Spring 2001; Volume 2, Number 1
When It Comes to Health Policy, Americans Are Not British
Robert Blendon, Sc.D. and Minah Kim
page 1 | endnotes
Over the last few decades, many health experts and national leadership groups have become concerned about the performance of the U.S. health care system. The persistence of high health care costs, a large population of uninsured Americans, wide disparities in access to health care and levels of health across the country, as well as a dissatisfied public have raised the question of whether the nation's health system needs to be fundamentally restructured.
The search for an alternative to the current U.S. system has aroused interest in the experiences of other industrialized countries in organizing their health care systems. Particular attention has been paid to Canada1 and Great Britain2, countries with strong cultural, language and historical ties to the U.S. Likewise, Germany3, a close ally, trading partner, and leader in the new Europe, is the focus of considerable interest with its tripartite business, labor, government managed health care system. All three of these countries have lower national health spending, universal coverage of their populations, more favorable health statistics (Table 1), and, based on survey data, a more satisfied citizenry4 (Table 2).
Yet, despite numerous papers, comparative research studies, conferences, visits by experts and legislators, and newspaper features on the better performance of these systems when compared to the U.S., these nations' systems have not been adopted as models for change in the United States. A number of reasons for this outcome have been offered including the nature of U.S. political institutions which are seen as making anything but incremental change difficult to achieve.5 The unique power of private interest groups in the U.S. resists change that might threaten their current role in the health care.6 In addition, as discussed below, there are important cultural attitudes in the United States that make the citizenry less receptive to health systems on the model of Canada, Great Britain, and Germany, irrespective of their merits.7
First, as shown in Table 3, Americans have an underlying antipathy to reforms that would involve greatly extending the power of government into the day to day activities of the health system. When compared to the citizens of these other countries, Americans are more likely to see their government as already too powerful, not trustworthy, and generally inefficient and wasteful in its activities. The anti-statist political values of the United States have been demonstrated in many political studies.8 The systems found in Canada, Great Britain, and Germany -- where the government is central to the management of the health care system -- conflict with these basic American cultural beliefs.
More specifically, compared with these other industrialized countries, Americans prefer a health system where government plays a less central role. As shown in Table 39, Americans are less likely to want a government role in either providing care to the sick or managing hospitals.
Lastly, the American public is less supportive of government efforts to achieve equity than the publics of these other three nations. For the U.S. to have a health system where everyone, regardless of income, receives the same high standard of medical care requires those with higher incomes to subsidize those with low and moderate incomes, as well as those unable to work at all. As shown in Table 3, when compared to these other countries, Americans are less committed to having those with upper incomes pay higher taxes or to favor policies that would provide a decent standard of living (including medical care) for those who are not employed.
Taken together, these cultural differences help explain why Americans, who are so dissatisfied with our current health care system, in the end never embrace health systems such as found in these three other countries. Canada, Great Britain, and Germany have very different health systems, but they all involve a central role for government in management and regulation, and a willingness to have government redistribute resources and tax those who are more successful in order to achieve equity in health care. As a result, Americans learn little from foreign experiences in health policy.page 1 | endnotes
Robert Blendon, Sc.D. is a Professor of Health Policy and Political Analysis in the Department of Health Policy and Management at the Harvard School of Public Health and the John F. Kennedy School of Government. Minah Kim is a doctoral condidate in the Political Analysis track of the Ph.D. Program in Health Policy at Harvard University.
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