The U.S. Health Care Debate

[Don Corleone]

I heard an interesting perspective on the health-care debate and the particular question of rationing.

The argument from the Right is that a single-payer system, by necesity, leads to scarcity and rationing issues, where issues of care are decided by bureaucrats on a government panel, not by the patient and doctor.

FOUL! cries the Left. The above is a disingenuous argument, because while it may be true, every system of health care has scarcity issues, and in the current system, decisions of coverage are also made by bureaucrats, only these ones work for the insurance company and at least the ones in a single-payer system would be appointed, and therefore accountable at some level through the political process.

While I agree with the Left that the Right is certainly glossing over a big gaping hole in their logic, I actually believe I have a rebuttal that puts their argument equally out of sorts:

-In order for the panel to be devoid of croneyism and nepotism, the panel will have to act indepdent of the will of elected politicians, thus voiding the "accountability & fairness" argument they're making.

-Actually, there is accountability in the current system. Yes, Aetna, BCBS, Harvard-Pilgrim & other large providers can (and do) spend large sums of money determining how best to avoid paying claims they'd rather not pay, there is a limit... should a provider pull this lever too often, their clients will leave. It's not a direct feedback system, because the provider is typically contracted by the employer, while the services are provided to the employees. But don't kid yourself into thinking there's no cause and effect here. According to HR, lack of satisfaction with the insurance provider ranks up in the pernnial top 3 complaints they receive.

What's more, I know I certainly researched the insurance options for any potential employer as part of my compensation package on the way in. If others can't be bothered to do this, I have little sympathy for them, nor do I believe that there is any system that could adequately serve such a woefully willfully ignorant consumer.

And before I get the hail of "You have coverage...." arguments, remember, I am NOT opposed to universal coverage. I am adamantly and irrevresibly opposed to single-payer systems.

[Banquo's Ghost]

At the moment, I am not really seeing much coverage of constructive alternatives in the press to which I have access. The proposals seem like a muddle and mess because real reform is being shied away from in favour of the minimum possible politically - and, it must be said, some startling level of cowardice being shown by Democrats if real reform is what they believe in. However, all I see of the other side is yah-boo scaremongering.

If I may, could I ask Don Corleone and Seamus to explain the kind of system that they would like to see in the United States? As far as I understand the numbers, something of the order of 46 million fellow citizens of the US are uninsured, many more part insured or vulnerable to redundancy, and there are 18,000 unnecessary deaths due to lack of medical insurance each year - and many more bankruptcies. (These are figures widely quoted in the papers here, so I am open to them being challenged with other evidence).

You two gentlemen are deeply Christian, wise and caring individuals who also believe in a conservative solution to most social issues. I may not always agree, but your opinions are always thought-provoking. Your thoughts on the best, even ideal, reform (given that the existing system, if the above figures are even remotely accurate, is deeply immoral and close to barbarism for a wealthy country) would be very valuable for me to understand the direction of the ongoing debate.

[Beskar]

The argument from the Right is that a single-payer system, by necesity, leads to scarcity and rationing issues, where issues of care are decided by bureaucrats on a government panel, not by the patient and doctor.

If you think about this, would all those people having access to medical care really ration it out? If so, build more hospitals. Anyway, it isn't rationed by some evil government panel which stops doctors and patients, it is rationed based on need and availability. What stops people now, is money, as doctors can't treat patients, or even worse, the doctors fleece the patients of their money.

Fact is, any real universal healthcare package would "ration supplies" as there is far more demand to supply. To solve the issue, you have more supplying.

[Don Corleone]

At the moment, I am not really seeing much coverage of constructive alternatives in the press to which I have access. The proposals seem like a muddle and mess because real reform is being shied away from in favour of the minimum possible politically - and, it must be said, some startling level of cowardice being shown by Democrats if real reform is what they believe in. However, all I see of the other side is yah-boo scaremongering.

If I may, could I ask Don Corleone and Seamus to explain the kind of system that they would like to see in the United States? As far as I understand the numbers, something of the order of 46 million fellow citizens of the US are uninsured, many more part insured or vulnerable to redundancy, and there are 18,000 unnecessary deaths due to lack of medical insurance each year - and many more bankruptcies. (These are figures widely quoted in the papers here, so I am open to them being challenged with other evidence).

You two gentlemen are deeply Christian, wise and caring individuals who also believe in a conservative solution to most social issues. I may not always agree, but your opinions are always thought-provoking. Your thoughts on the best, even ideal, reform (given that the existing system, if the above figures are even remotely accurate, is deeply immoral and close to barbarism for a wealthy country) would be very valuable for me to understand the direction of the ongoing debate.

Thank you much for the high compliments, sir, and for your confidence in me to propose a free market solution. I'm not certain I can, but I would argue that our current situation is not a free market system either. Some practices/guidelines I would adopt for cost savings:


I believe we have numerous problems which overlay to form the quagmire that is our current medical system.

1) We do not incentivize doctors to make people healthy, we incentivize them to "do something". I would recommend altering the way doctors are compensated to more of a fixed payment schedule, where they get paid the same whether they recommend you for additional procedures or not.

2) Costs are best controlled when the decision maker is well informed of the costs of their decision. This is why I am so strongly in favor of high-deductible plans (level of deductible based on your income, to make it a sliding scale... such as 0.5% of your gross income or some such). I myself just went on a a high-deductible plan, and I'll tell you, you learn to ask questions like 'And how much will this procedure cost?'

3) We have to nullify all the protectionist laws enacted on behalf of the pharmaceutical companies. They are anti-competitive and are a big part of how we got to where we are. End Medicare Part D (at the very least, the no bid requirement) and allow for competitive sourcing of drugs from other markets.

4) We need torte reform. I don't believe in limiting the ability to sue, or the damages rewarded. But I do believe that if the judge finds your case to lack any bearing, he can refer you to a judicial oversight committee. If they find your case to be utterly without merit, you (or your attorney) have to pick up the legal costs for the defense. That should end those "WhoCanISue.com" and late-night Robert Vaughn ads that run "IF you win, I get 1/3, if you lose, you don't pay a dime" shticks.

For the coverage issue:

I like the way Germany, Japan and the State of Massauchusetts are set up. Require insurance from a government approved medical insurance provider. However, as part of this:
-Remove tax incentives for corporations to provide coverage, put everyone into the open market.
-Allow the formation of buying groups or co-ops (which are currently illegal in the US....well, they are and they aren't... large corporations buying for their employees are allowed, but I'm not allowed to form one).
-On an evaluation of an individual's ability to pay, the government will subsidize medical premiums. Families that make less than 40K a year will receive 100% of the money they spend in insurance premiums back at the end of the year. 50% up to 80K and so forth. Once your family hits 6 figures, you pay the whole nut. But, if you violate the law and do not get insurance, you don't get one red cent.

And one more thing I would do, to incentivize the insurance companies to cover everyone...

Set their income tax based on a new figure I would call their coverage index.

A 24 year old male with no family history gets assigned a +20. A 79 year old woman with Crohn's disease, diabetes and early stages of cancer gets assigned a -20.

The index is the sum of all individual ratings of everyone you covered for the entire year, pre-existing condition cases not included (if you don't cover them, you don't get their index points). At the end of the year, when your accountants calculate your taxes, they add or subtract your index from your corporate income tax. If you go out and cover a bunch of end-of-lifers, you'll be rewarded handsomely by the taxman. If you insist on dropping coverage on all risks, you'll be taxed heavily for that policy.

Edit: Edited to add cost reduction measure number 4.

[Strike For The South]

You know where I see the death of America? In the sheer lack of manners I see at these town hall meetings. My momma would tan my hide if I ever spoke to another person (Esp. a stranger, an elder stranger, an elder congressman stranger. She may have killed me) like that. All these people are hootin and cussin, whatever happend to common decency?

I know your life savings are being bled or you're scared you're in a socialst paradise or you're having to deal with more brown people and quite frankly you don't like that

But my God, talk about uncivil discourse. Do people really think the louder they yell and the more times they invoke Hitler and the constitution they'll win? This is what happens when you let Yankees run the country.

Is the lack of manners not unsettling to anyone else? Or am I just being to gentlemanly?

[Louis VI the Fat]

Is the lack of manners not unsettling to anyone else? Or am I just being to gentlemanly?

You are just being too Dixie. Southerners like you and I have complained about the encroaching Yank and his unrefined manners for well over a century now. We've been right all along.


Thank you for your lengthy reply, DC. I would still vote you for President.

[Lemur]

That's actually a pretty good system the Don recommends. Corleone for President! Don't turn us into France, turn us into Germany!

[Lemur]

Fantastic, must-read essay on health care and rationing. The entire thing is worth your time:

All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.

Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?

Note: The author works for a healthcare insurance company, so his conclusions are (naturally) pro-insurance company. That's not interesting or surprising: what I found amazing was the admission and (rosy-colored, but still explicit) explanation of how rationing works under the current system.

[Xiahou]

I think these people should look up what rationing actually means.

The article's author points out:

Most economists would exclude this sort of market allocation as a form of rationing by definition.

It's not just economists- it's anyone who uses the literal definition of the word. Just because someone can't afford as much as a good or service that they would want to have doesn't mean it's rationed.

Rationing suggests that something is doled out more or less equally based on its supply. If I go down to the grocery store and buy all the Wheaties so no one else can get any, it's not the same as the grocery store rationing them.

[Centurion1]

I am against this health care plan. I am not against reform however. I do not understand the excessive need of the democrats to force this bill through right now, any later and the world will end. It makes me suspect they are hiding things.

I think we should start with actually reforming things. My main problem with obamas plan is in addition to medicare and the like we have this new system. Medicare, Medicaid, Social security need to be drastically reformed or scrapped and completely remade. No single payer system (current) should have as high of a cost per year as we do.

[Ariovistus Maximus]

It makes me suspect they are hiding things.

Quite so. You know, I think some of this debate must be culture-clash.

Perhaps Europeans tend not to have a deep-seated distrust of government like we often do?

That would explain some of the disagreements here.

[Xiahou]

It makes me suspect they are hiding things.

Where would you get that idea?

One reason the public so distrusts the health care plan being considered by Congress is that so many troublesome details keep bubbling out of the massive legislation.

The latest example is the $10 billion taxpayers will be asked to shell out to prop up the United Auto Workers' retiree health insurance program.

That provision is tucked deep into the bill passed by the House.

In effect, it would ask every taxpayer, regardless of whether they'll have health insurance coverage themselves after they retire -- and most won't -- to chip in to maintain the UAW's coverage, which even after the union's givebacks is still better than what the average American worker receives.

A $10bn payout to unions? Gee, I wonder why they're in favor of the bill?

Howard Dean recently stated that tort reform isn't in the bill because Democrats were afraid of making enemies of the trial lawyers. I guess a hefty payoff was what it took to get the unions on board. Bear in mind that people are still finding things like this in the bill almost daily. If Obama had gotten his way this bill would have been signed into law already. So yeah, I could see how you might think they're trying to rush it through before we see what's really in it.

[Tribesman]

The latest example is the $10 billion taxpayers will be asked to shell out to prop up the United Auto Workers' retiree health insurance program.

The government sholdn't put tax payers money into this insurance , they should let the ex workers use tax payer funded programs for people without insurance instead

[Ironside]

Quite so. You know, I think some of this debate must be culture-clash.

Perhaps Europeans tend not to have a deep-seated distrust of government like we often do?

That would explain some of the disagreements here.

Depends a lot from witch region of Europe you talk about, but comparing with Sweden, I would say that we're more trusting of the goverment. But I sometimes get the feeling of how the existing distrust is shown differently.
In the US, when the flaws are shown, people are more accepting of it when it's their side doing it (the news shows for example) or are using it as proof that the state are always corrupt and tries (and usually fail) to reduce the state instead of try to fix it. Then again, you do have more grass root movements as well (not sure what that means on the whole though).

I do suspect that the US governing problems are linked to how the congress work. Personally, I say that the best reform you would ever get, would to put about a dozen very talented people in the field, unconnected (or low connected) to interest groups, to work out the ideas for a year or 2 and then slam the suggestions through congress before they knew what hit them.

I mean, the longer a proposal goes through congress it gets more and more perked, porked and watered down. Some review is good, but the congress is overdoing it.

[Hosakawa Tito]

Like most issues the main problem is that monied interests, coporate or organized labor, throw so much 'free speech' at politicians whose real main concern is getting re-elected. Term limits for all would go a long way in fixing this legalized bribery.

[Banquo's Ghost]

Thank you Don, for taking the time to add such an interesting and constructive proposal.

1) We do not incentivize doctors to make people healthy, we incentivize them to "do something". I would recommend altering the way doctors are compensated to more of a fixed payment schedule, where they get paid the same whether they recommend you for additional procedures or not.

My grandfather used to tell me that the Chinese paid their doctors only when they were well - stopping payment the moment the doctor "failed" and they became ill. Like much of my grandfather's wisdom, this is probably entirely mythical, but it does raise an interesting perspective for state-run healthcare and preventative healthcare - maybe we should stop a doctor's salary when a patient gets ill? (Before rory has a coronary, I'm joking - but all health systems should have a substantial incentive towards preventative care - and how is this done in a "free market" rather than a public health system? The incentive for the free market is surely to have as many ill people as possible?)

2) Costs are best controlled when the decision maker is well informed of the costs of their decision. This is why I am so strongly in favor of high-deductible plans (level of deductible based on your income, to make it a sliding scale... such as 0.5% of your gross income or some such). I myself just went on a a high-deductible plan, and I'll tell you, you learn to ask questions like 'And how much will this procedure cost?'

I'm not sure what a high-deductible plan might be. I assume from the context that this might be similar to what we would term an "excess" - an amount of the total cost payable by the insured. The higher this amount agreed, the lower the insurance premium as the insurer is less exposed to the total costs. Again, young and healthy people will tend to take large excesses, knowing they are unlikely to need to claim at all - but when tragedy strikes, they then face enormous bills. Whilst I don't disagree that in most cases costs are controlled by information, the problem is one's health doesn't allow it. If you need a course of chemo for your cancer, the provider is in the box seat.

3) We have to nullify all the protectionist laws enacted on behalf of the pharmaceutical companies. They are anti-competitive and are a big part of how we got to where we are. End Medicare Part D (at the very least, the no bid requirement) and allow for competitive sourcing of drugs from other markets.

At the very least. Pharmaceutical companies are the ruin of all modern health systems. The patenting of drugs (most of which are researched by state-funded universities and then finalised into a marketable product by the pharmaceutical companies) plus aggressive marketing where patients and doctors are bullied and frightened into using the very latest and most expensive treatments should be the main aim for any reforms.

4) We need torte reform. I don't believe in limiting the ability to sue, or the damages rewarded. But I do believe that if the judge finds your case to lack any bearing, he can refer you to a judicial oversight committee. If they find your case to be utterly without merit, you (or your attorney) have to pick up the legal costs for the defense. That should end those "WhoCanISue.com" and late-night Robert Vaughn ads that run "IF you win, I get 1/3, if you lose, you don't pay a dime" shticks.

You have my vote.

For the coverage issue:

I like the way Germany, Japan and the State of Massauchusetts are set up. Require insurance from a government approved medical insurance provider. However, as part of this:
-Remove tax incentives for corporations to provide coverage, put everyone into the open market.
-Allow the formation of buying groups or co-ops (which are currently illegal in the US....well, they are and they aren't... large corporations buying for their employees are allowed, but I'm not allowed to form one).
-On an evaluation of an individual's ability to pay, the government will subsidize medical premiums. Families that make less than 40K a year will receive 100% of the money they spend in insurance premiums back at the end of the year. 50% up to 80K and so forth. Once your family hits 6 figures, you pay the whole nut. But, if you violate the law and do not get insurance, you don't get one red cent.

I like the idea. It would be interesting to do the sums and see if the cut-off point you propose actually does provide adequate cover. I'm totally amazed that you make co-operative illegal in the US - corporations really have the legislature wrapped around their fingers, don't they?

And one more thing I would do, to incentivize the insurance companies to cover everyone...

Set their income tax based on a new figure I would call their coverage index.

A 24 year old male with no family history gets assigned a +20. A 79 year old woman with Crohn's disease, diabetes and early stages of cancer gets assigned a -20.

The index is the sum of all individual ratings of everyone you covered for the entire year, pre-existing condition cases not included (if you don't cover them, you don't get their index points). At the end of the year, when your accountants calculate your taxes, they add or subtract your index from your corporate income tax. If you go out and cover a bunch of end-of-lifers, you'll be rewarded handsomely by the taxman. If you insist on dropping coverage on all risks, you'll be taxed heavily for that policy.

Fascinating proposal. I'm going to have to think hard about the implications of how that might be applied, since I would expect the big insurance corporations are unlikely to pay their full contribution to taxes anyway (they'd be mist unusual if they did). I suspect that like car insurance, there would still be a group of people who remained uninsurable because the balance of risk versus tax liability would mean most insurers would still cherry-pick with a token amount of "end-of-lifers" to reduce liability on the $15 they didn't salt away in the Caymans.

I am adamantly and irrevresibly opposed to single-payer systems.

This is an odd phrase doing the rounds, which I understand to mean a system where only the government buys healthcare. Even in the UK, patients have the opportunity to source their healthcare from a range of trusts, and even to pay for private treatment. These health trusts, while given taxpayers' money, have to apply a budget and they buy the services they need. Some trusts therefore develop an expertise in a particular field, which means patients will often try to access them for treatment in that field. The constraint of "trade" is the same for any system - distance from one's home.

The biggest damage to these budgets is the drugs bill - and as you noted, the lack of competition means the pharmaceutical companies can make up whatever charge they fancy. With the introduction of NICE (the body that decides whether a drug is worth the expense) there's been a number of times when the Pharma lobby has successfully railed in the press to get a rejected drug put on the list. If this pressure fails, they invariably drop their price quickly.

So I don't think the problem is so much the "single-payer" as the lack of a market from which to buy.

[Centurion1]

My grandfather used to tell me that the Chinese paid their doctors only when they were well - stopping payment the moment the doctor "failed" and they became ill. Like much of my grandfather's wisdom, this is probably entirely mythical, but it does raise an interesting perspective for state-run healthcare and preventative healthcare - maybe we should stop a doctor's salary when a patient gets ill? (Before rory has a coronary, I'm joking - but all health systems should have a substantial incentive towards preventative care - and how is this done in a "free market" rather than a public health system? The incentive for the free market is surely to have as many ill people as possible?)

Hmm, perhaps bonuses for finding diseases before they become dangerous.

[Don Corleone]

Thank you Don, for taking the time to add such an interesting and constructive proposal.

Thank you for the high praise, and for the constructive feedback.

I like the idea. It would be interesting to do the sums and see if the cut-off point you propose actually does provide adequate cover. I'm totally amazed that you make co-operative illegal in the US - corporations really have the legislature wrapped around their fingers, don't they?

I proposed one set of numbers and brackets, but by my very own admission, I have no earthly idea what the actual numbers should be. I meant them as variable placeholders. I think people who live below the poverty level should get their healthcare completely free, and I think the top 25% should be off the reimbursement. How it gets gradiated in between is open for discussion.

Fascinating proposal. I'm going to have to think hard about the implications of how that might be applied, since I would expect the big insurance corporations are unlikely to pay their full contribution to taxes anyway (they'd be mist unusual if they did). I suspect that like car insurance, there would still be a group of people who remained uninsurable because the balance of risk versus tax liability would mean most insurers would still cherry-pick with a token amount of "end-of-lifers" to reduce liability on the $15 they didn't salt away in the Caymans.

Thank you. Well, you're flirting with another one of my other big reforms... tax reform. I don't believe in taxing corporations more heavily. In fact, I believe in lowering corporate tax rates. But, I would end the loophole of paying taxes based on where you created a good or service, or where you record the income. Whereever the transaction takes place, for online transactiions this means wherever the buyer is at the time of the transaction, that is the prevailing tax rates & authority.

This is an odd phrase doing the rounds, which I understand to mean a system where only the government buys healthcare. Even in the UK, patients have the opportunity to source their healthcare from a range of trusts, and even to pay for private treatment. These health trusts, while given taxpayers' money, have to apply a budget and they buy the services they need. Some trusts therefore develop an expertise in a particular field, which means patients will often try to access them for treatment in that field. The constraint of "trade" is the same for any system - distance from one's home.

This could very well be the extremism of American politics raising its ugly head again, but it is my belief that one of the reasons for pushing for health-care reform is that the American left wants to collective health care. Not only engaging in cost-fixing measures (debatable) and universal coverage (laudable), but outlawing fee-for-preferred treatment or private insurance. I'm pretty sure that's how the system in Australia works, and that's how the American Left wants it to work here.

When you hear "single-payer-system" in America... rejected widely by the right, called for by the Left, initially called for by Obama, though now he claims he's willing to drop it FOR NOW, this is what we're all talking about... the ability to control your own medical care. It was over this very sticking point that Ted Kennedy and the Democrats in 1972 rejected Nixon's offer for Universal Coverage. And when you read most Left policy wonks today, like Paul Krugman, they allow that is the final goal, but one which Americans resist too much to be enacted now and therefore universal coverage must be a first step.

[Crazed Rabbit]

Some perspective on American life expectancies:

It's true that the United States spends more on health care than anyone else, and it's true that we rank below a lot of other advanced countries in life expectancy. The juxtaposition of the two facts, however, doesn't prove we are wasting our money or doing the wrong things.

It only proves that lots of things affect mortality besides medical treatment. Heath Ledger didn't die at age 28 because the American health care system failed him.

One big reason our life expectancy lags is that Americans have an unusual tendency to perish in homicides or accidents. We are 12 times more likely than the Japanese to be murdered and nearly twice as likely to be killed in auto wrecks.

In their 2006 book, The Business of Health, economists Robert L. Ohsfeldt and John E. Schneider set out to determine where the U.S. would rank in life span among developed nations if homicides and accidents are factored out. Their answer? First place.

That discovery indicates our health care system is doing a poor job of preventing shootouts and drunk driving but a good job of healing the sick.

CR

[Evil_Maniac From Mars]

Isn't the American life expectancy at birth also effected by a higher than average infant mortality rate?

[Beskar]

There are a couple of quotes from a TV comedy show about this, which I found amusing. Anyway:

"Only time a British person has the same Life-expectancy rate as an American, are when they do joint military manoeuvres."

"I read in an American newspaper that if Stephen Hawking was British and got treated by the NHS, he wouldn't be here with us today... which is a very good and emotional argument... however... Stephen Hawkings IS British, and he is commented saying he OWES his Life to the NHS, for saving him."

[Ironside]

Some perspective on American life expectancies:


CR

Any idea if they factored in what social group those who died a premature death belonged to? I suspect most ghetto residents doesn't exactly have the best healthcare the US can offer. But it looks like you might actually get something out of that 50% more spending than anyone else that you do.

[Beskar]

The biggest "drain" on the NHS is old people, with 6/8th of the patients being over the age of 65. In America, where there is a lot of gun-crime, etc, many people don't even reach that age and on-top of that, many old aged people might not get the help in America, due to lack of funds and the ones that do, could be argued coming from richer families where they might have a far healthier lifestyle such riches could bring. That is the problem about being selective with figures.

[Evil_Maniac From Mars]

The biggest "drain" on the NHS is old people, with 6/8th of the patients being over the age of 65. In America, where there is a lot of gun-crime, etc, many people don't even reach that age

You have all the things in the world available that cause death, and you pick gun crime as your top one?

I will never understand the left...

[Beskar]

Is it usual for the right to not read things properly since Ironside and CR was talking about gun-crime, homocide and accidents being the reason for low life-expectancy ?

I was talking about being selective with figures, not gun-crime.

[Evil_Maniac From Mars]

Is it usual for the right to not read things properly since Ironside and CR was talking about gun-crime being the reason for low life-expectancy ?

I don't see where they mentioned gun crime specifically, I do see where they mentioned homicides.

[Beskar]

Please return to the subject manner, if you want my opinion about guns, then go to the relevant thread. It has no meaning or bearing in here. I never said gun-crime was the top one, it was the one of many mentioned. It's nice though you felt the need to come in with a snippy comment though.

[Lord Winter]

Blaming our low stats on deaths is blowing crime and accidental deaths out of proportion. Also if that article was true wouldn't cost cutting still be needed to fight our deficit and to fight these epidemic non medical causes?

[jabarto]

Whenever I join a thread on healthcare, this is one of the first things I like to post. It's a post from Something Awful Forums user Gul Banana that pretty much perfectly outlines why we *need* universal healthcare.

There have been a lot of debates and discussions recently, both on this forum and in other venues, about the state of healthcare. Looking at the rising costs of health insurance, and at the growing numbers of the uninsured, many are calling for government intervention, and the institution of a system where care is guaranteed to all - usually described as "universal" healthcare. It's a fascinating topic - the issues involved include humanitarian, financial and ideological ones. Unfortunately, debate on the subject is characterised by a startling phenomenon: one side is right, and the other is completely wrong.

Given the importance of medicine, I feel that it would be useful to clarify this issue. I will explain clearly, and with evidence, why it is that universal healthcare of any sort would be better than the current system in every significant way. If you find yourself disagreeing with this assertion, I ask that you read on before replying, as all conceivable objections will be addressed and resolved.

Why The Current Situation Is Bad

At the moment, healthcare in America is provided mostly by private entities, who charge high fees. These fees can be attributed largely due to the difficulty and expense of the medical profession, and although they are significantly higher than those of similar nations this difference is only a small portion of healthcare costs. There then exists the health insurance industry, a loose network of corporations that charge individuals or organisations premiums and will pay for their health costs if any are incurred.

Unfortunately, this system has enormous problems. As of 2006, 44.8 million people in America do not have health insurance. Many are unable to afford it, many are denied coverage by insurers who believe that as customers they will not be economical, and others choose not to purchase it. Without health insurance, the up-front costs of health care are impossible for most people to afford. In fact, 50.35% of all bankruptcies were caused, at least in part, by medical fees. In 2001, this was 2,038,549 bankruptcies.

Furthermore, health insurance does not fully cover medical expenses. Different insurers and different plans have many exemptions, co-pays, threshholds and other expense-minimising devices. As a result, 62% of those two million bankruptcies occurred despite the debtors having health insurance coverage for the duration of their illness.

As well as failing to provide care, and driving individuals into bankruptcy, the existing system is also exorbitantly expensive. Health care spending is now 15% of U.S. GDP - the highest in the world. The costs to businesses, who commonly pay premiums for their employees in lieu of salary, rose by 13.9% in 2003. The annual cost increase has been above inflation since at least 1981. Paying more doesn't result in more value, either - obesity, diabetes, and similar disorders are more common in the United States than anywhere else in the developed world, the U.S. is ranked 72nd in overall health, and life expectancy is below that of 41 other countries.

What Is Universal Health Care?

Universal Health Care, or UHC, refers to a wide range of different systems, the common characteristic of which is that a nation's government guarantees all its citizens access to healthcare. Every developed nation (OECD member) in the world, apart from the United States, has a UHC system. There are three main types:

In a fully public system, there is no or little private healthcare, and the health insurance industry is not a significant one. Medical service providers are government employees, and the education of doctors is also subsidised. The most well known example of a fully public system is the original English NHS, although a private sector is now developing in the U.K. as well.

In an optional public, the government provides the same services, but a private health services industry also exists (generally regulated), and . Sometimes health insurers exist, used by people who prefer private services. This is the most common, and examples include Australia and Sweden.

In a subsidised private system, the government pays for health care, but it is provided by private entities. Either the government acts as a health insurer for the populace, or it pays the fees for private health insurers to do so. This is done in Canada.

For the purposes of discussion, I will be assuming the characteristics of an optional public system, like those used in most of Europe. However, the benefits of UHC apply to all of the above types of organisation.

How UHC Will Improve Things

The single largest problem with healthcare in America is that many people don't have it. It's obvious how UHC solves this: by providing it to all citizens directly (or paying for it to be done). By definition, this is no longer a problem under UHC. All developed nations other than the United States make this guarantee to their citizens, and have so far been able to uphold it. The two reasons which make a person uninsurable - insurer decisions and lack of money - will no longer exist.

The second major problem with the current system is its high cost. This can be divided into two parts: individual cost, and government cost - which to the individual shows up as taxation. UHC is inherently cheaper - far cheaper - due to economies of scale, the bargaining position of monopolies with regard to drugs and salaries, reduced administrative costs, and the lack of a profit motive. When it comes to individual health care costs:

According to the World Health Organisation, average American individual spending on healthcare is $3371 per year. Since this includes the uninsured and those covered by their employers, actual costs are higher. For comparison:

Australia: $1017
Canada: $916
Sweden: $532
United Kingdom: $397

The first of those is the second-highest in the world - meaning that Americans pay, not including taxes, more than three times as much as citizens of any other nation. This would be somewhat justifiable if they received better healthcare, but again - 28% have no care at all, life expectancy is below all other developed nations, and general health rating is below all other developed nations.

It is commonly assumed that this difference in cost is because under UHC systems, higher taxes are required to fund the system. Not so. As mentioned, UHC is a great deal cheaper than private healthcare, and as a result America's health-related taxation is also the highest in the world. According to the OECD, in 2006, American government spending on healthcare was $2887 per person. For comparison:

Australia: $2106
Canada: $2338
Sweden: $2468
United Kingdom: $2372

American healthcare taxes are in fact the highest in the OECD, with France second at $2714. In conclusion, every single UHC system in the world costs less money for individuals, requires lower taxes, and provides better care to more people than the American health care system. By implementing UHC in the U.S., things can only get better.

Frequently Raised Objections

There are many incorrect arguments against the implementation of UHC in the United States. In order to better facilitate discussion, I will explain the errors found in the most common.

"America isn't Europe!", or It Won't Work Here
The argument from American exceptionalism states that what works in Europe will not work in the U.S. It's said that this is because European nations have more people in less space, resulting in less logistical difficulties, and because European government is more competent.

Firstly, not all developed nations are European. The most obvious example that counteracts the logistical argument is Australia, where there are 20 million people in only slightly less space than America's 300 million. This does indeed affect prices, as can be seen by comparing Australia to Sweden or the U.K. - but it doesn't bring them anywhere near the levels currently experienced in America.

The argument that American government is uniquely incompetent, and cannot do things that every other nation in the world can do, is simply nonsense. Not only has America, and American government, achieved many things that other countries have not, America has so many resources and the improvement in care and cost from moving to UHC is so large that even with incredible inefficiencies it would still be a good idea.

"It is immoral to force me to pay for others' healthcare."
You are already paying for others' healthcare. Furthermore, you are paying far more than you would be under UHC. The U.S. government incurs massive costs from paying hospital fees when ER visitors have no money, and from the limited coverage that it provides, which cannot take advantage of economies of scale and which has to subsidise corporate profit.

As demonstrated above, U.S. taxes devoted to healthcare are the highest in the world. Even if you choose not to have health insurance, under the current system, you are still paying more for others' healthcare than you would be paying for theirs plus your own under UHC.

"This is socialism."
It is not socialist to recognise that there is a service the free market is inefficient at providing, and to decide it should better be provided by the government. Even the most staunch libertarian admits that there are some services in this category, such as national defence.

Secondly, it is irrelevant whether this is a "socialist" policy; it's effective. It costs less and provides better care to more people, and as a result is used literally everywhere else in the entire world. Those who want to ensure that society remains ideologically committed to market capitalism need to look for other issues, as if they cling to this one they will only end up providing evidence against their position.

"I don't want more government bureaucracy."
UHC will involve much less bureaucracy than is commonly assumed, as it can replace the existing partial systems like Medicare and also the plethora of state-specific programs. Regardless, the lives and money saved are more important than any potential expansion of the state.

"Why don't we try making the system even more private instead? That might help."
It might. However, there's no evidence to suggest it, and many reasons to presume it wouldn't. By its nature, the less publicly-supported a system, the more people will be unable to purchase health services.

The only potential gain would be reduced costs due to some sort of market mechanism, and in practice this has never occurred; every private healthcare system that has ever existed in world history has proved inefficient and been replaced by public systems, and given the demonstrable gains that have resulted the U.S. must follow.

"Doctors will be paid less."
They probably will. In nations with UHC, doctors often earn less - for example, U.S. doctors earn 30% more than Canadian doctors - but this isn't an inherent problem. It is still one of the highest-paying professions in the world, and there are many other ways of attracting skilled people to medicine - such as subsidising their education.

It is sometimes claimed that doctors paid less in a country with UHC will instead go elsewhere where they can be paid more, but once the U.S. has UHC there will not be an elsewhere to go.

"Medical research is funded by the payments of the rich in the current system, and will be reduced."
It is not true that most medical research is done in the United States. In 2000, U.S. research spending was $46 billion, but European spending was also $43 billion. And although U.S. research spending doubled in the last decade, the funding's efficacy has actually decreased.

Secondarily, if the option for private healthcare still exists - and there is no reason why it should not - there will still be people choosing to pay more for a higher quality of care, faster service, et cetera. Their profits will still be reinvested in the development of new drugs, equipment and understanding of the human body, as they still are in nations with UHC today. Even in the United States, private spending accounts for only 57% of research spending.

"With the option of private healthcare, the rich will 'opt out' and costs will go up."
This isn't necessarily true at all; although private healthcare is usually allowed in UHC nations (for good reasons), it doesn't have to decrease the taxes paid by all to support the public system!

"Other countries fix drug prices, so the US has to pay more for drugs."
This is another common misconception. U.S. healthcare does not include higher pharmaceutical spending than other countries; it's around the average or even slightly lower. From the OECD:

Canada: 17.7%
Germany: 15.2%
Iceland: 13.3%
Australia: 13.3%
US: 12.4%
Sweden: 12%
Ireland: 11.6%

In Conclusion

Thank you for reading. To those who were not previously supporters of UHC, I apologise if anything seemed condescending, but there's no shame in being wrong due to not having all the facts or having been misled. If anyone has questions feel free to ask, and hopefully we can now discuss what sort of UHC system ought to be implemented or how the political will for it can be gathered, rather than being bogged down by misconceptions about its desirability.

[Lemur]

jabarto, you gotta get hip to the [ex] tag when you post long texts. Example:

VERY LONG ARTICLE

Does wonders for your readers.

Meanwhile, hat tip to Slashdot for turning me on to a systems designer's perspective on HR 3200. Very eager to read the upcoming part 3.

-edit-

It is not socialist to recognise that there is a service the free market is inefficient at providing, and to decide it should better be provided by the government. Even the most staunch libertarian admits that there are some services in this category, such as national defence.

I should introduce the author to a couple of people I know. One guy, in particular, believes that the U.S. Military is a socialist boondoggle best replaced by well-trained mercenaries. He even argues that roads should be privatized. Admittedly, he's a kook, but he calls himself a libertarian.