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Author: Raine    Date: 02/01/2016 14:02:44

“Path dependence has to mean, if it is to mean anything, that once a country or region has started down a track, the costs of reversal are very high. There will be other choice points, but the entrenchments of certain institutional arrangements obstruct an easy reversal of the initial choice.”

I have written about this theory before. The last time it was related to our healthcare system and the ACA. This theory, be it political or economic, has been on my mind the past few weeks. On this day of the Iowa caucus, the first votes to replace President Obama are taking place. As with every few years, many people are firmly planted in their political camps. On our side of the aisle, we are faced with candidates that are stellar, competent and excellent choices.

The principals by which all are campaigning are as similar as they are different. For many, flags have firmly been planted in political camps. All that is left is to persuade those that have not decided. How people on social media go about trying to win people over has been hard to watch. I have friends who are passionate about the candidate they support. In all likelihood, the candidate I support will not win the nomination, which leads me to a conundrum. Who will I support?

This campaign season I find it difficult to listen to some supports from either campaign of the two front-runners. There is a lot of hyperbole and truth-stretching out there. Time and time again, I see all of the leading candidates having very similar ideas -- the difference to me seems to be the path on how to get there. in 2013, I asked How Did We Get Here? In 2016 I find myself asking, 'How do we get from here to where we want to go?'

Time and again, I find myself thinking about how things change in this nation. With a few exceptions, we rarely upend the apple cart or throw the baby out with the bathwater. We are a progressive nation, we just move forward conservatively. That is, I believe as our founding fathers wanted it to be. Time and time again, when I wonder about how I would like to see our nation go forward, I come back to that post I wrote over two years ago.
For supporters of single payer it would be natural to ask the question, why not every state? Why not just go all-in with Medicare For All? Why not a system like Canada? I know that I personally have asked those questions myself. Canada can actually give us good answers as to why we as a nation simply cannot just flip to single payer. That country's current health system didn't happen overnight. It didn't happen in a year or even a decade, arguably it's evolved for over a century. It'd been evolving for decades until it was signed into as the Canada Health Act of 1984. The true beginning to Canada's health care system began with a single state -- or province.
It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, the Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Tommy Douglas had hoped to provide universal health care, but the province did not have the money.
Alberta followed soon after, providing the foundation that is the Canada Health Act. Much like Saskatchewan and Alberta, it appears that Vermont is leading the way towards universal coverage. I still believe that we can achieve something like single payer in the United States, but it simply cannot happen by scrapping what we have in this nation. That means including and understanding what was in place before the passage of the ACA. Like Canada, the answers to how we get to a nationalized health care system lies in how we have operated in the past. The history of reform begins with change, that is true. Canada took one path, other countries have taken a different one. Great Britain's National Health Service evolved under a much different circumstance than it's European neighbor, France. The NHS was intended to be temporary and was to be disassembled after World War II -- it stayed though -- people liked it as it served the population's needs. France needed to figure out how to improve its nation's heath system after the devastation of the war as well. They opted to expand what they already had in place: a payroll tax-payer funded system. Before the ACA was written, when we were still calling it Health Care Reform (HCR), many wondered and debated the path that should be taken. To this day, people still debate where we should go. The answer depends on where we have been and where we are.

Are you still with me?

This article was written in 2009 and provides incredible insight and understanding to what we are seeing now. (I highly recommend reading the entire piece.)
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it 'path-dependence.' In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the qwerty typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. (snip)

With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are 'remembered,' continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.
He goes onto say:
There's a similar explanation for our employment-based health-care system. Like Switzerland, America made it through the war without damage to its domestic infrastructure. Unlike Switzerland, we sent much of our workforce abroad to fight. This led the Roosevelt Administration to impose national wage controls to prevent inflationary increases in labor costs. Employers who wanted to compete for workers could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one's place of employment a source of troubles (for employers and the unemployed alike) that we've struggled with for six decades. (snip)

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn't mean that ambitious reform is beyond us. But we have to start with what we have.

That kind of constraint isn't unique to the health-care system. A century ago, the modern phone system was built on a structure that came to be called the P.S.T.N., the Public Switched Telephone Network. This automated system connects our phone calls twenty-four hours a day, and over time it has had to be upgraded. But you can't turn off the phone system and do a reboot. It's too critical to too many. So engineers have had to add on one patch after another.

The P.S.T.N. is probably the shaggiest, most convoluted system around; it contains tens of millions of lines of software code. Given a chance for a do-over, no self-respecting engineer would create anything remotely like it. Yet this jerry-rigged system has provided us with 911 emergency service, voice mail, instant global connectivity, mobile-phone lines, and the transformation from analog to digital communication. It has also been fantastically reliable, designed to have as little as two hours of total downtime every forty years. As a system that can't be turned off, the P.S.T.N. may be the ultimate in path-dependence. But that hasn't prevented dramatic change. The structure may not have undergone revolution; the way it functions has. The P.S.T.N. has made the twenty-first century possible.
Our system is path-dependent. It can and has evolved since the ACA rolled out in 2010. It's a huge leap forward, but like the P.S.T.N., we cannot just scrap everything and start all over with single payer. We can, however, work towards that goal. We're building upon a system that we already have by improving what works and removing what hurts the population. We can't go back to the broken system the ACA was designed to fix. Perhaps Vermont is a sign of things to come. Massachusetts proved the path-dependent process works. That system provided the foundation to what we now call ObamaCare. Maybe that same process will take place with Vermont leading the way to single payer.

It can't happen overnight, but it can happen. I support single payer and I truly appreciate our allies like Senator Sanders and Representative Grayson, but the reality, for me at least, is that this will take time and patience.

I still firmly believe that we are a path dependent nation. I hold stong hope that we will see big changes for this nation, I just am not sure it will happen the way so many people seem to want it to happen.

Having said that, I want everyone on our side of the aisle to come along together for the ride, The enthusiam I see is wonderful. It would be wrong to quell that spirit but it's also wrong to alienate each other when ultimately we are on the same side. We need every last person along for the ride. We need to vote blue without worrying about who our nominee is.


12 comments (Latest Comment: 02/01/2016 19:57:34 by Will in Chicago)
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