Before the beginning of summer I had my annual medical. It was only a matter of seconds before my doctor, a decent old salt who’s seen it all, began complaining about his lot. Like every doctor I’ve spoken to throughout the US in the past two or three years, he didn’t know whether he could take the chaos of American health care much longer. The previous month, he had seen a very elderly patient who was already dying from malignant melanoma; but as he was examining the old man, he happened to notice that one of his toes had developed a bad fungal infection. He duly whipped off a prescription for the standard treatment – a daily dose of 250mg Lamisil tablets for 90 days – and thought nothing more of it.
In any western country with a national health service, that certainly would have been the end of the matter – but not in the US. The old man had full insurance, my doctor went on, but his insurance company refused to pay for the tablets until a lab had confirmed that he really was suffering from a toenail fungus. “Now any medical student on their first day – no, you – could diagnose a simple thing like that,” he told me. It meant nothing that my doctor had more than four decades of experience: the dying patient had to shuffle back into his surgery to have a swab taken to prove that the doctor’s diagnosis was correct. This minor incident, my doctor said, was the kind of thing that was happening dozens of times a day in his practice alone.
To me, that casual little anecdote was emblematic of the dire health system that so many Americans (and slavishly pro-American Brits such as Tony Blair and Gordon Brown) still delude themselves is the envy of the world. An already very ill patient had to make a hellish journey; my doctor’s valuable time was taken up going through a procedure he knew was pointless. The insurance company ended up having to pay not only for the swabbing and subsequent lab test, but for the medication, too. And the cost of that little bottle of tablets? I checked with my local CVS drugstore last weekend and established that, in America, 90 Lamisil tablets cost (I’m not making this up) a cool $1,379.99.
But Americans will never accept – shock, horror, gasp – socialised medicine, will they? Letting the government dictate which doctor they should have and what treatment they receive? Like those poor old washed-up Brits? For decades, that contrived chorus of indignation from the combined might of the medical industry itself, the pharmaceutical giants, the supine politicians who do their bidding and the pliant, unquestioning media has worked wonders in perpetuating a con trick. The result until recently has been that, aided by stupendous self-delusion and ignorance, most Americans really have been brainwashed into thinking they have the best health care system in the world.
Now, however, changes are afoot. Every Democratic president since Truman has promised health care reform and then been thwarted by that collective might; LBJ came closest in 1965 when he signed bills setting up Medicaid (for the very poor, and usually for limited periods) and Medicare (for those over 65 who have paid their social security contributions). The result in 2007 is that 47.7 million often relatively prosperous, middle-class Americans have been caught in the trap in between, unable to afford health insurance or land a job that comes with it. Families USA, a non-profit consumer health care advocacy organisation, says that the true figure is actually much higher – and that no fewer than 89.6 million Americans found themselves uninsured for at least some period during 2006-2007.
But now, like a giant that’s been tranquillised into quiescence for decades, the middle class is beginning to wake up and realise it has been duped. Opinion polls show that many believe health care, rather than the Iraq war, is the biggest problem facing the US. All the empirical evidence shows that Americans do favour “social ised medicine”, or at least some version if it.
Hillary Clinton, currently the clear front- runner to become president in 2009, unveiled her health plan last month – a relatively simple and feeble set of proposals set out in just nine pages with 11 footnotes, compared to the 1,342-page proposal with which the Clintons came into the White House in 1993. The apparent complexity of that plan played into the hands of right-wing propagandists – and was quickly destroyed by a $100m blitz of clever but wickedly disingenuous television adverts financed by the Coalition for Health Insurance Choices, a front group for the health insurance companies.
That debacle in turn led to a Republican rout in the 1994 midterm elections and sustained the fiction that Americans simply will never accept health care reform.
Hillary Clinton now proposes that those with private insurance should keep their policies as before, but that insurance for the rest must be financed by rolling back George W Bush’s tax cuts for the very wealthy.
“This is not government-run. There will be no new bureaucracies,” she says. “You can keep the doctors you know and trust [and] the insurance, if you have it. This plan expands personal choice and increases compe tition to keep costs down.” She says her scheme would cost $110bn a year, but some analysts believe that figure to be a huge underestimate.
Bang for their bucks
Predictably, leading Republican presidential contenders such as Mitt Romney jumped in to denounce the Clinton plan as “European-style socialised medicine” – even though only last year Romney himself, in the days when he was the moderate Republican governor of Massachusetts, introduced a remarkably similar scheme in that state. But Senator Clinton is perhaps the most steely and self-disciplined politician I’ve ever encountered, and says she has “learned some valuable lessons” from the failures of 1993.
I suspect that, ultimately, the most persuasive argument against the present system, for most Americans, will be that they are simply not getting bang for their bucks. Last year they spent $2.1trn, or roughly $7,000 per American, on health care – a figure expected to double by 2016, and which represents 16 per cent of the nation’s GDP. Half of this is spent on just 5 per cent of the population. The average yearly cost of a family insurance plan purchased by employers is now $12,106, plus an additional $4,479 paid by the employee; as a result of these hugely increased costs, only 59.7 per cent of American workers are covered by their employers’ health plans.
Yet what do Americans get from all this monumental expenditure? The leitmotif of Michael Moore’s latest fulminating documentary, Sicko, which has already grossed more than $25m in the US since its release in June and opens in Britain this month, is that Britons, Cubans and the French receive much better health care than Americans – a theme that is largely true, but undermined by Moore’s portrayal of those countries’ systems as positively utopian. Britain spends just $2,560 per citizen on health care, Australia $3,128 and France $3,191; yet a report this year by the Commonwealth Fund (a highly respected American charity) found that the US lags well behind these countries in the quality, access, efficiency and outcome of their wildly differing expenditures.
Put more brutally, the US ranked 22nd in infant mortality (between Taiwan and Croatia), 46th in life expectancy (between St Helena and Cyprus) and 37th in health system performance (between Costa Rica and Slovenia). In the “efficiency” ratings, the US came last. More American women are dying in childbirth today than were decades ago. The non-partisan Kaiser Family Foundation reports that 28 per cent of Americans have delayed their medical treatment, often for serious conditions, because of cost. And the Institute of Medicine calculates that 18,000 Americans die unnecessarily every year because they have no medical insurance.
Exactly when Americans will finally abandon their Alice-in-Wonderland, ostrich-like refusal to face the realities of their health care mess is anyone’s guess. The proposals of all the leading Democrats, including Hillary Clinton, are lukewarm in the extreme – but they will still be ruthlessly fought by a health care industry machine that has four lobbyists operating on Capitol Hill for every one congressman. Drug prices, for example, will remain ludicrously high: US sales of just one, the anti-cholesterol medication Lipitor, raked in a tidy $12.9bn for Pfizer last year. It is probably too late for that poor old fellow patient of mine, but the patent on Lamisil finally expired last June and 90 generic tablets can now be had for a bargain, er, $362.
Nonetheless, I believe that positively seismic rumblings have begun deep inside the American soul. The right has long convinced the masses that big government is bad and doesn’t work. This has always been a very selective argument: nobody has tried to argue, for example, that taxpayers should not pay for universal free education, or that schooling across the country is really “socialised education”.
But the collapse of American health care provision – and shocks such as the hopelessly inadequate response to a natural disaster like Hurricane Katrina – have shown many Americans that strong government is sometimes not only desirable, but downright necessary if they are to enjoy the life, liberty and pursuit of happiness that the US Declaration of Independence bestowed on them as inalienable rights. Nor can they continue to avoid a central and highly relevant question: why is it that America, the world’s richest nation, provides such shamefully lousy health care for its people?
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