The U.S. is unique among industrialized Western nations in the degree of its reliance on "free market" mechanisms to provide healthcare. Nations such as my own, Canada, have "socialized" systems that have been in place for a very long time.
The consumers of these socialized services have failed -- universally, so far as I know -- to express buyers' remorse at the ballot box. No party in Canada or elsewhere has moved to overturn their systems in favor of something like you have in the U.S.
One presumes that if there was broad and deep dissatisfaction with this style of healthcare then some party or politician would have capitalized and zoomed into power and dismantled it. This has not happened. Can you make sense of this conundrum for me?
Hello again and thank you for all of the letters you sent in response to last week's column. This week Bernie wants me to explain a conundrum involving socialized healthcare in democratic countries.
I have to admit that I wrestled with this for some time. Is Bernie asking me to explain a philosophical position or a political one? His question, as I read it, could be taken either way.
One thing I do know is that the failure of a political party to make the dismantling of the national healthcare system the central plank in its platform should not be seen as a tacit endorsement of the system by a country's electorate.
As a matter of politics it can take years -- even decades -- for a government-run system to deteriorate to the point where the costs outweigh the benefits to such a degree that the voters demand sudden and radical change. There was, after all, a gap of several decades between the moment California Gov. Ronald Reagan first proposed significant reform in the nation's welfare system and 1996, when Congress passed and President Bill Clinton finally signed the landmark (and, as it turned out, stunningly successful) welfare reform law.
Change on this level is often difficult to achieve and may only come about in extraordinary circumstances, like Great Britain in the late 1970s when things got so bad the voters were willing to embrace Mrs. Thatcher's radical program to bring free-market reforms to the British economy.
There are any numbers of reasons for the time lag, not the least of which is government being nowhere near as efficient in weeding out failures as market-based system have to be in order to survive.
At the same time, the politicians and most major political parties in Europe and in Canada have found ways to make the nationalized healthcare system work for them. Helping a constituent to receive services they need through the application of political pressure, rather than as a result of urgent medical need, can make a hero out of any ordinary member of Parliament. From their perspective, what's not to love about a system like that?
It is also true that most of the people who utilize the national healthcare systems -- to get stitches, to have broken bones set, to get regular checkups -- do not require innovative or life-saving techniques and so are probably perfectly happy with the inexpensive care the government can provide, pretty much without issue.
But, as one think tank director here in the United States told me, only a small percentage of Canadians have to deal, on a yearly basis, with the really bad outcomes, like a death caused by or contributed to by long waiting lines for diagnoses or procedures.
"If you have lost a family member because of the waiting lines, you are hopping mad and probably ripe for reform," the director told me. "For the vast majority of Canadians, though, the system has been fine. Until the day it isn't, that is."
The director of a free-market think tank in Europe told me pretty much the same thing. "What is playing out is Frederic Bastiat's difference between the seen and the unseen. Votes in the European Union (and American tourists) see cheaper healthcare prices. They do not see the longer waiting times to new treatments. And people with extreme acute pathologies -- ones that could benefit from having those new treatments jump over the Atlantic faster -- do not organize politically to make this happen because they prize keeping healthcare costs down far above the perceived benefits of innovation."
"It's a bit perverse," the American think tank director added, "but if the system treated everyone worse but didn't kill anyone, there would be a lot more pressure from voters seeking reform."
"The fact is that the system kills quite a lot of people -- but that's still only a tiny percentage of the overall population -- so it reduces the pool of people who are dissatisfied," she said.
Another point worth considering is the impact of United States healthcare system on the world's, in effect allowing populations underserved by non-innovative, ration-rich nationalized systems to act as free riders on the American plan.
As long as the United States exists as a safety value for those in need of urgent, critical or innovative care and therapies, the pressure that could be applied on politicians to reform their non-market based, government controlled systems will never materialize. Critics would say denationalization of the healthcare system amounts to taking away from the voters a free entitlement, something that is there's by right. And that's the winning argument as long as those whom the national healthcare system can't or won't help have someplace else to go when they need to, e.g., the United States.
There are also those Canadians who have been critical of the public system sending expectant mothers into the United States to get their babies delivered. But that's not because their babies are more likely to die because the U.S. has higher infant mortality rates (which is a subject for another column); it's because it makes it harder for family members to get to the hospital to visit. People may mind, they may be inconvenienced, but not to the degree that they want to invest time and treasure in changing the system.
It's fair to say that the demands for changes in the nationalized healthcare systems are ratcheting up in places like Canada and Great Britain, albeit incrementally. If the United States moves to a system more like Canada's or Europe's, expect the demand for change to come even faster.
I hope that helps.