Fifteen Eighty Four

For several decades now, policymakers seeking to increase access to health care in the United States have struggled to fit a square peg into a round hole. The square peg represents efforts to enhance insurance coverage using public or private means. The round hole is America’s health care industry, a highly specialized, bloated, fragmented, uncoordinated, and complex piece of machinery. To the extent that they have health insurance and understand what services their policies provide, Americans must then individually navigate this highly complex piece of machinery. Why should it surprise anyone that services are unevenly distributed across the United States, that aggregate and per capita costs are quite high, and that common measures of population health such as life expectancy often lag behind other countries?

I wrote US Health Policy and Health Care Delivery: Doctors, Reformers, and Entrepreneurs with two broad purposes in mind. The first was to dispel the notion that we could spend our way out, that universal insurance coverage, whether public or private, would remedy many of the problems that we face. The second was to provide students and general readers with some of the reasons for our current situation, for the fix that we are in.

I use a comparative approach, which I lay out in the first chapter, to dispel the notion that we can achieve universal health care through universal finance alone. I show that countries such as Britain and Germany have striven over the years to marry finance and delivery, to develop health care systems that are compatible with their respective insurance schemes. These countries have found that in order to maintain compatibility, two basic conditions must be met—the ratio of generalist and specialist physicians must be roughly equivalent, and certain mechanisms must be in place to coordinate primary and specialty care.

Because the US health care system emphasizes specialty over primary care and largely fails to coordinate the two, public and private insurers must spend substantially more—more on specialty care and more on fragmented care. Policymakers should ask themselves why they are using taxpayer dollars to perpetuate the existing scheme. Rather than purchase comprehensive insurance coverage for the poor and uninsured, why don’t they greatly expand and competitively staff health care facilities (community health centers, for example) in locations where many such persons live?

The second reason I wrote the book was to provide students of health policy and interested readers with the historical background for our current fix. How can we move forward if we don’t understand how we got here? While several very good historical accounts already exist, more often than not these accounts stress finance over delivery. In contrast, I have sought to emphasize the other side, to show that US health care delivery is out-of-sync with universal financing schemes.

Listen to Carl Ameringer on the podcast The Week in Health Law podcast.