Malcolm Gladwell delivers a lengthy polemic. He favors some form of national health insurance, but is this the correct conclusion? A few observations:
1. He is correct that "too much insurance" is not the problem. Health savings accounts are not the answer.
2. Many of the current uninsured are linked to immigration, or voluntarily uninsured. This is not pure institutional failure.
3. Gladwell downplays moral hazard, arguing that the fully insured wealthy do not forgo their golf games for superfluous doctor visits. But the real problem comes from the other side: doctors overbill or perform unnecessary procedures.
4. The U.S. health care system probably is the world’s best for some class of people, namely the well-off and I don’t mean just the super-rich. Trying to extend those benefits — however this might be accomplished — is a better approach than nationalizing the sector.
5. Much of our excess spending is to make people feel they have done everything they can for themselves or their relatives. It is partly voluntary in nature. Socialized systems don’t allow many of these options to reach the menu in the first place. We need to think long and hard about the right answer here; it is not useful to simply call these expenditures wasteful.
6. The whole debate is emphatically not about "a few simple questions," as Gladwell suggests at the end.
7. No one has a good plan for socializing American medical care or insurance.
8. Much European health comes from diet, walking, and tighter social networks of friends. Don’t expect European healthcare policies to produce the same level of well-being in the United States.
Thanks to Mark LaRochelle for the pointer.
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This ties in with your fifth point (the link in which is down, by the way), but it’s my impression that there is a much greater emphasis on end-of-life care in the United States in comparison to other developed countries. Huge amounts of money are spent keeping dying people alive a few more weeks or even just days. I see this as a case of misguided priorities rather than compassion.
I think the single biggest issues in American health care is the culture that exists in a large percentage of american’s that causes them to be unhealthy in multiple aspects of their health and the sense of entitlement to a cure. As someone who is healthy (through conscious decisions to eat right and exercise etc), works in the biomedical sector, and volunteers my time in a emergency trauma center I witness and am appalled with how American’s choose to approach their health. Here are a few examples..
We have elderly (80+) coming in, with the proding of their adult children, complaining about sore joints, stiffness, general weakness etc.. Your old, we can’t do anything for you, but thanks for costing the health care system 4 hours of a doctor, a nurse, a technician, and staff’s time, a place in a bed, and other resources.
Middle aged men and women coming complaining of a fever. Upon discussion, we learn that the headache isn’t that bad, has only lasted 3 hours and didnt go away with two advil. Oh, did I mention, the patient takes 4 advil a day for minor aches and pains. Umm, ever hear of tolerance to medacation. A headache isn’t something an etc should treat.
Parents, with their screaming three year old with an earache. Go to a pediatrion, nuff said.
I could go on for hours. But I think my point is that even though these people are insured, they are wasting and misusing resources. Which stretches demands on the whole system and causes costs to skyrise across the board. Americans need to realize that if you don’t take care of yourself you will get sick. And when you get sick and don’t take care of yourself, you get other complications. Socialized health care, in my beliefs, will only increase the thinking that pervades “oh i don’t gotta pay, so ill go in”
In regards to point 8, I have always been struck by the size of fast food portions served in the USA compared to the size served here in Canada.
When I was last in the USA, I ordered a small soda at Arby’s, and the thing must have been the size of a Canadian medium, if not a Canadian large. I was shocked that anyone could drink so much soda pop.
Or is this just an Arby’s thing? Considering that I’m an English Canadian that lives less than two hours from the American border, I never realized that this was a cultural difference between our two countries.
I suppose the explanation could also be some form of government regulation in Canada, but I think I would have heard of that. Or maybe the cost of producing coke in a state two hours away is cheaper in the USA for some reason.
I quote from Malcolm Gladwell: “In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be.” Poppycock. The NHS is notorious for its disasters. It is also notorious for its poor dentsl services. In Australia, even people at very low income levels take out private hospital insurance to avoid falling into the maw of the so-called ‘public’ health system. — Why does Gladwell assume that because it hasn’t happened yet in the US it hasn’t happened anywhere?
One of the things that Gladwell misses is that European countries can provide excellent coverage at low cost because of the current U.S. system. Pharma and medical device companies are willing to sell to European (and Canadian) systems more cheaply because they can charge ‘full price’ here. Part of the extra we spend is in subsidies for the rest of the globe.
Also — I think that Gladwell, in his anecdotes, overstates the causal relationship between infrequent medical care and poor health. I believe that those people who cannot afford insurance (or who decline to spend the money on it) also tend to have other unhealty habits in terms of diet, tobacco and alchohol use, lack of exercize, etc. Universal coverage will not solve those problems.
All of that said, though, I think some form of universal coverage is inevitable here and really, the question is how to do it right (or, at least, as right as feasible).
Bogus bogus bogus!
2. People routinely ignore some risks while overemphasizing others. We know people tend not to save enough… we try to do something about it. We know that given a choice, people insure their cars inadequately, or not at all. We do something about this. We don’t do the same for health insurance… this isn’t institutional failure? What is the point of an insitution devoted risk management if it doesn’t, you know, actually improve the management of risk? And as for this being linked to immigration – people from other countries, when they come here, often assume a functioning public health system or cannot figure out what they need to do in ours. They don’t know that they need to figure this stuff out till they have to… when they need health care.
3. I agree – a “real problem” comes from doctors overbilling and performing unnecessary procedures. And our solution is to – what? Force people with no knowledge of medicine or medical risk take decisions to control the costs of medical coverage? And to penalize them heavily, and institutionally when they get it wrong? If you’re going to apply caveat emptor to patients, you’re also going to have to apply it to doctors – that they might just get the pants sued off them if they aren’t demonstrably doing the right thing. Oh wait – we already have this.
4. “Let’s look at the situation of well off people with insurance. Now let’s figure out how to make people who aren’t well off and who don’t have insurance get those benefits. But without making them well off, or providing them with insurance.” Paraphrased this way, does, the vacuousness of this point become clear?
7. No one has a plan for socializing American medical care? Your link only says that none of the democratic presidential candidates for the 2004 election did. Bit of a stretch to claim that no-one has a good plan.
You’ve noted elsewhere that this question is hard, and no one has good answers… but making misleading, disingenous and vacuous “points” helps no one.
This is a curious discussion. Although it has been implicitly lurking in the background of some of the remarks made, no one has come out with the most important facts: we in the US not only pay by far more per capita than anyone else in the world for medical care, we pay more as a percent of GDP as well. Nevertheless, we rank very poorly on life expectancy (around 16th, lower if some miniscule countries are included) and even worse (around 32nd, again, lower if miniscule countries are added) on infant motality, although there has been gradual improvement in these areas. What is going on here? It is not all because we are subsidizing the rest of the world in pharmaceuticals, which is true, or that we have excessive malpractice awards (not discussed above). Pretty clearly uninsured are not getting preventive care, and to say that their problems are due to bad personal habits or too much “diversity” in the US population is pathetic escapism. Maybe it is politically impossible because of the power of the insurance companies, but the obvious fact is that the US is the only high income country in the world without some kind of guaranteed national health insurance. Pretty clearly such a system can be put in place without bankrupting medical practitioners or seriously damaging the health care available to most people (I agree that US health care for the quite well off or better, or those with very obscure ailments is the world’s best).
Can anyone post a link to empirical work on the impact of “tighter social networks of friends” on Europeans’ health?
IIRC, the difference in life expectancy between the US and the top countries is something like 16 months. So we’re not talking a serious gap. Factor out black ghettos, and American life expectancy is just as good as, if not better than, anywhere else.
Infant mortality is also not a particularly strong measure. Different countries report infant mortality differently: premie deaths are usually reported as infant mortality in the US (and correctly so, they are infants). In other countries, premie deaths are not reported as infant mortalities, or are underreported as such.
Interesting reading: CBO Report on US Infant Mortality Rate
- Josh
Barkley, unfortunately to claim that we spend more money than everyone else doesn’t mean that we should have the best health care. Its all about proper spending. It’s like saying well i spent 200,000+ on a Ferrari, why didn’t I come in first in a race across the african savanna. Its because you need a range rover to do that.
In America, because of our cultural and lifestyle choices we find ourselves treating diseases once we have them. This not only is futile in the long run to societal health, its pretty darned expensive. Treating preventively and not having to treat because we all eat right and exercise well, as well as drinking in moderation, not smoking, and understanding that when our time has come it has come and that a ventilator will not make you better when you are 85 and that all it will do is prolong your life a few weeks, months, years.
Unfortunately HMO’s rather not spend money for something that isn’t wrong yet. Its the good ol saying “if it ain’t broke don’t fix it” unfortunately with managed health care, they are odds makers, and they rather not pay money out for someone to receive preventative health care when there is a chance they won’t need it. Also, culture is culture, and that just doesn’t change easily. Example. the HIV/AIDS epidemic. Everyone knows AIDS kills and that you can get AIDS via unprotected sex. Still some people won’t pay the 50 cents to buy a condom, or hell get to a clinic and get boxes upon boxes for free.
It is unfortunate to hear so many lack health insurance. We really need to improve our health care system. Health insurance is a major aspect to many and we should help everyone get covered.
Factor out black ghettos, and American life expectancy is just as good as, if not better than, anywhere else.
The limited access to medical facilities and reliance on the service of health planner are mainly responsible for this situation.
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dentsl services. In Australia, even people at very low income levels take out private hospital insurance to avoid falling into the maw of the so-called ‘public’ health system. — Why does Gladwell assume
In America, because of our cultural and lifestyle choices we find ourselves treating diseases once we have them. This not only is futile in the long run to societal health, its pretty darned expensive.
Unfortunately HMO’s rather not spend money for something that isn’t wrong yet. Its the good ol saying “if it ain’t broke don’t fix it” unfortunately with managed health care, they are odds makers, and they rather not pay money out for someone to receive preventative health care when there is a chance they won’t need it. Also, culture is culture, and that just doesn’t change easily. Example. the HIV/AIDS epidemic. Everyone knows AIDS kills and that you can get AIDS via unprotected sex. Still some people won’t pay the 50 cents to buy a condom, or hell get to a clinic and get boxes upon boxes for free.
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