Washington. -- When I was 25, I lived in San Francisco and enrolled in a large "health-maintenance organization." I'm afraid the relationship ended badly.
At the time, I was experiencing bouts of fatigue -- this was before anybody had heard of "chronic fatigue syndrome." I was given a few standard tests at the central clinic, and then assigned to a rather unemotional doctor with a Germanic accent. After some questions, he pronounced his diagnosis: "Mr. Kaus, zere is nussink physically wrong viz you."
I haven't enrolled in an HMO since. I would have been happy, I decided, to spend more money, get more tests and have a chance at a more helpful result. This attitude may explain the disorientation I feel listening to Democrats prepare the political battlefield for health-care reform.
We are told, in outraged tones, that the United States spends 14 percent of its gross domestic product on health care. Unless we act quickly, that figure will rise to 20 percent by the year 2000. Meanwhile, Britain and Japan spend only 6 percent. Germany spends 8 percent.
There is a moralistic undercurrent to all this, as if spending large sums on health care was in itself a sign of national decadence. Alain C. Enthoven, a Stanford economist, boasts that his reform scheme will reverse the malignant rise in medicine's share of the economy: "It is altogether possible that a very efficient competitive system could get us back to 9 or 10 percent [of GDP]." The unstated premise seems to be that there would be something inherently wrong with spending 20 percent.
This premise remains unstated, of course, because if it were stated it would be obvious that it was wrong. One of the things people do as they get older and richer is spend more money taking care of their physical well-being.
As with individuals, so with nations. Economists have long documented a correlation between national prosperity and the share of GDP spent on health. You would expect the United States, as the richest nation, to spend the most.
Actually, you would expect us to spend even more than that, thanks to cultural factors. In Britain, I'm told, conspicuous
concern about one's health is still viewed as vaguely namby-pamby. In Japan, there is a taboo about telling patients they have cancer, which discourages aggressive treatment. But America is different. If we are sick, we stay home. If we have cancer, we try to beat it.
Most of the national health systems so admired by American policy nerds are inexpensive partly because they provide less care than Americans would find appropriate.
Washington, D.C., has about 35 magnetic resonance imagers -- diagnostic machines that cost $2 million apiece. Toronto has only five. As Malcolm Gladwell of the Washington Post notes, this means Canadian doctors often use a cheaper procedure, the myelogram, which requires spinal injections and can cause splitting headaches. Who needs that?
Or take AIDS treatment. Many of the newest anti-AIDS drugs, such as DDC, are difficult to get in Europe. Offering elaborate treatment to AIDS patients -- people who have a terminal illness -- can be portrayed as a waste of resources, especially if it doesn't increase life expectancy. But it can also prevent crippling discomfort and blindness.
"Is it important to have a 27-year-old person who is dying live happily for a year?" asks Dr. Jerome Groopman of Harvard Medical School. It doesn't reflect badly on us if we answer "yes." The alternative uses of our resources are not necessarily more noble. Which is the worthier choice: spending $15,000 to make somebody's life bearable for a few months, or spending $15,000 on a Mazda Miata?
Yes, the flaw in our system is precisely that it doesn't make us confront such choices. Untaxed, employer-paid insurance insulates us from the cost of ordering up fancy new medical technologies. But even if the inefficiency were wrung out of the system, and consumers were forced to make the trade-offs, they would probably choose to spend an ever- increasing income share on health care.
A crucial question, of course, is whether the trade-offs will be made at the individual or collective level. In Canada, society makes the call. Worrywarts can't get extra procedures even if they're ready to pay for them. That avoids a stratified system in which the rich buy better care than the poor. But would Americans give up their right to buy more care? Probably not.
The likeliest reform scheme ("managed competition") would offer consumers a menu of health plans. Everyone will get a basic benefit package, subsidized by the government if necessary. But I'll be able to spend more to sign up with the local Better-Safe-Than-Sorry Health Group, which doesn't stint on MRIs.
The trick, if you value the egalitarian aspects of Canada's plan, will be to keep to a minimum -- say, to 10 percent of the population -- the number of rich or risk-averse Americans who "opt out" of the basic system. That probably means slapping them with a tax disincentive. But it also means that the basic package has to be generous enough to attract the vast majority of Americans.
Egalitarianism, in other words, is yet another good reason to abandon the moralistic antipathy to rising health expenditures.
TRB is a column of The New Republic, written by Mickey Kaus.