Healthcare reform — why have other countries gone the way that they have?

Much of the discussion about healthcare reform seems to presume that we need to break everything we have into little bits and start fresh. In a recent New Yorker piece, Atul Gawande points out the problems with this notion. At the most practical level, our medical care system (such as it is) needs to function 24/7, all the year round. We can’t just stop it for a while, put the whole country on hold, as we introduce a new way of doing things.

But beyond that, Gawande brings up another fascinating angle to the question. Anyone who has read about the issue knows that Britain, France, and Germany, for example, have established systems that differ from each other in fundamental ways. Only in Britain does the government run everything. Gawande asks the question: why have these countries done things differently? The answer, it turns out, is that each of them built upon the system (and citizen expectations) that already existed in that country. In no case did anybody tear down completely what was there and erect a totally new way of doing things.

Gawande concludes that whatever we do will necessarily be built upon what we already have. This will offend some people deeply, particularly partisans from both sides of the political spectrum. It will not at all be a system that a dogmatic purest of any ideological stripe would plan from scratch. Rather, it will inevitably be a series of compromises and tinkerings with the way we are doing things now. And we will need to be willing to trim our sails if needed, modify the system, when it is clear one or another aspect of it is not working.

Change will come, one way or another. We cannot sustain the rate of rise of medical care costs, which already consume 16% of our GDP, far more than any other nation.


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