A Failure of the Imagination: T.R. Reid’s “The Healing of America”
People around the world make fun of our Health Care system. They make fun of it a lot. Actually, it isn’t really a system; it’s a market, and medical care is treated like a commodity. The Affordable Care Act of 2010 (Obamacare) didn’t fix this, though it made some notable improvements. Still, the problem remains: not everybody in America has access to affordable medical care when they need it. We spend more than other countries, we get worse outcomes, and people in this country still die from treatable diseases because they cannot afford to go to the doctor.
T. R. Reid’s 2010 book, The Healing of America: A Global Quest for Better, Cheaper, Fairer Health Care details these failures and highlights solutions and alternatives from all over the globe. He looks at different health care systems in a dozen or so different countries, all of which get better outcomes than our country, achieve universal or near universal coverage, and spend less than we do. The point isn’t that there’s a better way; it’s that there are lots of better ways.
Reid divides the healthcare issue into four different categories, and the U.S. falls short of other wealthy nations in each of them. First, there is coverage. Before the passage of Obamacare, about 49 million people lacked insurance. Many more were under-insured, meaning they had insurance, but faced costs that made up a large share of their income. As of 2015, approximately 33 million people in the U.S. still lacked insurance. That number has gone down some as the penalty for not having insurance has gone up, and as more states have opted into the law’s Medicaid expansion, but estimates for how many people are going without insurance still put the number somewhere around 30 million people. That’s over 10% of the population.
Obamacare sought to increase coverage in four main ways. First, it created a penalty for not having insurance, paid on one’s taxes. This penalty started small, and has increased modestly since the law went into effect. Secondly, it funded subsidies for people to buy insurance. These subsidies are available to people and families who live at 100–400% of the poverty line. Next, it ordered insurance companies to accept more people by requiring that they cover people with pre-existing conditions, allow young people to stay on their parents’ insurance plans until the age of 26, and limited the kinds of premiums insurance companies could charge the elderly. Finally, the law expanded Medicaid. Originally, the law required states to expand Medicaid to citizens making up to 138% of the poverty line, but the Supreme Court ruled that the Federal Government could not require states to do this. So far, 32 states have opted to take the Federal money to expand Medicaid, while 18 have decided not to expand Medicaid.
Many of the states who have not opted into the expansion are experiencing a “coverage gap.” Basically, people who don’t qualify for Medicaid (and in some of states, such as Texas, the threshold is dreadfully low) but aren’t at the poverty line can’t afford insurance because they can’t get Federal subsidies. This isn’t the only reason why coverage isn’t universal yet, but it is a significant one, and an area in which the law needs reform. It simply doesn’t make sense that a person can make too little to get help buying insurance, but too much to qualify for government run insurance.
The second category Reid breaks healthcare into is quality. What kind of outcomes does our country get? For our country, the results aren’t great. In 2015, the U.S. ranked 43rd in life expectancy. We ranked 44th in infant mortality. We ranked 43rd in life expectancy at age 60 (how many more years can a person at age 60 expect to live?).
The issue of overall quality is tied directly to coverage. If cost were not an issue, the U.S. would certainly fair better in world rankings. We have some of the best hospitals in the world, some of the most innovative research, and some of the best doctors. But if you don’t have insurance, none of that matters, because you can’t access it.
Obamacare tried to address the issue of quality in two ways: firstly, it expanded coverage, so that more people had access to the system, and secondly, it put more stringent requirements on insurers designed to encourage preventative care.
The third category is cost. The U.S. achieves middling outcomes while spending more as a percentage of GDP than any country on Earth. For all of the virtues of capitalism, it has led to Americans paying more for their healthcare than all other countries. We pay more for our prescriptions, more for our routine checkups, more for our surgeries, more for our billing departments (in large part, because there are so many bills), more for the administrative costs of insurance companies, more for our root canals. Obamacare tried to address this by creating a marketplace where customers could easily compare insurance plans against one another, leading to healthier competition. Proponents of Obamacare also argued that expanding coverage and getting a healthier set of customers for insurance customers (both by getting young people into the pool and also by encouraging preventative care), overall spending on healthcare, per capita, if not in raw numbers, would decrease. In theory, they were right, though in practice, we still have yet to see, if we will ever see, a lower cost for healthcare. During the first few years of implementation, the Federal government did come in under-budget, in part because insurance companies on the marketplace charged less originally than they predicted. Now, premiums are rising, and the marketplace is clearly failing in some places. Insurance companies have left the marketplaces, and in some spots, customers have only one plan to choose from. Like coverage, cost is clearly an area in which Obamacare needs major adjustment.
The final category by which Reid judges different systems is choice. I discussed this some in the previous paragraph. Choice isn’t necessary (you could just create one plan for everybody, as the British have done), but for a market like we have in the U.S., it’s supposed to be essential, and the marketplaces were designed to address it.
Two things should be obvious: 1) Obamacare is far from perfect. It leaves millions of people uninsured, it hasn’t yet brought costs under control, and it hasn’t guaranteed that everybody gets to choose the insurance plan that is best for them. 2) Obamacare is not “socialized medicine,” and is really isn’t close to it. Republicans on Capitol Hill are decrying the Federal government’s involvement in the health sector, but Obamacare took only modest steps towards fixing its problems. This modesty is readily apparent when you look at the way much of the rest of the world has sought to deal with health. The U.S. penalizes some people for not having insurance (there are exemptions, such as if you are one of those people stuck in the coverage gap between Medicaid and subsidies), but it does not do as some other countries have decided to do and garnish your wages to sign you up for insurance. We do not throw people in jail or threaten them with large fines. Obamacare grants subsidies to certain people at certain income levels, but it does not contain a public option for most people. You can’t buy your way into Medicare or get on a government-run plan simply because you lose your job. Obamacare places certain regulations on insurance companies, but they don’t require them to pay every bill (as anyone who has had a recent hospital stay can tell you, insurance companies in the U.S. are excellent at finding ways not to pay for things). Obamacare tries to rein in insurance companies, but it still allows them to operate as businesses. It did not suddenly turn them all into nonprofits whose sole purpose is to make sure patients don’t have to pay too much at the doctor’s office. The law did not do as many countries have done and seek to control costs by simply telling insurance companies and providers that they have to charge less for the services they are offering.
Obamacare is failing in several respects, but it seems clear that few or none of those failures are due to the Federal government being too heavy-handed. The problems that plague Obamacare plagued us before the law came into effect: too many people lack insurance because the costs are too high, our health outcomes are those of a second- or third-tier nation rather than those you would expect of the richest country on Earth, and we pay way too much for what we get. The ACA did not fix these problems for good, but if you go back to 2009, before the law was enacted, you will find the same problems, only worse.
That we cannot seem to solve these issues is, frankly, a failure of our national imagination. Other wealthy countries have figured out how to provide universal coverage to their citizens. We haven’t. Other wealthy nations have figured out how to keep their citizens alive for longer, and have figured out how to do so at a reasonable price, leaving us behind.
There are trade-offs, of course. Canadian and British patients experience long wait times for non-acute medical issues. French doctors often work in offices that Americans would consider dingy. Medical professionals in many other countries do not make the kind of money doctors in the United States make (they also don’t take on the kind of student debt or face the exorbitant fees our doctors have to shell out for malpractice insurance). These problems are not, however, matters of justice in the way that our country’s lack of universal coverage is a matter of justice. There are millions of people in this country who are afraid of getting sick, because being sick means going to the doctor and having to pay the doctor. That is, quite simply, wrong.
Republicans in Congress and the President-elect have made clear that they think repealing Obamacare is what the country needs. They have pledged to replace it with something better, though what that something is, nobody can say. They have an opportunity to improve on the ACA, and to truly replace it with something that covers more people and costs less overall to our country. I fear, though, that they will waste this opportunity and replace an imperfect law with something even less perfect that contains within it a basic assumption that healthcare is a commodity to be bought, sold, and traded on a marketplace. We can do better than that. We should do better.
