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.
