Satisfaction and Quality In Health Care Reform

There have been a number of posts around the blogoshere regarding the health care debate between Ezra Klein and Andrew Sullivan which I previously discussed here. Follow up discussion has raised important points with regards to subjective satisfaction and evaluation of quality in health care. Like the topics I reviewed yesterday, these also indicate areas where left and right need to consider the opposing viewpoints with both extremes being unrealistic.

Ezra Klein responds to Andrew Sullivan by displaying evidence that the British are more satisfied with their system than Americans are. I am surprised that Ezra allows himself to be backed in to the corner of even defending the British system as that is not on the table here. As the question is what forms of health care would be tolerated in the United States, and not what was accepted in the United Kingdom, Sullivan easily demolishes Klein’s argument:

Satisfaction is a subjective function of subjective expectations. If you have the kind of expectations that many Brits have for their healthcare system, it is not hard to feel satisfied. The Brits are very happy with their dentists as well. And there is a cultural aspect here – Brits simply believe suffering is an important part of life, especially through ill health. Going to the doctor is often viewed as a moral failure, a sign of weakness. This is a cultural function of decades of conditioning that success is morally problematic and that translating that success into better health is morally inexcusable. But if most Americans with insurance had to live under the NHS for a day, there would be a revolution. It was one of my first epiphanies about most Americans: they believe in demanding and expecting the best from healthcare, not enduring and surviving the worst, because it is their collective obligation.

I suspect it is also a matter of having lived under such a system and not knowing anything different. Both Brits and Americans are more accepting of the faults in their own system. The British system was also instituted closer to World War II. Brits at the time were far more willing to accept sacrifices for a national program than Americans would at present.

It is a problem that liberal advocates of health care reform defend the British system as Klein does because this suggests a lack of understanding of what forms of health care reform would be acceptable in the United States at present. Unfortunately many liberals think that HillaryCare failed not because it was a poor system but because of an advertising campaign by the insurance industry. The Harry and Louise Ads would not have been so effective if they did not raise real problems seen by many voters.

I also questioned Ezra’s support for the British system in the past, especially with regards to his support for capitated systems as opposed to fee for service medicine. Ironically, the British system uses a system of capitated payment similar to what was used by businesses utilizing HMO’s in the United States until patients got fed up with the problems of such systems and their use declined.

While there are undoubtedly abuses under fee for service medicine, capitated systems run a far greater risk of ignoring the needs and desires of the patient. Whether they are used in a government-run system in the U.K. or in HMO’s in the United States, they pit the financial interests of the doctor against the best interests of the individual patient. Capitated systems, in which doctors receive a fixed amount of money per patient (often with adjustments for factors such as age and health status), risk having doctors forced to provide inadequate care in order to get by on what is paid. Doctors are given financial incentive to see patients as little as possible, do as few tests as they can get away with, and treat as little as possible.

Americans both demand the best and demand a greater degree of freedom of choice than was present in either the British system, under HillaryCare, or in capitated American HMO’s. This does not mean that health care reform is not possible. Obama has showed understandings of the failings of Clinton’s approach such as in seeking a more transparent method for considering reform, avoiding mandates, and stressing the ability of those who are satisfied with their current coverage to remain in their current plans. This turned out to be an advantage for Obama not only over Clinton but over McCain’s health care plan in the general election.

Measuring quality in health care allows both the left and th right to make points. In his original post Klein claimed that the British do not suffer from lack of quality in their less expensive system. James Joyner has an excellent round up of this entire debate (including a link to my earlier post) and cites evidence which does show the superiority of the American system in certain areas.

Both Klein and Joyner are correct in arguing for the quality of opposing systems depending upon the criteria used. In general, when subspecialty care is evaluated the United States comes out among the best in the world–for those who have access to such care. When quality is measured based upon more routine care the United States does not rank very highly due to the large number of people without access to health care. All too often those on the left or right only look at one of these measures of quality and ignore the importance of the other. Any system developed for the United States must preserve the high quality subspecialty care we now enjoy in the United States while making health care affordable for a larger portion of the population.

How Do The Republicans Recover?

Marc Ambinder runs down the problems faced by the Republicans. His first point deals with a topic I discussed in several posts on after the election (including here and here) regarding the move by affluent, educated voters to the Democratic Party:

The class inversion. As described by Ron Brownstein, it’s the growing strengh of Democrats among a certain type of white, college-educated voter; Obama won 47% of these voters in 2008, the most ever for a Democrat, and the trend has been advancing.

This is very closely related to the Republican’s ties to the religious right, their hostility towards science and reason, and substitution of ideology for a reality-based view of the world. Many educated voters will not consider voting for a party with many members who are creationists, even if it means paying higher taxes or having some other policies they might otherwise not support.

Ambinder’s second point is that the Republicans will have a harder time recovering from being out of office than the Democrats did:

Party structure. Conservatives hold more sway in the Republican Party than liberals do in the Democratic party. To put it another way, conservatives make up a larger portion of the Republican base than liberals do of the Democratic base — a larger percentage, even of their national committee that liberals do in the DNC. Therefore, it’s more difficult for Republican candidates to challenge orthodoxy and dogma; it’s harder for a Bill Clinton figure to emerge.  You cannot build a Republican Party without social conservatives.

The Democrats not only had a Bill Clinton emerge, but also had a Barack Obama emerge to challenge the control by the Clintonistas. It is hard to imagine an analogous situation in which someone like Obama beats a strong presumptive candidate in the Republican Party.

These problems lead to Ambinder’s third point that the Republicans have little support outside of the south and some western states with few electoral votes. Demographics make the problem worse as minorities are less likely to support the Republicans.

Ambinder tries to look for solutions:

It’s hard to think of one  Republicans can’t win without social conservatives, and so they shouldn’t try to. They can’t win by “going back to their roots,” in part because that phrase is tautological and has no agreed upon meaning. By roots, does one mean anti-communism? Lower taxes? Cultural traditionalism? Libertarianism? It took Bill Clinton to bring Democrats out of their wilderness, but he took the party from point A to point B. Adapting conservative principles to modern developments like globalization is an obvious avenue to reform, but that’s easier said than done, and there are many in the party who believe that no change on policy is needed, just a new “tone.”

Ambinder argues that the Republicans can’t win with the social conservatives, but that is what dooms them in the long run. At present the Republicans cannot win a national election without bringing out the social conservatives in large numbers. However, it is this close connection to social conservatives which makes the affluent and educated voters vote against them, making it very difficult for Republicans to win a national election.

This dynamic could be seen in this year’s election. If McCain had run as a socially moderate centrist and had not have chosen a reactionary such as Sarah Palin as his running mate it is possible he would have done worse because many on the far right might have stayed home. However I felt that the moment McCain choose Palin he had made himself unelectable nationally, despite the short-lived bump until the country realized what Palin stood for. In addition, if McCain had lost as a centrist the Republican Party would have had something to build upon while out of office. Having made the Republican Party a party of the extreme right they not only lost this election but may have permanently lost both the educated/affluent vote as well as a whole generation of younger voters.

Supporting the policies of the social conservatives, along with their hostility to science and reason, is a losing proposition long term. Their views are only going to become more unpopular over time. The Republicans have dug themselves into a hole, and the first step to recovery is to stop digging–not accelerate the digging as many on the far right advocate.

In the past the Republicans managed to win by stringing along the social conservatives. They would play lip service to the religious right while calling them nuts behind their backs and trying to give them as little as possible once in office. George Bush changed this by actively pursuing the agenda of the religious right, even if Karl Rove continued to call them the nuts.  The moderates were driven out of the party, leaving the GOP firmly in the hands of the far right.

For a while the Republicans could win despite the baggage of the religious right by using tactics such as fear of terrorism or by demonizing the Democrats by distorting their positions. Such tactics have become decreasingly effective.  Republicans have lost their undeserved advantage on national security and their smears campaign against Obama was unsuccessful.

At present the Republicans have to hope that the Democrats screw up very badly, and it would be very hard to do a worse job than the Republicans have done in recent years. As long as they are tied down by the far right their decline will probably continue. If they jettison the religious right and the social conservatives they will have a hard time initially but at least they would be able to offer a viable option for those who disagree with Democratic policies. At present they provide such a terrible alternative that most educated people will see little choice but voting Democratic to avoid a repeat of the nightmare years under George Bush.