American Healthcare: How Much Does It Lower The Ceiling in Order to Raise the Floor?

All the ballyhoo about Michael Moore's indictment of the American health care system reminds me of one thing about free, universal, directly-government-funded health care: it sucks.
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I have not yet seen Sicko, Michael Moore's documentary indictment of the American health care system, and therefore cannot comment on it. But all the ballyhoo about its Cannes premiere and Cuban connections does remind me of one thing about free, universal, directly-government-funded health care: it sucks.

So, of course, does not having any health insurance, and I have no intention of defending the disgrace that is the American status quo. Still, in the interest of guarding against the pitfalls of basing tectonic shifts in national policy on a general consensus that the grass has got to be greener, you may want to take a look at my side of the fence.

I live in Ireland, where free health care is not available to everyone, but it is a lot more so than it is in the U.S. I am due to have my second child in early August. The good news is, all my pre-natal care here will be free. The bad news is, all my pre-natal care here will fit under the nail-tip of my pinkie finger. To wit: In February, I went to a General Practitioner, as is required of anyone who wants to see a specialist for any condition, even if the condition already has you throwing up and spilling out of your pants. The GP -- a very nice, clearly competent woman -- applied on my behalf for an appointment with a public obstetrician. (There are private ones, but they are like tables at the Rainbow Room on New Year's Eve: very few and fully booked way in advance.) Some days later, I received a letter in the mail informing me that my first appointment would be at 8:15 a.m. on May 1 -- that is, more than two months later. I went. After several hours' wait in a standing-room-only reception area, the doctor -- another nice, clearly competent woman whom I had never met, did not select, and may never see again -- looked at a scan, spoke to me for about 10 minutes, and told me to come back in six weeks. Fortunately, in the event that I have a question or a problem in the meantime, I can always send an one of my college roommates, who is an ob-gyn in the States.

Now, I am not fishing for sympathy here, and not just because I'm having the baby in Spain, anyway (long story). The truth is, I probably don't need any more or any better pre-natal care than I am getting here. In most cases, frequent, high-tech gestational monitoring, practitioner-patient bonding and all the rest that the American elite has come to expect, is probably more for the mother's peace of mind than for her -- or her child's - essential health. So if the Irish system were a general success story, the not-quite-Rolls-Royce maternity model might well be taken to reflect the most prudent use of finite resources, better sent flowing toward serious illnesses. But the story here is not one of success. The story, which you see in newspapers and hear from people all the time, is one that gets scarier with serious illnesses: very long waiting lists for procedures that can be life-or-death, very little choice, fairly common horror stories of people languishing on cots in hospital corridors; specialist shortages; diagnoses botched by the batch; the whole lot. National elections were held here recently, and the success of Teflon incumbent Bertie Ahern was decidedly in spite, and not because, of the state of the health service.

And remember, Ireland is not a remotely poor country. Nor is it unique in its public health-care laments. In Britain, when the papers aren't blasting Tony Blair for leading the country into Iraq, they're wondering how his government can have tripled the investment in the National Health Service and yet gained so little in the way of national health. In a country of happy health-care consumers, there would not be a TV program like the BBC's recent Can Gerry Robinson Save The NHS?, in which a famous entrepreneur tried to apply basic business-efficiency practices to reducing the ridiculous waiting time at one British hospital.

I know, I know, if I want health-care horror stories, I should really look back home to the good old U.S.A. Statistically, as a nation, our overall health-care system ranks behind that of Ireland, and England, and France and Germany and Canada and about 30 other countries to whom we like to view ourselves as superior. But in one politically important sense, those statistics are misleading. For the U.S. ranks much lower than it should not because the level of care that Americans get is so terrible. It's because there are so many Americans who get no care at all.

Clearly, that is a sin. But if we are serious about repenting this time, it is not enough for the currently uninsured to be lifted up. It is also necessary for the currently insured to want in. Therefore, it is not only morally acceptable, but pragmatically essential, to ask of any prospective program introduced by any prospective president: how much does it lower the ceiling in order to raise the floor?

Some comedown, of course, ought not only to be expected, but welcomed. Those Americans who are fortunate enough to enjoy decent coverage should be glad to trade some convenience and some degree of choice for the knowledge that millions of their fellow Americans are finally getting the care they deserve. On the other hand, apart from those few who are truly prepared for their hearts to bleed to death, it is hard to imagine anyone declaring, "I need to wait six months for that clearly indicated cancer scan -- but at least we're all in this together!" Or "my G.P. agrees that my daughter definitely has something wrong with her and needs to see a pediatrician -- who, alas, isn't available for eight weeks. At least she'll learn to wait her turn!"

Of course, poor people have always had to deal with such brutalities. But the point should be to mitigate their suffering, not to make everyone share in it.

Please understand, I am absolutely not suggesting that the automatic effect of national health care would be to spread health-care-related suffering even further among Americans. I am suggesting that, depending on the details, its doing so is a possibility -- and when I hear so-called "European-style" systems romanticized by Americans as if those systems don't come in all shapes, sizes and degrees of dysfunction, I fear that it could be a probability.

I am no expert on socialized health systems that work versus those that don't, but in a very few years of living abroad, I happen to have run across both. There are probably all kinds of reasons why the example I am about to give cannot apply to the United States. Nonetheless - and at the risk of implying that all health-care issues lead to my abdomen -- let me tell you about the other socialized-medicine setting in which I have been pregnant: Spain.

In Spain, I did not consider using the public health system because I did not have the right to. So, although the Spanish did seem generally much more satisfied with their public set-up than do the Irish -- and health care there is certainly nothing like the political powder keg that it is here -- I can't say I have experienced it first-hand. But the point about Spain is, what appears to be a rather good public system exists in parallel with what I know to be an excellent private system. Again, I can't pretend to know exactly why this is. But, as someone who has always both desired and feared the advent of a public system in America, I am enormously cheered that it is.

In Spain, one can buy private health insurance, as some 15 percent of the people do -- and buy it, incidentally, for a small fraction of the cost of its American equivalent. This option is also available to the French, to the Germans, and undoubtedly to participants in many other systems that Americans either idealize or vilify as "socialist." (Private insurance is also available to the British and the Irish, who complain incessantly anyway, so I'm not positing it as the key to paradise; just as a feature of some successful systems.) In Spain, insurance sends you to a network of doctors and hospitals that is independent of the public system, so if you pay, you are rarely skipping over a less monied person in line; you're usually freeing up space in the public sector. (I qualify my terms because depending upon what's wrong with you, you may end up in one of the public hospitals -- which, it is nice to report, are considered better equipped for some procedures than the private ones. But the general effect of the private system seems to be one of lessening the strain on the public one.) Moreover, people without private insurance can choose to pay out of pocket and go to a doctor for much less than it would cost them to do so in the U.S . None of this infringes upon their right to use -- nor excuses them from their obligation to contribute to -- the public system.

I know I must sound like an awful snob; as if I view the biggest question about universal health care to be the question of allowing the well-off to opt out and leave bare-bones public care to the no-choice masses. Then again, in a way, that is the biggest question. Reprehensible as the U.S. system is, it remains true that there are many more Americans who are insured than who are not. Thus, if, in approaching health-care reform, we don't think about the have's as well as the have not's, we may feel very noble -- but all we will end up doing is condemning the have-not's to more of the same. Moreover, in real life, health care is one of those areas where the two groups are not so distinct. Between the totally uninsured and the fabulously well-insured, there are, of course, the precariously insured, the woefully underinsured, the supposedly-insured-but-ultimately-screwed-by-the-insurance-company, and about a hundred other permutations. Likewise, in a sanely-socialized-medicine future, the group that uses the public health system would overlap significantly with the group that doesn't. Possible opters-out would not only include the rich and spoiled who want to reserve their right to waltz in and order up an MRI for the fun of it -- but also far less wealthy people who would mostly avail themselves of the public system, yet would be willing to pay to reserve the right to an alternative should they ever want one. And why in this -- and only this -- realm should the government tell people they have no right to want one?

I still can't believe the first appointment with my Spanish doctor, whom I met within a week of calling his office. At that appointment, we had a leisurely chat about all that childbirth stuff: whether I wanted pain relief, whom I wanted in the delivery room with me, you name it. The doctor gave me his pager number and told me to call him any time with any question. When I went into labor, he met my husband and me at the (beautiful) hospital, and stayed with us almost continually through the several hours until our (even more beautiful) child was born. He popped in to see me the next day. Soon he recommended a pediatrician -- who, yes, makes house calls.

Was this unbelievably attentive, luxurious health care, clearly tailored to those who can pay? Absolutely. Was it offered in a country that systematically sacrifices the basic well-being of those who cannot pay? Absolutely not.

Right here on earth, there are places where private choice and public care are not an either-or.

Wouldn't it be great if the U.S. were one of them?

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