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It amazes me that you think the solution to fixing a broken system is to just throw more money at it. The problem is in the incentives. A recent OECD study found that "the percentage of the respondents in need of elective coronary bypass who had been waiting for more than three months was 0% in U.S., 46.7% in Canada, and 88.9% in the United Kingdom." The study concluded: "The majority of providers of surgery [in the US] is private and is highly incentivised to meet demand by activity-related payments." It baffles me that non-economists still refuse to recognize the role that incentives play in the world.

Jason Rhode

"It amazes me that you think the solution to fixing a broken system is to just throw more money at it."

Didn't Gladwell *just* write:

"In fact, we already spend far and more the most on health care than anyone else in the world."

I don't think conservative boilerplate is going to get us any closer to the truth. The point is to spend less money, right?

Martin Tod


How do people without health care cover find out that they need a coronary bypass - before they die that is? Won't the other countries be affected by the fact that everyone (yup, everyone) gets health care - even the sick people.

If the surgery is elective (I'd have been more impressed by a non-elective comparison), might it also reflect that US surgeons are undertaking surgery that wouldn't be deemed necessary in other countries with better overall health statistics than the US (i.e. most other Western countries) purely due to the profit motive? Is it good that loads of US people have heart bypasses? Is it leading to better overall health outcomes?

And finally, what makes you think that countries outside the US don't use market incentives to get surgeons to perform surgery?

Peter Z

But of course the 0% US wait list rate bragged of by Robby IS costing the US at least 50% more for its health system than the Canadian model that covers everybody here, while the US "system" is leaving out a large percentage of its citizens who don't have health insurance and can't afford to even get onto a waiting list for "elective coronary bypass surgery".
Keeping people off the list entirely is, I suppose, an effective way to keep lists short, sort of a New Orleans recovery solution. Brought to you guys (I live in Canada) by the same good folks who brought you the Katrina response.
The real question is who is throwing money away at their health care?


I have a question. What would happen to the lines for health care in this country if the 40 million people currently uninsured were suddenly insured and got in line (and remember that many of these people are poor and perhaps in greater need of health care than the average person)? Wouldn't the lines for health care provision get a lot longer? So in that sense, maybe the quickness with which Americans can access care has something to do with the large portion of the population that has no access.


Do we really know how much Americans pay on health care? So many of us buy our own meds, including over-the-counter remedies, and in the movies the hero or the anti-hero always has a private physician or gets the bullet wound healed on the sly. Is all this counted? Does it not amount to much?


I suggest a tour of archimedesmovement.org, a blog begun my former Governor of Oregon John Kitzhaber, MD. He is beginning a grass roots movement to address disruptive health care reform of a broken system. His underlying principles and ways to participate can be found at the above site.

John Clark

I am a pulmonary and critical care physician and am very discouraged to be working in a system that has no efficient incentives to help patients to change behavior so that the demand for expensive health care interventions decreases. A bypass operation is "the ambulance at the bottom of the cliff" that might not be necessary if patients make appropriate lifestyle modifications. We spend an enormous amount of money treating potentially preventable endstage complications of chronic illnesses such as diabetes, hypertension, emyphysema, and heart failure. In younger patients trauma remains a significant cause of morbidity and mortality and if they survive often presents an incredible financial blow to the patient. We need to focus public dollars in a meaningful way on pragmatic, effective preventitive measures. We need to spend more money funding research on how to change behavior and less on designing very expensive treatments we cannot afford For the free market folks I will share with you that I am payed around 100 dollars for talking to a patient for 30 minutes about smoking cessation and aroung 1500 dollars to perform a relatively simple 20 minute procedure to diagnose their lung cancer. In cardiology the discrepancies are much larger - a heart catheterization with placement of 3 drug coated stents costs in the tens of thousands of dollars. The same cardiologist who performs this procedure gets 100 dollars for a visit where they discuss exercise, diet and smoking cessation. In a system that has perverse incentives you can count on perverse outcomes. Anyone who spends much time in an ICU knows that much of what we do now makes no sense and is an enormous drain on monetary, human and emotional resources.


As a Canadian who has lived in the United States, England and now Portugal (and is married to a doctor), I believe the single insurer system of health care is by far the best system around, in that it leaves no one out yet allows patient choice. However, patients have to understand that what they are getting is not "free" which is why low user fees are a good thing. What is not a good thing is allowing private medicine to creep in under the guise of offering semi-medical or elective services to reduce wait times for people who can pay etc. Before you know it, you have 2 parallel systems (England, Portugal and hopefully not Canada) and guess who suffers?


Beyond the funding issues in the U.S., I believe the root cause is deeply seated in the legal system. Litigation "damages" are funded through medical treatments sought. The higher the medical bills, the higher the pain & suffering awards, and you get the spiral effect.

Not to mention the volumes of CYA type diagnostics that are done for the doctors to protect themselves and their practice from litigation.

I feel that if we address our tort system in a way that still discourages negligence that harms individuals, yet does not incent medical treatment excess, we will be on the road to recover our U.S. healthcare problems.



I am a Canadian physican currently training in the United States. I have seen both health care systems first hand. Canada's universal health care coverage certainly is not flawless. Waiting lists are indeed longer and access to diagnostic tests are limited. But the goal of a health care systemn should not be to reduce waiting lists to zero percent and make MRI scans available within 24 hours. I would argue that a health care system should be designed to make people healthy. As far as I know, every marker of population health shows Canadians are healthier and live longer than Americans, despite spending approximately 50% less on healthcare.

By the way, I am very grateful to be training in the United States where I have access advanced technology that is simply not available in Canada.

Arya Nielsen

I agree with the physician from Canada, and am reminded of a quote from a medical student that was reported in the New York Times. In answering the question 'what is health' he replied: someone who has not had a proper medical work-up.

As long as 'good' equals 'goods', and profit is the measure, the products that manage disease need disease. Where is the incentive for health?

Will H

So when do we take into account the litigous (sp)nature of our current healtcare system?

The doctor above cited the perverse outcomes and variances in getting paid from various procedures, but what wasn't mentioned is that the doctor undergoes a near career ending amount of risk when he/she performs an unwarranted surgery just for a pay day.

I seriously doubt that the # of doctors operating to get a pay day vs those operating to save lives rivals the #'s of patients in socialized health networks that need insurance (that AREN'T being seen - wait lists etc).

Further, what no one else has brought up is the large amount of indigent health care that actually exists. In many large municipalities, government aided hospitals are reaching near epic proportions of un-insured treatment, so 60 - 80% in larger areas are uninsured. Yet, they are still getting treatment and still being taken care of. (Point being we have a two tier health system already, we just aren't managing our money effectively, or even realizing it's there!!)

I think that if we were to take the principles expressed in Mr. Gladwell's "Million Dollar Murray" article (power curve theory etc.) and overlap that with the existing problems in health care we might unlock some of the secrets and identify the most "at risk" citizens that need our system to accomadate their health care specific needs. The main difference in the two audiences are the vast majority of uninsured aren't healthy, murray conversely gets healthy just to be able to drink again etc. The recitivism is MUCH less in the un insured. (although it's a larger population by far)

Further points to be addressed, illegal immigrants impact on our health system, healthcare for those under 18, and employers impact or relief that might be given by federal options to those that need insurance.

Let's continue this discourse! It's rare, insightful, and best of all a-political (in other words constructive :-) )

Dejan Jelovic

Just to clarify Malcom's post: U.S. spends roughly 15 percent of its GDP on health care, which is about double the amount that other western countries spend.

Unrelated: Health systems of various countries with "socialized" medicine could be vastly improved by introducing some competition.

Instead of a, say, MRI machine being owned and operated by a government-run hospital, it would be better if MRIs were run by private firms that competed (on quality, not price) to woo the customers whose fixed-price bill would be paid by the government.

There would be some room for taking advantage of the system (e.g. doctors and MRI operators collude to defraud the government), but in this computerised age and large-scale fraud could be easily detected using statistical means.


Thank you Mr. Gladwell. And I'm sure our "Greatest Canadian", Tommy Douglas, would appreciate it too. Many of us will continue to fight for Tommy's beautiful idea no matter how many cats try to tell us mice what's good for us. Those of you Americans who have strong opinions about the Canadian healthcare system would benefit from listening to Tommy Douglas' great speech on the subject. Tommy Douglas, the gentleman who *created* our Canadian medicare system:

Trapier K. Michael

Antagonists of the US system claim LOWER spending and BETTER quality for socialized systems.

Are you saying that Canada spends less AND is of lesser quality? This would be a significant statement.

Trapier K. Michael

Dwight McCabe

There's one big reason healthcare costs so much more in the U.S. and it has nothing to do with rationing care.

The payment system for healthcare in the U.S. is based on a fatally flawed assumption: that competition will make private coverage more efficient, when it does exactly the opposite. No private insurer is required to cover everybody who applies to them. So they have great financial incentives to spend time and money to identify potentially high cost people and reject them. For individual insurance companies this makes economic sense, but for society as a whole this system creates an enormous duplication of cost and time.

The result: nearly 30% of all U.S. healthcare spending goes to administration, i.e. rules and red tape to screen out potentially high cost people, compared to 3% for Medicare and other single payer systems.

Several independent studies comparing many payment systems have found that a single payer system would cover everybody for less than we spend now. And with no reduction in the kind of coverage that most of us have now. We could save nearly 30% of our current healthcare spending and use it to cover everybody, with the same private care and quality as we get now.

You cannot fix a system that is based on a fatally flawed economic assumption by making small changes on the margin. You have to change the fundamental design of the system to get it to work.

We need to scrap healthcare’s crazy payment system which encourages enormous overspending on administration and switch to a streamlined system that covers everybody.


"Antagonists of the US system claim LOWER spending and BETTER quality for socialized systems."

NO, this is *your* frame, not ours. This is what Bush does all the time "If you're asking me ... ".

Those of us who advocate quality healthcare for all citizens aren't talking about cost-cutting. Cost cutting is the priority of the right. And people who don't like paying taxes for public services are the ones who favour those politics. Those of us who support public health care (and education) have, as our priority, a healthy, educated nation. There are a great many occupations that do not offer healthcare. Furthermore, privatized healthcare schemes favour the employers pocket book, not the health of its workers. Private healthcare is based on a profit model. The most obscene aspect of American culture, in my mind, is the profiteering off of health conditions. Most Canadians are horrified when they find out that Americans routinely go bankrupt for the cost of an operation or cancer treatment. Have you, you who object to public healthcare, ever considered, for one single moment, what it might be like to not have the money to pay for your hospital bills? To have to die simply because you are poor? Is that really acceptable to you?


The debate on health care is important and fascinating, but what really strikes me about the Gopnik/Gladwell debate is how painlessly and unabashedly you admitted that you'd changed your mind. What's with that? That never happens. Who ever says "I was wrong?" I'm taken aback! Yay.

Brad Hurley

Increasing funding would certainly help the system function as envisioned (though Canadians are already so heavily taxed that I wonder if we're willing to shell out more...as a resident of the province of Quebec my income taxes are already the highest in North America -- my income tax rate is 52%, and on top of that there's the roughly 15% sales tax), but there is also a lot of work to be done to encourage more doctors to practice here. We see a lot of reports of doctors who want to come here from other countries but who are thwarted by bureaucratic red tape and other flaws in the system. And we really, really need more doctors.


All this hand waving makes me dizzy. Universal health care is just universal access to waiting lists. The Brits fudge endlessly with schemes allegedly to reduce waiting lists but, when you play musical chairs with too few chairs no matter how you arrange the chairs there will be too few chairs and someone is left out. Socialist politicians always promise more than socialist economies can deliver. In that circumstance, some people ultimately have to be denied medical care. They give up, get better on their own, die on the waitng lists, or are prevented from even getting on a waiting list. Don't think so? The latest Brit scheme to reduce waiting lists has them denying unhealthy people access to the waiting lists. Brilliant.


NHS waiting lists, redux.


Pat L

My understanding is that much of the difference between US and EU/ Canadian expenditures can be accounted for by the fact that in the U.S. we keep very sick people alive as long as possible. You can look at this as waste or as a sign of strength, wealth, and vitality. No man left behind.

You can increase supply by increasing funding, but you still have to ration in some way. Who gets the new supply, those who pay more, or those who wait in line longer? And how do you know when to stop increasing funding and creating more supply when wants are infinite at a price of zero?

I don't deny that the U.S employer based insurance system needs a fix, but we are both way out of our element here. You may try www.marginalrevolution.com for a start. And say hello to Woody and Spike for me man.


malcolm, your hair is pretty :)

David L

There are two facts to keep in mind about the Canadian healthcare system when considering it as a model for reforming the U.S. system:

First, the Canadian system is funded in part by Canadian doctors in the form of lower fees, salary caps and, on occasion, wage freezes and rollbacks. Although some doctors don’t mind becoming de facto civil servants and, certainly, doctors training now in Canadian medical schools know what they’re getting into, I doubt if they will continue to feel good about their status and economic situation when they see the fortunes of their friends in the private sector improving while theirs erode over the years or remain stagnant. During the sixties and seventies, Canada benefited from an influx of top-flight British physicians who were refugees from the National Health Service. But once medicare was firmly established in the late eighties and nineties—and government bureaucrats felt freer to tighten control over services and funding—disgruntled Canadian doctors (and patients) emigrated to the U.S. for greater freedom and opportunity (and better care). There won’t be any place for unhappy doctors (or patients) to escape to once the U.S. system resembles Canada’s.

Second, Canada was, and still is, able to afford (sort of) its healthcare system because the U.S. taxpayer is chipping in a large chunk of the cost by paying for Canada’s defense. Canada doesn’t have to have a military capable of defending the country or of making more than a token contribution to overseas wars because during the Cold War, when Canada launched universal medicare, it lived safely under the American nuclear umbrella and now, when it sees few external threats worth confronting, it maintains a small force of mostly peacekeepers and lets the U.S. do any actual fighting.

Both of these sources of funding—reducing the livelihoods of doctors and having a limited military—were possible in Canada because of a socialist and pacifist ethos that was untroubled by seeing doctors humbled and the military curtailed. Before adopting the Canadian healthcare model here in the U.S. we should first decide whether we like all its implications.

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