Victory for a Compromise: Obama Care

After the American Century

It costs four times more more money to have a baby in the United States than it does in Germany or in Canada. 

Seen from outside the United States, the Supreme Court decision, which found the new American health system to be constitutional, is only a partial victory. For the law is a compromise that keeps competition and profit-making at the center of American health care. This means that the US will continue to spend billions of dollars supporting a vast health insurance industry and a huge number of tort lawyers. All those white-collar workers and all those buildings could be put to much better uses than making money out of human suffering and human need.

Doubtless there are some areas in which competition can improve medical care, but I doubt these benefits are worth all costs associated with a medical industry that is organized for profit, with all the legal fees, court battles over malpractice, and endless form-filling and record-keeping involved. 

It is much better, surely, to have a system like that in Scandinavia where all patient costs are automatically covered through taxation, and where hospitals compete to provide the best care, researchers compete for funds, and doctor's compete to be the best in their field.  This costs little more than half as much as the US system. Yet Scandinavians compare quite well with Americans when it comes to life expectancy, child morality rates, and other measures of well-being.

According to the 2012 Statistical Abstract of the United States. health expenditures rose as a percentage of American gross national product from 9% in 1990 to 16% in 2008. They do not give statistics for after that year, but surely no one is going to argue that medical costs have dropped since then. By comparison, in Denmark medical costs were 8.9% of GDP in 1990, almost exactly the same as in the US then, but since have only risen to 9.7% of GDP.  In Germany the corresponding figures are a rise for 8.4 to 10.5%, in the Netherlands from 7.4 to 9.9%, in Japan 6.5 to 8.1%.

In short, by 2008 Americans were spending one dollar in every six for medical care, while the Danes were only spending one out of every ten kroner, and Japanese were spending only one yen of every twelve.

How about the rest of the English-speaking world? In 2008 New Zealand used 9.9% of its GDP on health care, compared to 8.6% in Australia, 10.4% in Canada and 8.7% in Britain. In short, no nation on earth except the United States uses anywhere near 16% of its GDP on health care. The closest "competitor" was France, at 11.2%.

Americans have made progress with their new health system, which requires all citizens to carry medical insurance and makes certain that they can buy affordable coverage. But it is still an expensive and inefficient system compared to what already exists in the rest of the developed world. 

Health costs for the typical American family doubled from 2011 to 2011. President Obama was right to see that such galloping growth is unsustainable, and the new system he has put into place should stop costs from rising so fast. But Americans need to develop a medical system that can reduce costs to levels common in other advanced industrial nations.Even with Obamacare, the US system is behind the competition.

The Banality of Evil: What Americans now seem to accept

After the American Century

Fifty years ago Hannah Arendt compellingly argued that great evils are commonly not the work of sociopaths or deranged persons but rather are the work of ordinary persons. They have gradually accepted as "normal" certain actions and social conditions that their ideology tells them are inevitable or unavoidable. Arendt was writing about the kinds of people who carried out the Holocaust, but her insight applies to lesser evils as well.

The United States is hardly Hitler's Germany, but it is in danger of accepting some things as "the ways things are done" or as "normal procedures" that I find unacceptable. These  include.  

(1) Increasingly, Americans are using drone aircraft to assassinate people inside other countries, because they are alleged to be terrorists or because they have the bad luck to be in the vicinity when a drone flies in.  This does not seem fitting behavior for a nation that believes in the rule of law.

Drone aircraft

(2) Beginning after 9/11 Americans have openly taken up the practice of imprisoning people without access to a lawyer and without even being charged. The practice is limited to non-Americans who are outside the country, but once established might become US practice as well. Such imprisonment is against the principles of English common law and it would have been anathema to the Founding Fathers of the country.

(3) Another issue is whether to deny medical care and education to children who arrived in the United States as infants, through illegal immigration. These young people recall no other country as home, and they have grown up as Americans, whatever their legal status. 

(4) Rapidly rising costs of university education have outpaced inflation. These high costs have created a gulf between an ordinary American's aspirations and his or her real possibilities. This makes the United States a less egalitarian society, and also a less competitive one, because some talent will remain undeveloped because the tuition was too high. (By way of contrast, university education remains completely free in Denmark and Norway.)

(5) The United States was founded as a society based on egalitarianism. But today it is fast becoming a society of social classes based on huge differences in wealth. The gap between the average wage earner and the wealthiest 1% has grown enormously since the end of the Cold War, and threatens to become a permanent condition of inequality. This is a question of whether to tax wealthy people more, and also a question of whether to raise the minimum wage.

(6) It has become "normal" for American corporations to move jobs overseas where they pay workers poorly and manufacture with few pollution controls. Extremely successful clothing and electronics companies behave abroad in ways that would be judged unethical or illegal inside the United States. Not only are American jobs lost, but foreign workers are exploited to make every new Ipad and every pair of Nike shoes. Is this just the way things are now? No more discussion?

More issues could be added to this list, but the point would remain the same. These practices have become the new normal. In 2012 Americans seem to accept as ordinary practices, in certain circumstances, murder, imprisonment without trial, denial of medical care to children, loss of educational opportunity, the increasing rigidity of the social class system, and outright exploitation of workers abroad.  These things would not have been acceptable to most Americans a few generations ago, but now it seems that the country is getting used to them. But these practices are not normal or inevitable, they are the result of policies that are relatively recent and that are not common in other democracies.

Election 2012: Causes of American Political Polarization

After the American Century

Jeb Bush has now said what every thoughtful commentator has been saying for some time: the Republican Party has moved far to the Right. Bush is hardly a radical, but he noted that even Ronald Reagan would not fit well into the current climate of the GOP. It has moved so far toward right-wing positions that his father also feels marginalized. The GOP has gone through an internal transformation that has pushed him toward the margins.

This movement toward the Right and the polarization of the two parties will be one of the great subjects for future historians. In a simple-minded sense we can attribute it to the end of the Cold War, which freed Americans to be less cohesive, since there was no longer a common external threat. But if we accept that as the catalyst for this change, it still does not make clear what forces are at work inside the country.

The change can be compared to the slippage along a geological fault, which periodically leads to an earthquake, like the 1994 election with its proclaimed "Contract." To resist this change, the Democrats had to trim their sails and move toward the center. Clinton took some of his program from moderate Republicans, cutting back on welfare, for example, and embracing the NAFTA treaty against the wishes of the labor movement.  But the geological pressures kept building up, and under George W. Bush the country split more completely than before. The bi-partisanship that once was a hallmark of Washington, in contrast to some dysfunctional democracies elsewhere, has largely broken down. 

However, this is only a history of the political surface, not a sociology or history of the forces that have led to this seismic shift. Some of the reasons can be listed:

(1) The increased inequality between social classes. Between c. 1940 and 1972 equality was growing in the United States, as measured in real wages. Since then, the society has increasingly split, with the top 10% benefiting disproportionally, while the income of most of the population has tood still or fallen. 

(2) Greater political focus on non-economic issues, such as abortion, gay marriage, birth control, teaching evolution in the school system, and much else. These issues have been used by the Republicans to mobilize a considerable base. 

(3) The development of large church organizations, often media-based, that offer not only religious services but a community for the working- and middle-class. These mega-churches are typically controlled by a charismatic minister who is not inside a hierarchy like that of the Catholic Church or older, "classical" Protestant denominations. Politically, such churches are seldom on the left. There seem to be few heirs today of the social gospel movement that thrived in 1900, or of the Civil Rights Movement of the 1950s and early 1960s, when in part for religious reasons, millions of white Americans supported social reform.

(4) The persistence of traditional American values, notably individualism and self-reliance, along with resistance to anything that can be labelled "socialist" or "communist." 

(5) The rising cost of medical care and education has increased the difficulties of ordinary Americans. It has become a struggle to educate children and care for the severely ill. One might expect that the Obama medical program would be wildly popular, but it is often seen, instead, through the lens of the traditional values just mentioned.

(6) The persistence of racial and ethnic tensions, which are largely unspoken but a very real part of the shift to the right and the Tea Party demand for  tighter immigration controls.

(7) The transformation of public discussion, changed through the Internet, including Twitter and the blogosphere, which makes it possible, even likely, that people get only the news and opinion that they want to hear, rather than a spectrum of issues and ideas in a newspaper that appeals to a range of readers. Rather than being challenged to hear diverse opinions, the new social media can create on-line communities that share prejudice, rumor, and half-truthes.  "Narrow casting" is becoming the norm, in contrast to the broadcasting, which by its nature was conducive to forming a broader political base that adopted moderate positions. 

(8) The radical increase in campaign spending, along with the sharp rise in the number of negative advertisements. Rather than developing a program, many candidates can get elected by tearing down their opponent. This is not a new idea, of course, but it is more common, and it fosters polarization.

This list is not complete. A historian in 30 years time will be able to look back and identify more social and economic forces that are driving this polarization. It is not only a change inside the Republican Party, but inside the Democrats as well. President Obama understands this and has tried to position himself in the more conservative portion of his party, much to the frustration of many 2008 supporters.  He is a pragmatist, a bit to the right side of the Democratic Party.  On the right side of the Republicans, however, are ideologically driven leaders who reject pragmatism and compromise.

Will coming elections increase tensions and drive the parties further apart? Can the country begin to heal, or will it split further? 

What Does the Wisconsin Recall Vote Mean?

After the American Century

The Democrats failed to recall the sitting governor in Wisconsin, but Obama remains more popular than Romney. What can the candidates learn from these local results?

Which Underdog Will Lose the Election?

After the American Century

There may be an advantage to being a (slight) underdog in the American presidential election.  Both candidates seem to realize this. Supporters are more motivated if the victory seems achievable but not at all certain. The polls have see-sawed up and down, with Obama generally slightly ahead of Romney, but not always.

Obama, as a sitting president, would normally not have much trouble with reelection. In recent memory Johnson, Nixon, Reagan, Clinton, and Bush II all were re-elected. But the US economy apparently is slowing down, if the new job figures are accurate, and the only presidents not to be reelected since 1916 (Hoover, Carter and Bush 1) presided over weak economies. A weak economy always hurts an incumbent. Worse still, Obama's chances might be torpedoed by economic forces completely beyond his control, notably the Greek election later this month, which seems likely to cast Europe into economic chaos, or at least uncertainty. Moreover, the Republicans have raised more campaign money than Obama, which puts the president at a disadvantage in another economic sense. 

Romney is an underdog in quite a different way. As a Mormon he can easily seem to represent a little-understood religion. In the abstract, if you ask Americans are they ready to vote for a Mormon for president, the support is weaker than for a generic woman candidate. Romney is also an underdog in another statistical sense, in that the Republicans are the smaller party, in terms of registration. But perhaps his greatest liability, with many voters, is that he is tightly linked to the financial sector. The public generally distrusts, even hates, the banks. Romney was a key player at BAIN, and this is surely not the ideal qualification for office in the wake of the misdeeds on Wall Street that led up to the meltdown of 2008.

But perhaps the real underdog is the American pubic. In 2012 Republicans and Democrats together will spend $2 billion on the campaign, a rather obscene new record. Will American voters be, in effect, sold to the highest bidder? Will clever advertising replace serious debate? Will the election be won on spin rather than substance? The poor voter will be bombarded with half-truths and misinformation, much of it emanating not from the candidates themselves but from their supporters.  If on election day the big questions on voters minds are such things as how it felt to be Romney's dog on top of his car or whether Obama has a valid birth certificate, then the public will certainly have lost the election.

Are Europe and Greek Debt like the Titanic and the Iceberg?

After the American Century

Imagine that Europe is a large ocean liner called the Titanic, and that it is sailing straight toward a massive iceberg that has appeared in the Mediterranean off the coast of Greece. The original idea  for the ship was to create watertight compartments (national economies) below deck, so that if one or more of them filled with water (debt), the others would not also fill up. But this original plan was not fully carried out in the actual construction. The ship turns out not to be unsinkable because its compartments are not sufficiently strong, watertight, or numerous.

If I could go back in time and rebuild the Titanic, I would carry out the original design more completely. Greek debt is the iceberg smashing into the Euro, and I would rather each national economy had largely to stand on its own. Unfortunately, the European "reform" that seems to be favored by most leaders today is to remove most of the interior barriers and thicken the outside hull of the ship as a whole. The idea is that superior leadership and regulation from the center will avoid most of the fiscal icebergs of the future, and that when they do come the improved hull with be strong enough. I would rather not make well-functioning economies hostage to the Italians, the Greeks, the Spanish, and the Portuguese, or for that matter to any country that in the future might get itself into financial trouble.

What can Europe learn from this fiasco? I suggest that it ought to learn to keep the national economies more separate, rather than the widespread idea that what Europe needs is more integration. Better, surely, (1) to prevent banks from loaning more than 4% of their total worth to a single country, and (2) to limit how much money any nation can borrow abroad, making it finance a minimum 75% of its own national debt. If its own citizens will not buy most of the debt, why should anyone else?

More than two years ago I argued that Greece should not be bailed out. I wrote then, "Greece cannot pay its bills, even in the short run. With a national debt that is more than 110% of its gross national product, and a deficit of more than 10% for this year, Greece's debt will only get worse unless and until it enacts real reforms. So far it has failed to do enough, and the deficit will only get worse."

Most of what I wrote then is sadly still accurate now, except that the rest of Europe and the IMF have been pumping money into Greece while insisting on draconian reforms. But it has not worked. The choices then as now are either Greece leaves the common currency and goes back to its traditional overspending (with periodic drachma devaluation) or it really puts its house in order. Sadly, the second task is beyond its political capacity, as its recent, failed election process demonstrates.

As the crisis has been prolonged, money has been fleeing the country for safe havens before the collapse which seems to draw slowly but inexorably closer. It is difficult to know precisely how much money has been transferred or carried personally away from Greece, but it is more than €1 billion. This money could have helped keep the economy going. It is like taking blood from a dying man. Adding further to the misery, tourists are wary of booking trips to Greece, because it may descend into financial and political chaos. Why go there when other places are far more stable?

The only bright spot here is that the rest of Europe has had 27 months to prepare itself, by putting some firewalls in place. Whether these are good enough is not clear.

Had the Greeks been hit with a natural disaster like an earthquake, they would deserve sympathy and charity. But for years the Greek insisted on spending more than they could afford. They gave massive pay increases and early retirement to state employees that were not funded by taxation. Tax evasion was massive. There is no reason for the other European states to give or to loan them any more money. Giving them another handout will only delay for a short time the day of reckoning.

Education Provides the Infrastructure of Tomorrow

After the American Century              

For decades, the United States had a Department of Health, Education, and Welfare, and while these are no longer joined administratively, politicians all too often seem to think that these three things belong together. They do not. 

Education is part of the fundamental infrastructure a nation needs for the economy to work. Nineteenth-century manufacturers understood this, and supported compulsory education beyond primary school. They did so because numeracy and literary are essential for an industrial economy. And when the US Congress created the Homestead Act of 1862, which sold land very cheaply to settlers willing to take a chance and go West, they also passed a law that gave some of the proceeds from selling that land for the purpose of creating universities. Today, some of these land-grant institutions are among the best in the world. These nineteenth century politicians understood that to develop the economy, the citizens had to be educated. 

In both the United States and Denmark recent studies have underlined the centrality of education and research to a strong economy. A US report warns that in the last decade the nation has not kept pace with others in science and technology education. A Danish study shows that people with higher educations rapidly pay so much in taxes that within just two years society has gotten back its investment in them - this in a society where there is no tuition and the state therefore knows with some precision just how much it costs to educate each student. Even humanities students, whom politicians often disparage as pursuing useless knowledge, turn out to repay the cost of their education after working for just two years, almost as quickly as the scientists and doctors, who, of course, cost more to train. 

Education is the heart of tomorrow's infrastructure. It has the power to transform people's lives, to assist people who otherwise might be helpless to make vital contributions. A blind person with a good education can work and contribute to society in many ways. I went to college with a blind man who now is a judge in the United States. Without an education, he would likely have been a lifelong recipient of welfare.

Welfare rescues people in need. Welfare may help a child to greater success later in life or help a struggling parent who later becomes self-sufficient again. But welfare is not, on the whole, an activity that can or should be justified because it is profitable. Education is another matter. A good educational system will make society more entrepreneurial, richer, more agile, more adaptable, or in short, more able to meet the challenges of the future. 

Unhappily, politicians keep forgetting this fact. The response to the world economic crisis of 2008-2009 in all too many places was to cut back on education. In 2010 California imposed severe cutbacks on its schools and universities, which already had had their spending slashed in earlier years. A state which was once a model for others, with a powerful educational sector driving economic growth, seems to have lost its way. In many schools 30% of the staff have been fired, libraries closed, and class sizes increased by 25 percent or more. At universities, required courses are not always available, and some students will not graduate on time because they literally cannot get into a course they need. And those who do get registered may not get a seat, as the classrooms often are not large enough to hold the expanded sections. 

The failure to fund education adequately is hurting the Californian economy both short- and long-term. When people do not graduate on time, they to not repay the cost of their education as quickly. And when fewer people get an education at all and more people get a compromised education, the economy will be hurt for the entire lifetime of that generation. For a state, this is not just stupid, but self-destructive. In Denmark, national and local authorities have slashed budgets, closed schools, and created a high unemployment rate among newly trained teachers. The actual number of teachers has declined by 8% in primary school, which is a sign of very real political stupidity. At universities, there is almost no hiring, and those retired are often not replaced. A generation is being thrown away, or rather being driven away.

For people with skills are mobile. A survey found that half of all Danish workers find the idea of taking their skills elsewhere in Europe attractive. In the United States, people have always been quick to pull up stakes and try their luck in another part of the country. In 2008 135,000 more people left California than moved in, a trend that is accelerating. Often those who leave are among the most talented, such as a student who gets a scholarship, or the newly graduated student. The young often vote with their feet. The old fashioned kind of infrastructure like roads and bridges stays put. But a world-class scientist can be lured away, and an unemployed PhD will not usually linger where no one wants her, and a newly trained teacher or nurse who cannot get a job may go abroad. Thousands od the best trained Greeks and Spaniards are leaving for work elsewhere, and quite possibly they will never come back.

If education is infrastructure, it is mobile infrastructure. A society that cuts education will lose not only the skills of (and the higher taxes that would have been paid by) those it never trained - it will also lose some of the best new people it has most recently trained. Imagine that one country invests millions in a new highly mobile bridge, but then decides not to use it. Instead, another country imports this mobile bridge without paying anything for it, puts it into use and immediately begins to profit from the tolls (income taxes), and from the improved efficiency in transport that the bridge provides. Education is that kind of infrastructure. Denmark and California (and many others) have built and abandoned the infrastructure of tomorrow.

Election 2012: Romney the Bully? Gay Marriage and the Election

After the American Century

The Gay Marriage issue has turned into the worst sort of public relations for Romney, who now comes across in his youth as a rich kid, who was an insensitive, intolerant Mormon bully. That was an unexpected bonus for the Democrats. How did this happen?

When President Obama announced yesterday that he supported gay marriage, he did not do so because there was pressure on him to do so. Nor did he say this because Joe Biden "inadvertently" said he supported gay marriage last week. Anyone who believes that is naive. Biden and then other prominent Democrats came out in favor of gay marriage as trial balloons, to see how the public would react. 

On an emotional issue of this kind, Obama does not just casually make a statement. We can be sure that his staff consulted carefully on this issue and laid out a strategy to make the most of it. The goal here is not to win the gay vote, which is likely Democratic anyway. The goal is to force Romney to make a hard choice. Either he can come out against gay marriage and alienate moderates or he can alienate the Republican right, which already distrusts him, by remaining silent on the issue or saying that gay marriage ought to be allowed. Romney wants desperately to move to the center and look moderate, in order to win over the Independent and moderate voters. Obama is forcing Romney to make a hard choice. He cannot afford to create a rift with the Republican right, but he also cannot afford to embrace them too closely if he wants to become president. 

What is fascinating in this case is not the specific issue but the way that the Democrats are using what has been a Republican issue and making it their own.Obama and his advisers evidently have decided that bringing up such issues can exacerbate the divisions in the Republican Party. At the same time, they surely have calculated the potential effect on voting in swing states before going ahead with this plan. Put another way, this announcement makes Obama stronger in New York and California, which he would win anyway, and weaker in Alabama and Mississippi, which he has little chance of winning. The key question is whether this strategy will help him to win the swing states, especially Florida, Virginia, Ohio, Indiana, New Hampshire, Colorado, New Mexico, and Nevada. 

Romney when in High School

Obama got an unexpected bonus from this strategy, when it came out that Romney, when in high school, was one of a group of bullies who persecuted one of their fellow students, This was in Michigan, and he was the son of the Governor, attending a private school. The student he attacked had long hair and was gay, though apparently not yet "out of the closet" at the time. Romney and his buddies chased him, caught him, held him down, and clipped his hair off. Apparently this bullying was directed more at the long hair and the presumably left-leaning principles that tended to go with it. This act reveals an intolerant, vigilante side of Romney that moderates will find unpalatable. Ganging up on people and persecuting them because they are different suggests an arrogance and insensitivity unacceptable to much of the public, though it could help Romney hang on to the KKK vote.

Danish and American Medical Systems, a Basic Comparison

After the American Century 

Americans often hear that the Obama medical plan is socialistic. It is not, as anyone living in France, Germany, England, Holland, or the Nordic countries knows. The fundamental difference can be stated quickly and easily. In Europe, taxes pay for medical care, and you do not need to buy insurance. All residents have a card that they show when visiting a hospital or doctor, and they do not pay anything for their treatment. Furthermore, Europeans live longer than Americans.

Americans have to pay for insurance to avoid paying medical bills. Even so most  policies have rather large "deductables." Often the pateint must pay the first $500 or $1000 or more before the coverage kicks in. There are situations where the insurance company refuses to pay, for whatever reason. And of course there are lots of forms to fill out.

Having experienced the Danish and the British systems first hand, I can say that one of the great things about them is that the patient does not have to fill out forms, save receipts, make copies, or anything like that. You show up, get cared for, and go home. The only administration fromteh patient's point of view  is a simple swipe of a card. That is a socialist system.

What Americans now have is not socialism, but a hybrid system. The health care is still often private, private insurance companies get their hands on a lot of the money that flows through the system, and patients still have to pay quite a bit, by European standards. The Americans have largely private delivery of service, mostly private insurance, and the whole thing costs almost twice as much per person as in Europe.  Europeans have largely public delivery of service and only supplemental private insurance, but not so many people have that. I do not have private insurance for example, and even if I did have such a policy it would not cover the really big operations, which are almost all done in the public hospitals, which alone have the facilities and the research-based expertise. 

Which system is better? In terms of cost, the Americans pay a great deal more, overall, and yet millions of people have not had coverage until recently, and all must buy health insurance.  In the Nordic countries, everyone is covered and the total cost per capita is much lower. In Denmark, Sweden, Germany and France the annual costs (2008) were in each case close to about $3750 per capita. In the same year, according to the Kaiser Family Foundation, the US was spending twice as much, or $7500 per person. Partly this is because in Europe malpractice suits are relatively rare and pay infinitely less than in the US. Tthis in turn means that there is none of that expensive malpractice insurance. I do not mean to say Danish doctors never make mistakes, but the system automatically covers the costs of mistakes that can be rectified, so no one sues to get back extra medical costs, though they may sue for mistakes that cannot be corrected and fatal errors.

In terms of life expectancy, Danes live on average about four months longer than Americans (78.8 vs. 78.5 years). The results are even better in Germany (80.2), France (81.5), and England (80.2). Perhaps Americans should look more closely at Canada, where life expectancy is 81.5, fully three years longer than in the US. (All of these statistics come from the CIA World Factbook.) Putting this another way, because care is universal in Canada and Europe, the poor are generally healthier than in the US, where they often have to go to emergency rooms for treatment and do not have a regular doctor.

In both the UK and Denmark I know from personal experience that I can choose my own doctor, and I also have the right to change doctors if I want a different one. 

I am not going to say that the Nordic system is perfect, but it works well, and I have a bit of extra information, as my wife works in quality control at one of the Danish hospitals. 

For Americans who hate the Obama plan because it seems to rob them of their freedom, think of how free from worry you would be if medical care was a certainty, regardless of your wealth or whether you had a job or not. From Europe, the problem with the Obama plan is that it does not go far enough, leaving so much in private hands and building so much profit-making into the system. Think how much less expensive it would be without all those insurance company salaries, lawyer fees, accountants, court cases, malpractice payments, etc.

So, where do I stand on the Obama plan? It is probably the best that Americans can do at this time, as a compromise between the warring factions. I see nothing wrong with compelling all drivers to have a license to drive, and by the same token see no reason why people should not be compelled to have at least basic health insurance. Yet, if entire states want to opt out of the system, I think that ought to be allowed, with the understanding that then ALL the citizens of that state would have to go over to the local alternative programs or lack thereof. Opting out would create expensive complexity, I fear, but the federal system could and perhaps should allow that choice. Many companies have employees in several states, and administering such variety will be a headache. Moreover, some families have breadwinners in more than one state, creating further possible complexities,

The bottom line: the European system is preferable, supplying care to all citizens and eliminating individual economic ruin for those who have severe illness or who are victims of nasty accidents. No doubt the best care is often the most expensive care, which only wealthy people can afford, in exclusive private hospitals. But very good care is possible at much lower cost than Americans have been accustomed to paying.

Final thought. Japan's average medical costs per person are fully $1000 less than in Europe, but its citizens live longer than in any other large industrial country: 83.9 years. That is more than 5 years longer than in the US. There is no correlation between how much money a nation spends on health care and how long its citizens live.