Health care is a game-changer. The permanent game-changer. The pendulum will swing, and one day, despite their best efforts, the Republicans will return to power, and, in the right circumstances, the bailouts and cap-and-trade and Government Motors and much of the rest can be reversed. But the government annexation of health care will prove impossible to roll back. It alters the relationship between the citizen and the state and, once that transformation is effected, you can click your ruby slippers all you want but you’ll never get back to Kansas.
Why’s that? Well, first, the “health care” debate is not primarily about health, which chugs along regardless of how the debate goes: Life expectancy in the European Union, 78.7 years; life expectancy in the United States, 78.06 years; life expectancy in Albania, 77.6 years; life expectancy in Libya, 76.88 years; life expectancy in Bosnia and Herzegovina, 78.17 years. Once you get on top of childhood mortality and basic hygiene, everything else is peripheral — margin-of-error territory. Maybe we could get another six months by adopting EU-style socialized health care. Or we could get another six weeks by reducing the Lower 48 to rubble in an orgy of bloodletting, which seems to have done wonders for Bosnian longevity. Or we could lop a year off geriatric institutionalization costs by installing some kook in a pillbox hat as Islamic dictator and surrounding him with a palace guard of Austin Powers fembots. It’s as likely to work as anything Congress will pass.
What explains the yawning chasm of these six-month variations? Lack of funding? The United Kingdom spends three times as much money on “health” as Poland and their cancer survival rates are more or less identical. Okay, forget the cash and consider the treatment: Even within the United States, even within the Medicare system, there are regions that offer twice as much “health care” per patient — twice as many check-ups, pills, tests, operations — for no discernible variation in outcome. To one degree or another, any health-care “system” is a giant placebo. Right now, in a fit of mass hypochondria, large numbers of Americans have convinced themselves that they — or, at any rate, their uninsured neighbors — urgently need the magic Euro-cure-all. If they get it, it will improve their health not a whit.
But it will make a lot of other things worse. Government-directed health care is a profound assault on the concept of citizenship. It deforms national politics very quickly, and ensures that henceforth elections will always be fought on the Left’s terms. I find it hard to believe President Obama and his chums haven’t looked at Canada and Europe and concluded that health care is the fastest way to a permanent left-of-center political culture. He doesn’t say that, of course. He says his objective is to “control costs.” Which is the one thing that won’t happen. Even now, health-care costs rise far faster under Medicare than in the private sector.
By the way, to accept that argument is to concede a lot of the turf: Why is the cost of my health care Barack Obama’s business? When he mused recently about whether his dying grandmother had really needed her hip replacement, he gave the game away: Right now, if Gran’ma decides she doesn’t need the hip, that’s her business. Under a government system, it’s the state’s business — and they have to “allocate” “resources,” and frankly at your age your body’s not worth allocating to. Why give you a new hip when you’re getting up there and you’re gonna be kicking the bucket in a year or two or five or twenty?
There have been two trends in U.S. health care over the last decade. On one hand, a lot of Americans have become, by any rational standard, overinsured: They get tested for things they’ll never get. On the other, there has been an abandonment of health insurance by the rich. If you peel the Census Bureau and DHHS figures, of those alleged “45 million uninsured Americans,” one-fifth aren’t Americans; another fifth aren’t uninsured but are covered by Medicare; another two-fifths are the young and mobile (they don’t have health insurance, but they don’t have life insurance or home insurance, either — they’re 22 and immortal and life’s a party); and the remaining fifth are wealthier than the insured population. Really. According to a 2006 Census Bureau report, 19 percent of the uninsured have household income of over $75,000. Since the last round of government “reform” in the Nineties, wealthy Americans have been fleeing insurance and opting to bring health care back to being a normal market transaction. And if you look at the “uninsured discount” offered by doctors, one can appreciate that, for everything but chronic disability, it’s not an irrational decision to say I’ll get a better deal on my broken leg or my colonoscopy or my heavy cold if I just write a check for it.
And if you disagree, so what? In a free society, Mr. Smith should be free to be excessively prudent and overpay to be overinsured, and Mr. Jones should be free to conclude that he wants to pay cash down and get the best price for his broken leg. But a government system usurps both Smith’s and Jones’s right to calculate his own best interests. Whenever I cite some particularly lurid tale from the front lines of Euro-Canadian health care in National Review Online’s “Corner,” I get a flurry of e-mails from American readers offering horror stories from U.S. hospitals. And yes, it’s true, bad things happen in American hospitals. But the Euro-Canadian stories are not really about the procedure, the operation, the emergency room, the doctor, the nurse. They’re about impotence — not in the “Will Obama pay for my Viagra?” sense but in terms of civic dignity and individual liberty. I think of a young man called Gerald Augustin, of Rivière-des-Prairies, Quebec, who went to the St. André medical clinic complaining of stomach pain. He’d forgotten to bring his government medical card, so they turned him away. He was a Quebecker born and bred, and he was in their computer. But no card, no service: That’s just the way it is. So he went back home to get it and collapsed of acute appendicitis, and by the time the ambulance arrived he was dead. He was 21 years old, and he didn’t make it to 22 because he was forced to accept the right of a government bureaucrat to refuse him medical treatment for which he and his family have been confiscatorily taxed all their lives. “I don’t see what we did wrong,” said the administrator. “We just followed the rules.” No big deal, M. Augustin wasn’t anything special; no one in the clinic even remembered giving him the brush.
Roy Romanow, the Canadian politician who headed the most recent of the innumerable inquiries into problems with the system, defends the state’s monopoly on the grounds that “Canadians view medicare [as their system is called] as a moral enterprise, not a business venture.” If the St. André clinic were a business venture, they’d have greeted M. Augustin with: “You’ve got stomach pains? Boy, have we hit the jackpot! Let’s get you some big-ticket pills and sign you up for surgery!” But because it’s a moral enterprise they sent him away with a flea in his ear. If you have a bad experience in a private system, there’s always another doctor, another clinic, another hospital five miles up the road. But when the government monopoly denies you health care, that’s it: Go home and wait — or, like M. Augustin, die.
“Morality” is always the justification. Inaugurating Britain’s National Health Service on July 5, 1948, the health minister, Nye Bevan, crowed: “We now have the moral leadership of the world.” That’s how Obamacare is being sold: Even the New York Times reports (in paragraph 38) that 77 percent of Americans are content with their health care. But they feel bad about all those poor uninsured waifs earning 75 grand a year. So it will make us all feel better if the government “does something.” Not literally “feel better”: We’ll be feeling sicker, longer, in dirtier waiting rooms. But our disease-ridden bodies will be warmed by the glow of knowing we did the right thing.
What’s so moral about relieving the citizen of responsibility for his own health care? If free citizens of the wealthiest societies in human history are not prepared to make provision for their own health, what other core responsibilities of functioning adulthood are they likely to forgo? Oh, Smith and Jones can still be entrusted to make their own choices about which movie to rent from Netflix, or which breakfast cereal to eat. For the moment. But you’d be surprised how quickly the “right” to health care elides into the government’s right to tell you how to live in order to access that health care. A government-directed medical system can be used to justify almost any restraint on freedom: After all, if the state undertakes to cure you, it surely has an interest in preventing your needing treatment in the first place — or declining to treat you if you persist in your deviancy: Smokers in Manchester, England, have been refused treatment for heart disease, and the obese in Suffolk have been told they’re ineligible for hip and knee replacements. With a staff of 1.4 million, England’s National Health Service is supposedly the third-biggest employer on the planet, after the Chinese army (2.3 million) and Indian National Railways (1.5 million). And those couple of million Chinese and Indians are mere drops in oceans each over a billion strong, not a significant chunk of the adult population of a tiny strip of land in the North Atlantic. But the NHS still has to ration treatment. Patricia Hewitt, the former health secretary, says there’s nothing wrong with the state forbidding treatment on the basis of “lifestyle choices.” And apparently the “pro-choice” types who jump up and down in the street demanding that you keep your rosaries off their ovaries are entirely relaxed about the government getting its bureaucratics all over your lymphatics.
Ultimately, it’s not the nationalization of health care but the nationalization of your body. Right now, if you want an MRI, it’s between you and your doctors. In a government-run system, if you want an MRI and you can’t get one, it’s the government’s fault. And the government should do something about it. Not give you the MRI, of course (that’s too obvious, as well as too expensive), but at least introduce a new Patient’s Bill of Rights, as Gordon Brown’s just done, promising every Briton the “right” to hospital treatment within 18 weeks. Or your (tax) money back? Ah, well, no, but the prime minister’s charter will also give you “guaranteed access to cancer treatments,” as well as “the right to die at home,” which sounds a bit as if Mr. Brown were covering himself. Scotland’s cancer survival rate is 40 percent, compared with America’s 63 percent. So if the other 60 percent of Scots all exercise their right to die at home, that might free up some “guaranteed access” for the remainder. And if it doesn’t, the prime minister will perhaps introduce a new helpline — 1-800-PATIENT — in which all you have to do is punch in your postal code and some bureaucrat will come on the line to explain that the new cancer survival targets for your area will be introduced circa 2012 and please call back then if you’re not dead.
So elections dwindle down to a sterile argument over how to “improve” the system: The left-of-center party usually pledges to throw money at it. The right-of-center party is less enthusiastic about that, which generally makes it suspect on the issue, so it settles on some formulation to the effect that it can “deliver” better “services” more “efficiently.” In other words, the only viable rationale for the Right becomes its claim to be able to run the leftist state more smoothly than the Left. Every footling reform with any whiff of the private sector about it has the ranks of the great and the good lining up on TV to drone the indestructible cliché that “the NHS is the envy of the world.” Years ago, in the Daily Telegraph, I wrote that I’d seen a fair bit of the world and had never met anybody who envied the NHS, although presumably there must be a Bhutanese yak herdsman up-country somewhere who’d be impressed by it. A couple of days later, Mr. Sonam Chhoki, a Bhutanese gentleman, wrote to the paper to say that, while not a yak herdsman himself, he came from good yak-herding stock and, after a bit of grumbling about my outmoded ethnic stereotyping, declared that he certainly didn’t envy the NHS. His British parents-in-law “have had to wait more than two years for operations, after being turned away several times for lack of hospital beds. However basic the Bhutanese health service is, it has not yet come to this sorry state.”
Yet Mrs. Thatcher, one of the great fearless conservative figures of the age, could do no more than insist to a skeptical public that “the NHS is safe in our hands.” In the 2000 Canadian election, Stockwell Day, leader of the allegedly right-wing Alliance party, found himself forced to make similar prostrations in response to entirely unfounded rumors that the party was thinking of “permitting” private health care back into the country. In a televised debate, he wanted to be certain that, whatever questions he was asked, the public got the message that he had no plans to monkey with the government monopoly. So he brought in a little handmade sign and propped it up in front of the microphone to advertise his fealty: “NO TWO-TIER HEALTH CARE.” While he was distracted by a question on some inconsequential topic like foreign policy, Joe Clark, leader of the Progressive Conservative party (think RINO squishes with bells on), swiped the little placard and gleefully scored through the “NO” to let viewers in on Mr. Day’s hidden agenda: “TWO-TIER HEALTH CARE.” This is what it’s come to: the leaders of the two soi-disant right-of-center parties competing to see who can grovel most abjectly before the state monopoly. That’s the Republicans’ future if they collude in the governmentalization of health care — as Democrats well understand.
When health care is the government’s responsibility, it becomes its principal responsibility. Because the minute you make government the provider of health care, you ensure that, come election time, the electorate will identify “health” as its number-one concern. Thus, in a democracy, the very fact of socialized medicine seduces the citizenry away from citizenship. Buying health care is no more onerous than buying a car or buying a house — which, pre-Barney Frank, most Americans seemed able to manage. Indeed, most of the complications are caused by existing government interventions. If you were attempting to devise a “system” from scratch, you might opt for insurance for catastrophic scenarios and, for PAP smears and colonoscopies and whatnot, something similar to the tax breaks for a Simplified Employee Pension: C’mon, how difficult can it be? Back in the day, your grampa managed to go to the doctor without routing the admin through Washington. Matter of fact, the doctor came to your grampa. That’s how crazy it was.
But the acceptance of the principle that individual health is so complex its management can only be outsourced to the state is a concession no conservative should make. More than any other factor, it dramatically advances the statist logic for remorseless encroachments on self-determination. It’s incompatible with a republic of self-governing citizens. The state cannot guarantee against every adversity and, if it attempts to, it can do so only at an enormous cost to liberty. A society in which you’re free to choose your cable package, your iTunes downloads, and who ululates the best on American Idol but in which the government takes care of peripheral stuff like your body is a society no longer truly free.
In a nanny state, big government becomes a kind of religion: the church as state. Tommy Douglas, the driving force behind Canadian health care, tops polls of all-time greatest Canadians. In Britain, after the Tube bombings, Gordon Brown began mulling over the creation of what he called a “British equivalent of the U.S. Fourth of July,” a new national holiday to bolster British identity. The Labour party think-tank, the Fabian Society, proposed that the new “British Day” be July 5, the day the National Health Service was created. Because the essence of contemporary British identity is waiting two years for a hip operation.
They can call it Dependence Day.