Looking Overseas Gives Us Reasons to Be Thankful for Obamacare

U.S. Adults Are More Likely to Skip Care and Struggle with Medical Bills Than Adults in Peer Countries

This Thanksgiving, a lot of Americans will be giving thanks for Obamacare.

By the end of this month, HealthCare.gov will be able to handle 800,000 users per day, enough to enroll everyone who needs coverage by the end of the year. Meanwhile, the state-run exchanges are reporting “a November enrollment surge,” precisely as the Obama administration predicted. (Massachusetts also experienced a late enrollment surge when they adopted an individual mandate in 2006.) Everyday, we hear new stories about Americans who are saving thousands of dollars on their insurance costs, including House Speaker John Boehner, whose new Obamacare insurance will cost pennies on the dollar of his six-figure income.

And not a moment too soon. Earlier this month, the nonpartisan Commonwealth Fund published the results of their latest survey of eleven industrialized countries, including the United States, where they asked people about their experiences with the health care system in the past year. Their findings are a sad reminder of just how bad the status quo is — and why we demanded health reform in the first place.

Many Americans don’t go to the doctor when they’re sick because they can’t afford it. Many don’t go to the pharmacy or take their medicine. Add it all up, and 37 percent of Americans had some sort of “cost-related access problem” in the past year.

That kind of problem isn’t nearly as common in the Netherlands, where it only affects 22 percent of the population. Or France, where the number drops to 18 percent. Or Canada, where it’s 13 percent. Or the UK, where it’s 4 percent.

Fair enough, you might say. More people have more access, but they also have to wait in line longer, right? Not necessarily.

In fact, in most countries, the majority of the population could see a doctor within a day of their request. The United States placed second-to-last in this category. A quarter of our population had to wait six days or more — a little better than Canada, but far worse than Australia, France, Germany, the Netherlands, New Zealand, and the UK.

But that’s primary care. The United States is known for its specialists, where 76 percent of the population got an appointment in less than four weeks and only 6 percent had to wait two months or more. That’s a heck of a lot better than Australia, where only 51 percent got an appointment in less than four weeks and 18 percent had to wait two months or more. Or Canada, where the numbers are 39 percent and 29 percent, respectively.

But it’s about the same as the Netherlands, where the numbers are 75 percent and 3 percent. And the UK, where they’re 80 percent and 7 percent. And even Germany isn’t far behind, at 72 percent and 10 percent.

So it’s a mixed bag, but we’re certainly not in the lead.

In most countries, it’s a lot easier to get after-hours care than in the United States. Only 35 percent of American doctors have an arrangement to take care of their patients after the office is closed — by far the lowest percentage of all the countries surveyed. In Canada, it’s 46 percent. In France, it’s 76 percent. In Germany, the Netherlands, and the UK, it’s 90 percent or higher.

And the doctors have a lot more problems in the United States, where the paperwork piles up. One in three — 32 percent — reported significant paperwork or payment problems in 2013, compared to 23 percent in France, 17 percent in Germany, 15 percent in Canada, and 4 percent in the UK.

No wonder everyone else is happier with their health care than we are.

Only 25 percent of Americans think their health system works well. In the other countries, that approval rating ranges from 40 percent in France to 63 percent in the UK.

Whereas 27 percent of Americans think the health system needs to be completely rebuilt, that disapproval rating ranges from 12 percent in Norway to 4 percent in the UK.

That’s a lot of numbers, but they all tell the same story: The United States has the most complicated, most expensive, and most frustrating health care system in the industrialized world — and none of that is due to Obamacare, most of which took effect after the survey.

In fact, Obamacare is moving our system closer to our international counterparts. Based on these numbers, I’d say that’s definitely something to be thankful for.

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An abbreviated version of this op-ed was published in Friday’s South Florida Sun-Sentinel. This version was published in the Huffington Post.

The Myth of the Lazy Poor

On his recent trip to Israel, Mitt Romney attributed the poverty of the Palestinians to their “culture,” citing the work of economic historians David Landes and Jared Diamond. Middle East experts have rightly denounced Romney’s remarks as racist, ignorant, and untrue. Jared Diamond himself took to the op-ed page of the New York Times to set the record straight: “That is so different from what my book actually says that I have to doubt whether Mr. Romney read it.”

This kind of claim is common among our political elite. We regularly hear accusations against the “culture of poverty” on our own shores, ranging from the famous Moynihan Report in 1965 to the so-called “welfare queen” that Ronald Reagan created to get elected. The inverse is equally common. Peruse your local bookstore, and you’re bound to find half a dozen authors attributing the rapid growth of China (or, a few years ago, Japan) to their unique Eastern brand of capitalism.

But these stereotypes — good and bad — are hardly ever true, as proven by this excerpt from Cambridge development economist Ha-Joon Chang’s eye-opening book Bad Samaritans: The Myth of Free Trade and the Secret History of Capitalism:*

Having toured lots of factories in a developing country, an Australian management consultant told the government officials who had invited him: “My impression as to your cheap labor was soon disillusioned when I saw your people at work. No doubt they are lowly paid, but the return is equally so; to see your men at work made me feel that you are a very satisfied easy-going race who reckon time is no object. When I spoke to some managers they informed me that it was impossible to change the habits of national heritage.”

This Australian consultant was understandably worried that the workers of the country he was visiting did not have the right work eithic. In fact, he was being quite polite. He could have been blunt and just called them lazy. No wonder the country was poor — not dirt poor, but with an income level that was less than a quarter of Australia’s.

The country in question…was Japan in 1915. It doesn’t feel quite right that someone from Australia (a nation known today for its ability to have a good time) could call the Japanese lazy. But this is how most westerners saw Japan a century ago.

In his 1903 book, Evolution of the Japanese, the American missionary Sidney Gulick observed that many Japanese “give an impression…of being lazy and utterly indifferent to the passage of time.” Gulick was no casual observer. He lived in Japan for 25 years (1888-1913), fully mastered the Japanese language, and taught in Japanese university. After his return to the US, he was known for his campaign for racial equality on behalf of Asian Americans. Nevertheless, he saw ample confirmation of the cultural stereotype of the Japanese as an “easy-going” and “emotional” people who possessed qualities like “lightness of heart, freedom from all anxiety for the future, living chiefly for the present.” The similarity between this observation and that of today’s Africa, in this case by an African himself — Daniel Etounga-Manguelle, a Cameroonian engineer and writer — is striking: “The African, anchored in his ancestral culture, is so convinced that the past can only repeat itself that he worries only superficially about the future. However, without a dynamic perception of the future, there is no planning, no future, no scenario building; in other words, no policy to affect the course of events.”

After her tour of Asia in 1911-1912, Beatrice Webb, the famous leader of British Fabian socialism, described the Japanese as having “objectionable notions of leisure and a quite intolerable personal independence.” She said that, in Japan, “there is evidently no desire to teach people to think.” She was even more scathing about my ancestors. She described the Koreans as “12 millions of dirty, degraded, lazy, and religionless savages who slouch about in dirty white garments of the most inept kind and who live in filthy mudhuts.”

This was not just a western prejudice against eastern peoples. The British used to say similar things about the Germans. Before their economic take-off in the mid-19th century, the Germans were typically described by the British as “a dull and heavy people.” “Indolence” was a word that was frequently associated with the Germanic nature. Mary Shelley, the author of Frankenstein, wrote in exasperation after a particularly frustrating altercation with her German coach-driver: “the Germans never hurry.” It wasn’t just the British. A French manufacturer who employed German workers complained that they “work as and when they please.”

The British also considered the Germans to be slow-witted. According to John Russell, a travel writer of the 1820s, the Germans were a “plodding, easily contented people…endowed neither with great acuteness of perception nor quickness of feeling.” In particular, according to Russell, they were not open to new ideas; “it is long before [a German] can be brought to comprehend the bearings of what is new to him, and it is difficult to rouse him to ardor in its pursuit.” No wonder that they were “not distinguished by enterprise or activity,” as another mid-19th century British traveler remarked.

Germans were also deemed to be too individualistic and unable to cooperate with each other. Once again, compare this with a comment by the African observer that I quoted above: “African societies are like a football team in which, as a result of personal rivalries and a lack of team spirit, one player will not pass the ball to another out of fear that the latter might score a goal.”

British travelers in the early 19th century also found the Germans dishonest — “the tradesman and the shopkeeper take advantage of you wherever they can, and to the smallest imaginable amount rather than not take advantage of you at all… This knavery is universal,” observed Sir Arthur Brooke Faulkner, a physician serving in the British army.

Ever since the East Asian economic “miracle,” it has become very popular to argue that it was Confucian culture that was responsible, at least partly, for the region’s economic successes. Confucian culture, it was pointed out, emphasizes hard work, education, frugality, cooperation, and obedience to authority.

But, before the East Asian economic “miracle,” people used to blame Confucianism for the region’s underdevelopment. For Confucianism does have a lot of aspects that are inimical to economic development.

Confucianism discourages people from taking up professions like business and engineering that are necessary for economic development. At least in theory, individual peasants could gain entry into the ruling class if they passed the competitive civil service examination (and they occasionally did). Artisans and merchants, however, were not even allowed to sit for the examination.

To make matters worse, the civil service examination only tested people for their scholastic knowledge of the Confucian classics, which made the ruling class scornful of practical knowledge. Scholar-bureaucrats were supposed to live in “clean poverty”…and thus they actively looked down upon money-making.

Confucianism also discourages creativity and entrepreneurship. It has a rigid social hierarchy and, as I have noted, prevents certain segments of society (artisans, merchants) from moving upwards. This rigid hierarchy is sustained by an emphasis on loyalty to superiors and deference to authority, which breeds conformism and stifles creativity.

We can perform the same exercise with any culture’s belief system. Take the case of Islam.

Muslim culture is today considered by many to hold back economic development.

Alternatively, we could say that, unlike many other cultures, Muslim culture does not have a fixed social hierarchy… Therefore, people who work hard and creatively are rewarded. Moreover, unlike in the Confucian hierarchy, there is no disdain for industrial or business activities. Muhammad, the Prophet, was a merchant himself. And being a merchant’s religion, Islam has a highly developed sense of contracts… This orientation encourages the rule of law and justice — Muslim countries had trained judges hundreds of years before Christian countries. There is also an emphasis on rational thinking and learning — the Prophet notably said that “the ink of the scholar is more sacred than the blood of the martyr.” This is one of the reasons why the Arab world once led the world in mathematics, science, and medicine.

All this is not to deny that how people behave makes a difference to economic development. But the point is that people’s behavior is not determined by culture.

People from rich countries routinely believe that poor countries are poor because their people are lazy. But many people in poor countries actually work long hours in backbreaking conditions. What makes them appear lazy is often their lack of an “industrial” sense of time. When you work with basic tools or simple machinery, you don’t have to keep time strictly. If you are working in an automated factory, it’s essential. People from rich countries often interpret this difference in sense of time as laziness.

It is true that there are a lot more people “lazing around” in poor countries. But is it because those people culturally prefer lounging about to working hard? Usually not. It is mainly because poor countries have a lot of people who are unemployed or underemployed (i.e., people may have jobs but do not have enough work to occupy them fully). This is the result of economic conditions rather than culture. The fact that immigrants from poor countries with “lazy” cultures work much harder than the locals when they more to rich countries proves the point.

As for the once much-vaunted “dishonesty” of the Germans in the past, when a country is poor, people often resort to unethical, or even illegal, means to make a living. Poverty also means weak law enforcement, which lets people get away with illegal behavior, and makes breaking the law more “culturally” acceptable.

“Living for today” or being “easy-going” — words that many people associate with Africa and Latin America nowadays — are also the consequences of economic conditions. In a slowly changing economy, there is not much need to plan for the future; people plan for the future only when they anticipate new opportunities (e.g., new careers) or unexpected shocks (e.g., a sudden inflow of new imports). Moreover, poor economies offer few devices with which people can plan for the future (e.g., credit, insurance, contracts).

In other words, culture changes with economic development. It would be far more accurate to say that countries become “hardworking” and “disciplined” (and acquire other “good” cultural traits) because of economic development, rather than the other way around.

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*This excerpt has been lightly edited to accommodate American spellings and this blog’s punctuation style.