The US is not France

Henry Farrell argues that the worries that national healthcare will turn the United States into France are overblown:

. . . the claim that America is going to become 'France' 2 if we're not very careful doesn't really hold up. If this kind of change were likely, then the US would no longer have a France to become like.

This may require some explaining.There is a thriving literature in political economy on the forces driving convergence and divergence in the world economy. Much of this work sought to discover whether or not countries were converging in the 1990s and the early years of this decade on a single Anglo-Saxon model, given international economic pressures and the success of the US. France was a case in point. Francois Mitterand's efforts to revive and strengthen French social protections when he came to power in the early 1980s led to near economic collapse, and the momentous decision by the French socialists to accept the capitalist straitjacket of liberalized international markets. The succeeding two decades saw the steady erosion of the more social democratic (and socially protective Christian Democratic aspects) of the political economy in France, Germany and other European countries, the withdrawal of the state from ownership of large chunks of the economy and the spread of various more free-market oriented institutions and social practices.

France and other countries faced a profound crisis - a crisis which in some ways was even more profound than that facing the US today. They have faced continuing pressures to 'reform' institutions in a more market-liberal direction over the succeeding two decades. And they have indeed changed in some very important ways. But France did not converge onto the US model despite these pressures. If it had, presumably Crook's and Cohen's criticisms would be rather different than the ones that they are making Instead, it has reformed along a divergent trajectory to the US, with continued heavy state involvement in the economy but of a different variety than previously.

This reinforces a near-universal finding of the relevant literature in political economy as I read it. While there is some diffusion of policy lessons across states, it tends to have limited consequences. Different countries respond to common shocks in very different ways, because of their existing institutional structures. National economic trajectories are quite robust. Even in major crises, advanced capitalist countries tend to tinker around the edges of their institutional systems rather than opt for wholesale reform, let alone converging on a perceived 'better national model' elsewhere.

And this is what is happening in the US. The Obama proposals are not particularly radical departures from existing practice in the US. They are certainly nothing like traditional European social democracy. Even David Brooks effectively acknowledges this, when he says that they are potentially problematic in combination rather than individually. They aren't going to set the US on a different national trajectory, let alone make it 'French' or 'European.' Some of us might like to see this happen, but it isn't going to, even given the ideological trauma that the US is undergoing. And arguing that American individualism is likely to wilt if exposed to nasty foreign influences smacks more of a kind of capitalist-road José Bové-ism than any serious kind of intellectual analysis.

I think he's right:  the United States is not going to become France, or Sweden, or Britain.  But I also think that argument cuts both ways.  When conservatives object to national healthcare, liberals tend to put France front and center.  France only spends 11% of GDP on healthcare, patient satisfaction is high, etc. 

But, as Henry so ably points out, the United States is not France.  We are not going to get the French health care system, because whatever we build will be layered on top of our own institutions.  Unless you can meaningfully reform Medicare to do things like control physician salaries and ration care, there is no reason to expect that you will be able to do this under a wholly national system.  Medicare cost growth isn't significantly better controlled than inflation in the private system.  All of the problems with the Medicare reimbursement structure--and the problems are large--are a result of a historical legacy that has hardened into a nearly immovable system.  You can add to it, but no one has so far had much success with the substantial changes that would be necessary to make the system function better.  It's like trying to maneuver an aircraft carrier in your bathtub.

If we get national healthcare, we will not get anything like the neat little systems proposed by academics who can assume away many of the political problems.  I am aware that proponents would rejoinder, that yes, they know it won't be perfect, but . . . But I'm not making the perfect the enemy of the good.  A national healthcare system in the United States will not merely be something sadly less than ideal--it will be nothing like most of the internally coherent proposals.  It will be something jury rigged out of Medicare, S-Chip and insurance mandates, ugly and very expensive.

No, we won't be like France.  In this narrow instance, it might be better if we were. Instead, we'll be like America, where public institutions are costly, inefficient and generally not very well respected.