunization rate is lower. And look at how often we get
to see the doctor, how long we get to stay in the hospital. Canadians
see their doctors far more often than we do. Americans really can't
afford to go see their doctor. There's always some co-payment, some
deductible, or they have to pay out of pocket, or something isn't
covered. But in Canada, where everybody is covered for everything,
they go to the doctor much more often. When they are hospitalized,
their hospital stays are longer. If they're having a baby, they
get to stay four or five days. Japan has very long hospital stays.
Ah, it's almost a rest cure. People in Japan who are hospitalized
might lie around the hospital for a week or two just to take a rest.
So we're really not getting our money's worth. It's going to all
sorts of things, but not to doctors and patients.
are the dangers that we're facing right now?
the danger is that our health care outcomes will start to drop.
As I said, they're not all that good in the developed world. We're
of the 25 richest countries in the world, we're somewhere around
22-23 in terms of our health. That could get worse, but the greatest
danger is that spending so much money on health care risks the feeling
that we somehow have to cut back on access, we have to cut back
on availability, we have to cut back on quality because it costs
too much. Right now the economy is doing well. We're rolling in
money. So we feel, yes, we can have it all. We can put all this
money into health care and we can also have patients' rights bills
and maybe a pharmaceutical benefit for Medicare patients. But that's
going to increase the cost in this system. The only way to both
reduce cost and increase access and quality is to change the system,
to scrap it and start over.
it out and start over?
because it's based on a false premise. Our health care system is
based on the premise that health care is a commodity like VCRs or
computers and that it should be distributed according to the ability
to pay in the same way that consumer goods are. That's not what
health care should be. Health care is a need; it's not a commodity,
and it should be distributed according to need. If you're very sick,
you should have a lot of it. If you're not sick, you shouldn't have
a lot of it. But this should be seen as a personal, individual need,
not as a commodity to be distributed like other marketplace commodities.
That is a fundamental mistake in the way this country, and only
this country, looks at health care. And that market ideology is
what has made the health care system so dreadful, so bad at what
it does. Yes, it does do what markets are supposed to do. It expands.
That's what markets are supposed to do. And it distributes a good
according to the ability to pay. But that sure is not what we want
of health care.
led us to this situation?
very American. This is a very capitalistic country with relatively
few safety nets as compared with Europe and Canada. It's a cowboy
country. It's always been a cowboy country, and health care, as
I said, has been seen as just one more commodity and the genius
of the marketplace will take care of it. People don't think, "Well,
how will that play out? Suppose you're poor and you're sick, what
will the marketplace do for you," because if you want a VCR, for
example, and you're poor, you don't get it. So you do without a
VCR. Are you really going to say that to someone that has a brain
tumor? So you do without your brain surgery. And also what markets
do is they put out a lot of goods. The consumer pays out of pocket.
He or she looks around, looks for a bargain, decides maybe he can't
afford a VCR this year, he'll get one next year. Well, imagine you
have a brain tumor. You're gonna shop for a bargain? You're gonna
say, "Well, I don't want an excellent brain surgeon. I want a mediocre
brain surgeon. I want a cheap piece of brain surgery." No. And you
can't say, "And I'll wait until next year," either. This is a life
and death thing and we ought to treat it that way. We ought to treat
it the same way we treat education. You don't personally buy education
insurance or your employer doesn't buy you education insurance.
It's something that a decent society supplies to everyone.
would you pay for health care as a social obligation?
pay for health care in a single payer system, and what goes into
that pot can vary. In Germany, employers have to contribute to that
pot. I don't think that's a good idea. Ah, I would rather see it
come straight out of tax revenues, out of general revenues. Now
a lot of people bridle at that. They say, "What? Our taxes would
go up." First of all, I'm not at all sure they would. Ah, I think
if we got out all of the inefficiencies that the private sector
introduces in the health care market, oddly enough -- it's very
inefficient system. If we got out those inefficiencies, I'm not
so sure that we would spend that much more from taxes than we now
spend on Medicare and the other tax supported parts of our health
care system. But be that as it may, people bridle at the "T" word.
"My gosh, we don't want anymore income taxes." And yet we pay for
health care now. We pay for it out of our paychecks, out of the
cost of goods and services, out of deductibles, co-payments, out
of pocket for much of what we get now. It would be much more efficient
and cheaper to pay for it out of taxes. We might get down to where
the Swiss are. They have a very good system at 2500 a person. If
we paid for it in an efficient way, out of taxes, we might get down
to 2500 a person.
ethical concerns play a role in the debate about health care policy?
our health care system creates ethical dilemmas that no health care
system should create. In managed care, doctors are paid for doing
less. The employers pay the HMO a certain amount, as little as they
can get away with, and then HMO often pass along that risk to the
doctors themselves in the sense that the HMO gets a set premium
and if they spend more than that premium taking care of their enrollees,
then they're in the red. If the spend less than the premiums on
their enrollees, then they get to keep what's left over. And some
HMOs pass those incentives along to doctors, to individual doctors
and say to the doctor, "Your salary depends on doing less, and you
will have something deducted from your salary if you do more. If
you do more than, say, ten chest X-rays in a month, we'll deduct
something from your salary. But if you do fewer than five, we'll
give you a bonus at the end of the year." So there are financial
incentives directly affecting doctors now that put them at odds
with the best interest of their patients. Now, to me, this is an
unethical system, and it puts ethical doctors in a terrific quandary.
think doctors are really suffering now. They're suffering in the
sense that they feel torn between serving their patients in the
best way they can and dealing with all of requirements of the insurance
companies and the HMOs and the hassles and the paper work and the
increasing pressures to do less and less for their patients. And
the loss of autonomy. In a nut shell, their loss of autonomy. If
you go back to the old days, doctors were paid fee-for-service,
the insurance companies reimbursed whatever the doctors charged,
and whatever the insurance companies asked for in premiums, the
employers gave. In those days the doctors and the patients were
kings. The bargain was entirely between the doctor and the patient.
Doctors were often paternalistic and arrogant, but still the transaction
was between the doctor and the patient. Doctors who were paid fee-for-service
and whose fees tended to be skewed preferentially to reward high
technology procedures, tended to do more of these things, more high
technology procedures, more tests in general, more visits in general.
No questions were asked and so they began to do too much and that
gave rise to the incredible health care inflation that we began
to see in the '60s and the '70s. That was not a good system, and
yet it had one good element, and that is that the essential transaction
was between the patient, the sick person, and the doctor who was
going to take care of him or her. Now the patients and the doctors
are both more or less helpless.
are we maintaining the status quo?
there are a lot of reasons we've stayed here, and I think one reason
is that the economy has been so terrific in the past decade. It
can't go on forever, this wonderful economy. We can see that Harry
and Louise are back, that this will be an important issue in the
election in 2000. It's been the third rail for the last several
elections. Since the demise of the Clinton plan in 1993-94, nobody
wanted to go near health care reform after that. But it's back on
the front burner. And I think people will start to feel pain soon.
People are already annoyed as all get-out with their HMOs. People
don't like being told that "This is covered, this isn't covered."
They don't like not being able to collect and having to pay out
of pocket. They're not happy with their health care system. I think
they've been afraid, so far, to go for any big changes, partly because
of the propaganda about the government. I mean Harry and Louise
was a very effective ad campaign during the Clinton Health Care
Reform attempt, and they're back on television with the same dark
hints that if government takes over, we're all going to go to hell
in a bucket. But I don't think that's going to wash this time because
doctors and patients both know that after enduring the tender mercies
of the managed care industry, they might like a little bit of government
regulation. In fact, the most successful part of the American health
care system is Medicare. And Medicare, which is a single payer,
government financed health care system -- what Canada has essentially
is Medicare for everyone -- but this is a government financed, single
payer system for people over 65 and it's the most popular part of
our health care system now. I think people are going to wake up
to this and Harry and Louise are not going to have as much effect
do you see us going down the road?
happens could go in one of two completely different directions,
depending on whether we do the right thing as a society or not.
We could be a decent society that looks at all of our citizens as
part of the same country, the way that Canada does, and say, "Look,
a decent society provides certain things for its citizens and health
care is one of those things." Some people get sick expensively and
some people are well all their lives and then drop dead one day
and they cost the system nothing. But we share it all and we say
we're all in this together. We could do in that direction. And probably
begin by, while we still are in the time of prosperity, extending
Medicare decade by decade. Instead of over-65, going over 55. And
maybe working up from children toward the middle. Ah, and then we
would have a single payer system. Now naturally the insurance industry
will fight this like crazy. In Canada they just said overnight,
"You're out of business. No more health insurance here. You're out
of business," to the private insurance companies. I'm not sure we
could do that, but there may be some way to encourage them to go
back into fire and floods or something.
you look at Medicare, people say, "Government is inefficient." That's
not true. The overhead of Medicare is one percent. The overhead
of the private insurance industry is roughly 20 percent. That's
profits and administrative costs. So Medicare is extremely efficient,
even given the fact that they have to use private carriers, which
they do. But we could go in that direction to a single payer system,
Medicare for everyone. Or we could, instead of being one country,
we could decide that we're going to be like a Third World country
, like India. And the rich do fine and the almost rich do okay,
and the poor, who cares about them?
sometimes said the Canadian system works only because it's next
to the United States, that if you need something and you can't wait
whatever the period of time the wait is, you can go to the United
States and be treated.
Canadians do come to the United States to get treatment. But it
is greatly exaggerated, the number who do. Yes, on the border, in
Cleveland, Buffalo, hospitals will cater to rich Canadians who come
across the border for things that they want in a hurry. To me, that
underscores how terrible our system is because there are plenty
of citizens of Buffalo and Cleveland, United States citizens, who
can not get health care, but these hospitals and doctors will sell
the health care like a commodity to rich Canadians who can come
down and buy it.
you have an elective procedure in Canada, let's say a knee replacement,
you're not going to wait that long. Yes, you might have to wait
four months. That's probably roughly the average for a knee replacement.
If you're an American with private insurance that covers a knee
replacement, you might have to wait two days. If you don't have
insurance, you'll wait forever. So which is better, four months
or two days or never for your knee replacement?