Jonathan Oberlander, Ph.D., Assistant Professor of Social Medicine comments
School of Medicine, University of North Carolina - Chapel Hill, comments:
As a political scientist and a teacher of health policy to medical students, I have read Uwe's comments and the back and forth with much interest.
Uwe has long been an important voice in calling attention to the uninsured and need for health reform--and there are precious few among economists I am afraid. And his tone, which expresses outrage and indignation at the situation, and is no doubt designed to provoke a similar reaction from others, is both effective and in my view, absolutely on target.
I agree with much of what Uwe has written: that there is no basis for optimism on single payer, wishing it were otherwise does nothing to change the political climate; that Americans aren't exactly enthralled of the idea of making sacrifices for the uninsured right now (thus the policy solution de jour of relatively benign, in terms of their impact on the insured, tax credits); that the politics of health reform is defined by the fact that 85% of us have insurance, not that 15% do not; and that the debate over managed care is much more complex that simple anti-HMO backlash suggests.
However, I think from the exchanges with Ted Marmor and others it is obvious Uwe has hit a few nerves, perhaps unintentionally: Let me comment on one:
The idea that Americans have the health care system they want implies that the public both has no taste for universal insurance and that we have chosen the current system. Without rehashing all the political science on this, lets just say that there is not a 1:1 correlation between public opinion and public policies. In fact, there has for much of the period since 1940 been a permissive majority of Americans for national health insurance. It is too easy, as other commentators have done, typically of the Beltway crowd that includes Norm Ornstein (though I don't know his views on this), that the public killed the Clinton plan; Larry Jacobs excellent works presents a much more nuanced account.
Nor can the supposed exceptionalism of American political culture explain everything (or even Social Security). We are different in political culture and attitudes than either Germany or Canada. But no two countries that have universal insurance are identical (e.g., try matching Japan and England) and there is the problem with Canada of explaining if they were so different, why no national health insurance fully implemented until 1970?
Equally importantly, there is a temptation for those who oppose universal coverage to dismiss the chances for universal health insurance--and not just single payer--as a cultural impossibility. That is often, I fear, an intentional strategy on the part of providers to protect the status quo, and it needs to be exposed.
Lets be honest, political institutions are central to the story: if we had a parliamentary system, we would have passed national health insurance long ago, as early as the 1940s and no later than 1975, and it would be as popular as it is in other nations, and we would not be having this discussion. This does not mean it is not more difficult to enact such a program given American values and attitudes right now--the residue of anti-government thinking over the past 3 decades is, as the Clintons discovered, difficult to overcome. Single payer in this environment of public opinion is clearly impossible at the moment, though other strategies may certainly be more feasible. But we shouldn't be too hasty in taking prevailing public opinion and expanding that to define all of American political culture.
Finally, in many ways, insured Americans do have the health care system they want: private insurance, the multiple insurance products and market segmentation that Uwe mentions, the access to latest technologies and drugs. But I would argue that in one fundamental way these preferences--along with those of providers-- have inadvertently created a health care system they very much did not want: managed care (and for physicians I too have little sympathy on this score). Yet no one ever asked patients and they never voted on this, whatever the merits or flaws of managed care, it was top down policy imposed by employers and insurers. The current system then, is a long way from public endorsement, though perhaps the erosion of managed care will put things back closer to equilibrium and the golden age for physicians and patients, not an altogether favorable prospect for social goals in health care or the uninsured.
Jon Oberlander , Ph.D.
Dr. Oberlander is co-author, with Dr. Marmor, of "The Path to Universal Health Care" from "The Next Agenda," cited in yesterday's message from Dr. Marmor.