Friday, April 20, 2018
Perspective

Column: The fake freedom of U.S. health care

The United States is home to some of the world's best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere.

Such is the cost of freedom. As Vice President Mike Pence put it: "Obamacare will be replaced with something that actually works — bringing freedom and individual responsibility back to American health care."

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And I haven't even mentioned the millions of Americans who don't earn enough to pay for insurance or a lifesaving treatment. If you can't afford it, not buying it is hardly a choice.

Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system.

Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.

For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home.

If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.

All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

Republicans are fond of criticizing this sort of European-style health care. According to the Republican orthodoxy, government always takes away not only people's freedom to choose their doctor but also their doctor's ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. And the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries.

Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one's life. It's also not like buying some other service tailored to individual demands, because for the most part we can't predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.

What passes for a U.S. health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven't even been seriously sick or injured yet.

As a U.S. citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free U.S. corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.

In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It's a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries.

Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the U.S. health care system is taking that freedom away.

Anu Partanen is the author of "The Nordic Theory of Everything: In Search of a Better Life."

© 2017 New York Times

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