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All this grief adds up to a national trauma. Twenty-eight attacks in a year and a half have killed more than 500 people. After each one, the government says "Turkey will defeat terrorism". Politicians must say such things, but the words lose meaning when the attacks keep happening. There is a certain defiance here: after the twin bombings at Besiktas football stadium in Istanbul last month, crowds gathered at the site for days, one woman telling me "the terrorists want us to stay inside, not to go out and enjoy ourselves - but then they would win". In pictures: Istanbul after club attack But there is also, of course, deepening fear: that a city to which Arab tourists came to enjoy themselves on New Year's Eve was consumed by horror; police and soldiers wonder if they'll be blown up on patrol; that Turkey has gone from being a stable corner of the Middle East to yet another troubled hotspot. One friend tells me she wouldn't take the metro in Istanbul anymore, another that he would avoid public gatherings and concerts. Three years ago, Istanbul topped lists of the world's must-visit cities. Now tourism is plummeting and businesses are closing down. No matter that this is a huge country and the likelihood of an attack on its golden beaches is minimal - tourism works through image, and Turkey's has been blackened. If only this nation could come together in times of tragedy, it might help ease the pain.
These are very expensive categories of spending, because the incentives for restraint are small, and when someone tries to make them bigger, usually another someone (typically a politician goaded by angry voters) intervenes to make them stop. As our system gets more expensive, pressure rises for third-party payers to pick up even more of the tab for our health carewhich of course, just makes the problem worse. Astute readers may be asking why the problem is so much more serious here than in countries that have an even bigger government presence in the health-care market. There are two reasons. First of all, health-care spending in those countries tends to look more like Medicaid, with heavy price controls on what providers can charge. America has immense difficulty doing this, because the decentralized structure of our government makes it easier to lobby against unpopular payment controls until they are destroyed. And second of all, the fact that our market is kind-of-free-but-not-really makes it extremely difficult for anyone, public or private, to crack down on prices. Providers have a great deal of negotiating power, both because they can lobby the government, and because they can find other payers to give them better prices if one insurer or government program tries to play hardball on reimbursements. So we end up with the worst of both worlds.
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