The relationship between American government and American medicine is unique, contradictory, and fraught with conflict. Unique in that every industrialized democracy other than the United States has introduced some form of universal health insurance. Contradictory because America spends almost two and a half times what these other nations spend per capita on healthcare, but with poorer results: lower life expectancy, lower rates of immunization, higher rates of obesity and diabetes, and much worse infant mortality. Conflicted, finally, because there is an ideological chasm between those who would use the power of the state to provide health coverage for all (or most) Americans, and those who excoriate increased government involvement as “socialized medicine.” Health and Human Services Secretary Mike Leavitt recently acknowledged that his chief objective, in the final year of the Bush Administration, is limiting the federal government’s role in healthcare. 

 

Yet, no serious politician would suggest eliminating Medicare, which is, in effect, a single-payer system for senior citizens. Indeed, it was a Republican Congress and President who, in 2003, enacted the largest expansion of Medicare since its inception—prescription drug coverage—projected to cost $724 billion over 10 years. When citizens are asked whether government should increase the $30- billion National Institutes of Health (NIH) budget, polls typically report 75 to 80 percent in favor. 

 

Even so, anxiety about a government “takeover” of American medicine is not merely political posturing. Obviously, a program designed to cover the 45 million uninsured Americans would be expensive. So expensive, in fact, that no Democratic presidential candidate has offered a detailed explanation of how his or her healthcare plan would be financed. Republicans generally sidestep the question by endorsing minor changes to the tax code that would make individual health insurance policies tax deductible. For the GOP, it remains an article of faith that, given the right mix of incentives, the private market will offer affordable coverage to most of the population, without need for large-scale government intervention. 

 

The essential difference between the two parties’ views is how each understands the purpose of insurance and the role of the state. For Democrats, insurance should provide a financial and social safety net that protects everyone from calamity. To achieve this broad goal, as in Medicare, the sick and the well pay more or less equally. And the healthy subsidize those who are ill and need treatment. This concept is called “social insurance,” and it is the basis for all government-financed health coverage, from Canada to Japan. The main attraction of social insurance is that everyone enjoys a basic level of protection from catastrophic illness. 

 

Critics of government intervention cite the fact that, a generation ago, Europe was a world leader in drug development. Now, owing to national health plans that have imposed price controls on pharmaceuticals, innovation has migrated to the U.S., the last bastion of free-market healthcare. Thus, the producers of medical technologies—biotech, drugs, medical devices, diagnostics—fear that American officials and government bureaucrats will inevitably put a lid on costs, and that, as in other countries, innovation will suffer. 

 

The great unanswered question about American healthcare might go like this: What is the best system for sustaining innovation to invent new breakthroughs and to ensure that no one is denied the best medicine for lack of ability to pay? The life sciences industry has focused on the first part of this question. Politicians are increasingly focusing on the second. Resolving the tension between the two may require as much creativity as discovering the next monoclonal antibody.