Accidents of history.
The big thing that jumps out at me in Krugman and Well's new piece on the US health care system in the New York Review of Books, is how much of the current system was basically the product of historical accidents. For instance:
Employer-based insurance [which accounts for just under two thirds of pre-retirement-age health coverage in the U.S.] is a peculiarly American institution. As Julius Richmond and Rashi Fein tell us in The Health Care Mess, the dominant role of such insurance is the result of historical accident rather than deliberate policy. World War II caused a labor shortage, but employers were subject to controls that prevented them from attracting workers by offering higher wages. Health benefits, however, weren't controlled, and so became a way for employers to compete for workers. Once employers began offering medical benefits, they also realized that it was a form of compensation workers valued highly because it protected them from risk. Moreover, the tax law favored employer-based insurance, because employers' contributions weren't considered part of workers' taxable income. Today, the value of the tax subsidy for employer-based insurance is estimated at around $150 billion a year.
...
In The Health Care Mess Richmond and Fein tell us that Medicaid, like employer-based health insurance, came into existence through a sort of historical accident. As Lyndon Johnson made his big push to create Medicare, the American Medical Association, in a last-ditch effort to block so-called "socialized medicine" (actually only the insurance is socialized; the medical care is provided by the private sector), began disparaging Johnson's plan by claiming that it would do nothing to help the truly needy. In a masterful piece of political jujitsu, Johnson responded by adding a second program, Medicaid, targeted specifically at helping the poor and near poor.
Today, Medicaid is a crucial part of the American safety net. In 2004 Medicaid covered almost as many people as its senior partner, Medicare—37.5 million versus 39.7 million.
There's something really grimly funny about a country whose most important policy regime simply gets locked into its particular pattern of historical blips. But that really does seem to be pretty much the story with US health care, and the gun-shyness among liberal pols and policy advisors about tackling it in a progressive way. Back in 1994, Micheal Kinsley blamed the failure of ClintonCare (a proposed escape for the legacy of unplanned policy) on Americans' basic fear of "change":
The health care debate turned out to be a contest over who could promise less change. Clinton lost. But you might say he started it. His basic pitch, remember, was "health care that can never be taken away." For the minority of Americans who currently lack health insurance and can't afford it, this would be change indeed. But the currently uninsured are not an important political constituency, however sad their plight. For the vast majority of Americans who now have insurance coverage, Clinton's main selling point was freedom from fear of change: fear that you'll lose your insurance.
...Now the United States will remain the only advanced country in the world that can't find a way--some way--to provide health care to all its citizens, and the only one that spends anywhere near as much on the system it has...Democracies like Canada and Britain and Germany and Japan are perfectly free to repeal their systems in favor of one like ours, if they wish, and yet there is no political constituency for doing so...A Canadian-style system may not be the right answer. But the citizens of these other nations have come up with an answer. Why can't we? It's not just the fault of the politicians and the special interests.
Just last week, the New York Times ran a screamingly approving article about Canada's gradual shift toward opening its health policy regime to private health care under the banner "Canada's Private Clinics Surge as Public System Falters". The question is: Falters compared to what? Not to pick on the Times, but their article is written for its audience, and that audience is moderately liberal Americans who don't like to contemplate that other countries might do it better, that some fundamental shake-up might be in order to get the US up to international standards. Anecdotally, I had the same experience while hiking in the US three years ago, routinely surprised at how hostile healthy young Americans (mainly liberals as you'll find in the backpacking community) were to the very idea of "socialized medicine", which they invariably wanted to debate upon learning I was from Canada and somewhat politically-minded.
No, Canada doesn't do spectacularly well among international health cost or outcome rankings, though we certainly kick American ass. And our politicians, both Liberal and Conservative, are also dodgy and afraid to think big publicly or express clear alternatives and options about health care. Moreover, our big, clear-thinking party, the NDP, can't pull down 20% of the federal vote in even the most favourable election environment, like the most recent one. Political inertia and avoidance isn't an American phenomenon. It's just that the American inertia has solidified around a system that wasn't even intended to make long-run sense in the first place. One thing that confounds Kevin Drum's provocative argument that health care is the great liberal uniting issue and the natural litmus test for Democratic politicians is that what Americans -- and I meant those who would naturally be part of the Democratic coalition -- say, and even think, they want (more equitable, more efficient, universal care) and what the feel they want when it comes time to vote or to prop up a reformer's approval ratings (to avoid the risk inherent in change; to be told that things aren't really so bad and other countries aren't doing so hot either) are far enough apart to constitute one hell of a political challenge. Making the intellectual trump the instinctual -- restructuring the blips, so to speak -- is a tall order for any politician or Adminstration to pull off. That doens't mean it doens't need to be tried, but it will take a lot of latitude.
Employer-based insurance [which accounts for just under two thirds of pre-retirement-age health coverage in the U.S.] is a peculiarly American institution. As Julius Richmond and Rashi Fein tell us in The Health Care Mess, the dominant role of such insurance is the result of historical accident rather than deliberate policy. World War II caused a labor shortage, but employers were subject to controls that prevented them from attracting workers by offering higher wages. Health benefits, however, weren't controlled, and so became a way for employers to compete for workers. Once employers began offering medical benefits, they also realized that it was a form of compensation workers valued highly because it protected them from risk. Moreover, the tax law favored employer-based insurance, because employers' contributions weren't considered part of workers' taxable income. Today, the value of the tax subsidy for employer-based insurance is estimated at around $150 billion a year.
...
In The Health Care Mess Richmond and Fein tell us that Medicaid, like employer-based health insurance, came into existence through a sort of historical accident. As Lyndon Johnson made his big push to create Medicare, the American Medical Association, in a last-ditch effort to block so-called "socialized medicine" (actually only the insurance is socialized; the medical care is provided by the private sector), began disparaging Johnson's plan by claiming that it would do nothing to help the truly needy. In a masterful piece of political jujitsu, Johnson responded by adding a second program, Medicaid, targeted specifically at helping the poor and near poor.
Today, Medicaid is a crucial part of the American safety net. In 2004 Medicaid covered almost as many people as its senior partner, Medicare—37.5 million versus 39.7 million.
There's something really grimly funny about a country whose most important policy regime simply gets locked into its particular pattern of historical blips. But that really does seem to be pretty much the story with US health care, and the gun-shyness among liberal pols and policy advisors about tackling it in a progressive way. Back in 1994, Micheal Kinsley blamed the failure of ClintonCare (a proposed escape for the legacy of unplanned policy) on Americans' basic fear of "change":
The health care debate turned out to be a contest over who could promise less change. Clinton lost. But you might say he started it. His basic pitch, remember, was "health care that can never be taken away." For the minority of Americans who currently lack health insurance and can't afford it, this would be change indeed. But the currently uninsured are not an important political constituency, however sad their plight. For the vast majority of Americans who now have insurance coverage, Clinton's main selling point was freedom from fear of change: fear that you'll lose your insurance.
...Now the United States will remain the only advanced country in the world that can't find a way--some way--to provide health care to all its citizens, and the only one that spends anywhere near as much on the system it has...Democracies like Canada and Britain and Germany and Japan are perfectly free to repeal their systems in favor of one like ours, if they wish, and yet there is no political constituency for doing so...A Canadian-style system may not be the right answer. But the citizens of these other nations have come up with an answer. Why can't we? It's not just the fault of the politicians and the special interests.
Just last week, the New York Times ran a screamingly approving article about Canada's gradual shift toward opening its health policy regime to private health care under the banner "Canada's Private Clinics Surge as Public System Falters". The question is: Falters compared to what? Not to pick on the Times, but their article is written for its audience, and that audience is moderately liberal Americans who don't like to contemplate that other countries might do it better, that some fundamental shake-up might be in order to get the US up to international standards. Anecdotally, I had the same experience while hiking in the US three years ago, routinely surprised at how hostile healthy young Americans (mainly liberals as you'll find in the backpacking community) were to the very idea of "socialized medicine", which they invariably wanted to debate upon learning I was from Canada and somewhat politically-minded.
No, Canada doesn't do spectacularly well among international health cost or outcome rankings, though we certainly kick American ass. And our politicians, both Liberal and Conservative, are also dodgy and afraid to think big publicly or express clear alternatives and options about health care. Moreover, our big, clear-thinking party, the NDP, can't pull down 20% of the federal vote in even the most favourable election environment, like the most recent one. Political inertia and avoidance isn't an American phenomenon. It's just that the American inertia has solidified around a system that wasn't even intended to make long-run sense in the first place. One thing that confounds Kevin Drum's provocative argument that health care is the great liberal uniting issue and the natural litmus test for Democratic politicians is that what Americans -- and I meant those who would naturally be part of the Democratic coalition -- say, and even think, they want (more equitable, more efficient, universal care) and what the feel they want when it comes time to vote or to prop up a reformer's approval ratings (to avoid the risk inherent in change; to be told that things aren't really so bad and other countries aren't doing so hot either) are far enough apart to constitute one hell of a political challenge. Making the intellectual trump the instinctual -- restructuring the blips, so to speak -- is a tall order for any politician or Adminstration to pull off. That doens't mean it doens't need to be tried, but it will take a lot of latitude.
4 Comments:
Great post, Laura.
Canada doesn't do spectacularly well among international health cost or outcome rankings, though we certainly kick American ass.
One of the things that makes Canada's health care system so expensive is our geographic proximity to the U.S. and our similar, if not identical, standards of training and qualification. Unfortunately, Canada competes for health care professionals with the U.S. system which presently has the ability to generate higher salaries and better remuneration for service.
Canada's system, if it were allowed to maintain current funding, would be world class if our neighbour was, say, Germany.
I have to say you've done a masterful job of presenting a very difficult subject.
Dave -- you're exactly right. In part, it's living next to those incredibly high medical salaries and the powerful (and often nasty) AMA. That makes it so hard to keep doctors and to persuade them to take non-cushy practices.
The sad thing about the new Tory government is that, even if Harper resists Klein and Campbell's privatizaton pushes to some extent, as Canada moves away from single-payer, it validates American views on its "inefficiency" and makes it less and less likely the US will move toward a system that will make their system -- and ours by virtue of proximity -- better.
I'm not sure what to think of the Canadian system. Down here, I'm told alternatively that it is great/horrible, cheap/expensive, meets needs/people die waiting for service. I have no source of information in the media I trust. I can only relate my own experience with the US system. In 2003, my son was grievously injured in an accident and nearly died, and my wife became ill at about the same time. Since then, they've both required extensive surgery and multiple visits to hospitals.
The service they recieved was top-notch, in my opinion. However, without insurance and facing our new draconian bankruptcy laws, I'm going to be a debt slave to 150 different billing entities the rest of my days. Ergo, single-payer doesn't scare ME at all.
Accident of history? The persistence of the present insurance system is likely due to its advantages to the majority of voters. Most of us have ready access to most treatments that we or our providers believe have even a small hope of effectiveness. Those of us who prefer shorter waits or more commodious treatment can pay the extra for an out of network provider. With most of the cost of treatment paid through insurance we do not see the cost not have reason to complain about taxes. Most voters who experience temporary periods without insurance will not experience major health problems during such episodes. Those persons with long periods without insurance and with major medical problems have not constituted a sufficient voting bloc to expand coverage. No reform that changes the ability of currently advantaged voters to continue to with the same perception of quick and optimal care has much chance of success. Conversely a reform expanding health services and reducing risk will have to be perceived as in no way diminishing the progress of medicine or the access of the voter to the “best” care.
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