Most Americans agree that everyone needs doctors, hospitals, and access to the best medical care possible. Countries compete for the highest life expectancies and the lowest infant mortality rates. But in the U.S., when we start talking about how to get there, we stop agreeing–at all. Healthcare has become a political rallying point and a subject it might be unwise to bring up at the dinner table, but it’s not like this in other countries. How did a policy become a symbol for so much more in America today? In advance of Paul Starr’s visit to Zócalo to discuss our healthcare wars, we asked health policy experts what makes us a most peculiar nation when it comes to this issue.
Healthcare Realities Clash with Our Beliefs
Policy disputes about healthcare in the U.S. are about much more than healthcare. They’re really about our perceptions of ourselves as individuals and as a society. They are disputes about who we are, what we inherited from our history, and what kind of society we want to be.
The U.S. is divided between two groups. One group thinks the U.S. should become more like European countries, which have strong values of social solidarity and universal health systems. The other group is convinced the European model is the wrong way to go. Meanwhile, healthcare policy disputes force us to confront three deeply held beliefs:
1. The belief that the U.S. has the best healthcare system in the world. The Speaker of the House of Representatives, John Boehner, has insisted that the U.S. healthcare system is the best in the world. Experts in the U.S. and elsewhere know that is simply not true.
2. The belief that everyone in the U.S. who really needs medical care will receive that care, regardless of ability to pay. Many patients in the U.S. receive free or discounted care, but many other patients fall through the cracks.
3. The belief that Americans are “rugged individualists” who cannot be forced to do anything. Americans may indeed be more individualistic than other people, but they accept federal mandates like the payment of federal income taxes and Social Security taxes.
Debates about health policy and health reform force us to confront these deeply held beliefs. That’s never easy.
Dean M. Harris is a clinical associate professor in the Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill.
It’s a Three-Ring Circus: Politics, Symbolism, and Defining Ourselves
When Harry Truman first proposed national health insurance, Senate minority leader Robert Taft (R-Ohio) promptly tagged it “the most socialistic measure that this Congress has ever had before it.” Shouting “Socialism!” in the middle of the Red Scare was a serious charge, and Democratic Committee Chair James Murray responded furiously. “You have so much gall and so much nerve,” Murray screamed at his colleague. “If you don’t shut up, I’ll have … you thrown out.”
Every time the issue comes up (and it has come up often: 1946, 1949, 1962, 1964-5, 1974, 1979, 1991-4, and 2009), the rhetoric runs long, loud, and hysterical. Why? Because big health reforms always plays out on three different levels–every one of them a killer.
First, the debates rest on honest philosophical differences. Liberals believe healthcare is a basic human right while conservatives insist it is a market commodity. There are not many policy areas where the disagreement is so stark. Healthcare has become a badge of shame for liberals (“We’re the only nation without national health insurance”) and a point of pride for conservatives (“We’re the only nation without national health insurance”).
Second, national health insurance proposals provoke intense images. Never mind the actual proposal on the table; opponents always see the triumph of socialism, the death of free enterprise, the iron rule of the bureaucrats, or the cruel murder of innocents. “If this program passes,” warned Ronald Reagan about Medicare in 1963, “one of these days we will tell our children and our children’s children what it was like in America when men were free.” Sarah Palin offered the most memorable image during the latest round of health reform. “The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide … whether they are worthy of healthcare. Such a system is downright evil.” Palin’s “death panels” went viral. Talking heads, bloggers, radio jocks, editorial writers, Congressmen, and citizens all repeated and dissected the phrase.
Those supporting healthcare reform are invariably stunned by the assault. They try to dismiss the exaggerated charges. No, Medicare was not the end of the land of the free. No, health reform did not include death panels or anything like them. But their efforts don’t matter much, because even if the attacks are exaggerated, they connect with real anxieties. What reformers must articulate in response are hopes and dreams that go as deep as people’s fears.
Third, healthcare systems are about life, death, comfort, dignity, and pain. Every healthcare system in the world tells us something important about the society that created it. Healthcare reform gets to the most fundamental question Americans can ask: Who are we as a nation? That’s why the debate touches all the hot-button issues, like abortion and immigration. The debate gets especially angry when images of our community degenerate into nasty pictures of “us” and “them.”
So keep those seatbelts fastened. There’s lots more health reform turbulence ahead. It’s a political circus with three rings: a great debate about the nature of healthcare policy, lots of anxieties about the state of the nation, and a conflict over the deepest question of all: who we are as a nation and a people. If all that were not enough, there’s one final thing to consider: healthcare is often decisive in the battle for control of Washington, D.C.
It may not be pretty. But it’s the way we’ve been doing health reform since Harry Truman first tried it in 1946.
James Morone is professor and chair of political science at Brown University and author of The Heart of Power: Health and Politics in the Oval Office (written with David Blumenthal) and Hellfire Nation: The Politics of Sin in American History.
The Financial Stakes Are Higher Here
Because medical care involves the most basic issues of life and death, and because healthcare is a major segment of the economy in every wealthy nation, healthcare systems spawn endless debate and consternation all over the world. But health policy disputes in the U.S. tend to be the nastiest of all, for two reasons. First, the U.S. spends much more of its wealth on medical bills than any other country. We’re putting 17 percent of our GDP into health care; the other industrialized democracies spend about half as much. So there’s a lot of money at stake in our debate.
Beyond that, all the other industrialized democracies have already recognized the first principle of a healthcare system: they cover everybody. They consider it a moral imperative to do so. The United States has never committed to universal coverage. In 2011, we had 49.9 million people without health insurance.
Americans tend to do the right thing over time–the civil rights revolution is proof of that. Eventually, we will recognize that the world’s richest nation has a moral obligation to provide medical care for anyone who needs it. Until we do, our debates over health policy will continue to be angry and polarizing.
T. R. Reid is an author, lecturer, and documentary filmmaker. He is the author The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin Press).
It’s An Existential Debate
While people in Japan, Canada, and other nations enjoy gains in life expectancy every year, in the majority of U.S. counties, life expectancy is actually decreasing. Worse still, this reversal of fortunes is occurring in the context of the most significant health spending in the world.
According to Austin Frakt, a health economist at Boston University, there is no good explanation for the poorer outcomes and higher costs observed in the U.S. He writes: “Our population is younger than the average OECD country (source). Growth of U.S. health spending is much higher than that of other OECD countries even after controlling for population aging (source).”
In the presence of these evident shortcomings, you’d think that policy debates would be more technical, focused on any payment, pricing, or quality solution that promised to improve health and save costs. Instead, U.S. healthcare politics is anything but technical. Instead, the politics are party-driven, theatrical, and just plain nasty. Health reform was termed Obama’s “Waterloo” by Republican lawmakers in spite of its similarity to earlier Republican proposals. Don Berwick, a highly qualified technocrat, has been accused of an unpatriotic “affection” for the British model. The estimates of the non-partisan Congressional Budget Office are said to be “gamed.”
But while OECD countries aren’t different in terms of health behaviors and demographics, there are at least two reasons why their politics are less ugly.
First, there’s just less at stake. Financial and economic interests are just more limited. Most countries spend less than 9 percent of GDP on health. In the U.S., we spend almost double that amount. When the health sector is less important to the economy, there are fewer, less significant economic interests to lobby politicians and legislatures. Unlike the U.S., government is the main funder of care in most countries of the OECD. When government is the main purchaser, insurers and providers have less political leverage. Contrast this to the U.S., where multiple small-scale purchasing agents (employers, individuals) are dispersed, not easily organized, and lacking purchasing know-how and market information.
In most countries around the world, there is consensus on the role of government in healthcare. People expect their governments to help mitigate health and financial risks on their behalf. Political debates in these countries focus on why the government isn’t doing more or why the government is not obtaining sufficient value for money. They’re not focused on existential debates on whether risk sharing for the poor or sick should exist at all or whether people should be obliged to be insured.
Amanda Glassman is director of Global Health Policy, Center for Global Development.
*Photo courtesy of mediateletipos.