The policy/politics disconnect
When I talk to Americans about what I am doing there is a lot of interest. When Louise talks to other parents at school, health insurance (and specifically dissatisfaction and concern with it) is almost as much of a polite middle class conversational default setting as house prices in specific school catchment areas are in the south east of England. When I turn on the cable news channels to get my fix of politics and policy, health care and related health policy is right up there with potential corruption amongst Brazilian local government officials and the latest musings of Jose Mourinho. Yep, it’s nowhere to be seen.
This is baffling. There is near-universal agreement amongst everyone we meet that healthcare in the US isn’t working. Everyone really worries about it, and I mean really worries about it. It’s at the level of “will my insurance cover me if I fall sick?”, or “Oh no, my child needs to go to ER and I haven’t finished paying the bill from last time”. It makes the worries that people have in the UK about the number of NHS managers seem rather abstract. And yet, while in the UK, the state of the NHS is always near the top of the political agenda, in the US, it never appears. Politics is limited to Iraq, terrorism and the game of politics itself. Even more surprisingly, no-one we talk to seems to consider that their real worries about access to healthcare are the fault of government (and this in a distinctly “blue” area). In contrast you only have to read the BBC’s Have Your Say (albeit that it is deliberately moderated to be anti-government – I’ve now undertaken a controlled experiment to prove this) to see that there are large groups of people in the UK who still blame Tony Blair personally for a GP’s receptionist being rude to them.
Why is this? Three hypotheses:
1 American individualism, meaning that your health care is your own business and no-one elses’, versus British notions of social solidarity.
2 The belief of at least some of American society that social problems have simple causal links to individual (moral) choices. Therefore the role of government is to encourage (or force) individuals to make the right choice and then social problems are solved. Hence government has no role in fixing social problems directly. Hence policy and politics should not be concerned about something like healthcare.
3 Nye’s ridiculous comment about bedpans reverberating round Westminster still holds in the British psyche.
The individualism argument is an interesting one and leads onto issues about moral hazard and “skin in the game” which is probably worthy of at least two additional posts. The individual freedom and responsibility is one of the things I’m really admiring about America and Americans, although it has downsides where issues of social justice become ones of charity.
The theory of individuals bearing moral responsibility for social problems is, of course, an extension of this mindset, and strikes me as nonsense on stilts. The complexity of the psychological and sociological incentives of even comparatively simple systems – such as described in the last post – and the complexity that flows from the interactions of many individuals making complex moral decisions is so great that to imagine that if everyone behaved a bit better we would inhabit some pre-lapsarian paradise is ridiculous. I exaggerate, but only slightly. This is essentially the thinking of the authoritarian right who are certainly represented in the current US administration.
The final point is, of course, redolent of micro-management. What is clear is that we have had a period of micro-management of the NHS which both Gordon Brown and David Cameron are signaling a departure from. This seems all well and good, although it is worth any Conservatives reading this to consider that, as Simon Jenkins helpfully recalled, it was a period of laissez-faire “professional” control of the NHS in the late 70s and early 80s that led to the Griffiths inspired reforms of the mid 80s.
Where do I stand on this? It seems to me absurd not hold governments to account for the general running of infrastructural systems such as health. It is both moral and in a nation’s self-interest to ensure that a health system is in place which provides good care to individual citizens reasonably cost effectively. It is equally absurd however, to blame government for individual poor care which is not a direct consequence of the system. Thus, fair to blame the government for the 2 day GP wait debacle, unfair to blame them when the GP fails to spot my condition.
And certainly not right that the Daily Mail should force secretaries of state to intervene in rows about Herceptin.
This is baffling. There is near-universal agreement amongst everyone we meet that healthcare in the US isn’t working. Everyone really worries about it, and I mean really worries about it. It’s at the level of “will my insurance cover me if I fall sick?”, or “Oh no, my child needs to go to ER and I haven’t finished paying the bill from last time”. It makes the worries that people have in the UK about the number of NHS managers seem rather abstract. And yet, while in the UK, the state of the NHS is always near the top of the political agenda, in the US, it never appears. Politics is limited to Iraq, terrorism and the game of politics itself. Even more surprisingly, no-one we talk to seems to consider that their real worries about access to healthcare are the fault of government (and this in a distinctly “blue” area). In contrast you only have to read the BBC’s Have Your Say (albeit that it is deliberately moderated to be anti-government – I’ve now undertaken a controlled experiment to prove this) to see that there are large groups of people in the UK who still blame Tony Blair personally for a GP’s receptionist being rude to them.
Why is this? Three hypotheses:
1 American individualism, meaning that your health care is your own business and no-one elses’, versus British notions of social solidarity.
2 The belief of at least some of American society that social problems have simple causal links to individual (moral) choices. Therefore the role of government is to encourage (or force) individuals to make the right choice and then social problems are solved. Hence government has no role in fixing social problems directly. Hence policy and politics should not be concerned about something like healthcare.
3 Nye’s ridiculous comment about bedpans reverberating round Westminster still holds in the British psyche.
The individualism argument is an interesting one and leads onto issues about moral hazard and “skin in the game” which is probably worthy of at least two additional posts. The individual freedom and responsibility is one of the things I’m really admiring about America and Americans, although it has downsides where issues of social justice become ones of charity.
The theory of individuals bearing moral responsibility for social problems is, of course, an extension of this mindset, and strikes me as nonsense on stilts. The complexity of the psychological and sociological incentives of even comparatively simple systems – such as described in the last post – and the complexity that flows from the interactions of many individuals making complex moral decisions is so great that to imagine that if everyone behaved a bit better we would inhabit some pre-lapsarian paradise is ridiculous. I exaggerate, but only slightly. This is essentially the thinking of the authoritarian right who are certainly represented in the current US administration.
The final point is, of course, redolent of micro-management. What is clear is that we have had a period of micro-management of the NHS which both Gordon Brown and David Cameron are signaling a departure from. This seems all well and good, although it is worth any Conservatives reading this to consider that, as Simon Jenkins helpfully recalled, it was a period of laissez-faire “professional” control of the NHS in the late 70s and early 80s that led to the Griffiths inspired reforms of the mid 80s.
Where do I stand on this? It seems to me absurd not hold governments to account for the general running of infrastructural systems such as health. It is both moral and in a nation’s self-interest to ensure that a health system is in place which provides good care to individual citizens reasonably cost effectively. It is equally absurd however, to blame government for individual poor care which is not a direct consequence of the system. Thus, fair to blame the government for the 2 day GP wait debacle, unfair to blame them when the GP fails to spot my condition.
And certainly not right that the Daily Mail should force secretaries of state to intervene in rows about Herceptin.
posted by Exiled in mainstream at 12:41 PM
1 Comments:
I suspect that the Clintons' health care plan fell mainly because of Mrs Clinton's manner and inexperience. Now that she has found out how to work the Senate she might have better luck second time around.
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