by Danielle Ofri
New England Journal of Medicine
Status quo is a powerful determinant of both belief and behavior. Many of the things we do and we believe in occur just because this is what we’ve always done. This is why incumbents win elections, why we choose the same flavor of yogurt, why we take the same route to work, why we prescribe the same antihypertensives. For most Americans, our healthcare system is the way it is simply because this is the way it is. The logic of changing doctors when you change insurance, changing insurance when you change jobs, paying out of pocket when you don’t have a job, makes some sort of sense because this is simply the way it is.
A visitor from Mars, or Europe perhaps, would find this status quo shocking, much the way American tourists abroad are sometimes shocked to find toilets that require the toilet paper to be disposed of elsewhere. In this regard, Pamela Behan has somewhat of an outsider view on America. The title of her book, “Solving the Health Care Problem,” assumes that it is obvious that lack of national health care insurance is the problem in health care, which is what you learn once you read her book. This is surely how most Europeans would define the problem in US health care. But I’m sure that many Americans, even thoughtful ones, might think that other issues are the problem—cost of prescription drugs, inequitable research funds, FDA oversight. Even the subtitle—“How Other Nations Succeeded and Why the United States Has Not”—assumes that the adoption of a national health insurance is the definition of success in solving the health care problem.
Don’t get me wrong. I happen to agree with Ms. Behan that national health care insurance is what the US needs, but her title and approach make assumptions that might put off a percentage of the intellectuals and policy-makers who have a real role in the future of American health care.
The book lays out a very specific methodology to answer the question that the subtitle poses. It chooses Canada and Australia as countries that are relatively similar to the US, then traces the path those societies traveled in order to achieve national health insurance. Then it sketches the (unsuccessful) path that the US has traveled. In the manner of a case control study, the author attempts to compare these three experiences and calculate what the differences are, with the goal of explicating what the US would need to do in order to achieve that Holy Grail.
Readers from the medical community are well aware of the limitations of case-control studies of groups of human beings, even large, well-selected groups. But comparing three societies, with incalculable historical, political, and social differences that could conceivably outweigh their similarities…that is a tall order indeed. However, there are not many other research options out there other than speculation, so Ms. Behan gives it the college try, and offers what is probably the most careful analysis that can be performed.
The first chapter of the book frames the basic research question in three brief pages, then casually mentions that the last chapter “describes the study’s conclusion in layman’s terms, including the changes that may be needed to solve the problems of health care access and protection from its costs in the United States.”
Were this an Agatha Christie mystery or a Jose Saramago novel, I wouldn’t dare peek at the last chapter. But in a book that intends to provide the all-embracing research details in the intervening chapters, non-academicians are all but invited to jettison literary decorum and skip to the plot climax. If suspense is important to your reading enjoyment, then stop reading this review now, because I will divulge the outcome. The answer is that in order to enact national health insurance, countries need to achieve four necessary conditions—federal/financial authority in health care, a multiparty system, a health care legislative legacy, and strong trade unions. Countries also need one of two sufficient conditions—labor party power and lack of veto points (ability to easily block legislation from within or outside the system).
Depressingly, the US comes up short on almost every one of these six counts. I found the discussion of the veto points the most interesting. For the last century, almost every legislative gesture was soundly defeated by an unelected body—the American Medical Association. Sure, there were plenty of senators, representatives and presidents who added their two-cents’ worth of obstructionism, and the author takes pains not to paint the AMA as the devil, but the historical discussion reveals that most consistent anvil came, lamentably, from within medicine itself.
The very nature of the American political system— the winner-take-all voting system, the free-market attitude toward lobbyists, the ability of legislators to compromise bills into nothingness—makes far-reaching social change almost impossible. The necessary and sufficient conditions needed to achieve universal health insurance seem constitutionally unachievable in American society. The sad conclusion of Pamela Behan is that “[m]any of the chief blessings of democracy”— health care as a right is clearly included here—“will, ironically, elude those pioneers of democracy, the American people.” (from the New England Journal of Medicine)