We sometimes hear that the United States has “the best healthcare system in the world.” But there are at least two objections to that claim.
First, it is somewhat anomalous to
call our fragmented approach a “system.” Consider that the federal government
alone has six major health care provider or insurance programs: Medicare, Medicaid, the State Children’s
Health Insurance Program (SCHIP), the Department of Defense TRICARE programs,
the VA's clinics and hospitals, the Indian Health Service, and the US
Public Health Service. Through these efforts the federal government provides (or in the case of Medicaid, helps to fund) health care to about one-third of Americans and research and prevention activities
that can benefit everyone.
Below the federal level there are myriad public and private entities that also contribute to the delivery of health services. These of course include
private hospitals, physician practices, long term care facilities, hospices,
employer-owned clinics, etc. There are state- and county- and city-owned
hospitals; state and local health and public safety and environmental departments;
and other government-sponsored human services. And in the private sector are the
many charitable entities that sponsor recreational facilities, youth
development programs, and health education.
Calling this gallimaufry
of services a system turns logic on
its head.
A
second objection to the claim of “best healthcare system in the world” is that our
overall health status is poor relative to that of other industrialized nations.
Consider this data from a recent Modern
Healthcare article:
● The
US ranks 26th out of 35 developed countries in life expectancy;
● Our
infant mortality is 3 times higher than Japan’s, higher than every other
Western nation, and only better than countries like Mexico and Turkey;
● New
mothers in this country die at a rate of 17.2 per 100K births, a 46% increase
in the last two decades; and
● More than 27 million Americans lack health
insurance, most of those being either poor and/or members of an ethnic minority.
In sum, for those who are covered by
some form of insurance or who can afford to pay out of pocket, the
highest-quality healthcare on the planet is available in the United States. But
not everyone can access the care they need, so the claim that we have the best
healthcare system in the world is dubious,
if not risible.
These thoughts
raise a fundamental question: Should we have
a right to healthcare? This is the profound topic known as “distributive justice”
— how goods, benefits, and burdens should be fairly allocated in a society. Uwe
Reinhardt (the late, great Princeton economist) phrased it this way after
President Clinton’s health reform initiative failed in 1997:
As
a matter of national policy, and to the extent that a nation’s health system
can make it possible, should the child of a poor American family have the same
chance of avoiding preventable illness or of being cured from a given illness
as does the child of a rich American family?
The Hermit Philosopher
thinks the answer is a clear, resounding “yes.” But politicians and policy
makers are chary of confronting the issue explicitly because moral questions
are complex and fraught with emotion, and a thoughtful response doesn’t make a
good sound bite or campaign slogan. Thus, we grub on in a muddle, making great progress
in science and bringing about wondrous cures, while the public policy questions
remain mired in rancor, confusion, litigation, and political posturing.
For more than a
century have these issues haunted us. Theodore Roosevelt called for national health
insurance in 1912. FDR tried but was unable to make it part of Social Security.
Truman’s ideas went nowhere, and LBJ had to settle for coverage of the elderly
and poor (Medicare/Medicaid). Richard Nixon proposed a plan that might have resulted in universal access 45 years ago, but the Watergate scandal ended his tenure. Bill Clinton’s proposal
went down in flames. And the current President is doing all in his power to decimate
the Obama era’s Affordable Care Act, which is the closest we’ve come yet to
systemic reform.
In the next few
months political candidates will spew millions of words bloviating about healthcare, but darkness, chaos and conflict will continue to “hover through
the fog and filthy air.” The result will be little more than "tales told by idiots, full of sound and fury and signifying
nothing."
Lord Macbeth and the witches would understand.
