In yesterday's New York Times, David Brooks wrote, "bad policy can decimate the social fabric, but good policy can only modestly improve it."
All this fighting about health care policy and other government programs is misguided, he says. Sweden's health care program only increased life expectancy by a month or so. Their life expectancy was always 2.6 years above ours; their healthcare program only bumped up their life expectancy advantage to 2.7 years.
While a month or two of life might not be huge, the benefits of the Swedish healthcare program can be measured in other ways. The Swedes also don't have to worry about spending their final years consumed with the stress of paying for medication or Medicare forms. They also don't have to deal with the impact of sudden unemployment on health care, such as exorbitant COBRA payments or bankruptcy from medical catastrophes.
The impact of a program can be measured in many different ways.
Of course, government programs can't solve every problem. He's right that "historical experiences, cultural attitudes, child-rearing practices,
family formation patterns, expectations about the future, work ethics
and the quality of social bonds" matter quite a bit. That's why Asian-Americans have a life expectancy of 87 compared with 79 years for whites and 73 years for African-Americans.
Brooks is setting up a strawman argument here. I don't think anybody who argues in favor of healthcare policy or education or any public policy would say that government alone can make a difference. There has to be comprehensive change.
UPDATE: More from Matt Yglesias and Brad DeLong
Apt. 11d 
Brooks isn’t saying that Sweden’s health system increased life expectancy by 2.7 years. He says Swedsih life expectancy was 2.6 years higher than U.S. life expectancy in 1950 and, despite very different policy, the gap has not changed much.
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Oops. Thanks, MH. Let me edit.
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This is not a general fact about policy, but a particular fact about health care policy in particular, because the unhealthiness of our population and society is not down to lack of access to healthcare or inefficient spending on healthcare (the first of which causes a lot of anxiety, the second of which has other detrimental effects) but to the inequalities in the society and the stresses in particular on those at the low end of those inequalities. Sweden is a more equal society, so healthier for all, especially the less advantaged. The health care system we have is a symptom of the kind of society we have, and thus an effect, like the unhealthiness of the population, of a common cause, not an intermediate factor (except to a very small extent).
Alright, maybe the same is true of education. I dunno.
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As my grandpa jokes (at least I think he’s joking), “Swedes are the master race.” Grandpa is 3/4 Swedish.
My grandparents and some other relatives are visiting Sweden this summer. I look forward to reports from the mother ship. They’ll be meeting up with the Swedish cousins we’ve never met. From what I’ve been hearing, many Swedes are way into genealogy and it is not infrequent for them to know about American relatives before the Americans know about them and to have very detailed info about family trees on both sides of the Atlantic.
In any health care analysis, don’t forget that there are only 9 million people in Sweden. In such a small country, with such a strong sense of inter-relatedness, it’s easier and more natural for a nation to function like a family.
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Agreed. No policy is every going to make us as homogeneous and as functional as the Swedes. That’s fine. In order to improve the health, education, and everything in our country, we need to improve all those social woes that Brooks describes and put in place good policies. But it can be done. Look at the Equal Rights Act of 1964. It took years and years of real changes in society coupled with a serious law to get blacks to the voting booth. It can happen.
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I think Laura and Harry both get it right, with the latter’s comment being particularly insightful. Health and health care are not analogous to other policy areas. And the purpose of national health care isn’t primarily to increase life expectancy (or at least I don’t think it is): it’s to increase quality of life, for example through reducing insecurity over the lifecourse. It reduces contingency, and that’s important.
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One other thing: it’s worth remembering that the Swedes are a lot less homogenous now than we think they are. Just off the top of my head (no time to look it up: gotta go pick up the kid) I think that at least 12% of the population was born outside Sweden. Obviously that’s very far below American levels, but the trope that Sweden can only accomplish what it does because it’s homogenous (one trotted out fairly frequently here in the UK) just ain’t true.
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That Sweden can run its system as it becomes less homogenous is a very different thing than saying that Sweden could have built its system if it were less homogeneous.
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I struggle with the feeling that our lack of societal cohesion means we just can’t look to the Scandinavians for our models. I fear policy on that scale can’t work in the States. We’re much messier here, although we do eventually get it done. But it often comes from below, as opposed to imposed from above.
Currently economic factors are driving large numbers of physicians out of private practice and into large networks. It’s a huge transition, one that may in the end be the key to removing the waste from our health care system. Yet it’s happening not for policy reasons but for economic ones and technical ones. In Sweden I think this kind of change would have been mandated by the government.
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“That Sweden can run its system as it becomes less homogenous is a very different thing than saying that Sweden could have built its system if it were less homogeneous.”
Right. And part of the process involved a million or so of the most desperate Swedes leaving for greener pastures at the end of the 19th century/beginning of 20th century, before the whole socialism thing got going.
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Yes, it’s obviously different to become heterogeneous after the welfare state is in place. No one would dispute that. But Sweden is no longer homogeneous, and takes great pains to craft policies that work today, for its non-homogeneous (small) population.
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One of the best lines the Shah ever uttered was, “They want me to govern like the government of Sweden. Believe me, if I were governing Swedes, I would.”
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“But Sweden is no longer homogeneous, and takes great pains to craft policies that work today, for its non-homogeneous (small) population.”
It’s going to be fascinating to see if these policies continue to work in a more heterogeneous Sweden. I think I’ve seen a number of stories about Minnesota and its difficulties assimilating immigrants and minorities, which may be analogous. I don’t have the time to find all the stuff, but I note that the city of Minneapolis has only recently managed to pull its public high school graduation rate out of the 50s (57% in 2003, 53% in 2004 and 55% in 2005).
http://www.ci.minneapolis.mn.us/results/graduation.asp
On the other hand, I was looking up the Swedish immigration numbers yesterday on Wikipedia, and while the number of foreign-born is high (18%) I was somewhat surprised how small the number of non-northern European immigrants is. A lot of immigrants to Sweden are other Scandinavians (especially Finns) and Germans, with more than half of immigrants to Sweden being from other European countries. On the other hand, numbers aren’t everything for cultural influence–just studying US mass media, you’d never figure out that the US population is only 2% Jewish.
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Most European countries have limited experience assimilating immigrants on a large scale. The US has a lot of experience. I think it is a profound mistake (though common) to think that immigration and its results account for the failure of the US to establish and maintain a well-designed welfare state. There’s a much more glaring explanation that does, indeed, have something to do with heterogeneity, but tied to an experience that European countries don’t have.
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the s-word?
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There’s a much more glaring explanation that does, indeed, have something to do with heterogeneity, but tied to an experience that European countries don’t have.
European countries don’t have exactly the same thing. But, there are some similar situations. For example, I don’t think you could have the NHS if you didn’t first have an independent Ireland.
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Everyone seems to be ignoring the lead quote. Brooks is saying there is a HUGE potential downside with something as comprehensive as Obamacare, while the upside is minimal, leading to the question: “Is the risk worth it?” Incremental change, however, by definition presents a downside roughly as limited as the upside.
In Obama care we have bought a pig-in-a-poke. Now we find out that HHS suppressed its own report that found that practically NONE of the touted savings will accrue; that indeed ins premiums will rise–and rise–and rise. And that overall costs will go UP, NOT down. And of course the inevitable pressure will be brought to bear on the ins. companies to hold costs down–which will put them out of business with the “no pre-existing illness” clause waived–which means that only sick people will buy insurance–leading to premium cost death spirals. Already in MASS. its version of Obamacare Jr sees Ins Companies refusing to write any new policies as they are automatic money-losers. The result of all this, combined with numerous onerous provisions JUST NOW coming to light, is going to produce the sort of chaos capable of tearing apart the social fabric of which Brooks writes.
I, for one, have always favored Sir Winston’s political philosophy:”Look before you leap–and don’t leap if you can find a ladder.”
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‘nother Churchill line: there was a trough urinal in the House of Commons. This was after he had lost the postwar election, Clement Attlee was peeing and Churchill came in and went to the very end of the trough. Attlee said, “Winston! Shy?” and Churchill said, “Clement, it is my experience that if you see something that is large and works well, you want to nationalize it.”
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“Brooks is setting up a strawman argument here. I don’t think anybody who argues in favor of healthcare policy or education or any public policy would say that government alone can make a difference. There has to be comprehensive change.”
Actually, I saw pro-HRC arguments based on lifespan and US health expenditures all over the place before the bill passed. It was one of the most prevalent arguments, that “we” are spending so much on health care compared to other countries, but getting slightly worse results. (Here, I’d point out that “we” also spend more on education and the military, in the case of education also getting basically the same results as everybody else.)
With regard to “There has to be comprehensive change,” lots of luck.
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