Having seen British diplomacy snatch Cyprus during the 1878 Berlin Conference, an impressed German chancellor Otto von Bismarck congratulated prime minister Benjamin Disraeli: “This will be popular; a nation likes progress.”
The irony was not lost on Disraeli who, while reporting this to Queen Victoria, said that “Bismarck’s idea of progress is evidently seizing something.”
It was an accurate insight, even after considering Bismarck’s institution in 1883 of health insurance, a revolutionary move which, like his introduction of pensions in 1881, did not reflect affection for the masses, but fear of them.
Even so, Bismarck did 134 years ago what American leaders have not done to this day, an historic failure underscored by this week’s collapse in Congress of President Donald Trump’s assault on Obamacare.
While obviously adding to a young presidency’s mushrooming list of debacles and scandals, it is part of something much larger – a grave industrial, political, and social disease. The industrial dysfunction is appalling.
At $3 trillion, or $9,451 per capita, American health spending is by far the world’s highest. It is 35% more than the next highest health spender, Switzerland, and nearly twice the average of the 30 richest countries.
Despite this massive spending, and even after Obamacare’s partial insurance of 20 million previously uninsured citizens, nearly one in 10 Americans remains uninsured. Anything the American health industry sells, from heart surgery to an antibiotic pill, is far more expensive than its price elsewhere.
Israel’s contrast is a case in point. In turn for an automatic 5% deduction from our income, we are all fully insured, even non-citizen residents, and that includes expensive things like dialysis, chemotherapy, organ transplants, or triple-bypass surgery.
It is inconceivable in this society that anyone in need of such treatment would be abandoned. We pay but a few dozen shekels for over-the-counter drugs, and we have a basket of state-paid expensive medicines that leaves out but a very few, rare-disease medications.
Israel accomplishes all this while spending $2,533 on health per capita, less than one-third of America’s spending, while deploying 50% more doctors and sporting more than twice as many hospital beds.
Yes, we have private clinics and complementary insurance plans which draw a growing part of the middle class away from the public system. It isn’t perfect. Yet the fact is that for most of what brings patients to doctors, anyone here gets treated quickly, equally and well, thanks to a system we all owe to Yitzhak Rabin’s vision, leadership and compassion.
THE SYSTEM Rabin inherited was inefficient and corrupt, following decades of domination by the Histadrut labor federation, which funneled most Israelis involuntarily, through their employers, into its health-maintenance outfit, Clalit, while skimming off health-insurance payments as a union-member fee.
Rabin couldn’t stand this. He thought paid membership if anything should be voluntary, and that healthcare should be public and universal, but also competitive. Since all this made the unions resist his reform, Rabin parachuted into the enemy’s rear by having his protégé, Haim Ramon, run for the Histadrut’s chairmanship; which he indeed won, before using that position to disarm the plan’s main opponent.
Rabin then passed the National Health Law, which deducts health insurance payments from all salaries on behalf of the National Insurance Institute, which then funnels those funds to four not-for-profit health funds according to the number of clients they recruit. That is how we ended up with a system that combines affordability, universality, and competition.
Rabin, in short, had a plan. Trump doesn’t and neither did Barack Obama, who reached the White House so plan-less that he asked Congress to turn his abstract idea for accessible healthcare into a bill. That is why Obamacare took 15 months to become law.
Trump is even less planned. Spending less and charging more, as he promised in his campaign to do, is not a plan. It’s a whim. A plan would treat the industrial ailments that make American healthcare costs exorbitant, but that would mean confronting an insurance industry that thrives on the American health system’s deformities.
Israel’s healthcare prices are low, because its health system is dominated by not-for-profit health funds and hospitals, and also because its medical schools’ tuition is some $3,000 per year, while American levels range from $32,663 at Baylor College to $63,890 at Columbia University, fortunes whose repayment debt-ridden doctors thrust on their patients.
Mammon, then, is to the American healthcare crisis what the unions were to Israel’s last century. And mammon is also the part of the situation that both Trump and Obama would not touch – one for lack of motivation, the other for lack of guts.
This is why America’s situation will not change before it finds a leader like Rabin, whose reinvention of the healthcare industry was enabled not only by the industrial vision he brought and the political plan he devised, but also by the social compassion with which he was imbued. He really cared.
Obama also cared, but he lacked a plan and a vision. Trump lacks a plan and a vision, and he also doesn’t care. That is what Trump’s party colleague, West Virginia Sen. Shelley Moore Capito, insinuated when she explained her refusal to back the bill to repeal Obamacare: “I didn’t come to Washington to hurt people.”
Others, alas, did, and they are backed by millions of Americans who care for those who profit from America’s oppressive healthcare more than they do for those who can’t afford it.
Trump, then, is not the name of an American illness; he is its symptom.
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