In my previous post on Obamacare commenter Paul has suggested I’m putting too much faith in government intervention to reduce inequality or contain costs. I’m about to go away for the weekend so don’t have much time to attend to my blog (nor may I next week, when classes start) but here’s a pair of questions that I think are related to that question, and to the (apparently still unsettled!) government vs. private debate. These two questions possibly also show how much we don’t know about health systems.

Did the NHS reduce health inequality?

One of the big claims of the NHS is that it reduced entrenched health inequality by giving poor people access to healthcare they were previously denied. I’ve implied before that I’m not confident the NHS has achieved that much in this regard, and pointed to the existing health inequalities in the UK as evidence of this. I’m loathe to say that it achieved nothing, but this fascinating and excellent paper from the British Medical Journal, published in the year 2000, suggests that despite the estabishment of the NHS, health inequality in Britain has persisted for 100 years. So is it the case that the huge intervention in the market that is the NHS achieved nothing in reducing inequality?

Does the US health system need political, not system reform?

It’s true that there’s very little evidence that private health markets reduce inequality or contain costs, but there are only two developed nations that have actually conducted this experiment (the US and Switzerland), and although the experiment is ongoing in many developing nations they don’t provide a good health policy laboratory (due to all the development issues and tropical diseases they are dealing with simultaneously). Switzerland, obviously, is a bit special, so there is really only one major economy that is actually trialling an even close-to-privatized system, and there’s a big problem with the experiment going on there: the USA is a plutocracy, not a democracy, and its capitalist system is pretty busted (see, e.g. “Too Big to Fail”), in the sense that it is heavily captured by special interests and the political system in which it is embedded is corrupt, unrepresentative and basically not democratic. Furthermore, the USA has a significant race problem that doesn’t exist in other places, is historically very specific to the USA, and creates a whole set of social problems that a place like Switzerland or Australia doesn’t have to cope with. So is it possible that a root-and-branch political reform, based on breaking the sectional interests in the US economy and the power of the super-rich to influence politics, would enable a purely private health system to function? If so, it’s unlikely that any attempts to salvage the market-based system that are based on regulation or minimal government intervention are going to work, because of the power of those sectional interests. Should proponents of market systems for health care be looking to developing nations for their examples?

I’m off to take an extended bath in the country! So comments won’t get much attention until next week …

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