It was surely one of the oddest LPs ever cut.
Featuring a former movie star by then more familiar from television, the 1961 record was released by the American Medical Association (AMA), the nation’s foremost doctors’ group. Thereon, Ronald Reagan, whose consecration as a Republican folk hero would be completed during the Goldwater campaign, declaimed grimly: “One of the traditional methods of imposing socialism on a people has been by way of medicine.” It was the latest salvo in Operation Coffee Cup, the AMA’s nationwide effort to forestall the enactment of Medicare. The group was governed by a prescient fear that federal intervention in health care would bring skyrocketing costs, hamstrung care, and fewer choices for patients and doctors.
No one would be more surprised than the Gipper to learn that in 2019, the AMA is on the brink of repudiating every particle of their bygone collaboration. It almost happened at the group’s June meeting, where delegates narrowly rejected an effort to eliminate its longstanding opposition to single-payer health-care reform, legislation that would eliminate private insurance and establish the government as the sole purchaser of medical goods and services.
The AMA has shown increasing acceptance of government-run health care in recent years. In 2009, the group lent its support to the Affordable Care Act, and in 2017, when I served as a medical student fellow in the AMA’s federal advocacy office in Washington, D.C., I witnessed firsthand its ferocious opposition to efforts to repeal Barack Obama’s signature health-care law.
The June vote fits with this trajectory, but it is also a transition into dangerous new territory. Growing, younger constituencies within the organization have clamored for it to embrace single-payer, and outside groups — who picketed this meeting — have ratcheted up the pressure. The levee has buckled, but there is still time for America’s doctors to thwart this slide into statism, and they should.
To begin with, single-payer advocacy perches on a snarl of dubious assumptions. Consider the perennial chestnut about first principles: “Is health care a right or a privilege?” Unspoken but asserted is a criticism of the American system: If only we were as righteous as other nations, we’d be willing to make a comparable public investment. In reality, U.S. government expenditures on health care — federal, state, and local — account for 45 percent of our total health spending, or $4,832 per person in 2017. That year, total average health-care spending in Organization for Economic Cooperation and Development nations reached $4,069 per capita. In other words, our current public investment, which covers around 40 percent of Americans, exceeds the amount many developed nations spend to cover their entire populations. It’s not that we’re too heartless to open our pocketbooks; our dollars just don’t go as far. The scale, complexity, and staggering costs of the U.S. system present unique challenges that superficial moralizing and breathless international comparisons fail to answer.
For example, it is commonly believed that since some nations with expansive welfare states perform well in health outcome measures such as life expectancy and infant mortality, America should expect to achieve marked improvements by adopting the same model. It is true that Scandinavian nations regularly post impressive figures. But are their health-care systems the cause of their high performance? A recent analysis by Nima Sanandaji concludes otherwise. His review of 20th-century health-outcome statistics reveals that these countries already led the world in 1960, prior to the reforms Democrats would prefer to credit. The United States has actually narrowed its life-expectancy gap with Sweden and Norway in the interim.
The explanation is simple: Scandinavian nations have more in common than generous welfare states. They also share homogeneous populations with “high levels of trust, a strong work ethic, civic participation, social cohesion, individual responsibility, and family values” — to say nothing of active lifestyles and healthy diets containing plenty of fish. Their success predates, and may even explain, their enactment of socialized medicine. After all, Sanandaji argues, aren’t sweeping wealth transfers more politically feasible in trusting societies with healthy, economically equal populations? Viewed from this perspective, statist health-care reform seems more like a false pledge than a real panacea: a magic pill that, once swallowed, will obviate our responsibility to confront our ailing relationships and unhealthy choices.
In reality, the pill is bitter. Single-payer persistently degrades the principle of patient autonomy. Americans encountered the horrifying consequences of this erosion in Britain through the cases of Alfie Evans and Charlie Gard, infants with grave genetic diseases whose parents’ decisions to transfer care to willing providers outside the U.K.’s National Health Service (NHS) were overruled by judges and bureaucrats who decided they knew better. Such perversions of medical ethics are the inevitable result of a system that subordinates patient autonomy to the whim of impaneled elites.
By the same token, physicians participating in a single-payer health-care system can expect to find their own autonomy in jeopardy. If health care is a human right, the public is entitled to the services of the physician, and the state has a prevailing interest in compelling cost-efficiency in these services. Consider the perspective of medical trainees who have actually labored under the auspices of a single-payer system, like junior doctors in the NHS. In 2015, amid concerns about “morale and poor working conditions,” the U.K. government sought to impose a new contract on these trainees, effectively slashing their reimbursements up to 30 percent by categorizing hours worked on evenings and Saturdays as ineligible for overtime pay. Eventually the negotiations faltered, and these doctors went on strike, delaying hundreds of thousands of operations and appointments. (Of note, this is a recourse of which American trainees would be ethically prohibited from availing themselves, per the AMA.) A British Medical Association poll showed that eight in ten U.K. medical students were more likely to work outside the country as a result of the dispute.
The status quo in U.S. health care is untenable. However, the solutions we implement must be compatible with sound medical ethics and the American ethos of individual liberty. For example, by insisting on cost transparency, combating regulatory arbitrage, and transitioning away from tax-deductible, employer-sponsored health insurance, we can empower Americans to make wiser decisions, thus harnessing the market to drive down prices and improve access. The AMA once defended such precepts and regarded the government as a menacing interloper. But it is a different organization baffled by strident factions as it charts a new course in an uncertain age.