New York Times
The Public Imperative
NEW YORK — Back from another trip to Europe, this time Germany, where the same dismay as in France prevails over the U.S. health care debate. Europeans don’t get why Americans don’t agree that universal health coverage is a fundamental contract to which the citizens of any developed society have a right.
I don’t get it either. Or rather I do, but I don’t think the debate is about health. There can be no doubt that U.S. health care is expensive and wasteful. Tens of millions of people are uninsured by a system that devours a far bigger slice of national output — and that’s the sum of all Americans’ collective energies — than in any other wealthy society.
People die of worry, too. Emergency rooms were not created to be primary care providers.
Whatever may be right, something is rotten in American medicine. It should be fixed. But fixing it requires the acknowledgment that, when it comes to health, we’re all in this together. Pooling the risk between everybody is the most efficient way to forge a healthier society.
Europeans have no problem with this moral commitment. But Americans hear “pooled risk” and think, “Hey, somebody’s freeloading on my hard work.”
A reader, John Dowd, sent me this comment: “In Europe generally the populace in the various countries feels enough sense of social connectedness to enforce a social contract that benefits all, albeit at a fairly high cost. In America it is not like that. There is endless worry that one’s neighbor may be getting more than his or her “fair” share.”
Post-heroic European societies, having paid in blood for violent political movements born of inequality and class struggle, see greater risk in unfettered individualism than in social solidarity. Americans, born in revolt against Europe and so ever defining themselves against the old Continent’s models, mythologize their rugged (always rugged) individualism as the bulwark against initiative-sapping entitlements. We’re not talking about health here. We’re talking about national narratives and mythologies — as well as money. These are things not much susceptible to logic. But in matters of life and death, mythology must cede to reality, profit to wellbeing.
I can see the conservative argument that welfare undermines the work ethic and dampens moral fiber. Provide sufficient unemployment benefits and people will opt to chill rather than labor. But it’s preposterous to extend this argument to health care. Guaranteeing health coverage doesn’t incentivize anybody to get meningitis.
Yet that’s what Republicans’ cry of “socialized medicine” — American politics at its most debased — is all about. It implies that government-provided health care somehow saps Americans’ freedom-loving initiative. Some Democrats — prodded by drug and insurance companies with the cash to win favors — buy that argument, too.
I’m grateful to the wise Andrew Sullivan of The Atlantic for pointing out that Friedrich Hayek, whose suspicion of the state was visceral, had this to say in “The Road to Serfdom:”
“Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance — where, in short, we deal with genuinely insurable risks — the case for the state’s helping to organize a comprehensive system of social insurance is very strong.”
That’s why, when it comes to health, every developed society but the United States has such a “comprehensive system,” almost always with state involvement. However, pooled risk does not necessarily imply a public option. It can be achieved through mandated private-insurer coverage coupled with subsidies. That, for example, is the Swiss way — and where Congress seems headed.
But it’s nonprofit insurers who provide the coverage in Switzerland because health insurance is viewed as social insurance — as it is throughout Europe — rather than a means to make money. One fundamental reason a public option — yes, “option,” not single-payer monopoly — is needed in the United States is to jump-start the idea that basic health care is a moral obligation rather than a financial opportunity.
Another is to provide competition to private insurers and so force waste, excess and cozy arrangements out of the American system. Behind all the socialized medicine babble lurks a hard-headed calculation about money — all the profits skimmed from that waste and the big doctors’ salaries that go with it.
It’s not over yet for the public option. President Barack Obama should still push it with a clear moral stand.
He’s been too deferential. The best bit of his speech to Congress on health care was the last — and even there he left the most powerful words to the late Edward Kennedy: “What we face is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”
Obama then said he’d been pondering American character “quite a bit” and did some “self-reliance” versus government intervention musing.
He should have been clearer and punchier. A public commitment to universal coverage is not character-sapping but character-affirming. Medicare did not make America less American. Individualism is more “rugged” when housed in a healthy body.
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