Over the past week, David Gratzer of the Manhattan Institute and Jonathan Cohn of the New Republic have been engaged in a fascinating debate over health care reform, hosted at TNR’s website. The two agree that American health care has serious problems, including a large uninsured population and very high costs. But they disagree about whether government-funded systems in other countries offer a model America should follow.
Their debate basically comes down to a disagreement about health-quality statistics. But both Cohn and Gratzer ignore almost entirely the attitude of the American public toward bureaucracy in health care. Recent experience suggests that Americans would be very unlikely to put up with even the modest constraints on doctors and patients in the French system that Cohn proposes as a model (let alone the overwhelmingly burdensome constraints employed in some other state-funded systems, like those in Canada and Britain).
The American public’s rejection of the HMO model of health insurance offers some evidence on this point. Health maintenance organizations try to contain costs by using case managers to review physician referrals and care decisions, and so to avoid unnecessary procedures and expenses. They work: during the HMO craze in the mid-1990’s, private health-care spending per capita grew by just 2 percent annually, while today it grows by nearly 10 percent.
But as HMO’s became more popular, resentment grew too, among both doctors and patients, about the way health decisions were being made by bureaucrats rather than doctors. HMO’s quickly became some of the most hated institutions in America, participation declined sharply, and today many plans that still call themselves HMO’s don’t actually follow the case-manager model.
Everything Americans didn’t like about HMO’s would be worse under the kind of government-funded system many other Western democracies have. Americans have far less patience for intrusion into health-care choices than Europeans seem to (a point that elicited some broader reflection on government and culture by Jonah Goldberg last week).
In response to this concern, advocates of state-funded care might make the perfectly serious point that covering the uninsured is more important than playing to the selfish whims of the American middle class. That’s how wonks should think. But it’s not how any politician could allow himself to think, and so it’s not how any practical and plausible reform of the system could work.
The fact is, the American middle class would hate—and rebel against—the kind of reform Cohn has in mind, and that in turn would take the political wind out of the effort to help the uninsured. That means health-care reform needs to work by addressing some of the concerns of the (insured) middle class—concerns about stability and portability—while building ways of insuring the uninsured.
That latter effort, though, can’t proceed by creating new, more powerful middle-class anxieties about who makes medical decisions and the freedom of doctors. This also means it can’t proceed by replacing our private insurance system with a public one. It needs, rather, to use public resources to help those who can’t afford private insurance obtain private insurance.
French health care works for the French. But for cultural reasons as much as economic ones, it’s very hard to see how it could work here.