Yesterday CNN broadcast a panel discussion moderated by Anderson Cooper called “Extreme Challenges” featuring one of Washington’s most bi-partisan icons, David Gergen, among others. There were many things during the discussion that didn’t compute from where I sit. One of them was the reporting and commentary on some recent CNN poll results. Another was a comment by Gergen to the effect that there’s no way the American people will ever accept a single-payer system in which there’s Government run health care for all. First to the poll results.
CNN found that 83% of Americans are satisfied with their health care while 16% are unsatisfied. They also found that 77% think that major changes in health insurance are necessary, while 21% think that such changes are unnecessary. Now, it’s often difficult to interpret poll results, and there’s a great tendency to over-interpret them by pundits who aren’t necessarily trained in survey research. However, CNN’s commentators seemed to think that these results somehow involved a contradiction, rather than simply a badly constructed poll, or perhaps their own inability to make sense of poll results.
On the face of it there’s no contradiction in these results, because health care and health insurance mean two different things to people. Health care refers to the experience you have with your Doctors, hospitals, nurses, technicians, clerks, receptionists, etc. Health insurance refers to the experience you have with your insurance companies including costs of health insurance, experience with collections, complaints, cost inflation, denials of service, etc. Furthermore, when one considers that the failures of health care and health insurance resulting in death don’t get to record responses to polls like this, the results may be somewhat biased by nature itself, since those people who may be most dissatisfied with their health care and/or their health insurance don’t get a chance to respond.
The failure to keep the distinction between health care and health insurance in mind is a problem I’ve noticed many times before with the members of the commentariat, including David Gergen. At one point in the discussion, Gergen, referenced the differences in values found by sociologists and historians among nations. He pointed out that such research shows that “America” is unique in its emphasis on individualism and the extent of its distrust of authority and Government, and that we are very different from countries like England, Canada, and Australia in this way. He said that these value differences are fundamental to who we are as a people; that we don’t think like others; are not deferential to authority; are wary of Government, and have been throughout our history. And then, in response to a question from Sanjay Gupta, he drew the breathtaking conclusion that “There’s no way the American people will ever accept a single-payer system a Government-run health care system for all.”
This is breathtaking for at least a couple of reasons. First, none of the sociologists (and perhaps none of the historians as well) who study the value differences pointed to by Gergen would be caught dead saying that because these differences exist the United States will never accept single-payer. Sociologists and historians know better than to claim value determinism, the idea that our values determine our behavior, either at the individual or the national level of behavior. Our value differences with other nations may create a tendency for us to act differently, but they don’t determine that we will. Also, the truth is that we have acted differently already, and that our tendency to think and act differently partly explains our sticking with a failing privately funded health insurance system that kills 20,000 of us each year, and bankrupts one million more. Our English speaking compatriots have long ago adopted either single-payer systems, or in the case of the UK, socialized medicine, and the result has been that their health care outcomes, by-and-large are better than ours.
The fact that our values have guided us toward health insurance failure in the past, however, is no guarantee that we will tread the same path as in the future. The pressure to change has built up over the years. The failures of health insurance are more and more undeniable. Cost inflation in health care is unsustainable, and so the chances for real change are much better, and one prominent possible pathway for change is to extend Medicare to all Americans. While this is not the only path, and may not be the first thing we try right now, it’s perfectly clear that our values won’t prevent us from doing it. How do I know? Because we’ve already introduced single-payer for people over 65, and in the Military Tricare system we’ve gone as far as introducing full-blown socialized medicine. 81 million Americans are already in these two systems, almost half the number enrolled in the private insurance system.
Apart from his value determinism problem, the second reason why Gergen’s conclusion is breathtaking and also wrong, is because of its straightforward confusion between “socialized health insurance” and “socialized medicine,” a confusion that he ought to know better than to get into. Again, Gergen says: “There’s no way the American people will ever accept a single-payer system in which there’s Government run health care for all.”
But, no one has proposed, or is considering, adopting a solution like Tricare, or the UK’s National Health Sevice (NHS), in which there’s “Government run health care for all.” Such a solution would be socialized medicine. But the kind of single-payer system some have been considering, the kind represented in HR 676, for example, is just an extension and enhancement of Medicare and Medicaid, which are socialized insurance systems. So, since single-payer is NOT Government run health care for all, America doesn’t have to act against its individualistic and anti-authority values very much to accept the kind of system proposed in HR 676. All it has to do is to recognize a few realities.
First, it could cut health care costs by perhaps one-quarter if it adopted a single-payer system over the next twelve months. Second, it could cut the rate of cost inflation by perhaps 1/3 or more if it did that. Third, health insurance companies are themselves authorities that often operate without significant competition, and that have been extracting increasing revenue out of their customers which they use to pay excessive compensation to their top executives and for increased profits. Americans are now in a position where they can do little about arbitrary actions by these authorities which affect their very lives and core financial well-being. So, the present system is itself greatly opposed to American values and the American notions of fairness and equity. Fourth, adopting single-payer will very likely increase the choices of Americans in health care, rather than restrict them. That is, the present system has far more constraints on choice in health care than a single-payer system would. What Americans are now doing is sacrificing increased choice in health care in order to retain what they perceive to be greater choice in selecting health insurance vendors. However, because of a limited competitive market, they don’t get much choice, if any, in insurance vendors anyway, and due to constraints in their policies they give up the greater choice in selecting doctors, and provider institutions they would have in a single-payer system. That is a bad trade-off; and bad trade-offs run counter to American values.
Finally, Gergen’s problem in confusing single-payer with Government run health care for all, is something we find frequently in daily discourse about health care reform. We hear this from the right of course, but we also hear it from so-called respectable commentators in the MSM. I think we even hear it from Obama when he sometimes defends the public option against single-payer in town hall meetings and talks about the greater choice inherent in public option-based solutions for reform.
A truly honest commentary on this issue by the President, however, would emphasize that Medicare for All provides more choice for Americans than the PO in what they really care about, which is health care itself, while the PO sacrifices that kind of choice in favor of greater choice in the area of one’s funding for health care. This last kind of choice, however, is only important if it is effective in driving down prices or providing greater quality of health care. And the thrust of economic arguments like those of Kenneth Arrow and Paul Krugman following him, is that choice can’t be real in the health care market because the nature of the service sold, and our absolute need for that service, makes it impossible for a classical free market and real competition to exist. Since this is the case, the freedom to choose between public and private insurers, or among private insurers will not serve to get one lower prices for insurance, except at the margins, unless the public insurance company is allowed to charge less than the private insurance company due to the fact that it doesn’t seek profits. But presently proposed legislation, even where it introduces a PO, constrains it so that it won’t be able to “unfairly” compete against the private companies in the scope of its market lest it drives them out of business, and creates a single-payer system. However, if the PO is constrained from competition, the so-called greater choice provided by it relative to single-payer can’t possibly produce either lower costs or better quality of care for consumers. So the kind of PO we see in HR 3200, as distinct from Jacob Hacker’s original proposal is a fig leaf, which will neither provide effective choice in insurers to consumers, nor provide increased freedom of choice in health care providers, in order to improve one’s quality of health care. In its choice aspects, this bill is a sham, and we ought to forget about it and try to pass Medicare for All.