In the middle of a group discussion of health care reform last week, an acquaintance expressed puzzlement that the current debate isn’t more heavily focused on international comparisons. Modulo all the important differences—cultural, institutional, demographic, and so on—between the United States and other developed countries, shouldn’t we be spending most of our time weighing the merits and drawbacks of the huge variety of health care systems that deliver care as good or better than ours at lower cost? Now, I found this a little odd, because to me it seemed as though, if anything, we were hearing a lot more about international comparisons than we normally do in areas where one might think them relevant. But it’s certainly true that, while pundits and writers may make positive reference to other countries’ systems, elected officials almost never do. And the consensus seemed to be that this is because Americans never want to hear that some other country has figured out how to do things better than we have. If you want to use another country’s experience to denigrate a policy by talking about how awful it is over there, by contrast, you’ve got a free pass even if you’re just lying your tuchus off:
Obviously, this is a less-than-optimal state of affairs on face. I don’t expect politicians to start being forthright in ways that turn off voters, but I’m wondering if it there isn’t an opportunity here in the nonprofit space for some institution to start specializing in international policy comparisons, rounding up successful instances of policy entrepreneurship and so on. Annie Lowery, for instance, wrote a useful roundup of the worst health care reforms for Foreign Policy, and it seems like you could do something similar across the board—maybe some kind of biennial roundup of best and worse policy innovations in a whole array of areas.
A few reservations as a small-government type, given that much of the developed world seems to countenance significantly more expansive and intrusive government than we do. First, the benefits of government programs tend to be a lot more obvious than their harmful consequences, and given that you can’t actually run controlled experiments, it’s hard to know how to gauge the way one policy in a vast complex of entangled and interdependent policies affects employment or innovation in an equally complex, and probably quite different, economy. Second, these sorts of comparisons tend to privilege what’s easy to quantify over equally more important but necessarily more nebulous concerns. You can run a regression to estimate whether and to what extent mandatory morning calisthenics reduce obesity or heart disease, whereas the intrinsic disvalue of forcing people to do things isn’t easily rounded to three decimal places, and so tends to drop out of the picture. You can, of course, try running polls to see how unhappy people are about being compelled to do something, but some of us might regard it as even more worrisome if a population ceases to mind being told how many power squats they must perform before breakfast. These concerns notwithstanding, I can’t really bring myself to believe we’re better off for systematically ignoring data: If the rationale for federalism is that we benefit from having 50 “laboratories of democracy,” why stop gathering information at the water’s edge?
8 responses so far ↓
1 Doug // Jul 30, 2009 at 4:33 pm
I agree throughout and kudos on balancing. It will be very hard for some Democrats, having explained all the benefits to another model if many of us still don’t want that model. It will be reinforcing/frustrating to Republicans if many of us don’t find the translation of a European model to be emotionally upsetting. But what we clearly don’t need is happy Democrats or reassured Republicans.
2 Tim Lee // Jul 30, 2009 at 7:08 pm
The problem is that data do not speak for themselves. In order to know whether a given figure is meaningful, you need to know an awful lot about both how the figure was calculated and what policies surrounded its generation. When your audience is ignorant of basic facts about a country (as virtually all of us are about the majority of the world’s countries) it’s far too easy for ideologues with axes to grind to cherry-pick statistics that support whatever point they’re trying to make.
To make this concrete: liberals like to cite the higher life expectancy and lower health costs of other countries. Free-market types like to cite long waiting lists and sub-par innovation. While my sympathy is with the latter, I have to acknowledge that I really have no idea where to start in comparing these kinds of competing proposals. I simply don’t know enough about the other countries’ health care systems, cultures, fiscal environments, etc to know whether these things are because of or in spite of their health care systems.
Moreover, even if we establish that, say, Poland has a particularly good health care system, it’s far from obvious which aspects of the system are worth emulating. Again everyone will cherry-pick those aspects that are most similar to their preferred policies. And again, without knowing a lot about the health care systems in question, I have no way of distinguishing actual insight from clever bullshit.
These problems aren’t as severe with states because because states are much more similar to each other than the US is to other nations. I read the language, know people from other states, and know my way around a budget document. So it’s much easier for me to evaluate claims about the merits of competing state health care systems and reach a conclusion about why one might out-perform another.
3 Sam McManus // Jul 30, 2009 at 7:22 pm
The problem with these expansive programs like UHC is that often, they come down to actuarial tables and the like; nitty gritty data sets with many variables that the average person (myself included) simply don’t have the patience or ability to read correctly. This cuts both ways of the left/right divide, as one could make the argument that either the wonks in DC don’t know what they’re doing either or that the average republican voter is being obstructionist on policy issues they only know the broad strokes of. I see many more moral arguments about health care than I do pragmatic ones (and many many more arguments about what beer Obama should be serving tonight).
4 adina // Jul 30, 2009 at 9:38 pm
Data from other countries are so chock full of potential confounders, that anyone who tries to explain that a superior result is due to any specific policy is completely overreaching, at best. The U.S. is different from other countries in thousands of ways, and, if I wanted to, I could point to only one of those differences and claim that this is the reason for any given desirable/undesirable outcome. Bring on the data. But don’t think that having them will provide us any definitive conclusions, rather than simply inspire some hypotheses.
5 Jonny Scrum-half // Jul 31, 2009 at 5:58 pm
Poll results would only result in an exponential increase in unhappiness among those who value individual liberty, as it becomes apparent that a majority of our fellow citizens actually prefer being told what to do and when to do it.
6 Mark // Aug 1, 2009 at 4:56 pm
“it becomes apparent that a majority of our fellow citizens actually prefer being told what to do and when to do it.”
Or maybe a majority of our fellow citizens would just like to know that they can get the health care they need.
7 Barry // Aug 4, 2009 at 3:33 pm
I’d like to point out to the oh-its-so-complicated-and-there-are-so-many-confounders crowd that this also applies to any comparisons which justify things about the USA.
8 Gerald Fnord // Apr 24, 2011 at 6:56 pm
Saying that Europeans, can do something better than good Merkins is un-American. This country is the best, greatest gift that God has ever given Mankind on the face of the Earth, and they’re a bunch of soccer-loving, socialist, f-gg-ts who don’t worship Jesus enough, and anything that would make us more like them would be degeneration.