Obama Diagnosis, Won’t Prescribe

 

 

President Barack Obama starts from a pretty compelling argument: In the rich industrialized nations, the rich and the poor should be able to afford to get sick. They surely will. Disease does not means test.

 

But after that, the health care argument gets away from the president. In fact, he hasn’t made his own argument.

 

This week Obama has argued passionately for reform, as he did in his prime-time news conference Wednesday night. But we have yet to hear his personal view of what an American health care system should look like. One suspects that it is the solution that dare not speak its name: a single-payer system, a government system. Yes, a–dread word–socialist system.

 

The empirical evidence from Australia to Ireland, Canada to Norway is that this is the way to go. Every country with a national health service pays less for health care per capita than does the United States. And not one has contemplated canceling their system.

 

Yet it is a concept that may be too radical for Americans. It also may be too late in the evolution of the health care industry to nationalize the system.

 

Canada had the most difficulty nationalizing health care of any major country, and is still groaning. Canada did not plunge in; it waded into a state system, and put it all together in an age of sophisticated medicine. But it is not without problems: for example, Canada failed to comprehend that if everyone who needs to see a doctor sees one, more doctors will be needed. There is a chronic shortage of doctors in Canada.

 

Britain, by contrast, nationalized its health system after World War II, when medicine was simpler and the process was easier. It was also a time of post-war idealism. Today, like most state systems, it functions well enough but not perfectly. Well enough for Britons living abroad, including in the United States, to fly home for major surgery.

 

The world of single-payer does allow for private insurance, and it is flourishing in countries like Ireland. This provides a second tier for those who feel the basic system is too rudimentary. Under this arrangement if you want a procedure for a non-life-threatening ailment, which would require a long wait in the state system, you visit the specialist–called a consultant in the British Isles–and the insurance company picks up the tab. The idea is that the well-off get what they want, and the rest get what they want.

 

Obama’s problem is that he can diagnose the problem but has failed to prescribe a solution that he appears to believe in. He is waiting for Congress to produce something that he can sign onto, called reform, and that will not expand the budget. Where European and some Pacific countries have allowed private systems to piggyback on state systems, Congress is struggling with the reverse and the president is going along. Congress is planning to have the state piggyback on the employer-paid system.

 

The idea that employers should carry the health care burden probably goes back to the 19^th century when railroads, coal mines and ships found it best to employ a doctor to keep workers on the job. Today, it is an incongrous burden on American firms in an age of globalization.

 

The three principal schemes for a new day in health care seek to preserve private insurance as primary, mandate portability, demand that commercial insurers do not reject pre-existing conditions, and provide some kind of safety net from the government. And, yes, the whole new edifice will be revenue-neutral.

 

At his press conference, Obama was ebullient, funny at times–the very picture of a man about to get what he wants. By contrast, in the halls of Congress, the lawmakers who are supposed to deliver this package are despondent. They do not know what the president will accept and are not persuaded that huge federal spending will not result. There is real political fear on Capitol Hill. Wednesday night did not allay it.