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Friday, February 7, 2014

Health Care: Coming Apart

At The Wall Street Journal, Michael Barone points to evidence undermining three assumptions behind Obamacare:  that the uninsured will get insurance once it's available, that insurance leads to better health, and that people with  Medicaid are less likely to seek primary care from emergency rooms.
[The] apparent discrepancies between what policy makers expected and how many of the intended beneficiaries of ObamaCare seem to be behaving reminds me of the divide described in Charles Murray's 2012 book "Coming Apart: The State of White America, 1960-2010." Mr. Murray, my colleague at the American Enterprise Institute, documents the sharp differences in behavior between the upper (in education and income) 20% and the bottom 30% of white Americans.

The upper group has low rates of divorce and single parenthood and high rates of what Harvard political scientist Robert Putnam calls social connectedness. They belong to voluntary associations and churches; they vote and follow public-policy debates. They tend to be connected, engaged and conscientious. The lower (income and education) group has high rates of divorce and single parenthood and low rates of social connectedness. They tend to be disconnected and disengaged, and sometimes heedless. It should not be surprising that they may not respond to the same health-care mandates, incentives and nudges that policy makers and others in the upper group do.

Liberal policy makers have long regarded Scandinavian policies as a model. If a welfare state can work there, they have long argued, it can work here. But the Scandinavian countries have homogeneous populations with high levels of trust, conscientiousness and social connectedness. It is not a coincidence that in the two states with the highest levels of the social connectedness Mr. Putnam described, North Dakota and Minnesota, most people are of Scandinavian or German descent. But policies that work well in Scandinavia or Minnesota and North Dakota won't necessarily work well in a wider United States, where a much larger proportion of people are socially disconnected.