Health Care Debate’s Ecological Fallacy
Kevin Drum argues, correctly I think, that British- and Canadian-style socialized medicine is not on the table in the United States and that we should therefore frame the debate in terms of a French- or Dutch-style mixed system. He further cites Jonathan Cohn‘s argument that these systems are quite good.
But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.
Now, the fact that the French spend about half what we do doesn’t mean that we’d cut our costs in half if we adopted a French-style system. We wouldn’t. There’s too much path dependence and too many cultural differences for that. But what it does mean is that if we adopted something close to their system, we could certainly achieve high-quality 100% basic coverage — with the ability to purchase extra coverage for anyone who wants it — for no more than we spend now and possibly a bit less.
We won’t, of course, because too many people are still convinced that healthcare in the United States is better than it is in France — or anywhere else. It’s not. It’s worse and more expensive.
While I’m for a variety of reasons skeptical that an American system modeled on the French and Dutch systems would work quite so efficiently, I tend to agree that in the aggregate, such a system would be preferable to the crazy hodgepodge we have now. The combination of vast government programs like Medicare and Medicaid and the fact that most of us have private insurance and therefore only care about deductibles and co-pays means we don’t have anything close to a free market in medicine. And medicine wouldn’t be a truly free market even absent these institutions because being extremely sick rather limits one’s negotiating power.
But here’s the thing: most of us aren’t viewing this debate in the aggregate but rather as individuals. Most of us have the sense that ourselves and our families would be worse off in a system where the government was even more influential and even more people were free riding. Statistics about national level costs and outcomes don’t address that concern.
UPDATE: Dave Schuler has much more at his place.
Bernard Finel argues, persuasively, that what “most people” think about something is not necessarily something we should base public policy decisions on, citing several good examples.
He’s right, of course, that the majority sentiment on complicated public policy issues can be mistaken. Many times it is.
Could this be one of them? Perhaps.
But this is ultimately a problem where most people can in fact reasonably judge because it’s a personal-level decision. Most of us have insurance and can afford to go to the doctor and get the treatment we want. Some insured patients have HMOs or PPOs with various restrictions but those, too, are usually judgable by non-experts. (The exception being exclusions that kick in rarely at catastrophic times.)
Speaking for myself, I’m not and never have been ideologically opposed to the concept of a government-administered health system. Even going back to my days in College Republicans, I believed that medical care shouldn’t be one of the things controlled by how financially successful you are. Nor do I necessarily believe Americans enjoy “the best health care in all the world” at the aggregate level.
But I’m extremely risk averse a major overhaul of the system because most of us enjoy access to great health care and an extraordinary amount of autonomy in choosing how we want it delivered to us. We would trade away some of each, especially the latter, under any comprehensive system administered by the state in exchange for a massive gain for those who are now uncovered or undercovered.