In a remarkably thoughtful and lucid essay, Atul Gwande, a Boston cancer surgeon, surveys national health systems in other industrialized democracies and examines how they came into being. Outside the United States, from Britain to Australia, national systems guarantee medical coverage for all citizens. And while far from perfect, each is popular and successful in providing care. From country to country, however, the circumstances that led to universal coverage were quite different. In Britain, for example, government assumed an increasing role in managing physicians and hospitals as a result of German bombing and massive relocation of citizens to the countryside. Gwande explains that the NHS was not the result of ideology or social architecture. The National Health Service (NHS), formally established in 1948, essentially institutionalized a government-managed system already put in place by the war.
Borrowing from economics, Gwande suggests that our healthcare system, like so many other industries and institutions, is “path-dependent.” That is, choices made in the past – e.g. to subsidize private health insurance purchased by employers – strongly influence today’s alternatives. In designing a program to cover the uninsured, control costs and improve quality, “we’ll inevitably want to build on the institutions we already have,” Gwande writes. “That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship.” Beyond employer-sponsored private insurance, there is Medicare, Medicaid, the Veterans Administration as well as the Federal Employees Health Benefits Program. Each could be modified to expand coverage to new groups.
Gwande concludes by describing how his home state of Massachusetts has achieved nearly universal coverage (97.4 percent) by building on its existing system, mandating coverage and providing subsidies for low-income people. And while his patients sometimes used to forgo needed care in the past, “for the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage. And that’s a remarkable change: a glimpse of American health care without the routine cruelty.”
To read Gwande’s essay in The New Yorker, click here.
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