Why are certain U.S. healthcare system dysfunctions not endemic in other countries? Or are they?

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I’ve just finished reading the eminent healthcare economist Uwe Reinhardt’s last and posthumously published book: Priced Out: The Economic and Ethical Costs of American Health Care. Reinhardt passed away at age 80 in November 2017; the analysis in Priced Out of the Affordable Care Act and Republicans’ failed 2017 repeal/replace attempts continues to within months of his lamented death from sepsis.

The book, a characteristically caustic and ironic overview of the politics and economics of healthcare delivery in the United States, brings into sharp focus the core themes of Reinhardt’s scholarship and writing. Key takeaways:

• Republicans want to ration healthcare by ability to pay, but they won’t say it. The U.S. is the only developed country in the world that does not explicitly commit to providing equal access to healthcare for all (with some allowance for concierge service on a pay-for basis for the wealthy, which Reinhardt regarded as tolerable).

• The U.S. multi-payer system, in which each insurer negotiates its own prices, is insanely wasteful. Reinhardt pegged the cost of all the wrangling between providers and payers at close to $200 billion per year.

• It’s the prices, stupid*: Prices for medical services and drugs that are more than double norms in peer countries are also attributable in large part to our divide-and-conquer multi-payer system.

• No single-payer soup for you, U.S.: While Reinhardt helped design a well-regarded single payer system in Taiwan, and regarded single payer as one viable model for universal healthcare, he repeatedly asserted that the U.S. political system was too corrupt to manage it: industry would use its funding leverage to demand unsustainably high payment.

While these themes were familiar to me from Reinhardt’s prior writings (e.g., regular contributions to the New York Times’ old Economix blog) a few throwaway lines made me wonder why some U.S. dysfunctions that are not solely attributable to our failure to standardize prices are not shared by peer countries, or at least not to the same degree. 

Buttigieg goes first! -- Decries predatory hospital pricing and proposes to do something about it

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I have been part of a chorus of healthcare writers complaining that when Democratic presidential candidates excoriate profiteering by health insurers and pharma, they always give providers a pass. Relatedly, my last post salutes three hard-hitting stories published this year -- two of them in the last week -- that spotlight predatory billing or collections by hospitals and private equity-owned physician staffing companies.

While no candidate participating in the September 12 CNN debate took Kaiser Health News editor-in-chief Elizabeth Rosenthal's pre-debate invitation...

Will any of the candidates take on HOSPITALS' PRICING AND BILLING policies at tonight's #democraticdebate? They should and why they might not...in my latest for the @NYTimesOpEd. https://t.co/e808tYGdLe

— Elisabeth Rosenthal (@RosenthalHealth) September 12, 2019

one candidate caught the cue this week. Today, Pete Buttigieg is out with a "Medicare for all who want it" plan (rather like Biden's, FWIW). In a statement, as reported by HuffPost's Jonathan Cohn, Buttigieg rounded up the usual healthcare suspects -- plus one (my emphasis):

“For years, Washington politicians have allowed the pharmaceutical industry, giant insurance companies, and powerful hospital systems to profit off of people when they are at their sickest and most vulnerable,” Buttigieg said in a prepared statement. “My ‘Medicare for All Who Want It’ plan will create a health care system that puts power in the hands of each American.”

The Wall Street Journal's narrow view of narrow networks

I have see-sawed back and forth between respect for the Wall Street Journal's healthcare reporters and intimations that WSJ coverage of the Affordable Care Act has been skewed toward the negative.

Today's front-page story by Timothy Martin on the prevalence of "narrow networks" in plans offered on the ACA exchanges certainly emphasizes the negative -- without adequate context, in my view.

First, consider the broader context. News this weekend was full of "ACA signup surge" headlines: 1.1 million people have enrolled in plans via HealthCare.gov, and about 2 million overall have enrolled in ACA plans when state exchange totals (not yet fully tallied for the pre-Christmas surge) are added in.  That's well off original projections but signals a significant recovery and acceleration. Today's front-page Journal story is the first since these numbers came in, and mentions them only in passing.

Fair enough, perhaps. The story is about "narrow networks" -- ACA plans that exclude access to many doctors and hospitals within the coverage area. The narrative is built on a McKinsey study finding that 70% of silver plans offered on the ACA exchanges are "narrow" or "ultranarrow" as defined by the study: offering access to fewer than 14 hospitals.