BookEnds

I picked up Truman Capote’s In Cold Blood this summer and slowly worked my way through most of it, only to leave it lying unattended by my bedside for months.

Not that it isn’t a gripping tale. The non-fiction, which details the murder of a family of four in rural Kansas, often has the same appeal as a good horror flick. Before the bloody deed is done, it’s easy to get wrapped up in the suspense: the only question is how the victims, Mr. Clutter and his family, will be snuffed out.

My problem came after Kansas detectives bag Perry Smith and Dick Hickock, Mr. Clutter’s twisted assailants. Perhaps my disinterest can be blamed on having seen Philip Seymour Hoffman’s brilliant turn as the author in the 2005 film Capote. Unfortunately, I know how this story is going to end.

That aside, I’ve got a bigger bone to pick with Capote, and it has to do with good old-fashioned journalism. Capote’s claim to fame was his ability to conjure vivid, true-to-life scenes from actual events. The author himself called In Cold Blood a “nonfiction novel,” and laid claim to its total veracity.

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I finished Superfreakonomics by Steven Levitt and Stephen Dubner, last week but, with the president’s visit and increasing election coverage, haven’t had time yet to give you an update.

So here it comes, though I’m not going to review it, per se. As you may know, the book’s stirred some controversy because the scientist quoted in the final chapter on climate change told a climate blogger that he was misrepresented in the book. That’s a really serious charge against the authors, one of whom, Dubner, is a journalist. And many other scientists have come out against the conclusion in the book that geoengineering is the best way to combat climate change.

I don’t think the chapter would have stirred so much controversy had the authors not appeared so certain about topics outside their realm of expertise, which is what the book is doing in the first place. Perhaps it would have worked better had the idea that geoengineering is a better approach to curbing global temperature increases been approached as a question rather than presented as an uncertainty. In general, the authors can seem openly hostile to ideas that don’t fall within the book’s point-of-view. For ex  ample, you don’t get the sense that these guys think much of government at all. The follow excerpt was the kind of aside that was typical:

The Department of Homeland Security recently solicited hurricane-mitigation ideas from various scientists, including Nathan (Myhrvold) and his friends. Although such agencies rarely opt for cheap and simple solutions — it simply isn’t in their DNA — perhaps an exception will be made in this case, for the potential upside is large and the harm in trying seems minimal.

How efficient government agencies are is certainly open for debate, but to assert their anti-efficiency so baldly is a bit heavy-handed.

My bigger problem with the book, as I’ve said before, is how liberally they borrow from other writer’s discoveries. Whether you think Malcolm Gladwell is good or not, he at least presents you with research you might not have encountered before much of the time. But I had read about Myhrvold before in the New Yorker, in a piece by Gladwell. I’ve written on the blog before about how I encountered two of the big ideas — those of Sudhir Venkatesh and Joseph De May — in other venues. They also clearly read Atul Gawande’s Better, because that’s where I first read about Ignatz Semmelweiss, who plays a significant role in Chapter 4. It’s completely fine for authors to learn about something from another writer and  then do their own research and writing on it. It just seemed to me that Dubner and Levitt had been reading the same things I’ve read.

Either way, it’s destined to be a blockbuster.

Still on the search for a fix for his sore shoulder, Reid leaves Canada before the end of the book to visit India and pay out of pocket at an ayurvedic clinic. I’ll save you the suspense: After weeks spent eating healthfully, relaxing, and being intensely massaged, Reid’s shoulder felt better and had a better range of movement.

You probably don’t have to believe in prana or doshas to understand that paying such intense attention to your body may serve you better than pills or surgery. But the out-of-pocket model doesn’t do one thing very well, Reid says, and that’s address any sense of fairness. Most of the world’s poorest countries don’t provide health care, and people are left to pay for the care they can afford. Reid points out that that usually means that poor people go without any care at all, and the poorest in the poorest countries can expect today before their 40th birthday.

Reid points to an Institute of Medicine study to show that about 22,000 Americans die each year from otherwise treatable ailments because they can’t afford insurance. He tells us that about 85 percent of Americans believe health care is a fundamental right. So what’s to be done? Reid says we have to decide the moral question first, commit to universal health care, and then worry about how to pay for it. He argues that framing the issue as an economic one was one of the problems in the reform effort of then-President Bill Clinton in 1993, while at the same time Taiwan and Switzerland passed universal health care. That’s because Taiwan and Switzerland framed the issues in ways that resonated within their cultures — national pride and solidarity — Reid says.

Part of what he wants to do in the book is combat some common misconceptions: that every other country has socialized care with wasteful bureaucracies and sacrifice free-market style choice. But the prescription contains elements that may be a hard sell for Americans. Everyone — rich and poor, young and old, healthy and sick — is in it together in countries that make health care universal. That means that the rich subsidize the poor and the healthy subsidize the sick. But it also means the healthy version of yourself subsidizes the version of yourself that inevitably needs medical care. That’s what insurance is meant to be, a bulwark against bad luck.

It also means that in most countries no one makes a profit from health care insurance. That  might have been the biggest obstacle all this time: that really entrenched interests benefit from our current system.

As you all probably know by now, the Senate Finance Committee, one of five Congressional committees critical to health care reform, rejected two proposals Tuesday that would have created a public insurance plan to compete with private health insurance companies.

The public option has been a constant demand of more liberal lawmakers but is widely seen as a dealbreaker for most Republicans and moderate Democrats. The Finance Committee, as exhibited by Max Baucus’s chairman’s mark, left it out in favor of non-profit health care cooperatives.

As we know now from reading T.R. Reid’s book, France, German, and Japan (along with other countries) use non-profit insurance companies to provide health insurance to their citizens. Citizens then use the insurance companies to obtain care from doctors and hospitals that work for profit. But as Timothy Noah pointed out in Slate, for-profit insurance companies aren’t allowed in those countries. Also, as I think I can channel Reid to say, we don’t really have a model for non-profit health insurance companies in America.* What we do have are to big government-run programs, Medicaid and Medicare, that could be expanded.

But as Brian Lehrer pointed out in Wednesday’s show, none of this means the public option is completely dead.

*At least, not any more.

Whenever politicians talk about health care reform, Americans probably fear most the systems Britain and Canada have. It makes no difference that Reid and many others who have benefited from them extol their virtues. These systems are so different from what the U.S. does that they’re not likely to be implemented soon anyway.*

Britain is one of the few democracies that goes whole-hog: Your health care is paid for through direct taxation by the government, which also employs the doctors and nurses who see you. The downside, of course, is that taxes are high. Britain still spends less on health care than the United States does, but it may not feel that way if you’re paying 17 percent tax on a sandwich at the Pret-a-Manger.

Also, the government has to pay attention to cost, and can act like a gate-keeper on certain kinds of medications. This might feel like it makes more sense when you’re the taxpayer than it does when you’re the sick person who wants a treatment. In any event, Reid was not approved for shoulder surgery, or really any other kind of intervention, except the stiff-upper-lip treatment. Just learn to live with it, they told him.

Both Britain and Canada also install waiting-lists for non-emergency procedures, with the justification that if health care is free for individuals the temptation to overuse it is strong. This is the way a non-market system can internalize a cost on its users. Britain invested a lot of money after true and exaggerated scandals involving their wait lists; tales of patients waiting on gurneys while they slowly died. That’s the upside to government involvement, the government is ultimately answerable to voters. In Canada, the wait-list problem hasn’t been overcome, and that was the only country in which Reid didn’t get to see a specialist because of the wait. The upside, if he’d waited around for about a year, is that everything would have been totally free.

Reid posits that Canada provides the U.S. with another important lesson: Universal health coverage started first in one province, and then after it was proven popular and workable spread to the entire country. It’s called the demonstration effect. Maybe,he says, if more states like Massachusetts could provide universal coverage and actually control costs, the entire country would eventually get on board.

Another benefit, though, is that because both Canada and Britain will have to pay for the entirety of their citizens’ care from birth to death, they have a great incentive to keep you relatively healthy. So it really is care for your health, more than managing your sickness. Something tells me that wouldn’t wash in the U.S., though:  you basically have the government telling you what you should and shouldn’t do.

*Though, as Reid points out, the VA system works just like the British NHS, and Medicare and Medicaid work like the Canadian single-payer system.

Before he takes us to France, T.R. Reid explores all of the things that might increase medical care costs for Americans as opposed to their counterparts in other countries. He disabuses us of two notions right away: that it’s doctors salaries and malpractice insurance. Doctors do get paid more in the U.S. than they do in other countries, but Reid tells us the economists who study the issue calculate that lower doctors’ fees and drug prices wouldn’t save us that much money.

Malpractice costs are a long-time issue for advocates of tort reform that President Barack Obama addressed when he laid out his health care reform proposals. But Reid points to a study from a health care management professor at the Wharton School of Business, Patricia Danzon, to tell us that the more expensive malpractice insurance costs American doctors face add only about 1 percent to our total health care costs.

So what is it? Mainly high administrative costs. Private insurance companies in the U.S. spend about 20 percent of their budgets on non-health care related expenditures. Health insurance companies will tell you that not a lot of that goes to profit, but rather that they spend money mitigating against the free-market problems private companies face. As an undergraduate who was one class shy of an economics minor, I can tell you that I learned that health care markets are special, but I’ll spare you the wonkish details here. You can, if you’re interested, look here and here. Also, you can listen to NPR’S Planet Money podcasts, which document the kinds of information problems health insurance markets face.

So one of the ways countries that rank better both in controlling costs and improving outcomes is by getting rid of the overhead. In countries like France, Germany and Japan, everyone is required to get health insurance and health insurance companies are required to provide it. That gets rid of the people American companies employ to deny claims and investigate patient histories. It forces everyone to pay into the system, so it mitigates against the problem of adverse selection. And doctors don’t have to maintain patient records either. In France, everyone is issued a card to maintain their histories. (Computerizing health care is part of what the stimulus package wanted to accomplish.)

In all of these countries, which use a system started by Otto von Bismarck in Germany, health care providers are private doctors who work for themselves or for officers and hospitals that make a profit. What’s different is that non-profit insurance companies provide the funding, employers help employees pay, governments kick in to help out for people who can’t quite afford their premiums or are self-employed, and the countries control costs by controlling the reimbursement fees paid to doctors and hospitals. So it’s not to say that everything’s perfectly affordable. The doctors in France, Germany and Japan Reid meets are unhappy with the amount of money they receive. But no one Reid meets would change the system they work in entirely.

So how did his shoulder injury fare? In France, the doctor told him he would not recommend surgery because his injury was not that extreme, but if he didn’t like that diagnosis he could go to a doctor, get a new one and probably get the surgery with relatively no waiting time. In Germany, the system ok’ed the surgery, but the doctor told him she wouldn’t necessarily recommend it and told him to talk to a physical therapist before plunging in. In Japan, the doctor said health insurance would pay for Traditional Chinese Medicine, physical therapy, a monthly steroid injection and for the expensive total shoulder surgery, but like every other doctor but the American, he didn’t think the shoulder surgery was the best way to go. All of these doctors told him the surgery was usually reserved for people in pain, and his problem was stiffness. Surgery, too, would cause pain and require time and energy to rehabilitate afterward.

After this, Reid left the systems that are closest to what the American plan will likely end up looking like to visit the system Americans probably fear most, the U.K.’s NHS.

It’s important to know before reading “The Healing of America” that the author, T.R. Reid, takes as a given that the health care system in America is broken. This seems pretty uncontroversial to me at this point. Nearly everyone agrees on the diagnosis; it was a big campaign issue for both Democrats and Republicans in 2008. What’s less clear is the treatment.

Atul Gawande argued pretty persuasively in January that health care systems in other countries work best when they build on what already existed: The British fashioned the National Health Service after World War II when, bombed and bedraggled, it had a huge soldier and civilian population to care for. Other countries took different approaches because what existed before was different.

President Barack Obama argued something similar in his speech to a special joint session of Congress last Wednesday night when he said “Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn’t, rather than try to build an entirely new system from scratch.” And Reid takes the same approach. His book is meant to look at the bits that work well in other countries, the problems other countries face and how those things compare to the polyglot American system, the last in the developed world that doesn’t guarantee basic health care to its populace.

Reid’s medical problem is a perfect one for this investigation. An old shoulder surgery makes him ache and interferes with his golf swing, but doesn’t impede greatly on his quality of life. Treatment can range from physical therapy to radical and expensive shoulder replacement surgery (which is what his American doctor recommended.) How treatment is tackled for such a non-emergency, life-enhancing and potentially expensive problem says a lot about how a country decides to meet everyone’s needs on limited resources.

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While the health care debate looms as a major issue when Washington gets back from vacation, we’re planning to read a journalist’s look at health care systems in other countries after we get back from vacation. Start reading T.R. Reid’s The Healing of America with us after Labor Day.