Alternatives to socialized health care

[tombigbee]

I think we should try reforming our health care system before going to a government-run system. However, what I really want is to engage my fellow classmates in a discussion on this issue. It's a distance class and we have our discussions on a message board. In my opinion, our textbook somewhat subtly led most of them to take a position that we should copy Canada. We get to discuss Canada again in 3 weeks, and I want to be ready.

I looked ahead in the textbook. Germany, UK, Canada, and China have coverage that is "guaranteed portable, affordable, and universal or near-universal" and only "Mexico continues to struggle to improve access to care."

I believe that making health insurance mandatory (http://www.weeklystandard.com/Content/Public/Articles/000/000/006/312korit.asp ), moving to consumer-driven health care (http://www.thehealthcareblog.com/the_health_care_blog/2006/02/policy_can_cons.html), and individually-owned portable insurance (http://www.ncpa.org/pub/special/20060130-sp.html) could be better than a government-run system.

My justification is mainly centered on the affordability issue. For example, a critique (http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_14sep2005_e ) of Canada's system in 2003-2004 points out that 57% of visits to the emergency room were not really emergencies, resulting in long waits at times for people who were seriously ill (http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20051103/whistleblower_building_20051110/20051111/) . Also, some people in France abuse the system (http://news.bbc.co.uk/1/hi/world/europe/3419725.stm) by having the same tests performed 2-3 times. Wouldn't both of these be examples of challenges to keeping socialized health care affordable?

Overall, I favor capitalism over socialism because I believe it is a better fit with our human nature. Wouldn't it be a better cost-control measure for people to have some direct interaction with paying for their health care? (Sorry, I don't think I worded that very well!)

[Der Trihs]

Wouldn't it be a better cost-control measure for people to have some direct interaction with paying for their health care? (Sorry, I don't think I worded that very well!)Not really. The two fundamental problems that come with mixing capitalism and health care are that it's too complex and large a field for the layman to grasp ( and therefore make an informed decision ), and that people often have no choice but to buy. People in America pay medical bills that ruin their lives, because the alternative is death. When one side in a transaction has such a huge advantage, capitalism becomes fairly indistinguishable from robbery.

[Shagnasty]

I have given this some thought and think that the government needs to set up a lot of basic care clinics. I know that some of these exist but hospitals and other urgent care facilities spend way too much time and money dealing with noncritical care and routine matters. These clinics would serve each community to take a load off other facilities by providing basic, sound health care.

These basic care clinics would be public and "socialized" in the same way that public schools are socialized. They would be a place where anyone could go to get treated for colds, infections, education, and advice on health care. They sew stitches and deal with small emergencies. They would be equipped to deal with urgent emergencies but those would be sent to more critical care facilities as soon as the patient is stabilized enough to go.

These clinics wouldn't provide cutting edge care but they could provide sound health care. In practice, most of the people that would use them would be poor, elderly or others without health insurance but that should be OK.

The model they would work on would be very similar to student health clinics at most larger colleges. These would make many of the complaints about the current system less valid and take the burden off parts of the health care system.

[Sal Ammoniac]

I believe that making health insurance mandatory (http://www.weeklystandard.com/Content/Public/Articles/000/000/006/312korit.asp ), moving to consumer-driven health care (http://www.thehealthcareblog.com/the_health_care_blog/2006/02/policy_can_cons.html), and individually-owned portable insurance (http://www.ncpa.org/pub/special/20060130-sp.html) could be better than a government-run system.
Hey, you're back! Anyway, the things you mention will nibble at the problem, but do nothing to solve it. Healthcare is so expensive in this country because it has too many moving parts. The solution is to reduce the number of moving parts, or at least standardize them -- in other words, create efficiencies. All of the solutions you cite do nothing more than shuffle the money around -- they don't necessarily save anything, because they don't reconfigure anything in a more efficient way. Take mandatory insurance -- what does that do but impose a new tax on the individual, and a new administrative burden to make sure that individual has paid his or her tax?

We like to pretend that there's some difference between money being paid into the system through tax dollars, and money being paid in from elsewhere -- copayments, deductibles, co-insurance, etc. We have this horror of "socialized" medicine, and a horror of "bureaucrats telling us what doctor we can use" -- as if both those things don't already characterize the present system. But the fact is, we pay a tremendous penalty for this pretense. In the interest of not having "socialized medicine," we refuse ourselves the efficiency of having a single payer, and it costs us billions.

I see healthcare as a Gordian-knot problem: you have to cut through it at a stroke, not try to unravel it. To me this means a single payer, supported by tax dollars. I've made this point before, but the fact is, government is already paying half the healthcare costs in this country. And since we're paying, as a percentage of GDP, twice what other countries are paying, there's basically almost enough money already in the system to have universal coverage. We're crazy to settle for less.

But beyond simplifying the payment mechanism, and implementing some basic IT-based efficiencies in the delivery of healthcare, I would argue that medicine needs to be reconceived from top to bottom. I don't know if this is the place to go into that, or if it would just muddy the issue.

[Kimstu]

I recently read a detailed article on this subject that addresses a lot of your points: The Health Care Crisis and What to Do About It (http://www.nybooks.com/articles/18802).

I believe that making health insurance mandatory, moving to consumer-driven health care, and individually-owned portable insurance could be better than a government-run system.

According to the article, these aren't likely to be viable solutions by themselves. The biggest problem with non-single-payer systems is simply the complexity and overhead incurred by having so many different insurers, each with a different system.

The view that Americans consume too much health care because insurers pay the bills leads to what is currently being called the "consumer-directed" approach to health care reform. [...] The main idea is that people should pay more of their medical expenses out of pocket. And the way to reduce public reliance on insurance, reformers from the right wing believe, is to remove the tax advantages that currently favor health insurance over out-of-pocket spending. [...]

What's wrong with consumer-directed health care? One immediate disadvantage is that health savings accounts, whatever their ostensible goals, are yet another tax break for the wealthy, who have already been showered with tax breaks under Bush. The right to pay medical expenses with pre-tax income is worth a lot to high-income individuals who face a marginal income tax rate of 35 percent, but little or nothing to lower-income Americans who face a marginal tax rate of 10 percent or less, and lack the ability to place the maximum allowed amount in their savings accounts.

A deeper disadvantage is that such accounts tend to undermine employment-based health care, because they encourage adverse selection: health savings accounts are attractive to healthier individuals, who will be tempted to opt out of company plans, leaving less healthy individuals behind.

Yet another problem with consumer-directed care is that the evidence says that people don't, in fact, make wise decisions when paying for medical care out of pocket. A classic study by the Rand Corporation found that when people pay medical expenses themselves rather than relying on insurance, they do cut back on their consumption of health care—but that they cut back on valuable as well as questionable medical procedures, showing no ability to set sensible priorities. [...]

The administration's plans for consumer-directed health care, then, are a diversion from meaningful health care reform, and will actually worsen our health care problems. In fact, some reformers privately hope that George W. Bush manages to get his health care plans passed, because they believe that they will hasten the collapse of employment-based coverage and pave the way for real reform. (The suffering along the way would be huge.)

Implementing mandatory health coverage, without a system of universal coverage, would subject health coverage to market risks. What happens to your health insurance when your private health insurer goes bankrupt because they had to pay out more in claims than they took in in premiums? At present, private insurance companies minimize this risk by screening out the people with expensive illnesses, so that the sick and poor frequently end up uninsured. But what would happen if it was mandated that everybody get private health insurance?

"Most health costs are incurred by a small proportion of the population whose expenses greatly exceed plausible limits on out-of-pocket spending." In other words, if people had to pay for medical care the way they pay for groceries, they would have to forego most of what modern medicine has to offer, because they would quickly run out of funds in the face of medical emergencies.

So the only way modern medical care can be made available to anyone other than the very rich is through health insurance. Yet it's very difficult for the private sector to provide such insurance, because health insurance suffers from a particularly acute case of a well-known economic problem known as adverse selection. Here's how it works: imagine an insurer who offered policies to anyone, with the annual premium set to cover the average person's health care expenses, plus the administrative costs of running the insurance company. Who would sign up? The answer, unfortunately, is that the insurer's customers wouldn't be a representative sample of the population. Healthy people, with little reason to expect high medical bills, would probably shun policies priced to reflect the average person's health costs. On the other hand, unhealthy people would find the policies very attractive.

You can see where this is going. The insurance company would quickly find that because its clientele was tilted toward those with high medical costs, its actual costs per customer were much higher than those of the average member of the population. So it would have to raise premiums to cover those higher costs. However, this would disproportionately drive off its healthier customers, leaving it with an even less healthy customer base, requiring a further rise in premiums, and so on.

Insurance companies deal with these problems, to some extent, by carefully screening applicants to identify those with a high risk of needing expensive treatment, and either rejecting such applicants or charging them higher premiums. But such screening is itself expensive. Furthermore, it tends to screen out exactly those who most need insurance.

[tombigbee]

These would make many of the complaints about the current system less valid and take the burden off parts of the health care system.

One classmate says her family uses something like you've described, the JPS Health Network (http://www.jpshealthnet.org/about/connection.asp). She is "100% for socialized medicine." She mentioned that going for diabetes management took at least half if not most of the work day. I couldn't find hours of operation posted, but not being opened late evenings/nights seems a huge oversight. Anyway, here's your solution (in-part), but it didn't end the complaints in this case. I mean, why not just complain about the hours?

[Tevildo]

I looked ahead in the textbook. Germany, UK, Canada, and China have coverage that is "guaranteed portable, affordable, and universal or near-universal" and only "Mexico continues to struggle to improve access to care."I can assure you that the German system isn't. :) In Germany, no insurance == no treatment. The state does provide a cheap-rate insurance scheme, and all employers are required to offer it to their workers, but it's up to every individual to decide whether or not to take it up - there's no "National Health Service" in the same sense as in the UK, where all you have to do is pay your taxes to be guaranteed access to healthcare.

[MilTan]

Your affordability argument is a bit of a red herring. All of the countries you mention spend far less per capita on health care than the US (some, such as Canada, spend less than half as much!) while still achieving better health outcomes. So, even assuming that the issues you mention are severe cost drains, fixing them will only make the more cost-effective alternatives even cheaper.

[spazattak]

Not really. The two fundamental problems that come with mixing capitalism and health care are that it's too complex and large a field for the layman to grasp ( and therefore make an informed decision ), and that people often have no choice but to buy. People in America pay medical bills that ruin their lives, because the alternative is death. When one side in a transaction has such a huge advantage, capitalism becomes fairly indistinguishable from robbery.

Thank you. I like being told that I'm too stupid to make my own choices. Should we also have the government provide cars and computers, because they are also so complex that the average laymen cannot grap the concepts around them?

As for number 2 - cite. I doubt that a most of american healthcare revolves around death. Infact, I'd bet that most of it revolves around health and convenience. The alternative isn't death, but just staying sick or injured for a longer period of time, or feeling a bit more depressed, or being slightly more inconvenienced from pain.

[tombigbee]

Implementing mandatory health coverage, without a system of universal coverage, would subject health coverage to market risks.

My understanding is that doing the one means also doing the other. "The other -- and far more promising -- path to universal coverage is to approach health insurance as we approach car insurance: Make it mandatory." Health Insurance Required (http://www.newamerica.net/index.cfm?pg=article&DocID=1317)

A deeper disadvantage is that such accounts tend to undermine employment-based health care... Yet another problem with consumer-directed care is that the evidence says that people don't, in fact, make wise decisions when paying for medical care out of pocket.

I don't know if this quote from the "portability link" answers the first point directly since it's about health savings accounts, but maybe it does: "For employers, portable health insurance means that small groups are no longer treated as a self-contained pool and rated each year based on changes in health status of their employees. Instead, their employees will be members of very large pools in which no one can be singled out because of a sudden large medical expense, and premium increases are the same for all."

On the second point, I'm a bit confused myself. Why is it considered "out of pocket" when one has insurance? Evidently I don't understand my own cites!

[kellner]

I can assure you that the German system isn't. :) In Germany, no insurance == no treatment. The state does provide a cheap-rate insurance scheme, and all employers are required to offer it to their workers, but it's up to every individual to decide whether or not to take it up - there's no "National Health Service" in the same sense as in the UK, where all you have to do is pay your taxes to be guaranteed access to healthcare.That's technically mostly correct, but a bit misleading. It's true the obligatory health insurance doesn't apply to everyone. Originally you had no choice whatsoever if it applied to you. I recent years you can opt out of the system once and for all, but unless you know very well what you are doing, it can be a seriously bad idea. Few people actually do that.
It's also not the state that provides the health insurance, although is so tightly regulated that it might look that way.

[Kimstu]

Thank you. I like being told that I'm too stupid to make my own choices

There, there, nobody's calling you stupid. Der Trihs is just pointing out that medicine is an extremely complex and specialized subject, and the average consumer doesn't have the necessary specialized training to make wise choices about treatment. See the excerpt from my linked article above:

A classic study by the Rand Corporation found that when people pay medical expenses themselves rather than relying on insurance, they do cut back on their consumption of health care—but that they cut back on valuable as well as questionable medical procedures, showing no ability to set sensible priorities.

Lack of specialized knowledge != stupidity, but it can lead to poor choices anyway.

As for number 2 - cite. I doubt that a most of american healthcare revolves around death. Infact, I'd bet that most of it revolves around health and convenience.

Nope, the majority of costs come from a minority of the population needing expensive treatments. Again from my link:

In 2003, health spending roughly followed the "80–20 rule": 20 percent of the population accounted for 80 percent of expenses. Half the population had virtually no medical expenses; a mere 1 percent of the population accounted for 22 percent of expenses.

Here's how Henry Aaron and his coauthors summarize the implication of these numbers in their book Can We Say No?: "Most health costs are incurred by a small proportion of the population whose expenses greatly exceed plausible limits on out-of-pocket spending."

Moreover, (http://www.24hourfitness.com/html/corp_well/savings/cost/)

Some 18 percent of lifetime costs for medical care- over $40,000- is estimated to be incurred in the last year of life.

So yes, I think it's probably fair to say that a majority or thereabouts of US health care spending is spent either to save the lives of people with expensive conditions, or to prolong the lives of those who will die soon anyway.

[Kimstu]

My understanding is that doing the one means also doing the other.

Sorry, I meant that if health insurance is mandatory without a government-backed insurance system, then insured people will be vulnerable when their private insurance companies go tits up, as some private companies are bound to do in any market system, especially if they're no longer allowed to screen the most undesirable clients out of the risk pool altogether.

On the second point, I'm a bit confused myself. Why is it considered "out of pocket" when one has insurance?

One doesn't, at least if I'm understanding you correctly. "Consumer-driven" health care means things like health savings accounts, where the consumer pays out of pocket but gets a tax break on the cost, rather than insurance that undertakes to cover a wide range of potential costs. The idea is that not having insurance coverage will motivate the consumer to be more selective about health-care spending, thus cutting down costs. As my previous cite indicated, this doesn't seem to work very well in practice.

[tombigbee]

It's too complex and large a field for the layman to grasp ( and therefore make an informed decision )...

What did you think of some of these sites from the "consumer driven health care" link? I think the Internet is helping us become socialized toward checking out medical stuff ourselves (if "socialized" is the right word). NOTE: The links don't work -- it's copy and paste only.

"But for- and non-profit entrepreneurs have responded to the new demand for health information with various visionary health information ventures...

---

WebMD Health (www.webmd.com)
Subimo (www.subimo.com)
Healthline (www.healthline.com)
Healthia (www.healthia.com)
Interfit Health (www.interfit.com)
Wondir (www.wondir.com)
myDNA (www.mydna.com)
Consumer Reports (www.consumerreports.org)
MayoClinic.com (www.mayoclinic.com)

---

Meanwhile new models of healthcare provision are experimenting with upfront pricing...

---

MinuteClinic (www.minuteclinic.com)
RediClinic (www.rediclinic.com)
CashDoctor (www.cashdoctor.com)
SimpleCare (www.simplecare.com)

---

And insurnace companies are beginning to expose their previously proprietary negotiated prices...

---

G Boulton, "Health Plan Lifts Veil On Charges," Milwaukee Journal-Sentinel, 23 February 2006, http://www.jsonline.com/story/index.aspx?id=403820 "

[tombigbee]

We like to pretend that there's some difference between money being paid into the system through tax dollars, and money being paid in from elsewhere -- copayments, deductibles, co-insurance, etc.

AND

I would argue that medicine needs to be reconceived from top to bottom. I don't know if this is the place to go into that, or if it would just muddy the issue.

I just think we are better stewards of our money when it's closer to hand. With the huge aging population in every industrialized country, I don't think any system can afford waste/abuse. I have links to UK, Sweden and France citing mega health care budget problems, but I'm tired of doing links. :)

AND...Maybe not, but my sociology classes would tend to back you up. I'd love to discuss wild and/or sane ideas about health care, along with some other areas. We are in a major transition period in many areas of our society. For now, I'm having fun with this tread. If you start another one, please let me know!

[tombigbee]

All of the countries you mention spend far less per capita on health care than the US (some, such as Canada, spend less than half as much!) while still achieving better health outcomes.

What do you think of this situation?

"Another point to consider is that Spain takes a different view to rehabillitation, convalescence and terminal illness, leaving care in these cases usually to the relatives. There are very few public nursing and retirement homes, very few hospices and convalescence homes." Hot Topics: Healthcare (http://www.thinkspain.com/hottopics/healthcare/)

A roundabout way of bringing up rationing, doctor shortages, budget-overages, etc. (I'm testing you to see how many cites you request. :) ) Anyway, socialized systems may spend less per capita because there will always be pressure to keep taxes down, so they do less here and there, and means test some, stuff like that.

[GIGObuster]

I just think we are better stewards of our money when it's closer to hand. With the huge aging population in every industrialized country, I don't think any system can afford waste/abuse. I have links to UK, Sweden and France citing mega health care budget problems, but I'm tired of doing links. :)
Yeah, I have heard the same for more than 10 years in discussions like this and I am still waiting for them to default, tell me another one.

In the USA, for example, we now spend close to 15% of our GNP on health care, meanwhile:

http://www.sweden.se/templates/cs/BasicFactsheet____6856.aspx
Sweden's costs for its health services amounted to SEK 178 billion in 2000, a figure which includes pharmaceutical preparations and dental care. This corresponded to 8.5% of GNP

[Der Trihs]

Thank you. I like being told that I'm too stupid to make my own choices. Not stupid; ignorant. Unless you claim omniscience, I guarantee you are ignorant of something.

Should we also have the government provide cars and computers, because they are also so complex that the average laymen cannot grap the concepts around them?Using them isn't all that complex, compared to the entire field of medicine.

As for number 2 - cite. :dubious: You want a cite for the fact that medicine can save lives ?

I think the Internet is helping us become socialized toward checking out medical stuff ourselves (if "socialized" is the right word). Without an actual medical education, how can you tell if some medical advice you get over the internet is good, bad or outright fraud ?

What I hear in threads/discussions like this is that many people will trust corporations ( which have a motive to cheat you ) and unknown people over the internet, instead of the demonic force known as the govenment. That's just. . . bizarre to me.

We see in other countries that government funded/provided healthcare ( in several forms ) works just fine. American style healthcare is driving people to bankruptcy right and left. We should go to a system that actually works, instead of sticking with the American disaster of a "health care system".

[Happy Clam]

There is a fascinating article in this month's British Medical Review that suggests, based on the most recent information, that not only is the current US health system abandoning millions to disease, it is both less efficient and costs the US government more than equivalent programs in the UK, France and (I believe) Canada. Essentially, when you factor in funding for Medicare and Medicaid, support grants and tax write-offs for companies and (crucially) put in the extra cost of administrating the interaction between the various systems, health spending occupies 15% of US GDP (more than any other western nation- for comparison, UK is between 7% and 9%) and takes up a bigger chunk of government funding as percentage of spending than any other western country.

What conclusions can be drawn (other than that the system is in urgent need of change)? Well, I'm not sure. I'd say that the US is about sixty years overdue to move to full "nationalized" healthcare, paid for by the taxpayer (with private clinics still available, of course)- of course, such a system isn't perfect (as someone who has frequent interaction with the NHS in Britian, I know this better than most), but at least it would remove the current bizarre state of affairs where America has the most expensive and least effective healthcare in the developed world.

On the other hand, you could easily take the viewpoint that such a policy would be less efficient than, say, some sort of mandatory insurance scheme- on the other hand, if such a system is to be administered by the government I would argue that there is little differentiation between this and full-on "socialised" (such an ugly word- I'm a socialist and even I don't like it) healthcare, since only provision would be private, and even then the main customer being the government means that relatively little would be done to break the complex system of bureaucracy that is currently causing so much waste in the US system.

As others have pointed out above, some people choose to screw the system in a manner that wastes money- but you can both limit this by restricting what sort of treatment available and by co-ordinating healthcare provision with managment and local communities.

Ultimately, after all, isn't it in everyone's interest for the society in which you live to be healthy and relatively happy? It amazes me that getting some disease or injury when you lack health insurance can still be a serious threat in the US, one of the most advanced countries in the world. It sounds more like Victorian England than a modern state, and I would personally pay any percentage of my income (even the 40% top rate current in the UK) as tax to insure that I would not be left by the roadside after a car accident. Just as we don't debate whether the government should act to protect our water from pollution or our citizens from foreign invasion (in the most general terms), so it seems to me that the "consumer" cannot efficiently or rationally provide healthcare for themselves, and that the most basic function of government is to protect its citizens- including securing their health.

Of course, I am unacceptably tainted through having grown up in a socialist pluralist state where such things are taken for granted. No doubt had I experienced the US system at first hand I would be much quicker to extoll the virtues of a free-market based system. Why should my life come before the right of my doctor, drug company and health insurance firm to make a solid profit?

[tombigbee]

You're right. It's more that Sweden may have problems in the future.

Sweden currently spends just over 9% of its GDP on health care - a figure which has remained largely constant for the last 20 years, leaving the Scandinavian country with one of the best funded health systems in the world.

However, Sweden has the highest proportion of over 80s in Europe and will face unprecedented demands on its health and social care systems in coming years.

"In the 1980s there used to be money for everything. Now we are more limited and it does not look like we will be getting any more.

"I have noticed that there is more pressure to get people in and out of hospital quickly and that is not always best for patients.

"I think we have reached a turning point. It is a concern." Why I love the Swedish health system (http://news.bbc.co.uk/1/hi/health/4460920.stm)

How's their tax rate compared to ours, BTW? I have no idea.

[Happy Clam]

I just think we are better stewards of our money when it's closer to hand. With the huge aging population in every industrialized country, I don't think any system can afford waste/abuse. I have links to UK, Sweden and France citing mega health care budget problems, but I'm tired of doing links.

Interesting...I would argue that we are much worse stewards of our money when it comes to our own health, since A) our decision making is certainly weakened in extremisis (for example, lying in a hospital bed and B) there seems to me to be an unbridgeable dihcitomy between preseving the moral obligation of the physician to provide the best possible treatment and her understandable desire (as well as the desire of all her employers or those for whom she works as a supplier, e.g. drug companies) to make money. In this case, the government's writing a blank check for the individual's healthcare seems to me to be a much more sensible position. Then, of course, I would argue that the health service tends towards a natural monopoly- after all, you can hardly choose which hospital your ambulance should go to as you lie dying.

And as for problems of healthcare funding- the current system in America is, in sheer statistical terms, the least efficient in the western world. You may argue that an idealised free-market based system would be more efficient than nationalised medicine, but you cannot argue that the (free-market-based) healthcare system in America right now is less efficient than the (nationalised) healthcare system in, say, Sweden, the UK, France or Canada.

[Happy Clam]

How's they're tax rate compare with our, by the way?

Huge. Sweden is often quoted as being the most taxed nation in the world. I believe the top rate is 60% (I'll go look for a cite).

But they have excellent healthcare provision.

[MilTan]

What do you think of this situation?

"Another point to consider is that Spain takes a different view to rehabillitation, convalescence and terminal illness, leaving care in these cases usually to the relatives. There are very few public nursing and retirement homes, very few hospices and convalescence homes." Hot Topics: Healthcare (http://www.thinkspain.com/hottopics/healthcare/)

A roundabout way of bringing up rationing, doctor shortages, budget-overages, etc. (I'm testing you to see how many cites you request. :) ) Anyway, socialized systems may spend less per capita because there will always be pressure to keep taxes down, so they do less here and there, and means test some, stuff like that.

Yes, there is rationing in those systems. But that rationing doesn't exist in a vacuum. Rationing exists in the US too, we just don't call it that. It exists because tens of millions of people don't have any health insurance, and their care is rationed in so far as it is non existent (until they have to go to emergency rooms to get treated). It exists because the main way that cost increases were kept in check in the 90s was by moving Americans to managed care. What is a system where you must go to a primary care physician before seeing a specialist, where the set of doctors and hospitals you can go to and the types of procedures you can get are highly regulated but rationing under a different name?

You mention means testing, but what is denying the poor (although not the poorest) health care but a particularly perverse method of reverse means testing? You mention keeping taxes down by doing less here and there, but what is cuts in Medicaid but a method of doing less here and there mainly by denying the poorest in the name of keeping down taxes?

Basically, all the problems that you mention in other systems exist in some form or another in the US as well. We just don't call it that, and so can feel good about our healthcare system.

[wevets]

I think the US will be forced to go to a single-payer system as health care costs continue to rise (just IMHO).

A lot of people don't like the idea of government being responsible for it - I wonder what they would think of a quasi-governmental health care system, which would be connected only tenuously to the current branches of government. Something like the Federal Reserve, where governmental influence is somewhat restricted to the appointment of governing board members to 14 year terms. That should keep it relatively out of partisan politics. Or is the objection to government involvement based on something else?

[GIGObuster]

You're right. It's more that Sweden may have problems in the future.



How's their tax rate compared to ours, BTW? I have no idea.

And still it remains a "may". Virtually all reports against other systems are prepared by the same chicken little sources (or are made by the governments or local papers of their countries, funny thing is that when that is the case, the reports are made to prevent or warn about the problems. So far they usually take care of them or keep them in check), after more than 10 years in discussions like this (had several like this at UC Berkeley) I'm not trusting reports that usually are coming from the same folks that want to keep the current status quo.

A status quo that includes 45 million Americans that are uninsured and even more are not ensured properly, includes paying more and have less people being taken care off, and also the situation is getting worse:

http://www.medicalnewstoday.com/medicalnews.php?newsid=36157
American College of Physicians Predicts Looming Crisis In Primary Care, USA

In its annual "Report on the State of the Nation's Health Care," ACP focuses on the looming crisis in primary care and why reform of the payment system is essential to prevent this crisis.

There is growing evidence that shortages are developing for U.S. physicians, particularly in general internal medicine and family practice. Previous expectations of an excess supply of physicians have not materialized. Current projections indicate that the future supply of primary care physicians will be inadequate to meet the health care needs of the aging U.S. population.

This decline is the result of the current dysfunctional payment system for physicians' services. Primary care is under-reimbursed compared to other specialties, and many primary care physicians are struggling to keep their practices open at a time of escalating practice costs and excessive paperwork requirements that take time away from patients. The 4.4 percent cut in Medicare physician fee schedule payments that went into effect on Jan. 1 will only serve to exacerbate this problem.

http://www.dukenews.duke.edu/2006/03/nursing_oped.html
I recently left full-time nursing to help train future nurses and, this past year, to work on health care issues in Washington, D.C., for a leading U.S. senator. I learned in detail about good ideas such as “pay for performance measures” to help monitor quality, and electronic health records to improve efficiency. But I also followed with interest the contentious debate over proposed health savings accounts for individuals.

Proponents say these accounts will harness market forces to expand care for millions of people. Based on research and what I’ve seen personally, however, I don’t see how the accounts will provide much help for countless patients with chronic illness. Patients who lack health care are likely to forego the accounts and spend their money on other needs. Or, if they do purchase basic coverage, the deductibles will be so high they’ll avoid getting routine care.

This may sound like an acceptable trade-off to policy makers, particularly those who believe in market forces and avoiding “handouts” that discourage hard work. But grand policies can look very different when you’re the person worrying about an asthmatic child or a spouse battling schizophrenia. As an ED nurse, I witnessed far too many uninsured patients leaving with prescriptions for critical medications when they could barely afford their bus fare home.

Health care is difficult, both in the field and in the policy arena, but the least we owe people who are struggling is to stop fooling ourselves that we are a compassionate nation where only lazy and immoral people go without health care. That is a myth we are telling ourselves to feel better. It certainly is not the “law of the land” -- unless, of course, we choose to make it so.

[Anne Neville]

It sounds more like Victorian England than a modern state, and I would personally pay any percentage of my income (even the 40% top rate current in the UK) as tax to insure that I would not be left by the roadside after a car accident.

That, at least in theory, doesn't happen under our system of paying for health care.

What does happen, and not all that rarely, is that uninsured or under-insured people go into serious debt due to health care costs. Or the emergency room (which is required by law to treat anyone in need, regardless of ability to pay) becomes their only source of health care. People generally can get health care in an emergency situation, but they may bankrupt themselves in doing so.

I think our current health care system is a disgrace to us, but don't make it out to be worse than it actually is.

One problem I see mentioned in the context of reforming health care is the expense to doctors of malpractice insurance (and unnecessary tests that can be run to avoid the possibility of a malpractice suit). Does the government in any of the countries with socialized medicine have some way of keeping that expense under control? Or can people not sue doctors in those countries, because the doctors work for the government?

[Shagnasty]

That, at least in theory, doesn't happen under our system of paying for health care.

Correct. No one gets left beside the road or turned away from an emergency room. That is part of the problem from a system design standpoint. Not everyone has insurance but everyone can get care and the financial burden just drops all over the place and it is not designed to handle that correctly.

It is very easy to game the system. If you are poor or just don't have health insurance you make make a doctors appointment any time you want just by showing up at the emergency room of the best hospital you can find. They treat plenty of colds and sniffles there and while you are there, you can ask about those bunions etc.

If you really do have an emergency, once you are in the system, you are in. You can run up hundreds of thousands of dollars in bills before the hospital knows who is going to pay.

[Anne Neville]

It is very easy to game the system. If you are poor or just don't have health insurance you make make a doctors appointment any time you want just by showing up at the emergency room of the best hospital you can find. They treat plenty of colds and sniffles there and while you are there, you can ask about those bunions etc.

Exactly, and that's why the rest of us, who don't game the system, have to wait so long in emergency rooms.

[spazattak]

There, there, nobody's calling you stupid. Der Trihs is just pointing out that medicine is an extremely complex and specialized subject, and the average consumer doesn't have the necessary specialized training to make wise choices about treatment. See the excerpt from my linked article above:

Lack of specialized knowledge != stupidity, but it can lead to poor choices anyway.

This same logic still applies to my analogies. We go to doctors, friends, family, the internet, etc so that they can enlighten us on making those choices. We [atlease those of us responsible enough] go to similar sources on doing research for any major expenditure. Its our own personal responsibility to make educated choices, even (and especially) in complicated matters. Individually, we're the only ones qualified to do so.

Nope, the majority of costs come from a minority of the population needing expensive treatments. Again from my link:

Moreover, (http://www.24hourfitness.com/html/corp_well/savings/cost/)

So yes, I think it's probably fair to say that a majority or thereabouts of US health care spending is spent either to save the lives of people with expensive conditions, or to prolong the lives of those who will die soon anyway.
Well this would seem like the main problem with healthcare then, no? You cut the 'anything to keep them alive' routine and you dramatically cut healthcare costs - thereby dramatically cutting insurance costs - thereby making it more accessible. Am I wrong anywhere here?

[Anne Neville]

Well this would seem like the main problem with healthcare then, no? You cut the 'anything to keep them alive' routine and you dramatically cut healthcare costs - thereby dramatically cutting insurance costs - thereby making it more accessible. Am I wrong anywhere here?

OK, you run for office on a platform of passing a law saying that anyone who is on life support has to be taken off, and that certain patients should be left to die instead of receiving medical treatment. You'll piss off the "culture of life" types and the majority of us who don't think the government should be involved in such decisions. You've gotten liberal me to agree with Terri Schiavo's parents on a political issue- that's impressive. I think I've got a few candidates I'd like you to run against...

[tombigbee]

MilTan I really don't think it's fine, but I'd like some reassurances about issues I've raised with other systems if possible. Most have problems, similar to ours or different from ours, but problems. Like in Spain, where they rely on families more... It may not be a problem for them, but that will hardly work well here -- who can take the time off from work? (On the cite I used it wasn't clear if families received assistance for caregiving duties.)

This is a post I made to my classmates:
A problem with the American health care system is how to provide adequate long-term care in either an institution or in a home setting. Institutions generally have to watch expenses and follow regimented schedules, which interferes with individualized caregiving.

In presenting the Family and Medical Leave Act, the author [of the textbook] makes this point:

"In addition, the law is problematic because it reinforces the idea that caring for ill and disabled persons is the responsibility of the family--which, in practice, usually means women relatives--rather than the responsibility of society as a whole."

I tend to agree with sociologist Andrew Cherlin that public policy in America needs to promote the public family because no government can afford (financially) to do the caregiving tasks done by families. He says the main role of the public family is to take care of children, the frail elderly and the ill.

I think one challenge in supporting the work of the public family is in getting men to take on a caregiving role -- or sharing it -- more often.

The main problem with institutional settings seems to be quality of care -- and it's the same problem seen in public schools and daycare facilities. The people who work in these institutions should make more money and they should have fewer "charges" so they can have more individual interactions. Some might suggest the problem would be solved if government took care of funding, but public schools are non-profit and government-funded, and yet there are still too many kids in many classrooms.

Nursing homes discussed in the textbook had problems with quality of care. The two sections, "Working in Nursing Homes" and "Life in Nursing Homes" reminded me of life in a daycare center. I had to follow certain steps each time I changed a baby's diaper, and I had to document it. I had no time to play with the babies with all the federally-mandated stuff I had to do. Why? CYA - somehow the public, specialists etc. determined that each step is terribly important -- and it probably is. But as the book points out, there is no time for caregiving. In nursing home settings, the book points out that there is also no training for caregiving; I believe the focus in nursing homes is also on doing the steps mandated by federal or state regulations just as it was in the daycare center.

Here's why I don't think socialized health care will fix this problem:

Care of elderly a 'national disgrace' (http://news.bbc.co.uk/1/hi/health/695997.stm) BBC News

Patients face bill for long-term care (http://news.bbc.co.uk/1/hi/health/371855.stm) BBC News

The government will have to try to be good stewards of taxpayers' money, so I don't think the pressure to minimize costs will disappear.

I like the proposed legislation, MiCassa, which would allow Medicaid (and Medicare??) dollars to follow the person so they can choose where they would receive services and support.

I wish there was more tweaking/debating of whomever's alternate suggestions or discussion on how we can avoid problems in other countrys' systems.

[GIGObuster]

Here's why I don't think socialized health care will fix this problem:

Care of elderly a 'national disgrace' (http://news.bbc.co.uk/1/hi/health/695997.stm) BBC News

Patients face bill for long-term care (http://news.bbc.co.uk/1/hi/health/371855.stm) BBC News

The government will have to try to be good stewards of taxpayers' money, so I don't think the pressure to minimize costs will disappear.

I like the proposed legislation, MiCassa, which would allow Medicaid (and Medicare??) dollars to follow the person so they can choose where they would receive services and support.

I wish there was more tweaking/debating of whomever's alternate suggestions or discussion on how we can avoid problems in other countrys' systems.

:sigh:

Just like I also said in a previous debate: the people there make reports like this to find solutions for the current problems not to overhaul the system:

From the last link you posted:
Charities are now calling on the government to implement proposals from the Royal Commission on Long Term Care that all care, both medical and personal, should be free.

[tombigbee]

GIGObuster, the site you linked to had this info:

"The number of elderly people has risen substantially-with the greatest rise in the age group 80 years and older. Sweden is seen as having the world's oldest population, with 18% aged 65 or over. In spite of the democratic principles espoused by Swedish society, there are marked differences in health between different social groups, and these differences are growing."

Do you have an opinion about how we can avoid this here, or whether it is simply unvoidable?

[tombigbee]

:sigh:

Just like I also said in a previous debate: the people there make reports like this to find solutions for the current problems not to overhaul the system:

From the last link you posted:

Right, I understand. Do you think the solutions will cost more money, increase per capita spending? I saw an article about reforms France was proposing for 2004 or thereabouts for "projected overspend this year of eight billion pounds." I havn't found an update about how it's going, if it's working, etc. Have there been specific reforms in any country that you've liked and/or disliked?

[GIGObuster]

GIGObuster, the site you linked to had this info:

"The number of elderly people has risen substantially-with the greatest rise in the age group 80 years and older. Sweden is seen as having the world's oldest population, with 18% aged 65 or over. In spite of the democratic principles espoused by Swedish society, there are marked differences in health between different social groups, and these differences are growing."

Do you have an opinion about how we can avoid this here, or whether it is simply unvoidable?

It is happening here too, where have you been? Just the recent robbery and mishandling of medicines for the elderly should have gave you pause, and no it is not unavoidable, as I saw before, other "dire" problem in Sweden (I think it was people abusing their stays in the hospitals) was solved after a similar report 5 years ago.

Anyhoo.. This American irrational health care has gone far enough, too far even for American standards, you want to say that we should take care of our money, well, other systems use less money. Who gets more money in this irrational system that we currently have? CEOs of big farma and insurance. Can you guess were the millions that go to buy lobby congress to prevent even a discussion regarding the current fleecing of America is coming from? In the end it is not the CEO's...

[cerberus]

Let's not jump on the Canadian Model too prematurely:

some of them are shifting to private sources (http://www.cbc.ca/story/canada/national/2005/06/09/newscoc-health050609.html), and private care is alive and well. (http://www.cbc.ca/news/background/healthcare/public_vs_private.html)

At they seem to use the correct number of snakes on their shafts. (http://drblayney.com/Asclepius.html)

[GIGObuster]

Let's not jump on the Canadian Model too prematurely:

some of them are shifting to private sources (http://www.cbc.ca/story/canada/national/2005/06/09/newscoc-health050609.html), and private care is alive and well. (http://www.cbc.ca/news/background/healthcare/public_vs_private.html)

At they seem to use the correct number of snakes on their shafts. (http://drblayney.com/Asclepius.html)
Good, that was the only big item I had against the Canadian system, virtually all systems in Europe are a mix of private and public health care.

[mr_moonlight]

The two fundamental problems that come with mixing capitalism and health care are that it's too complex and large a field for the layman to grasp ( and therefore make an informed decision ), and that people often have no choice but to buy. People in America pay medical bills that ruin their lives, because the alternative is death. When one side in a transaction has such a huge advantage, capitalism becomes fairly indistinguishable from robbery.
Under any health care system, as a patient you will be faced with several options on how to deal with a health problem, and one or more doctors with possibly conflicting opinions will be advising you. Ultimately you will have to decide for yourself how to proceed. Patients will always have to make their own decisions (informed or not) unless treatments become forced on us, and I doubt anyone here is suggesting that.

Complexity in medicine is universal, and patients have to deal with it the best they can, no matter who is paying the bills. I don't see how socialized health care makes medicine safe for the ignorant.

[mr_moonlight]

Most (but not all) health problems appear to me to be directly linked to a patient's lifestyle. Tobacco, alcohol, narcotics, fast food, sedentary lifestyle, etc. all have an obvious effect on one's health. Genetics plays a role too, but genetics can often be compensated for with lifestyle adjustments, e.g. adult-onset diabetes can be avoided or cured with weight loss and diet modification.

Socializing the costs of medicine appears to me to be a way to transfer the costs of one's unhealthy habits to others. This seems immoral to me. Can someone explain to me why a fit, non-smoking adult, who chooses to forgo cable TV in order to spend extra money on a diet high in fresh fruits and vegetables should have to pay for the insulin shots of the Twinkie-eating chain-smoking couch potato that lives next door?

Does that same couch potato have the right to rob the healthy next-door neighbor at gunpoint to pay for his diabetes medicines? If not, then why would you believe it is right when a government does this?

(Apologies to any diabetics reading this--I don't mean to imply that all diabetics fit the above stereotype. I'm exaggerating to make the point.)

[clairobscur]

Does the government in any of the countries with socialized medicine have some way of keeping that expense under control? Or can people not sue doctors in those countries, because the doctors work for the government?

I can only speak for France. First, most doctors don't work for the government, though the majority of doctors working in hospitals do, since the wide majority of large hospitals are public (private hospitals tends to be smaller, more specialized, and to treat less serious conditions, generally speaking).

Until relatively recently, the courts' jurisprudence made very hard to get any dammage in case of medical error because the mistake had to be exceptionnally egrerious. But over the years, this standart was progressively relaxed, up to eventually accepting to grant damages in some cases when there was no fault at all (for instance harmful treatments prescribed at a time when it was not known they could have negative effects).

This evolution plainly followed societal changes. The french population used to accept the idea that generally speaking doctors were trying to help you, not harm you, that mistakes were unavoidable, and that if something bad happened to you it was unfortunate, but barring malevolence, utter incompetence or stupidity you didn't have much to complain about. Shit happens, after all. They don't think this way anymore, and at the contrary (not only in the field of medicine, mind you) I see more and more examples of dubious lawsuits and of the "*someone* MUST be responsible" mentality that is so often denounced in the USA.


It seems to me that people are still much more reluctant to sue doctors and hospitals than in the USA (actually, much more reluctant to sue anybody), and maybe even have more confidence in healthcare professionnals (completely subjective feeling of mine). However, this evolution of the courts' decisions nevertheless produced the expected results : the malpractice insurance costs rised significantly and in some specialities like obstetrics, dramatically.


So, no. It has nothing to do with the government trying to keep these costs in check, or people not being allowed to sue doctors, but it's plainly, IMO, societal. As I already said, courts are just miroring in their decisions the general population's feelings.

[clairobscur]

Exactly, and that's why the rest of us, who don't game the system, have to wait so long in emergency rooms.


But is it "gaming the system" if you don't have any other access to medical care?

[clairobscur]

I wonder what they would think of a quasi-governmental health care system, which would be connected only tenuously to the current branches of government. Something like the Federal Reserve, where governmental influence is somewhat restricted to the appointment of governing board members to 14 year terms. That should keep it relatively out of partisan politics.


Only to some extent. In France, the public healthcare system isn't ran by the government, but by an entity headed by half elected representative of the unions and half elected representatives of the employers (for historical reasons : the french public healthcare system was build upon the existing systems put in place by collective agreements in various industrial branches and originally covered only workers and retired workers).

However, essentially any significant decision has to be accepted (if not imposed)by the government because it requires some sort of legislation to be enforceable. And when people, or doctors, etc... are unhappy with something related to the healthcare system, it's the government that gets the flak, and legitimately so, because when all is said and done, it's still up to it to decide. An unelected body would hardly have the legitimacy to make decisions that impact directly people's life (or even death), people's paychecks, etc....

[Der Trihs]

I don't see how socialized health care makes medicine safe for the ignorant.For one thing, it's not run by people who have a financial motivation to screw you.

Does that same couch potato have the right to rob the healthy next-door neighbor at gunpoint to pay for his diabetes medicines? If they have no other means of getting the medicine, then yes. Survival trumps property rights, and a society that doesn't bother to provide health care to those who need it has already announced it's time for the law of the jungle anyway.

But is it "gaming the system" if you don't have any other access to medical care?IMHO, yes, but it's justified gaming.

[clairobscur]

Right, I understand. Do you think the solutions will cost more money, increase per capita spending? I saw an article about reforms France was proposing for 2004 or thereabouts for "projected overspend this year of eight billion pounds." I havn't found an update about how it's going, if it's working, etc.


I don't know if it will work, but yes, a number of reforms have been implemented.

For instance, a number of drugs with an "unsufficient medical benefit" aren't reimbursed anymore, or only partially reimbursed (don't worry, homeopathy is still partially reimbursed due probably to its well proven efficiency).

Also, there's 1€ co-pay for each visit to a doctor that isn't reimbursed nor by the healthcare ysem, nor by the mutual insurances(*).

You won't be able to see a specialist without being refered to him by a generalist first and be fully reimbursed anymore.

And finally we'll have to pick a generalist and to "register" with him to be fully reimbursed. You can switch to another if you want to and I understand that's it's intended to prevent people from seing half a dozen different doctors for the same issue but I still don't like the concept of not being able to see whoever I want whenever I want. It makes perfect sense when your medical expenses are covered by the collectivity, but I've not been accustomed to that. Besides, I had actually two doctors, who are twin brothers working in the same cabinet, and having to choose one put me in a diplomatically delicate situation.




(*) There are complementary insurances in France, and many of them, rather than for-profit companies owned by stockholders are "mutual insurances", non-profit organizations ran by the elected representants of the insured people. They're also very influential in healthcare policies since they're federated and generally mostly in agreement and represent a huge number of people. I've always been surprised that these are apparently mostly non-existent in the USA. I just received the documents for the election of the board of directors of my insurer, for instance, and I certainly think it beats being dependant on the decisions made to please stockholders.

[clairobscur]

Socializing the costs of medicine appears to me to be a way to transfer the costs of one's unhealthy habits to others. This seems immoral to me. Can someone explain to me why a fit, non-smoking adult, who chooses to forgo cable TV in order to spend extra money on a diet high in fresh fruits and vegetables should have to pay for the insulin shots of the Twinkie-eating chain-smoking couch potato that lives next door?


Problem is : since in the USA, you don't leave people with unhealthy habbits die in the streets, when fire comes to stove, you also end up footing the bill for these people.

Which is the right thing to do, anyway, IMO. Especially since it's difficult to assess who has unhealthy habbits. For instance I don't own a car, and cars are notoriously dangerous. Should I pay when a car-owner needs medical care because he was involved in an accident?

[yojimbo]

Socializing the costs of medicine appears to me to be a way to transfer the costs of one's unhealthy habits to others. This seems immoral to me. Can someone explain to me why a fit, non-smoking adult, who chooses to forgo cable TV in order to spend extra money on a diet high in fresh fruits and vegetables should have to pay for the insulin shots of the Twinkie-eating chain-smoking couch potato that lives next door?
It's just more obvious when it's a tax aided system. Someone still has to pay. In the States if the couch potato has insurance then they pay and the price of insurance will cover this cost. Even if the employee doesn't pay the company he works for does and so the employees job may not be as secure due to medical costs for the company.

At the end of the day you still are paying directly or indirectly for the medical of others. One advantage a socialized system delivers is that it generally helps the poor to stay healthier than they would in a US type system. I've read lots of examples on the SDMB of people not seeking out medical help because of the costs. Something that may cost a few hundred bucks to fix is let become something that eventually costs thousands to a ER because of the patients inability to pay.

[spazattak]

OK, you run for office on a platform of passing a law saying that anyone who is on life support has to be taken off, and that certain patients should be left to die instead of receiving medical treatment. You'll piss off the "culture of life" types and the majority of us who don't think the government should be involved in such decisions. You've gotten liberal me to agree with Terri Schiavo's parents on a political issue- that's impressive. I think I've got a few candidates I'd like you to run against...

If I'm pissing everyone off, I must be on to something :P And I mostly agree with you - laws aren't the best way to go about fixing problems. I think getting the major players in the healthcare industries and the insurance industries to sit down together and start evaluating treatments based on expected returns might do alot for the situation. Maybe legislate some incentives to instigate the changes... Though, since this is where the bulk of their income is, they might be hesitant to change. And I'd be more than happy to run on an unpopular platform (I think it'd be fun to spin this into something more palletable for the general population), are you going to fund me? Senator Spaz.. I like the sound of that :P

[tombigbee]

and private care is alive and well. (http://www.cbc.ca/news/background/healthcare/public_vs_private.html)

At the end of the above article:

Schumacher argues further privatization will not spell the end of medicare as we know it. “People worry that if doctors can go private, then they’re going to quit the public system. I would argue the opposite. If a doctor can take part of their practice private, they’re less likely to leave because they’re not tied solely to the government’s fee schedule.”

I know the definition of "medicare" there is different than it is here, but they are comparable I think. Isn't it a trend here that doctors are seeing fewer or no Medicare patients?

[WaryEri]

At the end of the above article:



I know the definition of "medicare" there is different than it is here, but they are comparable I think. Isn't it a trend here that doctors are seeing fewer or no Medicare patients?

Not all that comparable. Canadian Medicare is universal. Canadian doctors seeing no Medicare patients would see few patients indeed.

[spazattak]

For one thing, it's not run by people who have a financial motivation to screw you.

OK I call bullshit on this. How can you possibly reach this conclusion? Government has just as much, if not more motive to screw you. Elected officials are only there for a limited time. Get in - exploit the system personal gain - get out. There's no one to answer to after that. Companies atleast have to look after their own reputation.

If they have no other means of getting the medicine, then yes. Survival trumps property rights, and a society that doesn't bother to provide health care to those who need it has already announced it's time for the law of the jungle anyway.

I disagree. The couch-potato-diabetic could have just as easily changed his diet and started excersizing as he robbed his neighbor. By arguing at the extremities (life/death situations) you're not doing justice to the average folks who just have allergy problems, or just need a doctor once in a while when they get sick. You can't create a system tailored to the minority. It will, by definition, be an unfair system. You should treat the terminal like what they are - the exception.

[Voyager]

And finally we'll have to pick a generalist and to "register" with him to be fully reimbursed. You can switch to another if you want to and I understand that's it's intended to prevent people from seing half a dozen different doctors for the same issue but I still don't like the concept of not being able to see whoever I want whenever I want. It makes perfect sense when your medical expenses are covered by the collectivity, but I've not been accustomed to that. Besides, I had actually two doctors, who are twin brothers working in the same cabinet, and having to choose one put me in a diplomatically delicate situation.

My very good private insurance works this way. I'm registered with a large group. I have a primary doctor, but in a pinch others from the group can see me also. The group also has specialists, but I can go outside it when necessary. Does the proposed system require you to see one doctor, or allow you to see others in an office?

I like the system, actually, since there is continuity of care. My late mother in law had constant issues with drug interactions, from seeing different doctors for different issues, and I think this kind of policy has benefits in reducing that kind of problem.

[Voyager]

I disagree. The couch-potato-diabetic could have just as easily changed his diet and started excersizing as he robbed his neighbor. By arguing at the extremities (life/death situations) you're not doing justice to the average folks who just have allergy problems, or just need a doctor once in a while when they get sick. You can't create a system tailored to the minority. It will, by definition, be an unfair system. You should treat the terminal like what they are - the exception.
I hate to break this to you, but we're all going to be terminal at some time or another. Some of us will conveniently die quickly, though.

What I'd like to know is how you're going to distinguish this couch potato from someone with genetic problems, who sucks up health care for no fault of her own. I'm naturally healthy, and have chloresterol low enough that not even my doctor complains, but this is from the luck of the draw, not from any great moral edge I have. The whole point of insurance is to spread risk across as large a population as possible. That's why a single payer system will always beat a multiple payer system using the same rules.

I haven't seen the overhead the current system adds to doctors' offices addressed either. Each doctor's office, or even my small dentist's office, has at least one person working full time to handle insurance and billing issues. I'm sure this overhead could be mostly eliminated with a single payer system. Those living in such a system - do your doctors have insurance specialists associated with them?

[spazattak]

but with a single payer system.. whats to stop one from strong-arming the other? Especially when one is The Law? How would you drive innovation in healthcare management? Instead of your office employee, you'd replace it with a local government office to handle payment and whatnot?

[tombigbee]

Not all that comparable. Canadian Medicare is universal. Canadian doctors seeing no Medicare patients would see few patients indeed.

I would like to quit comparing things to what we have now (although I did it myself.) We obviously need reform. Consider this from The New York Times, 2/2006:

Canada has a national doctor shortage already, with 1.4 million people in the province of Ontario alone without the services of a family doctor.

I recognize that they are working to remedy this problem, but what caused it? Is it because they didn't have a mix of public and private like with other systems in Europe? Have European systems solved this problem?

[tombigbee]

Yet another problem with consumer-directed care is that the evidence says that people don't, in fact, make wise decisions when paying for medical care out of pocket. A classic study by the Rand Corporation found that when people pay medical expenses themselves rather than relying on insurance, they do cut back on their consumption of health care—but that they cut back on valuable as well as questionable medical procedures, showing no ability to set sensible priorities. [...]

Ok, I'm no longer for consumer-directed care being the sole solution. What if we had a mixure? I like HSAs because that's how I paid for my elective eye surgery. Also, I would like health insurance policies to be more consumer-friendly.

If we went to mandatory insurance, paid for by employers but making it completely portable and individually-owned, consumers would choose their insurance plan. I can choose between plans now during open season, but I have a hard time understanding the brochures and comparing benefits.

I have not researched what is proposed for unemployed people, but first things first.

That goal [consumer-driven health care] is the underpinning of the health savings accounts touted by President Bush and others as a way to check rising health care costs. The accounts, which allow people to save money for medical expenses tax-free, are paired with health plans with high deductibles. (my bold)

Disclosing limited information on prices and quality, though, is just the first step. Employers now must get people to use it.

"You have to get consumers to understand the role they play in controlling health care costs," said Dianne Kiehl, executive director of the Business Health Care Group. JS Online:Health plan lifts the veil on charges (http://www.jsonline.com/story/index.aspx?id=403820&date=2/23/2006)

[Voyager]

but with a single payer system.. whats to stop one from strong-arming the other? Especially when one is The Law? How would you drive innovation in healthcare management? Instead of your office employee, you'd replace it with a local government office to handle payment and whatnot?
The government is strong arming people now. The Times yesterday reported that pharmacists in Texas came to the White House to complain to Rove that they were losing money on the new Medicare program, since they were forced by the plans to take less than their costs. This is the same plan, remember, that forbade negotiating with drug companies. The pharmacists are Republicans, and they're pissed. Anyhow, what you call strong arming I call negotiation. The US is clearly getting ripped off.

As for savings - the insurance interfaces in the places I go seem to know the magic numbers to use to assign to procedures so the insurance companies will pay, get pre-approval of procedures, and understand the zillions of different plans their patients are covered by, with zillions of different forms. Don't you think one standard plan will save lots of money?

[tombigbee]

That's why a single payer system will always beat a multiple payer system using the same rules. I haven't seen the overhead the current system adds to doctors' offices addressed either. Each doctor's office, or even my small dentist's office, has at least one person working full time to handle insurance and billing issues. I'm sure this overhead could be mostly eliminated with a single payer system.

What if the costs to include the uninsured in a single payer system equaled out to about the same as before -- as in Taiwan's case?

Considering the problems in other systems that they are having to tweak/reform and not knowing at this point if they will work, if they will solve budget problems, or avoid the coming crisis with long-term care for the huge number of seniors, and considering that there are proposals to address administrative costs/efficiency issues anyway, should we still choose socialized health care over mandatory insurance, etc?

The moral choice has to include a way for everyone to have insurance, IMO. Considering a population that is divided between conservatives, moderates and liberals, that overwhelmingly either chooses not to or has barriers to exercising regularly and making the wisest food choices, etc., and that is likely to continually fight over tax rates....

...given all that and supposing that we will have to make compromises before anything is changed nationwide, and stressing again the hypothetical "what if the costs were about the same," would mandatory insurance, etc. be acceptable? Anyone?

Our data show that Taiwan was able to adopt the NHI without using measurably more resources than what it would have spent without the program. Lessons from Taiwan (http://www.hsph.harvard.edu/phcf/Papers/does%20universal%20health%20insurance%20make%20health%20care%20unaffordable.pdf)

[Voyager]

What if the costs to include the uninsured in a single payer system equaled out to about the same as before -- as in Taiwan's case?

It would be an excellent result. Thanks for the link - I just browsed it, but it is good data. It sounds like in Taiwan, at least partially, reduced transaction costs paid for the previously uninsured. I think we might do better, since more insurance could mean more prevention, and thus lower cost and earlier treatments. But even if this does not happen, care for all at the same price is a good thing.

Considering the problems in other systems that they are having to tweak/reform and not knowing at this point if they will work, if they will solve budget problems, or avoid the coming crisis with long-term care for the huge number of seniors, and considering that there are proposals to address administrative costs/efficiency issues anyway, should we still choose socialized health care over mandatory insurance, etc?

Everyone is going to have the senior problem. I heard Lester Thurow say China is going to get hit worse than us because of their low birthrate. As for problems, anything we adopt will have problems, but they seem to be less than the ones we have today.

As for mandatory insurance, I have some questions. Does everyone get the same coverage? How many hours are required for coverage? My daughter knows people employed by retailers with good insurance who can only get a number of hours per week that is just below the minimum needed for the insurance to cut in. If there are loopholes that allow employers to cheap out to reduce their costs, they'll often take them. Of course, keeping the same multipayer system won't reduce paperwork as much, and thus not reduce costs. So, I'm not sure it is a good idea in practice.

[tombigbee]

I knew I messed this up! I meant what if the costs to move to a mandatory insurance, etc. system cost us about the same as now? It seems Taiwan didn't save any money going National -- is it unaceptable if we don't save any money going Mandatory?

I looked at the National Center for Policy Analysis to see what's being proposed, and it looks like PT would be covered, and that people would choose between different plans. I don't know if that means that every 60-year-old could get the same coverage or not, but it makes sense that a 20-year-old and a 60-year old would have different needs. I'll keep looking...

Reform No. 8: Insurance Options for Part-time Employees. Part-time work is common, especially for single mothers and spouses in two-earner couples. While some need health insurance, those who don’t should be able to choose between health insurance and higher wages. As in the previous example, employers generally cannot give their employees such choices under current law. NCPA Brief Analysis 497 (http://www.ncpa.org/pub/ba/ba497/)

[Gorsnak]

I recognize that they are working to remedy this problem, but what caused it?
What is the root cause of the doctor shortage? A shortage of places in university medicine programs. It's certainly not a shortage of people wanting to become doctors, as entry into medicine is ridiculously competitive. I have no clue why more positions aren't made available, but I really can't see how it is in any way related to our socialized medicine.

[BrainGlutton]

What is the root cause of the doctor shortage? A shortage of places in university medicine programs. It's certainly not a shortage of people wanting to become doctors, as entry into medicine is ridiculously competitive.

Is that true? I thought doctors in Canada earned considerably less money than in the U.S. And yet students are still pounding on the door for a chance to spend four+ years preparing for such a career?

BTW, this seems as good a time as any to revive this old GQ thread -- "How does the rise health care costs since the '50s compare to rate of inflation?" -- http://boards.straightdope.com/sdmb/showthread.php?t=333560 -- to which I never got a satisfactory answer. If you think you know something, please go there and weigh in.

[Voyager]

I knew I messed this up! I meant what if the costs to move to a mandatory insurance, etc. system cost us about the same as now? It seems Taiwan didn't save any money going National -- is it unaceptable if we don't save any money going Mandatory?

I bet they saved on social costs of uninsured people, such as lost work, dependence on relatives, etc. If Mandatory had the same result, that would be fine with me. The issue is that the US pays more for a worse outcome than other societies. It would be nice to pay less for a better outcome, but paying the same for a better outcome would at least be a step forward.

I looked at the National Center for Policy Analysis to see what's being proposed, and it looks like PT would be covered, and that people would choose between different plans. I don't know if that means that every 60-year-old could get the same coverage or not, but it makes sense that a 20-year-old and a 60-year old would have different needs. I'll keep looking...
Your quote says that people can not trade off salary vs. health insurance. That's not quite true. Many cafeteria plans, like the one I'm in, force minimum coverage, but have different levels at different costs.

As has been mentioned above, you have to be a bit careful about different levels of benefits, since young people tend to subsidize old ones. That doesn't mean all coverages have to be identical.

I don't know that it is impossible to give part-timers the same options as full-timers have today. Perhaps it is impossible to let them opt out of the system if health care is offered. I doubt this is the reason it isn't offered in so many places, though.

[tombigbee]

I have no clue why more positions aren't made available, but I really can't see how it is in any way related to our socialized medicine.

Why not hire doctors who trained in other countries? The author of the article quoted below agrees with you in part, but then goes on to include factors from the socialized system. No solutions were proposed.

The doctor shortage is not as much about a shortage of bodies but also points to a shortage of resources. Why Not Ease the Doctor Shortage with Foreign Graduates? (http://www.aresearchguide.com/drkshort.html)

[tombigbee]

If Mandatory had the same result, that would be fine with me. ...but paying the same for a better outcome would at least be a step forward. Yeah!

Your quote says that people can not trade off salary vs. health insurance. That's not quite true. Many cafeteria plans, like the one I'm in, force minimum coverage, but have different levels at different costs. Maybe it's just unusal. ?? I've not needed my employers' insurance plans for years. One international company reimbursed me somehow (can't remember now) for what they would have spent -- it wasn't an increase in hourly wages, but should be considered an increase in salary. At a small company where I worked recently, it was take the insurance or nothing. I'm not sure if you are taking issue with mandatory insurance, etc. here, so I'll move on.

That doesn't mean all coverages have to be identical. So, you don't consider it a requirement if we go to mandatory insurance, you just wanted to know if that was part of (someone's) proposal? If yes, I'll leave off researching this for now.

[tombigbee]

How does the rise health care costs since the '50s compare to rate of inflation?

Just curious -- why did you pick the 50s?

[Voyager]

Maybe it's just unusal. ?? I've not needed my employers' insurance plans for years. One international company reimbursed me somehow (can't remember now) for what they would have spent -- it wasn't an increase in hourly wages, but should be considered an increase in salary. At a small company where I worked recently, it was take the insurance or nothing. I'm not sure if you are taking issue with mandatory insurance, etc. here, so I'll move on.

Just a point of information. Cafeteria plans are common at big companies. You get a certain amount of money to be spread over health insurance and other types of insurance. You pay more if the money available doesn't cover (common) but if you don't use it all, you get money back. So going to a lower coverage plan is an increase in salary.

So, you don't consider it a requirement if we go to mandatory insurance, you just wanted to know if that was part of (someone's) proposal? If yes, I'll leave off researching this for now.
There's insurance and there's insurance. If the mandatory amount was a WalMart like plan with very high deductibles, it is different from a plan like the Taiwan one with copays. Titles don't mean much. When I lived in New Jersey we had "no fault" car insurance which supposedly costs less, but the threshold for suing was so low it was a total joke. I can easily see those against universal heath care offer a mandatory insurance plan that would be almost useless also. So I withold judgement until I see more details.

[tombigbee]

BrainGlutton, I think the quote below is comparing health care costs and inflation from 1965 to the 1990s, but I'm not sure. (my bolding) I'm glad I found this site, FISpace, in researching your question, BTW. It's in my favorites list now.

In 1965 Medicare became law, and set off a golden age of medicine with the promise to pay “customary and usual fees’’. For the first time there was a third party payer for all above age 65. Hospital construction boomed, new innovative medical procedures arrived, and the income of health care professionals rose dramatically. In the Early 1970’s the Nixon Administration embarked on ‘wars’ against cancer and heart disease bringing the age of big science to heath care. In due course medical research spending dramatically increased leading to further technological improvements, new drug therapies, and advanced procedures. In the 1980’s worry developed that health care costs were going out of control; managed care arrived in force and Medicare began to cap the rate of spending. Hospitals saw shrinkage in patient days and a concomitant fall in income. In the 1990’s hospital closings and reductions in patient beds became the norm. The ratio of hospital staff giving care to patients dropped as a new bureaucracy and processes to manage the costs and reimbursement of care went into place. Costs were held close to the rate of inflation until the late 1990’s when rapid increases again materialized. The Value of Power (http://www.fispace.org/home/health_system/index.html)

[clairobscur]

My very good private insurance works this way. I'm registered with a large group. I have a primary doctor, but in a pinch others from the group can see me also. The group also has specialists, but I can go outside it when necessary. Does the proposed system require you to see one doctor, or allow you to see others in an office?.


I asked, and it seems to be possible to do the same in the case of some groups, but not in my case. My doctors apparently aren't considered to belong to the same office. That's two offices that just happen to be situated at the same place and to be belong to twin brothers, apparently.

Anyway, most generalists in France don't belong to large offices, but to small ones or just work alone.

Regarding specialists, you can see whoever you want, but your generalist must recommand that you see an (undetermined) cardiologist, stomatologist, etc..

Actually, I don't even know what happens if you see another generalist you're not registered with or a specialist without seing first a generalist. I believe you're only reimbursed partially, but maybe you're not reimbursed at all.

Objectively, there's not much I can say against this system. It makes changing doctor a little more complicated since you have to do some paperwork, and you can't take anymore directly an appointment with a specialist (well..you can, but you have to pay) and I'm sure it will be somehow reduce some abuses, but subjectively I don't like these restrictions. I've always been accustomed to call and take an appointment whith whomever I felt like.

[clairobscur]

I haven't seen the overhead the current system adds to doctors' offices addressed either. Each doctor's office, or even my small dentist's office, has at least one person working full time to handle insurance and billing issues. I'm sure this overhead could be mostly eliminated with a single payer system. Those living in such a system - do your doctors have insurance specialists associated with them?


This issue has been often mentionned in previous threads on the same topic, and many posters seem to think that the overhead cost due to the existence of many insurances, with their own rules, redtape and paperwork plays a more important part is the higher costs of healthcare in the USA than the liability issues previously mentionned.


Once again it works differently in each country, but concerning France :


There's one form the doctor has to fill. He has a pile of them in his office, printed in his name. He picks one, write your name on it, the code number(s) of whatver medical act(s) he did, how much he charged, signs it and hands it to you. End of the insurance-related paperwork as far as he's concerned. Then , you have to send it to your local "securite sociale" office that reimburses you.


Actually, in the case of most generalists, he doesn't do that anymore. You hand him a chip card, he passes it in reader, enter the codes mentionned above and the amount he charged in a specific terminal, and don't give you any document. The reimbursment is directly sent to your bank account, IME within two weeks. I don't think any human being is involved in this process at any point in most cases.


I'm sure there are more paperwork than that that I don't see and that various issues arise with the healthcare system that he has to deal with when I'm not around but in any case, he doesn't have to juggle with a dozen different insurance companies having each its own requirments. The two doctors I mentionned above have one secretary between them who answers the phone, lets you in, does the paperwork, gives me back whatever I left this time in the office (checkbook, prescription, jacket...), etc....

[The Flying Dutchman]

My justification is mainly centered on the affordability issue.

Have you noticed that Americans are coming to Canada to buy their prescription drugs ?

I've been a taxpayer for over 40 years in Canada, and my justification for supporting the Canadian system is that I and all my fellow Canadians can afford it and most of us have all the amenities provided by our overall capitalist system such as a home, a running car, food and clothing and a computer on line that Americans have.

[clairobscur]

I recognize that they are working to remedy this problem, but what caused it? Is it because they didn't have a mix of public and private like with other systems in Europe? Have European systems solved this problem?



Still concerning France. Yes, we've a shortage of doctors too. However, not at all on the same scale as in Canada (as far as I understand the situation in Canada). I'm unaware of anybody who would be unable to find a family doctor. Actually, I understand it's rather the reverse and some generalists are lacking patients. There are some issues with lack of generalists in the countryside, but it has more to do with doctors being unwilling to be roaming on the roads 18H/24 7 day/7 to answer housecalls in small villages than with a shortage of generalists per se.


However, there's a shortage in some specialities. For instance psychiatrists (which is weird, because I checked out once and they're making quite a lot of money by comparison with other doctors. So, I'm not sure why more doctors don't become psychiatrists). Also obstetricians, if I'm not mistaken. And more importantly doctors of all kind in hospitals. The problem in hospitals is currently "solved" by "importing" doctors (with a lower pay, more work hours, less guarantees) from eastern europe, developping countries, etc... Preferably after making them jump through various hoops for some years. I know a romanian doctor who eventually gave up and became a nurse.



As for the causes? I suppose they aren't paid enough by comparison with their responsabilities and workhours in hospitals hence prefer to open an office.


There's also a shortage of nurses, by the way.

[clairobscur]

I just wanted to point out an issue, which, it seems to me, is never mentionned regarding healthcare in the USA.


Assuming that the USA would hypothetically switch to a socialized healthcare system : what happens to the currently existing insurance companies?

[BrainGlutton]

Assuming that the USA would hypothetically switch to a socialized healthcare system : what happens to the currently existing insurance companies?

We call in Dr. Kevorkian! :)

[clairobscur]

What is the root cause of the doctor shortage? A shortage of places in university medicine programs. It's certainly not a shortage of people wanting to become doctors, as entry into medicine is ridiculously competitive. I have no clue why more positions aren't made available, but I really can't see how it is in any way related to our socialized medicine.


Hmmm... That's an issue too in France, even more so since there's a "numerus clausus" in medical schools and doctor's unions have been know sometimes in the past to lobby strongly so that the number of positions would not rise too much.

However, nowadays, when the issue is discussed, I way more often hear about poor work conditions or insufficient income to be the cause. Though indeed, medical schools are ridiculously competitive. So, maybe I pay too much attention to the plight of doctors.

[Voyager]

Assuming that the USA would hypothetically switch to a socialized healthcare system : what happens to the currently existing insurance companies?
They could be used to administer the system, under contract. However, they all have plenty of other businesses - selling life, auto and home insurance. They'd shrink, but none would disappear.

[Sal Ammoniac]

I think the point we need to keep in view is that all the mechanisms proposed byt tombigbee et al. are just ways to shift the spending around. Frankly, it's what we're doing now, and it's not a reform. This all seems to be driven by a psychological reistance to the idea of "socialized medicine," and not by a desire to make the system more efficient overall. In America, we're addicted to this idea of achieving reform through tiny increments, such as by jiggering with the tax code (see HSAs as an example). I know this is about politics, in that we can pretend to ourselves that because we're not making a Treasury outlay we're not spending tax dollars, but it's still maddening from the perspective of the healthcare consumer, who is given just one more thing to worry about (and gamble on, as well).

I'm here to say that these patchwork solutions are wrong, wrong, wrong. The amount of money we waste every year is staggering, and as tombigbee notes, the demographic trends are not in our favor. We need to solve the problem now before it devours us alive. And frankly, I think it's not all that difficult, though I think it's easier when you start at the state level.

Here's what I would propose. Because I live in Massachusetts, where most people are covered by HMOs paid for by their employers, I would advocate retaining most of the existing system. The only significant change I would make is that the state would pay the cost of enrolling each taxpayer in an HMO of their choice, and the state would fund this by imposing a tax on employment. This tax could be graduated based on the size of the employer, so that a self-employed individual might only pay 10 or 20% of the levy. Why would I do it this way? Because business are already in paying for health insurance. In my proposal, business would simply send their payments to the state, per employee, and get entirely out of the business of negotiating with the insurers, administering the benefit, and haggling with the unions over health benefits. I think, even with a small increase to cover the uninsured, businesses would still come out ahead.

The only other large-scale change I would make would be to make all medical providers bill using a standard medical coding system and claim form, which would probably go to some centralized clearinghouse. The insurers would still negotiate with providers to set their rates, and the HMOs would still have to make themselves attractive to individuals, which would keep some market forces at play in my proposal.

Is this socialized medicine? Only in the sense that the government becomes the one payor. In every other sense, the existing system is retained. Most people would in fact see no change whatever. But you would achieve significant administrative efficiencies, and could then go forward and talk about the shape of the health system of the future. Because that, while a separate issue for the purposes of this discussion, is something that ultimately needs to be looked at.

[tombigbee]

Sal Ammoniac, thanks for taking the time to write your proposal. I'm doing homework today and will look at it again later. In the meantime, I have some side comments and a couple of questions.

Comments -- I myself don't fear socialism. Early Christian church members practiced a form of socialism. I think socialism and capitalism are both ideals whose pure forms have never been achieved on earth on a large scale. We are continually tweaking capitalistic and socialistic systems, I believe, to solve problems caused by people being people. I like the benefits of capitalism and I think as a system it plays better against peoples' tendancy to look out for #1. There have been built-in barriers to implementing innovative solutions to our current health care system, and these innovations should be included in any reforms we eventually adopt.

Questions -- Could you expand on your proposal in the areas of 1) including the uninsured (as MA is dealing with this also and I believe is considering a type of mandatory insurance provision), and 2) promoting the public family (if you think that is an important goal)?

[Sal Ammoniac]

My proposal would provide 100% coverage. There would be no uninsured, since everyone could pick the HMO of their choice. I have no opinions on the "public family" idea. It seems more like a philosophical framework than a policy proposal, no?

And "socialized medicine" has nothing actually to do with socialism in my view, and in spite of numerous arguments to the contrary over the years. In the proposal I set out, providers might be either for-profit, or nonprofit. Rarely would workers own the means of production -- it would violate the Stark laws! (Sometimes, that is.)

[tombigbee]

So I withold judgement until I see more details.It's such a complex subject, I doubt most would bother to read all the details if posted on this message board. I encourage you and others to follow up on your own (and I know you will!).

Things I learned today: South Africa has no national health care insurance system and has used HSAs for many years. One people-being-people result is that insurance companies have competed for the healthiest in the population. The solution is that the government will penalize insurance companies that don't have a good mix. The cite says South Africa's system has failed, but I don't see why we can't make GIGObuster's point here also, that it is a problem that needs solutions, not overhauling the system. Don't know that much about it though. They don't seem to have a problem with people putting off getting needed care. South Africa and the failed HSA experiment (http://www.tpmcafe.com/node/27044)

Finally, I think that even with every efficiency in place in a National or Mandatory system, the cost of health care is going to rise because of the increase in life expectancy. That means an increase in the number of people with chronic health conditions needing long-term care. Citizens in each country will have to pay the increasing costs in one way or another. In both a National and Mandatory system, it's likely to mean either higher taxes and/or shifting funds around from other programs. The latter would mean reducing other government services overall. In a National system, it could also mean rationing in a roundabout way (long waits). Those are guesses I know, but I think they are reasonable ones. Consumer choice: Can it cure the nation's health care ills? (http://www.ncpa.org/prs/cd/2005/20051213wsj.pdf?PHPSESSID=64a6b1e70572461c713c4c66182e361c)

I have a huge problem with long waits, whether it's to see a GP or a specialist, but it seems that wherever health care is 'free' or 'cheap,' it's likely there will be long waits. Maybe dentist offices would be an exception. :) I believe that's why many people end up in emergency rooms now with our current system -- they can't 'afford' to take the time away from work or caregiving duties to wait at a free clinic for hours.

A main goal of consumer-driven, mandatory health insurance is rationing by pricing and not by waiting. Wait! There's much more to it than that!

I'm disappointed that my classmates are so quick to jump on the "Let's copy Canada, Sweden, etc." bandwagon because I think they're doing it without understanding how those systems work. Posts from clairobscur show that a national system may also be a challenge to fully understand without making an effort.

When, where and how are we going to debate the pros and cons of each system if we don't bother to understand them? I do not aim this personally toward anyone. I thank everyone who participated...it helped me a lot.

[Mr2001]

I like HSAs because that's how I paid for my elective eye surgery.
I dislike them because they're worthless until long after they're opened. If I start an HSA today, and next month I break my leg, the few dollars I will have managed to put in my HSA by then won't help me one bit, and the mandatory high-deductible insurance plan won't kick in until I've spent half a year's pay.

You could've paid for your eye surgery with a checking account, or even a credit card; it just would've cost a little more. As far as I can tell, the only point to opening an HSA is avoiding taxes on the money you save for medical expenses.. but IIRC you can deduct medical expenses anyway, no matter what kind of account you keep the money in.

[clairobscur]

I have a huge problem with long waits, whether it's to see a GP or a specialist, but it seems that wherever health care is 'free' or 'cheap,' it's likely there will be long waits.


Hmmm... Waiting lists aren't an universal problem in countries with a socialized healthcare system. Canada and the UK are notorious for them, but I'm not aware of any long wait in France, or in say, Germany.

Healthcare isn't a "good" similar to most others. The demand is very unelastic. If you hand out free cars, I'm sure there will be long waits. But free heart surgery won't have the same appeal.

Of course, I'm sure that there are people who will pay a visit to a doctor ot take drugs though there's no need for it when it's "free". However, besides the fact that many people don't like much seeing a doctor (even when they need it), healthcare is "free" or "cheap" for all insured people. Being covered by a public healthcare system or by a private insurer has the same result. Once you've paid your taxes or your insurance premiums, healthcare becomes "free" or "cheap". The american with a medical coverage is exactlty in the same situation as a british or Swede. An universal public healthcare system just gives to more people the opportunity of "consuming" "cheap" medical care, it doesn't create it.

A problem is that healthcare rarely is "rather costly". In most cases it's either "mostly free" (when you're insured under whatever system) or "mostly unaffordable" (when you aren't).