The narcissism of minor differences

Cohen in the NYT today: "Some of my summer in France was spent listening to indignant outbursts about U.S. health care reform. The tone: “You must be kidding! What’s there to debate if 46.3 million Americans have no health insurance?”

I think the French are right. I don’t think there’s much to debate when France spends 11 percent of its gross domestic product on health care and insures everyone and the United States spends 16.5 percent of G.D.P. and leaves 20 percent of adults under 65 uninsured. The numbers don’t lie: The U.S. system is wasteful and unjust.

It’s not just the numbers. It’s the intangibles. Two of my children were born in Paris — a breeze. One of them got very sick on arrival in the United States — and my wife fainted in a doctor’s office from the anxiety of finding the appropriate care (when we did, at the eleventh hour, it was excellent). The American health system is an insidious stress-multiplier whose hassles, big and small, permeate already harried lives.

So I’m convinced there’s no real argument. As President Obama put it last week, “We spend one and half times more per person on health care than any other country, but we aren’t healthier for it.” Why would the United States cling to the dubious distinction of being the only wealthy nation that does not afford basic health insurance to all?

The answer can be found only in myths and misleading stereotypes, so let’s try to dispel a few in the interest of having a more fruitful discussion.

I’ve said I think the French are right. But the French are also wrong. To cement a land-of-capitalist-cruelty American stereotype, they tend to believe no elements of the European welfare state exist in the United States.

Most would be shocked to hear about American social security, let alone Medicare and Medicaid, the government-run health care systems for the elderly and the poor that together form one of the largest publicly financed health systems in the world.

Americans obsess less about France than vice-versa but when they do they tend to suffer from equally delusional ideas. The French — like many Europeans — loom as a feckless multitude coddled by a nanny state that’s so big it must be socialist.

In fact, ever since President Mitterrand tried broad nationalizations in the early 1980s with catastrophic results, France, like most of Europe, has been on a steady march toward freer markets, trade and competition. In its way, it has been Americanizing.

The French health system uses a mixture of public and private funding, guaranteeing basic coverage through national insurance funds to which employees and employers make contributions. Most French people supplement these benefits by buying private insurance. The distinctions from the single-payer British system are significant, the results better.

So beyond all the hectoring, the main French-American difference on health care is not ideological but a question of efficiency. Both countries use a mixture of public and private. France is at a very far remove from “socialism.” The United States has already “socialized” a significant portion of its medicine. (Nothing illustrates right-wing ideological madness in the United States better than calls from some to “keep the government out of my Medicare!”)

The real difference is that the French state mandates health coverage for everyone, picks up the tab where necessary (as for the unemployed), holds down costs through a national fee system, and uses mainly nonprofit mutual insurers even for supplemental private coverage. The profit motive is outweighed by the principle of universal health care, with a corresponding effect on doctors’ salaries.

These are real distinctions. But the “socialism sucks” Republican broadside on Obama’s reform plans — with its overtone that the “cosmopolitan” president wants to “Europeanize” American medicine — is nonsense. It’s nonsense because the free market is vigorous in France (and Europe), because there are all sorts of European approaches to health (within the compulsory coverage), and because the United States has already “socialized” aplenty without turning its capitalism pink.

As Peter Baldwin makes clear in an interesting new book called “The Narcissism of Minor Differences: How America and Europe are alike,” U.S.-European contrasts can often be more about playing politics by comforting old myths — individualist at the new frontier versus collectivist at the beach — than facts.

Still some facts of the trans-Atlantic health care contrast are disturbing and justify the incredulity of my French friends, none more so than the furor over President Obama’s support for a government insurance option (like Medicare) that would, among other things, keep private insurers honest. Its Republican critics have portrayed this idea as so dangerous it represents a fight for freedom over tyranny.

So Obama has retreated a little and portrayed this option as a “only a means to an end” that could be discarded. He should not retreat. The public option best enshrines the principle of the state’s commitment to insuring everyone.

It’s therefore essential. Without it, we’ll get tinkering at best. The commitment to that health-as-right principle is what distinguishes France from the United States far more than all the socialist-capitalist claptrap."

I know that even saying the word "France" is throwing more red meat to the right in the US, but the perspective of the US health care debate from Europe is one of utter incredulity. I'm not sure how an expansion of health care turned into a recipe for tyranny. Maybe that's the source of the wackiness in the American political dialogue: every argument is immediately taken to the extreme... socialism, tyranny, etc.

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