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 doctors in various countries. In the United States, a top orthopedist recommends a major joint-replacement operation, costing tens of thousands of dollars. In France and Germany, general practitioners offer him the same surgical option, at little or no cost, but steer him instead toward a regimen of physical therapy. In Britain, the doctor is unimpressed with his injury and tells him to go home. In Canada, he is offered a place in line, where he will wait a year just to consult a specialist. In India, he is sent to an ayurvedic clinic, where he is treated, quite effectively, with herbs, massage, and meditation.
America’s system has become wildly unfair and expensive. In fixing it, Reid says, we should follow other countries where health care is fairer, cheaper, and produces better results. He’s right that we can learn much from practices elsewhere—why, for instance, can’t we have those nifty smart cards the French use instead of paper records? But the lesson I took away from Reid’s book was somewhat different: Health care systems are not just policy choices but expressions of national character and values. The alternatives he describes work better than ours not just because they’re well-designed and competently managed but because they reflect the expectations and traditions of their societies.
All advanced, wealthy countries have structures that are more egalitarian and cost-effective than ours. Each also has its quirks, which tend to reinforce familiar stereotypes. Britain, land of the stiff upper lip, rations care explicitly, providing what to us would seem shockingly minimalist treatment. It doesn’t cover many procedures we regard as standard, such as PSA tests for men in their 50s or even regular physical exams for adults. That’s what you get when you spend 8 percent of your GDP on health care (versus our 16 percent). The Japanese, on the other hand, venerate doctors and visit them 14.5 times per year on average, three times the U.S. rate. They do this in an orderly, ritualized way, usually bringing a bottle of sake or cash in an envelope as a gratuity.
America’s evolved, undesigned system is also an expression of our culture at its best and it worst. Health care in the United States 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 work s in this hodgepodge but about how we can bring health care into better alignment with our own national identity. In reforming our system, we need to create something that is “more like us,” in the phrase of the journalist James Fallows—not more like what the French, Finns, or Swiss have, as appealing as that might sound.
The current system of American health care is at odds with America’s character in three fundamental respects: moral, economic, and sociological. Morally speaking, Americans are surely more accepting of economic inequality than their European brethren. But the random unfairness that condemns the uninsured to bad health and the risk of untimely death offends the social 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, education, labor, and pensions 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 health care than anybody else. We are a rich country, we want the best treatment available, and we’re prepared to pay for it. But we also need to recognize that we’re getting a crazy-bad deal by spending so much on health care and leaving so many people out. Our society and government are threatened by runaway medical inflation, which saps business profits and undermines fiscal responsibility. On this score, the $1 trillion bills working their way through the House and Senate, which lack incentives to hold down spending, rate poorly. The Congressional Budget Office says they will make a bad situation worse.
It is on the sociological level, though, that we’re missing the boat most completely by sticking doggedly 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. As the Senate’s smartest health care wonk, Ron Wyden of Oregon, says: “A big part of the reform challenge is to look at how the culture of the American workforce has changed since the basic structure of American health care was put in place. Today’s culture is all about flexibility.”
The premise of Wyden’s bipartisan bill is that we should move away from job-based insurance. It would do this by converting the tax deduction for employer-provided health insurance into a tax credit and requiring that individuals use it to buy insurance. Wyden’s bill would achieve universal coverage, apply meaningful cost controls, and, according to the Congressional Budget Office, pay for itself within a few years. It’s going nowhere. Instead, Democrats are poised to pass legislation that spends an additional $1 trillion, fails to restrain spending, and shores up an anachronistic employer-based system. I guess you could call it a uniquely American solution.
A version of this article also appears in this week’s issue of Newsweek.