Commentary Magazine


Health-Care Reform

To the Editor:

In his generally inaccurate and exaggerated article, “What Health Care Crisis?” [February], Irwin M. Stelzer takes a series of statements from an article of mine in Domestic Affairs and uses them to mislead your readers.

My question was whether any possible differences in services justify the much higher costs of medical care in America than in other countries. The answer is no. That does not mean the United States should want to spend as little as even the most expensive other country, Canada. In the article, I discuss which differences in cost are clearly unnecessary (such as the overhead associated with our risk-rating insurance system, or some of the “excess” capacity of high-tech equipment); which we might choose to reduce slightly (much higher incomes for our providers); and which we might choose to retain (some amenities and extra capacity).

Mr. Stelzer then selects from my article and misapplies what I actually said. According to Mr. Stelzer:

Joseph White . . . concedes that “Britain has restricted capacity severely and makes people wait much longer for services that Americans would consider necessary, than we would accept.”

Yes, Britain has restricted capacity severely and created long waiting lists. I would spend more money, but he gives the impression that our level of spending is necessary to eliminate waiting lists. That is absurd. The British spend less than half of what we do as a share of their economy; they could double their hospital spending and still be nowhere close to our level of costs.

Mr. Stelzer then implies that I cite the “British rule that patients over fifty-five are not eligible for kidney dialysis.” The British are much more conservative about dialysis, and should do more, but there is no such rule. Further, dialysis is the last example any American should cite as an evil of “socialized medicine.” A competent analyst would realize that treatment for end-stage renal disease in the U.S. is a federal entitlement. Dialysis in America is “socialized” because our private insurers would try to exclude any potential customer who needed it.

Next, Mr. Stelzer reports that “Australia faces both availability restrictions and ‘spiraling costs.’” I cannot tell if he is deliberately misrepresenting what I wrote or if he does not understand insurance. My sentence reads:

Australia has reached a point where restrictions in its national system, while not nearly as severe as those in Britain, are serious enough to keep private insurance and hospitals in business, despite adverse selection that creates spiraling costs.

In Australia the government guarantees care, but people can also use private insurance and hospitals. “Adverse selection” is a term that is used to describe a situation in which people who are especially likely to incur costs choose to insure. Adverse selection to a national system is impossible, since everybody is automatically a member. Australia has spiraling costs in its private, voluntary insurance system because most people figure the government system is fine, but people who need an elective operation soon are more likely to buy private coverage. Australia does not have spiraling costs in its public system, or overall. And one can argue that in essence its system guarantees basic care to everyone but enables people to pay extra, especially for more choice of physicians—as opposed to the U.S., where people pay extra for more choice, but there is no basic guarantee of care.

Mr. Stelzer cites me accurately as to “stirrings of dissatisfaction” in France, which means that there is not enough of a problem for anybody to have defined it as a serious issue (and French doctors are not shy about protesting).

On Canada he actually raises a substantive point, but couches it in tendentious blather. In a few well-publicized cases, the growth of demand for care in Canada has outstripped supply—particularly in the case of cardiac surgery. He is right that shortages caused by planning are often unintentional. But that is not because “planners” have “preferential access.” Canadian “planners” are not “Kremlin bureaucrats” who do not have to “queue,” as Mr. Stelzer claims. He has no evidence at all for that slur.

Mr. Stelzer says: “Canada’s recent response to unbearable cost increases—a reduction in the services covered—passes without mention in White’s analysis.” Wrong again. First, there has been very, very little “reduction in the services covered.” Second, the “unbearable” cost increases have been much, much lower than the increases in the United States—which Mr. Stelzer claims has no cost crisis! Third, a sentence that he quotes begins, “That does not mean in the future.” Fourth, all my comparisons are explicitly to 1991 data. Fifth, I state that Canada had more difficulty restraining costs than other systems (except compared to the U.S.!) in the 1980′s and that “suggests any set of institutions can limit health-care costs only to a certain extent.” As for Patricia Danzon’s analysis, Mr. Stelzer fails to note that Canadians go to the doctor more often than Americans, hospital stays are longer, hospitalization rates are higher—in short, by many measures, Canadians get more services.

Then there are Japan and Germany. Mr. Stelzer is right that the Japanese may be more stoically accepting of waits (though try telling that to subway riders). In fact, there is not much waiting for surgery in Japan because not much surgery is prescribed. As with the British, the Japanese spend so much less than America that comparisons of service for spending are essentially absurd; nobody could imagine that we are buying enough extra to explain the difference. And, as in the British case, I state explicitly that we would not want to spend so little.

But then Mr. Stelzer goes on to Germany, and in a paragraph that is based on my article, he reports that Germany “achieves low costs by limiting malpractice suits. . . .” Which I never said. Yes, the Germans have price controls and buy less high-tech equipment. And costs grew relative to income during the recession after reunification (adopting a whole country gets expensive). But the fact is that German costs as a proportion of GDP went down during the 1980′s! They remain much, much lower than in the U.S. And if Mr. Stelzer has evidence for his claims that the Germans save money by letting the terminally ill die, I would rather he cite it (so I could see it) than imply that he learned it from my work.

In short, Mr. Stelzer has either intentionally distorted or misunderstood every single point a reader might believe he took from my work. He takes any statement of a possible problem, however limited and however much it might be (over) balanced by good points, and exaggerates it. . . .

There are many facts, and if selected out of context they can be used to deceive people. But the basic pattern is very clear. The U.S. spends much more for health care than any other country in the world. Many Americans, unlike in other advanced industrial countries, do without treatment because they do not have insurance. American health-care costs have grown much faster than those of every other country during the past decade. That is one reason a larger proportion of individuals and businesses cannot pay for insurance. The only possible argument for superior American quality is easier access to elective surgery if you are insured. But America has lower average quality in many other ways (such as access to immunizations and prenatal care). Up until 1971, when adoption of the Canadian health system was complete, U.S. and Canadian costs and health-care statistics tracked each other closely. Since then, health-care costs as a share of the economy have grown twice as quickly in the U.S., with no positive difference in outcomes. . . .

Joseph White
The Brookings Institution
Washington, D.C.

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To the Editor:

. . . It is not my intention to debate the semantic question of whether the problems in American health care are serious enough to constitute a “crisis” (although it is worth noting that in a recent Gallup/CNN/USA Today survey more than eight in ten Americans thought they were). Rather, I wish to identify and challenge several misleading statements Irwin M. Stelzer makes about the current state of our health-care system.

Mr. Stelzer claims that the current sense of crisis is in part a reflection of “the well-documented liberal bias of the major media.” My research indicates otherwise. If Mr. Stelzer were correct, we would expect to see public dissatisfaction with the health-care system rise only after the media began to focus on the issue. In fact, the data support the opposite conclusion. In October 1987, for example, a full 72 percent of Americans felt the health-care system needed to be fundamentally changed or completely rebuilt. That same year, not one story on health-care reform or national health insurance appeared in three of the most widely read national newspapers—the Cristian Science Monitor, the New York Times, and the Wall Street Journal. It was not until 1991—the year Harris Wofford won Pennsylvania’s special Senate race after campaigning on a platform that included national health insurance—that media coverage of health reform began to take off. In short, the evidence simply does not support Mr. Stelzer’s argument. To the contrary, it indicates that the press was reacting to, not driving, public opinion and political events.

Mr. Stelzer also invokes media bias to explain what he calls “one of the great anomalies in the health-care debate,” the fact that Americans are overwhelmingly dissatisfied with the health-care system, but satisfied with their own health care. Yet this “anomaly” can be explained more easily. The public is not anxious about the care it gets, but about the adequacy and security of its health-insurance coverage. Americans worry that they or one of their family members or friends will be unprotected from a major medical expense. According to the U.S. Census, in a two-year period one out of every four Americans lose their health-insurance coverage. Roughly half of employed Americans have had their health benefits cut during the last two years, and one in five households is home to someone who has been denied coverage for health insurance because of a preexisting condition. There is no need to search for a media conspiracy to explain why these widely recognized problems foster public discontent with our health-care system.

Mr. Stelzer also dismisses widespread concern over high and rising national health expenditures, arguing that America, as “the richest nation in the world,” should be expected to spend more on health care. But he misses the point. We not only spend more on health than other nations, as one might expect, but we also spend a much higher percentage of our national income. Thus, the United States . . . spends more per person relative to its per-capita GDP than any other nation.

I agree with Mr. Stelzer that these figures do not account for differences in quality. But what does the evidence show? America has performed poorly by international standards on such basic (and admittedly crude) health indicators as infant mortality and life expectancy. Mr. Stelzer may be right to argue that our poor performance reflects the distinctive character of American society—our abundant supply of “crack babies,” “bullet-ridden drug pushers,” “members of urban gangs,” and “black women” who are disinclined to “avail themselves of prenatal care”—but he provides no evidence, save a New York Times article, to support this claim. What is known with some certainty is that the percentage of health spending that goes to administrative costs is higher in the U.S. than in other industrialized democracies. We also know that a significant percentage of care delivered in the United States is either unnecessary or inappropriate, and that there is substantial, unexplained regional variation in the use of procedures. And we know that more people are uninsured in America than in any other OECD country. Mr. Stelzer chooses to ignore all these facts.

And what of Mr. Stelzer’s claim that societal expectations are to blame for our high health spending? It is flattering to think that Americans are more demanding than the citizens of other countries. But is this true? Americans contact their physicians less frequently than the citizens of either Canada, Germany, or Japan, and they spend fewer days in the hospital. While Americans may demand more technologically intensive care than citizens of other nations, it would be a mistake to assume, as Mr. Stelzer does, that this is a “basic American value.” It is doctors, not patients, who make the lion’s share of treatment decisions, especially the most costly. And physicians’ styles of medical practice are shaped at least as much by the structure of our health-care system, with its open-ended, third-party reimbursements, as they are by the demands of patients. To be sure, Americans would not accept the explicit rationing that takes place in Britain. But Britain spends about one-third of what the U.S. spends on a percapita basis. . . .

Mr. Stelzer is to be commended for taking a hard-headed look at the arguments made by those who wish to reform our health-care system fundamentally. But the inadequacy of his response is clear testimony to the severity of the problem.

Jacob S. Hacker
Harvard School of Public Health
Cambridge, Massachusetts

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To the Editor:

In his article, Irwin M. Stelzer states: “Lost in all this [debate] has been the large question of whether a massive transformation of our health-care system is necessary.” Mr. Stelzer bases this opinion, at least in part, on the belief that most of the 37 million people who lack health-insurance coverage at a point in time will remain uninsured for a short time, and cites research conducted by Katherine Swartz and myself on the length of uninsured spells. He then concludes that “the chronically uninsured group in our society numbers closer to 5.5 million than 37 million people.”

Unfortunately, these conclusions about the uninsured are based on a misinterpretation of our research.

In fact, the number of chronically uninsured is much larger. I have recently completed more research on this topic which shows that 54 percent of the uninsured at any point in time will remain uninsured for more than two years and 75 percent will be uninsured for more than a year. This implies that of the 37 million uninsured at any one time, between 20 and 28 million persons are “chronically uninsured,” a number much larger than the 5.5 million Mr. Stelzer cites.

The confusion here relates to the difference between stocks and flows. At any point in time, a simple head count of those who are without health insurance constitutes the “stock” of uninsured (e.g., the 37-39 million uninsured at a point in time). However, each month there is a “flow” of people into and out of the uninsured category. It is well known that for any duration variable such as the duration of “uninsurance,” the stock will contain many more people with long spells than will the flow of people into and out of uninsurance. But Mr. Stelzer cites research about the flow of new uninsured spells and applies these percentages to the stock of uninsured at a point in time.

Mr. Stelzer also minimizes the uninsured problem by claiming that most of the rest of the uninsured are uninsured by choice, i.e., that they are either rich or young. But this conclusion is not supported by data. A large portion of the uninsured (63 percent) will remain uninsured for more than one year and are not between the ages of eighteen and twenty-four. Forty-three percent of the uninsured at a point in time will remain uninsured for more than one year and have incomes below 150 percent of the poverty line.

A careful examination of the data on the uninsured suggests that the problem cannot be minimized. Thus, any comprehensive health-care reform proposal must deal with the large segment of our population that cannot obtain health insurance.

Timothy D. McBride
University of Missouri-St. Louis
St. Louis, Missouri

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To the Editor:

. . . Ever since I received my first M.A., I have been teaching English part-time at two to three colleges and community colleges while receiving a second M.A. and applying incessantly for full-time positions. . . . I have had two M.A.’s for a year now, and the job prospects continue to look bleak. I work hard, I am highly respected by colleagues and students, and, though working more than a full-time load, including summers, I barely make ends meet. Thus, I cut corners where I can, one of these corners for the past five years being health insurance.

Close to half the community-college English courses in California are taught by part-timers; the percentage is not much lower in other disciplines or in other parts of the country. Of the twenty or so pepole who got M.A.’s in my English-teaching program last year, none has a full-time job and most probably won’t get jobs for years.

I present all this simply to dispel Irwin M. Stelzer’s notion that most of us without insurance are students awaiting jobs that are right around the corner, or folks temporarily between jobs. I represent only one field among, I imagine, a multitude that teems with overworked part-timers who are not receiving health benefits. . . .

The American health-care system is great, but that does not mean it cannot be better.

Seth Mendelowitz
Oakland, California

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To the Editor:

. . . However Irwin M. Stelzer analyzes the situation, there are facts of clinical life “on the ground” that I, a psychiatrist in private practice in Massachusetts, have to live with on a daily basis.

The past two years have seen the proliferation of managed-care companies in mental health whose purposes are to contain the cost and scope of services by controlling the delivery of care. This proliferation is being driven by the perception of large employers and insurance companies that mental-health costs have run out of control and need to be contained. Even if Mr. Stelzer’s statistics disprove the existence of a crisis, employers think there is one, and are acting accordingly.

Every health-care consultant I have spoken to asserts that these trends in mental health are the leading edge for all medicine. I have heard of managed-care companies that have been formed for oncology and for obstetrics/gynecology. Can cardiology be far behind? . . .

Mega-medicine is coming. Its advent is being driven by economic exigencies perceived by those who are paying the costs (employers, primarily), with the insurance companies, of course, always ready to maximize their profits. The resulting pressures on physicians to join large organizations are creating a system of care which is becoming increasingly bureaucratically entangled. More and more, every medical decision is carried out with one eye on the financial auditor and the other eye on the quality-assurance reviewer. . . .

The trends toward the bureaucratization of medical care are being driven by economics and the marketplace. The Clinton plan has little or nothing to do with this. It is happening anyway. However, the Clinton plan is compatible with it (of course, adding another level of bureaucracy).

Perhaps Mr. Stelzer might argue that these developments do not constitute a crisis, but merely changes, and are a good example of how a free market can solve problems. I would argue, however, that the way everybody receives care is being driven by profit-oriented marketplace forces, and that consumers (patients) might not, in the end, like the entangled product that they get. Certainly the heavily managed providers do not like it.

I think that there is a crisis and that somebody needs to think about whether the system that is emerging from it is the system that we want.

Ronald Abramson, M.D.
Tufts University School of Medicine
Wayland, Massachusetts

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To the Editor:

Irwin M. Stelzer’s assessment of health care in America has the correct perspective on health-care spending in relation to other expenditures and the current tendency to dump societal failures and their attendant costs onto the medical system. I would add two areas which would allow significant cost savings and medically make “sense” in terms of appropriate medical management.

First, hospitals, and especially their intensive-care units, are overwhelmed by a great many elderly, debilitated people, often with severe intellectual impairment from a variety of causes, who basically should be kept at home or in a nursing home. For many of these patients, there should be no hospitalization under any circumstance. . . . The judgment here extends not just to elderly patients, but to those who have other chronic, end-stage, debilitating diseases. We have to know when to stop.

The second area of cost-savings includes cost-shifting toward the patient for utilization of the system. Most Americans believe they should have every advantage of advanced medical technology, essentially free. They push for diagnostic testing, such as MRI, CT scans, and referrals to specialists. We need higher deductibles and increased co-payments so that patients would assume more of the costs. For those who are on the lower end of the income scale, tax write-offs for medical expenditures should reduce the burden, but upfront fees would certainly make people think twice about demanding more and more testing.

Physicians, especially primary-care physicians, face an onslaught of demand for referral and objective testing, which minimizes the physician’s clinical judgment and emphasizes the risk of malpractice suits. At the other end of the spectrum, chronically ill and debilitated patients should not be completely exempt from some of the costs of utilizing the health-care system at later stages of life. Again, that would make those patients and their caretakers less inclined to push the system to its limits to preserve a life inappropriately.

Martin D. Caplan, M.D.
Richmond, Virginia

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To the Editor:

Kudos to Irwin M. Stelzer for demolishing the myth of the health-care crisis. He does an excellent job of showing both how limited the gaps in health-insurance coverage really are and the unreality of the problem of health-care costs. However, he does not go nearly far enough. First, there is no health crisis. Mr. Stelzer makes the valid point that many of America’s health problems originate outside the health-care system, but he fails to note that, even so, Americans are healthier than ever. Infant-mortality rates have been steadily decreasing for the last 30 years or more, while life expectancy, especially over the age of forty, has increased. . . .

Second, there is no health-care-quality crisis. American scientific medicine is the envy of the world. In fact, the rest of the world, which has greatly benefited from American medical and biological science, has obtained a free ride at the expense of the American taxpayer. Also, American doctors are the best-trained and -equipped medical professionals anywhere. Even the Prime Minister of Canada and the Premier of Quebec come to America for medical treatment. . . . What kind of health-care system is it where the country’s leaders have to go elsewhere for the best treatment?

Third, Mr. Stelzer is quite right that the liberal media are biased against the American health-care system, a condition that predates the Clinton presidency. . . . Most health-care experts, outside of a few physician groups, despise the American health-care system generally and doctors in particular. They almost unanimously favor some form of socialized or corporatized medicine. This can easily be seen by simply attending a few meetings of the American Public Health Association. When I taught a course on the American health-care system, I was unable to find a single supportive text to balance the countless critical ones.

Probably the best-known general work on the American health-care system which expresses these widely held views is sociologist Paul Starr’s Pulitzer prize-winning book, The Social Transformation of American Medicine. Starr, an adviser to Hillary Clinton, endorses the growing decline of physician influence in health affairs as the just comeuppance due an arrogant bunch of the greedy. Thus, by scapegoating physicians, insurance companies, and drug companies, the Clintons are only following a well-trodden path created by countless academics.

Robert Lerner
Rockville, Maryland

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To the Editor:

Expert opinion has found grave flaws in the Clinton health-care plan. Generally, critical intelligence—including that of liberals—is skeptical, even as almost everyone goes along with the generous sentiments. But we are going to have to live down the football-rally emotions as we get around to more serious reflection.

We ought to consider that, political crowd-pleasing aside, the deepest flaw in the Clinton plan has to do with the very idea of universal coverage at a fairly high level of care. Essentially that is a utopian, even totalitarian, idea that has been tried and found either disastrous—as in the Soviet Union—or bankrupting, as in contemporary France, which this year is actively phasing back its health-care program that has put the nation $20 billion in the red and is being widely abused through fraud and waste.

Universal anything . . . goes against basic Americanism, according to which each person earns his way and is self-reliant as far as is humanly possible. For those who do not make it on these terms, there are safety nets, at a generally lower level. . . . We should consider extending that kind of service (perhaps with community clinics taking the pressure off emergency rooms). . . .

There can be no universal coverage of high quality; not only because it violates the realistic market approach appropriate to free democratic people (we are urging it on the Russians!), but because there are not enough resources for it. We cannot have universal coverage and maintain the truly high-quality medicine 160 million Americans want and are now getting unless we raise taxes drastically and go bankrupt that way. . . .

Robert Greer Cohn
Stanford University
Stanford, California

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To the Editor:

Bravo to Irwin M. Stelzer for addressing the central issue that everyone, including those most intimately affected, seems to have accepted: namely, that there is a health-care “crisis.” . . .

The world looks to the United States for superior care, and Mr. Stelzer quite rightly points out that care is available to everyone who needs and wishes it. We need to find a way to convince a culturally mixed population to avail itself of already available care and to determine how to prevent many of the diseases and catastrophes that result from social and societal failures. . . . Yes, we probably have too much duplication of expensive technology, . . . but this follows in part because of antitrust actions by the government and because of local demands that inadequately reflect true needs. Nevertheless, one cannot compare proportions of national expenditures devoted to medical care: if the proportion is greater in one country, then less is spent on something else. Good health may be worth a sizable proportion of our budget.

One other point is worth mentioning. I brought it up in a speech to the American Academy of Political and Social Science in 1973; it is still valid: the emphasis on general practice, another centerpiece of the Clinton plan, is an exercise in nostalgia. The 21st century, soon to be upon us, . . . will make the corner doctor obsolete. What we will need is more specialists and . . . a triage system adapted from our wartime experiences in Vietnam, the Gulf, and elsewhere, whereby those truly in need of urgent care can be evacuated to centers equipped with the latest technical advances. Various health professions may well spring up to offer the kindly hand that the public craves and can serve as the first step in the triage system, but what we need are specialists concentrated in centers who can render instant opinions to those who are far off and give care to those patients who have been brought to the centers. The care of chronic diseases may devolve to allied health professions under the direction of specialists.

If we wish to avoid the rationing that is becoming a feature of all the systems we are told to admire and emulate, we must attempt to understand the future. . . .

George E. Ehrlich, M.D.
University of Pennsylvania
Philadelphia, Pennsylvania

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To the Editor:

As a physician who grew up in Britain and became a doctor in the socialized health service of that country, lived three years in the United States while taking specialist training, and has practiced for the past 21 years in Canada, I have just one word for those who think of bringing a Canadian-style health-care system to the U.S.: don’t.

Americans are being grossly misled about the real state of health care in Canada today, by being shown snapshots of the Canadian system as it was ten or fifteen years ago. Things have changed dramatically since then, and the changes have been uniformly negative. Here in Ontario, the province with the largest population in Canada, almost every doctor will tell you that in the nine years since first a Left, and then a far-Left, party came into government, there has not been one single change for the better in medical care.

What we have today are increased waiting lists, delays in treatment, progressive reductions leading to shortages of staff and equipment, poorer availability of services, and contractions in what is covered under the so-called “free” universal coverage. The drive to lower costs has come with increased bureaucratic intrusion and controls and higher taxes. Choice has been lessened, as other priorities demand funds from the single, diminishing resource.

Worst of all, though, is the absence of incentives, which is inherent in a socialist system that pays the new, unproved graduate exactly the same fee as a highly competent, experienced specialist. This discourages excellence, and has already contributed to nearly tripling the number of doctors who have left the country in the past year.

The health-care system in Canada survives now only because of the dedication of an older generation of physicians who gained their training and experience under very difference conditions, and because of the generosity of you, our neighbors to the South, who still offer Canadians the excellence and the innovation that can develop only where a private alternative is allowed the freedom to flourish, and who provide the heart surgery and other treatments that are unavailable or greatly delayed here.

Americans who think that in pursuing a Canadian-style system they will be obtaining a combination of quality, efficiency, lower costs, and reasonable choices are deluding themselves. That was the Canada of fifteen years ago. What you would be getting is not Canadian-style health care, but what Canada is rapidly on its way to becoming, which is a country with Romanian-style health care. Is that what Americans really want?

Joseph Berger, M.D.
Downsview, Ontario, Canada

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To the Editor:

For at least twenty years an assortment of intellectuals, academicians, and Democratic politicians has been proclaiming a crisis in American health care. The news media have willingly conveyed this message to the public, scaring the wits out of some and convincing many that something must be horribly wrong, even if they personally thought their medical care was superb.

Irwin M. Stelzer has done an excellent job analyzing the facts behind this phony crisis, and, more importantly, explaining why it was concocted in the first place. He is right to note that the Democratic party needs the welfare state and it needs as many people dependent on the welfare state as it can possibly get. By the early 1970′s, the Democrats had nothing further to gain from the poor and the working class. In order to survive and thrive, the Democrats must create greater dependence among middle-class Americans. Health-care “reform” is one way this can be accomplished.

Mr. Stelzer is correct that the two most important components of the “crisis”—costs and the uninsured—have been exaggerated and the data manipulated to achieve the desired political effect. We do spend a great deal of money in the United States on health care, but we receive a great deal in return. When middle-class Americans find out what cost controls really mean on a day-to-day basis, they are going to be surprised.

Mr. Stelzer is also correct about the problem of the uninsured. The number of chronically or long-term uninsured is much smaller than the figure used by the news media. Something needs to be done for this group of people, but the Clinton approach is that if you have a fly in your china cabinet, kill it with a sledgehammer.

The real point of the Clinton plan is neither health nor health care. It is power. The point is to give Washington greater control over the lives of middle-class Americans. If these tactics work, look for a housing “crisis,” and a food “crisis,” and so on.

The battle over the health-care system began years ago and is certainly not over. Irwin M. Stelzer’s article deserves to be read by all those who think ours is a pretty good system. They should also keep in mind that the health-care system is like a fine old mansion. Once it is demolished, you will never see its like again.

Thomas Wilson
Montgomery, Alabama

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Irwin M. Stelzer writes:

I am content that any fair reading of my article and these letters will lead the reader to conclude: (1) the magnitude of America’s health-care problems has been overblown by those who need to generate a “crisis” in order to garner support for a radical overhaul of a system that, in its present, imperfect form, already satisfies three-quarters of the American people; (2) this country’s health-care system is superior to that of other countries; witness the fact that few Bostonians eschew Massachusetts General in order to fly to Japan or elsewhere for care, whereas the reverse traffic is well known; (3) costs can, indeed, be lowered by curtailing the availability of care (rationing) or reducing its quality (four-minute visits to doctors), but this is not what Americans want.

That leaves the question of how many people are uninsured, either temporarily or for what seems to various commentators to be a substantial period of time. Rather than wade through these statistics again, it seems that we can safely conclude that however many uninsured there are at any given time, they are not denied health care; the total includes many who quickly become insured again and many uninsured, especially the young, who can afford but do not choose to buy insurance. The genuine problems of the uninsured can be solved by subsidizing the insurance premiums of the poor and by mandating portability, both of which measures I favor. No radical socialization of the American health-care system, no huge bureaucracy, no quotas for specialists, no compulsory limitation of freedom of choice, and no system of price control are called for by any of the data presented in any studies or in any of these letters.

To Joseph White, who feels he has been misquoted, I offer my regrets for any pain I may have caused him. But a careful reading of his letter reveals more anger than reason. I said Britain has kept its costs down by restricting its capacity to render care. “Yes,” says Mr. White. He would spend more money, were he British, but is quite confident that he would not have to spend as much as we spend in America in order to eliminate waiting lists. How he knows that is not revealed. And he now concedes that the British “should do more” to assist those in need of dialysis.

Mr. White rejects my characterization of his study of Australia. I said that one can reasonably conclude from his work that “Australia faces . . . availability restrictions. . . .” He responds by quoting his original text, which states that Australia “has reached a point where restrictions in its national system . . . are serious enough . . .” to induce people to buy supplementary private insurance. And he concedes that “people who need an elective operation soon” do indeed buy private coverage. Why? Because they are satisfied with the capacity of the national system to render service? Hardly.

He also objects to my characterization of his conclusions about Canada. And then, remarkably, he agrees that, “in a few well-publicized cases,” including the important one of cardiac surgery, “the growth of demand for care in Canada has outstripped supply.” I go on to say that Canada has reduced the services covered, to which Mr. White replies that there has been “very, very little” such reduction. I suppose that the magnitude of the withdrawal of services is in the eye of the beholder, but withdrawal there has been, supporting my point that Canada’s experience suggests that President Clinton’s promise of health care “they can never take away from you” is clearly not proved by the Canadian experience, where some of the health care offered by the national system has just been “taken away.”

And, turning to cost, Mr. White makes what he must think is a cute debating point by stating that the cost increases I have characterized as “unbearable” in Canada have been lower than the increases in the United States. But that misses the point: we are a richer country. We can tolerate higher costs for medical care—and choose to do so. So increases that are unbearable in Canada are bearable in America, especially if required to avoid the “increased waiting lists, delays in treatment, . . . shortage of staff and equipment, poorer availability of services, and contraction in what is covered” described by Joseph Berger, a physician practicing in Canada. And for Jacob S. Hacker to join Mr. White in citing the facts that Canadians visit their physicians more often and stay in hospitals longer as proof of the superiority of Canadian care is odd, rather like saying that the people who visit their repairman most frequently, and leave their cars there for the longest time, have the most serviceable automobiles. Is not one plausible reason for the greater frequency of visits to physicians that those visits are shorter, as Mr. White, if asked, would surely tell Mr. Hacker is the case in Japan? And, perhaps, as a consequence of brevity, less efficacious.

Failure to understand the difference between rich and poor countries’ consumption patterns also leads Mr. Hacker astray. He says not only do we spend more on health care than do other countries, but we also spend “a much higher percentage of our national income.” Of course we do. Citizens of poor countries spend almost 100 percent of their incomes on food and shelter, and a trivial percentage on health care. Are they therefore better off, the beneficiaries of a more efficient health-care system? As a rich country, one whose citizens spend what elsewhere would be small fortunes on family trips to Disneyland, we should feel no embarrassment at devoting a higher portion of our income to health care—and a higher portion, still, of any future increments in our incomes.

I could go on. Mr. Hacker says that Americans are not more demanding of first-class health care than are citizens of other countries, and offers as support the fact that we “spend fewer days in the hospital.” Most observers think shorter stays are a good thing, a result of insistence on the technologically-intensive medicine that brings Americans so many benefits—among them, shorter hospital stays and, important in appraising costs, fewer work days lost. If Mr. Hacker’s academic studies lead him to conclude that “it is doctors, not patients,” who demand costly diagnostic and treatment techniques, he might consider Martin D. Caplan’s letter. Dr. Caplan’s experience is that patients demand “every advantage of advanced medical technology,” and his suggestion for higher co-payments is a quite sensible solution—far better than doctor-bashing or rationing of medical services by a government board.

But enough. The facts, it seems, are catching up with the scaremongers, and support for the most draconian features of the Clinton plan is drifting rapidly away. Senator Moynihan says that the regional buying groups are dead; most Democrats concede that employer mandates will not be part of the final package; the provision that would have government planners limit the number of doctors who may be trained in each specialty, and compound the insanity by setting gender and racial quotas for each specialty, remains attractive only to Mrs. Clinton and her adviser, Ira Magaziner, and should be buried forever if we heed George E. Ehrlich’s warning that more, not fewer, specialists will be needed in the future. The more the public learns about the Clinton plan, the less it likes it. So it may all come right in the end, as we sensibly address a problem, and tweak the system rather than panic at a manufactured crisis, and destroy it.

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