Jonathan Cohn’s Sick belongs to the “60 Minutes” school of journalism: a series of sad human stories deployed to win an argument that is never quite explicity stated. The sad stories are very well told. Cohn does his reporting work well: In the space of a few paragraphs, the reader comes to feel that he knows the people Cohn has profiled.
Still, conservatives and market-minded people generally will find the book deeply unpersuasive. They’ll note that one could find a dozen equally compelling tragedies in Canada, the UK or even Cohn’s preferred alternative: France. The book is a standing violation of the statistician’s saying that “for instance” is not proof. That said – this book is important. It nicely, even elegantly, encapsulates the view of the world that will animate the politicians and officials who will be making America’s big national healthy policy decisions in the new administration.
First we meet the Rotzlers, Gary and Betsy. They live in upstate New York, where Gary worked as an aerospace engineer. In a corporate reorganization, Gary lost his status as a permanent employee and with it, his health insurance. He continued to earn a middle-class living, but for one reason or another he never bought health insurance for himself. The need to pay doctors’ bills in cash discouraged Betsy from seeking medical attention. She ignored for months the early symptoms of breast cancer, until finally the increasing pain drove her to a free clinic. There, her cancer was diagnosed, but too late. She died, and Gary was left with $40,000 in debts. He declared bankruptcy soon after.
Next we meet Orlando resident Janice Ramsey. Self-employed and diabetic, Ramsey encountered difficulty finding affordable insurance. So when she received a glossy brochure from a company called American Benefit Plans offering reasonably priced insurance to professionals with no individual medical assessment, Ramsey bought right in. Unfortunately for her, the Plans proved a scam. She racked up some $20,000 in unpaid medical bills while supposedly covered – leaving her in debt and still uncovered.
Elizabeth and Steven Hilsabeck are professionals living in Austin, Texas. In 1992, Elizabeth gave birth to two severely premature babies: each weighed less than 2 lbs at birth. The boy was soon diagnosed with cerebral palsy. Elizabeth enrolled him in physical therapy that might just possibly enable him to walk. Her HMO declined to pay. She became a ferocious political activist, seeking changes in the law that would allow her to sue her HMO. Consumed by her advocacy, Elizabeth loses her job and her marriage.
Three more cases follow. A union retiree whose company drops its health benefits – burdening him with prohibitive costs for the medication his wife needs to fight her lung disease. Two working class Tennesseans who cut back their prescription use when their state Medicaid program becomes less generous. A lone woman who incurs a huge bill at a Catholic hospital and is then hounded for a payment she cannot afford.
All of this builds to the conclusion to which Cohn wishes to lead the reader:
In every universal health care system, the government begins by defining a set of benefits to which everybody is entitled, and then finds a way to make sure everybody gets these benefits.
That short phrase “finds a way” of course conceals a vast ocean of difficulties.
After all, in Cohn’s second-to-last case study, the couple were enrolled in a government-provided system of benefits, Medicaid. The trouble was that the state could not “find a way.” The rising cost of healthcare is just as ruinous to government-run systems as America’s private system. (See Denys Arcand’s film “The Barbarian Invasions” for a nightmare vision of Canada’s government system.) If health care costs consistently rise faster than national income, nations will struggle to finance health care, regardless of whether their systems feature competitive markets or not.
Cohn imagines that his complaint is against for-profit medicine. It’s really against the existence of any constraints at all on the human desire for health and longevity. Cohn for example guides his reader to sympathy with Elizabeth Hilsabeck’s crusade. Yet he offers no reason to believe that the physiotherapy she sought would have made any difference to her son. A state system might have been just as likely (maybe even more likely) as her HMO not to fund that therapy. (Cohn also breezes past the hints in his own reporting that Hilsabeck was really seeking not coverage, but a big malpractice payout from her HMO: he mentions in an aside her theory that her son’s condition was caused not by his premature delivery but by an interruption in his oxygen flow – the same false theory that made John Edwards’ fortune as a trial lawyer.)
Resources are finite. That’s the first law of economics generally, and of health care economics in particular. The US spends a great deal on healthcare already. Cohn takes it for granted that government could deliver healthcare services a) more cheaply, b) more universally, and c) with more sensitivity and compassion than private providers. This case is not articulated, just assumed. Nor does it seem to bother Cohn that his case contradicts the almost universal experience of government-provided services in areas ranging from food to education.
It could (and should) be said that in many ways the US already has government-provided healthcare, and by the bucketful. Government in one form or another spends nearly half all the healthcare dollars spent in the United States. Government tightly regulates almost all the rest. Some (me for one) would argue that it is just this half-in, half-out government role that has so badly distorted the US health market. Cohn mentions only in passing his reason for thinking (or imagining) that a greater government role would yield better results:
[G]overnment can (and usually does) adjust … required payments depending on people’s ability to pay. It can also use leverage to control costs more effectively than a fragmented, non-universal system can.
Redistribution + command & control: These ideas are not yet so old as to have become new again. Aside from all the other flaws with the command-and-control approach to economics, there is not even much reason to think that it would help very much even in the kinds of situations Cohn chooses to focus upon.
Look again at the story of the Hilsabecks. Their situation (or rather: the situation of people like them) would challenge any healthcare system, even one endowed with all the resources of the US government. A generation ago, their healthcare costs would have been small. They would have gone to the hospital, Mrs Hilsabeck would have delivered two very premature babies, the babies would have died, the cost would have been negligible. Now the babies can be saved – but at immense (and in the case of the severely disabled boy) lifelong cost.
This story can be replicated a hundred thousand fold: the cancer patient who can now battle through for years, the stroke victim who can be rehabilitated through physical therapy, and on and on. Hundreds of thousands – if not millions – of children and adults who would at other times have been inexpensively dead have gained years of active life. This is a magnificent human achievement, and thanks to the healthcare system Cohn deplores, almost all of the innovations that have enabled the achievement have originated in the USA. But they cost money, and as long as the pace of innovation continues, rising amounts of money. And it is inevitable, given that fact, that some decision-maker public or private will have to make decisions like: Should we spend hundreds of thousands of somebody else’s money on physiotherapy that may (but may not) help Mrs Hilsabeck’s child? Or should we tell her no, and use that money where it might do more good – including by the way leaving it in the private economy where it might be invested to create new products and services? Socializing the problem does not make it go away.
Indeed, socializing the problem could well make it worse. One of the most important factors in determining our future health and wellbeing is our own personal behavior. Politicians euphemize this important fact by talking about “wellness” and “preventive medicine.” Yet it’s not medicine that prevents sickness. It’s individual choice.
A generation ago, the choices we worried about most were smoking and seatbelts. By avoiding cigarettes and wearing belts, individuals could dramatically improve both their length and quality of life. Great progress has been made on both fronts. But while Americans were making wiser choices with their lungs and at the wheel, they were making much worse choices about exercise and eating. Obesity and overweight have become increasing burdens not only upon the health and happiness of Americans, but upon the healthcare system. Smoking kills. Obesity does not. The obese live almost as long as the non-obese: but they get and stay a lot sicker along the way. The Centers for Disease Control estimate that about one US healthcare dollar in ten is spent to deal with the effects of obesity and overweight.
Encouraging individuals to make better choices is essential to delivering better health at a bearable cost. “Patient-centered care” sounds like one of those horrible pieces of gobbledygook corporations spew to justify charging employees more for a flu shot. But it truly is the essence of the problem. The patient – or the prospective patient – is the center of the story. If he or she walked more, ate less, owned a pet, drank moderately, got and stayed married, and sought early help for depression and anxiety – then the whole healthcare perplex would be a lot more manageable and at lower cost.
Too often, we conceptualize the healthcare system as a system of response to illness. You get sick, you enter the healthcare system. Once in, somebody has to pay. Since few of us can afford to pay ourselves, some third party must step in, and since government is the least likely to impose onerous conditions on the sick, Cohn prefers that this third party be government. If on the other hand, you aren’t sick, you stay out.
This way of thinking is obsolete. We are all in the healthcare system all the time. The decision to take the stairs or the elevator, to order your turkey sandwich with cheese or without, to spend Sunday afternoon watching football or playing football: these are all healthcare decisions.
A private system can offer incentives to support wiser choices. Private life insurers, for example, charge higher premiums to smokers. Governments find it much more difficult to enforce such distinctions. Medicare takes the same premium from the obsese and the non-obese. As the health system becomes more Medicare-like, the role of individual choice will inevitably be downgraded. The obsolete conception of healthcare as something separate from normal life will only be entrenched.
Advocates of a greater government role often speak of healthcare as a right. It would be equally apt to describe it as a responsibility. The larger the collective role, the more apt that description becomes – and this is true whether the collective role takes the form of private insurance or taxpayer contribution.
Yet this language of “rights” has consequences. It creates expectations that no healthcare system can possibly satisfy. The moral quandaries that vex Cohn’s insurers vex governments too, and more so. People of Cohn’s point of view often argue that healthcare is not suitable for market discipline. I am not so sure that is true: The information gap between investors and CEOs seems at least as wide as that between patients and doctors – and yet we still trust people to make their own savings decisions. But even if Cohn and his allies are right about the error of conceptualizing patients as consumers, there is no escaping the reality that doctors and hospitals are very subject to economic laws in their capacity as providers. They won’t work without pay, they will look for ways to maximize their income, and unless they are incentivized to do so, they won’t bother to innovate or cut costs. Somebody has to tell them “no,” and if it is not insurers or HMOs, then it will have to be the state.
Ironically, the record suggests that the main merit of the government systems admired by Cohn is precisely that they are much tougher-minded about saying “No” than the private insurers Cohn so dislikes. They make patients wait longer, accept higher amounts of individual pain and fear, and are more resistant to heroic measures to extend the final hours of infants and elderly deemed unlikely to live. Everybody gets something, but nobody gets as much as the sickest Americans get. The people who experience such systems seem satisfied enough with the inherent tradeoffs. Yet these tradeoffs can occur precisely because government healthcare systems do not take seriously the idea that healthcare is a “right” in the sense that speech and religion are rights.
We hear little about these tradeoffs. For reasons it would take a book much longer than Cohn’s to fill, writers shun reporting of the real life consequences of command-and-control healthcare. (Here’s one exception.) They leave us to imagine that if only the public treasury could be opened and individuals emancipated from any encounter with cost, choice, or constraint, all difficulties would vanish. In reality, that’s when the trouble truly begins.