In his new book The Healing of America, the journalist T. R. Reid employs a clever device for surveying the world's health systems: he takes an old shoulder injury to various countries. In the United States, a top orthopedist recommends joint-replacement surgery, costing tens of thousands of dollars. In France and Germany, doctors steer him instead toward a regime of physical therapy. In Britain, they tell him to go home. In India, he is treated, quite effectively, with herbs, massage, and meditation.
Reid argues we should follow other countries, where health care is fairer and cheaper and produces better results. He's right that we can learn much from practices elsewhere. But the lesson I took away from his book was somewhat different: health-care systems are not just policy choices, but expressions of national character and values. The alternatives he describes work not just because they're well designed but because they reflect the expectations and traditions of their societies.
All advanced, wealthy countries have health systems that are more egalitarian and cost-effective than ours. Each also has its quirks, which reinforce familiar stereotypes. Britain, land of the stiff upper lip, provides what to us seems shockingly minimalist treatment. It doesn't even cover regular physicals for adults, which is what you get when you spend 8 percent GDP on health care (versus our 16 percent). The Japanese, on the other hand, love doctors and visit them, on average, 14.5 times per year, three times the U.S. rate. They do this in an orderly, ritualized way, usual-ly bringing a bottle of sake or cash in an envelope as a gratuity.
America's undesigned system is also an expression of our culture at its best and its worst. Health care in America is innovative, entrepreneurial, expensive, litigious, and wasteful. It is decentralized, driven by self-interest, excellent at the high end, and increasingly unequal. It resists acknowledging trade-offs or limits and is characterized by shocking gaps in basic care. As we plunge into a long-overdue comprehensive overhaul, it's useful to think not just about how we can build on what works in this hodgepodge, but also about how to bring health care into better alignment with our own national identity.
The current system of American health care is at odds with the American character in three fundamental respects: moral, economic, and sociological. Morally speaking, Americans are more accepting of economic inequality than our European brethren. But the random unfairness that condemns the uninsured to bad health and the risk of untimely death offends the national conscience. There is a general consensus among nearly all supporters of change that we need to move strongly in the direction of universal coverage. On this score, the bill supported by the House Democratic leadership and the one passed by the Senate health committee both do well.
At the financial level, we might as well admit that we're going to continue spending more of our national income on medicine than anybody else. We're a rich country and want the best care available. But we need to recognize that we're getting a crazy, bad deal by spending so much and leaving so many people out in the cold. Our society and government are threatened by runaway medical inflation, which saps private-sector profits and undermines government finances. On this score, the trillion-dollar bills working their way through the House and Senate, which lack incentives to hold down spending, rate poorly.
It is on the sociological level, though, that we're missing the boat most completely by sticking with a workplace-based system that no longer makes sense. America has always been a mobile society, with a labor market that grows more fluid over time. Once, the norm was to work for a single employer for one's entire career. Today, people change jobs an average of 11 times before they reach 40. Fear of losing health coverage keeps people in jobs they would otherwise leave, creating a drag on economic efficiency.
The Senate's smartest health-care wonk, Ron Wyden of Oregon, believes we should move away from job-based insurance. He has introduced a bill that would do this by converting the tax deduction for employer-provided health insurance into a tax credit and requiring individuals to use it to buy insurance. This would achieve universal coverage, apply meaningful cost controls, and—according to the Congressional Budget Office—pay for itself within a few years.
But Wyden's bill is going nowhere. Instead, Democrats are poised to pass legislation that spends an additional trillion dollars, fails to restrain spending, and shores up an anachronistic employer-based system. I guess you could call it a uniquely American solution.