Universal Careful

I'm a fan of universal health care in the countries that have it - it seems to work great for them. But at heart I'm a realist (pessimist, perhaps) about what is possible, and I just can't see universal health care working in the United States. Not because there's something fundamentally wrong with a single government system (it's got flaws, of course, but so does every other system), but because there are some fundamental aspects to Americans themselves that can't be ignored.

1) Universal Health Care is expensive. Of course European countries pay less in total for their health care (and it's reasonable to say that many of those countries provide better care to the bulk of their populations than we do), but their costs are all lumped in one big number. Americans pay piecemeal, and piecemeal means we never have to see the whole cost. Heck, most Americans couldn't tell you what the total employer plus employee costs are for their own health insurance, let alone the entire nation. And with 300 million people, the total cost of American universal health care would be phenomenally huge. We can't wrap our head around the cost of the Iraq War (200 billion or so really isn't that much). Can you imagine 1.2 billion for health insurance every year!?! (That's the cost if we spent what Ethiopia does per person for health care.) How about a more reasonable number - say we pared down to just $4400 for each of us (what a former employer said was their cost), we'd hit $1,320,000,000,000! Of course that's less than we spend now, with all of our varied plans or lack of them, but that's beside the point. That many zeroes would sap a lot of public support fast.

2) It's easy to underfund. England's been doing it for ages, and the U.S. has a fine history of underfunding all sorts of things. We're busy underfunding Katrina relief as I write today. With the giant numbers of the previous point to back them up, the more conservative and libertarian members of Congress would be happy to cut, slash, and drown the whole system in a bathtub. Europe doesn't have the same political culture - and we shouldn't forget that.

3) Government programs are a favorite way to control others' moral lives. Food stamps are full of rigid rules because we can't imagine the poor ever deciding for themselves, and universal health care would be just the same. The reason Medicare is largely free of this is because every woman on Medicare is menopausal and people are comfortable turning off the machines when the patient is 90. Imagine Terri Schaivo and the HPV vaccine fights magnified a hundred times. Brace yourself for the rhetoric: "why should my tax dollars pay for Pap smears for sluts?" Even when they pay cash we can't help tsking the drunks who get kidney transplants. Now any and every medical condition will be fair game because "we" are paying for it: fertility treatments, cancers with potential behavioral causes, birth control, birth defects with potential maternal or genetic causes, STDs, injuries due to abuse, injuries due to carelessness, etc.

4) Existing universal systems aren't posh enough for our taste. For those of us who know the numbers, it's so tempting to see the dollar amounts for European health care and imagine a big cut if we made the move, but it probably wouldn't work out that way. Europeans are content with a lot less posh. In fact, they'll even share rooms! I've seen American hospital rooms that are larger than whole apartments in London or Paris. Those nice digs cost money, as do full body scans, 3D fetal sonograms, and waiting-room aquariums. In America success is visible - in a fancy car, big house, and marble countertops - will we trust a hospital that doesn't look successful? And how happy will be be receiving care there?

5) We're pretty damn sick compared to other places. We've got a lot of uninsured people just waiting for a chance to receive care. We've got more poor, and more rural people without much in the way of access today. The second we insure these people, there will be a surge in demand. And that could last several years. Of course it could make Medicare cheaper, as those in their early 60s stop putting off treatment until they're pretty far gone, but it'll be pretty pricey to get up to speed.

6) The government will start to look at public health issues as a bottom line reducer. That's great, right? Well, sure, until they start handing out all sorts of rules and regulations that we don't like. And it'll be a pretty big fight on our hands as we try to debate a few billion saved on heart disease and diabetes versus a fat tax. C'mon, you really want to eat your cake, and buy it cheap too. Just as some businesses have responded to health care costs by banning smoking near entrances and pressuring staff to start exercise programs, the government will do the same. And that's not something Americans are used to putting up with. A significant number of us still bristle at seat belt laws or required home smoke detectors. Suddenly everything has the potential to be a government health care cost saver from gun locks to hand washing.

7) We don't expect it to work. We've believed for years and years that it won't work. It's just a recent blip that we've found the current system too expensive. The second we're on universal care every wait or list or restriction will bring our minds right back to 1994 and HillaryCare. Statistical increases in infant survival or broader availability of preventive care can't compete with perception, and we're primed to perceive it as a failure.

I know this is pessimistic, but I'm not totally without hope. Some states are full of people willing to pay up and judge the system by the same criteria that Europeans and Canadians do. And those states should go ahead and do it. Just don't expect what's good for Massachussetts to be good for Mississippi, even if Mississippi "needs" it more.