Devil's advocate: saving America from socialized medicine.

Great Debates
1

OK, I’ll try this from the other side. I’m going to try to argue why the USA should not have single-payer socialized medicine. I’ll number my attempts (with any reasons they seem undercut in sea green). It’s a bit odd, I know, but this is sort of how I hash stuff out in my head.

  1. It’s too expensive. We can’t have that kind of drain on our economy.

Uh,factually contraindicated.

No, wait, I can make this work: Yes, we pay more for health care than other first world countries, but with single-payer, we would pay even more, or get less. The existing health care system would continue its present pricing theory, treating the government as a support for their inflated prices.

So we might need government to have a stronger hand, rather than just a bankroll. How about a UK-style NHS?

  1. Using government power to dictate health care expenditures is less effective than the free market.

The experience of Australia, Canada, & the UK indicates otherwise.

  1. Hang on. Wouldn’t that inhibit the strength of the American system–the experimental medicine?

Why? Private concerns can still fund research, & you know the US government will fund medical research as much as ever.

  1. I just can’t used to the idea of someone taking my money & using it for someone else’s health care.

So do you also deplore private health insurance?

  1. Isn’t private health insurance a demonstration of the ability of the free market to handle this?

See the cites in #1. Doesn’t look like it’s doing that well. And isn’t it a bit like saying private security firms obviate the need for police?

  1. OK, there’s a reason not to do it. It’s too efficient. It costs people their livelihoods. [Note, this was the actual subtext of a discussion I saw on the NewsHour last year.]

Institutions are not so much more important than the services they exist to provide. Would you save unnecessary military bases in the middle of Indiana? Should Eisenhower have given grants to buggy whip makers in lieu of building an interstate highway system? At this point, saving private health insurance looks like pandering to special interests.

  1. …what if we don’t want the service?

Who’s “we”?

America. Maybe we, or a majority of us, are quite happy with the way things are. Why mess with a good thing?

Because the economic efficiencies would free up money for other purposes, like engineering green cars. Or because a system wherein hospitals can’t bankrupt your parents may mean more capital stays in the hands of those “working families” politicians love to invoke. If it’s a good idea, it’s worth doing even if it doesn’t sell to a skeptical public. And it’s not that hard a sell.

  1. It’s un-American! Our culture is just…different from Europe!

Like immigration was un-American once? Or rock’n’roll was “jungle music”? I thought Americans were proud of being adaptive & innovative!

But we can’t use a European idea! We have to make the Answer for The Future up ourselves. :cue stirring nationalist anthem:

This may be what people think, but it’s not a good reason not to adopt the idea. We don’t need to reinvent the wheel. (And considering the popularity of British performers & Sony products, I think we’re really less xenophobic than that.)

  1. Fine. Here’s the reason. The One Good Reason. Single-payer would give slackers & wastrels health care for free. Which they don’t deserve.

Do slackers & wastrels not deserve police or fire protection?

That’s different. The police & fire departments protect society from spreading menace. Except for infectious disease & a few other clear public health issues, health is a personal thing. One should take personal responsibility.

Eh? You mean morally? What about the person who wants to take better care of himself but can’t for economic reasons?

He should economically take care of himself first. Health care is a luxury, not a right.

Positivistically, the question is whether it should in fact be a right.

No, absolutely, it is not a right & should not be a legal right.

And saying one has to make X amount of money to pay for it, is that a moral absolute? If so, how?

Persons must be responsible for themselves.

Do you apply this standard to victims of crime as well? Should police be forbidden to stop a robber in broad daylight?
Anyway, it’s a flimsy argument. Even with socialized medicine, a person will still have to care enough to go to the doctor. It’s just a way of ensuring affordability.

But with single-payer, lazy people will get free health care!

So will hard-working people who aren’t making enough money to budget health care, whether because their employers underpay them or their industry is in a rough patch or any number of other good reasons. And the seriously unemployed may be able to get treatment for the conditions that make them unattractive to employers–injuries, mental illness, chronic infections–& have a greater chance to make a living.

But someone should have to work to earn the money to spend on health care!

Work ethic? OK, can hospitals tell trust fund babies their money’s no good? More to the point, we have free clinics now. Is that immoral?

That’s not what I mean.

It’s not that different. An employer can choose to provide for his employees. A parent for his children. A government for its citizens. A donor can fund a charity which provides for the poor. In each case, someone is using his credit for someone in his care.

  1. Not the government. That’s not OK. The government gains money by extortion.

Twaddle. The government has the constitutional authority to print money. The only reason they delegate that to the central bank is to minimize hyper-inflation due to politically driven mischief. Taxing money out of the system & spending it on “good works” is simply a non-inflationary variation on releasing money into the economy to do “good works.” We are within the government’s care, & it has the constitutional right to care for us.

  1. Ah, but the USA Constitution leaves rights to the states, & it’s up to the states to run health care!

I’d love to see this happen on a state level. But most states are terrified of having to pay for the residents of other states & ending up screwed. If we can’t do it on a federal level, poorer states won’t do it at all. So “states’ rights,” or the “laboratory of democracy” wherein states try things out first, doesn’t give us progress in this arena. I think this is the real reason that it hasn’t happened here; a quirk of constitutional law.

  1. It would still suck.

Things suck now. At least there’d be a mechanism for what would amount to effective progressive pricing with tax-funded medicine.

2

IMHO thread from last year describing socialized medicine as practiced in other countries.

3

Count my vote for an opt-in national health plan. I just flew from the US to Europe because I needed surgery and do not have (can’t get) insurance in the US. The cost of my flight, plus the cost of the doctor visits was less (much less!) than it would have cost in the USA… and it was cheap enough that it did not even meet the minimum to be paid via insurance.

Based on estimates, health care costs in the US are about 20 times what they are here… and I have a doc that went to med school in the US and had a practice there for 20 or so years.

4

I had open heart surgery last December on my heart at a hospital that has a 100 percent 1 year heart transplant survival rate. (I only had a valve job.) This hospital does a lot of heart transplants. All the patients live. They do other transplants as well, and have higher than average survival rates, if not the highest survival rates of any hospital in the area. Only one other hospital in the state is considered better. Need I say that this hospital, UCSF, is a public and not for profit hospital serving the community. US News and World Report, a conservative magazine, ranks it as the number 5 overall hospital in the nation. The best hospital in the nation according to USNWR? UCLA, another public hospital. I just got the bill that the insurer paid. $25,000. One tenth of what it would have cost me to pay for the operation at the fine local hospital near my home (35th in the nation, yay John Muir) out of pocket.

I would expect, if your right wing jerkiness of the knee had any validity that dozens of private hospitals would be better than these public hospitals in these rankings, and that virtually any hospital that was public would not make the top 100 or so. Once again, reality has a bias against conservative dogma, which just turns out to be a set of prejudices that are for the most part, contrary to what goes on in the real world.

The situation is that the US pays more for health care than any other industrialized nation and adequately serves a much, much smaller portion of the population.

Frankly, I pay too much in taxes for the roads and mail I use. I don’t like or need the government spending so much on the military. In a developed nation, taxation without health care is tyranny, and taxation without health care while paying for the killing of half a million Iraqis is just plain idiotic. We are over militarized and under medicalized.

Just my opinion. And my prognostication is that Obama is going to do something about it. And my gripe is that the Republicans intentionally destroyed our economy to argue that we can’t afford it. We can, simply raise the upper limit of the social security tax to include all income so that the rich are finally taxed at the same rate in social security as the not so rich and the middle class and the poor.

5

I deplore compulsary private health insurance. If someone thinks the predictability of insurance payments makes the higher average cost worthwhile, that’s their decision. But that doesn’t mean I share their opinion.

And unlike even compulsary health insurance, a single-payer system makes no attempt to minimise the cost to other customers of providing treatment to an individual. Even if you never smoke, never drink, exercise every day, and never have so much as a cold until you die at the age of 120, you still get charged the same for a service you don’t want and never use.

6

Personally I don’t mind paying taxes so that “slackers and wastrels” (really, people in the underclass) get free health care. What I do mind is routinely sharing doctors, hospitals, etc. with them. It seems to me that one likely outcome of national health care is a requirement that all such resources be allocated equally. The practical result of this is that families who are vaguely in the middle class are likely to see a reduction in the quality of health care they receive.

My opinion only.

7

I agree and want to add that I resent paying high premiums to the insurance company to fund all the costs that go into having and raising children (which includes things like IVF!), as well as smokers, couch potatoes, drug abusers and all the other high cost essentially elective treatment problems out there. I can only see this getting worse if I was paying premiums to cover those who are un- or underemployed, which are the ones that socialized medicine is aimed at.

Also, the US government does not do a good job at running health care as it is. Medicaid is (or at least was) routinely abused by doctors and patients alike. And no, I don’t have any cites, I just paid out hundreds of thousands of dollars back to Medicaid to reimburse them for care they gave to patients that were insured by the company I worked for. Some of the care had been given years prior - how many of those office and hospital bills did Medicaid never find out were covered by private insurance? Medicare is also poorly run, difficult to understand and at times difficult to get care from.

Heck, the government doesn’t do all that good a job taking care of the huddled masses of poor as it is - it seems to me that if we were to give them free health care on top of free/subsidized housing and food stamps, it would just make them more dependant.

8

(I will use Medicare as the catch-all term for government run healthcare. I realize that in reality we have Medicare, Medicaid, Tricare, and a few other programs out there.)

To provide choice and coverage:
Let anyone buy into Medicare on a sliding scale based on income with a cap (like Social Security).
Let people buy private riders that allow them to use Medicare if they like, or to use the extra services paid for by the rider (similar to what currently exists - extend it to everyone).
Let people buy private insurance.

To ensure that Medicare is a decent plan:
Put every Federal Government employee on Medicare, including all members of Congress and military retirees. One system, not the multiple systems we have now.

To help innovation:
Let each state run their respective Medicare program.

Transition issues:
Medicare reimbursement rates SUCK for many areas. As I stated in a mini-rant, I recently closed a physician’s office because his practice had grown to 50% medicare and he could no longer afford to stay open based on their reimbursement rates.

9

This is a real part of the problem. Due to a historical anomaly*, the majority of US residents with private health insurance get it through their employers. This is still subsidized by U.S. tax policy**, and has lead to a situation where middle to upper middle income earners could see a decrease in quality of care under a single payer system. The overall average will go up if the U.S. follows a single payer model that increases efficiency (or merely does away with the profit margin of the insurance companies), but if the average employee of a large company with good medical has coverage rated at 8***, and the uninsured have 2, then everyone may end up with a 6. To some this is unacceptable.

  • During WWII private companies could not raise wages to attract workers due to government policy, so they started offering non-monetary benefits such as insurance. That has now become an expected part of compensation in the U.S.
    **Medical coverage paid for by employers is not taxed, but if you buy it yourself it is.
    ***This high level of coverage is sometimes an illusion. Wait times may be low and service great for common issues an catastrophic incidents, but long term and chronic conditions (especially if you lose your job) may be a different story.
10

This sounds a lot like my old objection to Social Security, except of course the person not benefiting from SS would die long before 120.

But I now look at social security as a pensions system, if an imperfect one. A way to make sure that those who have provided for the country are provided for in time of need. (Thus, we should means-test it on one hand, & not shut down payouts when it stops being a net income per annum for the government on the other.)

I’m not bothered by SS anymore, & I hated the idea when I was young.

11

That said, I would also deplore compulsory private health insurance. We’d end up with a model halfway based on compulsory private car insurance, & a lot of poor people would take the low-premium plan & end up with huge costs in time of need anyway. Private companies might get away with unscrupulous practices for a long time; if you’re paying for something you may never use, how can you tell if you’re getting value for your dollar? How can the government tell to prosecute fraud?

But note that we’re already in a situation roughly equivalent to that. Many persons think they need health insurance but don’t pay for full coverage. Abuses already happen.

This is why I lean toward a British-style system, where basic health care & emergency care are provided as a service to the community, not a good to consumers. It can be regulated as a valued part of the commons instead of as a service sold.

12

I was bankrupted by a kidney stone a few years ago, and I had Blue Cross. That would never happen in any other industrialized nation. I can do without the exotic geegaws of House, M.D. if I can just get the treatment for illnesses I’m likelier to get.

Single Payer? Where can I sign up?

13

That’s fine - but you prevent those not getting insurance at 25 from getting it at 50? If not, you are clearly allowing them to game the system. My private health insurance is compulsory (though you have a choice of paying more for better coverage) for this very reason.

There is no reason to think that a single payer plan wouldn’t try to increase efficiency, for instance by paying more for preventative coverage to reduce the instance of expensive problems that could have been caught early. Yes, some people won’t get full value out of their insurance. That is what insurance is all about. I’m not pissed off because I buy term life insurance and then make it worthless by refusing to die. I’ve paid a lot more for car insurance than I’ve taken out, and I’ve never even made a claim on my homeowners policy.

14

So it’s important to you that programs for the poor remain poor programs?

What I notice is you say, “one likely outcome.” But this is still America. If the middle class despise the poor so much as not to share facilities with them, we can certainly write the law to keep public health care as demeaning as possible & allow private money to provide more for “middle class” people.

Then again, there’s a lot of income variation in the self-described “middle class,” so I’m not sure how to write a law around snobbery. You may have a point.

But I think this is actually covered under the efficiency aspect. If basic health care is cheaper, if infrastructure is state funded, then it’s really cheaper for everybody. There’s still private insurance in Britain for those who find the NHS insufficient or objectionably low-class, & it’s cheaper than basic health insurance in the US.

15

curlcoat, your objections are an expanded version of my OP’s point 12 & are answered in Voyager’s post 13.

Someone may have a better refutation, but as I said, things suck already.

So we make it clear that one can buy more if one can afford it. I see no administrative reason to pay for the poor’s health care with the middle class’s money. A political reason geared toward sabotage, I can see. But the very rich should be expected to pay for the very poor if we’re trying to actually make it work.

16

They could only be considered to be “gaming the system” if you are over-charging people when they are young and under-charging them when they are older. This does not mean you need to force people into insurance when they are young, it means you need to change your pricing structure.

I disagree. What insurance is all about is replacing unforeseen costs with foreseen costs. This can be achieved by redistributing costs over time, rather than between people.

And even if that is what insurance is all about, how does that justify forcing people to buy your insurance?

17

If I understand you correctly, then yes.

I’m not sure if it’s demeaning or motivated by hatred (or intended to be so), but that’s basically what we have now, i.e. a two-tier system. There is a lower tier (public hospitals, medicaid, etc.) to provide for people in the underclass; and a system of private health insurance for most others.

Let me ask you this: Do you believe that under national health care, the quality of care for a typical middle class worker with good health insurance will improve, all things being equal?

18

Honestly, I have no idea. It could hold steady. It could dip for ~3 years as the system adjusts to a new paradigm & then stabilize around where it was, or possibly better. Might be slightly lower quality, but cheaper for their employers.

I do believe the quality of care for a typical working class family with* poor* health insurance will improve. And even that not immediately, because the system has to be built up & tweaked over time.

And I don’t think it’s really a matter of, “all things being equal.” It’s a matter of new policy making a new economic reality & everyone’s paradigm shifting. A lot of adaptation will have to take place. Massachusetts has been going through growing pains with UHC.

But long-term, the lower middle class, the working poor, & their employers, will get more stable coverage & less price pain. White collar workers in small firms, who often lack unions, will probably get a better deal than they are now. Large firms with very good health coverage, like GM, will stop having to provide all the funds themselves, which means those who now see their coverage going from brilliant to lacking as GM collapses might find a floor before they hit bottom.

So, yeah, I think it’s a good risk for everyone. If you’re relying on your income or your employer, the really amazing coverage you have now may be gone in twenty years with economic shifts.

19

Insurance is more efficient with a bigger set of people. You can give discounts to drive behavior, like no smoking discounts of safe driver discounts, but age is out of a person’s control.
Why force people to get insurance? Because everybody gets sick, and unless we want to not treat those who don’t pay, you need insurance. Lots of people who can pay premiums can’t pay for expensive treatment. What you get is the rest of society underwriting those either too stupid to get insurance or greedy enough to want a free ride. I’m not counting people too poor to pay for insurance here, only those who would opt out but can afford it.

Having a risk pool of one is statistical nonsense. Do the few who get hit early go bankrupt? How about those who get unlucky and need to spend more than any conceivable savings? Clearly you can’t have everyone save the mean for possible expenses every year, since then a large number of people will run out of money paying for healthcare. At what level would you recommend them paying? (If you enforced this rule, insurance companies would go away since there is no reason to pay for their overhead when you are self-funding.) Say you set it so 95% of people more than cover their costs. You still have 5% in trouble.

20

Please define quality of care. For me, I’d expect that I’d be able to see my cardiologist as quickly as I do now, but would have to wait longer to have my bunion taken care of. Works for me.