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The High Price of Free Health Care

  Trouble in Single-Payer Paradise There are two kinds of people who support single-payer health care in the United States: Those who point ...

 Trouble in Single-Payer Paradise

There are two kinds of people who support single-payer health care in the United States: Those who point to the British system as a successful example, and those who know something about the British system.

Under the Conservative government of Boris Johnson, the United Kingdom will see taxes raised to their highest-ever peacetime level with a new surcharge going to support the financially wobbly National Health Service and “social care,” meaning nursing-home care or at-home care for the elderly. The taxes will fall disproportionately on the wages of young people, who don’t vote Conservative, to the benefit of wealthier retirees, who do.

One of the proverbs you hear when it comes to comparisons between the United States and the United Kingdom goes roughly: “Sure, they pay higher taxes, but at least they get something for it, including free health care.”

Neither one of those is exactly true.

Apples-to-apples comparisons are difficult to make, because both countries have multiple taxing jurisdictions (high-income New Yorkers pay more than high-income Texans, and high-income Scots pay more than high-income Englishmen) and tax things like investment income and profits from selling a residence differently. That being said: Middle- to upper-middle-income Britons do pay higher national income taxes than do their American counterparts, but when state and local taxes are taken into consideration, the math looks different, with middle-income households in New York State, for example, liable in at least some cases to pay higher income taxes than they would in the United Kingdom. (By way of comparison, taxpayers in Denmark typically pay nearly twice the income tax they would in the United States.) Overall, British income taxes are slightly but not radically higher than American taxes.

So, comparable income-tax rates and all that sweet free health care — it looks like the British are getting a great deal, no? But, of course, it is more complicated than that.

The Brits take a great deal of national pride in the NHS, but, for many in the United Kingdom, that pride is not enough to get them to actually rely on the NHS for health care: One in five Britons choose private care funded out-of-pocket rather than the NHS care funded by the taxes they already are paying, according to the BBC, citing delays, lack of available services, and the indignity of having to “fight for treatment” with the NHS bureaucracy. One in four NHS patients say that working with the state-run system has harmed their mental health.

Meanwhile, residential and at-home care for the elderly, a growing concern in aging nations such as the United Kingdom, can be outrageously expensive. Britons with modest assets (say, $35,000 in home equity) might expect to pay around $90,000 a year for retirement care. In some cases, those expenses can run into six figures.

It isn’t just care for the elderly. Mental-health care in the United Kingdom is poor (though not as poor as it is in the United States) and getting poorer as the number of available treatment spots are cut.

That’s typical of the socialist model of providing scarce goods and services: The things that are free you can’t get, and the things you can get aren’t free. There is a reason that, contrary to what you hear from American progressives, few countries in Europe or elsewhere actually have national single-payer systems. Germany doesn’t have one. France doesn’t have one. Health care in Switzerland happens in an entirely private (but highly regulated) market.

The new surcharge and the related reforms are meant to get social-care costs under control. And while the government of Boris Johnson is not always obviously competent, this is not a Johnson problem: British governments have been grappling with social care since the 1970s. The timelines there are always kind of interesting to me: The welfare state in the United Kingdom took its modern form in 1948, and, less than 30 years later, the country was a wreck. But now as we approach a half a century since the crisis that brought Margaret Thatcher to power, many of the basic problems with that welfare state remain unaddressed. Thatcher’s government made important and fruitful reforms, but there is only so much one government can achieve. Tony Blair tried, and largely failed, to reform the system. Theresa May’s government attempted to deal with the social-care problem and got burned in much the same way the George W. Bush administration did when it tried to reckon with the financial imbalances of Social Security.

These problems are in the lesser part economic and in the greater part political.

Of course, a very rich country such as the United Kingdom has the resources to provide care for the indigent and the elderly. But it has lots of other things it would like to pay for, too: an army and a navy, educations for young people, roads, bearskin hats at $1,500 a pop. The British also want to have a private economy with lots of investment and trade, and enough left over for the occasional Spanish holiday. Choices have to be made.

The NHS is chronically underfunded for the same reason U.S. public pensions are chronically underfunded: Politicians run for office every couple of years, and they have powerful incentives to spend money on things for their constituents in the here and now rather than set aside resources for the use and enjoyment of future beneficiaries. Real investments require real money, but promises are free. And so money goes to where the votes are. And it doesn’t go where the votes aren’t — that is why in the United States, the architects of our social programs have generally tied the interests of the broad middle class to the welfare state through entitlements such as Social Security and Medicare. As the proverb has it: “A program for the poor is a poor program.”

A very tiresome mode of political argument is the one that goes thus: “The ideal version of my imaginary system is preferable to the actual version of your real-world system.” We saw this in the Barack Obama-era health-care debate, when Democrats and the just-the-facts gang at places such as Vox sniffed that the (grievously misnamed) Affordable Care Act would reduce the deficit. Critics, myself included, responded: “That may be true, if the cost projections are not exceeded, and if all the unpopular tax increases are fully implemented. But that isn’t going to happen.” When tasked with giving the ACA a deficit-impact rating, the Congressional Budget Service did everything except make rude masturbatory motions as its analysts dutifully reported, “Sure, in the imaginary world in which this all goes according to plan, it will reduce the deficit.” In reality, everybody knew that measures such as the “Cadillac tax,” a levy on the expensive health-care benefits enjoyed by Democrats’ union allies, were never going to be implemented. As it turns out, many of the key features of the ACA were never implemented.

We see the same dynamic at work in areas other than health care; e.g., with the same big-city progressives who demand higher taxes to fund expanded welfare benefits fighting against higher taxes to fund expanded welfare benefits when those taxes fall on big-city progressives in the form of capped federal income-tax deductions for state and local taxes.

Recent COVID madness notwithstanding, Australia is, in general, a very well-governed country, and a rich one. Its single-payer health-care system is a mess, “under pressure and underfunded,” as the Australian Medical Association puts it, with “delays to treatment, bed shortages, and lengthy waiting lists for elective surgery.” New Zealand, another rich and well-governed country with a similar system, suffers under a “drastic shortage of specialist staff,” expecting to lose up to a third of its neurosurgeons in the coming years with no easy way to replace them. Canada has similar problems. These shortcomings are endemic.

None of this is to say that the U.S. model is the only model, or even that it is a good one. There are several different good ways to do health care. The Swiss model has many American admirers, and the ACA was in part an attempt to adapt Swiss practice to American realities. Many American progressives profess to admire the German way of doing things. But what the German model and the Swiss model have in common is a ruthlessly enforced individual mandate to purchase private health insurance; i.e., one of the parts of the ACA regime that both Republicans and Democrats were content to abandon.

And that points to the fundamental issue that we never seem to get around to really thinking about. The case for single-payer health care, like the more general case for a health-care system with a larger role for government, is not at its foundation about economic efficiency, quality of care, or even access to care. Some largely public systems perform pretty well on the efficiency and access criteria, and so do some largely private systems. Our health-care debate is not based in economics but in temperament — mainly risk-aversion.

The great sources of stress in the American system are the threat of losing coverage and then incurring some massive medical costs, and the related issue of general price opacity. If you want LASIK eye surgery, you can get a quote, you can get three competing quotes, you can arrange financing if needed, etc. The same for many kinds of cosmetic surgery, some kinds of dentistry, and some other services. Of course, not everything can be priced that way. But the lack of transparency, prices, and accountability is, I think, the root of our anxiety about health insurance and health care.

A single-payer system such as the NHS is attractive to some people because it promises — often falsely — to relieve that anxiety. I have even heard some more thoughtful people put it in the appropriate terms: “I would be willing to accept health care that is less innovative and of slightly lower quality, with longer waits and fewer amenities, in exchange for knowing that I was never going to get a bill for anything more than a relatively trivial copay.” And that is not a necessarily irrational position — it is the position of someone who prices risk in a different way from what you or I might do.

A single-payer system also introduces new problems and new sources of anxiety. And so much of our debate ends up being a comparison between the British system and the U.S. system, or the Canadian system and the U.S. system, or the French system and the U.S. system, whatever. Politically, that means exaggerating or emphasizing the defects of the system you like less and waving away the defects of the system you prefer. That is an unprofitable use of time and energy.

What would be more productive, I think — especially for proponents of more liberal and market-oriented solutions on such issues as health care — is to understand and appreciate the stress and anxiety that some Americans believe could be alleviated with an NHS-style monopoly or similar system, and develop reforms that speak to these concerns — which are legitimate concerns and deserve to be treated as such — in a way that is more consistent with our values and with American practice. Local norms and culture matter enormously in these things: I am a great admirer of the Swiss model of government, but I think it would be catastrophic to attempt it in the United States.

I am not much of an admirer of the NHS, which I also think would go simultaneously up in smoke and down in flames, Hindenburg-style, if attempted in the United States.

As Boris Johnson can attest, it isn’t working that well in the United Kingdom, either.

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