Preaching to the choir

I keep hearing Americans talk about universal healthcare as if it were a bad thing. Being English therefore loving the NHS as one of the great institutions of my homeland (along with the BBC and and tea drinking) I admit I may be a bit biased when I think that universal healthcare would be good for the US, however, I think I have good reason to think so beyond just nationalistic bias.

Let's ignore for the moment the 'it's wrong to let people die of curable diseases just because they're poor argument'. That argument doesn't wash with a lot of Americans for several reasons. Firstly, I've noticed Americans tend to attribute bad health to lifestyle choices more than English people tend to. This fits into a deep cultural difference in the way Brits and Americans view the world. Rigid class systems and the paternalism that grew out of it led to a culture that one's place in the world was not necessarily one's own fault and the rich had an obligation to care for the poor. The second world war led to British people accepting the idea that the government could and should interfere hugely with people's economic lives for the greater good. The US is a nation of immigrants who went there with the dream that they could be in charge of their own destiny. Americans also tend to look to non-governmental solutions to problems more than Brits do, so might see the best way to deal with health inequality as through NGOs. Also, to be honest medicaid provides more of a safety net for the poor than a lot of Brits imagine. Either way, the case for universal healthcare doesn't have to depend upon distribution because, I would argue, the US system just isn't cost efficient.

The US spends more per capita on healthcare than any other country. That's not so surprising but the magnitude of some of the differences are. In 2002 the US spent over twice as much per capita on health care as: Austria, Canada, Australia, Finland, Italy and the UK. Was US healthcare in 2002 really 255% better than in the UK? The really shocking thing is when you look at the level of per capita government spending on healthcare. In 2000 the US government was the third highest spender per capita on healthcare. The US public sector spending on healthcare was 144% UK per capita spending on the NHS. Since than UK spending on healthcare has gone up a lot and is now higher than US public sector spending per capita but is still way below US total per capita spending. Most developed countries in the world have some system of compulsory health insurance or tax funded health service. There spend less on health than the US and the US doesn't have better health outcomes for their money. Their child mortality rate is high, their peri mortality isn't great. They don't have higher life expectancy, particularly certain sections of the US population.

Lots of Americans admit that European countries have cheaper and just as good healthcare systems but still don't think that it would work in the US. I can see their point if it were to be introduced on a state by state level because the high mobility in the US between states would lead to a lot of health tourism to any state with lead the way. I don't necessarily see why it couldn't work introduced across all states. I can, however, think of sound economic reasons to explain why the US system is so inefficient. Most of these reasons come down to information problems in health care.

Health insurance markets are plagued by information asymmetries. Someone taking out insurance is likely to have a better idea what medical conditions they are likely to have during the course of the cover, either because of their lifestyle choices or knowledge of symptoms and undiagnosed issues in their family which aren't enough for them to have to declare them on the form. This means that it's really difficult for certain conditions to be covered by health insurance in a competitive market. Take birth control. Most universal healthcare systems subsidise contraception because contraception is cheaper than abortions which are cheaper than antenatal care and birth. Unplanned pregnancies are really cost ineffective compared to contraception. However, women tend to be in a better position than insurance companies to know how likely they are to want to use contraception. Imagine there are two plans, one which covers contraception and the other doesn't. The no contraception one is 50p cheaper because not covering contraception saves them a little bit on average. At first only the lesbians and Catholics go on the no contraception plan because for 50p it's worth having it covered if there's any risk you'll need it. But that makes the proportion of people on the contraception plan who use contraception higher than before so the average cost goes up and the premium goes up. So now the kids who really intend to wait until marriage honest switch across and the women who figure they must be close enough to the menopause not to worry switch across and that increases the contraception covering plan's premiums even more. Eventually the only people on the plan which covers contraception are people who definitely want to use contraception and this means that the premiums for the contraception covering plan are higher than the no contraception plan by the cost of contraception so you may as well just be on the no-contraception plan and pay for the pills yourself. Everyone apart from the Catholics and the lesbians would be better off if the only plan available was one which covered contraception and was 50p more. This is why a friend of mine has insurance which won't cover contraception but will cover up to two abortions a year even though a year of contraceptive pills costs less than two abortions. It's also why employee health insurance tends to cover more stuff than private policies.

Another informational problem is that doctors know better than patients what patients need. If doctors get paid in turns of procedures performed they have an incentive to recommend very expensive procedures even if the cost to benefit ratio is very high. Patients aren't in a position to tell whether a treatment is really necessary and insurance companies each trying to come up with a scheme of cost and benefit which will decide which treatments are covered tends to be very expensive and leads to weird rules about what is and isn't covered because coming up with a complete schedule that can cover all eventualities is impossible, especially due to regular medical advances.

Another problem with private healthcare is that it doesn't take into account externalities. Government healthcare pays a lot of attention to contagious diseases, particularly those that can cause problems later in life. The NHS has a crusade against chlamydia at the moment because finding and treating the people who are infected now is cheaper than treating the infertility it will cause to all the people who get infected if it goes untreated for 10 years. I was offered a chlamydia test in a toilet at my university's society fair. Similarly, the NHS is cracking down on the prescription of antibiotics for minor ailments because it leads to resistant strains. It also tries to avoid unnecessary C-sections because of the problems they cause for future pregnancies.

I'll be honest, there are some losers from universal healthcare systems like the NHS. You're better off in the US if you have good insurance and you might benefit from a really expensive treatment that has a slim chance of working. Infant mortality in the US is quite high compared to other countries but extremely premature babies are much more likely to survive if they are born in the US.

(no subject)

Alec saw a notice on a fence in Cambridge which read "The world stopped the Nazis. The world stopped apartheid. The world must stop Israel." It's a great example of the kind of wank people get really excited about trotting out every time the conflict between Israel and her neighbours heats up. Let's talk about what's wrong with this.

The reference to apartheid highlights the very annoying overblown sense of self importance that some people think they have in the affairs of other countries. 'The world', by which I assume they mean Guardian readers carefully avoiding purchasing South African courgettes, did not end apartheid; South Africans did. Apartheid ended because it became unworkable for the white South Africans to manage. There were several factors in this. Demographics meant that the white minority was becoming an increasingly small minority. The resistance within black townships made them increasingly difficult, expensive and dangerous for the white government to manage. The economy faltered, not because of boycotts, but due to the huge costs of keeping apartheid going and the fact that economic development would require a different workforce to the one provided by apartheid. Banning South African's from sporting events was annoying but certainly not enough to topple apartheid. I find the pronouncement that 'the world' ended apartheid, symptomatic of an imperialist world view in which all of the countries of the world are supposed to somehow see the error of their ways if English people have a nice march in London. It doesn't work that way, any more than Americans were willing to vote for John Kerry because the Guardian had a campaign to make them. London isn't the centre of the world any more and the citizens of other countries are not just schmucks waiting to be told by their European superiors what the morally correct military policy is.

Next, now I'm going to say this slowly so that everyone can get it through their thick heads. Just because some Jews have done something that you disagreed with, it doesn't make it OK for you to say purposefully offensive things about Jews in general. Before I get comments saying "Palestinian babies are dying and your complaining about things being offensive" I'd like to point out that it's not like fairies in Peter Pan. A Palestinian baby doesn't come back to life every time an English person says something anti-Semitic. I don't really have much of an argument with Palestinians under fire saying nasty things about Jews and Israelis, it's very understandable, just as I'm sure some of the people under fire in Sderot have some pretty nasty things to say about Palestinians, Arabs and Muslims. These kinds of attitudes might not be that conducive to peace but they're an understandable reaction to having your life threatened and made a misery. I do have have a big problem with people who are living comfortable lives in Europe and the US and are not affected by the conflict, using it as an excuse to say all of the anti-Semitic bullshit they're not normally 'allowed' to say. In a way I see this as a double whammy of racist bullshit because they're basically using the suffering of one set of non-'white Christian Europeans' as an excuse to attack another group of non-'white Christian Europeans', which is really sick. I've also seen this go the other way with English people falling over themselves to explain how the actions of Hamas give them an excuse to say Islamophobic and racist bullshit about Arabs.

Enough of the references to the Holocaust already. You see, the fact that some Jews are doing something you disagree with doesn't make what they're doing like the Holocaust and doesn't mean that you can absolve your country, race or religion of the guilt for collaborating in the Holocaust or not helping the victims escape by comparing Israel's actions to the Holocaust. And Israel's actions really aren't that like the Holocaust. The ideology is different. The scale is different. The aim is different. Gaza really isn't as densely populated as the Warsaw ghetto. Jews didn't elect a leadership with the stated aim of destroying the German state, the Nazis made that bit up. They are similar in that people are dying and Quakers are against both of them. However, if one's aim were to illuminate the situation through comparison, rather than to downplay the atrocity of the largest genocide in world history and kind of hint that it might have been better if Hitler had finished the job, there are more apt situations to pick for comparison. Alec is more generous than me and suggests that maybe people think that the Jews should know better than to be nasty to people because people were so nasty to them. To test out that idea for size imagine a survivor of sexual abuse and imagine that she does something you disagree with. Now imagine saying saying to her "That Bad Thing you did is just like when your dad repeatedly raped you and no-one helped you even though you begged them for help". Do you think that would start a constructive conversation? Do you think that it would be a reasonable thing to say? I think that the idea that Jews in general and Israelis in particular should be held to a higher moral standard because of the Holocaust is anti-Semitic. It's lovely when someone learns from their abuse to be a wonderful self-sacrificing person in an Oprah book club sort of way, but often survivors just learn that there are horrible people in the world who want to kill them and most of the rest of the world doesn't care enough to help and the only way they'll be safe is to have land and weapons and never allow themselves to be that vulnerable again. That's one of the reasons I think that Israel/Holocaust comparisons are particularly counter productive. Every time people say that kind of crap it just confirms to Israelis that the world is full of anti-Semites so they better not rely on the international community for their safety.

Another thing about the Holocaust. To you it may be something you have to do in school history or even a fun subject to make a porno about, but it really isn't. There are still living survivors and to them it's about how every single person in their village apart from them was murdered, or about how they were gang raped and watched their children being murdered in front of them. It's first hand knowing just how evil humans are capable of being. As these survivors develop dementia they can't hold back the memories they've been trying to avoid all of their lives. For many more people it's having been raised by severely traumatised parents. Always knowing that there was some terrible unspoken horror because your family history only seemed to go back to 1948. It's never completely forgetting that here and now isn't different enough from 1920s Germany. Always sort of having a plan in your head for how you'd flee the country you were born in. If you still think that that's good material to score rhetorical points with, then you're seriously fucked up.