Thomas Hobbes tells us that in the state of nature, as distinct from that of civil society, “the life of man [is] solitary, poor, nasty, brutish, and short.” Which is not to say the same can’t be said of some civil societies, e.g. Nazi Germany, Stalinist Russia, Apartheid South Africa, to name just a few. So libertarians and anarchists are right to point out that the state can as readily be the source of that brutishness as an escape from it. But for the purposes of today’s analysis, let’s put those cases aside. In fact here let’s confine our discussion to those polities we regard as the relatively affluent liberal democracies in the world today.
With that scope in mind, it seems to me that there are three things that mark the distinction between a civil civil society and a still-brutal one. They are the abolition of the death penalty, women’s reproductive autonomy, and single-payer healthcare. The first two cause the citizen to fear the state; the third to appreciate it.
By these measures, then, Canada, the Antipodes, and most of Europe are civil societies. The United States is not. I’ll leave capital punishment and abortion for another day. Here I want to focus exclusively on healthcare.
Single-payer healthcare was adopted in my native Province of Saskatchewan in 1962, and shortly thereafter the rest of Canada followed suit. Over the course of my life I’ve had major surgeries and other medical services that I’m sure have cost the taxpayer well over a million dollars. Let’s compare that portion of the taxes I pay for this with what I would have had to spend either out-of-pocket or for private insurance. Am I ahead of the game or behind? I have no idea. But even if I did, what’s the price-tag on not having to give the threat of bankruptcy a second’s thought? Again, no idea. But there are people, south of the 49th, who do weigh these costs and have opted to pay them directly rather than through their taxes.
Of course the same was true in my native Province of Saskatchewan prior to 1962. As I recall it was only kicking and screaming did they pay their taxes and accept the coverage. I know of no one, either in Saskatchewan, or elsewhere in Canada, or in the Antipodes, or in Europe, and no matter how independently wealthy he might be, kicking and screaming against socialised medicine today.
Is this change of heart because the above calculations are now beyond us? I suspect not. I suspect it’s because among the dividends of single-payer healthcare is a certain civility we’re no longer prepared to live without. That is, it’s not that I couldn’t pay out-of-pocket or afford the premiums. It’s that I know that others could not. And it’s not that I care so deeply about them. It’s that I want to avoid the discomfort of being surrounded by desperate people. Left to my own devices I wouldn’t pay to alleviate that discomfort. Avoiding this kind of discomfort is a collective action problem. So I welcome the state solving that problem for me.
But if I’m entitled to my judgment call on this, why isn’t the equally well-off American not entitled to his? He is. At least until the majority of American voters, as did those in Saskatchewan in 1962, decide otherwise. But I want to grant that there’s another autonomous effect of socialised medicine that may be preying on the American mind, one not to be dismissed out of hand. And that’s that socialised healthcare, though it offers us freedom from financial worry, there are other freedoms it taketh away. Such as? Such as the freedom not to wear a seat belt.
I’m using the seat belt issue here as a stand-in for that vast array of issues that arise out of the negative externalities your behaviour is imposing on the rest of us. In the absence of socialised medicine go knock yourself out! But not if the rest of us are having to bear the cost of your stupidity. So since we have skin in the game, there’s a powerful moral intuition telling us that likewise should we have a say in it. But of course one man’s modus ponens is another’s modus tollens. Or, less pretentiously, one man’s proof is another’s reductio. So whereas the stereotypical Canadian accepts the right of the state to require seat belts, his American counterpart takes it as an argument against making the taxpayer pay for the stupidity of others, including one’s own.
As I’ve already indicated, my own view, for what little it’s worth, is that paying for the stupidity of others is a burden I’m willing to take on in exchange for their paying for mine. But maybe that’s because I know, from experience, just how stupid I can be.
Categories: Social and Political Philosophy
Paulosophical Vimplications 
Canada is the only OECD country that operates a single-payer healthcare scheme. (Some wags say that the only other country in the world that does is North Korea.). All other OECD countries, including all the ones you cite, permit (and strongly encourage) citizens to purchase coverage from another (private) insurance company to pay for the same range of services that the state will pay for. Canada prohibits patients from paying for any service privately (by self-pay or through insurance arrangements) that the province lists as a covered medically necessary service. No other OECD country does this. These private arrangements in other countries typically enable queue-jumping, choice of doctor, or access to private hospitals and specialists with better reputations or quality, particularly important in Italy as we saw in the pandemic. Two-tier medicine, in other words. Single-payer they are not.
It is true that in most OECD countries (including Canada where you have no choice), you can make out OK if you want to save money with just your state insurance card, as everyone is eligible for it and it covers emergencies and the range of things most people will need. In this respect the U.S. is different from the OECD and is probably unique in the world. Only the U.S. has large numbers of citizens with no health insurance at all. But depending on country, specialists and hospitals are free, as in the U.S. with Medicaid, to not accept the state insurance plan and many won’t, or they limit the number of “state” patients they will accept. France, through it’s state control of the various funds that cover different slices of the population, covers many services with public money that Canada does not, particularly out-patient prescription drugs. Most countries, except Canada, impose some cost-sharing on users, I.e., co-payments and deductibles. This is a detail I mention only because none other than TC Douglas himself thought that some patient accountability through price signals was necessary to prevent abuse. (Most academic studies show them to be useless or perverse.)
Now, I agree that the Canadian “all-in” approach using the full power of the state better achieves the desiderata for solving an otherwise intractable common action problem for all the reasons you state…and I can think of a few more. I thank you for putting it that way. Do you think it is likely that the residents of other OECD countries — leave out the U.S. if you wish — experience more moral discomfort from having retained or expanded their multiple payer, “two-tier” schemes as they seek to reduce strain on public budgets?
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I stand to be corrected, though of course, like anyone, I deeply resent it. Still, I’m not entirely convinced by how Leslie is parsing these coverages. Of course strictly speaking there’s no polity that can afford to socialise ALL our medical demands. For example, I’m told that good general health starts with good oral health, i.e. dental care, but I know of no polity, even in the so-called First World, that can afford to cover dental. Some cover psychiatry, others don’t. Same with chiropractic and acupuncture. Moreover, I know of no polity that doesn’t have at least SOME tier-edness, usually greater than two. For example, even in Canada members of Parliament have their own medical service, as do members of the armed forces. And of course one can often jump the queue – I’ve done so myself – by knowing the service provider personally. My only point was to argue FOR socialised medicine, as far as we can afford it, even though of course Leslie is right that nowhere is it an all or nothing thing,
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I think we can agree that the U.S. is uniquely uncivil in the OECD in not providing any level of universal state-funded coverage. Single-payer or multi-tier is for wonks and is perhaps beside the point. Nowhere else in the rich countries are there large groups of citizens who have no guaranteed cover at all if they get sick, other than charity or bankruptcy.. Even workplace-based insurance, which most Americans seem to believe is better than what they would get with “socialized” care, ends if you lose your job. If you are self-employed, buying private insurance as an individual is very expensive because of adverse selection: the insurance companies figure that only people who expect to make a claim will buy coverage voluntarily. (Young healthy men are better off going naked.). That was the quid pro quo of ObamaCare: the insurance co’s would cover everyone with no denials for pre-existing conditions only if everyone had to buy it. Striking down the “individual mandate” was the death knell for ObamaCare. One effect is sclerosis in the job market for the well off. You don’t change jobs unless the health plan is good. It’s also enormously wasteful, but then one man’s waste is another woman’s job working for an insurance company…or a stockholder in one.
Americans have convinced themselves that the benefits of universal state care, even at just basic safety-net levels with optional private higher tiers retained, would be concentrated among low-income black people and, possibly, undocumented aliens….at the expense of themselves as currently well-insured taxpayers. Medicaid for the indigent is deeply resented but the far more expensive Medicare (and Social Security) they love. That this is an expression of fundamental incivility I have no doubt. But it will never, ever change.
I do enjoy people’s stories about jumping queues in Canada. What it would cost an American many thousands of dollars to do, to pay out of pocket for an operation his insurance company deemed not necessary, a Canadian with connections can do for free. No wonder “American-style” medicine is vilified by our opinion leaders.
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I couldn’t have said any of this better myself, so I’ll pretend I did.
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“Striking down the “individual mandate” was the death knell for ObamaCare.”
Last I checked the individual mandate was still in place. Trump Care (which is the colloquial term for a number of candidate bills: AHCA, BCRA and HFCA) was rejected when John McCain cast the deciding vote against the HFCA in the Senate. Trump talked during his latest failed campaign about repealing the individual mandate, claiming that it was the only real conservative objection (a stark shift from the days of the tea party saying all of Obama Care would destroy the country).
Also worth noting is, that while the various bills would have removed the individual mandate, they all kept the ban on denying pre-existing conditions. The different versions had different ways to offer quid-pro-quos to the insurance providers like allowing them to charge extra for lapses in coverage or compensating them for loses due to the ban. Whether these provision would have worked had the bills passed is anybody’s guess but these details tended to get lost in the debate which was, and still is, awfulized by both sides.
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The Affordable Care Act, including the individual mandate, is back before the U.S. Supreme Court. Oral arguments were heard in November and a decision is expected (much) later this year. However, the IRS has not been enforcing the financial penalty for “going naked” for some years now — it was meant to be imposed on tax returns — and regardless of how the Court rules, there is no practical consequence to an individual of ignoring the mandate.
As with so many other “breakthroughs” and “catastrophes”, life just keeps muddling along.
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Be my guest. I am sincerely honoured.
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