Judge American medicine by the standards its critics prefer—life expectancy and cost per quality-adjusted life year—and it is easy to present a harsh indictment in PowerPoint. We spend more than anyone. We die earlier than the Germans, the Japanese, and a lengthening list of other social democracies. If the purpose of the system were to maximize population health, the American arrangement would be a waste and, given what we pay for it, a catastrophe.
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Yet Americans have never asked their doctors to max out their life table. They ask that when a body fails, a competent stranger will answer quickly, without first requiring the patient to justify himself to a committee. What we purchase, at the highest prices on the globe, is not health. It is responsiveness.
This is the revealed preference of a people who will tolerate almost any inefficiency except being told to wait. The proof is the Department of Veterans Affairs system—the most socialized large medical provider the United States maintains.
When the VA explodes into scandal, the detonator is never veteran life expectancy. It is the waiting list. The Phoenix VA in 2014 became a crisis not because the department had failed a utilitarian audit of years added, but because veterans who had already stood in line for the country were asked to stand in line again, and some died while the list was being massaged. Congress does not ask why American veterans live fewer years than Israelis. It asks why in February the next appointment is in November. The mandate is access. The metric of outrage is delay.
That fact should embarrass every wonk who treats American medicine as an unfinished European project. Even where the payer is the state, the American customer is always right, and the American customer expects to be seen NOW. A clinic that makes a woman in pain wait 18 weeks for an MRI or a specialist has, to our American mind, already failed. Instant consumer service is not an overlay on our medicine. It is the goal.
The rest of the civilized world has arranged its affairs to exploit American impatience. Other competent governments ration and negotiate. They decide a drug adding three months of life is not worth the list price, and they do not buy it. Their citizens live with gatekeepers and denial clothed as stewardship. In return, they pay less and live longer in reasonable health. The research that produced the new drug that eventually enters the approved basket is financed by the American refusal to trade away access for cost savings and more quality years of life.
The United States thus accounts for a share of global spending on new medicines far out of proportion to its population or its share of rich-world income. American prices pull the returns that justify the next trial. Other national systems then buy the new pill at a discount that would be impossible if they had to carry the fixed cost themselves. This is a global public good paid for by the generous impatience of the American customer who will not take no for an answer.
Americans are beginning to see through the ruse. They have noticed that the same pill costs a fraction of the Cleveland price in Hamburg or Paris and that their premiums finance pipelines whose fruits appear abroad after they have already paid the introductory ransom. A people famous for impatience may yet decide it no longer wishes to be the world’s innovation, Daddy Healthbucks. That American revolt, if it comes, will be a decision to stop being the buyer who will keep paying for another three rings to toss in hopes of the newest and biggest and shiniest kewpie doll.
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Until then, the American scheme has a virtue its critics have not named. It is a meta-responsive market. It does not impose one official tradeoff among quality years, money, and agency. It lets households choose which good they will sacrifice.
Optimize for longevity, and you can have the European way of illness and death. Enter a strict HMO like Kaiser Permanente. Accept the gatekeeper. Wait for the scan. Live, with merely average luck, like a German or an Israeli: longer, less burdened by treatments and side effects, and less free to demand the next appointment on your own schedule. Many Americans may say they want that bargain. Fewer keep it once the bell begins to toll.
Optimize for preserving family and communal resources, and another path remains open. Communities that treat medicine as a mutual obligation rather than an unlimited claim—the Amish are the starkest case—spend as little as one-fifth as much as the average American by declining the hope of another month of life for the very old and very sick. They buy the best care for children and working-age men and women. They refuse to let the dying consume the shared patrimony. This choice may seem harsh to those who choose to prolong their dying outside it. Yet it, too, is morally coherent.
Optimize for agency, and you have described the American default. Private insurance, Medicare, workers’ compensation, and the VA itself are all built to maximize the patient’s power to force the system to respond. That is why they are expensive. Responsiveness is not an accident or a come-on. It is the goal being sold and, mostly, delivered.
The wonks believe that medicine is a public utility whose output should be read off a chart of “quality-adjusted life-years.” The American mind has never quite believed that. It treats the body as a private trust and the physician as a hired servant, not as a guardian of the population. The American disposition produces apparent waste, massive inequality in what is spent on some as against others, and a bill for innovation the rest of the world is happy to let Americans carry. It also produces a medical culture in which a patient still expects the staff to jump to it when he says he is in pain.
Reformers want Americans to wait, to be denied care, and to call the denial wisdom. They may be right that the charts would improve. What they cannot do is pretend the present system failed at a task it was never assigned. Americans did not set out to buy the longest quality life at the lowest average cost. Americans want more than anything else the right not to be told to come back in three months. Measured against that demand, the American system is not just a bloated county fair of quacks and pioneers. It is a mirror of the American disposition and the engine of medical progress for the world.
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