In 2007, fifty-seven million Americans had difficulty paying their medical bills, up fourteen million from 2003. On average, they had two thousand dollars in medical debt and had been contacted by a collection agency at least once. Because, in part, of underpayment, half of American hospitals operated at a loss in 2007. Today, large numbers of employers are limiting or dropping insurance coverage in order to stay afloat, or simply going under—even hospitals themselves.
Unfortunately, Gawande spoils an impressive history of other Western countries’ experiences with annoying hyperbole like:
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 marketeers 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.Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have. 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.
And sweeping generalizations like:
There’s a similar explanation for our employment-based health-care system. Like Switzerland, America made it through the war without damage to its domestic infrastructure. Unlike Switzerland, we sent much of our workforce abroad to fight. This led the Roosevelt Administration to impose national wage controls to prevent inflationary increases in labor costs. Employers who wanted to compete for workers could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one’s place of employment—a source of troubles (for employers and the unemployed alike) that we’ve struggled with for six decades.
The rise of employer-offered health insurance wasn’t the organic marketplace development Gawande suggests. It was a deliberate decision by the major industries after WWII designed to thwart calls for government-sponsored health care for all, lead by union leaders like UAW President Walter Reuther.
It’s hard to feel sorry for the major industries, the large employers and the hospitals when it comes to the downside of our employer-based health insurance system: they’ve fought comprehensive reform for decades, often out of a vague fear that a larger role for the government would lead us on a slippery slope towards communism and/or socialism (Ronald Reagan made a good buck back in the 1950s peddling that exact argument).
Either way, Gawande sees the likely path forward, even if he wrongfully claims that neither "left" nor "right" ever had his brilliant insight:
It won’t necessarily be clear what the final system will look like. Maybe employers will continue to slough off benefits, and that lifeboat will grow to become the entire system. Or maybe employers will decide to strengthen their benefits programs to attract employees, and American health care will emerge as a mixture of the new and the old. We could have Medicare for retirees, the V.A. for veterans, employer-organized insurance for some workers, federally organized insurance for others. The system will undoubtedly be messier than anything an idealist would devise. But the results would almost certainly be better.