Why is it so hard to reform health care? National identity

Documentaries, such as Sicko and Sick Around the World, visit other countries and ooh and ahh over their rational, effective, and equitable health care systems. Why is it that France, Italy, Japan, the UK, Canada – all the major developed countries – have managed to solve the problem of guaranteeing affordable health care while the US just can’t seem to get it together?

Every country is unique, so it’s unproductive to imagine the US duplicating another country’s health care system. What the US has now is a very complicated arrangement for delivering health care and paying for it, a convoluted system that’s been evolving for decades – ever since Marcus Welby-like family doctors stopped making house calls.

Comparisons to other countries can be useful, however, in discovering the characteristics — those we have and those we lack — that make health care reform so difficult.

National identity

Arnold J. Rosoff, a professor of legal studies and business ethics at Wharton, has studied the health care systems of Argentina, France, Italy, Japan, and Singapore. A question he likes to ask is: What was characteristic of these countries when they put universal health care into practice? One thing that stands out is a strong sense of national identity.

When it comes to cultural identity as a nation, Italy and France are much more unified, more “consolidated” than the US. In Singapore, most of the residents are Chinese (three quarters of the population). The majority of Japanese citizens are of Japanese ancestry, and there is a strong sense of national identity in Japan.

The US, on the other hand, prides itself on being a nation of immigrants. We emphasize the individual and his or her rights. There’s a strong distrust of government that goes all the way back to the Pilgrims, who were escaping persecution. Put these together and you have a population that doesn’t want the government interfering with personal choices.

Certain cultural and historical features of other countries made it easier for them to institute universal health care. France and Italy had a strong history of providing public services. The political system in France features strong executive power. Public debate doesn’t come into play until students take to the streets.

Argentina had Juan and Eva Peron as strong thought leaders in the debate on health care.

Japan’s health care system works well because it pays precise attention to detail and distributes funds equitably, qualities that come easily to the Japanese.

Singapore had a highly effective system of government left over from British colonial rule. It also had a youthful population and a strong economy.

A strong economy is helpful for reform, but not essential. When Italy and France implemented universal health care after World War II, their economies were devastated. Counterbalancing this, though, was the right mix of nationalism and socialism.

Politics: Let’s oppose health care reform so we can break Obama

When the US needs to agree on a major policy initiative, our diversity translates into political differences. The democratic nature of the political process becomes a major roadblock to health care reform.

During Clinton’s attempt at reform, conservatives in Congress opposed his plan because its success could have generated support for the Democratic Party. In a recent press conference, President Obama said: “I’ve heard that one Republican strategist told his party that even though they may want to compromise, it’s better politics to ‘go for the kill.’ Another Republican senator said that defeating health reform is about ‘breaking’ me.” It’s déjà vu all over again.

Is anything different this time around? In the 1990s, employers saw health care benefits as a resource to attract and retain valuable employees. They were heavily invested in the status quo. Today the cost of insurance is a liability for employers, not a recruitment perk.

What hasn’t changed are the powerful players with vested interests: Doctors, hospitals, insurance providers, the pharmaceutical industry, device manufacturers, politicians. The non-powerful players with a vested interest are the patients.

Gradual vs. revolutionary change

Because we lack a unifying national identity, it’s extremely difficult to reform health care. We can make minor changes, but nothing major. Nothing revolutionary, like a single-payer system. According to Rosoff, change will most likely happen in small, incremental steps. “It’s probably the only way to get there from here. Given our history, politics and national character, sweeping health care reform would be too big a pill to swallow.”

Thanks to KevinMD for the link to Arnold Rosoff.

Related links:
Why is it so hard to reform healthcare? Rugged individualism
Why is it so hard to reform health care? The historical background
Why is it so hard to reform health care? Political structure
Why is it so hard to reform health care? The issues are complex
‘Mad Men,’ the sixties and the culture war over health care
Health Culture Daily Dose #8: Health care reform