Canada v. U.S.

A health-care debate between Adam Gopnik and Malcolm Gladwell 

Adam Gopnik:

I have lived under three different medical regimes: Canada, the United States, and France. I have been seriously sick under all three regimes and had many family members with similar experiences.

My wife's sister had a very, very premature baby born in Edmonton six years ago, the kind of baby who normally lives in about 20 percent of cases--and they had eight months of intensive care. I mean really intensive care. And the baby ended up living. It was a pound and a half at birth, the smallest baby that survived in western Canada in that year. The one thing they never thought about, the one thing they never considered, the one thing they never had to pay a moment's attention to was: How much will this cost? When does our insurance run out? It simply was not in the agonizing equation of worry and concern that they had to face. That seems to me, in itself, the most powerful argument you can make for socialized medicine, to put it in the bluntest possible terms.

Malcolm Gladwell:

It's interesting, because my own personal experience ... We'll start with the anecdote. When I was 16, I was working 12-hour shifts as a dishwasher. I was biking home one night in the dark and something happened and I ran off the road and I basically impaled my eye on a stick. I was unconscious for several hours, came to, biked home. When I woke up the next morning, my right eye had essentially ... The pupil had come out of the socket. A huge swelling. I went to the doctor. The doctor examined me and sent me home. The swelling didn't go down.

AG: This was in Nova Scotia?

MG: This was in Canada, in Ontario. They checked me into the hospital and observed me and the swelling didn't go down. Finally, eight days later, they took me to Toronto where I got a CAT scan. Now this is 1984, and it took them nine days to give me a CAT scan after blunt trauma to the head. The main thing in America is that's an open and shut malpractice suit. We had to drive a hundred and twenty miles to get to a CAT scan. What's interesting about this, of course, was that the doctor looked at me, and before he even gave me the CAT scan, assumed that I had suffered irreversible brain damage. He informed my mother--I was about to go to college--my mother said, "Well, [he's] about to go to college", and he said, "Well, your son isn't going to college. He has clearly suffered irreversible brain damage."

AG: So he's going to write for The New Yorker instead. [Laughter.]

MG: We're nine days after the accident! In 1984 this was state-of-the-art medicine in Canada because there were at that time something like, I think, five CAT scans in the Province of Ontario. Now, at the same moment in 1984, there were some hospitals in America ...

AG: Individual hospitals ...

MG: That had five CAT scans. CAT scans were in doctors' offices. And this is sort of a small thing but it tells you the cost. Canada has achieved a wonderful thing, which is universal health-care coverage, but it has achieved it at a price, and that is quality of care. Canadians will argue until they're blue in the face that, in fact, the sacrifices in quality care are not that great. That is, I think, a lie. There are critical sacrifices that have been made and you can argue whether those sacrifices are worthwhile or not. I happen to think that they're not. And I would rather live in a system--and perhaps this is simply a difference with me--I would rather live in a system with the economic fear, knowing that in extreme cases I'm likely to get world-class care than the reverse. I think that one of the principal functions of a health-care system is to offer all of those in the system the greatest possible chance of survival in the event of some extraordinary occurrence. And I had an extraordinary occurrence and I was given essentially Third World care. Now, I was lucky enough to survive, but that is not a risk that I would ever want to take with my own children.

AG: And you're persuaded that was, in no sense, an anomaly.

MG: In America there are clearly several tiers of care. If you're rich you get better care than if you're poor. No question about that. The benefit of that is at the high end there is ... People who are upper middle class in America demand, and there is a very efficient market mechanism for delivering to them, the absolute highest quality of care imaginable. Cost is not an object. You go over to Cornell Medical Center and walk through those halls. And I think it's really valuable to have at some point in the system an area where cost is not an object, because that's where all the innovation comes from; that's where doctors get better training; that's where those resources are available when somebody has some extraordinary event.

AG: I'll accept that description. I think that the question then becomes, though, what the trade-offs are, because what you're describing, what you're basically saying now in plain English is, we'd rather have a system in which you have the possibility of superb care, an MRI in every doctor's office, and the understanding that means there will be many people who will simply drop off the lower end--there will be kids who get a stick in the eye and never recover from it--than have a system which attempts to equalize every stick in every eye and in doing so, fails to deal adequately with everyone. These are kind of classic questions of egalitarianism and free enterprise that go far beyond health insurance.

Again, I have to keep coming back to ... And, you know, I could offer ... I came down with a digestive disease. When you were suffering with a stick in your eye, I was suffering at the other end; and I thought that the care I got at that point ... I could put my colonoscopy against your failed MRI, and mine was beautiful.

But rather than do that, I do think that the core issue again--and it's not just a question of Canadian health care, but the larger question of health care in general--is the question about what kind of society you want. Again, I've just come four months ago from the experience of having a baby in France, which has a system that makes the Canadian system look sparse: A hugely expensive system for which we French taxpayers, for which I pay an enormous amount of money, and the system includes a guarantee of four nights in a hospital or clinic for every woman. Here in New York, with the best kind of medical insurance we could have, we had 36 hours to have the baby (my wife did, have the baby) bond with the baby, and get out. In Paris she not only was guaranteed, but it would have been very difficult for her to have less than four nights in a hospital or clinic. In fact, there was a woman who wanted to leave after three nights. An American woman. And the head of the clinic came in and said, "What's the matter? Are you very unhappy here? We're not treating you well?"

MG: Yes.

AG: And I should add, too, that in France, particularly--and I know this is true in Canada, too--it's genuinely democratic. That is, our' little boy's babysitter, who's a Sri Lankan immigrant, was pregnant at the same time my wife was and got exactly the same care: four sonograms, four nights in the hospital, the same amount of paid leave, and so on. It's expensive. There's no question about it. Although I should add that we pay in France almost to the penny the same amount of tax that we paid in New York City, because by the time you add in the state tax and the city tax and the taxes we pay to build weapons we will never see and will never be used, it comes out to be very much a wash. The crucial point is, I think, the difference in social tone between a society in which universal access to medical care is taken for granted and one in which it is something that weighs constantly on all of us, even though some of us are lucky to have good insurance, and becomes an omnipresent preoccupation to the lower middle classes and to the working poor. It's enormous.

One of the most memorable experiences I had in France was when our little boy got terribly ill with what turned out to be salmonella poisoning last Christmas in Paris, as sick as I hope I ever see him. We had to take him to the pediatrician. Our pediatrician got very emotional about it. One of the big differences between American medicine and French medicine is that French doctors are not trained to be clinical. When they see a sick child they say "Oh, my God, he's so sick! I've never seen anyone so sick! You'd better get him to a hospital right away?' So it sends the parents into a panic. We ran into the children's hospital in Paris. He got terrific care. They did a barium enema with him, and they did an MRI, and they did an x-ray. There are many people who say that the French over-test: You shouldn't be doing x-rays on four-year-old children unless they're on the verge of dying. Nonetheless, they did all these things and they did it in three and a half hours. They realized it was no physical obstruction and it had to be an infection. They gave us a prescription, and he was much better, after being profoundly ill, the next morning.

We were leaving the hospital to get a taxi and I turned to my wife and I said, "Nobody asked us anything about money!" Nobody asked us to show them our insurance. Nobody asked us to show them a credit card. It simply wasn't addressed. About six weeks later we got a bill from the hospital--because we're in a slightly funny situation because of the nature of the taxes we pay--for 600 francs, about a hundred dollars. The overriding fact was that when we arrived--and I have arrived in emergency wards in America with sick children, and you spend half an hour figuring out who is going to pay and how this sick child will be paid for--when we arrived at the emergency ward in Paris with a sick child, who would pay for this sick child's illness was simply not a question that anyone raised.

As somebody who's lived under both systems I feel a kind of ease and pride in a system where the primary question is not who's going to pay and who's going to make money from my kid's illness or my daughter's birth. The answer is, I pay; and I pay big taxes in France in order to have that particular civilization rather than some other one. Having lived under both, for me it's a no-brainer: I would rather pay the extra money and know that everyone I looked at on the subway was not going to worry about how they were going to pay for their kid's illness.

MG: Let me reframe the argument for a moment. It's clear that these systems mean different things to different people at different stages in their lives. I think it's very useful to think of them ... If I might offer one sort of reductive way of looking at these questions, let's think about this in gender terms. Women and men use health care in profoundly different ways. Women and small children use ... The most important thing that they need is a personal relationship with a doctor. They use the health-care system chronically, that is to say, from the age of ... From the moment that they reach reproductive health, from the moment of menarche through to the end of their lives, they go to the doctor, need to go to the doctor about every month, every couple of months.

AG: Regularly. Certainly systematically.

MG: Systematically. And the kind of health care that women need up to middle age is, by and large, relatively low tech. It is, by and large, things that we know how to do, and the real critical' questions for women are almost always solved by: Have you seen your doctor recently? Are you getting a check-up?

AG: A Pap smear. A breast exam. Whatever.

MG: If you look at patterns of mortality for women, and morbidity, there are many, many more things that can go wrong in a 30-year-old woman than there are in a 30-year-old man.

Look at the way that men use the health-care system. They use it not chronically, but acutely. The problems that strike them, strike them well into middle age. A 30-year-old guy does not need to go to the doctor ever unless there is something obviously wrong with him, and, in fact, many 30-year-old men, 40-year-old men do not go to the doctor. The pattern of male illness ...

AG: Not to interrupt, but Dave Barry has a whole thing about the doctors for guys. He just looks at you and says, "You look fine!" And then you go home.

MG: And if you look at the reasons why men get sick as opposed to reasons why women get sick, men, up until their 60s, essentially, they either get shot or they die in car accidents. Women do not get shot or die in car accidents. It's actually quite striking. Women die of cancer, or they die of very, very different things until you get up into the late 60s and 70s.

AG: When they'll start dying of heart attacks.

MG: They go boom and it's over. That suggests to me that the ideal health-care system for a man is very different from the ideal health-care system for a woman. In fact, what a man wants from a health-care system is a health-care system that is acutely oriented, not chronically oriented, that is much more interested in quality of care, much less interested in access. A man doesn't need access to care until he's very old. He wants a high end, super-specialized system that when he has something seriously wrong with him fixes it right away. A woman, on the other hand, wants a system that's low tech, that sacrifices quality for a kind of presence. She can go to the doctor three times a month if she wants to and get a personal relationship with that doctor.

The Canadian health-care system is a health-care system for women. The American health-care system is a health-care system that is perfectly situated for men. It's the male health-care system. This whole debate about what is better, the American system or the Canadian system, is essentially a variant on the gender war. As a man, I am infinitely better off in America than I am in Canada. Were I a woman, I would be much happier with the Canadian system, where I can go and see my ob/gyn for free, day in and day out if I wanted to, than I would be in America. I think once you think about those systems that way it sort of clarifies what's wrong with each. The Canadian system is not a good system for men.

There are two things that America developed that would not have been developed without Americans: trauma care. The idea of sending in a helicopter to pick up someone who was in a car accident and getting him back to a helipad at a hospital, rushing him downstairs and dealing with him right away. That comes out of the Vietnam War. That is an American invention, and it has saved thousands of lives. It has saved male lives.

AG: Women don't get in accidents or get shot in bars, right?

MG: Right. They don't get shot, and they're not involved in multi-car pile-ups at 2 a.m.

The other great thing that Americans have discovered is, of course, organ transplants. If you look at the gender breakdown in organ transplants, organ transplants are all about men. Women don't need liver transplants because they're not drinking the same way men are drinking. It's not women who need heart transplants at 45, or have kidney failure. Liver transplant is precisely the kind of incredibly expensive, incredibly high end, incredibly complex health-care intervention that is really important if you're a guy. Transplant in Canada and trauma care lag behind America by 15 years, so I don't even know what the numbers are.

MRIs and the whole medical technology thing is another example. Canadians were incredibly slow to adopt this kind of cutting edge. Why? Because women don't need MRIs! It's a female health-care system. So, if you look at it that way ... I don't mean to sort of completely rag on the Canadian system. I think it's good. I think it's perfectly designed for feminine care.

AG: Since you've also mentioned the fact that the American system is for rich men, perhaps the Canadian system is for poor women.

MG: I disagree profoundly. I have never bought the argument that the American system is all that bad for poor men. I think it's fine for poor men. Remember, men don't need health care until they're middle-aged. If you look at the population of people in America who are uninsured, they're all young. There aren't old people on that list. And it is not a bad thing for a 25-year-old male not to have health insurance. That's not a crisis. I'm sorry. It's something ... If he gets in a car accident, he gets the care. Hospitals are non-profit in this country for a reason: They provide charity care. They are obliged by law to provide charity care to those who don't have money; so there is a method in play for the extraordinary events that happen to a man.

Now, for a woman of 25, I would say that's a problem, but I don't think for poor men the American system is a problem. They get the same access to quality ... If you get in a horrible pile-up and you're broke, the helicopter still comes.

AG: Hold on a second, Malcolm. If you get testicular cancer, which does happen to young men, then you're in rough shape. I'll buy your analysis, which I think is brilliant. But it strikes me that, again, it touches on a question of values. When you say the Canadian system is good for women, what you mean is that it's designed to be a system of care, that is, it's a non-heroic system, and its emphasis is on non-heroic medicine. And it strikes me that much of heroic medicine that is done in America is useless. In fact, you know how much American health care gets spent on the last two years of life. You know how much money is spent in the last 18 months of life.

MG: Is that specific to America?

AG: Yes. That's not true in Canada. That's not true in Canada. In the book you sent me, in fact, it's ...

MG: O.K., you've done research.

AG: We all know stories, personal stories of old people who are dying of lung cancer or something else who were, in effect, kept alive (I don't want to say unnecessarily), but who were kept alive by heroic measures that were hard to justify in terms of what they cost and what was involved. And I think that tends to be much more an American model than a Canadian model. The Canadian system does not encourage and does not reward heroic medicine as a matter of course. And the American system does encourage and reward heroic medicine. I know the crucial thing about most women's cancers is early detection. In fact, if you go regularly and get it looked at, if you catch breast cancer and cervical cancer early, they can be cured pretty well. If you catch it late, you can't cure it at all. That's true about most of those kinds of cancers. I'm not sure that the things that American medical care is good at, all those heroic measures, transplants and helicoptering Sonny Bono in after he hits the tree, are sufficiently valuable to society as a whole to justify the social cost. Look at the figures. Depending on how you fiddle them, the outcomes are similar.

MG: That's a very interesting point, which I will address. But go ahead.

AG: All right. Let's stipulate for a moment that the outcomes, though different ... That is to say, life expectancy, which is, in fact, somewhat higher in Canada; infant mortality, which is much, much worse in the United States than in any other industrialized country and I think is partly a function of our system ...

MG: Wait, wait, wait! I refuse to let you get away with that! You've given three whoppers! One is the suggestion that outcomes are similar between Canada and the United States. They are similar in mortality; they are very different in morbidity, and that's a critical point. The second thing is the suggestion that there is any link between the health-care system and infant mortality is, to me, utterly outrageous!

AG: Well, how do you explain the American rate of infant mortality?

MG: These are dramatically different countries with dramatically different cultures, with dramatically different social and economic problems. Find me an inner city in Canada.

AG: But isn't that a circular argument? In other words, yes, it's quite true. These are different civilizations with different cultures. But the United States is the anomaly. That's what I'm trying to say by drawing in the example of France as well. The standard model in rich industrialized countries is that you have universal health care of one kind or another. I think, having seen the British and the French and the Canadian systems together, I like the Canadian one. That may be a prejudice. But the United States is the anomaly here. It's quite true. There aren't inner cities to the same degree; and to the degree that there are urban poverty problems in France, for instance, they are not reflected in health problems of that kind particularly. They're not reflected in infant mortality rates. It's true that they're reflected in teenage mortality rates more and more, and those are questions of knives and guns rather than anything else. But my point is that--it's exactly the point I'm trying to make --before they express some particular pragmatic model of care, health-care systems reflect the values of society.

It's perfectly true that the American system reflects the values of (and now I'm going to be unfair. I'm going to take an argument I never would have thought would come from my mouth) a male-dominated, heroically-oriented, inegalitarian society; and if that's a model that you find effective and pleasing and acceptable, I can't argue with that. On the other hand, it seems to me that the systems, different as they are in societies as different as France and Canada, reflect an attempt, at least, at a more egalitarian, a more universal approach to health care.

I'm going to return now, obsessively, to the point I was talking about: the difference between walking into an emergency ward with your child knowing that what it costs and who makes a profit is of no consequence to anybody involved in the transaction, and a system in which it is of real consequence, even if, in fact, in the long run one can finagle it. But knowing that it is a consequence strikes me as being radically different and it seems to me that one is clearly desirable and the other is not. And let me add, it's probably the most powerful argument one can make for the whole question, different as the systems in France, Britain, and Canada are, as you know the approval rate among the populations just soared. No one in Canada, no one in France, no one even in Britain with the National Health Service, which one could be enormously critical of--it seems to me in many respects a failure--no one would touch it. Margaret Thatcher wouldn't touch the National Health Service in Britain.

MG: That's whopper three. I'm going to take them in reverse order. Let's talk about the approval. The approval question is very, very interesting. But as with many of these kinds of opinion polling questions, it grows much more paradoxical once you look closely. If you ask people in Canada (or in any kind of single-payer system--but let's use Canada as an example), "Do you like your health-care system?"--they love it. Ninety percent plus. If you ask Americans, "Do you like the health-care system?"--they hate it. Then you ask a slightly different question: Do you like the quality of care you get? In Canada, the numbers plummet. In America, the numbers soar. Americans love their personal care and hate their system. Canadians hate their personal care, love their system. That, to me, speaks volumes about the differences between the two systems. The American system is one of those systems that looks horrible from the outside, but to those who actually participate in it, they begin to appreciate what is specific and wonderful about the system.

That leads me to the second of your whoppers, which is if you look at ... People always do this when they want to idealize the Canadian health system. If you look at mortality figures, Canadians live just as long or a little bit longer. If you look at their specific death rates from diseases, Canadians aren't dropping like flies, so what's so great about the American system? Well, the issue is not mortality; it's morbidity. If you look more closely, if you take something like heart disease, Americans and Canadians die of heart disease at roughly the same rate. If you look at the levels of suffering, if you look at the guy who is 68 years old and has got blocked arteries, in America that guy gets a bypass and his level of how active he is, whether he's going to work, whether he's playing golf twice a day, the American is way better off. The Canadian isn't going to get ... Take a 72-year-old Canadian with severe angina. He does not get a bypass. The American, he gets a bypass in a week!

AG. If he can afford it. If he can afford it.

MG: If he can afford it. Well, most 72-year-olds ... Probably a 72-year-old would be on Medicare; so if he's on Medicare, then that question is lifted.

AG: I'm not sure. I'm not persuaded that the 72-year-old Canadian certainly wouldn't get a bypass.

MG: Oh, because if you look, and I actually did this once. I once did a study--I find this question fascinating--in which I compared Toronto and Washington, D.C., two metro areas that are exactly the same size. There is one team of cardiac surgeons in Toronto that does the bulk of the bypasses. In D.C. there are, like, six. The number of bypasses done in D.C. is many multiples of the bypasses done in Toronto. If you complain of even the slightest chest pain in America and you're, say in your 70s, boom! Bypass! And you can obviously do too much of it. But the point is that low morbidity does not extend your life. You don't live longer, but you live better! That's why Americans love the system, because American doctors are willing to go to extraordinary lengths to make sure that you live better, not necessarily longer, but better; and I think it's all about better. I don't want the extra year of life if I'm in pain.

Then there was whopper number three that you told, this whole notion that somehow infant mortality rates in this country were ...

AG: Tied to, in some cases the consequence of the health system.

MG: Well, this again is one of those questions that is really, really fascinating. When you talk about infant mortality in America, you're essentially talking about African-Americans. Why do African-Americans have an extraordinarily high infant mortality rate? If we had a Canadian system, would that rate be any different? Probably not. Why? Because infant mortality is a function of birth weight, and birth weight is one of those weird things that African-Americans have for generations had lower than average birth weight, much lower than average birth weights. Why? Well the literature is enormous. All these arguments have to do with things like ... There's an argument that this is a holdover from the days of slavery, that years and years and years of systematic deprivation creates lasting consequences. That is, if you are a low birth weight baby, when you have a baby, your baby is more likely to be low weight as well. In other words, you get in a permanent cycle of low birth weight. That goes back 100 or 200 years. That has nothing to do with the nature of the system. Better prenatal care doesn't fix that problem. That is a holdover from the legacy of slavery that goes back to the 17th and 18th century. I mean, yes, that says Canada and America are very different societies, but it has nothing to do with the particulars of the health-care system.

AG: It seems to me, though, that the generalization isn't sufficiently large here, and that the whopper you're perpetrating here is that health care in the United States isn't perceived to be in a crisis. I watched Gore and Bradley debate last night. And Bradley sincerely said that he had tears in his eyes, that a mother was telling him about how one of her kids got sick and they were uninsured and that as they were writing a check the kid said, "Mom, I'm sorry I got sick" And he said it was the one time in his life he had cried. Whether that particular story actually made him cry, that's a true story. That happened. That's not a manufactured story. That's a story that you literally could not imagine happening in any other civilized, industrialized, western country save for the United States.

And it seems to me that all the arguments you're making you could make just as well against Social Security, against old-age pensions; that it would probably be true, and it certainly was true that if you didn't have the national Social Security system, for the most part, people would be taken care of by private pension systems and the people who weren't taken care of by private pension systems would be treated as charity cases, and that, in fact, for young men like you and me, or relatively young men, what do we care about whether or not we have a pension? In fact, chances are we have a reasonable chance of being dead by the time we're 65 anyway. We'll be shot or run into a tree or something. And you could construct an entire argument to say--people have constructed those arguments--that Social Security is, in fact, a waste of resources; it's not a good way of solving the ,problem of how you take care of old people.

MG: You drag in a complete red herring.

AG: I don't think this is a red herring. There are other ways one can imagine caring for the elderly other than having a nationalized system of pensions. Right? And people did get looked after that way. Why could no one touch Social Security, then? Why is it sacrosanct in the United States? Is it because it's the most logically defensible and perfect system for looking after old people? Not at all! It is simply because there's a built-in constituency for it? A little bit, but not entirely. Because it clearly resolves at a societal level a problem that troubles people deeply, which is how do you make sure that people--when they're no longer able to feed themselves, and they're no longer able to work for them-selves--how do you guarantee that they'll be taken care of? And the answer is that you have to have a universal and national system that has a lot of built-in inequities and a lot of anomalies, but you'll accept the inequities and the anomalies because the overriding principle is so important to you.

So that's exactly the same decision that every other civilized Western country has come to about health care, which is not to say that the system is perfect, but that it resolves a fundamental problem society is faced with. Each society has resolved it in a slightly different way. O.K., the British system seems to me extremely poor, and the French solution seems to be better and the Canadian better in another way, but I don't think you can argue away ... Now, it's true that Americans, on the whole, who have doctors, like their doctors. But it's clear that it continues as a crisis, or Gore and Bradley wouldn't have been debating it last night. And this is a problem that has been resolved in the rest of the ... in Canada, certainly, as a social problem, and has been resolved in France and has been resolved in Britain. And it is true, no whopper at all, to say that Margaret Thatcher, the most radical libertarian free marketeer, would not and could not touch the National Health Service of Great Britain and defends it to this day.

So it seems to me when you're dealing with something that clearly seems to resolve an anxiety that's felt at a universal level in every society, and you have a way of resolving that anxiety (of course, you can argue your way out of it), you resolve the anxiety. You resolve the anxiety.

MG: O.K. A couple of responses. One is, it's a gross misreading of the Canadian experience to say they have resolved the anxiety. Every time I go back to Canada all I mad about is huge arguments in the local papers about health-care funding. They have an argument about health-care funding every year.

AG: I didn't say it was perfect. Yes, of course, them are always arguments.

MG: They have not resolved the anxiety; they have shifted the anxiety.

AG: No, I don't accept that, Malcolm. It seems that they've resolved the anxiety in the sense that you cannot imagine any possible political circumstances in which you could possibly return to an American-style system in Canada. It would be politically impossible. It would be politically impossible to return to an American-style system in France. It would be politically impossible to return to an American-style system in Great Britain. Doesn't this suggest that them is some deep social need that is resolved by universal health insurance, that is not resolved by a patchwork free enterprise system?

MG: Well, let's talk about the patchwork free enterprise system for a moment. What Americans say is, if you're poor, we're going to give you essentially a universal health-care system, Medicaid. Right?

AG: If you're very poor.

MG: Well, anyone who doesn't have a job basically qualifies for Medicaid.

AG: Not if you're working poor, but go ahead.

MG: And then we say that if you're old, you're going to get health care. And incidentally, Medicare and Medicaid, if you look at the funding of those systems, those are two of the most generously funded systems in the entire ... In fact, over-funded.

AG: My uncle was in geriatrics, in fact, because that's where the money is.

MG: So, we take the two most vulnerable and deserving groups in society and we take care of them. And then we say: O.K., if what we want to design for everyone else who's working is a system where them is maximum flexibility. Your employer can choose to offer you; it cannot; or you can choose to get your own health care or you cannot. So that system leaves some proportion of people without insurance, which means that two things happen. And that proportion, I would point out, is 20 million, somewhere ...

AG: Oh, it's merely 20 million! [Laughter.]

MG: Of those 20 million, like I Said before, I'm not that concerned about what proportion of those are young men. I don't know that young men need health insurance.

AG: Let me just say parenthetically that young men tend to father young babies. In that sense they need health insurance.

MG: I know, but even then ... It's not as if hospitals are naming people away who can't pay. Hospitals in this country, as I said before, are non-profit for a reason.

AG: They aren't all non-profit. Most of them aren't.

MG: They have a social obligation to provide charity care, and if you look at the charity care burden of most nonprofit hospitals in this country it is not inconsiderable. They provide an awful lot of free care and they do it because they are serving that underserved ... Now the question is, are the advantages associated with having that middle portion of working people under a maximally flexible system greater than the disadvantages? I think they are overwhelmingly greater.

Now, let's bring up something that has not come up so far in this conversation and I think it is a striking omission, and that is, if you look at the level of medical innovation in the world in the last 25 years, virtually everything comes from America. Absent America, medicine in the world is in the dark; it is retarded; it is at a level that all of us would find unacceptable. What is happening right now is that all these cheap single-payer systems are essentially poaching. They are cherry-picking off the American system. The American system is pumping money into research, has got this free market system which is incredibly dynamic and incredibly innovative. Everyone else just sits back and cherry picks all of the things we come up with. What happens if there's no America tomorrow? What happens if we junk our system? Where does medical progress come from?

AG: Again, I think that's an exaggeration, to put it mildly. I first got interested in this problem when Paul Tsongas was running for president and he said that the surgery he'd had wasn't possible in Canada. In fact, that surgery had been pioneered in Canada--the bone marrow transplant that he had.

For the great majority of illnesses that people face and non-illnesses, like giving birth, which is not an illness but is a medical procedure, you don't need heroic technology; you don't need cutting edge technology. You need what doctors and nurses are able to give. In those ways it seems to me the question of what you call cutting edge, what we might otherwise call heroic medicine, is more or less irrelevant. Let's return to something we were talking about before. Certainly there's no problem getting a sonogram in France or getting a sonogram in Canada. It seems to me that if you put the emphasis on heroic medicine, if you define good medicine as heroic medicine, that is, transplants and heart bypasses, which, as you know better than I, are of marginal value, of debatable value as to how much you get from that money you put into it, and put the emphasis instead on the kinds of things that everybody has to deal with all the time--giving birth, getting a stick in the eye, breaking limbs and so on ...

MG: Adam, what you're saying is, essentially ... You're are infusing a massive prejudice in your system. You're saying that I'm going to erect a system that is biased against people who happen to get ill with diseases that are unusual.

AG: I think that's not an unfair description of the Canadian system. Another way of putting it is it's heavily biased towards people who do have things that are more or less predictable. So, let's come back to the example I gave at the beginning, that is, the premature infant, right? Now, the level of care is superb in Canada for preemies, in fact. Now premature infants are not like guys who need kidney transplants in the sense that what they need is not perfectly understood, but reasonably well understood. They need a lot of care. You build one system that says, okay, we're going to give them a lot of care. We're going to give them round the clock nursing. We're going to give them an incubator. They don't need heart transplants. They don't need artificial limbs. They need round the clock care. We're going to build them a system that's very good at giving them that, and giving them that for free. Well, obviously it's not free, but you won't have to be concerned about cost.

And it's perfectly true that on the other end the 72-year-old man who needs a heart bypass is going to have a relatively harder time. Not impossible but he'll wait eight or 10 months. Those are social decisions that will have to be made. You're a risk-taker. I think that picture doesn't disturb you at all. I have to say--maybe these differences are temperamental, but I think they are deeply ideological in fact ... The notion that you and I both could at the whim of our employer lose our health insurance ... Now, I'm in quite a different position because I have a family to worry about. Now, it's perfectly true we could get it back again by improvising, by spending money and so on; but tomorrow we both would be unable to pay our doctors' bills if one of our kids or ourselves got ill. That strikes me as quite a e to pay. I know that if I'm in France or in Canada that not a possibility that I'm e are facing that literally every day in the United States.

MG: But, Adam, you can buy health-care coverage. For instance, I pay $234 a month for my health-care coverage. I'm a free-lancer so I pay my own health care. It's not a lot of money given what I'm getting for it. Car insurance is more than that. Another thing you said ... We're over-using "whopper" here. Heroic and cutting edge are not the same thing. You've been conflating the two in order to ...

AG: I've been deliberately claiming that what you call cutting-edge medicine sounds to me like what could properly be called heroic medicine.

MG: Let me give you an example of how that's not true. A woman gets a hysterectomy. In Canada, and in most parts of the West, a hysterectomy is fairly major. This country has pioneered laparoscopic surgery with a laser. It is initially a very expensive procedure. You've got to buy the laser. You've got to train the guy in using the laser. However, what it means to a woman is a hysterectomy becomes essentially an outpatient operation. You walk in, you get the hysterectomy, you walk out. Maybe you stay in the hospital a day. So that requires a significant up-front expenditure, but the result is that the woman doesn't sit around a hospital for two weeks. She can go home, she can go back to work, she can take care of the kids. In other words, this is a typical example of what American medical technology does. The American system is willing to pay a large amount of money on the medical side of the equation in order to save a lot of money on ...

AG: ... the care side of the equation.

MG: No, no. The American system shifts costs from businesses and families on to the health-care system. The Canadian system does the opposite. The Canadian system says, let's give this woman a traditional hysterectomy, which will cost far less, but she's going to be on her back. She's going to be in the hospital for longer and she's going to go home and she's going to be useless for two weeks. The Canadian system has no problem inconveniencing the family and fundamentally inconveniencing the employer. The American system says, no, we're not going to inconvenience the family. We're not going to inconvenience the employer, but I am going to pay more on the health-care side. That trade-off is extremely typical of the American system.

AG: As an adopted Frenchman I find something chilling in this utilitarian model of what the ideal out-come of a hysterectomy should be: getting that woman back to productive labor as quickly as we possibly can.

MG: Yes, but laparoscopy is certainly less painful!

AG: Yes, I understand that, but that's like the argument about how much time a woman should spend in the hospital after giving birth.

MG: Hospitals are dangerous places!

AG: Believe me, when a woman has been through labor and particularly when she's had a Caesarean, there's a larger psychological need that's fulfilled for that woman by the sense that she is being cared for. She's in need of it. Now we can argue about whether that's ... We can argue ... In many respects, Malcolm, this is a King Lear question. This is "reason not the need," right? This is a question of what people demand from their society. And you still haven't answered my initial problem, which is, a preemie baby is born, a pound and a half, and when I say that when this happens in America, your insurance runs out. You run up bills of hundreds of thousands of dollars to care for that baby. And I have friends for whom the insurance has run out.

This is not a whopper. This is not something I'm imagining. This is something that happens with regularity in the United States, and you are left with an enormous medical bill as a consequence of having kept your child alive. This happens in the United States. This does not happen in Canada. This does not happen in France. This does not happen in Great Britain. These are fundamental human facts, and we can argue about modalities a lot because modalities change all the time and the ideal number of days for a woman in a hospital after a hysterectomy is a modality that we an argue about, what the best way is to do. Similarly about pregnant women. The model--and I keep coming back to this and I know that this strikes you as unduly abstract and rhetorical, but it strikes me simply as focusing on the real question of values rather than of medical strategy--the difference in a society in which a one and a half pound baby is not going to be a financial burden on his parents if he survives, and one in which it will be an enormous and crushing financial burden on his parents, is of two very different societies.

MG: But, Adam, one of the things that you've done very cleverly, but consistently throughout this discussion, is you have taken technical questions and elevated them to philosophical questions. It's always my approach to say, before we discuss the philosophical end, let's see if we can resolve it technically. Your preemie baby example, to me, is a perfect example of this particular rhetorical technique of yours. Can we resolve this technically? Well, as it turns out, we can. If an American family has health insurance that runs out if they have a preemie, they've got the wrong health insurance. This is a purely insurance question. Can you buy health-insurance policies that cover you for an unlimited amount of time if you have a preemie? Yes, you can. Should women who are at high risk of having preemie babies buy that policy? Yes, they should. And if they don't, whose fault is that? Well, it's lots of people's fault, but people should be aware. We haven't described a fault in this system; we've simply described a fault in educating people about the need to buy appropriate insurance.

AG: Malcolm, it strikes me you've really gone native in the United States [laughter] because, O.K., so it's the woman's fault. Tough luck on the baby!

MG: No, no, no, Adam. I deliberately did not say it's the woman's fault. No, no, no, no. What we've described is the market breakdown, a breakdown in the market. That's lots of people's fault. My favorite thing in discussing reproductive health issues is to blame the ob/gyn. I think ob/gyn's have to say that if a woman is 36 years old or is having a first child and is a smoker and herself was a preemie baby, they should say to her: Is your insurance adequate for this pregnancy?

AG: But it's in the nature of health emergencies that they're emergencies; they're unpredictable, and that, therefore, nobody can adequately anticipate what's going to ...

MG: So maybe all women who are having babies over the age of 30 ought to buy ... And it's not going to be that much more expensive.

AG: Can you really imagine educating women effectively in a society like ours?

MG: Why not? Are you trying to tell me that now the principal reason that we ought to have single-payer state health-care systems is that we can't educate consumers?

AG: No, but I think you've put your finger on exactly the point: Are you going to see the health-care system as a consumer system? Are you going to have it run by a model of consumers and producers, and is it a good idea to see every social transaction in terms of a market model? That's the core question we're asking here, and that's not a philosophical question masking a technical question; that's a real philosophical question. Because what you're asking for, Malcolm, basically, is a classic free market argument, that the market will solve its inefficiencies and will ultimately give you all the things markets give you: innovation.

But one of the consequences of market arguments is, if you lose, tough luck! That's basically what the market says to the losers. It says, tough luck; try again next time. Only we're talking about human lives. We're talking about premature babies. "Tough luck, try again next time" strikes many people as an inappropriate answer.

MG: But, Adam, the percentage' of those American women, families, who have premature babies and whose insurance runs out and who, as a result, are left deeply in debt is not large.

AG: This is an argument Mr. Gradgrind would love. This is truly an argument Mr. Gradgrind would love. It doesn't happen to many women. Are there no work-houses?

MG. I don't think that the case against the American health-care system stands or falls on the treatment of some women who happen not to have adequate insurance for their highly premature babies. And I would also point out that if we examine closely the history of care for premature babies that all of it came from America. This is a classic condition for which the American health-care system pioneers treatment.

AG: I am, as I am on all the technical details, inexpert on that. But you choose to call rhetorical and sentimental points which strike me as the common sense values of the civilization. You have, on the one hand, a society in which, when you take the kid to the hospital, nobody asks you who's going to pay for it and one of the things you don't worry about is who's going to pay for it; and, on the other hand, you have a society in which people do worry about it. And people do worry about it. This would not be a live issue in the 2000 presidential election if people were not concerned about it.

MG: I don't mean to suggest that America is blameless. In fact, I take a lot of your criticisms. But let's take the preemie baby thing. Let's assume that you're right, okay? That this is a terrible problem. Look, it is a very simple matter for congress to pass a law which says that all health insurance covering obstetrical care must include an unlimited component for preemie babies. You don't have to change the system.

AG: Okay, but now we are getting into questions of modality. In other words, we can slowly--and this may have been a much wiser solution than the ones that the Clintons came up with--slowly grow Medicaid and Medicare until you have a universal system. You take in one thing after another that's going to get looked after. That would probably be the most realistic solution within an American political system.

I do think that trying to make analogies between health care as a problem and every other problem we're confronted with as consumers is ultimately a false analogy. Two things have happened, it strikes me, if I may now really move to a Hegelian level of historical generalization. Two things have happened simultaneously in the 20th century. One is we have seen just how valuable the market model is in ways that nobody could have predicted at the turn of the last century, and at the same time we have withdrawn certain aspects of our lives from the hold of the market, and we've done it because we have the Dickensian model behind us.

We see what happens when you have workhouses and poorhouses as solutions to the problem of poverty. We see what happens when the elderly poor don't have a reliable means of pension. And what strikes me as interesting about this is that those two move together, that is, seeing how clearly markets uniquely create prosperity and at the same time removing certain aspects of human life from the hold of the market, have happened almost universally throughout Europe, Canada, throughout all of the rich industrialized world, except in the United States, where we still have the strange anomaly that we've got health care stuck still in the market model. It strikes me that it's really as simple as that, that it's one of those things, one of the few things in life that needs to be withdrawn from the market model.

MG: I would like to say as my closing comment that what impresses me most about health care is the extent to which more is going to change around in medicine and health care in the next 15 years than changed in the last hundred. I think, for example, the hospital as we know it is dead. I think that drugs become infinitely more important in the next 10 years than they've been previously. All kinds of diseases are going to be transferred from the surgeon to the pharmacist. What I'm most concerned about is what kind of health-care system is the most flexible, the most willing to deal with these changes, the quickest to adapt to them, the most innovative. To me, it's an open and shut case that single-payer systems are extremely inflexible. That is a great cost. The Canadian system has been very slow even to catch up with the change in the last 20 years. And I worry that if we were to move in this country towards piecemeal social engineering we would in some way compromise the system's flexibility at a time when, to me, the most important thing in the next 15 years is going to be flexibility.

We're about to figure out the human genome, for God's sake. Everything hinges on the speed at which we are able to adapt and bring to market that sort of knowledge base. I'm just terrified of tinkering with such an extraordinarily dynamic system at a time when dynamism is, to me, the paramount. I mean, this is the crux of our disagreement. You're impressed with what the medical system is now capable of providing. I am, on the contrary, impressed by what the medical system has not yet provided. And that's why I favor a system that is, for all its faults, incredibly dynamic; and you favor a system that, for all its faults, is incredibly good at delivering the status quo.

MALCOLM GLADWELL and ADAM GOPNIK are staff writers for The New Yorker. ROBERT WORTH is a contributing editor for The Washington Monthly.