Untangling health care

Neither candidate is giving it serious attention

CHAPEL HILL -- As a professor in a school of public health, what the presidential candidates have to say about health care naturally interests me. What is striking is how little they actually say about the fundamentals of the system, and the fundamental need for a health care overhaul. While improving coverage is a desirable goal, neither Barack Obama nor John McCain is really addressing the underlying forces and features shaping health care. I can identify six key aspects of our current system that neither candidate is addressing seriously.

1 - ANY HEALTH CARE SYSTEM IS DOOMED TO DISAPPOINT. Many countries have health care troubles. It seems, for example, that every time I visit the United Kingdom, the health system there (the National Health Service) is experiencing some sort of catastrophe. One part of a reasonable discussion of health care is the recognition that the system must ration care. No system can be affordable and can provide every consumer with every service that might be of some therapeutic value at no cost to him- or herself.

A reasonable discussion would start by considering what level of basic care can we guarantee to all citizens.

2 - THE UNITED STATES SPENDS AN ENORMOUS AMOUNT ON HEALTH CARE. A recent report on the countries in the Organization for Economic Cooperation and Development indicates that the United States spends 50 percent more per capita than the next-closest country, Switzerland. Scholars debate the underlying causes, and one is that our country is affluent. Nonetheless, as a percentage of gross domestic product, we spend 20 percent more than Switzerland.

A reasonable discussion would start by asking whether we're getting good value for these high expenditures.

3 - WE'RE NOT GETTING A GOOD VALUE FOR THE MONEY. By a wide range of indicators, the U.S. health care system fares relatively poorly in cross-national comparisons. In a six-country survey of patients, the Commonwealth Foundation reports that the United States ranks last in overall quality and last in four of the six categories rated.

A reasonable discussion would start by asking how we can spend so much and yet lag in so many categories.

4 - WORSE STILL, THE HEALTH CARE SYSTEM IS RIVEN WITH ERRORS. One of the six categories where the U.S. system fares especially poorly is patient safety. Our system has a miserable safety record. Unbelievably, medical errors kill 100,000 people per year. (That's right -- a one followed by five zeroes). That's more than twice the number of deaths due to auto accidents.

A reasonable discussion would start by asking how errors can be so common in a system and whether something fundamental needs to change about how health care is organized, delivered and regulated.

5 - THE GOVERNMENT ALREADY HAS AN ENORMOUS INVOLVEMENT IN HEALTH CARE. All politicians decry "socialized medicine," but our government already is a major player in the health care market. Roughly half of all health care expenditures involve public funds. This figure is less than in many Western countries (such as the United Kingdom) and comparable to others (such as Switzerland).

Whether the figure should be higher or lower is difficult to say, but a reasonable discussion can begin by asking whether those funds are expended in the public interest.

6 - THE MARKET FOR HEALTH CARE SERVICES IS BROKEN. Perhaps most fundamental is the recognition that the markets for health care services and for insurance are fundamentally broken. Economists have various conditions for a free market to allocate resources in the manner best for society. The health care market meets virtually none of them.

For example, both consumers and producers are equally well informed in a well-functioning market. In health care, information "asymmetries" abound: obviously consumers have a very difficult time assessing how much they are likely to benefit from a given procedure.

I used to teach a course on market failures, and I used examples from many sectors. After a while, I found it was just easier to use health care and health insurance to illustrate all of the failures.

A reasonable discussion begins by asking not whether the government should be in health care, but how.

Sadly, the candidates are not dealing with -- or even acknowledging -- these basic principles. The last attempt to do so was Hillary Clinton's health care reform efforts in her husband's administration. We all know how that turned out.

In the end, the implications of these six principles are expansive, and addressing the fundamental problems of health care delivery, difficult. I would be less discouraged, however, if the candidates were even addressing these issues.

(E. Michael Foster is a professor in the School of Public Health at UNC-Chapel Hill.)