By Paul Krugman

The New York Times

Friday 09 November 2007

The United States spends far more on health care per person than any other nation. Yet we have lower life expectancy than most other rich countries. Furthermore, every other advanced country provides all its citizens with health insurance; only in America is a large fraction of the population uninsured or underinsured.

You might think that these facts would make the case for major reform of America's health care system - reform that would involve, among other things, learning from other countries' experience - irrefutable. Instead, however, apologists for the status quo offer a barrage of excuses for our system's miserable performance.

So I thought it would be useful to offer a catalog of the most commonly heard apologies for American health care, and the reasons they won't wash.

Excuse No. 1: No insurance, no problem.

"I mean, people have access to health care in America," said President Bush a few months ago. "After all, you just go to an emergency room." He was widely mocked for his cluelessness, yet many apologists for the health care system in the United States seem almost equally clueless.

We're told, for example, that there really aren't that many uninsured American citizens, because some of the uninsured are illegal immigrants, while some of the rest are actually entitled to Medicaid. This misses the point that the 47 million people in this country without insurance are an ever-changing group, so that the experience of being without insurance extends to a much broader group - in fact, more than one in every three people in America under the age of 65 was uninsured at some point in 2006 or 2007.

Oh, and finding out that you're covered by Medicaid when you show up at an emergency room isn't at all the same thing as receiving regular medical care.

Beyond that, a large fraction of the population - about one in four nonelderly Americans, according to a Consumer Reports survey - is underinsured, with "coverage so meager they often postponed medical care because of costs."

So, yes, lack of insurance is a very big problem, a problem that reaches deep into the middle class.

Excuse No. 2: It's the cheeseburgers.

Americans don't have a bad health system, say the apologists, they just have bad habits. Overeating and teenage sex, not the huge overhead of America's private health insurance companies - the United States spends almost six times as much on health care administration as other advanced countries - are the source of our problems.

There's a grain of truth to this claim: Bad habits may partially explain America's low life expectancy. But the big question isn't why we have lower life expectancy than Britain, Canada or France, it's why we spend far more on health care without getting better results. And lifestyle isn't the explanation: the most definitive estimates, such as those of the McKinsey Global Institute, say that diseases that are associated with obesity and other lifestyle-related problems play, at most, a minor role in high U.S. health care costs.

Excuse No. 3: 2007 is better than 1950.

This is an argument that baffles me, but you hear it all the time. When you point out that America spends far more on health care than other countries, but gets worse results, the apologists reply: "Sure, we spend a lot of money on health care, but medical care is a lot better than it was in 1950, so it's money well spent." Huh?

It's as if you went to a store to buy a DVD player, and the salesman told you not to worry about the fact that his prices are twice those of his competitors - after all, the machines on offer at his store are a lot better than they were five years ago. It is, in other words, an argument that makes no sense at all, yet respectable economists make it with a straight face.

Excuse No. 4: Socialized medicine! Socialized medicine!

Rudy Giuliani's fake numbers on prostate cancer - which, by the way, he still refuses to admit were wrong - were the latest entry in a long, dishonorable tradition of peddling scare stories about the evils of "government run" health care.

The reality is that the best foreign health care systems, especially those of France and Germany, do as well or better than the U.S. system on every dimension, while costing far less money.

But the best way to counter scare talk about socialized medicine, aside from swatting down falsehoods - would journalists please stop saying that Rudy's claims, which are just wrong, are "in dispute"? - may be to point out that every American 65 and older is covered by a government health insurance program called Medicare. And Americans like that program very much, thank you.

So, now you know how to answer the false claims you'll hear about health care. And believe me, you're going to hear them again, and again, and again.

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