Single Payer Health Care

This topic has been discussed recently, so I was hesitant to start a new thread for it. However, I couldn’t find the old one, and since there are at least three different evolution threads going on, I suppose it isn’t an unforgivable sin.

I’d like to know what everyone thinks about single-payer health care in the US. I am involved with Physicians for a National Health Plan, an idealistic group of doctors pushing the idea that single-payer is the only way to save our system.

For the uninitiated, single-payer is the form of socialized medicine found in Canada. (“True” socialized medicine, in which medical personnel are direct gov’t employees, is found in England.) All hospitals and clinics are given an operating budget for the year by the government to see a certain number of patients. Decisions on treatment are made by the doctor or the hospital. (For a more complete outline– )

I’d be especially interested in the viewpoint of our Canadian dopers. To any non-Canadians whose objections are based in the problems with Canada’s system, please check your facts–there’s a lot of misinformation out there. (For instance, that largely mythical throng of people who come to the US to get care they can’t get in Canada.)

I am preparing to speak to the med school on this topic, and I’d like to get a good view of the objections and get my facts straight. (I generally trust PNHP, but Dr. J’s Rule #1 is “never completely believe anyone with an agenda.”)

Thanks in advance!
Dr. J

I live in Canada, and the medical system is okay but not perfect. Here in Alberta we are trying to move to a two-tiered system with some privatization, but the federal government keeps stepping in the way.

We have all kinds of problems with the system here. For example, since a doctor’s ultimate customer is the federal government and not the patient, we get a lot of doctors who set up ‘assembly lines’ to maximize profit. The government pays a GP something like $50 for a regular physical. So these GP’s will set up an office with maybe 10 rooms and see 10 people at a time, flitting from one to the other. In the end, the doctor will spend maybe five minutes with you for your physical. Is that enough to catch all the possible problems you might have?

There are also problems with waiting lists, especially in the poorer provinces. Some people have to wait months for necessary surgery. A story that made the news last year was a child who got put on a waiting list with a BROKEN ARM, and had to wait so long (I believe a couple of weeks) that the doctors had to re-break it to set it properly because it had begun to knit. There have also been lots of people who died while on waiting lists for necessary surgery, and British Columbia is toying with the idea of refusing a large number of lifesaving medical treatments to people over 70 years of age. (We’re not talking about DNR orders or keeping them on ventilators, but refusing things like dialysis, kidney transplants, heart surgery, etc.)

There are no free lunches. Make health care completely free, and you won’t be able to keep up with the demand for it. As the population ages, this is going to become a serious problem.

In the U.S., the first thing I’d do is end the universality of Medicare. Why should Bill Gates get free medical care once he turns 65? Make the rich people pay for their own damned care. You can have a sliding deductible based on net wealth (i.e. if you’re worth $100,000, you have a $1000 deductible, but if you’re worth $1,000,000, you have a $10,000 deductible). At least that would be a start.

I deal professionally (at least partly) with a variety of health care systems (mostly outside the U.S., others in my firm focus on U.S.).

Bottom line: there is no perfect system. There never will be. The perfect system would be full and complete health care for all, highest quality service, latest technology… with practicioners all well-paid… at no cost. Can’t happen.

Health care is a limited resource; the question at bottom is how each society determines it should be allocated. Countries with a more socialized system (which means every developed country in the world except the U.S.) believe the allocation should be made by some sort of medical standard and supervised by the government. In the U.S., allocation is made based on how much money you have: the rich (or well-insured) can afford treatments that the poor (or lower-insured) can’t.

Go for it, DrJ, I think personally that a single-payer system is the only hope to stopping America’s health care system from sliding down the tubes entirely.

Well, there are two extremes.

In one, the government pays for everything, period. TANSTAAFL, that just couldn’t work, at all. Technically, with no cost, demand is infinite. Ain’t gonna happen.

On the other hand, everyone could pay for whatever they needed right then. Unfortunately, health is expensive, so many people would suffer without necessary treatments. Again, most people feel this is unacceptable.

So, what’s the acceptable middle ground? In theory, everyone would like it if there could be a way that everyone was perfectly healthy all the time at no cost to anyone. Unfortunately, wonderful as that would be, that’s not going to happen any time soon.

First off, we want to be able to set up a system whereby those with less money are able to get necessary health care. That’s actually, I believe, the whole issue. What’s necessary and how do we pay for it?

The first is largely semantic and would take more time to discuss than I have right now. Let’s go to the second.

Obviously, in a government subsidized health care situation (which I believe we all agree would be the case) it would be paid for by taxes. In any tax situation (accept regressive, which is silly), the rich will pay more than the poor, and the poor would be getting it back and then some in the form of health care. Once it’s decided what would be paid for, the problem would be solved.

Unfortunately, that’s the sticking point. What should be paid for by that government health plan?

I don’t know right now. I’m sure that there’s propoganda galore out there, if anybody is willing to take the five seconds to find it and the lifetime to sift through the bullshit.

Hey now! I think this might get interesting! It’s one of the few non-religious debates I’ve seen here, people!

Headline in this morning’s Edmonton Journal:

“New National Poll Says 75% Of All Canadians Favor Move Towards Private Health Care”**

This poll was motivated by a new government report which indicates that waiting lists have been growing longer in the last 4-5 years, and are extending to emergency rooms which are understaffed. People with severe, painful (but not life threatening) injuries are often having to wait even days after going to the ER for treatment.

Yeah, right. There was a big headline about a year ago about how the German socialized health care system was floundering and about to be junked. Turns out, they were doing some cost-cutting tricks, like cutting back from 14 days hospital stay for maternity to 12 days.

A major problem with this topic is that people have hidden agendas, to “prove” that an individualistic/capitalistic approach is better than a community/socialistic approach (or vice versa.)

As I said before, health care is a limited resource. The question is how you want to allocate that limited resource, and who you want making the decisions.

My wife broke her foot last time we were in London. We went to a West End London hospital. There was a large sign posted, indicating how priorities were assigned – life-threatening first, children, etc. Elderly people would be given priority in late afternoon so they wouldn’t have to travel home in the dark. And so on.

We got a triage (sp?) within about ten or fifteen minutes, and an ice pack fairly quickly after that. Then came a wait, but once it was our turn, things went fairly quickly (x-ray, cast, etc.) Entire process took a little over two hours (a U.S. emergency room visit would almost certainly have been longer.) Cost to me: zero. (Not entirely true, we had to pay a small deposit for the crutches since we were leaving the country in a few days.)

OK, beware anecdotes, because anecdotal evidence can prove anything. But our experience with British National Health was quite positive.

Sure, socialized health care has long waits. I called my doctor in the States to set up my annual check-up, and the earliest date they could give me was three months later.

The difference is that the allocation of the resource in the U.K. is made by the medical boards, in conjunction with government, based on need. The allocation of the resource in the U.S. is made by each individual (patient or doctor) based mostly on how rich the patient is.

The basic question is, is the government obligated to provide healthcare for its citizens? If so, how much and under what circumstances? (As has been noted before, it is impossible to provide unlimited, high-quality healthcare to everyone.)

If the government should subsidize health care, what purpose should this serve? To prevent the spread of communicable disease? To ensure the health of the next generation of citizens? To prolong life? To reduce suffering? To pacify the voters?

It benefits all of us when the government provides certain healthcare services, such as immunizations. But what about services that benefit only certain individuals, at great cost? A ninety year old man with Alzheimer’s disease needs dialysis; should tax dollars pay for it? A twenty four year old woman is in a permanently vegetative state following a massive head injury; she also has advanced cervical cancer. Her family wants the cancer treated aggressively with surgery, radiation, and chemotherapy. Should the government pay? In both of these cases, the government (via our tax dollars) DOES pay.

I would like to see less of this sort of thing and more money spent on screening for diseases such as cancer, diabetes, hypertension; prenatal care to maximize the health of our future citizens, and well-baby and childhood check-ups. It doesn’t make sense to me to spend millions of dollars on desperately ill elderly people while so many children have no access to basic healthcare. Senior citizens vote; kids don’t. Hmmm…I wonder if that has anything to do with it?

Profit taking by third party payers is the root of all evil. Eliminate that and there’s more than enough to go around.

I am also for local medical advisory boards. It could be an elected office, holding the members that deny treatments held accountable to the voters.


Several US HMOs will no longer pay for and ER visit if it is not life threatening.

The better ones will pay if you believe your condition is life threatening. Others have a very short list of obvious ER cases, such as severe trauma, unconsciousness, etc., and anything else has to be pre-approved over the phone by one of the plan’s doctors. If he doesn’t think it is life-threatening, you can wait until his office opens and try to squeeze in, which again may be difficult if it isn’t life-threatening.

Just like those in the US don’t have a great idea what health care is like in Canada, I believe the Canadians may have an overly rosy view of our system.

Dr. J

Does anyone have news of how Oregon’s health plan is working? I found it to be one of the sanest ways to tackle health care discussed in the United States.

The plans completely covers the top five hundred ailments, including preventative treatment. Trauma of one sort or another is also covered.

Pneumonia, diabetes, heart disease, cancer, and a myriad other conditions that the average person would run into were taken care of. The kicker came for conditions that fell below that 500 cut off. Reconstruction surgery for breast cancer is not covered. The aggressive care needed to save drastically premature newborns was not covered. It hurts, but the money that used to go for that helped a much larger number of people.

The last I heard was that the plan was doing very well, but it faced legal challenges in the court over the Americans with Disabilities Act.

Anyone have news on that?

Will work for sig line.

Just thought I would throw in this tidbit, in response to

From Newsweek

A ‘Frustrated and Angry’ Nation

Although a majority of Americans believe the health-care system will take care of them if they’re ill, six in 10 are unhappy with the system, and more than half say fundamental changes are needed.

La franchise ne consiste pas à dire tout ce que l’on pense, mais à penser tout ce que l’on dit.
H. de Livry

Arnold: That sort of proves my point: Health care is very expensive, and even rich societies can’t afford all the health care people would like. Therefore, there is bound to be dissatisfaction with the system, regardless of what it is. That doesn’t mean you have to tinker with it.

Canada’s health care system is pretty good, overall. I don’t think it is any better than what you have in the U.S., and in some ways may be worse. But they’re close. And the two countries spend similar amounts of money.

However, Canada’s system may be getting worse. Another front-page story in today’s paper was that 3 out of 4 major hospitals in the city yesterday were turning away ambulances and not accepting patients of any kind in the ER because of overcrowding. A reporter interviewed one girl who finally went home after waiting for a bed for four days. She had a bad asthma condition that had flared up and was making it hard for her to breathe, but there were no beds.

Since we don’t have to pay for ER visits, our ER’s are often overcrowded. People will go to the ER with a cold, or a headache, or all sorts of minor ailments that really don’t belong there. But hey, if it’s free why not? The doctor may even give you some free medication.

In my mind, the difference between “socialized” medicine and “privatized” medicine (very simplified of course):

In “socialized” medicine, everybody gets decent care, but hardly anyone gets excellent care.

In “privatized” medicine, rich people get excellent care, poor people get bad care.

I think which system you think is better would depend on your views of what a “fair” society is.

La franchise ne consiste pas à dire tout ce que l’on pense, mais à penser tout ce que l’on dit.
H. de Livry

Similar to Dex, I deal with health care financing issues on a daily basis. In fact, I’m currently drafting legislation regulating HMO’s and their finances. I’ve given these issues lots of thought.

Here’s my view of the health care system. Health care for the American people will cost a certain amount each year – say X. This amount is pretty much set in concrete (utilization review et al may have a minor effect, but not much).

So, for the whole of our society, we have to pay $X per year for health care. As I see it, there are two questions.

First, how much is X, and what causes X to increase year by year. In this regard, I haven’t run across too many physicians, hospitals or pharmeceutical companies which are losing money these days. Many (too say the least) are very profitable. Perhaps these entities are entitled to these profits. I don’t know. I can only suggest that profit is a substantial percentage of our hypothetical “X”. If we are interested in reducing X, perhaps profit could be reduced. I know we’ve all heard the sob stories about how hard physicians have it these days. I only wish the ABA was as good a lobby as the AMA…

Second: For any given year, X is a fixed number. The only question is how do we divide X among the members of our society. We have various mechanisms to do this: taxes which fund Medicaid and Medicare programs, insurance premiums which fund the bills paid by health and workers comp insurers, and salaries which fund self-insured employers health costs.

My point is simple – As a society, we have to pay X each year for health costs. How do we allocate this costs among the various sources available?

For instance, in a single payer system, the costs are all allocated to the taxpayers. All of X is paid through taxes. For a middle class taxpayer, this may not be so bad, considering that we currently pay most of X through our health insurance premiums, taxes allocated to Medicaid/Medicare and salary offsets to pay for our employers’ health costs. However, the concern is that a single payer system does not necessarily include a motivation for providers and participants to reduce X. In fact, single payer systems may induce the public to over-utilize the healthcare system, thereby artificially increasing X. This results in arbitrary limits on utilization, including service denials or delays (we’ve all heard the horror stories about folks in other countries limbing around for decades while they wait for a hip replacement.)

So, what’s the alternative? The commercial system, whereby the long term pro rata costs of an individual’s health care are supposedly approximated in his insurance premiums. The problem with this approach is that the commercial insurer is in business to make a profit. How do they acheive this? By reducing the pro-rata cost of health care provided to each premium payer to less than premium paid.

As an aside, I will note at this point, that this is very, very difficult to do – at least in my local market. It is virtually impossible for health insurers to be both competitive and profitable in my market – which helps to insure my continued employment, thankfully.

How do health insurers make a profit off health care? Reduce utilization through close monitoring of providers, shrewd underwriting of health risks (not possible here – we have guaranteed issue), or advantageous contracts with providers. None are easy to acheive without offending a group which is highly influential to the insurer’s future fortunes. This either results in financial problems for the insurers, consumer complaining about unpaid or denied claims or irate physicians.

What to do? How do we equitable divide X among the various elements of our society while still including the free market motivations to minimize costs and inefficiencies?

Hell if I know.

I can only hope there is some happy medium between the two currently available extremes. Since X constitutes a large percentage of our nation’s economy, this is a vital question which we need to resolve. Our society’s demographics radically worsen the situation. We’re an aging population (happily, I’m on the young side of the bell curve, but that’s completely irrelevant). Because a larger and larger percentage of our population is older, X is rapidly increasing. Expensive technological advances only enlarge X.

It’s a difficult problem. I know I’ve offered no solutions in this extended monograph (Gee, I can’t help myself. You offer me the opportunity to hold forth on something I actually know about and I contract a severe case of the verbal trots. Oh well.

DoctorJ, based upon your profile, I should be able to provide you lots of help in your research project, considering I’m about 25 miles from you. I can either provide you with lots of info first hand or hook you up with the right people. Send me an e-mail.

Plunging like stones from a slingshot on Mars.

Damn that was a long post!

The first tweak to the system that ought to be tried in the US would be to disengage the health insurance system from employment. When the consumer is not the purchaser, you end up with difficulties applying free-market economics to the situation. The insurer is in need of reducing price to make the product competitive to employers; the provider is encouraged to over-supply the medical care to keep the consumer happy. The typical result is an employee or dependant who sees a doctor for every imagined ailment, a doctor who offers any and every treatment or diagnostic option he/she can, an insurer who tries as hard as possible to make sure as few treatment costs are actually paid, and an employer who shops each year for a new plan with the least cost to it.

Now, I am NOT saying that the automobile insurance industry works perfectly, but it DOES seem to do a better job of cost control than the medical insurance industry. The main difference between the two (aside from the fact one is your body and the other your car) is that the consumer is also the purchaser.

As for socialized medicine, I’ll deal with that in a separate post… :slight_smile:

I frankly don’t think that Canada’s health care woes are the fault of its being socialized. In fact, I’d refuse to live anywhere that doesn’t provide socialized medicine. I think the problems are the fault of governments who value corporate-welfare queens and tax cuts more highly than universal health care. I and my mother, the doctor, are going to fight tooth and nail to keep the medicare system from going down the tubes. I look at the United States as little more than a pathetically bad example.

Dr. J, when I was in the service, the hospital I worked at(Madigan AMC in Tacoma, WA) tried this system. I’m not sure if it is still going on, but i remember that there was a big problem with physicians being encouraged not to order imaging studies because there was no extra reimbursement coming from anywhere. It was presumed that many patients went on with undiagnosed problems because physicians were more interested in saving the money for more “crucial” things like surgeries which are very expensive. Hospitals usually lose money on the procedures while making money off of diagnostic procedures like radiology and laboratory studies. Not to mention the ER waiting problem.

“Teaching without words and work without doing are understood by very few.”
-Tao Te Ching

Hi! I’m just moving this thread to the top for the other debate about health care.