Wednesday, October 17, 2012
Social scientists, and especially economists, are disdainful of “anecdotal evidence,” generally preferring “wide-ranging studies,” statistical tables, graphs, charts, and other quantitative evidence designed to tame the eccentric and the exceptional. This first came to my explicit attention when Ronald Reagan was widely criticized for “anecdotalism” for talking about “welfare queens with Cadillacs.” Yet however exceptional a vivid personal experience may be, its vivacity will likely outstrip that of a statistical essay in a learned journal.
A few years ago I stepped into a convenience store near Jamesburg, in semi-rural New Jersey, and found myself in a short queue behind a foul-mouthed teen-aged girl who was trying to buy lottery tickets with food stamps. The store clerk would not allow the transaction, of course, but the episode left me with a vivid impression. I have not constructed upon it a generalized theory of “food stamp culture,” but I think of it whenever I hear “food stamps.”
I need to feint at a defense of anecdotal evidence in order to engage briefly with the dismal subject of national health insurance. I am goaded to do so by back-to-back op-ed essays by two influential columnists in the New York Times. On one day Nick Kristof published a piece called “A Possibly Fatal Mistake,” which was followed the next by Paul Krugman’s “Death by Ideology”. One of Kristof’s implicit points, which becomes explicit in Krugman’s essay, is that those who oppose Obama care (as, for instance, the Republican presidential candidate does) are wishing death upon a sizeable portion of the American population.
I suppose it would be futile at this dreadful stage of this dreadful presidential campaign to hope for sweet reasonableness or rhetorical moderation from any quarter. I suppose that by this point Mr. Romney has become as inured to being called a murderer by Democrats as the President has become inured to being called a socialist by Republicans.
Kristof’s piece is not merely anecdotal; it is a single extended anecdote, some of it in the very words of its subject, the columnist’s one-time roommate at Harvard (class of ’82). One doesn’t usually categorize Harvard graduates among the wretched of the earth; but this man has fallen victim to a scourge that is no respecter of persons or educational backgrounds, prostate cancer, which had already reached a very serious stage by the time of first diagnosis. He failed to discover the cancer at an early stage, despite tell-tale symptoms, because he consciously eschewed medical examination. He had given up his job-provided health insurance when he quit his job in a “midlife crisis”, did not want to buy private insurance (“very expensive”), and declined to pay out-of-pocket. You would have to read the column to adjudicate for yourself whether and where fault is to be assigned. No reader of the column, least of all your bloguiste, will fail to sympathize with Kristof’s friend. Many, I think, will doubt that the anecdote is a definitive demonstration of the wisdom of Obamacare.
A serious intellectual error flaws a good deal of the discussion on this topic. Many supporters of Obamacare write of health insurance as a terminal good in and of itself. But health insurance is a means, not an end. A health insurance card never made a single diagnosis, wrote out a single prescription, or administered a single electro-cardiogram. Those things are done by medical professionals. This is not a distinction without a difference or an exercise in casuistry. The aim of a policy of “affordable” health care is to allow people to get needed or prudent medical attention. The Affordable Health Care Act meets this standard only if your definition of “affordable” is “paid for by somebody else”.
I return to a personal anecdote. I enjoy the best socialized medicine on earth—namely, American Medicare. The last time I was in an emergency room I actually had to talk the doctor out of ordering a cat scan of my head to rule out some exotic one per cent possibility. But for good chunks of the last several years I was living in Paris, effectively on my own without medical insurance. I hadn’t put myself in that situation without some forethought. Nonetheless I was most anxious when I suddenly developed an obvious heart problem—which turned out to be atrial fibrillation. I might on my own have made the stupid decision to try to wait until I got home to check it out, but my daughter would not allow it. She had me in the office of an expert academic cardiologist within twenty-four hours.
There were many amazing aspects of my experience as a fee-paying private patient in France. It overturned numerous false pre-conceptions. I think I have written about the experience elsewhere, though I cannot at the moment find where. This was not a personally pleasant episode, but it had its instructive elements. So far as I can tell the care I received was excellent. It was certainly prompt and thorough. It involved altogether four consultations with two cardiologists, one of whom administered an echo-cardiogram. (Both men, incidentally, had happy memories of time spent in training at Mass General in Boston.) But above all it was affordable--not free, not even cheap, but affordable. There is not a lot that is cheap in Paris, certainly not housing, food, or clothing. A few years ago some higher-end Parisians were flying to New York for a weekend’s shopping. They said the savings on the consumer goods paid for the airfare. They would never fly there for a doctor’s appointment. But the cost for my entire cardiac drama, including prescribed medicines and continuing blood tests, was less than a month’s rent, and not all that much more than a blowout family meal at a fancy Parisian restaurant—not that I have ever actually had such a thing.
Rainy days are unlikely to cease merely because we have quit saving for them. That a person of moderate means could absorb the costs of a medical emergency without bankruptcy is of course no argument that everyone else could. But what my own anecdotal experience suggests to me is that Americans need to talk about the costs of our medical care as well as our undoubted need for it.