Skimming through the early archives of the National Industrial Conference Board today at the Hagley Library I came across a folder dense with information on how the first effort—between 1918 and 1923—to provide some form of national or state public health insurance was defeated. And the second (in the 1930s), and the third (in the 1940s), and the fourth (in the 1990s) ...
It's really quite simple. Opponents of universal health insurance expressed a lot of sympathy with the idea that everyone should receive coverage, and then threw up enough doubts about changing the current system to peel off enough supporters that any one positive proposal for change could not get through. The emphasis of these doubts has varied from decade-to-decade. In the early 1920s the notion that reasonable men, the leaders of labor and business, could work these things out together without the complicating effort of government was stressed. At all points the idea that public health insurance was "un-American" was mentioned, the notion that this would cost more, the appeal to fear of a new and different system giving you worse care, while others benefitted.
Opponents of public health insurance have a lot to work with. In any rational reform of American health care, some people will consume a lot less health care than they would under the current system. That's a different matter than whether those people will be less healthy. It's well known that parts of the American health care system spend vast amounts of money in the last six months of life, pouring good money after the soon-to-be-dead. But if you're not dead yet, it's not clear why they shouldn't keep spending money on you. The last six months criticism is true as a matter of fact accounting, but also ignores that we don't know when that last six months starts. And who wants to think that in any new health care system they might die a little earlier because less money was spent on them. Not many.
Advocates of public health insurance claim, and probably rightly, that it would save money, at no cost to the overall health of Americans. This is a great argument, at a societal level, in an academic setting. The idea of getting the same health for fewer dollars is surely appealing. But it opens up an avenue for opponents of public health insurance to suggest that it would be you who received less health care with less health care spending. Everyone is in favor of saving money overall, but few would volunteer that the savings come from what is spent on them.
In any case, it's clearly the season for putting out earnest proposals for health care reform. Four articles in this month's issue of the Boston Review, and two posts by the thoughtful Brad Plumer address the issue.
Plumer makes this point:
... like any redistribution of wealth, reform will create winners and losers .... If health care reform, like Medicare-for-all, can lower total health care costs without hurting health outcomes—and the European experience suggests this is very likely—then the winners will win much more than the losers lose. Think of it like free trade. Maybe we'll all be winners.
But if it's like free trade—a good analogy—the benefits will be dispersed and the losses from change will be concentrated. The potential losers—health insurance companies—have money to spend to defeat this. Where I think this round of potential health insurance reform may differ from the past is that the insurance companies may be more isolated than in the past. When health insurers, doctors, and major employers all oppose reform that's a major barrier. Doctors' professional organizations are more open to reform, and some major employers could also support public health insurance. But the American political system makes major institutional change at the federal level difficult to achieve; guided by history it's always better to bet against proposals to expand government social spending succeeding.
update, 30 November 2005 @ 18:30 I should add that one effective line of opposition to public health insurance is precisely that it might well lead to less health care being consumed, even if there was no cost to anyone's health. First off, health care producers—from hospital administrators to nursing aides—would probably prefer not to lose their jobs. Second, even if some health care has no appreciable impact on health status, people might still choose to consume extra health care beyond what's necessary for physical health because it feels good.
And there's the rub. Who should pay for medically un-necessary care that individuals might want because it gives them more pleasure than alternative purchases like massages or health club memberships? In any health care financing system where consumers do not bear the marginal costs of care, public or private, some medically un-necessary health care is inevitably provided.
Posted by robe0419 at November 29, 2005 4:39 PM