Satisfaction and Quality In Health Care Reform

There have been a number of posts around the blogoshere regarding the health care debate between Ezra Klein and Andrew Sullivan which I previously discussed here. Follow up discussion has raised important points with regards to subjective satisfaction and evaluation of quality in health care. Like the topics I reviewed yesterday, these also indicate areas where left and right need to consider the opposing viewpoints with both extremes being unrealistic.

Ezra Klein responds to Andrew Sullivan by displaying evidence that the British are more satisfied with their system than Americans are. I am surprised that Ezra allows himself to be backed in to the corner of even defending the British system as that is not on the table here. As the question is what forms of health care would be tolerated in the United States, and not what was accepted in the United Kingdom, Sullivan easily demolishes Klein’s argument:

Satisfaction is a subjective function of subjective expectations. If you have the kind of expectations that many Brits have for their healthcare system, it is not hard to feel satisfied. The Brits are very happy with their dentists as well. And there is a cultural aspect here – Brits simply believe suffering is an important part of life, especially through ill health. Going to the doctor is often viewed as a moral failure, a sign of weakness. This is a cultural function of decades of conditioning that success is morally problematic and that translating that success into better health is morally inexcusable. But if most Americans with insurance had to live under the NHS for a day, there would be a revolution. It was one of my first epiphanies about most Americans: they believe in demanding and expecting the best from healthcare, not enduring and surviving the worst, because it is their collective obligation.

I suspect it is also a matter of having lived under such a system and not knowing anything different. Both Brits and Americans are more accepting of the faults in their own system. The British system was also instituted closer to World War II. Brits at the time were far more willing to accept sacrifices for a national program than Americans would at present.

It is a problem that liberal advocates of health care reform defend the British system as Klein does because this suggests a lack of understanding of what forms of health care reform would be acceptable in the United States at present. Unfortunately many liberals think that HillaryCare failed not because it was a poor system but because of an advertising campaign by the insurance industry. The Harry and Louise Ads would not have been so effective if they did not raise real problems seen by many voters.

I also questioned Ezra’s support for the British system in the past, especially with regards to his support for capitated systems as opposed to fee for service medicine. Ironically, the British system uses a system of capitated payment similar to what was used by businesses utilizing HMO’s in the United States until patients got fed up with the problems of such systems and their use declined.

While there are undoubtedly abuses under fee for service medicine, capitated systems run a far greater risk of ignoring the needs and desires of the patient. Whether they are used in a government-run system in the U.K. or in HMO’s in the United States, they pit the financial interests of the doctor against the best interests of the individual patient. Capitated systems, in which doctors receive a fixed amount of money per patient (often with adjustments for factors such as age and health status), risk having doctors forced to provide inadequate care in order to get by on what is paid. Doctors are given financial incentive to see patients as little as possible, do as few tests as they can get away with, and treat as little as possible.

Americans both demand the best and demand a greater degree of freedom of choice than was present in either the British system, under HillaryCare, or in capitated American HMO’s. This does not mean that health care reform is not possible. Obama has showed understandings of the failings of Clinton’s approach such as in seeking a more transparent method for considering reform, avoiding mandates, and stressing the ability of those who are satisfied with their current coverage to remain in their current plans. This turned out to be an advantage for Obama not only over Clinton but over McCain’s health care plan in the general election.

Measuring quality in health care allows both the left and th right to make points. In his original post Klein claimed that the British do not suffer from lack of quality in their less expensive system. James Joyner has an excellent round up of this entire debate (including a link to my earlier post) and cites evidence which does show the superiority of the American system in certain areas.

Both Klein and Joyner are correct in arguing for the quality of opposing systems depending upon the criteria used. In general, when subspecialty care is evaluated the United States comes out among the best in the world–for those who have access to such care. When quality is measured based upon more routine care the United States does not rank very highly due to the large number of people without access to health care. All too often those on the left or right only look at one of these measures of quality and ignore the importance of the other. Any system developed for the United States must preserve the high quality subspecialty care we now enjoy in the United States while making health care affordable for a larger portion of the population.

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  1. 1
    John Freeland says:

    Journalist T.R. Reid and Frontline put together an excellent documentary called “Sick Around the World.” Reid categorized health care systems in different nations as variations on four different models, the Beveridge Model, the Bismarck Model, the National Health Insurance Model, and the Out of Pocket Model. Reid says Americans are somewhat familiar with all of these. If you get VA care, you have essentially the British Beveridge Model. If you get insurance through your employer, you have essentially the Bismarck Model used in Germany. If you’re on Medicare, you get the Canadian-style National Health Insurance Model. If you are one of the 47 million uninsured, you use the Out of Pocket Model.

    What may work here is something like the system Denmark uses. They use private insurance companies, but they are heavily regulated, similar to the way the U.S. used to regulate utilities, and they are subsidized to cover everybody. 

  2. 2
    Larissa says:

    If France is rated #1 in healthcare, why not fashion our healthcare system after the Bismarck model?

  3. 3
    Katherine says:

    I am wondering why we believe it is up to legislation to determine health care costs, services and availablilty? Are the lawmakes, who are all elected thanks to the amazing power of lobbyists, the authority on health care? I am afraid of the sub-standardization this will bring. I want all rich and poor alike to receive excellent care. I am afraid mandated “public option ” simple gives authority to govenment.

  4. 4
    Ron Chusid says:


    If you want “rich and poor alike to receive excellent care” the first thing we need is to change the system so that all have access to care. Providing such access is the point of health care reform–not determining costs, services, and availability.

  5. 5
    Fritz says:

    Definitely, if the goal is for everyone to get the same product, then any type of market (even a regulated market) is your enemy.  Markets focus on differentiation and price points.
    Of course there are interesting long-term consequences to that path.

  6. 6
    Ron Chusid says:

    Except that the goal of the health reform legislation is not that everyone gets the same product. It is to offer people a choice of products, with a common floor as to providing insurance coverage. While there will be a common floor, there are multiple possible options, and there is no ceiling for people like yourself who want a Cadillac plan.

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