• Print

Who Pays the Doctor?

In response to:

Health: The Right Diagnosis and the Wrong Treatment from the April 23, 2015 issue

To the Editors:

Several red herrings mar an otherwise thoughtful review by Marcia Angell of Steven Brill’s America’s Bitter Pill [NYR, April 23]. Angell is so enchanted by a single-payer health care system that she gets her facts wrong. Single-payer systems are not, as she claims, “the sort of system every other advanced country has.” France, Germany, Switzerland, and the Netherlands, to name a few, do not have single-payer systems. France and Germany have a predominantly public system of insurance, but with multiple payers, which include private insurers. Switzerland and the Netherlands have fully privatized the health insurance function, which is carried out by multiple payers subject to government regulations. The countries mentioned have universal coverage, because they require all residents to purchase health insurance. Such a mandate is not a health insurer ploy, as Angell erroneously suggests it is under Obamacare. Mandates serve to pool good and bad risks, mitigating the potential for adverse selection. Single- and multiple-payer systems alike require that virtually everyone pay into the health care system, either through taxes or premiums.

Obamacare represents a pragmatic, albeit messy solution to the hitherto intractable problem of substantially reducing the numbers of un- and underinsured. Rather than attempting (and likely failing) to revolutionize our health care system, Obamacare reforms from within. Its success can be measured in terms of fewer un- and underinsured, and implementation of policies that address costs. The latter is not being done using blunt instruments favored by Angell, like price controls or explicit rationing of care. Instead, Obamacare adopts approaches consistent with the existing health care framework, such as integration of accountable care organizations in Medicare, steps toward value-based payments, and a massive boost in federal funding of studies of the comparative effectiveness of drugs, devices, and medical procedures.

Contrary to Angell’s claim, Obamacare can and does work, precisely because it has buy-in from key stakeholders that make up the American health care quilt. This includes health care providers, not-for-profit and for-profit health insurers, and the biopharmaceutical industry.

Joshua P. Cohen
Research Associate Professor
Tufts University School of Medicine
Boston, Massachusetts

Marcia Angell replies:

The difference between the US and all the other countries is that the others, regardless of the source of funds (taxes, employers, out-of-pocket premiums), ensure universal care by coordinating the distribution of resources through a national or regional public agency. While some countries do have private insurers, they have little in common with private insurers in the US, because both prices and benefits are regulated and largely uniform. In addition, health care is delivered in a predominately nonprofit system, unlike in the US. In the UK, people may purchase private insurance to cover care that is also provided by the National Health Service, but they are still in the system—in the same way that children who go to private school can at any time switch to public school. And only a small minority choose to purchase private insurance.

As I pointed out in my review of Brill’s book, unless fundamentally reformed, Obamacare cannot provide universal and affordable care, because it retains the profit-driven insurance and provider industries. These are primarily responsible for our ever-increasing costs and inadequate coverage. We can already see that as costs rise, the response is to increase out-of-pocket expenses through higher deductibles and copayments and limits on third-party coverage. But that is not a permanent solution.