|
reprinted from
November 7, 2005
Paul Krugman
Pride, Prejudice, Insurance
General Motors is reducing
retirees medical benefits. Delphi has declared bankruptcy and will
probably reduce workers' benefits as well as their wages. An internal
Wal-Mart memo describes plans to cut health costs by hiring temporary
workers, who aren't entitled to health insurance, and screening out
employees likely to have high medical bills.
These aren't isolated
anecdotes. Employment-based health insurance is the only serious source of
coverage for Americans too young to receive Medicare and insufficiently
destitute to receive Medicaid, but it's an institution in decline. Between
2000 and 2004 the number of Americans under 65 rose by 10 million. Yet the
number of non-elderly Americans covered by employment-based insurance fell
by 4.9 million.
The funny thing is that the
solution — national health insurance, available to everyone — is obvious.
But to see the obvious we'll have to overcome pride — the unwarranted
belief that America has nothing to learn from other countries — and
prejudice — the equally unwarranted belief, driven by ideology, that
private insurance is more efficient than public insurance.
Let's start with the fact
that America's health care system spends more, for worse results, than
that of any other advanced country.
In 2002 the United States
spent $5,267 per person on health care. Canada spent $2,931; Germany spent
$2,817; Britain spent only $2,160. Yet the United States has lower life
expectancy and higher infant mortality than any of these countries.
But don't people in other
countries sometimes find it hard to get medical treatment? Yes, sometimes
— but so do Americans. No, Virginia, many Americans can't count on ready
access to high-quality medical care.
The journal Health Affairs
recently published the results of a survey of the medical experience of
"sicker adults" in six countries, including Canada, Britain, Germany and
the United States. The responses don't support the claims about
superior service from the U.S. system. It's true that Americans generally
have shorter waits for elective surgery than Canadians or Britons,
although German waits are even shorter. But Americans do worse by some
important measures: we find it harder than citizens of other advanced
countries to see a doctor when we need one, and our system is more, not
less, rife with medical errors.
Above all, Americans are far
more likely than others to forgo treatment because they can't afford it.
Forty percent of the Americans surveyed failed to fill a prescription
because of cost. A third were deterred by cost from seeing a doctor when
sick or from getting recommended tests or follow-up.
Why does American medicine
cost so much yet achieve so little? Unlike other advanced countries, we
treat access to health care as a privilege rather than a right. And this
attitude turns out to be inefficient as well as cruel.
The U.S. system is much more
bureaucratic, with much higher administrative costs, than those of other
countries, because private insurers and other players work hard at trying
not to pay for medical care. And our fragmented system is unable to
bargain with drug companies and other suppliers for lower prices.
Taiwan, which moved 10 years
ago from a U.S. style system to a Canadian-style single-payer system,
offers an object lesson in the economic advantages of universal coverage.
In 1995 less than 60 percent of Taiwan's residents had health insurance;
by 2001 the number was 97 percent. Yet according to a careful study
published in Health Affairs two years ago, this huge expansion in coverage
came virtually free: it led to little if any increase in overall health
care spending beyond normal growth due to rising population and incomes.
Before you dismiss Taiwan as
a faraway place of which we know nothing, remember Chile-mania: just a few
months ago, during the Bush administration's failed attempt to privatize
Social Security, commentators across the country — independent thinkers
all, I'm sure — joined in a chorus of ill-informed praise for Chile's
private retirement accounts. (It turns out that Chile's system has a lot
of problems.) Taiwan has more people and a much bigger economy than Chile,
and its experience is a lot more relevant to America's real problems.
The economic and moral case for health care reform in
America, reform that would make us less different from other advanced
countries, is overwhelming. One of these days we'll realize that our semi-privatized system isn't just unfair, it's far less efficient than a
straightforward system of guaranteed health insurance. |
