We've Got You Covered

May 15, 2023
The only reason the U.S. healthcare system is not completely broken is because there’s no solid thing to break, argue economists Einav and Finkelstein (coauthors, Risky Business) in this impassioned call for ground-up reform. According to the authors, critics of the current system of medical coverage tend to overfocus on the 30 million uninsured Americans, when in fact 90% of the total population is underinsured, at risk of losing coverage, or saddled with significant debt. Einav and Finkelstein contend that the government ought to take inspiration from the success of systems like those in Singapore and the U.K. by drawing a distinction between “health” and “care” and developing an approach more comparable to air travel: those who can afford to fly first class may be more comfortable, but everyone on board gets from point A to point B. Countering arguments that the integrity of such a system, even when guaranteed by law, would be threatened by variations among factors like hospital wait times, the authors draw on philosopher John Rawls’s equality principle, which they claim suggests that guaranteed adequacy is better than failed equality. Thanks to the sensible pragmatism of the authors’ approach, healthcare reform activists will find this a useful tool.

Starred review from June 15, 2023
A highly insightful examination of how to fix America's woefully inadequate health care system. Einav and Finkelstein, professors of economics at Stanford and MIT, respectively, manage the impressive feat of appearing neither liberal nor conservative, portraying the American health care system as not merely deplorable, but grotesque. Its patches, exceptions, complexities, and cutouts illustrate our "plug-the-leaks, squeaky-wheel-gets-the-grease approach of the past half century." The authors make a compelling case for going back to the drawing board to do it right. The idea of universal health care is rooted in an unwritten social contract: to provide essential medical care regardless of resources. Most liberals and conservatives accept this concept, at least in theory. Current reforms miss the point by emphasizing the uninsured, ignoring the fact that 90% of insured Americans have problems. Even the coverage we do have is a mess. The authors argue for a fixed government health care budget to provide free universal coverage for basic services and the option to buy additional, supplemental coverage. Conservatives may be discomfited to learn that almost every high-income nation with free, "socialized" medicine operates under a fixed health care budget. America doesn't and vastly outspends them all. Ironically, much of American health care is already socialized--i.e., paid for by the government with salaried doctors at the VA hospitals and community health centers. Taken as a whole, our taxes already pay for universal basic coverage, but basic coverage must be just that: basic. Some extras--private rooms, choice of doctors, good food, short wait times for routine care--don't qualify. The authors' vivid examples vary from tolerable (Australia, Singapore) to unpleasant (China). Their plan would create a two-tier system benefiting those with supplementary coverage, but we already have that. The advantage is that it would fulfill the social contract we all accept. Today's basic coverage for the poor--i.e., Medicaid--is not only a failure; it's often undeniably cruel. One of the best entries in the health care reform genre.

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