Obviously I don’t agree with this argument. But I’m not setting it up merely in order to knock it down. My point is, instead, that while there is a morally coherent argument against universal health care, it’s an argument you almost never hear in political debate. There are surely a significant number of conservatives who believe that the government has no right to spend taxpayers’ money helping the unlucky; the late Molly Ivins was fond of quoting a Texas legislator who asked, “Where did this idea come from that everybody deserves free education? Free medical care? Free whatever? It comes from Moscow. From Russia. It comes straight out of the pit of hell.”[1] But national politicians never say things like that in public.
The reason they don’t is, of course, that they know voters don’t agree. You’d be hard pressed to find more than a relative handful of Americans who consider it right to deny people health care because of preexisting conditions, and polls suggest as well that a large majority believe that all American citizens should be guaranteed health care regardless of income. The moral case for universal health care isn’t in dispute.
Instead the opposition to universal health care depends on the claim that doing the morally right thing isn’t possible, or at least that the cost—in taxpayer dollars, in reduced quality of care for those doing okay under our current system—would be too high. This is where the facts and figures come in. The fact is that every other advanced country manages to achieve the supposedly impossible, providing health care to all its citizens. The quality of care they provide, by any available measure, is as good as or better than ours. And they do all of this while spending much less per person on health care than we do. Health care, in other words, turns out to be an area in which doing the right thing morally is also a free lunch in economic terms. All the evidence suggests that a more just system would also be cheaper to run than our current system, and provide better care.
There’s one more important thing to realize about health care: It’s an issue Americans care about, in large part because the system we have is visibly unraveling. Polls consistently suggest that health care is, in fact, the most important domestic issue to likely voters.
Shared values; good economics; importance in voters’ eyes—all these should make health care reform a priority. And everything we know about the economics of health care indicates that the only kind of reform that will work is one that is, by any definition, liberaclass="underline" It would involve government action that would reduce inequality and insecurity. Health care reform is the natural centerpiece of a new New Deal. If liberals want to show that progressive policies can create a better, more just society, this is the place to start.
Before I can get to proposals for health care reform, however, I need to talk a bit about health care economics.
If the past is any guide, during the next year half of Americans will have negligible medical expenses. Maybe they’ll buy a few bottles of aspirin, maybe they’ll have a checkup or two, but they won’t get sick, or at least not sick enough to need expensive treatment. On the other hand a minority of Americans will incur huge medical expenses—they’ll need a heart bypass operation, or dialysis, or chemotherapy. Overall 20 percent of the population will account for 80 percent of medical costs. The sickest 1 percent of the population will, on average, need more than $150,000 worth of medical care next year alone.[2]
Very few Americans can afford to pay sums that large out of pocket—especially if costly medical care goes on for years, as it often does. Modern medical care is available to middle-class Americans and their counterparts in other advanced countries only because someone else pays most of the bills if and when the need for expensive care arises.
In the United States, uniquely among wealthy nations, that “someone else” is usually a private insurance company. Everywhere else most health insurance is in effect provided by the government, and ultimately by taxpayers (although the details can be complex). Even in the United States, a taxpayer-funded insurance program—Medicare—covers everyone sixty-five and older, and another government program, Medicaid, covers some but not all of those too poor to afford private insurance. But the great majority of Americans who have health insurance get it from the private sector. That reliance on private insurance also makes the United States the only advanced country in which a large fraction of the population—about 15 percent—has no insurance at all.
A word on terminology: Opponents of government health insurance sometimes call it “socialized medicine,” but that’s misleading—it’s socialized insurance, which isn’t at all the same thing. In Canada and most European countries, the doctors are self-employed or work mainly for privately owned hospitals and clinics. Only Britain, among major nations, has actual socialized medicine, in which the government runs the hospitals and doctors are government employees.
So how does the U.S. health care system, with its unique reliance on private insurance, stack up against the systems of other advanced countries? Table 7 tells the story. It shows how much different countries spend per person on health care, and compares that spending with average life expectancy, the simplest measure of how well the health care system is functioning. The United States spends almost twice as much on health care per person as Canada, France, and Germany, almost two and a half times as much as Britain—yet our life expectancy is at the bottom of the pack.
| Table 7. Comparing Health Care in the Western World | ||
|---|---|---|
| Spending per Person, 2004 | Life Expectancy, Years, 2004 | |
| United States | $6102 | 77.5 |
| Canada | 3165 | 80.2 |
| France | 3150 | 79.6 |
| Germany | 3043 | 78.9 |
| Britain | 2508 | 78.5 |
Source: World Health Organization, http://who.int/research/en/.
These numbers are so stark, and such a refutation of the conventional wisdom that the private sector is more efficient than the public sector, that some politicians, pundits, and economists simply deny them. Our health care system is “the best in the world,” says Republican presidential candidate Rudy Giuliani—except that the World Health Organization actually rates it as number 37.[3] Europeans face huge hidden costs from delays and from inconvenient or uncomfortable service, says Tyler Cowen, a conservative economist—except that cross-national surveys say that even the British have better overall access to health care than Americans do: they wait longer for discretionary surgery than we do, but they find it easier to see a doctor on short notice, especially after hours or on weekends. And the Germans and French have no significant delays of any kind.[4]
2.
Figure based on Kaiser Family Foundation,
3.
World Health Organization,
4.
Commonwealth Fund, “Mirror, Mirror on the Walclass="underline" An Update on the Quality of American Health Care Through the Patient’s Lens,” http://www.commonwealthfund.org/ publications/publications_ show.htm?doc_id=364436.