It was an easy step to go from web chatter about health coverage and how poorly the US does to wondering why the popular media does such a lousy job discussing it.
Ezra Klein wonders why it's so difficult to have a rational, fact-based debate. He starts with what always makes Americans uncomfortable, an unfavorable comparison with other countries:
... it also shows why we're having such trouble in the health care debate. We've lost all our examples. The right took hold Canada and, despite the fact that their system scores far better than ours and spends much less doing it, painted a nightmarish and wholly false scenario of elderly refugees streaming to Vermont for hip surgery. O'Reilly and friends have spent the last few years striking the word France off the map and crayoning in "UnAmerican Land", so we can't quite laud France. So what have we got? Sweden? Tiny and homogeneous. Britain? Uh, best not to mention them. Germany? Yeah, but not really a single-payer system. And so forth.
It's not that folks don't like the idea of government-run health care so much as we've let the prominent examples of how it works get turned against us. So now we mention single-payer and the return volley is full of sick Canadians being strechered into Detroit and uppity Frenchmen in stinktastic waiting rooms. Making single-payer safe for public discussion will require some rehabilitation of its international incarnations. Invoking France's doctor choice and lower spending is a good way to begin, but we're really going to have to tie France to Canada (as they're the most frequent counterexample), make the case for why both are better than what we've got, and then wonder why Republicans don't think American terrifictude can improve on these versions. Because that's really the disconnect here. Other countries aren't perfect, but we're much worse. The argument should then be that we can better the improvement they represent. We are, after all, America; shouldn't we be able to teach the world how health care's done?
I've no real problem with what he states affirmatively, but it's all current stuff. He neglects the history and that might teach us something as well as give us something that we can leverage. What's changed? A lot!
- Doctors. Let's recall that it was the AMA that soundly defeated the first couple of attempts at universal coverage. The first time was early during World War I and they tarred the idea as the "German" solution. After World War II, when Truman tried it, they tarred it as the "Communist Russian" solution. Today's medical community is fractured, the AMA is barely more than a shell of what it once was, and many of the leaders pushing for universal coverage are physicians.
- Employers and the employment relationship. Back in the days when employment based coverage was expanding rapidly, the US economy was dominated by firms like GM. They were financially healthy and their workers (mostly well paid, blue collar) were tied to them for decades. Most importantly, they didn't have serious international competition. Not perceiving a threat, corporate leaders were comfortable falling back on their ingrained free-market, capitalist principles. All that has changed dramatically and with it the interests and attitudes of corporate leaders.
- The relationship of business to government. Building on that last point, when we were on the upslope, the typical business attitude was don't tax us, don't regulate us and all will be fine. Essentially, they wanted only a minimal relationship. That all changed most dramatically with the Chrysler bailout in 1979. As business has gotten more sophisticated (is that the right word here?) since then, many business leaders have come to see that their relationship with and use of government can give them considerable competitive and financial advantages. Both the positive and negative roles of the state are now an essential factor in any business's strategy. Remember when Microsoft wanted nothing to do with lobbying? Even without the anti-trust case, those days would be long gone by now. (Think about their interests in international trade, intellectual property and a host of other issues.) So ignore their free-market rhetoric and watch carefully what they actually do. Across the full spectrum of issues, business leaders today are far more pragmatic about government and the role of the state than their predecessors a generation ago.
- The position of organized labor. A century ago, Samuel Gompers, the founder of the American labor movement vigorously rejected government sponsored health coverage. He believed strongly that workers should rely on collective bargaining for such benefits and that coverage was one of the things that differentiated organized from unorganized labor. The importance of being organized and all it could bring trumped any individual benefit. A generation ago, New York's AFL-CIO allied itself with business in defeating then Governor Nelson Rockefeller's proposal for mandatory employment based coverage. In the early 1980's, AFL-CIO representatives were still proud of that effort and their rationale directly descended from Gompers. Today, in their weakened state you can find many labor organizations, probably a majority that take a different position. If coverage is provided through government, it's one more thing that we don't have to bargain for and we can concentrate on other issues. It's a complete reversal of their position. The AFL-CIO position's is that the "best solution" is to "reform our health system to ensure universal health coverage for all Americans" or at least to expand public programs and to mandate employment based coverage. They, like the employers, have gotten much more pragmatic about government and the role of the state.
- Growth in governmental programs and funding. I needn't expand on this point here. The bottom line is that government is already spending huge amounts of money on health coverage, enough to be the longest lever in the US for moving the healthcare system in one direction or another. This is a complete change from 40 years ago.
- The complexity of the healthcare system. Also changed radically from 40 years ago, perhaps even more recently, is the complexity of the system. Four decades ago, most medicine was still one doctor with one patient with rare trips to the hospital. When the patient was with the doctor, they actually conversed. Pharmaceuticals and other medical technologies only hinted at today's capabilities. Pediatricians, OB/Gyns, and general surgeons were about the only specialists that most patients might come into contact with. Today you might see both specialists and a couple of sub-specialists for a wide array of conditions.
- Patient dissatisfaction. Even without the increased costs for which they are increasingly responsible and even without problems with care, patients are restive. Many have lost their personal connections to professionals to help them through the most threatening and intimate circumstances. They are baffled and frustrated by the organizational complexities shuttling from one bureaucracy to another and repeatedly handed a clipboard so that they can fill out the same information still another time. They are often overwhelmed by the information thrown at them and by the choices they must make.
Regardless of what Bill O'Reilly or other TV talking heads may say, the trajectories of all these trends will come to bear on the issues at hand.
Brad Plummer offers his analysis on why media coverage of health care systems in other countries is "dismal" (his emphasis). (My comments relative to some points are in italics.)
- Reporters just don't know all that much. It's hard enough to develop some knowledge of what's going on in this country and report on it, much less write effectively about what's going on in other countries. (This may be partly a function of the complexity of the US system. It takes more time to learn it. Most of the reporters I deal with are making the effort. JWR)
- Anecdotes count for more than statistics ... Reporters lo-o-o-ove covering the poor grandma who waits months for a hip replacement—it's a human interest story! Or those long lines for surgery. Yeesh! (True, but those reporters know their audience. I've found the same to be true of legislators and most everyone else I've dealt with for decades. JWR)
- Health care professionals in single-payer systems have reasons for drumming up "crisis" rhetoric. This is something that doesn't get noticed very often. For instance, in a national health care system like Canada's, every year the government has to set a budget for hospitals, limit how much doctors can charge, etc. It's a big debate, and to gain leverage, doctors of course love to talk about how there are shortages and people can't get necessary treatments and so on and so forth. Naturally, their complaints get picked up by the Canadian media and trickle on into American papers. But no one stops to think that these health care professionals are all self-interested actors who have their own reasons for playing up the system's faults. (You don't think health care interests in the US drum up crises? Oh man, come to New York just for one repeated example. JWR)
Then Matthew Yglesias takes the baton from Plummer and adds several points:
- The England Problem. For linguistic and other reasons, the European country Americans are most cognizant of is the United Kingdom which happens to have a health care system (the NHS) which goes very far in the opposite direction from the U.S. system in terms of command-and-control health care and which, consequently, offers a very exaggerated version of the downsides of government-run health care.
- The France Problem. While the NHS model actually has a certain appeal to me (leave that for another day), it's something that utterly lacks political appeal in the USA and isn't a realistic model for any American reforms. The most likely candidate for something we would want to imitate is France. Unfortunately for the cause of American health care reform, France and the United States have a long-term history of cultural antagonism that makes "we should do it more like they do in France" a public policy kiss of death. Worse, most people are aware that the French economy does not perform in a manner many Americans would want to imitate ... (Our friend Dr. Paul Sorum is not only a proponent of single-payer. He knows France and the French system extremely well. Let's ask him. JWR)
- The Canada Problem. The US-Canada health care dynamic is asymmetrical, because wealthy Canadians can travel to the United States to take advantage of the aspects of our system that work better (for relatively prosperous people) than does their system, while working- and middle-class Americans can't go to Canada to take advantage of the aspects of their system that work better than ours. The result is that you have lots of anecdotal evidence of people fleeing Canadian waiting lists to get their hips fixed in the USA, but no anecdotal evidence of people taking their kids to Canada to get affordable, high-quality preventative care for their kids. In the limited domain of pharmaceuticals, this has changed and Americans now can (and do) go to Canada to get cheap drugs. Not coincidentally, I think, this is the area in which you have the most public support for left-wing solutions. (The asymmetry may be true as far as it goes. But Canada's political culture is quite different from that in the US. Remember that while we were rebelling, they were remaining with England. JWR)
- Cost Underestimation. Apropos of the French-style taxes, it seems natural to assume that governments which provide health care for all their citizens are spending more than are government which provide health care to only some citizens. It's natural to assume, but it isn't true ... (Correct, but every estimate of what universal coverage would cost in the US adds expense - with no savings - because we dare not make explicit what we're going to take away. That would make political enemies. JWR)
- Hidden Costs. On the private-sector end, few people understand exactly how much is being spent on health care. This is because the employer side of insurance premiums is hidden from the view of all but payroll people and policy wonks. Additionally, the scale of tax subsidies provided to the health care industry is basically unknown to all beyond the elite. (These are very important points to which I will return later. JWR)
- Bipartisanship as Fairness. Perhaps the biggest problem is simply that since single-payer isn't the official view of the Democratic Party. One problem with "he said, she said" writing is that if he is lying, he gets to get away with it. Perhaps a bigger problem is that if he and she agree that we shouldn't do X, it winds up going without saying that X is, in fact, a terrible idea. If a major political official started insisting that France had a great health care system, you might be able to browbeat the press into acknowledging that he was right. But until someone does it, it will simply continue to be taken for granted that it must not be.
- Rich Journalists. Last but by no means least, one must point out the obvious. If you're well-off and seriously ill, the American system probably is the best in the world. Even if you are wealthy, you might never have gotten so seriously ill if you'd been living in a country with proper health care, but once you are seriously ill, the USA is the place to be. Journalism is dominated by relatively prosperous people, and perceptions of the health care system are dominated by people who have a great deal of experience with it, which is to say people who have been seriously ill who who've had close family members fall seriously ill. The things the American system is really, really bad at tend to be hidden from view. (Too bad our journalist readers can't respond to this. Most would say they are far from rich - we're not talking about Chris Mathews here after all. In any case, this posting about the the writer Matt Miller and his wife Jody points out that this theme certainly doesn't apply to freelance writers. I suspect there are many more like these. JWR)
There's a particular Medicaid angle here that I've been thinking about recently. I'll post on that separately.