Your recent editorial on universal health care skirts some key realities ("Moral Imperative," March 20 & 27). The health systems in France and Japan are very different. France has more hospital beds per capita than the United States, but many states have "certificate of need" regulations that prevent new hospitals from being built--unless newcomers can overcome incumbents' lobbying against competition. So increasing the number of hospital beds in the United States requires less government control, not more. And, in Japan, health insurance is provided by over 5,000 different plans; this competition leads to more effective investment in diagnosis and prevention. In the United States, competition between health insurers is also limited by states' mandates. In Canada, however, medically necessary physician and hospital services operate under a complete government monopoly and produce deadly waiting lists. Last year, Canada's Supreme Court determined that, in Quebec, this monopoly violated patients' civil rights.
Your editorial also cites questionable data about the number of uninsured in the United States. Although one 2004 Census Bureau survey (the Current Population Survey) puts it at just over 45 million, another series of surveys from the same agency (the Survey of Income and Program Participation) puts it at about half that estimate. Nor do you discuss how current government regulation needlessly increases prices of health insurance, physician and hospital services, and prescription drugs.
John R. Graham
Director, Health Care Studies
Pacific Research Institute
San Francisco, California
I agree with almost all of your editorial, but you should stop repeating the liberal canard that Medicare is "efficient." True, Medicare's overhead costs, as a ratio of expenditures, are extremely low. But that is a sign of inattention, not efficiency. Take a tour of, say, the Medicare mills that line the strip malls of South Florida to confirm that Medicare pays almost all bills of any kind, no questions asked. Granted, the "incentive" fee structures--so dear to market theologians' hearts--mostly generate only a waste of paperwork. But the medical technology has outrun the ability of the average practice to cope, and intelligent medical management is sorely needed. A dollar-shoveling machine is not a model for reform.
Charles R. Morris
New York, New York
Unfortunately, there is a reason that the United States will never have universal coverage: No policymaker or health care advocate has the courage to face the bête noire and sine qua non of universal health care-rationing. Remember the patient enthusiasm for HMOs and managed care? In this country, when you are sick, the expectation is that you will get anything and everything available, and that you will get it now. And it's not simply an infatuation with twenty-first-century technology. Care for the sickest is inherently more resource-intensive, and it occurs at the cutting edge of available therapy--whatever that may be. It was penicillin, back when penicillin was new and expensive.
Demonize physicians for this if you wish, but, most of the time, it is driven by patient and family expectations and is a reflection of our national character. Delay is unacceptable, and for a physician not to offer an available therapy or even order an available test is to court accusations of malpractice. To equate bed counts or MRI machines to amount of care is specious, and neither the Japanese nor the French system is without rationing and capital expenditure limits in some form. Medicare may be "popular" and "efficient," but, last I heard, it was going bankrupt. Universal health care could no more afford to provide everything to everybody than universal transportation could afford to let every driver choose his or her own car. Tragically, every American would accept nothing less than a Ferrari.
We cited the wide availability of technology in Japan and ample supply of hospital beds in France as proof that universal health care can provide "more" health care than the U.S. system does, if that's the public's desire. John R. Graham can't dispute the statistics, so he suggests we've misinterpreted them. In his view, France and Japan have so many resources because they allow such free competition. But the governments of France and Japan interfere with their health care markets more aggressively than ours does, starting with the kind of price-setting for services that Ted Kennedy only dreams about here. And, of course, France and Japan guarantee insurance coverage to every citizen. We're not as wild about the Canadian system. Even so, the available statistical evidence suggests that, overall, Canadians end up just as healthy (if not healthier) than Americans, while spending considerably less on medical care. Plus, they don't have thousands of people dying every year because they lack insurance coverage. As for the data on the uninsured, even the Survey of Income and Program Participation (SIPP) finds that more than 40 million people are uninsured at any point in time. Conservatives argue that not all of those people are uninsured for the entire year, which is true. But when one hospitalization can drive you into bankruptcy--and when, as the SIPP also confirms, more than 80 million people will lose coverage over a two-year period--who cares?
Charles R. Morris makes an important critique of Medicare. Indeed, it probably could scrutinize payments even more carefully. But that's precisely why its low overhead is a virtue. It can afford to spend more on "intelligent medical management" and still deliver care with less waste than the private sector. That's also part of the answer to Adam Zivin. He's right that more isn't always better (although sometimes it is). Every society struggles to balance the demand for new medical treatments with the expense of paying for them. But countries with universal health care can produce solutions that are more efficient and that require less overall sacrifice.
As someone who studies the poet John Milton for a living--and is thus a member of the field where Stanley Fish has made his most significant, and sometimes maddening, contributions--I spend a good deal of time resisting the temptation to which Leon Wieseltier openly succumbs: I struggle regularly not to be an "asshole" to Fish, even when the courtesy is not returned ("Jollies," March 20 & 27). This position also gives me some insight into Fish's piscine statements in The New York Times favoring the "strongly held faith" of Islamist zealotry over the invertebrate tendencies of modern liberalism. Surely he has in mind the distinction between liberty and license so important to Milton: "Licence they mean when they cry liberty; / For who loves that, must first be wise and good." Liberty in these terms is not simple absence of external constraint; it reaches its fullest expression when the virtuous produce upright action.
In this light, Wieseltier would do well to recognize that Fish is up to much more than cheap button-pushing. If he tends toward the irrational, he does so, again to cite Milton, to "bow things the contrary way, to make them come to their natural straightness"--in this case to provoke liberalism out of its present-day nothingarianism and into recovery of its sense of moral insistence (an errand quite in tune with sentiments regularly voiced in these pages and entirely in keeping with Wieseltier's truism that "free speech is the beginning of a liberal order, not the end").
Feisal G. Mohamed
Texas Tech University
Clay Risen draws an oversimplified conclusion from Robert McNamara's--and now Donald Rumsfeld's--Pentagon, implying that business ideas have no place in national defense ("War-Mart," April 3). Risen is right to point out the naïveté of the idea that the complex systems and multidimensional analytics that neatly solve business problems can be applied easily to problems of war-fighting. But the reason these don't work is not because the problems of war-fighting are so messy and intractable (which, of course, they are), but rather because complex systems and multidimensional analytics almost never solve business problems, either. It may not be a matter of life and death when large companies are trying to solve complicated business problems, but the "fog of war" is very much present in the form of disruptive technologies, organizational complexity, unpredictable competitors, and the many other forces that attenuate the link between an executive's action and the resulting business impact. The need to create the right outcomes despite these challenges is why businesses innovate. War-fighting is different, but, if we insist that it has nothing to learn from innovations in business, we are as mistaken as we would be in insisting that it has everything to learn from them.
New York, New York
This article originally ran in the May 1, 2006, issue of the magazine.