Sunday, September 13, 2009

Should We Bother About America's Healthcare Debate?

To someone who grew up in India, and knew what it meant to have below par healthcare and greedy doctors, and then lived in Britain and experienced NHS, world's greatest mystery is indeed why do Americans fear the idea of universal health care. The news have it that tens of thousands marched last week protesting against the government spending money on health care reforms, which will cover most people in America and possibly fix a broken system. But, truth be told - my wonderment did not start in the last few days; I have always found it baffling that Americans do not like the idea of government paying for health care, and label it 'socialism' for some unfathomable reason.

I would have tucked it away in my brain as another peculiarity of the strange country which is possibly the most religious in the world but holds the right to own a gun so dear to its heart. But, America's refusal to let its government spend money on health care is more serious than that and affect many people even outside its border. This is because the American health care doctrine is carried around across the world by the same insurance companies, their lobbyists and health care firms across the world, where many people can not really afford health care and their governments believe that spending money on health care isn't sound policy. In a way, the rest of the world is waiting to see what happens to Obamacare.

I think it takes a tremendous leap of faith and an extraordinary level of statesmanship to imagine universal health care, because the primary objection to this will invariably come from who matter most in its provision, the Health service providers themselves. Health care is indeed one of those prime examples of an area where the rule of the market does not work. Consider the principal objection against universal health care and you start to get it: Choice! As one of the observers of health care reforms in many countries succinctly put it in a private conversation: "Choice? What Choice? Indeed, choice matters if you are getting a plastic surgery and if you think of health care in those terms. But the patient who had a heart attack does not want choice; she needs care!"

The problem with the theory that Choice essentially leads to better service provision stems from two fundamental assumption. First, it assumes rational decision making. In most cases and countries, health care is a particularly nuanced and opaque area for consumers to make rational decisions. The scope of misrepresenting the available information is many and varied. On the other hand, the consumption of health care services is universal - one can not decree that you have to be educated and well-informed to be able to avail these - and hence, choice in this area may not essentially lead to better decision making.

Second, coming back to our beloved NHS and the lack of choice - long wait lists, which is oft cited as the problem, is primarily an issue about underfunding and not any other systemic malaise. Now, the usual argument was that private enterprise unlocks the funding which is usually unavailable to public efforts, but the same did not really held true when it came to bank rescues and all that happened in the last 24 months. So, lack of choice is not necessarily equated with public provision of a service, but the lack of intent on the basis of the provider.

This intent issue is so crucial that it needs a truly committed leader to push through this seemingly obvious requirement. It did take the post-war British government, who were bankrupt in the first place, some extraordinary leadership and conviction to put the NHS together [against bitter opposition of the health care community]. Despite the fact that Barack Obama's opponents tried to misdirect the American people about the social provision of health care by equating it with socialism, this was indeed sound capitalist principle that worked for Britain. One may argue that the advent of welfare state was the prime reason how the spread of socialism was finally contained, the domino effect of soviet occupation of East Europe was stopped and capitalism as a better economic model finally won the day.

However, as I think about it, I believe that this extraordinary reticence to let the Government do a good thing comes from a very American character - that of not coming in terms with the idea of mortality. Americans possibly think of health care in terms of plastic surgery, and not in terms of that moment when they may need critical care, because they believe, somewhere deep in their mind, that death is optional, and possibly can be postponed if you have enough money. And, besides, on the flip side, they possibly think that those who do not have enough money to pay for health care are not American enough, and they have no parts in an American dream. So, bankers are worth paying for, but not those who could not pay for health care - so goes the thinking, perhaps!

Indeed, I know that there are millions of Americans who do not think that way and would want to build a humane society like any other person. They are not joining this parade of selfishness cheered on by a few unscrupulous politicians, mostly on the payroll of the health insurers. However, the debate today is not about socialism versus capitalism at all; but about two versions of America and the message it sends out to the world.

And, I think, this is the missing bit that every one needs to see. For all its promise, we know Capitalism as we know it is a crisis prone system, which allows systemic manipulation of many by a few all the time. The redeeming feature of Capitalism, so far, has been that it allowed a fair chance of success, without being harsh to those who could not make it. Since the 1980s, however, it seemed to have changed: the company men with lifetime jobs withered away, public provision of essential services have gone out of fashion and a sort of jungle capitalism, not very unlike Upton Sinclair's days, have made a comeback. This recession is a stark reminder that the system itself is unsustainable, and if we do not change course, we may manage to repeat our history and destroy our civilization in a bloody repeat of what we managed to do during the last century. The great significance of this health care debate is whether one can win the agenda away from those failed prophets who got us here in the first place. We just hope that Barack Obama, a formidable man, can win this debate and change the course for us.

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