Health Care and American Exceptionalism

One of the weirdest things to me about America is our insistence, in the political sphere anyway, that we are the best at everything. Since there are a couple of hundred countries in the world, the notion that one could be at the top in every category that matters is absurd on its face. Yet we insist, every election season, that our candidates flatter us with lies about how great we. The surest way to lose an American election is to say, "We should think about doing [some major government activity] like the French do it." And yet could it possibly be true that the French government does nothing better than ours?

Lately the leaders of the Republican Party have latched onto American exceptionalism in their own strange way by insisting that our health care system is, as John Boehner recently put it, "the best in the world." One would think that this claim would be instantly shot down in the press, when you consider the numbers: we rank 49th in life expectancy among the world's nations, 46th in infant mortality, and somewhere in that range for every other category of health. There is no health category in which we rank even in the top ten, and none in which we come up to the European average.

The reason we rank so badly is quite simple: while we have excellent doctors and hospitals in America, we exclude 50 million people from our system by denying them health insurance. White Americans with health insurance live as long as Europeans, and they are also very happy about the quality of care they get. We lead the world in medical research. So if John Boehner meant that we have the best health care system for white people who are not poor, he was getting closer to the truth. And since the basic plank of Republicanism is that if people are poor that is their own fault and it is wrong to do anything about it except encourage them to try harder, his position makes some ideological sense. Indeed one could mount a principled defense of our system as better precisely because it excludes poor people, thereby giving them another kick in the pants to get jobs and get themselves un-poor. No leading Republican is honest enough to put it this way in public, but the case, as I said, could be made.

Where our system is truly maddening, no matter how you feel about caring for poor people, is in how much it costs. We spend much, much, much more on health care than anyone else spends; we spend twice as much per person on health care as the British, who live 4 years longer than we do. Republicans are supposed to care about this. Nearly half of our total health care spending comes from the government, and Republicans are always fulminating about government spending. There is no way to control the future growth of government spending without controlling health care costs, something that our "greatest in the world" system has proved itself incapable of doing.

When it comes to costs, our system is the worst in the world. It is the most expensive because of its basic structure, which combines the worst features of socialism and capitalism. It is socialistic in the sense that most people don't pay for their own care, so they have no incentive to limit their use of the system, and it is capitalist in that we have no overall government authority controlling costs or setting prices, relying on "the market" to do that. Except how is a market supposed to work when consumers don't pay for what they buy? In a true market there would be a range of medical services available at differing costs, with some cut-rate clinics giving minimal care while others charged more for top-flight medicine. This happens only to a very limited extent because most people have insurance that pays for their care no matter whether it is at the Target Minute Clinic or the Mayo Clinic. In fact, under many plans you pay more out of pocket for a five-minute visit to a cheap clinic than to get extensive tests from a university specialist. Every attempt to reign in costs is resisted tooth and nail by powerful interest groups (doctors, hospitals) and by consumers, who consider it their constitutional right to receive whatever care they want, no matter how expensive or experimental it is. A majority of Americans tells pollsters that cost should be "no object" in health care. As yet, neither political party has been willing to say that this is a dangerous fantasy.

This mess is the reason I personally support a single-payer health care plan; such a plan would have a defined budget and so would have to set prices and limit how much care it would pay for. It would compel a certain level of honesty about how much things cost. Obamacare contains many little tweaks to our system that are supposed to help keep costs down, but I doubt they will work. Nothing will work until somebody stares Americans in the face and says, "no, you can't have everything no matter how much it costs." (Death panels!) Come to think of it, there is at least one group of Americans that understands there is a limited amount of money in the universe: those elderly voters who have been screaming about how their Medicare should not be cut to help provide care to the poor. This outrageous display of selfishness did at least acknowledge that health care spending has to be limited somehow, at any rate for somebody else. But not for me! No, for me cost should be no object!

It is sometimes said that Americans have a genius for compromise, and our political system does seem set up to force compromise much of the time. Sometimes compromise works. Sometimes it is a disaster, and our health care system is example number one. Here, compromise gives us the worst of all possible worlds, a hugely expensive and very cumbersome system that delivers a mediocre outcome. The French do it much better.