And as for the Medicaid expansion -- it is 'good' in that it is a desirable end, but it is 'evil' in that it perpetuates a two (or more)-tier system of medical care in which the richer folks get all the benefits of the system and the poorer folks get shunted to a pared down version of the system, which eventually is pared down further and further as the cost of sustaining the 'rich' system becomes unsustainable to more and more of the 'rich' -- in a more simple form, this is the very debate that both Canada and to a lesser extent Britain have engaged in for many years.
In Canada, the decision of the population (except for what are regarded in Canada as right wing nuts) has been firmly on the side of maintaining a single system of care for everyone, regardless of the cost in terms of rationing by queue. In part this is because some parts of the Canadian system are amenable to influence by money --for instance, one can buy insurance that provides private room care, pharmaceuticals, dental and chiropractic and other items that are seen by most consumers as more directly affecting their well-being than the more occasional use of the intensive aspects of the medical system.
At least that has been my experience in talking to friends in Canada --we are there once a year for a couple of months and I get the impression that Canadians bitch about the quality of medical care far more than they do about access to medical care. In other words, just like the typical US citizen only more so.
The one difference that I have always found remarkable between the typical Canadian and the typical US citizen is this: there is a marked, almost a palpable, sense of anxiety about loss of employment or change of circumstances in the US citizen that is entirely lacking in Canadians. I attribute this anxiety entirely to the loss of health care that goes with loss of employment for the typical us citizen. I make this attribution because again and again I hear that directly from friends, from acquaintances, from polling and on the web.
For instance, I heard it just last night from a friend who is a high-end manager at JC Penney, wants to leave her job, has a husband with a PhD who has a part-time teaching job, and cannot leave her job because, in her words, 'we need the health insurance.' Of course this is no surprise to you Andy, nor to most of the people with whom we correspond, but I think the realization has not hit the gestalt of the country -- loss of health care access thru loss of health insurance is treated as a dirty secret. When one loses one's job, Americans typically take that with equanimity, knowing that there is always another job, even if it means less pay or harder work or less prestige. But when one loses one's job that has great health insurance, that is hardly ever mentioned, because loss of access to health care becomes something like a scarlet letter, a badge of unworthiness, a signifier that 'I am not worthy because I cannot find a job that pays for health insurance, I am only good enough to find a crappy job.'
This impending shame, looming over all Americans who have jobs or have had jobs with health insurance, and looming over many that want such a job, is a very powerful reason that we do not talk about health care as a human right -- we have been taught to regard health care access as an indicator of our individual worth.
As I said in starting this unintended screed, this leads directly to the lack of a certain anxiety in Canadians, but an anxiety which is very palpable, nearly universal and nearly continuous (at some level) among US citizens.
