Steve Reads

I can’t recommend this book highly enough. At first glance, one might expect its structure to be gimmicky:

1. Interview someone who suffered because of our country’s health-insurance system.
2. Zoom out from that person to explain the political and economic background to his or her suffering.
3. Zoom back in.
4. Repeat 2) and 3) a few times.
5. Move on to the next person and repeat from step 1).

Far from being a gimmick, I couldn’t imagine a better narrative device. Jonathan Cohn combines the passion of a muckraking journalist with the erudition of a historian. His delivery is simple, unpretentious, and never cloying.

His conclusion is simple: health insurance as delivered by private companies doesn’t work, because their incentive is always to cut services to the bone; the ideal hospital for an insurer is one that has no patients. The history of health insurance, as Cohn tells it, is the history of nonprofit corporations and idealistic doctors slowly getting replaced by for-profit corporations that destroyed the industry they were ostensibly meant to save.

Of course there’s a way out; it’s the way that every other industrialized nation uses, namely guaranteeing citizens the right to health care as a basic condition of citizenship. They spend far less than 16% of their GDP on health care, which is where the U.S. is today. The main obstacle to universal health care in this country is political and ideological; it’s because this country is so dominated by libertarian political orthodoxy. We overcame that orthodoxy in the Sixties and got Medicare and Medicaid; in Cohn’s telling, they are models of efficient health-care delivery. (He says that surveys of the elderly, who are covered by these programs, find that they’re more satisfied with their coverage than are young people in private insurance programs.) It will take a political change to bring us universal health care, but we’ve come close before. There’s no reason we couldn’t do it again.

American dissatisfaction with government, though, is much greater than it was during the Great Society. And we’ve elected at least two presidents (Reagan and Bush) who’ve proved that government is dysfunctional by staffing their departments with dysfunctional true believers in the virtues of the free market. Most of us seem convinced that government is in fact the problem, because we’ve either never seen it work right, or because we’re trained to look at it as through a glass, darkly. But why should government be any worse now than it was in the Sixties, or for that matter the Forties? I’m not convinced that there’s anything standing in the way of efficient government-funded health care, other than the perception that it can’t work.