It's the culture, stupid
Callahan, Daniel
or many of us in health care, nothing is so frustrating and baffling as the failure of this country to enact some kind of universal health-care plan. While Bill Bradley and A1 Gore have made...
...For us, it is not clear at all...
...Employer-based insurance plans-the main way most Americans get their health care declined from 69.2 percent in 1987 to 64.2 percent in 1997, with no end in sight...
...and now, to back that up, there is a huge federal budget surplus, as well as considerable backing from the medical community, for decades a powerful opponent of what it liked to call "socialized medicine...
...Yet even after reviewing all the more obvious reasons why the United States--alone among all the developed countries of the world---does not have universal health care, there is still a lingering mystery...
...We have no trouble understanding the need for universal education, fire and police protection, and for national defense...
...Nor is there anything on the cultural horizon to indicate that any serious change is in the offing...
...The core European notion of solidarity as the ethical foundation for the provision of health care, rather than an appeal to rights, is quite apparent when those practices are observed...
...What they show me is an even more serious form of solidarity: a willingness to put up with the sometimes unpleasant, undesirable behavior of others...
...Consider the strength of public transportation systems in Europe, the easy availability of public toilets (and the willingness of restaurants to allow nonpatrons use of their rest rooms when there are no handy public facilities), and the willingness of people to share their tables in crowded restaurants...
...From my travels in Europe, let me note some of them...
...Because a radical change will then be required, of just the kind that has traditionally fared poorly in this country...
...There are many subtle, and not-so-subtle, features of our culture that make it hard for us to change...
...For every other developed country, it is obvious that health care belongs among them...
...Common sense and an appeal to simple justice seemed to point inexorably in that direction...
...At that point, it is said, the stage may be set for one more push...
...For years, going back to the Truman administration, pundits and policy analysts have predicted that this country would eventually be forced to provide universal health care...
...No one figured out how to make that case, which seemed to require a wholesale change in the entire system for the benefit of a minority...
...The Clinton team bungled by its closed-door method of drawing up the plan, by its inability to overcome the public's aversion to governmentrun programs, and by its failure to gain backing from the business community, which was worried about the imposition of a higher burden...
...Clearly, the language of a "right" to health care, or the wide-scale publicity about the suffering of those without insurance, did not then--and does not now--have the power to move us away from the present crazy and inequitable system...
...Its greatest failure, however, was its inability to find a way to persuade 85 percent of the population, reasonably well insured, to accept some risk in their coverage to help ensure coverage for the other 15 percent...
...While Bill Bradley and A1 Gore have made different proposals and the Republican contenders talk about the problem a bit, none of them has offered a bold plan...
...Why not...
...Our supposed pluralism never goes that far, and our American individualism and self-righteousness about health behavior do not create good soil in which to grow universal health-care coverage...
...Culture and inertia seem far harder to overcome than anyone suspected...
...Why...
...You don't have to look far...
...These practices are almost always forbidden in the United States...
...What makes matters worse is that there are now 43 million uninsured, a number that is growing by 1.7 million a year...
...Even so, we are going nowhere...
...But even more subtle and telling are two other common European practices: greater tolerance of smoking in public places, and a greater willingness to allow pets on subways, trams, and in restaurants...
...The longer trends of this kind go on--particularly when combined with a steady increase in annual health-care costs (now double the rate of general inflation)--the more costly it will prove to introduce any strong government program...
...The failure of earlier efforts, such as Clinton's 1994 proposal, can be traced to bad politics, bad thinking, and bad public relations...
...All turn on the importance given the public sector in other countries, and its failure to be taken with sufficient seriousness here...
...Their proposals are all incrementalist, aiming to improve access to health care but not, once and for all, guaranteeing basic care to all regardless of ability to pay...
...If there is one hope, it is that the middle class, now well covered, will begin hurting, forced to pay more out of pocket and increasingly insecure about jobprovided coverage...
...Commonweal 8 February 11, 2000...
...We are incrementalists, but in this case the incrementalism is moving in the wrong direction...
...I say that also, but I would not place a very large bet that it will happen...
Vol. 127 • February 2000 • No. 3
