By Hazel Schaeffer

TMW: You are widely considered Macalester’s resident expert on health care. You also hail from Canada, which gives you a unique perspective on the issue. What got you interested in healthcare?Terry Boychuck: I became very interest in comparing Canadian and American systems because in the 1980s and early 1990s there was a lot of interest in Canada; people wanted to know a lot more about the system and whether it was a system that we could possibly adopt in the United States. Eventually the Clintons opted not to go toward a single pare universal program, adopted something called manage competition as their model. It occurred to me that it was important to put the two countries side by side and compare them systemically, not on the basis of their performance but on why on why they differed so much from each other in the first place, when they had such common roots.

How closely is healthcare interwoven with other social issues?

When Canada instituted national health insurance, which created health care as a social right, it became a very important part of the national identity, and so it had very important consequences for other social policies that Canada adopted afterwards. A universal right to healthcare translated into a universal right to housing, income, food, shelter and so forth. It has a very important halo effect; it transformed most of Canada’s other social policies to make them more generous and egalitarian.

How does health care in the U.S. compare to that of other countries that you have studied?

It’s the most expensive healthcare system in the world. Canada on a per capita basis spends two-thirds as much on health care as the U.S., and Canada’s is the second most expensive. But typically most nations will spend a third to a half of what the U.S. spends. The reason the original interest in national health care emerges is that from the best available evidence that we have, if you create universal health care insurance and finance it by government, you could finance it at a much lower cost, and yet the health benefits tend to be the same. If you look at health indicators (longevity, infant mortality) it turns out that egalitarian systems do a much better job of safeguarding the health of the population. The best indicators we have suggest that we can spend a lot less and do a lot better. That’s always been the motive behind reform for the past 30 years.

It’s widely assumed that American health care is poorer than other industrialized countries. It certainly covers fewer people. But does it have any advantages?

There’s a very broad belief in the United States of what we call American exceptionalism. The premise is that what other countries do is fine for them, but if you ever tried to import those kinds of institutions into the U.S., because Americans are different from other people, it would be catastrophic. Clearly, America has the system that best fits Americans. One of the beliefs about the American healthcare system is that if we organize it on a market as much as possible in the near term it might appear inefficient, in the long term it will be the most efficient, the most innovative. This belief that the market inevitably produces better outcomes in the long run, creates a more innovative technologically advanced form of care, and that the U.S.’s health care system, because it’s organized on more of a market basis, will create all the innovations and advances for all the socialized health care systems around the world. One of the arguments is that the U.S. bears the burden of creating this center of ingenuity for the rest of the world, and that it needs a market driven system in order to fulfill this function. I don’t believe that. If we look at patterns of innovation in health care, it’s true that American health care system produces an innovation, but most of the innovation is in what we call “half-way technologies.” That is they really don’t solve the problem, they provide some slight remedial effect to help manage what we call chronic conditions sometimes but really don’t get at the root of diseases.

What the other health care systems focus on much more carefully is that, rather than let disease proliferate, how do you stem it in its earliest stages? So they have a much greater emphasis on preventive care (catching things early), so that you don’t need magic bullets at the end of the process, invasive surgeries and lots of pills to manage conditions. It’s a very different cultural model at work here. Part of the problem in health care reform is changing those perceptions of what the medical profession can possibly do for you. Americans have a very inflated sense, almost a magic sense, or what healthcare can do, and so they tend to focus more on the curative aspect rather than the preventive aspect. That’s part of the genius of the other systems. The presumption is that Americans culturally can never imagine prevention or primary care as the solution. They want to have their cake and eat it too.

Is the romanticized view that many have of Canadian health care justified, in your view?

All human institutions are fallible institutions. Canada has solved an number of important issues . [however there are] secondary problems that require constant attention and are source of controversy. Because Canada invests so much in primary care, and primary care doctors are paid relatively well, there’s a shortage in specialty doctors. Most of the shortages are generated by the high incomes in the U.S., and so Canada finds it very hard to keep very skilled surgeons because they can make several times their salaries if they moved to the U.S. So, often times in Canada there are large shortages of specialists. So, that is problem. Do we take resources from primary care doctors so that we can pay specialists much more than we pay them, and therefore increase the income gap? That’s a controversy that Canada can’t quite solve. So we find ourselves recruiting specialists from places like India and Britain and South Africa. In such a sense we are torn by that because India and South Africa and Brittan also need its specialists. It creates this medical leap-frogging market. People are constantly moving up the medical chain into higher paying countries but leaving the most vulnerable populations without specialty care. It’s a global problem.

As a sociologist do you look at healthcare differently than the other academics that craft public policy? If so, what do they miss?

There’s a broad divide between sociologists and economists on matters of social policy. Typically, sociologists prefer social democratic resolutions to healthcare and welfare state issues. They tend to believe that governments have an obligation to intervene into markets, to reduce inequality through these types of programs, and to create a range of social services that are available not because we are wealthy or hold jobs. they generally argue that there are important tradeoffs that come with social welfare programs, that you reduce efficiency of markets if you interfere with market incomes and therefore you tend to suppress the wealth generating potential of society. That is the model that the U.S. has typically followed when it comes to social policies. It sees government as a provider of last resources for people who have failed. This is the great divide, whether government is something that provides access to publicly need services as a last resort, and the rest purchase it through the market. They see this as the free society or the emancipated society, that markets are the best for serving individual needs. Sociologists tend to believe that markets themselves will not create the kinds of egalitarian outcomes that foster a sense of citizenship.

Obama has made a top priority of twin goals: “to extend coverage to millions of uninsured Americans and to slow the fast-rising rate of inflation for medical care.” Are these goals achievable in the foreseeable future?

I don’t believe that he can slow health care inflation (the costs
of health care rising faster than people’s incomes). I believe that what he has is a set of public declarations from the hospital and medical and pharmaceutical industries that they will limit increases in costs. These are not firm commitments, they are not written in stone. It’s quite possible the day after they may back away from them and say they were unreal and we announce goodwill toward the program, but to be honest things have changed, and we cannot abide targets we’ve announced for ourselves. The saving he projects because costs will come down are really soft predictions; there’s no hard science to say this in fact will happen. What the plan will do most likely is increase the money spent on healthcare. Without a hard budget if you introduce 40 million people into the system its quite possible that the country will spend even more on healthcare than it does right now . I think the costs will be higher than they expect, which might lead to the undoing of the proposal to undo the current system.

Has health care always been as politicized as it is now?

Healthcare has been an endless source of anxiety and political turmoil in the U.S. since the first proposals for national health insurance were introduced in the Great Depression. About every decade Congress returns to consider healthcare reform in some major way and there’s a large deal of public interest. Usually what’s left behind at the end of the day is not much when it comes to reform. History is not on the side of Barrack Obama. If he can pull it off, it would be an enormous victory. The opponents have always carried the day. It was true in 1935; it was true in 1948 when Truman wanted it. There’s a joke in health policy circles: Bill Clinton dies and goes to heaven and talks to St. Peter and asks for an audience with God. St. Peter says, “Yeah, I can arrange that, let’s go.” So Bill Clinton says to God, “I wanted universal healthcare insurance, Jimmy Carter wanted universal health insurance and Richard Nixon wanted universal health insurance. Will the United States every have universal health insurance?” And God says, “Yes, but not in my lifetime.” It’s always an elusive quest. I hope that it becomes a reality. If you can establish in principle that everybody should have healthcare, it becomes easier for the government to make all types of changes down the road that they can’t make initially. Once Americans believe in the principle of universality, it usually gives the government enough leeway to reorganize health insurance markets and healthcare providers so that they become more affordable and more efficient.

How would public opinion be swayed that health care is fundamental?

The moment people get used to the idea that they will always have health care when they need it, to try to take that away from them, would be very hard. Once they become used to that type of security, I don’t think they would be willing to go back to a world in which they can lose their health insurance if the change jobs or become to sick. The attitudes will catch up with the institutions once you create
universal healthcare.

But it’s hard for the government to act without public support but the people will not have the knowledge of the security until the government puts it in place.

It’s always been the catch-22. Historical experience in other countries shows that health insurance becomes one of these very important sources of identity, they become proud of it. . Once they are in place they become very difficult to remove. This is what the Republicans are afraid of, rightly so. They know that that if you create universal health insurance, there is not going back. This will create enormous popularity for a government managed health care system, not run, but supervised and financed. It really is the beginning of something greater. If you are ideologically opposed to the notion of anything but the market allocating health resources and the government is a provider of last resorts, then this is a tremendous symbolic [defeat]. It changes the meaning of being an American and a surrendering of a faith or a credo in private markets to best manage things. It’s a do or die issue for them usually to defeat proposals such as this. Its very scary for them, there’s a great terror in the ranks of the party.

A lot rides on [this past] Wednesday night’s speech. Demand for health care reform is very high in the beginning. Once it is attacked, normally support for reform drops and drops the longer the issue is on the table. The fact that this issue has already been on the table for six month means that the pressure on Republicans and Democrats to cooperate lessens every single day. The president’s really got to race against time. If he pulls it off, it will be something of a miracle, but it’s a miracle I hope for. You still have to believe in miracles after all of this.