Socialized Medicine and Single Payer Systems

Great Debates
1

I have a few questions about countries that have instituted socialized medicine and single payer healthcare systems. I’m looking for factual information and logical discussion as well.

My friend and coworker is very libertarian, and was making a few of the following arguments today about socialized healthcare.

  1. If the government should have a single payer healthcare system, why shouldn’t they be the sole provider of things like clothes and food, which are items that everyone needs to live and function in society, and nobody has any choice of whether or not to buy them. We all need clothing and food and healthcare, so if we are going to go to a state-regulated/state-run healthcare system (whether that’s socialized medicine or single payer health insurance), shouldn’t we also have socialized agriculture, and socialized textile/clothing industries? What are the fundamental differences for why healthcare should be socialized, and food/clothing (or other necessities that no one can actually live without) should not be run/regulated by the government. That is to say, farmers and clothing manufacturers would be either government employees themselves (like socialized medicine), or that the citizens would receive vouchers or “insurance” of some sort to buy the clothing and food that they needed (like single payer, I guess).

  2. He is very concerned about socialized medicine or single payer systems (or even Obamacare itself) resulting in health care rationing. He believes that there are documented examples of people in the UK being refused healthcare for various reasons, and that they were unable to get care from any doctors. Similar things in Canada. So do these countries have health care rationing mandated in laws by the governments there, and if so, how does this compare to laws in the United States? Specifically, he says that it is documented that Britons who have dementia, Alzheimer’s and similar elderly problems have to be taken care of mainly by family.

I was also wondering about a quote from a book he is having me read, “a survey of almost 3000 doctors by doctor and hospital doctor newspapers found 1 in 5 doctors know patients who have suffered harm as a result of rationing. More than 5% of GPs [general practioners?] surveyed also said they knew of patients who had died as a result of being denied treatment by the NHS.”

This is a very poor cite and I haven’t been able to confirm it. Does anybody have any empirical evidence of health care rationing in Canada or the US?

  1. Do Canadians often view America as healthcare havens after they have been denied care under their system. Is it true that a lot of people from countries with socialized medicine and single payer systems flock to American hospitals and doctors for care, because of care rationing? What are the statistics on this?

I am sure this has been debated here a million times, and that these concerns have probably been addressed in thread after thread, so I apologize. If you want to link me to some other threads/posts that you know of, I’d appreciate it.

Thanks all!

2

I’ll take a shot

  1. Unlike food and clothes, medical expenses are highly variable, with most of the spending made by a small majority of unlucky people. As a result unlike food and clothing it isn’t possible for all people to afford their own healthcare. I would also point out to your friend that we have food stamps to provide food for those who can’t afford it, and the lack of naked people walking the streets indicates to me that thrift stores and clothing drives are enough to satisfy this need.

  2. Rationing medical care is a fact of life. The only difference between us and those with universal healthcare is that in our case the rationing is done by the health insurer who has a financial interest in not paying for your care. I would be interested in seeing the numbers of doctors in the US who know of patients who suffered harm as a result of reimbursement being denied by an HMO. I bet it would be much higher than 1/5 and probably approach 100%.

  3. The US has the best health care system for those who can afford it. I am not surprised that those who can afford it flock to the US to get the very best treatment. With enough money you can get world class physicians to take your case. However if you don’t have money, then tings are not so rosey. The question is do you want your healthcare system geared towards everyone or only the well off. I personally would prefer the former. Even in the case of universal single payer healthcare, I don’t think that there is any objection to those who want more advanced care and are willing to pay out of pocket, or who want to pay extra for supplemental insurance that would reimburse for treatments that are not covered by the universal system.

3

Did you watch the Olympic opening ceremonies? A tribute to the National Health System was huge part of it and got huge cheers from the crowd. My British relatives, even the conservative ones, are horrified by the US system and would never for a minute think of scrapping their system for ours.

This is a case where the facts are so obvious you need to be an ideologue to reject them. No other country in the world spends as much as we do per-capita for healthcare and we can’t even cover everyone. If this was “most” other countries, or “9 out of 10” you could maybe make a case that UHC might not work, but it works everywhere else. It even works in the US for people over 65.

You can’t use reason to argue someone out of a position they didn’t use reason to take.

4

I think the answer to this is that you COULD socialize/nationalize those industries as well, but that they are much more diverse (i.e. they are more horizontal industries, instead of health care which is more vertical) so unless you were planning to go full socialist it doesn’t really make much sense. Healthcare sort of does, especially if you don’t have a long history of a hybrid system like we do, where the costs of healthcare have been part of ones salary and not part of a higher level of taxation. It might amount to the same thing in the end (I doubt it here in the US), but peoples perceptions here would have to alter to “I’m paying more in taxes, but my take home is unchanged since the company is not taking out the part that covered my health care costs before”. Of course, you’d actually have to demonstrate this to get most folks in the US onboard with something like UHC/single payer system, and I remain unconvinced that you could get the same level of care that the majority of Americans currently have but expanded to all the Americans that don’t have formal coverage while keeping the costs the same and not expanding our healthcare infrastructure (which would cost more). To me, simply saying that the government would of course save money over private industry is fairly unconvincing. The fact that most other industrialized countries seemingly have done this stems from the fact that they have a history of having a single payer system, and don’t have all the baggage you’d need to get past to radically alter our system, which has been chugging along exactly as it is today for my entire adult life (longer really).

All systems have rationing. Ours is no different. The only change is, who decides how medical care is rationed? A lot of folks are uncomfortable with private industry in the form of insurance companies making those decisions. They feel the government would be a better, more balanced and fair arbitrator. I’m not seeing that, to be honest, since in the end it’s still going to be about the bottom line, whether you are talking private industry or the government. I suppose the comfort level is going to stem from which you are more comfortable with making those sorts of decisions.

I don’t think a lot of Canadians envy our system. :stuck_out_tongue: There are some Canadians I’ve heard of who come here for specific, vertical type care or procedures, since at the top end our healthcare rivals anything in the world. That’s probably true of other places too, but I doubt there are a lot of either Canadians OR Europeans coming to the US to get medical care, since their own systems usually have a private and upper end care option (if you are willing to pay for it).

Our system is a kludge…it’s a mess that sort of evolved from earlier times and that has been perpetuated because it manages to muddle along. I have no doubt that there are more optimal solutions out there, and that our own system could stand some major reform. The trouble is, I think it’s apples to alligators to try and compare the systems that have evolved in other countries to ours and then blithely state that we could just shift to that with little or no change. Something major is going to have to give…and, my guess is that will be both the cost (which I think will go up a lot, especially initially) and the care (which I think will go down until our medical infrastructure can be increased to take on the new load). And that this change will mostly be negative for the majority of people, with folks that are currently at the bottom getting the most positive results.

5

I’ll take a shot at

  1. Using some other topic to use as an analogy is utterly useless and should be left only to legal speakers and the like. All subject for discussion can only be argued on their own merit and comparison with other things seems logical, however this is highly misleading and is indicative of lazy thinking.

All governments regulate lots of things, and this point is merely taking just one item and comparing it to one other item, should be have completely unregulated banking to look after your own money - after all we all need banking don’t we? Maybe the manufacture and design of safety features in cars should be left up to the market shouldn’t it? We all need, electricity, maybe we should completely deregulate the transmission line standards.

We could go on and on, making each position more absurd and less connected to the markets than the next.

The fact is, we as a society have decided that many things should be overseen, and often times very closely regulated, that’s why we have anti-trust laws.

The idea that we should wish to see healthcare regulated and fairly shared amongst the population is not at all radical, in fact, in the developed world it is seen as a baseline for a civilised society.

You have only ever lived under a system of insured healthcare, and if you are not one of those fortunate portion of society then you cannot appreciate the extent and scope that it imposes upon your life.

It seems counter tuitive to imagine a system that has such a significantly costly billing system, along with and insurance industry whose very existence is predicated upon the continuing existence of a price rationed system - making commodities scarce has always been an easy route to profitability, especially for a life essential commodity.There is a whole and massive layer of bureaucracy involved in ensuring that premiums are as high as the markets will stand, and this leads to much higher per head medical costs in the US than almost anywhere in the world - for those that have such coverage, it is excellent - but it is not an open and free market, and of course over one third of US citizens are not directly covered.

There is another, and perhaps much more important structural reason, and its to do with economy and the flexible movement of labour.

Every economy in the world needs to attract the most talented labour to the most productive parts of the economy. Many times this means start-ups and innovations. The labour force needs to be able to move easily from one role to another, and libertarians will also argue that employers need to be able to fire at will to ensure they can remain flexible and competitive.

This is where their arguments fall down on universal healthcare, because this actually works against labour flexibility. Once you have an employer with good insurance, you are not inclined to move on to another employer, or to take a chance and step out on your own, especially if you have developed a medical condition or someone in your insured family has developed a medical condition.

You simply cannot move to another employer with another healthcare insurer, because you will not get cover on that existing medical condition - basically you are tied down. Seems the libertarians like the employers to have labour flexibility, but they want the labour itself to live in medically insured servitude.

Now try compare that medical insurance market to the food market, and its not hard to demolish the argument your friends make, because food as a commodity is nothing like the same as healthcare as a commodity, the markets do not operate in anything like a similar manner, yes they are both essential but you are comparing apples to oranges and its why the analogy fails

6

Healthcare can be catastrophically expensive. Food and clothing can’t.

This is perfectly true. Funds are not unlimited. You might care to ask how often it happens. Such decisions are also subject to appeal. And sometimes people have to wait; sometimes other people require more urgent treatment - if you needed treatment for a broken arm, wouldn’t you let the doctor treat the patient having a heart-attack first? Some people get told that they won’t be treated unless they meet certain conditions (e.g. cutting down on drinking for liver transplants or cutting down on smoking for lung transplants). And you know what, you can also buy insurance.

Your friend should ask himself if he is letting the quest for the perfect get in the way of the good enough.

7

I appreciate the logic. It seems to me my friend inherently distrusts government, and the rationing thing scares him. He would rather have the free market do the rationing, as he sees it as less evil or whatever.

He also says that he is not against people getting the treatment they need even if they are uninsured, but instead of having the government help subsidize hospitals who can’t collect money from the poor people they have to treat by law, he wants hospitals to simply shift the costs onto people who do have insurance, or who do have the means to pay more. So basically, he wants the rich/wealthy to get charged out the wazoo to help make up for the poor who can’t afford to pay for their healthcare, but not by taxing the population or having a federal mandate.

I argued that such a system couldn’t work in practice, because there are lifetime limits to insurance, so you can only charge people so much, and there aren’t enough ultra wealthy people going to hospitals who could just pay an enormous amount of money for life saving treatment to help make up for those who can’t pay.

Could such a system work?

And, is it better to have the private insurance rationing healthcare than the government?

8

As a die hard conservative I hate to admit this but I feel healthcare at some point will need to go to a total federal agency where the hospitals, and all amployees are basicaly paid by the govermenet. We presently have an unsustainable amount of money flowing into the healthcare system at this point. Either through private insurance, cash or federal and state payouts. Companies are leaving the country because of health insurance costs. It is breaking the system from every angle you approach it.
Taxes would have to pay for it. Healthcare and education in a wealthy advanced country such as ours should be available to everyone and it is not at present. We may even have to open our own medical schools to train these Dr’s. Who knows? I just know it is not sustainable at status quo.

9

Well, you did say he was a Libertarian. :wink:

This is pretty much what we do now. If you are shot in the US you get treated, not left to bleed to death, whether you are insured or not. If you aren’t insured then basically those costs get passed on to the insured by a non-zero amount in their rates to make up the difference. The trouble is, if you aren’t shot or having a heart attack or some other acute issue, then you can’t really get proper care…so, no preventative type care. THAT is the issue that this all revolves around, and why a lot of folks in the US (especially on this board) want a single payer or UHC system instead of what we have.

The only part he gets wrong is that the rich aren’t the ones paying out the wazoo…pretty much everyone who uses healthcare in the US, including the companies paying their half for employee insurance are paying those additional, mostly hidden costs.

10

As I said, you friend is an ideologue and nothing you can say will change his mind about govt involvement in healthcare if he doesn’t trust govt in the first place. If hospitals pass on the cost of the uninsured to the rest of us then it is not hurting the wealthy, it is hurting the middle class. If he thinks that hospitals can charge more to the wealthy then he is just nuts.

11

Wait, really? I thought that one of the main arguments for the health care law was that the government already has to pay hospitals to help subsidize them for customers who can’t pay. Is there really no federal or state money that goes to hospitals to help offset the customers who don’t have the means to pay?

12

There probably is some state and federal money from stuff like Medicare and Medicaid going towards it, but yeah…the costs of treating the uninsured are pasted on to the insured in the form of higher rates. It all gets bundled together into the mish-mash that makes up our health care kludge, and why even (some) conservatives agree that reform is needed. Our system wasn’t designed…it evolved into this monster over time. It’s a hybrid system…neither privatized NOR public, but something in-between both.

13

This is basically the system we have now, and it is highly inefficient. The way in which those who have insurance pay for those who don’t is a pretty ad hoc system that varies from hospital to hospital, and primarly nails those who don’t have insurance (so can’t bargain for lower prices) but have substantial savings/income that they hospitals can take/garnish to subsidize those who don’t. Further those who don’t have insurance will likely do without early or preventative care with the result that their outcome will be worse, and their eventual cost to the system will be much higher.

14

Not that I’m aware of, no. The government only pays for Medicaid (basically mothers and children that are extremely poor), Medicare (old folks), and Vets (through the VA).

What you may be thinking of is that the law that requires hospital ERs to treat all comers (the EMTALA) is tied to their Medicare/Medicaid funding, which most hospitals can’t do without.

15

Rationing? Like in WW2 or something?

Does your friend understand that people who live in countries with universal healthcare voted for it, it’s a choice for every first world country that has a choice - the people of the USA have never had that choice.

16

1 and 2 have been pretty well addressed, so I’ll just take a stab at 3:

No, it is not true. Not only is is not true that care rationing is why “a lot of people from countries with socialized medicine and single payer systems flock to American hospitals and doctors for care,” it’s not even true that “a lot of people from countries with socialized medicine and single payer systems flock to American hospitals and doctors for care.”

Hospitals and clinics in states which border Canada (which is where we’d expect to see the most “medical tourism”, right?) see fewer than one Canadian per month. 40% of them haven’t seen a Canadian as a patient in the previous year. Of those, 80% were urgent care visits - tourists injured in the US who needed treatment for accidents or illness before they went home. Only 19% of those 12ish patients a year came here for an elective treatment - so that’s, what, 2 Canadians a year for each hospital/clinic surveyed? I can’t find any semantic argument whereby that’s “a lot”.

Limit your surveys to just “America’s Best Hospitals”, places that provide very specialized and/or superior care, and only one of them sees more than 60 Canadian patients a year.

Survey Canadians themselves, and only 90 out of 18,000 surveyed got care in the US, and 20 of them electively (the rest urgent or emergent).

http://content.healthaffairs.org/content/21/3/19.full

17

I’ll just put a note on this one, since my opinions on the other points have already been captured by other people:

In health care, and especially health insurance, the incentives do not work the same way they do in other industries. For most consumables, if I’m running a business that produces consumable X, the people who I most want to serve are people who consume more X because more X being sold results in more money for me. I can make my X better to attract customers that would otherwise go somewhere else for X, or I can come in at a lower price point and entice customers that would not normally consume as much X into consuming more X because it’s so cheap.

In the long run, I have an incentive to make X better and cheaper because doing that makes more money for me. And this is true for X = food or X = clothing, and it’s the basis of the idea that the free market makes things better, and in these markets it’s completely true.

But if I am a health insurance provider, and X = health care, this argument breaks down because my best customers are no longer the people who consume a lot of X – in fact they’re my worst customers. And I am certainly not going to lower my prices for the purpose of encouraging more customers like that. My best customers are the ones who consume no X at all and just keep paying me for nothing.

So my incentives are then to make things better for the people who don’t consume any health care at all, because that’s the kind of customer I want to attract. Making health care itself cheaper or better would only attract the kind of customer who would consume more of it, and that’s not the kind of customer I want. So the invisible hand is not providing me with any incentive to improve health care at all.

18

This is an interesting argument, but let me focus on something he touched on with the free market.

He too sees the insurance market as being mired down and terrible. He doesn’t like the way our current insurance works. Or that it can be pretty much impossible to get non-life-threatening care/procedure done without it. For example, there are lots of procedures that, if you wanted to just pay out of pocket yourself for (even if you did have insurance), it’d be a logistical nightmare for the doctor and everyone involved to try and bill you for that, because the system is all built around providing healthcare to people who have insurance (unless it is life threatening).

So he does support insurance reform. Though I don’t know to what extent. But I know he wishes that the system were sort of tore down, so people could just clearly know how much medical procedure X costs, and that there isn’t any bargaining or negotiating, or separate prices for insured vs uninsured people (if it’s even possible for the uninsured to get a particular procedure). Basically, he’s arguing that we don’t really have a free market system now (and especially not under Obamacare), because people don’t really have the free choice to choose a given medical procedure under an easily understandable price.

So I guess what he is saying is that if the system were somehow changed so that people had more choice, more transparency in healthcare and individual procedure costs, things would be better, costs would be lower, etc. Not sure how he would want to achieve that reform now. But as he sees it, the current/old system is not free market.

19
  1. Food and clothing are low cost and stable over time (you spend about the same on food and clothing next month as you will this month). health care is far more dramatic in its price composition, and most people cannot possibly obtain the level of income when true disaster hits. Add to that the fact that when you are truly sick, a lot of people can no longer work so their incomes are reduced. You may spend $3000 a year on food each year and $1000 a year on clothes, but that won’t change. With health care you may spend $2000 a year for 20 years, then spend $150,000 in one year plus lose your job because you aren’t healthy enough to work.

However you can make the counterargument ‘then why isn’t all insurance single payer and government sponsored’? Why don’t we have a single payer auto insurance or single payer home owners insurance system? I don’t know.

Single payer systems overseas cost far less and provide far higher quality care than the US’s system (even our single payer system, medicare, provides higher quality of care for less money than our private insurance).

But nations that don’t have single payer and that instead have something like RomneyCare or Obamacare (Israel, Switzerland, the Netherlands, lots of other countries) also have higher quality care for less money. So single payer in and of itself is not always better than mandatory private insurance. Israel covers everyone for a lower % of GDP (8%) than Canada (11%) despite Canada having a single payer system and Israel having mandatory private insurance.

  1. In the UK they calculate payments based on quality adjusted life years added per treatment (QALY). I think the calculation is anything that costs less than 35,000 pounds per QALY is covered. Anything that does not isn’t covered, but the NHS will cover the first 35,000 pounds of your treatment.

I have no idea how Canada works.

In the US over 60% of people have avoided needed health care due to costs. Your statement was that ‘1 in 5 doctors knows someone who has been hurt by rationing’. But a doctor will know hundreds, thousands of patients. So that makes the actual number of people hurt by UK rationing maybe 1% (I am assuming, if you assume each doctor ‘knows’ 20 people)? A system where rationing hurts 1% is far superior to one where rationing hurts 60%.

Considering that the average doctor in the US sees thousands of patients over the course of their career, how many would say they’ve seen people die because of either an inability to get insurance or because insurance refused to pay their bills? In the UK it is 5%. In the US it would likely be 50-90%. However the number might be on the lower end of that scale because people over 65 (most deaths occur in those over 65) are on medicare. But I’m sure lots of doctors have met uninsured cancer patients.

  1. My understanding is the Canadians who do come to America do so because of privacy. they have embarrassing health problems and don’t want it in the canadian medical record system. Another reason is that the US does have a lot of doctors since we have 7x more people, so there are more places to pick. Plus elective surgery can take a year or more of waiting, and some people don’t want to wait that long.

As a counterpoint, endless millions of Americans buy medication from Canada, and millions travel overseas for surgery. So the number of Americans getting health care abroad is far higher than the number of Canadians who come here.

Canada will also pay for your health care in the US a good deal of the time.

20

According to factcheck and the Kaiser family foundation it costs about $350 extra per person per year in higher insurance premiums, medical expenses and taxes to cover the uninsured.

So right now a family of five may pay about $1750 a year in one way or another to cover the uninsured.