The Underlying Problem
With American Health Care: How We Pay For It


Leonard Zwelling

         Lately, I have had a series of discussions about health care
delivery in the United States with students and interested others. In an effort
to clarify what I think has been the purposeful dissemination of confusion by
the insurance industry, big pharma and the large hospital systems, allow me to
try to explain a few things.

         First, no, America does not have the best health care system
in the world if you believe that the most important metric of excellence in
health care is the population’s health. Yes, we have the keenest technology.
Yes, we have the priciest surgeons. Yes, if it can be invented, it will likely
be invented here, but we are way down the list in life expectancy, infant
mortality and the availability of basic health services, including cancer screening, to all of our people.

         Second, there is nothing in the ACA (ObamaCare) that is
likely to have a meaningful impact on controlling health care costs or
improving its quality. The ACA is a gimmick to try to get health insurance for
more Americans. It has worked to some extent as many previously uninsured now
have insurance (probably about 9 million, not the hoped for 34 million). Whether or not they have access to good health care is another
matter. Insurance premiums are rising as the large companies did not anticipate
the increase in their costs the ACA would generate. This has forced many to
request large jumps in premium prices from their regulatory agencies. (There was
a reason those people couldn’t get insurance before—pre-existing conditions
priced them out of the market they are now allowed in. I.e., they were already

one knows what quality looks like anyway so how will we know if it gets better?

         Third, the system is no system at all. If you are employed
and receiving health insurance through your employer you are in Germany with
good coverage and private docs. If you are over 65, you are on Medicare which
resembles Canadian care with government insurance limiting reimbursement to the
private docs. If you are in the military, the VA System or an American Indian,
you are in the UK with a totally socialized system. And, if you are uninsured,
you are in sub-Saharan Africa with emergency rooms. There is, obviously, no single
American health care system, but four, each with its own problems of cost,
quality and access.

         Fourth, this “non-system” is all largely an outgrowth of
wage and price controls during WWII giving birth to the use of “benefits” to
entice workers to industries when pay raises were not allowed. The benefits including
health insurance became “entitlements” and we all got used to someone else
paying for our health care. Then the government jumped in with both feet with Medicare
and Medicaid and we have the mess that is our “system” now. The ACA changed
none of this.

         Finally, everyone expects someone else to pay for his or her
healthcare. OK, let’s. If we create a single payer system and tax everyone in a
progressive fashion related to his or her income level and use the money to pay
for good care dictated by the medical professional societies and linked to
educational processes in all schools teaching good eating habits, exercise, no
smoking, no drugs and safe sex, we might actually be able to have the best
health care system in the world defined by having healthier people, better able
to compete in the world’s economy and more likely to be able to beat up ISIS if
need be.

is all just a suggestion. You may have a better idea, but I sure didn’t hear
any when I spent 9 months on Capitol Hill in the early days of the debate over
the ACA in 2009. If you want a health care system designed by lobbyists from K
Street, you got it. If you would like one now designed by health professionals,
we need to start over.

there’s a concept!

Leonard Zwelling