By: Scott L. Greer
This blog post is based on a book talk and discussion hosted by the Center for the Study of Europe of Boston University’s Pardee School of Global Studies on April 14, 2020. The book in question is Well: What We Need to Talk About When We Talk About Health by Sandro Galea (OUP 2019). The book begins by comparing the state of public health in the United States with the health policy outcomes in ‘other rich countries’ – especially European nations. It is a fact that, while spending much more than Europe on health care, the US fares significantly worse: child mortality rates are higher, life expectancy is lower, etc. From this premise, Galea develops his core argument: the American obsession with health ‘care’ ― doctors, hospitals, and drugs ― obscures the real roots of sickness: money, status, education, race, environment, and inequality. Public health ― Galea concludes ― requires investment in public goods such as education, universal health coverage and environmental regulation.
How do we get from where we are to thinking differently about health, and actually getting well?
It’s easy to think that public health would be a goal we could all agree upon. The world it promises is attractive, the things it decries unattractive. Nobody really wants to live in a low-trust, precarious world. If people seem to disagree, it’s likely that they think we never can share such benefits, that is an irrefutable fact of life. It is a statement about what is possible rather than what is desirable.
The policies that public health scholarship supports also, unsurprisingly, poll well, pretty much wherever. Jobs guarantees, universal health coverage, free or low-cost education, paid holidays, family leaves, high minimum wages, good occupational health, a clean environment they are all popular with people in most countries. I could go on, but the key point is that a competently executed poll will usually find a thumping majority in support of these individual policies and many more.
So why don’t we get jobs guarantees, universal health coverage, free or low-cost education, paid holidays, family leaves, high minimum wages? The simple answer from many in public health, which is not wrong but is too simple, is Industry with a capital I. Industry is the hobgoblin of many public health writers. And what we learn about how Industry behaves is pretty dispiriting, whether it’s tobacco, pharmaceuticals, autos, or anything else. But Industry, and others who are not supportive of public health goals, can be effective in blocking popular goals because they can tap deep elements of public opinion and elite politics. Elites shape agendas and frame politics, but they can do that because they know how to shape public opinion through several key mechanisms.
One is tradeoffs. Simply put, tradeoffs mean that when you ask voters their view of something like a jobs guarantee, universal health care or walkable neighborhoods, in the abstract, they might say yes―but if you ask them to trade those values against their own incomes, insurance, or neighborhoods, they might change their minds.
The second is framing. Much of politics is about framing things, shaping how we think about issues. For example, arguing that social democratic policies contribute to desirable states of health. The problem is that there is competition over this, and it’s easy to reframe health policies as paternalism, a nanny state, wasteful, or just a benefit to somebody else. Better public transit is a good goal if you value sustainability and social mobility, but if you think that public transport is for kids, thieves and layabouts then you might not be so interested in it.
Third, people personalize issues rapidly. Most of us know a few lazy good for nothings whose uselessness and bad habits we do not personally wish to support. Surveys find all sorts of semi-personalized animosity.
Thus, for example, surveys currently show that most Europeans are mildly positive about an EU stockpile of emergency resources for a crisis. Right now, EU support in crises is mostly that of a matchmaking service: I have spare firefighting equipment, you have a fire, let me help you out. Good Europhiles point to the surveys and say let’s go beyond that, and have a supply of medical equipment that could be given out by the EU to the place that needs it.
The problem is, the minute you present such a plan, every politician who might see themselves as losing or getting stiffed will have cause to oppose it. We saw the same kind of polling with refugees in 2015, and needless to say European solidarity on questions of where to send them collapsed immediately.
(plus why on earth did anybody think your average Syrian refugee would want to be put in a bus to Hungary anyway?)
You see the problem. A good idea in isolation in polls, or even backed up with scholarship, isn’t the same thing as an idea that is attractive to politicians or voters.
That said, good things are possible. European Union countries―all European Union countries―are broadly better at delivering health than the US. And they all run better, and better value, health care systems.
First, though, here are the caveats:
– Europe, or even just the EU, is very diverse.
The US states are less diverse than the EU; the gap between Bulgaria and Luxembourg is bigger than the gap between Mississippi and Connecticut.
The EU also shows the difficulty of mapping health outcomes onto policies. There are countries with worse health outcomes than their health care systems would suggest, such as Germany and Austria, and others, such as France and Spain, which have better outcomes than a look at the health care systems would suggest.
– The EU also broadly has lower GDP than the US―while many Western European countries, in particular, have higher productivity per hour than the equivalent Americans, they take more leisure relative to Americans. That’s almost a definitional decision to have more health at the price of less money to spend on health care or whatever else Americans spend money on.
– And finally, there is a social democratic package in our heads, ranging from universal health care to unionization to progressive taxation to parental leave. But no country has that. Even Sweden, which has been run by right-wingers for most of the last three decades, always financed the social democratic people’s home with taxes so regressive that US Republicans would admire them. There’s no ideal type European country.
So why do Europeans, who are just as likely to be awful human beings as Americans, get nice things?
I want to highlight two things.
One is the politics of other people.
– Every society has other people.
– Every ingroup has an outgroup.
Europe has a long and bloody history of state-building. What was the twentieth century in Europe? In good part an immensely bloody project of forging homogeneous states, one substantially completed by Stalin with population transfers after world war two.
Nationalism really matters. Brexit is mostly a story of English nationalism. National stories matter. No European country has anything quite like the US racial divide or the US level of internal fractionalization, but all of them have long and powerful stories of nation-building.
In general, when you trust other people, you give them money. This is what happens in Nordic societies.
If you don’t trust other people you regulate them. Low-trust but very nice European societies like France regulate the heck out of life. The EU itself is like that―a mechanism for regulating other countries in the shared interest unmatched by actual transfer of resources. Ask any Dutch voter how much they trust Sicilians or Romanian politicians with EU funds.
This has somewhat scary implications for Europe, for two reasons. First, it suggests that a continent which spent bloody decades creating relatively homogeneous nation states is not well prepared for the manifest mobility of this century. Switzerland‘s population is a fifth immigrant. The populist radical right runs against Islam all across the continent, and the bulk of immigrants to the EU are Muslim. It is no surprise, even if appalling, that populist islamophobia is doing so well.
Second, it suggests that the EU itself is better adapted to its politics than to its potential needs. Europeans do not, as a rule, trust other countries as much as they trust their own citizens (some European citizenries, especially in Southern Europe have consistently rated the EU above their own governments, but EU politics since 2010 have largely eliminated that advantage). European elites and voters alike are more comfortable sharing rules than sharing resources.
The other is institutions.
We actually know the best basic formula for democratic states that deliver. It’s parliamentarianism with proportional representation.
Parliamentarianism fuses the executive with the legislature so there is no division. In a parliamentary US, Nancy Pelosi would be the actual head of government and Trump would be a largely ornamental figure like a British or Spanish Royal or the presidents of Austria and Germany. (He might quite like that―I am not sure he enjoys being held responsible for COVID-19).
Parliamentarianism means that responsibility is clear, parties mean something, and politicians share incentives to argue about big packages of attractive things. The UK National Health Service, for example, was the decisive action of a unified Labour government in the UK.
Proportional representation means that parties get seats in proportion to their votes. Our two big parties are an artifact of our electoral rules―if you vote Green all you are doing is subtracting a vote from a party that might win, called Democrats. Ask Al Gore. If you want more parties, you need to change electoral rules.
If you put the two things together, you get a responsive government that can make substantial policies and take real risks. If you get one without the other, it’s less attractive. The UK’s parliamentary system is combined with an electoral system like ours, and the result is that a minority of voters have enabled strong governments which drove the country off a cliff.
But together they enable:
– Real policies.
– Real debate. It is easy to imagine four or five parties in the US with Proportional Representation, debates, and elites who will speak with the authority of a party.
I hasten to add, by the way, that this means temper your expectations of the EU. It has moved towards a model that looks a bit more parliamentary, but it shares many of the defects of the US model.
So how do we come to think differently, and get well as a society? The political process is inevitably there, and the incentives of politics matter a lot. Proportional representation, campaign finance, and the rest are public health policies.
There are many things I haven’t mentioned. Spain is not Portugal, let alone the EU the US. There is no ideal European country that Americans could try to imitate. But the politics of Europe show us the extent to which we can come to think differently while we do politics differently. People change their actions before they change their ideas, so making the policies for health will often trigger the thinking we need to go further. Healthy people participate more in politics―so improving the health of the less well-off enables them to support more policies that encourage health.
In conclusion, be aware of the people who don’t like to think the way Galea and other public health leaders think, focus on action as well as thinking, and always be aware of the incentives for politicians. It is tempting to ask for statesmanship and heroism, but there is a reason political scientists hate that phrase. It is better to work with incentives that work for ordinary jobbing politicians and their voters. It’s got an upside―over time you can make the radical obvious.
Scott Greer (@scottlgreer), a Professor of Health Management and Policy, Global Public Health, and Political Science at the University of Michigan, is an expert in the health policies of the EU and of several European nations. In this blog, he finds Galea’s argument clearly persuasive, but reflects on the gap between Galea’s aspirations and the reality of politics. To learn more about Professor Greer’s work on EU health policies, check out Everything you always wanted to know about European Union health policies but were afraid to ask and his ongoing research at the Health Management & Governance Lab at the University of Michigan.