A long time ago I read an article which classified the health care funding systems of countries into three types: socialized medicine (with overtones of Stalinism and stinking waiting-rooms and lines which never move), the system initiated by Bismarck in Germany (paternalism, health care insurance clubs, with overtones of an old fat guy in a uniform wearing a very bristly mustache) and the cowboy system (all market-based, money used to decide who gets what, private insurance, with overtones of Marlboro men valiantly riding on forever). What came as a surprise was to find that the cowboy system isn't actually used in the United States: roughly one half of all health care spending is channeled through various levels of government. But Americans think they have the cowboy system.
And this is partly because of the much greater loathing of the government here than in any other similar industrialized society I know of. Many Americans truly do not trust the government at all, and the reason for this may well be in the family stories passed on from generation to generation by the descendants of those who escaped oppressive governments to come here. The sad thing is that there are tasks for which some form of communal activity is needed, and it is beginning to look like health care finance might be one of those fields.
Consider the current U.S. system. Around forty million people without any coverage at all. As many as eight million children without coverage. The average cost of health insurance keeps rising, year after year, and the policies people have cover fewer and fewer treatments. Yet the overall expenditure on health care swallows more and more of our gross national product.
Some sort of change is urgently needed, and here is where the paradoxical views of Americans are the major problem. From a recent poll on health insurance:
A majority of Americans say the federal government should guarantee health insurance to every American, especially children, and are willing to pay higher taxes to do it, according to the latest New York Times/CBS News Poll.
While the war in Iraq remains the overarching issue in the early stages of the 2008 campaign, access to affordable health care is at the top of the public's domestic agenda, ranked as far more important than immigration, cutting taxes or promoting traditional values. Only 24 percent said they were satisfied with President Bush's handling of the issue, despite his recent initiatives, and 62 percent said the Democrats — not the Republicans — were more likely to improve the health care system.
Americans showed a striking willingness in the poll to make tradeoffs for a better health care system, including paying as much as $500 more in taxes a year and forgoing future tax cuts. But the same divisions that doomed the last attempt at creating universal health insurance, under the Clinton administration, are still apparent. Americans remain divided, largely along party lines, over whether the government should require everyone to participate in a national health care plan, and over whether the government would do a better job than the private insurance industry in providing coverage.
One question offered a choice between the current system and a national health insurance program covering everyone, administered by the government and financed by taxpayers. Thirty-eight percent said they preferred the current system, while 47 percent preferred a government-run approach.
Nearly half said they thought it would be unfair to require all Americans to participate in a national health care plan, financed by taxpayers.
See? The problem isn't just the distrust of the government but also the great heterogeneity in the American values. This heterogeneity cuts across many other political questions, too, and in some ways means that Americans don't perhaps have very much fellow-feeling towards each other. The country is too diverse for that. But the fellow-feeling is necessary for those shared public tasks.
The initial solution to the health care insurance problem might be to expand public funding to cover more poor people. That might be palatable to those who don't want a taxpayer funded system for everybody. This solution has its disadvantages. For one, it would mark the programs as something easy to attack as handouts for the poor and so on. For another, it wouldn't do much to reduce the cost pressures on those who would be left to find private insurance, either on their own or through their employers.