Health Care Special Issue: Creative Destruction

More than a decade ago, Michael Kinsley, the journalist and former editor of this magazine, developed Parkinson's disease--a degenerative condition that impairs motor and speech control, producing tremors, rigidity, and eventually severe disability. While the standard regimen of medications helped, he knew that his symptoms were bound to get steadily worse with time. He needed something better--something innovative--before the disease really progressed. In 2006, he got it at the famed Cleveland Clinic in Ohio.

The treatment Mike received is called Deep Brain Stimulation, or DBS for short. It began with a physician--one of the world's top Parkinson's specialists--drilling two holes in his head, into which were implanted two thin electrodes made of titanium. The electrodes were attached to wires, which the physician threaded behind the internal portions of Mike's ear, down his neck, and eventually into his chest cavity, where they were connected to a pair of tiny battery-powered controllers. After the surgery, the doctor activated the controllers using a remote device, unleashing a steady pulse of small electrical shocks that ran across the wires, through the electrodes, and--finally--to the part of the brain that regulates movement. DBS doesn't cure Parkinson's, but it has been shown to control the symptoms for extended periods of time. And that's what happened for Mike (who is also, full disclosure, a friend).

DBS represents the cutting edge of Parkinson's treatment; the Food and Drug Administration approved it only ten years ago. It is also very costly. Medtronic, a company that makes the electrodes, says the whole procedure costs between $50,000 and $60,000. And, because the treatment's main effect is to suppress and delay the onset of symptoms, rather than cure the disease, Mike started wondering whether a system of universal health insurance would pay for it--and, if so, in which cases.

After all, in universal coverage systems, the government typically defines a minimum set of benefits--a list that is put together based on frank assessments of cost effectiveness. (Even if the government achieves universal coverage through private plans rather than through a single-payer system, most insurers would likely end up offering something very close to that same set of benefits. ) The government might decide that $50,000 or $60,000 is simply too much to spend for something that doesn't cure Parkinson's--or, at least, limit the treatment to certain people, such as those in more advanced stages of the disease. Mike could always have paid for the procedure out of his own pocket. But most Americans couldn't. If the government decided the treatment wasn't cost effective, he pointed out, many Americans would be forced to go without it--unless they could find a doctor and hospital willing to do it for free.

And that prompted another thought--not from Mike but from me. All of this was assuming DBS even existed. The United States is famously the world leader in medical innovation--in part, it would seem, because we spend like a drunken sailor when it comes to medical care. Today, we devote 16 percent of our gross domestic product to health care, by far the largest proportion of any country in the world. (The highest spending country in Europe, Switzerland, devotes just 12 percent.) That huge, largely uncontrolled spending translates into large profits for health care companies, offering an incentive for them to do research and development--the kind, presumably, that plays a significant role in breakthroughs like DBS. Universal health care would attempt to bring health care costs under control by, among other things, using government's leverage to drive down prices of everything from medical services to drugs and devices. And, if the payoff for something like DBS weren't as big as it is now, who's to say a company would have bothered developing it in the first place?

As Mike himself acknowledged, none of this seals the case against universal health care. On the contrary, maybe the trade-offs between covering everybody and fostering innovative health care are inevitable--and perhaps innovation has to come second. Maybe what is good for some people with Parkinson's isn't necessarily in the best interests of the country as a whole. On the other hand, people with Parkinson's can contribute more to the economy (and society in general) if their symptoms subside. They might also need less ongoing care, which could actually save money. Besides, true innovation ultimately benefits everybody by pushing the boundaries of the medically possible. Can we really count on a universal coverage system to weigh all of that? In other words, can we really be sure that universal health care won't come at the expense of innovative medicine?

It's a valid set of questions, which is more than you can say for most of the arguments against universal health care circulating these days. If you've listened to Rudy Giuliani or any of the other Republican presidential candidates lately, then you've probably heard them claim that creating universal health care would necessarily lead to inferior treatments, particularly for deadly diseases like cancer. But that just isn't so. While the United States is a world leader in cancer care, other countries, such as France, Sweden, and Switzerland, boast overall survival rates that are nearly comparable. For some variants--such as cervical cancer, non-Hodgkin lymphoma, and two common forms of leukemia--the U.S. survival rate, although good, lags behind at least some other countries. You may also have heard critics complain that universal health care inevitably leads to long lines for treatments, as it sometimes has in Britain and Canada. Again, the facts just don't back that up. According to the Organization for Economic Cooperation and Development, France and Germany don't have chronic waiting lines. Access to care in those countries turns out to be as easy as, if not easier than, in the United States, where even people with good private insurance must sometimes wait to see a specialist or go through managed care gatekeepers to get tests and treatments recommended by their physicians. As National Review's Ramesh Ponnuru recently acknowledged, in a refreshing burst of candor, "[T]he best national health-insurance programs do not bear out the horror stories that conservatives like to tell about them."