Health System

The January 26th issue of The New Yorker published a provocative essay on the US health care system by Atul Gawande. He begins by noting: “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.” Those currently abound in our own country.

He argues that it is essential to respond to the US health care crisis by building on the current system and attempts to support this view with examples (selectively) from other countries that have a universal health care system.

For example he reports that in Great Britain: “The N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War….As a matter of wartime necessity, the government began a national Emergency Medical Service to supplement the local services. By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone.”

And in France: “With an almost impossible range of crises on its hands—food shortages, destroyed power plants, a quarter of the population living as refugees—the de Gaulle government had neither the time nor the capacity create an entirely new health-care system. So it built on what it had, expanding the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen sixties. And the remainder of uninsured residents were finally included in 2000.”

Gawande claims that in each case the response to the crisis that existed in these countries gave rise to a health care system based upon the existing one, a process he calls “path dependence” following social scientists who have used that term to describe similarly designed system-wide social changes. The new system was not created de novo or based on a totally new design that replaced the existing system, but rather each countries “own history, however, imperfect, unusual, and untidy.”

In the United States it is estimated that the cost of health care is twice as much as other “developed” nations that have a universal health care system. The US also ranks well below these countries on various measures that assess the overall health of its citizens. More than 40 million American are said to have no health insurance, including a sizable number who are denied insurance by for-profit private insurance providers.

These conditions are crises enough to mandate change. But unlike Great Britain, we do not face a wartime emergency or like France, a post-war breakdown of society. While we face major economic problems, we do have adequate time to consider a fundamental change in the US health care system, one that would take the best of our current system and combine it with features that make it universal and more cost effective. We do not have to ignore what is currently in place, but we do not have to retain all of it either.

On my view that would involve a universal health care system based on Medicare, our current hospital and physician services, research facilities and pharmacies. It would also eliminate for-profit insurance providers that are no longer necessary under this type of universal health care program. In short, such a program would build upon our current system while, at the same time, centralizing its administration, expanding its coverage, and reducing its costs.

While this is far from the major topic of Marks in the Margin, it is one that interests me enormously. I can’t help but think it is one that most everyone is confronted with today and the fact that it is the subject of a thoughtful analysis in The New Yorker led me to write a few words about it. Some additional passages from Gawande’s essay are posted below.


Today, Securite Sociale provides payroll-tax financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds. The French health-care system has among the highest public-satisfaction levels of any major Western country, and compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians and lower costs.

…at some alchemical point, they [the stories] combine with opportunity and leadership to produce change.

On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And on the right, the free marketers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no.

…other countries came to universalize health care under entirely different circumstances.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens.

Employers who wanted to compete for workers [during World War II] could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one’s place of employment…that we’ve struggled with for six decades.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge allowed our choices to be constrained by history and by vested interests.

So accepting the path-dependence of our health-care system—recognizing that we had better build on what we’ve got—doesn’t mean that we have to curtail our ambitions.

It should leave no one uncovered…It should no longer be an economic catastrophe for employers. And it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for make care better, safer, and less costly.