National Health Insurance Revisited

Prologue: America's occasional flirtations with national health insurance have been a footnote to our history for most of the twentieth century. Once again, as health costs soar for people with insurance and access to care erodes for the disenfranchised, the United States is discussing health financing reforms. One of our nations most astute observers of this long saga is Victor Fuchs, the Henry J. Kaiser, ]r. Professor at Stanford University. In this essay, Fuchs revisits the subject in the context of a paper he wrote fifteen years ago entitled, “From Bismarck to Woodcock: The ‘Irrational’ Pursuit of National Health Insurance.” When Fuchs began to practice health economics in the mid-1960s, it was little more than a gleam in the eye of the broader discipline of economics. In the ensuing years, it has taken U.S. health policy making by storm, leaving the allied disciplines of the social sciences, for better or worse, in the dust. One of the many interesting messages Fuchs has sought to deliver over the years should (but at this point clearly does not) resonate with health policy practitioners who look to health financing reform as a nirvana that will dramatically improve the health of the nation. In his influential 1974 book, Who Shall Live?, Fuchs wrote: “Today … differences in health levels between the United States and other developed countries or among populations in the United States are not primarily related to differences in the quantity or quality of medical care. Rather, they are attributable to genetic and environmental factors and to personal behavior…. Indeed [except for the very poor] higher income often seems to do as much harm as good to health, so that differences in diet, smoking, exercise, automobile driving and other manifestations of ‘life-style’ have emerged as the major determinants of health.”