Letters: How Can We Make Health Care Work?

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Re "The Health Benefits That Cut Your Pay" (Sunday Review, Feb. 17):

David Goldhill's solution of catastrophic health insurance would not significantly reduce costs but would leave millions of Americans with inadequate health care.

Health costs are highly concentrated. The top 50 percent of health care spenders account for more than 97 percent of health expenditures. Almost all of their "catastrophic" spending would still be insured, presumably by the government.

The bottom 50 percent account for about 3 percent of spending, hardly enough for Mr. Goldhill's imagined savings. Meanwhile, a large number of Americans would be unable to afford necessary and preventive care. Many would postpone or do without care until their conditions became more expensive or "catastrophic."

About 22 percent of American children live below the poverty line. Imagine what this proposal would do to them.

DAVID SHACTMAN
Siesta Key, Fla., Feb. 17, 2013

The writer is co-author of the book "Power, Politics and Universal Health Care: The Inside Story of a Century-Long Battle." To the Editor:

David Goldhill writes: "Try to imagine what homeowners' insurance would look like if we expected everyone's house to burn down and then added coverage for each homeowner's utility bills and furniture wear-and-tear. This would be insanely expensive without meaningfully reducing anyone's risk. That, in short, is how health insurance works."

His analogy is flawed.

The costs of heating and electricity are predictable and can be controlled by buying smaller houses and turning down the thermostat. But while the costs of chronic illnesses are predictable for large populations, they are highly unpredictable for people and their families.

The maintenance cost of remedying shabby furniture and peeling paint can be balanced against other nonessential spending, and the consequence of delay is born solely by the family, while the cost of inadequate prenatal care and incomplete vaccinations will be paid by society as a whole.

Thus, health policy that covers only catastrophic illness, as Mr. Goldhill advocates, might work well for the healthy middle class but would fail miserably for families with chronic illnesses and discourage preventive medical care.

RACHEL BRONHEIM
Princeton, N.J., Feb. 19, 2013

To the Editor:

With the best intentions, David Goldhill has described a free-market fantasy of health care. Market prices are based on power. In the United States today, hospitals and large doctor groups wield enormous market power, and they exercise it ruthlessly; consumers have none. Hospitals charge whatever the market will bear; uninsured patients pay the highest prices.

Large insurers bargain for "discounts" from prices set high enough so that hospitals still profit, and pass some of the "savings" on to large employers, who also have market power, but not to small businesses or individuals.

Whatever their faults, single-payer systems using government leverage, like the Canadians' — or Medicare — deliver decent quality care to more people at lower cost. Mr. Goldhill makes the best the enemy of the good.