Sunday, December 05, 2010

Why are Americans so different?

How many civilized countries are there in the world? How do you define civilized?

There would have to be free and fair elections, freedom of speech within reasonable laws of libel and slander, freedom of religion - and that means being able to change your religion if you want to, freedom from want - not some unreachable definition of relative poverty, but sufficient access to food and shelter, equality before the law, without fear or favor, access to education. Should it include access to health care without impossible impoverishment?

By my reckoning there are very few civilized nations. There are 27 countries in the European Union - not all of them could be described as civilized, and if you added a criterion that public officials must work for the public good rather than in their own interests, then very few of them would make the grade.

Outside the EU there are Norway and Switzerland in Europe.

Outside Europe, the USA, Canada, Australia and New Zealand. As far as I can judge none of the South or Central American states would meet the standards. In Asia, Japan, South Korea and possibly Singapore would be candidates. There are small former colonies which might qualify including Gibraltar, the Falkland Islands and possibly some of the West Indian Islands. There is no African or Middle Eastern country except, perhaps, Israel that is up to scratch.

These thoughts have been prompted by an article in the New England Journal of Medicine by Victor Fuchs

From the late nineteenth Century onwards government's role in paying for health care has increased rapidly. For most relatively rich countries there is some form of national health insurance so that virtually all the population is eligible for health care by a government-organized insurance system. America is different, but even there the government's role as paymaster has increased over the past 50 years so that the taxpayer's share of the bill has risen from 20% to nearly 50% (or perhaps less, depending how you do the calculation). The Chicago school of Economics avers "If an economic policy has been adopted by many communities, or if it is persistently pursued by a society over a long span of time, it is fruitful to assume that the real effects were known and desired." In other words people get what they want despite the unplanned-for consequences.

The most obvious difference between the US and other countries is that the US spends much more on health care whether measured per capita or as a share of the gross domestic product. The US spends 50% more than the next higher spender and twice as much as the average OECD spend.

The reason for this trend is obscure, but it is probably true to say that Americans really do want the system they have rather than a 'European' one. Sure the political system is against change, and special interests have to be humored, but Mr Joe Plumber must like what he's getting. What is he getting? Instant access is one thing. There is no delay for appointments with specialists, blood tests or imaging procedures, or even for treatment. Then there are the front of house facilities. American are more likely to choose a five star hotel-like hospital with mediocre results that an 'ordinary-looking' hospital with excellent results. "I'll have my coronary by-pass with chrome fins, please."

All insurance is redistributive. Large amount of care is used by a small proportion of policy holders and is paid for by the premiums of those who use little care. The difference for a national scheme is that premiums are not assessed on the risk of catching something, but on the ability to pay. Rich people pay more taxes - unless they cheat the taxman - but tend to use the service more. In the UK, you don't get a rebate for using the private sector rater than the NHS.

So why is the US so reluctant to adopt the more redistributive model that Europe, and the rest of the Anglosphere has acquiesced to? Perhaps because America is a nation of individuals rather than communities. I notice that the watchword for most American movies is 'Freedom' whereas in British films, certainly in those made before 1950, that word was 'Service'


David Arenson said...

I think you have a point about the American character. There is a libertarian streak here that many Europeans don't understand. The idea is that individuals can do what they please without their actions being directed or restricted by the government. The government exists to provide a few basic and essential functions such as defense; otherwise it should not interfere with the freedom of action of citizens. You're free to live as you please and therefore to sink or swim. Charity can take care of those who sink; it's not the government's role to force you to provide for others.

This element was tempered over time, especially through the period of Roosevelt's New Deal through Johnson's Great Society. Goldwater and later Reagan gave rise to a countermovement that goes back to those original principles, and the Tea Party is an example of this desire to return to a purist vision of the past.

At this point in American history, powerful corporate interests (insurance and drug companies) have essentially bought control of enough elected officials through campaign contributions to insure that little will happen to damage their interests. So we end up with a half-baked health care reform law.

Would a majority of Americans approve of Medicare for all? I think the answer is yes. But they don't have the influence that the vested interests have. And the vested interests have become increasingly closer to idealogues on the right that say government should let corporations do as they please without government interference because that is the American Way.

Anonymous said...

Dr. Hamblin,

Most of us would love universal health care - but we have a strong minority who do not want to pay for it. Those who do not want a change either have excellent care paid for by their employer, or they are providers in the current system and are doing very well under our current fractured system. Not to mention the Insurance Industry Lobby who have bought and paid for large numbers of our state and federal congressmen.

Then there is the problem of States Rights vs. the authority of the Federal Government. Our Medicaid system, which is usually represented as providing care for the poor, is a system that has historically been a financial responsibility paid for by individual states out of state tax funds. In reality Medicaid spends 70-80% of program funds not on care for the poor, but on nursing home care for the elderly. No private or government insurance in the U.S. covers nursing care for more than 90 days and most individuals cannot afford the additional $150-$500/month for long term care insurance (on top of the $1,000 a month they currently pay for family health insurance). If nursing home patients having no family, or if their families have already depleted their finances paying $35,000 - $60,000 a year trying to pay nursing home fees privately and are unable to do so - then Medicaid steps in. But you have to have no assets left before you qualify for Medicaid. Many times an elderly husband or wife is left bankrupt and without a home trying to support a husband or wife with a serious physical or mental decline. Many families resort to nursing homes because all the wives and daughters are already out in the workforce trying to help support their own children and families. There is no one left at home who can take care of an failing senior, even if it is physically possible to do so.

This is a very complicated issue here in the United States and I do not believe we are going to see any solution in the near future. The retirement of the "baby boom" generation is only going to make the situation more critical. v

Brian Koffman said...

Another big cost in the USA in the built in expense of "CYA" medicine as the fear of litigation for missed or delayed diagnosis forces most providers to aggressively pursue every possible issue when many would just resolve with time. And of course the direct and astounding cost of the actual suits is factored into the office costs and the cost of new medication and technical developments.

Anonymous said...

The only estimate of the impact of tort reform on health care costs that I've seen puts the savings at a little over 1%. in any case I haven't seen those that advocate tort reform willing to estimate the benefits to society. Just another perk for the priviledged?
As an owner of the federal government I'd like to see health care and pension benefits ended for federal employees If I can't pay for my own why should I be paying for their's. It could reduce the deficit and perhaps congress would see how the rest of us live.

john liston

Terry Hamblin said...

Every country in the world has a problem with the elderly population who can no longer care for themselves. Scotland has decided to fund it at England's expense. In England there is a distinction between medical care which is paid for by government and personal care, which is not. But in dementia it is a difficult distinction. In order to get state help with dementia care, you first have to impoverish yourself by selling your house and spending the income on nursing home fees. In Denmark the state pays for everything - but income tax is at 52%.

Many children in the UK resent their parents spending their inheritance. My view is give your money to your children when they need it - univerity, early twenties, first time house purchase - set up pension funds for your grandchildren when they are babies, and then spend the rest how you want to spend it, be it your favorite charity or a policy for your nursing home residence.

Burke said...

America is the "nation of the Enlightenment," a nation FOUNDED on the ideas of the 18th Century Enlightenment: reason and individual rights. In Europe, the Enlightenment was just a fashion that died out after about 100 years. But in America our Founders were men of action determined to put those ideals into practice by creating a govt to protect the rights of individuals.

Everything great about America is consequence.

"Access" to health care, education, housing, is just a euphemism used to obscure the practice of forcing some to provide for others, virtually the definition of slavery which is what socialism is.

Anonymous said...

Instant access is one thing. There is no delay for appointments with specialists, blood tests or imaging procedures, or even for treatment.

Yes, for people who are for4tunate enough to have insurance through their employers or who can afford it themselves. For huge numbers of people, the only medical service available is through emergency rooms.

Anonymous said...

I'd rather be forced to pay for healthcare than be forced to pay to bail out the pigs on wall street or for a war to destroy WMDs that don't exist.

john liston

George said...

The difference is that people in Denmark and Norway are not "forced" to pay their taxes, they're excited to do so...I feel that they define how a well functioning state cares for its taxpayers...Terry, regarding Israel, I doubt that it ticks all your boxes for a civilized country....

Anonymous said...

The American system is the best. As you mention, there are little to no waiting. There are more cutting-edge therapies in the US than anywhere else.

There are more drugs available here.

Insurance works as you mention; people pay into it in case they need it. Most of us don't need it until we get old and have some major health problems. That is balanced by the young (or lucky old) who pay into it and never need it in a significant fashion).

The bleeding heart liberal's hear a story here and there about a sick illegal immigrant child who needs extraordinary care, and then demands free and copious care for all illegals, who have no right to be here.

They hear of the case of those who game the system, not buying health insurance, until they get seriously ill. The liberals then demand care for those with pre-existing conditions.

Bottom line: Americans don't know how lucky they are.

Other countries do not offer life-saving drugs for cancer and other maladies.

Liberals want to drag the country down to the level where everyone else lives.

America is special, even if Obama doesn't think so.

Note to anonymous on ER care: Medicaid exists for the poor.

Note to Mr. Liston: Weapons of mass destruction did exist in Iraq. No one disputes that Saddam used poison gas against the Kurds. All intelligence services believed that Saddam did have them. I suspect the remaining stocks were moved or destroyed before the war.

Note to George: Nothing is stopping you from sending all your money to Washington. Obviously that's what caring people do.

Burke said...

The key to understanding leftists is knowing that virtually everything they say and do is a rationalization for exploiting and destroying successful, happy people, the freedom that makes such people possible, and the nation that protects them.

Leftists care nothing for the causes they claim to champion, the poor, the environment, gays, blacks, women, etc. These causes are just platforms for striking out at others.

The rallying cry of Marxists was "Workers of the world unite."

For leftists it should be "Losers of the world unite."