Dear Science,

Most of the complaints about health care seem to be about how expensive things like pills are, not that they don't work. American health care seems the envy and leader of the world. So excuse me if I'm not thrilled about throwing this whole system out for some sort of socialized nightmare because some penniless losers can't earn a job. To the extent government-run health care works elsewhere, it's because of the better example from the United States.

Count Sneezinton

The most successful parts of the American health-care system are the socialized parts. Veterans Affairs (VA) hospitals are responsible for caring for all military personnel for several years after they return from active duty. For injured vets, once they're in the VA, they're in for life. The VA maintains its own set of hospitals. The doctors, nurses, and everyone else are direct employees of the government. No insurance companies are involved; it's a pure single-payer socialized-medicine system. Dozens of experiments have been done in the past few years comparing these citizens under socialized care to their privately insured neighbors—with the VA (and therefore socialized medicine) universally coming out ahead. Patients in the VA system had lower blood pressure, lower cholesterol, and lower blood sugar than their privately insured doppelgängers. VA patients were three times as likely to have their colon cancer caught before it spread throughout the body.

The private insurance market works, but it selects for outcomes we really don't want. Private, particularly employer-based, health insurance is inherently episodic. Any one of us can be expected to bounce from plan to plan throughout our life. The goal of a private insurance company, in a market ruthlessly pushing for lower costs, is to avoid care with long-term benefits but short-term costs. The magic word here is turfing. When faced with someone sick, the private insurance system is strongly encouraged to pass him or her off in a sort of macabre game of hot potato ending finally at Medicare. The market's hand is strong—so strong that everyone in the U.S. health-care system, from lowliest clerk to nurse and doctor to mightiest administrator, all loathe sick people. Those with a complicated set of interconnected problems—or insidious but otherwise simple to treat problems like high blood pressure or cholesterol—are a plague to be avoided at all costs. To the extent that private health insurers succeed at anything, it's transmitting this feeling of financial loathing down the chain of the health-care system. The VA succeeds, in part, because the patients are there for life—starting in their early, not late, decades. In such a system, the incentives shift to long-term health maintenance. The public option, even if functioning as a sort of last-resort insurer, would have a similar dynamic and focus on keeping its patients as healthy as possible for decades. And that's why Science supports the public option.

Socializingly Yours,


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