Obamacare and climate change

2010-03-23

in Economics, Law, Politics, The environment

Now that the Democrats have had a success on health care reform, my thinking turns naturally to what this means for climate change legislation. In one sense, it looks as though an obstacle has been removed. Important as it was to reform health care (and imperfect as the solution that has emerged is), it had clearly become the top priority of the administration and the Democratic leadership in Congress. That inevitably meant less attention for an issue that will ultimately be much more important, given that it may substantially affect the habitability of the whole planet.

While Democrats in Congress may now have a bit of confidence, born from success, and a bit more openness in their schedules, there does seem to be reason to think that climate change legislation will be a very tough sell. Health care only seems to have passed because Senate agreement was secured while the Democrats still had their slim super-majority. Furthermore, while Congresspeople may thunder on about how health care reform will prove the death of liberty, that remarkably science-averse institution will find far more reason to complain about anything that restricts the emission of greenhouse gases. Regional interests are certainly a lot stronger on this matter, though it is ironic that the regions that suffer most from the environmental effects of things like coal mining nonetheless have representatives who will fight tooth and claw to protect that filthy industry.

What do readers think? Will success on health care embolden Democrats, or make them even more timid on account of upcoming mid-term elections? Is there any change of Waxman-Markey or some similar cap-and-trade bill succeeding in Obama’s first term? What about a more novel carbon pricing scheme, such as one based on tax-and-dividend? What about regulation of greenhouse gas emissions by the Environmental Protection Agency (EPA)? Will that provide an alternative to Congressional action, or will it not prove a potent enough tool to make a difference? Also, might Congress close off that option as well?

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{ 30 comments… read them below or add one }

R.K. March 23, 2010 at 9:57 am

The Obama bill focuses more on expanding coverage than on reducing health care spending. As a result, it seems likely to further weaken government finances. Hunger for revenue could be one factor pushing Congress towards putting a price on carbon.

. March 23, 2010 at 10:25 am

Coalition of 22 Democratic senators urges floor vote on climate bill this year

Last Friday, Sen. Tom Udall (D-NM) sent a letter to Senate Majority Leader Harry Reid, co-signed by a broad and diverse selection of Senate Democrats, expressing strong support for passing comprehensive climate and energy legislation this year.

“Our lack of a comprehensive clean energy policy hurts job creation and increases regulatory uncertainty throughout our economy,” Udall writes. “Businesses are waiting on Congress before investing billions in energy, transportation, manufacturing, building and other sectors. … We need to take action in order to lead the emerging sectors that will drive our economic recovery.”

Interestingly, the co-signers include several crucial moderates and fence-sitters, including Casey, Begich, Tester, Stabenow, and Cantwell. This is a positive sign that, divisions aside, real appetite remains in the Democratic caucus for tackling this issue.

Kerry vs. Bingaman on the Senate’s approach to energy

Tristan March 23, 2010 at 10:29 am

I recognize you did call the solution “Imperfect”. However, calling it a solution at all is already taking sides on the issue. It’s not a solution, it’s a joke. It really does demonstrate the inability of the American political situation to get anything right.

I think the failure of the health care reform says a lot about the possibilities for climate change legislation. I.e. we might get some, but we shouldn’t be surprised if it is only “politically possible” by actually increasing corporate welfare to oil companies. I.e. we might see something like cuts in emissions permitted by huge amounts of tax money directed directly into energy company profits.

Milan March 23, 2010 at 10:45 am

The health care bill will do a number of important things. It will reduce adverse selection by mandating the purchase of insurance, and it will ban insurers from excluding people on the basis of pre-existing conditions.

Those two things alone make it a worthwhile reform.

Milan March 23, 2010 at 10:46 am

As for your comments about climate change legislation, I think that was always true. The health care bill doesn’t change any of that, though its passage does potentially create more political space to work on climate issues.

. March 23, 2010 at 11:57 am

The overhaul will extend health coverage to 32 million Americans, expand the government health plan for the poor, impose new taxes on the wealthy and bar insurance practices like refusing cover to people with pre-existing medical conditions.”

Milan March 23, 2010 at 12:04 pm

It’s not a solution, it’s a joke.

It hardly seems like a joke to extend health care to the approximate population of Canada, and protect people with existing conditions who want to change jobs or insurers.

That being said, it is not clear whether this success will strengthen or weaken the Obama administration’s ability to press its wider agenda.

. March 23, 2010 at 12:05 pm

“Mr. Obama has now emerged as a winner on the issue that has mattered most to his presidency. But the price of victory was steep. His decision to follow Ms. Pelosi’s advice and press on with health-care reform in the face of Republican antipathy effectively killed any hope of negotiating bipartisan compromises on other issues. And it forced Democrats from conservative districts into the unpalatable position of choosing between their party and their own political survival.

Neither the GOP nor the now endangered Democratic incumbents are likely to forget that soon. Mr. Obama’s vow to fight for immigration reform, tougher financial regulations on Wall Street, climate change legislation and an education overhaul – causes close to Ms. Pelosi’s heart – will run up against that harsh reality.

“To think that we’re going to see another major domestic initiative that isn’t focused on jobs between now and the midterm elections just isn’t plausible,” Boston University political science professor Douglas Kriner opined in an interview. “If all [the administration] was interested in was counting major pieces of legislation, they could have moved on other issues before health care and gotten more of them. But if health care is going to be the defining issue of the Obama presidency, then the administration might argue it was worth the sacrifice in terms of other agenda items.””

Antonia March 23, 2010 at 1:06 pm

http://www.timesonline.co.uk/tol/news/world/us_and_americas/article7071970.ece
They haven’t even got the health care in place yet. Most due to take effect in 2014, the Republicans have said they’ll repeal it and even before that, ‘Republican lawyers in at least 12 states announced repeal attempts yesterday, based on claims that the Bill to extend health insurance to 95 per cent of Americans for the first time infringes on states’ rights. ‘

Sadly I think the trend of elected officials concentrating on politics over government in the US and elsewhere is set to continue. I’m beginning to wonder whether all future legislation is either going to be confined to tweaking already-broken systems or being lamed almost the instant it is passed, so its actual merits and potential never have the chance to materialise. Interesting contrast between business approaches to change, where the point where the majority recognise that you must change now is seen as an indicator that you have already strategically failed, whereas in politics and government the point where change is universally recognised as necessary is the point at which interminable negotiations about the nature and extent of desirable change kick off, with the actual change falling years if not decades later, unless counterproductive knee-jerk populist legislation is your ‘solution’. Of course in the former case (as with public body IT) by the time the urgent change of 5 years ago is made its too late to be any good and there’s something else you should have spent the last 2 years preparing for, while in the latter you now have the mess from the impact of the bad legislation to sort out, as well as the original headache.

Antonia March 23, 2010 at 1:07 pm

Bother. Tired and full of cold. Transpose latter and former in the last sentence for the public sector stuff to make sense.

. March 23, 2010 at 1:13 pm

What would it take to repeal health care reform?

Realistically, a Republican majority in the House and Senate, plus a Republican president. Even if the GOP won back a majority in the House and Senate in 2010, President Obama could still veto any legislation that would repeal any part of health care reform. Republicans would then need a two-thirds majority in both chambers to override his veto. That’s unlikely.

If the Republicans control the House, Senate, and presidency in 2012, they will still need 60 votes in the Senate to overhaul the bill in its entirety. They could, however, cut off funding for it through the budget reconciliation process, which only requires a 51-vote majority. But they wouldn’t be able to tamper with any part of the legislation that doesn’t affect the budget, such as the ban on discrimination against pre-existing conditions.

Say I have a pre-existing condition. Can I get affordable insurance now?

Wait three months. The requirement that insurance companies take any and all comers—known as “guaranteed issue”—doesn’t kick in until Jan. 1, 2014. But the Patient Protection and Affordable Care Act allocates $5 billion for the establishment of “high risk pools” within 90 days across the country. These group insurance plans will provide coverage only for people with pre-existing conditions who can’t find insurance through normal avenues. By law, they must take all eligible applicants and can’t charge more than the standard rates.

. March 24, 2010 at 10:49 am

“So Republicans will try to discredit Democrats by extending this debate through November’s midterm elections, but that, too, is a difficult strategy. Republicans could look like sore losers, endlessly complaining about health-care reform—an issue that, it’s safe to say, has exhausted the country—while the Democrats move forward on their agenda, from jobs to financial regulation. Meanwhile, Democrats believe the early effects of the bill, including a ban on exclusions for preexisting conditions and tax breaks for small business, will combine with the luster of legislative success to make their plan more popular.

“The Republican Party wants to go out and say to that child who now has insurance or say to that small business that will get tax credits this year … ‘You know what, we’re actually going to take that away from you,’ “ David Axelrod, the president’s message guru, recently said on Meet the Press. “Let’s have that fight. Make my day. I’m ready to have that and every member of Congress ought to be willing to have that debate as well.”

The Republicans could be right, of course, that this bill’s passage is their ticket back to power. But even if there are short-term political gains for the GOP, one thing is nearly sure: Republicans won’t be able to repeal the bill, just as Social Security and Medicare are now sacrosanct when Americans became accustomed to their benefits.”

. March 24, 2010 at 12:09 pm

“This poor bill is still better than no bill at all for two reasons…

The first has to do with coverage. This newspaper loathes needless government intervention. But it also thinks that it is wrong for a country as rich as America to have tens of millions of people without health insurance. Beyond them is the much larger number of people who fear falling into that position through losing their jobs; and the larger number again who cannot get affordable insurance because they have an existing medical condition, or because they are too old, or because they have exhausted the “lifetime caps” imposed by insurance companies. The health-reform plan represents the last chance, perhaps for decades, of erasing one of the least creditable differences between America and the rest of the industrialised world. If this president, who came into office with solid congressional majorities and stratospheric ratings fails, neither he nor his successors will dare touch health care for many years to come; and that would be a tragedy.

The second somewhat paradoxical reason is that this bill will have to be improved on after it is passed—especially when it comes to costs. America’s health-care system is a nightmare of perverse incentives. Because employer-provided health insurance is not considered to be a taxable benefit, people feel insulated from the real cost of their coverage and consequently over-consume. Because hospitals and medical practices in many areas face too little competition, they charge absurdly too much even for simple procedures. Because of the rapacity of America’s lawyers, the fear of lawsuits encourages doctors to practise “defensive” medicine, again driving up costs.

The current bill chips away at all of these problems. Gold-plated insurance policies will in effect lose their tax-exempt status, though not for a while, and not in full. An independent presidential commission will have some power to force down the rates paid to medical-service providers—though, insanely, hospitals are exempted. Tiny steps in the direction of tort reform are also provided for. All these things could be expanded in due course. For instance Republicans elected in November may well return to the issue of malpractice costs.”

Russil Wvong March 24, 2010 at 2:56 pm

“Now that the Democrats have had a success on health care reform, my thinking turns naturally to what this means for climate change legislation.”

My guess is that attention will immediately shift to unemployment. I don’t think the prospects for legislative action in the next couple of years look very good: the Democratic majority in both the House and the Senate will likely be reduced, as it usually is in mid-term elections.

Even more critically, public opinion isn’t on board yet. Climate change skeptics have gotten a boost from Climategate and from the heavy snowfall on the East Coast this winter.

At this stage I think the thing to do is focus on educating public opinion, especially in the US (my latest attempt at a summary). People will try to hold on to the status quo as long as they can, but the scientific evidence keeps getting stronger and stronger.

CO2 is higher than it’s been in the last 15 million years (UCLA, October 2009).

Visualization of increasing CO2 levels, taken by the NASA Aqua spacecraft (November 2009).

Arctic temperature record (BBC, September 2009).

Arctic sea ice is disappearing faster than the models project (BBC, December 2008).

Milan March 24, 2010 at 3:04 pm

Even more critically, public opinion isn’t on board yet.

Things are more complicated than this. For one thing, the Obama administration had to lead – rather than follow – public opinion on health care, to a large extent. They might be able to do so again, particularly if they succeed in highlighting why fossil fuel dependency is such a big problem (for reasons including but extending beyond climate change), as well as the economic opportunities that exist when it comes to transforming American energy, transportation, and infrastructure systems.

Milan March 24, 2010 at 3:06 pm

That said, I agree that going from here to pushing for a strong climate and energy bill before the mid-term elections would be a bold choice. Hopefully, Obama has recognized what a vital issue climate change is, and will make the best strategic choice, regarding when to try to act on it.

Russil Wvong March 24, 2010 at 6:53 pm

“For one thing, the Obama administration had to lead – rather than follow – public opinion on health care, to a large extent.”

You don’t want to get too far ahead of public opinion, though. Politics is the art of the possible. If there’s a 60% chance of getting something approved, the risk of failure might be worth it. If there’s only a 10% chance, though?

In the case of health care, support for major change was quite high: a Pew Research Center poll in June 2009 showed that 70% of the US public thought that the health care system needed either “to be completely rebuilt” or “fundamental changes.”

On climate change, public opinion (especially among Republicans) is nowhere near this. Gallup, May 2008.

Although increasing proportions of both Republicans and Democrats agree that a majority of scientists believe global warming is occurring, the pattern is very different for the second key conclusion of the IPCC — that human activities are contributing to global warming.

Gallup’s trend data show that Republicans have become less likely to accept the idea of human contributions to global warming over the past half-decade — the percentage believing that global warming is due more to “the effects of pollution from human activities” has declined by 10 percentage points, from 52% in 2003 to 42% in 2008.

Milan March 25, 2010 at 8:12 am

We certainly cannot wait for the majority of Republicans to accept the key tenets of climate science.

Rather, Obama could work with some things they do accept, like the importance of getting away from dependence on fossil fuel imports and the need to create jobs, and latch those together with policies to reduce emissions.

It will definitely be an uphill fight, but if we want to have a decent shot of avoiding 2˚C of warming, action in developed states must seriously begin almost immediately. Global emissions need to peak within the next ten years, and ideally within just one or two. Making that happen while developing states continue to emit more (at least temporarily), requires deep cuts in developed states which are not offset by simply importing more carbon intensive goods.

Russil Wvong March 25, 2010 at 7:23 pm

I completely agree about the urgency of the problem. I’m just pessimistic about the prospects for legislative action in the near term, given how unwieldy the US political process is. EPA regulation seems like a more promising route, although without public opinion onboard, even that is likely to be watered down or overridden.

We certainly cannot wait for the majority of Republicans to accept the key tenets of climate science.

But the way the US political system works, there’s Democratic representatives elected in Republican-leaning constituencies. And if their constituents don’t see the need for action, it’ll be difficult for them to vote for action.

Hence the need to keep working on public opinion (and I admire your persistence!).

Milan March 26, 2010 at 12:04 pm

It is hard to know which route is most promising, but it is asking far too much to expect American voters to become scientifically literate before action is taken on this file.

Do you think the majority of the population in states doing much more on climate change (like Germany, the UK, etc) actually have a much stronger understanding of climate science?

. March 26, 2010 at 2:21 pm

“On balance, I think if you polled Republican strategists right now and they were being honest, they’d probably concede that Democrats are better off for having brought health care to completion after having invested so much energy in it before. The Democrats have a case they can make now — we’re making the tough decisions and getting things done — which may not be horribly persuasive to much of the electorate but is at least marginally better than the complete directionlessness they seemed to be exhibiting a few weeks ago.

On the other hand, I think if you polled Democratic strategists and they were being honest, they’d probably concede that — electorally-speaking — Democrats would have been better off if they’d found a different direction last year, focusing perhaps on financial reform and then only turning to health care if their numbers warranted it. One of the risks in undertaking health care in the first place, indeed, is that there was essentially no exit strategy: no matter how badly the electorate reacted to the policy — and they reacted quite badly — Democrats would probably have been even worse off if they’d abandoned it somewhere along the way.”

. March 27, 2010 at 4:42 pm

When he plotted polling data on “trust in government” against growth in disposable income, John Sides, a political scientist at George Washington University, found a high degree of correlation. “The economy explains about 75 percent of the variance in trust.” When the economy is doing well, people are less disgusted with Washington and “they approve of the president and their senator more.” As a general rule, the president’s party loses seats in the midterm. But University of Denver political scientist Seth Masket, who has charted income growth in the three quarters before the fall midterm campaign season over the last 16 cycles, found that “if the economy seems to be growing and people are making more money, they tend to reward the party that’s in power a little more.” Translation: An expanding economy over the next seven months could lessen projected Democratic losses.

Yale economist Ray Fair has developed a relatively simple and highly accurate economic model for predicting what percentage of the total vote parties will receive in presidential and congressional elections. It relies on inflation and economic growth over the seven quarters before the election. Fair, who has a somewhat optimistic take on growth for 2010, says Democrats are likely to get a 51.6 percent voting share this fall. “The Democrats are not going to gain seats, but it doesn’t look like there will be anything like a disaster.” (You can plug in your own variables here.)

One caveat: High unemployment and ­housing—­factors not considered in Fair’s ­mode—may play an outsize role in people’s feelings about the economy. And perception can matter as much as the underlying economic reality. Running against one-party control may be a winner in the fall campaign. But running against a weak economy? Perhaps not. On CNBC, Jack Welch, the rock-ribbed Republican former CEO of General Electric, detailed the signs of revival at the companies with which he works. If they’re counting on the poor economy alone, he said, “Republicans are going to get an awful shock.”

Milan July 26, 2010 at 5:21 pm
. October 15, 2010 at 12:03 pm

Health care and the mid-term elections
Coming back to bite him

Republicans want to repeal Barack Obama’s health laws. How badly could they hurt the reforms—and how much will this help them in November’s elections?

Oct 14th 2010 | New york

“WHAT does Mrs D’Amico care about most?” That question, concerning a fictional but representative constituent from his Long Island base, is one that preoccupies Steve Israel, a moderate Democratic congressman from New York. He worries that the answer, all too often, is Barack Obama’s controversial new health-care reform bill, enacted back in March. His strategy has been to tackle the issue head-on, by trumpeting the virtues of “Obamacare”, such as the planned end to lifetime caps on insurance payouts or the guarantee that insurance must be offered to all, without discrimination on the grounds of pre-existing conditions. “I just got sick of the Republicans getting away with murder,” he declares.

This makes him a rare bird, for most Democrats running for re-election are staying mum or apologising for their votes for reform. Republicans, who have noisily declared their intention to repeal the new health laws if they win control of Congress, appear to have found a useful weapon in the campaign.

An outright repeal is impossible, as Mr Obama could simply veto any such bill. So Republicans are planning instead a strategy of “defunding” the new health law. Even Tom Daschle, a prominent Democratic former senator, thinks this is the Republicans’ best weapon. In “Getting It Done”, a new book published this week, he declares “It would be all too easy to kill the reform effort not by repealing it, but by starving it.” The bill will need over $100 billion in around 100 new authorisations over the next decade, all of which will require approval from Congress. Besides that, the Republicans could attach provisions to vital bills, such as the budget, that would forbid federal workers (say, at the Internal Revenue Service) from implementing the law. Congressman Paul Ryan, an influential Republican from Wisconsin, insists that “We’ll try every angle, from defunding to budget reconciliation.”

Another strategy is to challenge the unpopular “individual mandate”, which requires everyone to buy health insurance. Coalitions of states are pursuing several different lawsuits challenging the constitutionality of this mandate. A federal judge in Michigan ruled in favour of the Obama administration earlier this month in one of the suits, but the matter is likely to be fought all the way to the Supreme Court.

. November 5, 2010 at 10:35 am

Most bills aren’t more important than elections. This one was. Take it from Mitch McConnell, the Senate Republican leader. Yesterday, in his election victory speech at the Heritage Foundation, he declared, “Health care was the worst piece of legislation that’s passed during my time in the Senate.” McConnell has been in the Senate for 26 years. He understands the bill’s significance: It’s a huge structural change in the relationship between the public, the economy, and the government.

Politicians have tried and failed for decades to enact universal health care. This time, they succeeded. In 2008, Democrats won the presidency and both houses of Congress, and by the thinnest of margins, they rammed a bill through. They weren’t going to get another opportunity for a very long time. It cost them their majority, and it was worth it.

And that’s not counting financial regulation, economic stimulus, college lending reform, and all the other bills that became law under Pelosi. So spare me the tears and gloating about her so-called failure. If John Boehner is speaker of the House for the next 20 years, he’ll be lucky to match her achievements.

Will Republicans revisit health care? Sure. Will they enact some changes to the program? Yes, and Democrats will help them. Every program needs revisions. Republicans will get other things, too: business tax breaks, education reform, more nuclear power, and a crackdown on earmarks. These are issues on which both parties can agree. Which is why, if you’re a Democrat, you deal with them after you’ve lost your majority—not before.

Anon March 27, 2012 at 9:46 pm

If the Supreme Court rules Obamacare unconstitutional, this really will have been a wasted presidency.

oleh January 21, 2013 at 11:38 pm

I noticed that the 2nd inaugural address today did not highlight health care reform – I wonder why.

The implementation of it presents the challenge.

It will also be a challenge to fund it at the same time as dealing with the size of the national debt in that about 99% of the funding is to come from the federal budget.

He also paid little attention to the military.

The best result would be to reduce the military to seamlessly fund health care reform without increasing the debt.

. September 29, 2014 at 5:50 pm

America devotes 17% of GDP to health care, compared with 9% in Britain, yet nearly 50m Americans were uninsured in 2012 and life expectancy is slightly below average for a rich country. And the taxpayer foots much of the bill: government health spending per head in 2012, before Obamacare’s main provisions took effect, was 50% higher than in Britain, which has a nationalised health system. Some spending, such as the huge Medicare programme for the elderly and Medicaid for the hard-up, is obvious. But much is opaque.

http://www.economist.com/news/leaders/21618788-americas-health-care-system-remains-dysfunctional-it-could-be-made-better-how-fix

. January 20, 2017 at 1:17 am

Considering it doesn’t exist, Trump’s imaginary health care proposal has accomplished a great deal. For one, it has tempered the enthusiasm of congressional Republicans for unraveling Obamacare too quickly. It’s reminded them that the road to replacing Obamacare is fraught with peril for the GOP, and that “insurance for everybody” is a message that appeals not just to Democrats but to a growing number of Republicans.

. August 25, 2017 at 8:31 pm

Nor is single-payer health insurance synonymous with “European health care”: not just because insurance is not care, but because much of Europe does not have a single-payer system. European countries that do not have single-payer health insurance include Switzerland, the Netherlands and an obscure republic called Germany. These countries achieve universal coverage through a mix of private, for-profit and not-for-profit insurers. This private-public combination may sound like the sort of ideological breakthrough that could serve as a compromise between Democrats and Republicans. But it isn’t new. Germany has been using some variety of this model ever since it invented public health insurance, 134 years ago, during the administration of Otto von Bismarck.

In fact, what is interesting about European schemes for universal health insurance is precisely their variety. The systems fall into three paradigms. In the first, the government takes over both health insurance and the provision of care, employing doctors and running hospitals. In the second, the government provides universal health insurance, but leaves much of the provision of care to the private sector. (This is the “single-payer” model to which Mr McConnell refers.) In the third, the government leaves both insurance and care to the private sector, but uses regulation, government subsidies and an individual mandate to guarantee that everyone is covered.

Most countries fall somewhere between these three. Britain, Italy, Spain and Sweden essentially use the first system. Everyone is enrolled in a national government-run health system, most health care is paid for by the government, usually free of charge, and most doctors work for the public health service. But there are also some private doctors and hospitals, and private insurers offering supplemental plans for those who can afford them.

France’s health-insurance system, like Canada’s, is mostly based on the second paradigm, the “single-payer” concept. Doctors are mostly private, but the basic insurance schemes that provide universal coverage are government-funded. Most people in France top up their coverage with supplemental private insurance plans. Germany, meanwhile, falls somewhere between paradigms two and three: most citizens are covered by government-administered schemes, but those earning above a certain threshold can choose to buy private health insurance.

Finally, in the Netherlands and Switzerland, health insurance is handled almost entirely by private insurance companies, and doctors and hospitals are generally private. Coverage is universal because citizens are legally obliged to buy it, which ensures that healthy people stay in the system, holding insurers’ costs down. The government keeps premiums affordable by pumping in generous subsidies, and bars insurers from rejecting those with pre-existing conditions. It also regulates providers in order to control expenses.

If this last variant sounds familiar to Americans, that is because it is essentially the same as Obamacare. One salient difference is that because the Netherlands and Switzerland provide more subsidies, premiums are much lower. They also enforce the mandate more strictly. As a result, they manage to insure over 99% of their citizens, whereas America insures only about 90%.

All this may seem terribly complex. In fact, European countries’ health-insurance systems are, without exception, simpler than America’s, which is a bewildering hodgepodge of private and public systems. For those over 65, America has a single-payer system, Medicare, that dishes out taxpayer money to for-profit private health-care providers with virtually no cost controls. For those earning below a certain threshold (which varies by state), there is another single-payer system, Medicaid, that does have cost controls. For those who have served in the armed forces, America has a single-payer system, the Veterans’ Administration; some veterans are treated at government-run hospitals, as with Britain’s National Health Service. For those who are employed by businesses above a certain size, America requires employers to provide private insurance subsidised by a regressive tax break. For those who earn too much for Medicaid but whose employers do not provide insurance, America has Obamacare: a heavily regulated, government-subsidised system of private insurance exchanges with an individual mandate, like the Netherlands and Switzerland.

That complexity contributes to costs. America spends vastly more on administration: 8% of health spending, versus 2.5% in Britain. As of 2013, Duke University hospital had 400 more billing clerks (1,300) than hospital beds (900). Americans also consume more health care. The result is that health care manages to chew up about 17% of GDP without even covering everyone. (No European system costs more than 12% of GDP.) Americans would be getting a terrible bargain even if their resulting health was as good as that of Europeans. In fact, it is worse. Europeans have longer life expectancy than Americans. Fully 28% of Americans have multiple chronic health problems (such as diabetes or arthritis), more than in any European country. America does manage to outperform most European countries on cancer mortality, though even there, Sweden does better. Even on that hoary measure of public health, adult height, America fails. A survey of the youngest mature adults (born in 1996) shows that the latest cohort of Americans are shorter than the French.

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