Random Notes on Living in the United States
I lived and worked in the U.S. for a year, and a year ago this week I returned to Canada for good. It was an amazing experience. For me, stereotypes were shattered, and coincidentally, I learnt much about my own country. Some observations on living in the United States, purely subjective and anecdotal, and in no particular order:
- Americans believe they make a good cup of coffee. They don't.
- Greasy spoon breakfasts, on the other hand, are far superior to the Canadian variety.
- Brown toast is wholewheat toast. As a waitress explained to me: "Honey, all toast is brown."
- I met several, well-educated people who managed to complete four years of high school and four years of university without ever reading Shakespeare. This was by no means an infrequent occurance. Reciting bits of The Merchant of Venice ("The quality of mercy is not strained. . . ") or Macbeth (Tomorrow, and tomorrow, and tomorrow. . .) always caused amusement.
- Americans are incredibly generous. People I hardly knew gave me Christmas presents.
- I lived in a suburb, X. Everybody drove everywhere. The streets were utterly empty of human activity. Walking itself was a suspicious activity, making you liable for police questioning, because only the poorest of the poor walked anywhere.
- Relatedly, public transit was virtually non-existant. Only the poor used public transit and only of necessity. We made a sport of spotting buses, so rare were they.
- Race (and racism) is the great unspoken social divide, the two solitudes of American culture. Still.
- Being Canadian, and cheap, I asked where the local Wal-mart/K-mart was. ( I needed household goods.) I was told it was better to shop at J.C. Penney because only "blacks and immigrants shop at K-Mart."
- More to the same. Every year, the suburb in which I lived had a "Keep X Clean Day", where the citizens would participate in cleaning up the municipality. But "Keep X Clean Day" had its origins from a notoriously segregationalist mayor who sought to keep blacks out of the suburb.
- More to the same. This same mayor has a street named after him.
- More to the same. Nobody objects to #9 or #10. It's "old" history.
- Americans despise their health care system, yet believe it is the best of all possible worlds.
- The American health care system is incredibly bureaucratized, over-regulated and inefficient in ways that would make a Canadian's head spin. (Note to those who would impose an American-style system in Canada on the grounds of cost-effectivess: you guys are blowing smoke out your posterior orifices. You have no idea what you're talking about.)
- The local print media was, in a word, pathetic. Two newspapers, owned by the same company, in a city approximately the same size as Toronto, filled mostly with wire stories.
- American working-class bars are homey, cheerful and a lot of fun. And you can drink the beer for hours. There is, unfortunately, no exact equivalent in Canada.
- Freeways. Loved American highways. I could drive the equivalent of Morningside and 401 to Yonge and King (Toronto readers will understand the significance of this) in 15 minutes or less. During rush hour.
- On the other hand, every drive downtown became an object lesson on the destructive impact of freeways on urban development, as I sped by derelict neighbourhoods and abandoned houses that, in the equivalent location in Toronto, would fetch prices in the multiples of 100K.
- Americans are far more deferential to authority than Canadians are. This surprised the hell out of me. Respect for the President, even from self-described liberals, was nearly universal.
- Possibly relatedly, everybody had some connection to the armed forces, either by personal service or by knowing someone who was serving. At least a third of my work colleagues had served in some branch of the armed forces.
- The cost of living was far higher than I expected, and much more so than in Canada.
- My local supermarket, twenty lanes of merchandising hell under fluorescent lights, had fewer --- and hideously more expensive --- brands of olive oil than my grocer in Norwood, Ontario (pop. 1100).
- "What's a blue box?"
- X had several large shiny new buildings --- a public auditorium, for example --- donated to the municipality by the large multinational headquartered there. If Canadian corporations would be so geneorous! The public library, on the other hand, had chunks of missing masonry from its facade.
- After dealing with the American federal bureaucracy, I could understand why Americans despise government. I began to despise bureaucrats too, after awhile.
- The flag truly is a fetish. Memories of driving down neat suburban streets, with each tidy house bearing a flag. Without exception.
- Getting a bank card was like applying for a mortgage.
- The razors were never sharp enough. I was forced to import these from Canada.
- My accent identified me instantly as Canadian.
- Americans are not so ignorant of the rest of the world (including Canada) as incurious. Since they live in the greatest, strongest nation, they don't see the need to be otherwise.
- Americans truly believe they live in the best country in the world, the final destination of all aspiration. They could not understand why I wanted to return to Canada.
posted by Michael at 8:55 a.m.|
13 Comments:
Hmm, thought it was Chicago (where I spent the last 7 years) until #15.
Anyway, welcome back; I'm greatly enjoying my return although I've been here only since August. I had forgotten how different it was.
Do all we ex-ex-pats (re-pats?) end up in Toronto?
I have my own rather lengthy take at my blog.
Publius,
http://godscopybook.blogs.com/
Looks pretty fair.
Two comments:
1. If it's public transit you want, go to places like NYC or Boston. I had an easier time getting to and around midtown Manhattan than heading to a neighbouring suburb in NJ to write the LSAT during my time down there.
2. About getting a bank card. You were with the wrong bank. It took me, oh, ten or fifteen minutes to open a bank account and get a temporary bank card with a VISA stamp (permanent to arrive in the mail) when I headed down there. Two minutes to close it when I graduated.
And one more comment for good measure:
About the bureaucracy -- I've never found a government bureaucracy I could deal with well, except in Canada. I can't quite figure out why ours is less inhuman than others'. One of the mysteries of the world, I guess.
A counter-counter fisking:
Re: #4 I think each of our observations are anecdotal. The bulk of people I know are children of immigrants from outside of northern Europe. Shakespeare means nothing to them or their parents. The obession was simply to get a job, all that culture stuff just wasn't on the agenda. None the less, both cultures are becoming less literate. Your point about the lack of Shakespeare in the schools may explain why there are more good Canadian Shakespearean actors than Americans, who are mostly WASPs. Though of course having a place like Stratford, Ont, does help.
Re: #8 One of the terrible things about race relations in the US is the almost complete lack of honesty, even as social debates go. Who has the guts to state the simple fact that half of the crime commited in the United States is black on black violence. To say so in any public medim is denounced as spreading stereotypes. Yet it is a fact. It is also a fact that the American black population of fifty years ago was poorer and faced greater barriers yet was more law abiding than their white counterparts. To this I refer you to the work of Thomas Sowell and Walter Williams. The story of the American black is almost an endless sequence of heartbreaking success and failure. Just when you think the American black is about to reach a state "normalcy" something disasterous happens, often at the hands of well intentioned whites. Much of the New Deal and Great Society programs fall into this category.
Re: #14 The third rail of Canadian politics, and indeed public policy debate at all levels. First off, I understand where you're coming from, I had much the same view but consider the following, even though I know you probably won't find it satisfactory.
1) Let's get over our national neurosis with the United States. Not just on health care but on everything. There are nearly 300 independent and semi-independent countries in the world, why must we be so bloody myopic. One of the insincerities of the Canadian left in general is their use of the U.S. as a rhetorical weapon. Either we adopt this policy or we become Americans, or begin suffering American style problems. Virtually every country in the world has some kind of for profit two tier health care system, why don't we examine what the Australians or the New Zealanders are doing. Some of the educational reforms adopted by the Kiwis twenty years ago are only now entering the public debate. May be they have a better solution. What about the French or the Germans, perhaps parts of their models have something to show us. But no, America, America, America. It isn't the right that's obessed with America it's the left, the myth of what America is has become too useful to the likes of the Toronto Star or the CBC.
As for our system versus the Americans, it's difficult to defend it since it is not a genuine free market system, or even close. One thing you should keep in mind is that our system has plenty of bureaucracy itself, I don't think the size is much different just the nature of it. Plenty of the same restrictions though in different forms. Denial of care in the States is blamed on insurance companies, here one level of government blames the other, the effect is the same. As for mortality rates, again the issue of race pops up. I think the black and hispanic numbers distort everything. What is the difference in quality of care for poor whites versus poor blacks? How does the greater incidence of poverty among blacks affect how that care is delivered? What about the health problmes of simply being poor? Bad diet (not lack of food but the temption to get bad cheap food) lack of education and less healthy employment also play a role.
My main issue with the Canadian health care system is that it is a socialist bureaucracy at heart. What I mean precisely is that there is no price system, no way to co-ordinate supply and demand except by centralized guessing. A bureaucrat, however well intention and however adept at regression modeling etc... can never match either the efficiency or knowledge of the market place, in other words the decisions and actions of millions of consumers and producers. This is why a pure socialist economy (which the USSR wasn't) are doomed to fail. The USSR last as long as it did because ther were some real prices in some key capital goods.
Another basic problem is rationing, in our system the government rations health care, which they tell us is done equally but I've known plenty of line jumpers who know somebody who knows somebody. The need to ration a good or service exists in any economy, whether it is done through waiting lists or higher prices. The advantage to higher prices however is that it summons more capital into the market. The decision to build a new hospital, or a new power plant for that matter, in this country is made politically. Can the government afford it, or if it can afford it does a more pressing political concern supercede it. The current shortage of both doctors and power plants is partly attributable in Ontario to the decisions of the Peterson and Rae governments to cut places in medical school and not build new power plants. The reasons were varied but they were almost all politically motivated. Mind you the Harris government did little to correct it. A government, however well intentioned, acts politically, the decision is not made based on need (as defined by effective economic demand), as say the decision to build anything from a supermarket to an office tower.
Another part of the problem is that in a public system a nurse or a doctor isn't responsible to the patient, whatever ethical oaths they might have taken, he or she is responsible to the government. In theory the government is responsible to the people, but that's not exactly how it ever works. A bureaucrat, and I use this term not as one of derision but a technical definition of someone who is employed by the state, is responsible not to the customers he or she serves but to the bureaucrat above, and so on and so forth in theory up to the responsible minister. The average minister is in office for less than two years at any given portfolio and even decades at such a post would not help. Unlike large private corporations that can be displaced by more innovative competitors our system is one size fits all and innovation must be approved. Such a system does not allow for dissent, for those who want to try new methods. The element of risk so vital to the rest of the economy is inherently lacking.
Finally, and I do appreciate your response, the issue is not "efficiency." Efficiency is a weasel word too often used by conservatives who either don't know, or don't have the guts to state that they don't like government doing something. Efficiency must be measure against some other standard, and not a standard which is simply imposed by the state. It would be a lot more "efficient" for everyone to live in large Soviet style apartment blocks, but we are nor machines and we each have our personal preferences of what we want.
I usually hate recommending books to people, here read this long boring book because I'm too lazy to explain a concept or idea to you, or summarize and defend it properly, but I'm afraid that's what I want to do here. I'm not coming at the health care debate from the perspective of the reflexive conservative who just doesn't like government. I also believe that the government that governs least governs best, but I think why I believe that is more than just a gut instinct.
One of the best explanation of my point of view when it comes to economics is the works of Ludwig von Mises. His 1944 book Bureaucracy explains the thrust of my complaints against a socialized health care system. But parts it come from other works and other economists. The book is very short and no math is involved if you are not fond of calculus, which I'm not despite the Economics minor. It is avalible here: http://www.mises.org/etexts/mises/bureaucracy.asp
We could spend weeks throwing statistics back and forth talking about all the levels of bureaucracy one systems has versus another, but I think only a good theoretical frame work will put it in perspective.
Regards,
Publius
http://godscopybook.blogs.com
This comment has been removed by a blog administrator.
How about these numbers. The number of doctors per capita, as cited in the Britannica Year Book:
Canada 1 per 539
Australia 1 per 395
France 1 per 330
Germany 1 per 286
Greece 1 per 255
Portugal 1 per 320
United States 1 per 357
United Kingdom 1 per 716 (Whose NHS our system used as a model)
I think each of those figures go along way to explaining the differences in GDP percentages. It isn't just administrative fat that a socialist system cuts away, but flesh and bone as well. In fact that's part of the problem. When the Peterson government in Ontario cut spaces in medical schools in the late 1980s it claimed this was a cost saving measure. Indeed it was, it saved the government money, and now we have a shortage of doctors. This is a perfect example of how governments run any kind of economic enterprise. In the market place cost is traded off against quality, for governments cutting costs is simply a matter of either balancing the books or being seen to balance the books. Consumers of the government monopoly have no way of expressing their displeasure with the reduction of quality as there is no alternative. All they can do is gripe and wait in line. They can protest, but what's the point everyone agrees that socialized health care is a "sacred trust."
As for 97% of health care dollars in Canada going to health care, really? Whose statistic is that? The government's? Who of course have no reason to distort those numbers by playing with definitions? Why is it that in the leftist view of the world only private companies are selfish and destructive and never, or rarely, governments? As if governments can run something as complex as health care so efficiently why have so many nationalized companies been such busts. The British steel industry, the Italian airlines, the French banking system in the 1980s? If government control makes so much sense why does it all fall apart when you try it on a wider scale?
"No system anywhere in the world has a free-market public health system, and there are excellent reasons for this. "
No, but only three other countries have a system that limits the private sector's role to the same extent as Canada; Cuba, Libya and North Korea. Even if you believe the government needs to intervene why not take a look at other national model rather than stick with our own? I have relatives who are nurses in Lisbon, Portugal. The waiting lists are nowhere near as bad as here, and Portugal is a country with half of our standard of living. Given that a partial market approach is used almost universally maybe that might point to the need for one here.
"A free market requires rational uniformily informed actors to function properly. No one is rational, in a classical economic sense, w/rt health care."
This is nothing more than a straw man. No market in the world has a "rational uniformily informed actors." Not even the most adept of commodity brokers knows what everyone else in his market knows. This is merely creating an impossible ideal and demanding the world conform to it. Some of the more rigid neo-classical economists might of have taken this approach, but the typical Austrian or disciple of Milton Friedman would find such a statement absurd.
The assumption you are making is that somehow the government officials doing the planning and co-ordinating know more and are more rational than the consumers. A nice conceit, though not one borne out by history or even logic. The result of state planning is something closer to the example I gave earlier about the Peterson government.
"Similarly, the nature of medical care makes healthcare funding full of asymmetric information; the doctors know more than either the patients or the insurers, and even their knowledge is extremely imperfect."
Again, this is a strawman. We could say the same thing about any economic good or service. The butcher, the baker and the car mechanic all know more about their product, that is the nature of the division of labour society. If millions do not know what is best for themselves how are dozens in government supposed to know. The market is no more perfect that the people who comprise it, that a systems fails to meet an abitrary standard of perfection is no reason to throw it out. In fact information is a commodity like any other. You speak of asymetric knowledge, yet there are whole industries that specialze in giving information to the consumer and surmonting these problems. Instead you argue that we should simply confess our ignorance and let Big Brother take care of things.
"Finally, people's health are simply not fungible; years from my lifespan are note exchangable with someone elses, much less for widgets."
Nice trick, and more than a few economists who can't see past their own mathematical models would agree. As I point out in my previous comments, read Mises, or indeed any of the Austrians. The end purpose of consumption is not profit, it is consumption. I don't eat food so I can go work tommorrow, I work so I can eat. No parent would calculate the economic risk/reward of a child because children are not capital goods, except to the perverse or the insane. One of the slanders frequently launched against the defenders of the free market is they want to put a price on everything. Quite the opposite.
In practice it is the central planners at the Ministry of Health who make such calculation when they de-list services (McGuinty), or cut hospital beds (Harris), or cut medical school spaces (Peterson). In some countries, with more socialist systems (such as Cuba), they outright deny access to certain services to people above a certain age because they will never be able to pay it off in taxes to the state. Such cold economic calculations are work of statists who view men as numbers, not private individuals taking care of loved ones.
"Health care is practically the model for a need that a classical market system is not likely to find an optimal allocation of resources."
Then who will decide where the resources go optimally? The state, which is the only alternative you offer? If people cannot govern their own lives, will others, knowing far less about their personal circumstances, govern them better? Will they be as compassionate when all they see of people is numbers and "social returns" on "social investments." Which is how actual health public policy analysts talk.
Finally, the only way the defenders of a socialized health care system, fully or partly, can defend their position is by saying that the laws of economics, indeed even common sense it seems, do not apply to health care. The fearful parent may not be in the best position to make a decision, that is why we have doctors. When we are on trial we are also not at our rational best, should we socialzed lawyers as well? We must trust in experts, who have a moral and legal obligation to us. They may break that trust, regardless of what socio-economic system they exist in. We trust experts, often complete strangers, about the food we buy at supermarkets, the cars we drive, the elevators we take at work. All of these are day to day and even life and death matters. Oddly the laws of economics (classical or otherwise) apply to them, as they do to health care.
As for all my words, numbers are useless out of context. As your numbers demonstrate.
"We could spend weeks throwing statistics back and forth"..
Well, forth, maybe, but I'm not sure about back. You wrote a lot of words, but not a single number or piece of data to contest the fact that: (a) Canada pays less in absolute *and* in GDP terms for healthcare, and (b) a much larger fraction of that spending (~97%) actually goes to medical care, as compared to 82-88% for commercial care in the US (as low as 67% for some high-advertising HMOs!). It's hard to argue in the face of the data that Canada's system is the bureaucratic one. Even in the face of really persuasive arguments, actual data always trumps theories and assertions.
No nation anywhere in the world has a free-market public health system, and there are excellent reasons for this. A free market requires rational uniformily informed actors to function properly. No one is rational, in a classical economic sense, w/rt health care: when was the last time you heard a parent, upon hearing that their child was gravely ill, do a calculation comparing the expected lifetime earnings of the child to the cost of treatment before requesting treatment for that child? They'd be considered monsters, and quite rightly. Similarly, the nature of medical care makes healthcare full of situations of asymmetric information; the doctors know more than either the patients or the insurers, and even their knowledge is extremely imperfect. Finally, people's health is simply not fungible; years from my lifespan are not exchangable with someone elses, much less for a finite number of some widgets. Health care is practically the model of a need for which a classical market system is not likely to find an optimal allocation of resources.
I deleted and re-posted my comment to fix some typos, which is why it now appears that the comment comes after one which responds to it. Sorry for the confusion.
So far, publius, you have not offered one actual piece of data to support your paragraphs and paragraphs of assertion. All those references to 50+yr old textbooks would be much more compelling with some, you know, actual data from reality. You quote doctor per captia numbers. Does that mean that Greece's system is better than that of the US? Worse? Would you rather be sick in Greece (1 per 255) or the UK (1 per 716?).
I'm all in favour of looking at other nations systems and making changes to our own. Some private providers might even be a reasonable choice. But realize that the US's system is vastly the outlier, has vastly higher overheads than would be considered acceptable anywhere else in the world, and is much more expensive than any other system in the world. Despite for some people who believe that the US system simply *has to* be better for ideological reasons, there's not much to show for all that extra money in terms of actual public policy results. That's not to say there are no lessons to be learned there -- Kaiser Permanente is doing truly innovative, if controversial, things with the handling of patients -- but to assert that Canadas is vastly more bureaucratic than the USs and mutter dark warnings about the Soviet Union and North Korea under your breath is absurd.
Free markets don't work well for everything, despite what Mises wrote all those years ago. (Nobody, _nobody_, who is a serious policy analyst takes the Austrian school seriously, except as a triumph of theory over reality.) Do you think we should disband the military and have a free-market, outsourced national defence? Should Elections Canada be gotten rid of, and companies compete to provide the services better? After all, the market does everything better, right? Right?
You make bizarre flip flops -- you say that we should rely on experts, but that only free-market experts can be trusted, governmental experts are inherently scary (mumble mumble cuba North Korea mubble) despite the fact that we, in a democracy, set the public policy that these experts must obey.
In closing, you say, ``Finally, the only way the defenders of a socialized health care system, fully or partly, can defend their position is by saying....''. See, this is just proof you're not listening. I don't need to point to dusty textbooks. Defenders of a nationalized healthcare system point out actual results. There isn't a system in the world that is perfect, and they all need working on. But the US's system is grossly more expensive, is unavailable to 15% of the population (and 20% of the chidren), and provides a shorter lifespan than that of *ANY OTHER DEVELOPED NATION*. It's called data; look into it.
And so we finally arrive at it. Personal attacks and snide remarks.
Instead of citing data out of context, such as your comparison of Greece vs. the UK, you might have noticed the pattern. The more socialized systems, Canada and the UK, have fewer doctors per capita than the less socialized ones. By wide margins. If you are interested in looking at reality rather than theory, there is good place to start. Those figures are all no more than four years old.
As for the data, you sighted one set of numbers. Where are all the rest? My facts aren't fifty years old and simply dismissing the Austrian school with an authoritative wave of the hand shows only your intellectual dishonesty. It's wrong because I say so. Argument from authority.
As for the American system, you keep asserting the U.S. has more bureaucracy, by what standard? You only cited government statistics with no definition? You didn't respond to my comment about why if state control works so well in health care it failed to work elsewhere? Your theory states that governments are more efficient than markets, therefore the American system is much more bureaucratic? Yet I'm accused of placing theory above reality!!!
"That's not to say there are no lessons to be learned there -- Kaiser Permanente is doing truly innovative, if controversial, things with the handling of patients -- but to assert that Canadas is vastly more bureaucratic than the USs and mutter dark warnings about the Soviet Union and North Korea under your breath is absurd."
The comparison with the USSR and N. Korea was to illustrate the point that the basic economic principles are the same. The state knows better than private individuals. If you find the communist system too dark how about Britain in the 1970s with huge swaths of its economy nationalized? Was it more efficient than the market? If so, why was the British taxpayer subsizing it to the tune of billions of pounds. There are plenty of other examples from around the world. Read Daniel Yergin's the Commanding Heights. He has plenty of statistics, few of which are fifty years old and only some dusty. Whether socialism is democratic or dictorial, well intentioned or not, the principle is still the same: "the man in Whitehall knows best."
"Do you think we should disband the military and have a free-market, outsourced national defence? Should Elections Canada be gotten rid of, and companies compete to provide the services better? After all, the market does everything better, right? Right?"
You're putting words in my mouth. Anyone even remotely familiar with the literature of free market capitalism knows perfectly well that the government, being an organization that deals in force, is outside of the market. The market deals only with voluntary actions.
You, however, wish to bring force into the delivery of health care. You demand that people be forced to consume the services the government allows on the government's terms. You make at this point, and elsewhere no distinction between voluntary acts and force. I didn't flip flop when I said people in a market trust experts, but somehow, your words, the government experts are all wrong. I have the choice to ignore what my doctors tells me. If a government official decides I can't access a service, or forces me to stay in line, what can I do, within the system? And don't tell me this doesn't happen on a daily basis in this province.
"...governmental experts are inherently scary (mumble mumble cuba North Korea mubble) despite the fact that we, in a democracy, set the public policy that these experts must obey."
Government experts are scary when they force us to act as they decide. If a private individual does it, its called assault. But if I make a private contract with a doctor and set our own fees both of us can go to jail. If you don't find the turning of a simple private and voluntary contract into a crime scary what do you find scary? Where, in your view of the world does an individual have a right to act?
As for "us" deciding on health care. Does being in a democracy allow me to dissent? Does it allow me to use my money as I see fit? You say "we" set the policy. No "we" don't. An elected minister, who is elected for a variety of reasons perhaps having nothing to do with the topic at hand sets the policy. If the rights of the individual are not protected, the right to dissent, in speech or economic activity, then "democracy" is no different from tyranny. Which is why most of the pure democracies, ones' without bills of rights or understandings of individual rights, wind up as tyrannies, like Athens. That 51% has decided on something does that mean I am a rightless serf? I wasn't muttering darkly, whether governments violate the rights of their citizens with, or without, an election it makes its actions no more just or practical. And if socialized health care is such a wonderful system, why do feel the need to force everyone to go along?
You said nothing in regards to my point about the role of government versus private individuals, why the government is somehow more knowing and wise than private citizens. Your crack about private versus governments experts fails to point to a crucial difference. I have a choice which experts I listen to in a free market, I don't under a state controlled system. Who knows what's in my best interest, me or the government? Neither is all knowing, but it is absurd to argue that simply because a person works for the government he knows more and will act more rationally.
As for more my "dark mutterings" about North Korea I was merely pointing out how out of step our system is.
You say that you point to reality not textbooks. Well let's look reality. You have yet to explain why people are dying on waiting lists in this country and people are being sent, by the government, to American hospitals for rountine procedures. You accuse me of only dealing in theory, you have yet to point to any fact except a small collection of statistics compiled by the government, which as I pointed out have a vested interest in distorting those numbers. You said nothing on that point.
"But the US's system is grossly more expensive, is unavailable to 15% of the population (and 20% of the chidren), and provides a shorter lifespan than that of *ANY OTHER DEVELOPED NATION*. It's called data; look into it."
Again, what data? You keep citing the same figures from the same inherently biased sources. Honestly, is there anything in the world that runs at 97% efficiency. You say that 97% of money spent on health care goes into health care. If it works so well, why does it fail elsewhere. I keep bringing up this point and you keep ignoring it.
As for the American mortality rates, as I pointed out in my original post, much of the difference is attributable to race and to decades of bigotry. Look at the data of life expectancy of White Americans versus White Canadians (who were born here). The gap is far narrower and depending on whose figures you look at sometimes within the margin of error (many of the vital statistics, including life expectancy, used by both public and private sector are samplings, not aggregates) If this is a lie, show me the numbers you're looking at. The ones that break down along racial lines.
As for leaving 15% to 20% of the population without coverage, what does that really mean? Do we have coverage here simply because the Minister of Health says so? Are people who are dying on waiting lists, in every province, whether it is run by Tories, Liberals or NDPers, whether have or have not provinces, are they insured in any meaningful sense?
Finally, I don't point to the American model as a model to strive toward. It is not a free market model, in fact it is very heavily regulated and that it is one of the reasons that it performs so poorely compared to other two tier systems, like Australia, which I would argue are less regulated. (If you think the Australian model is more controlled point out exactly why.) Using America as a benchmark for capitalism is a strawman, and not a very effective one. Even if we do assume the US model is pure capitalism, what does it say that Canadians are flooding American health care clinics looking for MRIs. No I don't have any statistics on that particular point, but when even the Toronto Star is running stories about this it should make you think.
I'll be interested if you come up with some -- indeed, any -- evidence on how free markets improves provision of a nations health care. Until then, you are just writing very long diatribes insisting that it does because, well, it has to. Don't expect that approach to convince many people.
Evidence? Maybe you've been reading someone's else posts. Oddly, you've refused to explain why your position works, aside from some illusions to a rather distorted understanding of econonmic models. Which I attacked and which you refused to defend. If I'm so out to lunch, so filled with theory and no facts, why don't you disprove what I wrote. I asked you to provide specific data on mortality rates that disproved what I said. You didn't even say my facts were wrong.
You seem to believe only statistics are facts. I could fill pages with statistics proving my point, and you would turn around and keep quoting the same statistics you quoted earlier. That's all the evidence you've provided. The American system is more bureaucratic, and here are some out of context statistics. You haven't defended your points, merely sneered and said my arguments are diatribes.
I've had plenty of arguments where I spent hours, with professors and students, throwing numbers at each other, they proved nothing. Statistical data out of context is useless. I quoted doctor to patient ratios and you merely sneered that the numbers were old. Which I replied stating that none of the figures were more than four years old. No reply from you.
I point to specific instances of government reducing quality of care to meet costs, the government imposing its choices on the people of this province, the actions of the Peterson, Harris and McGuinty governments. I've cited the examples of nationalized British industry to show that government control is not more efficient. You have dealt with none of these points merely repeated the mantra "theory not reality" and "where are the facts." Those are facts.
I've read textbooks from the 1960s that "proved" with a mountain of data that nationalized industries were more efficient than privately owned companies. Yet all of those statistics and regression models failed to explain why virtually all of the nationalzied companies were losing money, while private sector companies, lacking the same monopoly advantages, were profitable. Data with theory is gibberish. That is why I provided both.
You say I've provided no proof that private free market health care is more efficient or effective, was not that patient to doctor ratio some evidence of my point? Not even a little? Aside from the snide comment about the numbers being old you said nothing. What about the pattern I mentioned? More government control, as in Britain and Canada, leads to fewer doctors per capita versus countries with less government involvement, Australia and America. Given the frequent complaints in this coutnry about a doctor shortage I think that relationship should give at least some pause. I included Portugal and Greece because both countries are far poorer than either Britain or Canada yet they have more doctors. Do you think there is any relationship between your ability to get a doctor and your quality of care? Most health care economists I met in university seemed to agree, though when I pointed out the various ratios they became a little defensive.
I was once asked by a fellow student why I thought capitalism was more effective at raising living standards than full blown socialism, why complete government command of the economy wouldn't provide higher living standards for all. What I said, in effect, was look out a window. Canada, a relatively free market country, is richer than India, which spent forty years under socialist rule and became increasingly poor until the free market reforms of the 1990s. I pointed to how China's brutal poverty only started to let up when some elements of a market were introduced. I pointed to per capita income data that clearly co-related higher income with more freedom. I pointed him to the Heritage Institutes ranking of free countries. I cited the historical examples of Britain and America versus their South American and continental neighbours. Still he insisted show me the proof. Finally I asked him, what do you want in the nature of proof. In effect he said I want a regression model showing me the difference. I don't know if you are quite so literal minded, but your insistance on proof despite all the proof, and theory, I provided points to it.
Finally, given the success of the free market, within a regulatory frame that recognizes the rights of property and personal liberty, at raising living standards for the past two centuries in diferent cultures through out the world. Given the simple fact that most of what keeps us alive on a day to day basis is provided for profit, why is health care somehow exempt from the laws of economics and historical precedent? You said health care failed to conform to the classical market model, I pointed out that the model you propose of capitalism is a strawman. You refused to challenge me on that point.
Given the success of capitalism, the burden is on the proponents of government intervention, particularly so severe a form as in Canada, to prove that socialism works. I've read plenty of statistics that say it does, but oddly the numbers don't explain the slums of Calcutta after forty years of socialism, while South Korea, a poorer country than India in 1950, lives in a comfort superior to more than a few members of the EU. The same economics principles, of central planning and government control kept the people of India in poverty, and those same ideas, albeit focused on one industry, health care, are putting Canadian patients at risk.
See, here's the thing.
You are arguing for an hugely radical change to the way Canada provides health care -- a completely free market approach. This goes far beyond anything that has been attempted by any developed country, *ever*.
But you think the onus is on *me* to argue why we *shouldn't* make that change.
Now, that's a little off. In a democracy, if you want such a drastic change to be made, you need to convince - not argue at, convince - me, or at least a majority of voters, that such a change is warranted. Perhaps your posts here have convinced people, I don't know; but I'm a scientist, and so argument alone doesn't do it for me; I need data to be convinced.
You keep suggesting I'm defending socialism, but I haven't done anything of the sort. I have very little interest in `isms'. Canada's system is far from perfect. It turns out, though, that it's one of the best in the world; the cost of the system, as a fraction of GDP, is smack dab in the middle of what the other G7 countries pay; but we're on the high end of most measures of how well the system does; infant mortality, overall health of citizens, lifespan of citizens, lifespan of those diagnosed with cancer.
People do get sick or die unnecessarily in waiting lines in the Canadian system, and each death is a tragedy. But people die in waiting lines in the US, too, for instance waiting for organs. And they get needlessly sick and die because regular check-ups or preventative medicine are unavailable to a too-large number of Americans, and easily diagnosable and treatable illnesses become something far more grave. I wish I had good numbers for this aspect of the Canada-US comparison, but by definition most of those cases in the US are of those who die outside the system, uncounted.
I really wish I could present a template for a health-care system in which no one dies unnecessarily. But I can't. And neither can you.
Even though in proposing such a drastic change the onus for convincing is properly on you, not on me, I think I've done a pretty good job. The only developed country which has attempted small steps towards a private-run system in the post WWII era has been the US, and in overall health, lifespan, infant mortality, and most other health measures, Canadas results have been better. Now, maybe a completely free-market system would function vastly better than the USs hybrid system, but that's a matter of wild speculation, and it is irresponsible to make huge changes to policy on wild speculation. The evidence, however imperfect, is strongly on the side of the system of the rest of the developed nations, not a private-run system. The US system has a lot going for it -- if you are rich and can afford the Mayo clinic, for instance, there's no better place to be sick in the world. But the system as a whole is, by most measures, not as good as our own. Certainly not dollar-for-dollar.
I've presented some data which hasn't convinced you. You still believe that, for instance, Canada's system is more bureaucratic, because damn it, that is what you know *must* be true. The fact is, I sort of admire your idealism. But there are a lot of ideals out there, and not all of them can be true. Science, and empirical testing, can't exactly help us search for truth, but it can help us distinguish falsehood. Theories, when confronted by contrary facts, must succumb. It's a lesson that the Austrian school never learned, sadly.
This'll be my last post on the subject, because it's clear that neither of us has the tools to convince the other. Best wishes.
Since it is clear you intend no malice and argue sincerely and honestly from your point of view, I offer the same to you.
My only reply to your comment about imposing such a radical change is that such a change would not be, so to speak, moving forward, but backward. A free market in health care existed before the Second World War, and it functioned as well as any system could at that time. Many people died needlessly because they were poor. It was the great hope of the reformers, like Tommy Douglas in this country and Beveridge in Britain, that such deaths would never again need occur. That no one need die for something so absurd as a lack of money.
That people died, and suffered then, was not because of capitalism, it was because Canada, and the world of the time was too poor to allow everyone access to life saving care or even basic care. Look at modern India, it is not for lack of either desire or ideological restraint that half a century after independence India still has nothing comparable to Medicare. Old Age Pensions were introduced I think only in the late 1990s. Almost seven decades after Canada and nearly a century after Britain. Poverty was the problem not capitalism, and it has been the freer economies that have raised the standard of living of their peoples the highest over the last two centuries.
As for evidence versus theory, there is no evidence I could present that would convince you. But let's, for sake of argument, assume you are correct, the Canadian model is more efficient in having a smaller bureaucracy. What of it? Are we really better off? Is having people die on waiting lists for lack of doctors and equipment better than people dying for lack of money? The way I see it the latter problem is much easier to solve. The Americans at least have the capacity, their problem, a problem in large measure created by an American tax and regulatory code that makes it very difficult for many to afford private insurance (health expenses are not always deductible), is that not everyone can access it.
The reason I'm suspecious of data that says that the Canadian system has less bureaucracy is the same reason you would be suspecious if a known law of nature was contradicted by a new piece of data; however absurd it may sound to compare economics to science. You would first question the data, and if proved true, and no other possible explaination found, then you question the law. I look through the history of government involvement in the economy and see over and over again the same results from the same actions. Why should I believe, on first sight, something that contradicts that?
Theory doesn't trump data, but without theory data is meaningless gibberish. The two need each other and my point was simply that without a theory to organize that data it would be a set of numbers thrown back and forth. And what do the numbers mean? 97% of the money spent on health care goes into health care in this country. How is that figure calculated? Is it simply the cost of the various ministries of health subtracted from total expenditures on health? What about individual hospitals? What if the figures that are labelled "health care" include both the money paid to doctors for treating patients and filling out paper work required for government purposes?
The government doesn't tell us the methods, and the papers that I've read from health care economists either don't question how various governments arrived at their numbers, or they complain of a lack of transparency.
The reason I'm so cynical about this point is that I've seen it before. One case in point. The debate over nationalized industries in Britain after WWII when it was claimed, right up until the 1980s, that a nationalized monopoly in say coal and steel could, and in fact was, more efficient that a free compeitive market. Same arguments as then. But the defenders of nationalized industries couldn't explain why, if the system was so efficient it needed such large subsidies. Just as today the defenders of medicare fail to explain why costs keep rising and the quality of care, often by their own admission, keeps falling, and doctors and patients (who can)leave the system. It's not just new technologies driving up costs. Introducing new technologies, aside from start up costs, reduces costs in other sectors of the economy, except health care.
"It turns out, though, that it's one of the best in the world; the cost of the system, as a fraction of GDP, is smack dab in the middle of what the other G7 countries pay; but we're on the high end of most measures of how well the system does; infant mortality, overall health of citizens, lifespan of citizens, lifespan of those diagnosed with cancer."
Good health is not just a product of good health care, it's a cultural thing as well. We've always had very stong vital statistics, relative other top industrialized countries even before Medicare.
Look at Japanese life expectancy through out the 20th century. Even when Japan was poorer that other industrialzed countries its vital statistics in terms of life expectancy and rates of disease were surprisingly strong. The reasons for that were cultural; diet, exercise, and the nature of urban and rutal life.
In Canada our greatest advantage is that we lack a permanent racial or ethnic underclass as they have in the States or most of Europe. Break down those vital statistics along regional, class and racial lines and I would strongly suspect a somewhat different picture would emerge. The solution to those problems is not to be found in health care policy.
"I really wish I could present a template for a health-care system in which no one dies unnecessarily. But I can't. And neither can you."
Of course not. Nothing short of omnipotence could prevent any needless deaths. My argument is that a free market approach, one that includes private charity, would reduce those needless deaths to a minimum. As for private charity being forth coming, I doubt a people who would vote again and again for governments that take large portions of their income, much of it to help others, would not voluntarily contribute to charity in very substantial ways. That may seem idealistic, but that people continue to support socialized health care is in no small part because they want to help others.
"The only developed country which has attempted small steps towards a private-run system in the post WWII era has been the US, and in overall health, lifespan, infant mortality, and most other health measures, Canadas results have been better."
One of the key differences between the Canadian approach and those of other developed nations, aside from the U.S. which was trying to create a socialized health care system, and then changed its mind rather abruptly. That alone, I think, has caused most of the havoc. At least in other countries the definition and relationship between the two tiers is relatively clear and well managed. The goal of the public system here is to provide health care for all. The goal of other developed nation's systems is to provide health care for those who cannot do so themselves. I believe Australia falls into this category. I'm also pretty sure Canada prior to Medicare falls into this category as well, but this of course varied from province to province.
What I think we need to do, and I'm not proposing a free market over night in anything, is to go back to the Medicare debates of the 1960s. Try to re-examine the objections some had to the system and how they've turned out. If you go back and look at some of the comments made by the then Premier of Ontario, John P. Robarts, who bitterly opposed Medicare, about how it would fail to control costs by removing individual responsibility, I think that might give a new, or old, perspective on the debate.
"You still believe that, for instance, Canada's system is more bureaucratic, because damn it, that is what you know *must* be true."
All the numbers I've seen come from the government, which has a vested interest in showing the public it is doing a good job in spending its money. Even independent studies rely on government data, compiled in an often byzantine ways.
Look at the debate during the recent provincial election over the size of the deficit. If a government can fudge numbers like that, ones so much in the public eye, and so much more examined than the ones on health care you cited, than what can't they do.
Take another example, the LCBO. Supposedly it is a wildy profitable venture for the government and a great source of revenue. On paper the LCBO is a model of efficiency. I've heard more than a few people say that government can run businesses as well as the free market citing the LCBO as an example. What the government reports don't tell you, you have to do a little digging, as a few reports at both the Post and the Star did, and found out, about a year ago, that the LCBO was a money loser. You see, the government accounting procedures count the tax charged on the bottles as revenue for the LCBO. If you subtract the tax, which would be charged regardless of who sold the liquor, then the LCBO runs at a loss, even with its monopoly status.
If the government can do this, why should I trust them with regards to a far more sensitive issue. And it isn't just in Ontario, or in Canada. This is something inherent in the nature of government bureaucracies, something shown over and again through out the world.
You say I put theory ahead of facts, but all the facts you've present me come, ultimately, from biased sources. The reason I assume the Canadian system is more bureaucratic is because in almost every other case I have looked at of a government backed monopoly it has been more bureaucratic than the free market approach.
When that hasn't been the case, it's because quality has been sacrificed. We need bureaucrats to run a system as much as we need front line workers, why should I assume governments know how to strike that balance, between too much and too litte. I've seen no evidence outside of health care to assume that it would be so within health care.
Given what I know coming into the debate I don't think it at all irrational to assume something that has been shown to happend in similar contexts repeatedly through time and in different parts of the world.
I'm not saying the American system isn't horribly bureaucratic, and at first sight it seems completely absurd compared to a system where all you need is one card, but that is only at first glance. Much of the American bureaucracy exists to enforce government imposed standards. Much of the problems with private insurance stems from having to be compatible with Medicare and Medicaid. If I have Medicad, for instance, offering me only partial coverage then I need a private insurer as well. That insurer must meet Medicad standards and fill out Medicad paper work to insure that the client isn't exploiting either the government or the insurers. The line between the private and public sector is murky in most circumstances in the modern western world, in American health care the line has blurred almost completely. The fault lies, however, not with the market, but with the intervention. Yet there is enough of a somewhat free market to provide good coverge to perhaps a third to a half of the population.
There is a famous story of Milton Friedman visiting Sweden and being told by a proud Swedish economist that there was very little poverty in his country compared to the U.S. To which Friedman replied, "That's interesting, because in America Swedish people also have very low rates of poverty." I think you are giving our health care system more credit than it deserves, and less than the rest of our society deserves.
Publius,
I've re-posted this entire exchange here:
http://godscopybook.blogs.com/gpb/2005/01/debating_health.html#more
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