Few things cause eyes to glaze over faster than discussions of health care. Unless, of course, your insurance rates just spiked, or you couldn’t get insurance, or you thought you were covered for a procedure but aren’t, or you’re trying to keep your company’s benefits competitive, or you’re just kind of appalled at the fact that there are more than 45 million Americans without any health insurance at all. With the 2008 presidential election campaign heating up—and in the wake of Michael Moore’s documentary Sicko—the business of health care is suddenly, if not a hot topic, one that can’t easily or responsibly be ignored.

To get some insights, we asked four Penn-based experts in the field for their thoughts on health-care matters: Dr. David Asch, executive director of the Leonard Davis Institute of Health Economics and the Eilers Professor of Health Care Management and Economics; Dr. Arnold Rosoff, professor of legal studies and health-care systems and a member of the medical school’s public-health program; Dr. Mark Pauly, professor of health-care systems, business and public policy, insurance and risk management, and economics; and Dr. David Grande GM’03, instructor of medicine. All four are senior fellows at the Leonard Davis Institute.

How would you summarize the current state of health care
and health-care coverage in the U.S. today, both for those with insurance and those without?

Asch: It is pretty common to hear complaints about health care in the U.S. that remind us that we spend more on health care than any other country and achieve population health outcomes lower than other industrialized nations and, to boot, we leave 47 million of our citizens uninsured. But those sorry facts end up disguising the much more complicated reality, which is that what we really have is an extremely broad distribution of health-care costs and spending across segments of the population and an extremely broad distribution of health-care outcomes across the population. So, when someone asks me to characterize the state of health care in the U.S., I need to ask them, “Which U.S. are you asking about?” The averages tell you nothing in a country like ours.

Pauly: Medical-care spending growth has slowed substantially, but it’s still higher than GDP growth. The slowdown is largely due to a slowdown in drug spending growth, caused by older drugs going off patent, and the rate of introduction of new drugs has slowed a lot. So for those who can still afford insurance, the good news on spending and premium growth is mixed with bad news on beneficial but costly new technology.

The proportion of the population with no insurance is still growing, and has now exceeded its previous high-water mark in 1996. The story is quite different for those with insurance: Both the amount of insurance benefits and the proportion of spending paid by insurance is growing. The dollar amount of consumer cost-sharing has increased, but less rapidly than the dollar amount of insurance benefit payments. But the fraction of those without this better coverage is rising somewhat. The uninsured have very mixed characteristics, but the most typical uninsured person is a young lower-middle-class worker in reasonably good health employed at a small firm. Serious and costly efforts to broaden coverage like SCHIP [the State Children’s Health Insurance Program] and Medicare Part D are probably not going to have much of an effect on the overall measures of coverage or spending, though they help selected subpopulations. Moving toward universal (or even just much more) coverage will require dealing with insurance purchases for able-bodied adults.

Rosoff: Although there are more quality-control problems than there should be—i.e., medical error, as highlighted by the Institute of Medicine’s 2000 report “To Err is Human”—U.S. health care overall is quite good. In terms of technology and the educational/skill level of health-care providers, the U.S. ranks near the top of the world’s health-care systems. For Americans lucky enough to have good health insurance—a substantial portion of the population—U.S. health care is excellent.

There is, of course, a problem with rising cost, even for people with good insurance. This problem is increasingly felt by the general public because employers, who traditionally have borne the greatest burden of health-care costs, are increasingly shifting that burden onto their employees in various ways.

Michael Moore’s Sicko shines new light on old problems that are getting worse as time goes on. First, costs for health insurance continue to rise, pricing some—including small employers and their employees and dependents—out of the market. Second, too many people who have insurance find that when they need care, their insurance has limits and exclusions they didn’t know were there. Third, too many people simply don’t have insurance coverage.

The U.S. is the only major industrialized nation on the planet that has not committed itself to the ideal of universal health-care coverage (UHC). Despite Medicare for the elderly, Medicaid for the poor, SCHIP, and other state and federal health-care programs, roughly 47 million Americans—close to 1/6 of our population—still lack coverage. EMTALA (the Emergency Medical Treatment and Active Labor Act of 1986) requires all hospitals participating in Medicare to assess, and treat if necessary, all who show up appearing to need emergency care; but that’s way too small a band-aid to cover up the gaping hole in coverage.


Sicko seems to have touched a nerve in this country. What is Moore right about and what is he wrong about? Are his depictions of the health-care systems of Canada, the U.K., France, and Cuba fair and balanced or is he looking through a rose-colored camera lens?

Asch: Here’s what Michael Moore got right: a sense of outrage. I think we need to congratulate him for so effectively communicating some serious problems within U.S. health care. Fixing those problems won’t be as easy as complaining about them. But complaining about them is important.

I’ll admit that Michael Moore is not the right person to ask to fix our health-care system. But neither is anyone asking any of us to make movies.

One of the common statements about the Canadian health system is that no matter how well it works, it would work a lot worse if Canada weren’t so close to the U.S. The proximity of the U.S. to Canada gives some options to impatient Canadians.

Pauly: Americans want insurance to pay for the care they want, when they want it, and from whom they want it. That does not happen in Canada, the U.K., or Cuba; I am not an expert on France. Generally access to primary care is better in those countries, but access to costly or high-tech care is rationed either by wait time or (in the case of Cuba) by political position. Some, perhaps many, Americans might prefer these kinds of systems, but surely not all.

Rosoff: Canada and the U.K. have well-documented problems of “rationing by the queue,” that is, long waits for elective and semi-elective treatments. (Some things that would be considered urgent care in the U.S. are classified as “elective” in Canada and the U.K.) Significant numbers of people in Canada go outside of their country’s universal health-care system and come to the U.S. as “medical tourists” to get care without the wait.

Although I have little first-hand knowledge, I tend to believe that the French health-care system is quite good, as the World Health Organization’s ranked France’s health-care system No. 1 in the world in 2000.

While I doubt Moore’s depiction of the Cuban health-care system as superior to our own and doubt that the average Cuban gets care anywhere near as good as the Americans that Moore took with him to Cuba, the WHO’s statistics show Cuba as having more than twice as many physicians per capita than the U.S. and 50 percent more hospital beds per capita, too. Still, WHO’s 2000 ranking listed Cuba 39th among the world’s health-care systems and the U.S. only slightly better, at 37th.

Nov|Dec 07 Contents
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Diagnosing Health Care by Samuel Hughes
Photography by Jim Graham

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Clockwise: David Grande, David Asch,
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Last modified 11/09/07