Brothers' Keepers: Cognitive Dissonance in American Health Care

So I'm reading Diffusion of Innovations by Everett Rogers, a classic text on how technology and ideas spread. Rogers presents a case study about "The Daughter-in-Law Who Doesn't Speak," a labor-saving contraption introduced in a Malian village. The women of the village each pay a small fee to use the Diesel-powered machine to perform tasks like grinding grain and nuts, sawing wood, and pumping water. The time they save—corn-pounding that took three days takes the machine just fifteen minutes—frees the women and girls to go to school and start businesses. Even the men dig all this liberation, as their wives have more spare time and softer hands.

Rogers notes that the practical advantages of the machine weren't the only reason it caught on. Innovations also need to be compatible with existing knowledge and values:

The new machine is too expensive for any single person in the village to afford it, but the Sanankoroni Women's Association, once formed, served to foster collective efficacy among the village women. The notion of collaborative associations of women to accomplish some action that they could not achieve individually is compatible with West African village values and with past experiences. So the innovation of The Daughter-in-Law Who Doesn't Speak was highly compatible with West African village life, as well as having considerable relative advantage [Rogers, E.M., 2003. Diffusion of Innovations, 5th Edition, New York: Free Press, p. 248].

An innovation catches on because it is compatible with local values, in this case with a belief in collective efficacy.

And my brain jumps to American health care. (Yes, it's quite exciting living in my brain.) I wonder if America remains the last bastion of resistance to national health care in the industrialized world because we reject the idea of collective efficacy, the idea that we can do things better as a group than we can as individuals.

Wait: we do believe in collective efficacy. Right now, the vast majority of Americans do not pay for their own health care. Almost no Americans can: almost anything beyond a routine checkup costs more than we can afford out of pocket. So we chip in and pay for each other's health care. Since our daughter was born, my wife and I have paid over $10,000 in health insurance premiums that have almost gone almost entirely to cover other policyholders' medical expenses. We've paid into Medicare to help cover health care costs for my dad and millions of other old folks.

Odds are, so have you. If your employer offers health coverage, your and your employer's contributions pay not just for your medical bills but for everyone's in the pool. Every now and then you break a leg or get cancer and cash in (lucky you), but more often than not, your money and your boss's money go to other people.

Almost no one in America pays his own medical bills. Almost no one can. Only through collective effort, through a mishmash of government and private pools, can most of us financially survive a major medical event.

The next logical step would be to join our patchwork pools into one giant pool to minimize individual risk and maximize coverage. But then Dennis Kucinich and I shout Single-payer!, someone else shouts Collectivism! Socialism! Marxism!, and the plan falls apart. What gives?

America pays for health care primarily by collective means. But Americans cling to an individualist worldview. This individualism runs deep. We think we can solve crime and general moral decline if each of us just packs a gun. We flock to evangelical churches that promise a personal relationship with God and preach that salvation hinges on personal decisions and actions (memo to the faithful: that last part is wrong).

To resolve the cognitive dissonance between our belief in individual efficacy and our reliance in health care on collective efficacy, we trick ourselves. We deliberately compartmentalize, individualize, detach ourselves from the community of policyholders our dollars take care of. If we have employer-based health care, we think strictly in terms of our insurance as a benefit we earn for ourselves through our work. If we buy insurance on the individual market, we probably don't even know the fellow policyholders we support and who support us when we need them (if our insurers don't drop us). And as we get older, we tell ourselves that social support programs are really "my Medicare," as if each of us will simply draw from our own individual pot of money earned strictly by our own labor.

We tell ourselves health care is still all about personal responsibility, although really, from cradle to grave, we buy into a social protection system of our own making that fundamentally rejects individualism. That's cognitive dissonance.

We're like a crazy Malian villager who uses the machine to pound the corn, then claims to have done it all by hand. We've already bought into collective efficacy in health coverage; we just can't admit it. And we just can't admit that a national health insurance system, providing more coverage and more autonomy to more Americans, is not a Marxist revolution but merely the logical extension of a system we already depend on.

We're already our brothers' keepers. Let's do it better with a single-payer system.