Most Europeans don't understand the U.S. healthcare debate. They don't understand it because the opposition to it, and its breadth and depth, runs so counter to the experience of almost every European born since World War Two. It's an experience so deep, so vigorously underpinned by government action and social teaching, that it has become a moral credo. They think healthcare is and should be a public provision. Most Americans don't seem to.
The Europeans, who think of their unions as stubborn defenders of public provisions, don't understand why a bunch of U.S. union leaders have come out against some of Obamacare's central elements, arguing in a letter that it will "shatter not only our hard-earned health benefits, but destroy the foundation of the 40 hour work week that is the backbone of the American middle class." (They worry that the thresholds for employers to provide health insurance will mean employers shift full-time employees to part-time work.)
The Europeans also don't understand the visceral opposition of the right to the proposed system. Harvard economist and Obama advisor David Cutler looked at Mitt Romney's 2012 campaign and said, "Never before in history has a candidate run for president with the idea that too many people have insurance coverage." Yet Romney got a respectable vote. To oppose universal healthcare in Europe would be to guarantee instant political oblivion.
West European states have cradle-to-grave medical care for all of their citizens — and the residents of all the West European states go to their graves, on average, later than Americans, even if only by a year or two. This isn't a direct measure of the quality of the medical care, and there's a sizable debate about the connection between life expectancy and quality of healthcare. But Europeans believe in it, because they see it as a crutch in their sicker old age and believe that the U.S. system is heartless to the poor. In every West European country socialized medicine has become a matter of sentimental attachment as well as practical assistance. (Remember London's tribute to the National Health Service during the Olympics?)
Now, though, that belief in socialized medicine is under strain, for the health services of the rich European states are in various kinds of "crisis." I put the word in quotation marks because healthcare is ritually said by journalists to be in crisis: it's the word that cries wolf. But this time there is a wolf.
In Italy, the UK, Spain and France, cuts of varying depths are now being introduced. In France, where the health system is usually seen as the best, the budget is exceeded by billions of euros every year: the head of the association of French pharmacies says the system cannot survive more than six years without deep reform. In the UK, the new director of the Care Quality Commission that oversees standards, said after his appointment earlier this year that "the system is on the brink of collapse."
The more socialized the U.S. system becomes, the more it will find itself facing the same dilemmas as the Europeans'. These dilemmas are all symptoms of the way we live now.
In nearly every country, people live longer than they once did. And in most countries, women give birth to fewer kids. In 2000, around 16 percent of Germany and the UK's population was over 65 in 2000, while the U.S. had only 12.7 percent. But in the U.S., the proportion of over-65's will increase to near 20 percent of the population in 2050, and over 80's to around 8 percent. The UK will have over 20 percent of 65-plus citizens by 2050. Germany will have around 30 percent of 65-and-up by 2050; it will have around 15 percent of its population in their 80s.
So there will be fewer economically active taxpayers in North America and Europe while there's a greater need for taxes to pay for socialized medical care.
Most of these older people will be healthier than previous aging generations and they may get relief from illnesses that others didn't. Many fewer will smoke, because anti-smoking campaigns have meant that the diseases associated with smoking are down: the proportion of smoking Europeans is under 25 percent.
But they're also likely to be fatter and some will be obese: within Europe the UK and Germany tend to lead in the obesity stakes, but France and even Italy, with its Mediterranean diet, are coming up fast. More will be prone to terrible degenerative diseases, of which Alzheimer's is the most common — and most costly, at around $100 billion a year in the U.S.
Obamacare puts the U.S. closer to the Europeans in its generous universality, and closer to the Europeans' budget problems. Behind the mendacious claim that the Affordable Care Act would create state-appointed "Death Panels" lurks the germ of an insight. Once medicine is paid by tax revenue, health becomes one of the government's central concerns. It has little choice but to intervene directly to try to stop people's bad habits that land them in the hospital. Governments have pressed harder and harder on smokers, and it's working, if slowly. But if, for example, the obesity trends continue, the specter of Fat Panels may swim into view.
Making, and keeping, citizens of all income levels healthy is the biggest welfare challenge for the early 2000s. Socialized medicine always had a moral hazard tucked inside it: the healthy citizens subsidize the smokers, the drinkers, the food bingers, and the drug takers who occupy the emergency rooms every night.
Warnings of collapse now come often, with too much authority behind them to be dismissed. The creation of a system of medical services that is available free for everyone is a fine thing for a country to do for its citizens: but it needs citizens who won't overload it by letting their appetites off the leash — for then everyone suffers.
(John Lloyd co-founded the Reuters Institute for the Study of Journalism at the University of Oxford, where he is Director of Journalism. The opinions expressed are his own.)