As the so-called New Right continues its transformation into the Old Left, some of the people who spent the Obama years caterwauling about “socialized medicine” have discovered a strange new respect for … socialized medicine—the real kind, not the oogedy-boogedy “socialized medicine” of talk-radio hysteria and Fox News huffery-puffery.
Former New York Post op-ed editor Sohrab Ahmari, who only a few years ago was wringing his hands over the “illiberalism” of the Affordable Care Act (remember when these guys worried about the state’s illiberalism? Good times!) has found a new idol: the United Kingdom’s National Health Service. Ahmari writes that his “own sense of vulnerability” was heightened by fatherhood, but he had the good luck to be working for the Wall Street Journal in London at the time of his son’s birth. “Each time my wife and I confronted the illnesses of early childhood, we received decent, humane care from the NHS,” he writes. “And there would be nary a copay, let alone a scary bill.”
Of course there is a scary bill to pay. That the British are not sure they can pay it is one of the central facts of public life in the United Kingdom today.
The NHS is, in fact, in the midst of what the Financial Times describes as “its worst-ever crisis.” Its financial position is unsustainable and bordering on the catastrophic. Spending is dramatically up—in inflation-adjusted terms, the NHS spends today almost twice what it did 25 years ago—though very little of that money goes to investments in critical health care infrastructure. Staff is up, too—though no one who knows anything about modern bureaucracy will be surprised to learn that staffing is up much more sharply among senior managers and consultants (23.7 percent combined) than among doctors (13.4 percent), while the number of general practitioners has declined a bit (1.9 percent) in recent years.
But even with all these additional resources in place, wait times are up, waiting lists are long and getting longer, and the NHS as a whole is doing fewer procedures, seeing fewer patients, etc. In fact, the NHS backlog is so severe that it has been paying patients to use private alternatives to the public system. This is supposedly for “elective” care, a category that includes, in the NHS’s reckoning, hip and knee replacements—which aren’t exactly things done on a whim.
It is the predictable outcome of a socialized enterprise, whether you are talking about Soviet collective farms or U.S. state-monopoly schools: Doing less with more. There are important differences between Soviet socialism and British health-care socialism—such as gulags—but the underlying economics produce similar failures for similar reasons. And the failure of the NHS is stark. From an Institute for Fiscal Studies report issued in December:
For five of the eight care types … the NHS is treating substantially fewer patients than it was in 2019. Focusing on the latest month of data, there were 13.8% fewer outpatient appointments, 13.8% fewer emergency admissions (despite this including COVID-19 admissions), and 11.1% fewer elective and maternity admissions than in 2019. Because many elective admissions and outpatient appointments are for patients on the waiting list for care, the number of patients treated from the waiting list was also down 10.5% compared with the same month in 2019. There were also 9.5% fewer incidents recorded by ambulance services (and 19.1% fewer conveyances to A&E, despite 4.1% more 999 calls—which, in part, reflects a deliberate effort to treat more people outside of hospitals).
This isn’t Sen. Elizabeth Warren’s hysterical “people will die!” This is: People are dying.
As the Royal College of Emergency Medicine runs the numbers, as many as 500 people are dying every week from delays to emergency care alone. For perspective, that means that the British health care system is killing more people weekly than the number who die weekly in firearms murders in the United States—in a country with one-fifth the U.S. population. A separate analysis by the Times of London put the excess deaths at 1,000 a week.
What a peculiar time to hold up the NHS as a model of good policy. But, then, Ahmari is damned peculiar as a political analyst.
You wouldn’t know it to hear U.S. progressives talk—or to hear it from the so-called New Right, either—but U.K.-style national monopoly health care systems are found almost nowhere in Western Europe or in the developed world outside of former British territories, notably Canada, or in East Asia, namely in Taiwan and the Republic of Korea. France has a complicated public-insurance system in which patients are expected to pick up about 30 percent of most expenses; 30 percent also is the target patient co-pay in Japan. Switzerland has an ACA-style individual mandate—with the important difference that Switzerland actually enforces its mandate—and no government provision of medical services at all. Sweden’s system, typical of Nordic practice, is largely administered at the municipal level and includes both public and private elements; Denmark’s system is largely run at the regional and municipal level, with private insurance to cover co-pays charged by the public system. The notion that Americans are the only people in the world who walk away from the doctor’s office with a bill to pay—potentially a big one—is nonsense.
That does not mean that Republicans were doing the smart thing (when do Republicans do the smart thing?) during the ACA debate by simply stamping their feet and insisting that—all together now!—“America has the best health care system in the world!” If Americans had been satisfied with their health care system, Barack Obama would not have gotten so much juice out of the issue as a candidate. Our health care system is, in many ways, a mess, and Ahmari is right to put his finger on uncertainty as the critical issue. Single women in the cities and suburbs vote for Democrats, and old white guys in downscale rural areas vote Republican, but what those two demographics have in common—where they are starting to make common cause, politically—is that they are risk-averse. The most reliable Trump voters and the most reliable Biden voters are united in their opposition to entitlement reform and similar projects.
One of the things libertarian-leaning critics consistently overlook is that risk-averse Americans are not necessarily being irrational when they prefer more statist systems (not only in health care but in education and much else) to more market-oriented alternatives even when confronted with ironclad evidence that those systems produce terrible results, as with the NHS—they are simply evincing values at odds with the ones the free-market advocates think they should have. In the case of health care, many Americans (though they might not put it precisely this way) would prefer an inferior system with predictable pricing and terms of access to a superior system with unpredictable or opaque pricing and terms of access. Those putting together free-market alternatives will continue to fail, as a political matter, until they learn to address that risk-aversion. Price transparency would be a big start, but that only helps so much if prices remain impossibly high.
The negative case is pretty easy to make: The NHS is a mess, but even the better European systems have some features that would be a hard sell in the United States. The Swiss system, of which the ACA regime was supposed to be an adaptation, requires a pretty heavy regulatory hand and ruthless enforcement of the individual mandate, which Americans rejected as … un-American. Denmark’s model of government has many things to recommend it, but its health care system is, among other things, a dystopian surveillance-state nightmare. Scandinavian decentralization has created perverse political incentives to try to push expensive beneficiaries over the line into the next municipality or region. Germany faces severe understaffing in its hospitals and other medical facilities. Canada is a great place to spend eight hours “curled up on the floor in agony, sometimes vomiting,” while suffering from potentially fatal appendicitis.
The positive case for the U.S. health care system is easily expressed: There isn’t one. Our system stinks, and voters have noses. The positive case for a better, consumer-oriented alternative is much more difficult to make. Call it risk-aversion, or simply chalk it up to the fact that Americans have lots of experience with imbecilic (and occasionally predatory) medical business practices—and even worse experiences with health insurance companies, which along with banks and airlines have done more to turn people against capitalism than Karl Marx ever did.
Health care reform proposals calling for a larger role for the state—or those simply trying to prop up the status quo of health care entitlements—promise greater security and predictability, and that is why they are attractive. The promise, however, is a false one. The current system offers no long-term security to entitlement beneficiaries or to Americans at large. Responsible analysts—left and right, progressive and conservative—agree about the basic math touching the major U.S. entitlement programs. In 2022, the federal government collected a total of about $4.9 trillion in taxes, and 84 percent of that money was consumed by a handful of entitlement programs, the so-called “mandatory spending.” And there are lots of other things the federal government has to do with the remaining 16 percent—so many things that very large deficits are projected … forever, unless something changes. Assuming there is a limit on how much money the world will lend to the U.S. government to spend on retired middle-class people (that’s where the lion’s share of the entitlement money goes, after all), the two possible outcomes in our future are either fiscal reform or fiscal crisis. Wishing it otherwise may make for a good campaign speech, but it is not so. The people who say that this can go on forever—or that it can all be fixed by raising taxes on people you don’t like—are lying.
Weirdly, though, the problem with our health care system isn’t that we lack resources. Far from it.
You may have heard that Americans spend a lot more per capita on health care than people do in most of the rest of the rich world, and this is true. We also spend a lot more on all sorts of things—legal services, for example—than they do in the rest of the world. One of the reasons for this is that Americans are so unbelievably rich. How rich Americans actually are is something that few Americans seem to understand. We go to Europe, we see the nicest parts of Amsterdam or Zurich or Paris, and we feel like the Europeans are doing at least as well as we are. But they aren’t. By the most relevant metric—GDP per capita—the United States is so far ahead of the rest of the world that it is hardly even a contest. A handful of small countries have GDP per capita greater than the United States—usual suspects such as Switzerland, Singapore, and Luxembourg—but none has a population equal to that of the Dallas-Fort Worth metroplex. And hooray for them: There’s lots to like about Switzerland and Singapore. But when you compare the United States to countries that have a bigger footprint than, say, Riverside County, California, things get dramatic. GDP per capita in the United States is twice the European Union average and well more than twice that of Japan; it is 45 percent higher than that of prosperous and happy Sweden, 54 percent higher than Canada’s, and 74 percent higher than that of the United Kingdom. As to the other countries with very large populations (the United States has the world’s third-largest), U.S. GDP per capita is six times China’s, eight times Brazil’s, 16 times Indonesia’s, 31 times India’s, 50 times Pakistan’s, etc. If France were a U.S. state, it would be the poorest one, with a per capita GDP coming in about $3,000 a year behind Mississippi’s, as figured by the U.S. Bureau of Economic Analysis.
I write this only to emphasize: Our problem, vis-à-vis health care and much else is not a lack of resources. One of our problems is program design. We keep trying to “fix” health care and keep creating new programs that do not work very well: Medicare, Medicaid, the Social Security disability system, the ACA regime, which was designed to satisfy headline writers at Vox (who pretended not to know that many of the unpopular parts of the act—especially the taxes and the individual mandate—would never be implemented, meaning that the fiscal projections used to sell the bill were good marketing but garbage policy), and probably whatever comes next. It didn’t take Democrats 25 years to go from creating HMOs to demonizing them as the great villain in the U.S. health care system. These programs have all delivered less and cost more than promised. But if your problem is bad program design, then you don’t want to cite the NHS as your preferred model, because—and this part matters!—it is a mess.
And the United States has shown, time and time again, that it is not very good at imitating other countries’ programs—and it is far better at importing foreign failures than foreign success: As mentioned above, the ACA was basically modeled on the Swiss system—individual mandate, coverage mandates, lots of subsidies, lots of provider regulations—but omitted the parts that make that system work. The United States is culturally, politically, and economically ill-suited to import Scandinavian or German practices, or Singaporean practices, or even British practices, even though we share a language and a history.
The problem is that Americans are, politically speaking, teenagers: We expect to be taken care of but resent being told what to do. Balancing the risk-aversion that causes many Americans to look longingly (if wrongly) at British or European practice with the hallmarks of American economic success—consumer choice, competition, entrepreneurship, financial innovation, etc.—has proven exceedingly difficult as a policymaking matter, to the extent that it has been tried at all as a policymaking matter. But turning to a proven failure such as the NHS model for purely emotional reasons isn’t even adolescent—it is childish.
But childishness is in many ways the defining characteristic of the so-called New Right.