Medicine and the Market: Equity v. Choice

7. The Future of the Market in Health Care: Undercurrents from the Past, Riptides from the Future

C H A P T E R S E V E N The Future of the Market in Health Care Undercurrents from the Past, Riptides from the Future Most people want decent health care to be readily available at an affordable price. When they hurt, they want a doctor to look at them, a nurse to care for them, drugs they can afford, and a hospital to take them in if they need medically necessary surgery or complex care. Increasingly in developed countries, they also want their personal preferences, variable though they may be, respected . When all is lost, the battle all but over, they want long-term or nursing home care, and without beggaring them or their family. As the diversity of the world’s health care systems shows, there are many ways of attempting to satisfy these desires, and many ways as well of judging just what counts toward their achievement. The terms decent health care, readily available, affordable price, and medically necessary are all contestable. At least one reason why health care can never be a technically perfect market is that of its murkiness to most people: complex, usually in flux, short of meaningful information, full of medical uncertainty, and suffused with political and social arguments. What is clear for most people is often that their health system is not clear. That is one reason why health care reform is so difficult, full of too many variables to be put together in some perspicuously coherent way, able to go in many possible directions, few of them fully predictable in their outcomes. It is not for nothing that wide-scale health care reform has been so difficult in the United States, with its tripartite constitutional government, its longstanding debates about the relationship between the market and government, its plethora of interest and advocacy groups, and its deeply ingrained individu- 248 M E D I C I N E A N D T H E M A R K E T alism. Canada and the European countries have had an easier time of it, by virtue of their welfare state traditions and with the force of parliamentary governments that can act decisively to bring about social change. But the possibility of noticing these national traits—sometimes easier from the outside than from the inside—makes another point clear: the force of history and tradition in the shaping of health care systems. The European health care systems, with their strong solidarity commitments , are traceable back to the nineteenth century and have been reconfirmed over the decades despite periodic financial stress. The failure, by contrast, of the United States to achieve universal care despite many attempts to do so, the intensity of its market proponents, and (perhaps perversely) the fact that Americans seem more to take pride in the quality of their high-technology medicine than to feel shame at the forty-five million uninsured, all bespeak a tradition as deep and enduring as that witnessed in Europe. If it is comparatively easy to characterize the American and European systems with some broad strokes, that is less easy to do with the developing countries of the world. Too often their health care systems have not grown out of deep cultural roots but were superimposed either by colonial powers or, in their aftermath, by authoritarian and often repressive governments, or by well-meaning, but not necessarily helpful, international agencies such as the World Bank. MAKING JUDGMENTS: GOOD AND BAD HEALTH CARE SYSTEMS For our part, attempting to look into that uncertain gray zone that is the future, two conclusions seem supportable: on the best and worst kind of health care systems, and on the threatened future of the best. The Best and Worst Kinds of Health Care Systems We do not hesitate to say that the best health care systems are found in Canada , Western Europe, and a few other countries in the same tradition. They are systems run along Bismarckian or Beveridge lines. Their strength lies in their universality, with coverage for all; in their quality for the money spent, producing high levels of health for significantly less per capita than the United States; and in health outcomes that are the best in the world. All of them have their faults—waiting lines in some places (notably Canada and the United Kingdom), T H E F U T U R E O F T H E M A R...