Choices in Universal Healthcare

Beijing, China -- As the health care debate in Washington begins in earnest, a quick trip around the world over the last week has given me a fresh perspective.  My first stop was Sweden, to deliver a talk on the America's economic prospects, post-financial crisis.  But, first I found I had to see a doctor for a mild, recurrent eye infection, and I experienced first-hand some of the advantages and drawbacks of one of the world's best national health care systems.  I saw a physician who prescribed antibiotic drops within an hour - try to do that in America -- and the visit and the prescription together cost me less than $50.  (It would have cost a Swede nothing but taxes).   It also turns out that the medication was one developed years ago - one reason it was so inexpensive - and which takes about 10 days to clear up the problem instead of five to six days using the more advanced drops I would have received at home, at a much higher cost..  It was a small example of how national health care can trade-off technological advance for universal access - thankfully in this instance with no difference in the outcome. 

My next stop was Ulan Batar, the capital of Mongolia, to give government officials advice on economic development.  It's one of the world's poorest countries, yet the government has set up networks of clinics around the country to reach not only those in the cities, but also the other half of the population, many semi-nomadic peoples, who live in the vast countryside.  (It's a place with 2.6 million people spread across an area three times the size of Texas.).  Again, access is near-universal with much of the cost coming from taxes - business pays them there.  And while the quality of care is basic and often spotty, so is the quality of everything else in Mongolia.  It was a small example of how a society with very little of anything chooses to devote enough of its small resources to provide most of its people much of the health care they need. 

I'm writing now from the sparkling, cavernous airport in Beijing, waiting for my flight back to Washington.  Here, the government used to deliver basic care to everyone through agricultural communes and state-owned enterprises.  When the leadership decided to unravel those institutions in favor of market-based enterprises, they also unraveled the old health care guarantees, so they could channel the resources into economic development.   About 20 percent of Chinese today have coverage - essentially, those working for the central government, the People's Army, and foreign-owned companies (they're the only ones required to insure their workers).  The rest of China lives with a system they call "pay or die" -- if you're sick or injured and can't pay on the spot, you simply don't get treated.  The result is a 30 to 40 percent personal saving rate - ironically, one of the underlying factors that created the conditions for our financial meltdown - by people terrified of getting sick or having an accident.  And international health experts estimate that literally millions of Chinese die from conditions which can be treated easily.  It's the world's biggest example of how the tradeoff between providing universal care and spurring economic growth can leave most people profoundly vulnerable.

No one imagines the United States will ever find itself in China's position, although a small share of Americans do so regularly.  But the three examples can provide lessons for us.  From China, we can learn about the pitfalls of unraveling the way we currently deliver medical insurance to most people, through the tax preferences for employer provided coverage provision.  Unravel that without making provision for government-guaranteed coverage, and millions of us in the world's richest society will find ourselves profoundly vulnerable. From Sweden, we can learn that the cost pressures associated with an efficient, universal system inevitably produce less access to the most technologically advanced and expensive treatments, although it may not make much of a difference for most people.  Of course, that also means it will make some difference in the health of some people - although certainly less of a difference than whether or not they smoke, drink or exercise.  And from Mongolia, can't we learn that we can establish universal coverage tomorrow, if we choose to?  We'll just have to pay for it - and the bill will be a whopper as medical advances grow even more expensive and tens of millions of baby boomers reach the age when the most costly-to-treat conditions become most prevalent.  Yes, alongside the cost-saving reforms and efficiencies from phalanxes of experts, there will also have to be higher taxes.   But if the choice is, your money or your health, what choice is there?