Book Review: Solving the Health Care Problem

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Reviewed by Danielle Ofri, M.D., Ph.D.
New York University School of Medicine
For the New England Journal of Medicine

Status quo is a powerful determinant of both belief and behavior. Many of the things we do and the things we believe in transpire because they are what we have always done or believed. This is why incumbents win elections, why we always choose the same flavor of yogurt, why we take the same route to work, why we prescribe the same antihypertensive medications. For most Americans, our health care system is the way it is simply because this is the way it has been. The logic of changing doctors when you change insurance, changing insurance when you change jobs, and paying out of pocket when you do not have a job makes some sort of sense because this is simply the way things are.

A visitor from Mars, or Europe perhaps, would find this status quo shocking, much the way American tourists abroad are sometimes shocked to find that they are not supposed to dispose of toilet paper in some toilets. In this regard, Pamela Behan has something of an outsider’s view of America. The title of her book, Solving the Health Care Problem, assumes that the lack of national health insurance is the biggest problem in U.S. health care, which is what you learn once you read the book. This is surely what most Europeans would call the biggest problem in U.S. health care. But I’m sure that many Americans, even thoughtful ones, might think that other issues — the cost of prescription drugs, inequitable funding for research, Food and Drug Administration oversight — are the biggest problems. Even the book’s subtitle — How Other Nations Succeeded and Why the United States Has Not — assumes that the adoption of national health insurance is the definition of success in solving the biggest health care problem. I happen to agree with Behan that national health insurance is what the United States needs, but the title of her book and her approach make assumptions that might put off some of the intellectuals and policymakers who play an influential role in the future of American health care.

The book lays out a very specific methodology to answer the question that the subtitle poses. It chooses Canada and Australia as countries that are relatively similar to the United States, and it traces the paths these societies traveled to achieve national health insurance. Then it sketches the (unsuccessful) path that the United States has traveled. Approaching the problem as if it were a case-control study, the author attempts to compare these three experiences and calculate the differences, with the goal of explicating what the United States would need to do to obtain that holy grail.

Readers from the medical community are well aware of the limitations of case–control studies involving groups of human beings — even large, well-selected groups. But to compare three societies, with incalculable historical, political, and social differences that could conceivably outweigh their similarities, in the expectation of a clear finding is a tall order indeed. Aside from speculation, however, there are not many other research options out there, so Behan offers what is probably the most careful analysis that can be performed.

The first chapter of the book frames the basic research question in three brief pages; there is a casual mention that the last chapter “describes the study’s conclusion in layman’s terms, including the changes that may be needed to solve the problems of health care access and protection from its costs in the United States.” Were this an Agatha Christie mystery or a José Saramago novel, I wouldn’t dare peek at the last chapter. But in a book that intends to provide the all-embracing research details in the intervening chapters, nonacademicians are all but invited to skip to the plot’s climax. If suspense is important to your reading enjoyment, then stop reading this review now, because I will divulge the outcome. The answer is that in order to enact national health insurance, countries need to achieve four necessary conditions: both federal and financial authority in health care (that is, the national rather than the local government manages and funds the health care system), a multiparty system, a health care legislative legacy, and strong trade unions. Countries also need one of two sufficient conditions: labor-party power and lack of veto points (that is, the ability to block legislation — easily — from within or outside the system).

The United States comes up short on almost every one of these six counts. I found the discussion of the veto points the most interesting. For the past century, almost every legislative gesture was soundly defeated by an unelected body — the American Medical Association (AMA). Behan takes pains not to paint the AMA as the devil, since plenty of senators, representatives, and presidents added their own obstructionism. But the historical discussion reveals that the most consistent pressure came from within medicine itself.

The very nature of the American political system — the winner-take-all voting system, the free-market attitude toward lobbyists, the ability of legislators to compromise bills into nothingness — makes far-reaching social change almost impossible. The necessary and sufficient conditions needed to achieve universal health insurance seem constitutionally unachievable in American society. Behan’s sad conclusion is that “many of the chief blessings of democracy” — and health care as a right is clearly included here — “will, ironically, elude those pioneers of democracy, the American people.”