No country for sick men

I reminded Davies that Canada does an admirable job of providing free and prompt care to anybody with an acute medical condition,but for non-emergency cases,the system often provides nothing but a long wait. “We keep people waiting,” Davies said,“to limit costs. Canadians don’t mind waiting for elective care all that much,so long as the rich Canadian and the poor Canadian have to wait about the same amount of time.”

Thus,Davies had set forth the national ethic of healthcare in his country: medicine is not a commodity to be sold to the highest bidder,but a right that must be distributed equitably to one and all. In short,the Canadians have a health-care system that neatly fits the Canadian character: ferociously egalitarian,but thrifty.

I found that same pattern—a health-care system that reflects a nation’s basic cultural values—everywhere I went for a PBS documentary and a book on how wealthy countries provide healthcare. “The fundamental truth about healthcare in every country,” notes Princeton professor Uwe Reinhardt,one of the world’s pre-eminent health-care economists,“is that national values,national character,determine how each system works”.

But the primary issue for any health-care system is,as President Obama made clear last week,a moral question: should a rich society provide healthcare to everyone who needs it? If a nation answers yes,it will build a health-care system like the ones in Britain,Germany,Canada,France,and Japan,where everybody is covered. If a nation doesn’t decide to provide universal coverage,then you’re likely to end up with a system where some people get the finest medical care on earth,and tens of thousands are left to die for lack of care. Like the USA.

Cultural influences govern much of the nitty-gritty of daily medical practice. In the Confucian nations of East Asia,doctors were traditionally expected to treat people for free; they earned a living by selling medicine. To this day,doctors in Japan and China do both the prescribing and the selling of medicine. In Britain,Spain,and Italy,the basic rule of medicine is that people never get a doctor’s bill; healthcare is funded through general taxation. In France,patients are expected to make a cash payment for any encounter with the health-care system,even though the insurance plan will reimburse most of that within a week or so. The French have decided that people should be reminded that healthcare costs money—even if it’s the insurance company’s money.

The most important influence of national culture can be seen in the most basic question: who is covered? The USA has never made a commitment to provide medical care to everyone who needs it. According to government and private studies,about 22,000 Americans die each year of treatable diseases because they lack insurance and can’t afford a doctor. All the other rich countries cover everybody. A French physician,Dr.Valerie Newman,explained it: “You Americans say that everybody is equal,” she said. “But this is not so. Some are beautiful,some aren’t. Some are brilliant,some aren’t. But when we get sick—then,yes: everybody is equal. We should all have the same access to care when it comes to life and death.”

That principle seems so obvious to people in Europe,Canada,and the East Asian democracies that health officials asked me to explain why it isn’t obvious to Americans. “healthcare for everybody,paid for by everybody,” a deputy health minister in Sweden told me. “You Americans are so clever. Why haven’t you figured that out?”

Nearly all European countries (except Russia) have signed on to the European Union’s Charter of Fundamental Rights,which is enforceable by the courts. “Everyone has the right of access to preventive healthcare and the right to benefit from medical treatment,” the charter says. The new democracies that have emerged since the fall of the USSR generally include a “right to healthcare” in their constitutions. But they don’t all agree on the way to assure that right.

Britain,Spain,Italy,and New Zealand,among others,have decided that providing healthcare is a job for government. Here,government owns the hospitals,employs doctors,and pays the bills. Meanwhile,Germany,France,Switzerland,the Netherlands,Japan provide universal coverage with private doctors,private hospitals,and mainly private insurance plans. Some countries—Canada,Taiwan,Australia—have private-sector doctors and hospitals,but a government payment system. The Canadian model — private providers,but public insurance to pay them—is the system US President Lyndon Johnson copied when he created Medicare in 1965. The difference is that Canada,Taiwan,and Australia provide the public insurance for everybody,US restricts it to seniors and the disabled.

Every country rations healthcare because no system can afford to pay for everything. In the other developed democracies,there’s a basic floor of coverage that everybody is entitled to; that’s why nobody dies in those nations for lack of care. But there are limits on which procedures and which medications the system will pay for.

In the US,some people have access to just about everything doctors and hospitals can provide. But others can’t even get in the door. That amounts to rationing care by wealth. This seems natural to Americans; to the rest of the developed world,it looks immoral.