Princeton Professor Uwe Reinhardt makes a claim that I have heard repeated often from health policy experts who tend to advocate for more government involvement in health care. The thrust of his argument is that people in the United States, despite the loud and visceral claims to the contrary, would and have accepted the idea of socialized medicine being instituted in this country already. He uses the Veterans Affair system (VA) as an example of a health care system that both functions as a form of “socialized medicine” and is rarely, if ever, attacked by Republican politicians as being generally detrimental to our nation’s veterans. Others, like MSNBC pundit Rachel Maddow, have used Medicare – the largest single-payer system in the world – to make a similar point.
But the reason American citizens, and politicians specifically, have been hesitant to assail these institutions is not that we secretly and unknowingly love socialized medicine, but that 1) we think of these programs as benefiting a much more narrow population than they actually do and 2) it would be positively dangerous, politically, to do so.
Professor Reinhardt lumps average Americans together with Republican politicians in their universal approval of the VA, but it seems that the causes of silence are actually rather different. For the lay person, when thinking about who the VA benefits, one typically does not envision the healthy, educated (thanks to the G.I. Bill) man or woman in their 20s, 30s, or 40s who needs the occasional doctor’s visit but generally does not require much more care than that. Rather, it is far more likely that one imagines the wounded veteran needing a lifetime of physical and behavioral health support to even come close to leading a normal and healthy life after having made tremendous sacrifices in the name of protecting our country. Likewise, when one imagines a Medicare beneficiary, they may picture their own grandparents, but often the mental image will be of grandma or grandpa lying in a hospital bed having just undergone an extremely long, intensive, and probably expensive operation. Several of them. They tend not to imagine the decades their grandparents spent healthily living in Florida with little to no health problems other than the regular doctor’s visit and strict adherence to daily medications.
The cost of care for the extreme cases is undoubtedly very high. An entire lifetime of care management, frequent hospital visits, and sudden flare-ups from an intense behavioral health issue require a lot of money to treat. So too does granny in the last year of her life. But that is not everyone in the program – it is not even close. It is a fraction of the total number of beneficiaries, while the rest have far fewer medical needs and, consequently, require far less medical spending.
For the wounded veteran and/or dying grandparent, socialized (i.e., free at the point of care) medicine is clearly one of the most feasible and seemingly-attractive options for covering the costs of years or decades of expensive and repeated procedures. Warren Buffett-types aside, no one can afford this level of care by paying out of pocket. But, because these patients’ costs are so high and will remain that way, private insurance is not what these patients need either, the same way someone whose house already burned down does not need fire insurance: they need a new house. This is what socialized medicine is intended to do. It covers the cost of extremely expensive care for those who could not possibly obtain normal private insurance on their own.
The average American, picturing the extreme cases within each program, naturally feels comforted knowing these patients’ care will be covered when they need it most. What they tend to ignore is the much larger share of VA or Medicare beneficiaries for whom socialized medicine may not be the optimal financing mechanism for their care. It is human nature for the lay person to picture the extreme case and build a system to provide for that person, but health care experts should know better. That gets me to why Republican politicians rarely come right out and say it either.
The problem is that they just can’t. The environment around health care, even before a three-year long civil war that started when health care reform began to be discussed in the summer of 2009, is simply too poisonous for any politician to come out and say they favor allowing the most extreme and dire cases to remain on a socialized financial system but that the vast majority should be moved to a privatized model. Liberals, Democrats, and probably most journalists would conveniently ignore the distinction and proclaim loudly and deceitfully that Republican Politician Smith wants “to kill your grandmother and the veterans that sacrificed for your freedom.” To deny that this would happen is either naïve or dishonest.
So the American people and their representatives in Congress remain quiet. This is not out of approval for socialized medicine, but either a misunderstanding of the demographics of socialized systems we have in this country or, much of the time, political necessity.