The above title is from another NEJM article. It’s interesting from a number of perspectives. It admits that medical care is provided to uninsured patients through a network of public and voluntary hospitals, free clinics, etc. It concludes that this safety net has prevented the collapse of the system that many have predicted over the last forty years. The author of the piece, Lawrence D Brown professor at Columbia, seems to imply that it is unfortunate that the system has not collapsed because this noncollapse has prevented reform of a flawed patchwork nonsystem. It is nice to see something in the NEJM that admits that patients without insurance do get medical care even if the admission is surrounded with distaste.

Arguing that our health care (an amazing misnomer) system will not collapse because it has yet to do so is like arguing that someone won’t die over the next forty years because he has not done so over the last four decades. Professor Brown believes that the survival of our noncollapsing system “resists any semblance of the planning that a $2 trillion annual enterprise demands.”

Here’s the nub of the issue. Is it possible to intelligently plan a $2 trillion enterprise? Professor Brown and many others obviously do believe so despite the repeated failure of central planning in the 20th century. Can you imagine what such a plan will look like after Congress and every special interest group in the country gets through with it? Then there’s the bureaucracy heaven that this plan will create which will again attract the special interest groups (which total more than the country’s population because everyone belongs to several) like medical students to a free lunch.

Professor Brown should take heart; the system (or nonsystem) likely will collapse under the burden of its cost. Then he and his ilk will get a chance to create the world’s largest bureaucracy and show skeptics like me that it can be done efficiently, at a reasonable cost, will deliver care that is appropriate to the needs of our population, and that this care will satisfy the public.

Mozel Tov