I overheard most of Obama's health care speech the other night.
I usually duck political speeches, but it came on during a break
in the music, and I wasn't much enjoying the music. Seems like he
made the basic case clearly, although he didn't go very deep, in
large part because he's not trying to fix very much. I heard one
peculiar round of boos, but didn't catch what occasioned it --
maybe that Rep. Joe Wilson flap. And I heard three or four more
boos, clearly coming from Laura in the TV room. I agree with her
that the only way to actually fix the system is to wring the
profit incentives out of it and to restore a professional ethic
of care giving, and that the first step should be to institute
single-payer insurance. Obama's credentials as a progressive and
for that matter his reputation as someone with a grip on reality
were tarnished by his eagerness to make light of single-payer.
He also came up short on two other key points: one is whether
government can run programs that serve the people, which is
really a key article of faith for anyone who professes belief
in democracy; the other is deficits question, where the right
answer is: we'll spend what we need to spend to provide everyone
with quality health care, and if that's more than is in the
current budget we'll raise taxes to cover it. But then, as I
said, Obama wasn't trying to fix very much. And if he manages
to make it possible for someone like me who can afford to buy
health insurance but can't find any insurance company willing
to sell me a policy, I at least will be pleased. On the other
hand, lots of other people will remain disappointed. One thing
for sure is that Obama won't be the last president to attempt
to reform the health care system. Even if he delivers what he's
promised, he'll leave plenty more to be done.
Over the last few weeks, I read three health care books I
found at the library. I've read more over the last few years,
and have more on tap. The books are:
Ezekiel J Emanuel: Healthcare, Guaranteed: A Simple, Secure Solution
for America (paperback, 2008, Public Affairs): The perscription
here is for a regulated private insurance system, allegedly because
people want choices, but then goes on to expect big changes in the
provider segment -- a much higher bar to reform than simply dropping
private insurers no one likes anyway. Emanuel is Rahm Emanuel's brother,
which may be one reason Obama leans in this direction, but even Emanuel
sees bigger problems and goes further to fix them than Obama does.
Jill Quadagno: One Nation Uninsured: Why the US Has No National Health
Insurance (2005, Oxford University Press). This is a good full
range history of political efforts to reform health insurance going back
to the progressive era before World War I. One consistent thread is how
business interests have played decisive roles each step along the way --
even Medicare was slanted in favor of special interests, and did much to
vastly increase growth in spending and costs. The reform section at the
end is weak, but the historical survey is essential.
Arnold S Relman: A Second Opinion: Rescuing America's Health Care
(2007, Public Affairs). Probably the best policy book I've seen. At
least Relman gets the essential contradiction between profit-seeking
and quality care. He favors both single-payer financing and a major
reorganization of medical care in favor of large, non-profit PGP groups.
The latter may seem like a radical idea, but there are several good
examples already established (e.g., Kaiser-Permanente) and they have
superior results for lower costs. One weakness is that he doesn't
get into pharmaceutical and technology companies.
Some older books that I read and commented on earlier:
Donald L Barlett/James B Steele: Critical Condition: How Health
Care in America Became Big Business -- and Bad Medicine
(2004, Doubleday): Long on case histories, a/k/a horror stories.
My note has more about Bush's "ownership society" plots.
Robert H LeBow: Health Care Meltdown: Confronting the Myths and Fixing
Our Failing System (2003, Alan C Hood): More convincing stories
of failure; more sensible but cautious steps to help out.
Phillip Longman: Best Care Anywhere: Why VA Health Care Is Better
Than Yours (paperback, 2007, Polipoint Press): A report on
the VA system, the closest thing the US has to a fully socialized
government run system, also a remarkably effective one.
David Mechanic: The Truth About Health Care: Why Reform Is Not
Working in America (2006, Rutgers University Press): Another
useful survey of the manifest problems with cautious recommendations.
Julius B Richmond/Rashi Fein: The Health Care Mess: How We Got Into It
and What It Will Take to Get Out (2005, Harvard University Press):
Jimmy Carter's Surgeon General surveys the current situation, registers
his opinion that single-payer insurance would be the right fix, then
offers an alternative that closely matches Kerry's 2004 campaign platform.
Susan Sered/Rushika Fernandopulle: Uninsured in America: Life and Death
in the Land of Opportunity (paperback, 2006, University of California
Press): My book note here mostly derives from a Malcolm Gladwell review
that takes off from the book to provide a superb summary of the issue
(see quote below).
Malcolm Gladwell: The Moral-Hazard Myth.
An article published in 2005, in part a review of the Uninsured in
America book cited above. When I originally posted a quote from
the article, I didn't bother tracking down the URL, but now I've found
the piece online. Part of the quote deserves reiteration (the only
thing that has dated it is that the costs are even more outrageous
One of the great mysteries of political life in the United States
is why Americans are so devoted to their health-care system. Six times
in the past century -- during the First World War, during the Depression,
during the Truman and Johnson Administrations, in the Senate in the
nineteen-seventies, and during the Clinton years -- efforts have been
made to introduce some kind of universal health insurance, and each
time the efforts have been rejected. Instead, the United States has
opted for a makeshift system of increasing complexity and dysfunction.
Americans spend $5,267 per capita on health care every year, almost
two and half times the industrialized world's median of $2,193; the
extra spending comes to hundreds of billions of dollars a year. What
does that extra spending buy us? Americans have fewer doctors per
capita than most Western countries. We go to the doctor less than
people in other Western countries. We get admitted to the hospital
less frequently than people in other Western countries. We are less
satisfied with our health care than our counterparts in other
countries. American life expectancy is lower than the Western
average. Childhood-immunization rates in the United States are
lower than average. Infant-mortality rates are in the nineteenth
percentile of industrialized nations. Doctors here perform more
high-end medical procedures, such as coronary angioplasties, than
in other countries, but most of the wealthier Western countries
have more CT scanners than the United States does, and Switzerland,
Japan, Austria, and Finland have more MRI machines per capita. Nor
is our system more efficient. The United States spends more than
a thousand dollars per capita per year -- or close to four hundred
billion dollars -- on health-care-related paperwork and administration,
whereas Canada, for example, spends only about three hundred dollars
per capita. And, of course, every other country in the industrialized
world insures all its citizens; despite those extra hundreds of
billions of dollars we spend each year, we leave forty-five million
people without any insurance. A country that displays an almost
ruthless commitment to efficiency and performance in every aspect
of its economy -- a country that switched to Japanese cars the moment
they were more reliable, and to Chinese T-shirts the moment they were
five cents cheaper -- has loyally stuck with a health-care system that
leaves its citizenry pulling out their teeth with pliers.
I started assembling a list of miscellaneous books related to health
care policy issues, starting with my previous book prospecting blogs.
Wound up with a pretty long list, which probably needs a few more notes,
so I decided to hold it back. Tomorrow, maybe.