Universal Health Care (UHC)

[Nick Capozzoli]

I'd like to open a discussion on this topic. Of course it is a big "political" issue, since it's being debated in Congress and the radio talk show commentators are discussing it, but let's try to obey SC's rule about "no politics," if we can.

Everyone wants good medical care, just like they want the other necessities of life. Most people don't worry about medical care when they are healthy, but when you are sick, medical care is as necessary as food when you are starving...

One difference is that most people have the wherewithall, at least in theory, to find food when they are starving. If you are sick and need medicine or some medical intervention, you need to get help from a specially trained person, called a physician. Thus, most people cannot really provide their own health care. They have to rely on others. In the past, the others who provided the healthcare did so via free marketplace incentives. That is, physicians provided care in the same way that plumbers provided services to their clients. If you need a plumber, you hire one to do a job.

No one has suggested that there is a "universal right" to "plumbing care." The push for UHC is based on the idea that "health care is a right."

We may decide that healthcare is a right, but if we do so it will be the first time that we define as an individual right something that can be provided only by someone other than the individual who has that "right." This, to me, is the crux of the debate about UHC. Don't you think it odd that even though having food to sustain life might be considered a "right," no one has suggested or even legislated a mandate that farmers or grocery stores provide food to people regardless of their ability to pay for it?

I have a lot more to say about this topic, but I think this is a good start.;)


UHC

[Nick Capozzoli]

I have a lot more to say about this topic, but I think this is a good start.;)
UHC

Since there were no bites, I'll add some more for discussion...

With few exceptions (read such works as the A Barefoot Doctor in China etc.), you are not going to be able to provide yourself with DIY medical care for any serious medical problems... The main problem is that medicine has advanced greatly over the past couple of hundred years. If we were back in the 1700's or earlier, an intelligent literate amateur could probably handle his medical care with a modicum of attention to DIY style handbooks.

Of course back then physicians really couldn't treat much of anything, with the exception of surgical types who could make a real difference in cases of things like dental abscesses, wounds, bladder stones, broken bones, and gangrene, or those rare cases of childbirth where a Caesarian would be needed... Even then, an amateur would have a problem trying to perform a C-section or "cut for stone" (which even Hippocrates advised against).

Back then life expectancy was about 45...

It's different today. You need specially trained people to provide medical care. Physicians in the USA have a very long training period. 4 years of college, usuallly in a scientific subject, but in any case with a minimum of at least a couple of years to complete "pre-med" academic requirements in Biology, Chemistry, Physics, and Math needed to be admitted to Med School.

Then you have 4 years of Med School, after which you have to complete a minimum of one year of Internship, and then from 2 to 6 or more years of Residency training depending on what type of medicine you want to practice.

So, the doctors who will have to provide your medical care will need from 11 to 15 years or more of education beyond High School....just to become competent enough to do things like take out your ruptured appendix or keep you from dropping dead after a heart attack...or fix any number of other medical problems you may have.

UHC will have to find a way to provide you with medical care, and this care will have to be provided by highly trained physicians. This is an even more daunting problem than getting US farmers, grocery store owners, or plumbers to provide food or plumbing services to Americans were we to have "Universal Food Care" or "Universal Plumbing Care.":)

Nick



Think about that for a minute

[Thomas Lucero]

As I see it, there are (at least) three parts to the situation. These may also apply to UFC (universal food care), etc.

1. Ethical/compassion - we see the suffering in ourselves and others, and want to do something to help. Not trained as a medical doctor or other professional, our options to help are limited.

2. Financial and economic. Medical care can be expensive. This is the issue the medical insurance industry (Blue Cross, private insurance, Medicare/Medicaid, etc.) was designed to address.

3. Systematic - we can look at the system as a whole, and see many problems in medicine that are made worse by the current structures - both financial and others. I dealt with these issues for many years as an actuary, before deciding that I was not making a positive difference in the system.

I think to get an acceptable range of answers, we need to get basic. And the basic question I have learned to ask is: who decides?

We (as individuals) can decide to enter medicine and allied fields as a career. Or we can donate time and money to help those we deem needy. But I don't find it moral or ethical to tell other people what to do at the point of a gun, and all government-sponsored plans have the implied use of force to back up what those in power think is best for the rest of us.

I could pick a better insurance plan than the choices my former employer gave me. I could (sometimes) do better medical research on my health issues than my doctor has time for. I can choose to eat healthy, not smoke, exercise, etc. The boy hit by an uninsured driver doesn't have these choice, and his family doesn't have the time to find the best care. The trouble is, we as a society don't have enough wealth and compassion to fix all the medical/financial issues (not can we feed everybody, all the time).

So it gets back to who decides gets what level of medical care. I was comfortable with the old Blue Shield method of charging x percent of income as payment in advance in full. When the private medical insurance industry started charging flat rates per month, that, also, was voluntary, but left hospitals and doctors scrambling to pay for the uninsured and non-pay. The current system is ugly because nobody really knows what will be paid by the insurance and what will not, including the insurance company and hospitals and doctors. It's fixable, but not in a highly politically charged, high stakes poker environment.

[TheFifthElement]

We have universal health care in UK.

[The Atheist]

And New Zealand!

[JBI]

We have free health care here in Canada too, though our system isn't quite as good as the Australian one.

[Nick Capozzoli]

They have UHC in NZ, Canada, Aussieland, the UK, and indeed in most European countries, not to mention China and Russia.... I wouldn't refer to any of these as "free health care." UHC costs money, but the money is collected by the state in the form of taxation, so it may seem "free" the citizens. We could do this in the US, but it would require a huge increase in taxation.

Thomas Lucero made some really good points, especially about compassion. It would be nice if we had some sort of priestly class of medical caregivers (physicians, nurses, etc., who were so driven by their desire to help others that they made huge sacrifices to dedicate years of their lives learning the art and science of medicine without much thought of becoming wealthy by their work. They would also be willing to work really hard and long hours, because providing medical care is a 24/7 thing. Somebody has to staff all those hospitals and emergency rooms in the middle of the night, and you want to have doctors to care for you when you have that heart attack at 3AM, don't you? You don't want your doctor to have the mindset of a civil service worker, like the folks at your local DMV who shut their doors at 5PM...

UHC would essentially turn physicians into civil servants, like those wonderfully helpful and compassionate people who work for the Post Office and the DMV.

I think that most Americans who go into medicine do so because they want to serve. But they also expect to make a decent living commensurate with the arduous training and the long hard hours of work that they have to put in even after they are trained and licensced to practice. How much do you think should be paid to the physician who has to come in in the middle of the night to treat your heart attack?

There is another area of concern when we turn over healthcare to the state, and it is that the state will assume control over what sort of and how much healthcare you will receive. Even though you will be paying for the healthcare of "everyone" in your country via taxes (and these will almost certainly be "regressive" and/or "progressive" taxes), the state will dole out healthcare based on some sort of schedule and formulary. For example, if you are 70 years old and have a bad hip joint, the state may determine that you shouldn't get a "free" hip replacement because it wouldn't be "cost effective." The state will make similar judgements regarding kidney transplants, coronary artery bypass surgery or angioplasty, treatments for stroke, multiple sclerosis, hepatitis C, various cancers, etc.

I'm sure that UHC serves the needs of most of the folk who have it now in places like Canada and the UK. There are apparently many people from those countries with serious medical problems who come to the US for treatment they cannot get from their home countries. If the US adopts a similar style of UHC, where will these folks go? I've heard that India and Thailand are offering vacation packages that include surgery...:lol:

[JBI]

I think most people here who go for medicine do so because they think they will be guaranteed rich when they grow up. We have medicare, yet doctors still make huge salaries, though, not as ridiculously as in the States (therefore 1/4 doctors trained here end up there within a few years of graduating, though, we brain drain quite a bit from other countries, so it balances out in our favor).

I think here though, people consider healthcare somewhat of a given - they think they have a right to it, because of their citizenship - being Canadian, in a sense, means not paying for health care (as apposed to Americans, who have to).

No one, for instance, could try and remove medicare from Canada without getting burned politically, whereas if someone tries to create medicare in the US, often they get brushed aside (I won't comment on contemporary politics, as that is against the rules, but I am willing to justify this statement via PM if someone wishes to contradict it).


As for going to other countries - generally people who go to the States want some form of alternative medicine or another which, quite frankly, cannot, and will not ever be covered by a medicare plan, for the simple reason that there is no conclusive evidence it really does anything, and no scientifically coded form of going about it (get 10 Natropaths together, and chances are, they'll prescribe 10 different things to the same patient, though they argue they get the same results through different methods). In that sense, yes, you do get to buy what you want in the US, but there are just more facilities for it in the US, that's why people generally go - there are facilities in Canada, but if you go to the States, it probably will cost the same, and you can skip the lines.

In that sense, there is a tyranny - rich people thinking they should bypass the lines in Canada, and use their money to get treatment faster in the States - just as long as they still pay taxes, quite frankly I could care less - that's coming out of their pocket, not the Crown Coffers, so in the end, it ends up benefiting this system more.

When it comes down to it though, as soon as you need expensive medications or surgeries under a system without medicare, and you don't have coverage and a bottomless bank account, you'll feel the want for it - I think the vast majority of Americans have been saying they want medicare for the longest time (modeled on the Canadian system since they don't know anything about other systems which are probably better) but nothing has really been done, as neither party has had any inclination to pass something that their backers would deem too costly (again, I won't talk about the current government, as that is against the rules), yet the people want it.


Nick, I see your point with bringing up the idea of what happens if people cannot go to the US, but, at the same time, there is a strong campaign to improve medicare in Canada for instance - I think the chances of that improving significantly are better than of a completely public system being implemented down-south. I think by then, that things will become very, very hectic - the So called New World Order of the First Bush days, and the post-cold war policy is about to really take its toll, so whatever happens, the political outlook and medical structuring of the next 20 years in the States will be very, very strange - quite frankly, for all its worth, I don't know if China would even be up for financing an American program, because certainly the domestic government won't have the capital to do it.

[Tsuyoiko]

They have UHC in NZ, Canada, Aussieland, the UK, and indeed in most European countries, not to mention China and Russia.... I wouldn't refer to any of these as "free health care." UHC costs money, but the money is collected by the state in the form of taxation, so it may seem "free" the citizens. We could do this in the US, but it would require a huge increase in taxation.

In the UK, it is free in the sense that you are still entitled to it even if you don't currently pay, or have never paid, tax; children, retired people and those unwilling or unable to work have exactly the same access to the NHS as those who pay taxes.


There is another area of concern when we turn over healthcare to the state, and it is that the state will assume control over what sort of and how much healthcare you will receive. Even though you will be paying for the healthcare of "everyone" in your country via taxes (and these will almost certainly be "regressive" and/or "progressive" taxes), the state will dole out healthcare based on some sort of schedule and formulary. For example, if you are 70 years old and have a bad hip joint, the state may determine that you shouldn't get a "free" hip replacement because it wouldn't be "cost effective." The state will make similar judgements regarding kidney transplants, coronary artery bypass surgery or angioplasty, treatments for stroke, multiple sclerosis, hepatitis C, various cancers, etc.

As far as I know, the state here doesn't refuse procedures to individuals based on cost, but on the interests of the patient. If they refuse hip surgery to an elderly person I think it's because of the danger of surgery, not because of cost. However, I think certain types of procedure are refused to everybody on the basis of cost.

That seems preferable to the situation you have now in the US, where I hear that insurance companies employ people specifically to find ways to avoid paying out.

[Scheherazade]

R e m i n d e r

Please keep in mind that discussion of current politics is not allowed on this Forum.

This thread will remain open as long as it delve into political side of the topic.

[Nick Capozzoli]

1In the UK, it is free in the sense that you are still entitled to it even if you don't currently pay, or have never paid, tax; children, retired people and those unwilling or unable to work have exactly the same access to the NHS as those who pay taxes.



2As far as I know, the state here doesn't refuse procedures to individuals based on cost, but on the interests of the patient. If they refuse hip surgery to an elderly person I think it's because of the danger of surgery, not because of cost. However, I think certain types of procedure are refused to everybody on the basis of cost.

3That seems preferable to the situation you have now in the US, where I hear that insurance companies employ people specifically to find ways to avoid paying out.

First of all, I note and agree with the need to keep "politics" out of this discussion, and I hope we can all do that. My comments will not be partisan, but it will be necessary to discuss certain general political ideas, like individual and group rights, the "public good," taxation, etc. I think we can all engage in an honest and polite discussion without raising the temperature to the point this thread gets shut dowm.


Re: #1. While it's true that UHC provides care to all, even those who don't pay taxes, or to those who pay less in taxes than they receive in state sponsored benefits, UHC is definitely not "free." Someone pays for it, and if you are receiving UHC and not paying for it "in full," others are paying for your care.

Re: #2. The state has to ration healthcare because there are limited funds to pay for care. It's a matter of supply (limited) and demand (potentially unlimited). All medical interventions, like hip replacements, have risks, and doctors weigh risks versus benefits all the time. The UK's NHS also uses actuarial tables to make decisions. Part of the calculation involves your life expectancy, the probabilities regarding how long you will live and remain "productive," etc. If you're 65 and retired, for example, the state might decide that the money that would be spent on your hip replacement would be better spent providing pre-natal care and childhood vaccinations... If you have a brain tumor that has a 10% survival rate with the most agressive treatment, the state might decide you're not worth spending any more money on. The calculations can become pretty cold-blooded (so much for compassion), and if you or a loved one comes up on the short side of the calculation, it can be very frustrating indeed.

Re: #3. Indeed our insurance companies, HMOs, and other "managed care" programs employ "Utilization Management (UM)" to decide whether or not to pay for medical care. UM is just another form of rationing. The difference between the US system and others is that in the other systems in which the state provides medical care, there is more of a chance for denied claims to win on appeal. When the state makes the UM rules and doles out the care, you have much less of chance appealing a denial.

There is a big difference between the US system, where the state regulates health care and looks after the rights of healthcare consumers, and a system where the state completely controls the whole shebang.:(

[kasie]

Let me get this straight - you would rather rely on an insurance company, which is in business to make profits, to pay for your medical care than on a nationalised system where the government is answerable to the electorate for its management of public funds?

btw - 65 is more likely to be the starting age for a hip replacement rather than the cease date - surgeons in UK are reluctant to take younger patients because of the likelihood of having to perform repeat operations when the replacement joint wears out: length of service is reckoned on average to be twenty years.

[Virgil]

Let me get this straight - you would rather rely on an insurance company, which is in business to make profits, to pay for your medical care than on a nationalised system where the government is answerable to the electorate for its management of public funds?


I would. The insurance companies are answerable to customers. If you are in business and you are competing you listen for what the customer wants. The electorate is quite finicky. It would prefer tax cuts, it prefers social programs, it would prefer good roads, it would prefer a slew of things. Actually it prefers more than it's willing to pay for. In the absense of competition, gov't will make decisions based on a plethora of needs. I don't know about you but I think every country in the world has budget problems. It will attempt to satisfy as many of those requirements as possible and therefore not fund them fully. And you have no recourse. If you're not happy with a particular service from a solitary provider, and they decide they will not spend money on that particular service, where do you turn? In a competing environment, I can choose another insurance company or appeal to the gov't. Once the single provider, and that single provider is the gov't, makes a decsion you have no recourse.

[TheFifthElement]

I think this debate is nigh on impossible without a clear understanding of how universal health care systems work in practice, and how insurance funded healthcare systems work in practice because lots of assumptions are being made about things nobody here quite understands. Basic mistakes are being made in the assumption that the state controls healthcare in an UHC system. In a good UHC system this is not the case.

For example, and I can speak only for UK, the government does not directly run the health service. The majority of the health service is run by healthcare trusts who are answerable to both the government (in terms of meeting targets for healthcare provision) and to their customers (being the healthcare receipient). The conduct of doctors is regulated by the General Medical Council who, again, are an independent organisation. Some aspect of the health service are run by other independent organisations such as The National Institute for Health and Clinical Excellence (NICE) whose role is to provide national guidance on the promotion of good health and the prevention and treatment of ill health. including regulation of and providing guidance on medicines and sharing clinical excellence. You can read about how the NHS is structured here: http://www.nhs.uk/NHSEngland/aboutnhs/Pages/NHSstructure.aspx

The health service is funded by National Insurance contributions which are not considered a 'tax' as the government does not have access to it for general spending. The government cannot take the NHS budget and use it for building roads or for the military or any other purposes.

So there are checks and balances, at least in the UK system, to ensure that whilst the government is responsible for the health service, the control of the health service is independent. Whilst there is much talk of the government what tends to be forgotten is that the National Health Service belongs to the people, is paid for by the people and is accountable to the people. It has its own constitution embodying the principles by which it should abide which you can read about here: http://www.nhs.uk/NHSEngland/aboutnhs/Pages/Constitution.aspx

And there remains competition as healthcare trusts compete with each other, as well as private healthcare providers.

Neither have I ever encountered healthcare 'rationing'. Judgements around whether treatment is given or otherwise are made by doctors, and not the state, and the doctors primary responsibility is the best care of the patients. If a patient is not satisfied with the opinion they receive they are entitled to request a second opinion from a hospital of their choosing.

I personally don't know enough about the insurance funded healthcare systems to know what the benefits/detriments are compared to the universal healthcare system. Though there is insurance funded healthcare in UK this is mainly used for queue jumping purposes, and there are many restrictions over what will and won't be treated - i.e. they won't treat pre-existing medical conditions, so many people end up relying back on the NHS anyway. Maybe someone who understands more about how this works in practice could give an overview so that those of us who have UHC can understand why this might be a more beneficial system?

But if you ask people what their preferences are they're always going to choose that with which they are familiar so those in an UHC system will pick that unless it's not delivering in which case they'd choose the opposite, and those who have insurance funded healthcare will probably pick their current system if they currently have a good health insurance package, or would probably choose UHC if they don't because self interest would steer them in the direction of a system which gave them healthcare rather than one that excluded them. None of which is making an objective assessment of one system over the other.

[kasie]

Virgil - Businesses may listen to what the customer wants but they also have to provide profits for their shareholders. Disgruntled shareholders expecting a payout of profits quickly affect decisions made by the Directors.

The electorate is indeed quite finicky and, in the UK at least, it wants a Health Service that works and if it perceives that the incumbents at Westminster are not ensuring the efficient provision of that service, it has a potent recourse - the ballot box. There's nothing a political party fears more than losing votes and a rumoured threat to the Health Service is a sure way to cause a swing to the rival faction. (I speak of the UK here, of course.)

Thanks, Fifth, for a concise overview of the situation in the UK.

[The Atheist]

I've been watching this thread with some interest, particularly in view of a certain poster's stated aversion to politics [ :) ], because this subject is as political as it gets - a clear choice between capitalism and socialism.

No problem to me, because I'm sticking to sociology and history.


I would. The insurance companies are answerable to customers. If you are in business and you are competing you listen for what the customer wants. The electorate is quite finicky. It would prefer tax cuts, it prefers social programs, it would prefer good roads, it would prefer a slew of things. Actually it prefers more than it's willing to pay for.

Actually, it's even more complicated than that.

I think people are likely to vote on far more socially-constructed lines than any belief that one form of democracy is better than another, or even that theocracy, monarchy or dictatorship is any more flawed than another - there are lots of benevolent dictatorships around, it's just that the likelihood of failure through corruption is fairly high.

Over this part of the world, we're big on social responsiblity resting on society rather than the individual and we have the best human rights and social policy systems on earth. You can argue lots of things, but NZ has been the world leader in every "soft socialism" policy extant - from universal suffrage to human rights to gay marriage to social security for single mothers, we rule!

Over your way, the history is far more insistent on individual responsibility, and political parties tailor their policies accordingly.

I think it's an impossible question as no control exists to compare USA to. Your size, population, wealth and ethnic make-up means it's impossible to compare like with like, so the question is meaningless without recourse to debate on the goods and evils of the various political approaches.

[JBI]

I would. The insurance companies are answerable to customers. If you are in business and you are competing you listen for what the customer wants. The electorate is quite finicky. It would prefer tax cuts, it prefers social programs, it would prefer good roads, it would prefer a slew of things. Actually it prefers more than it's willing to pay for. In the absense of competition, gov't will make decisions based on a plethora of needs. I don't know about you but I think every country in the world has budget problems. It will attempt to satisfy as many of those requirements as possible and therefore not fund them fully. And you have no recourse. If you're not happy with a particular service from a solitary provider, and they decide they will not spend money on that particular service, where do you turn? In a competing environment, I can choose another insurance company or appeal to the gov't. Once the single provider, and that single provider is the gov't, makes a decsion you have no recourse.

And if it was a pure market system, the doctor himself would be free to prescribe to get a better pay, the pharmacist could charge more, as could the supplier, the doctors all hike up their prices, the quality be dashed in order to provide more cost efficient products, procedures hurried to cut wait times, etc. That's the market model - you must look supply side as well.

The government still is using laws to regulate the field, if not pay for it - you might as well get them to pay for the procedures too, as happens here. Sure there are flaws, but in the end, most people are going to be unsatisfied customers without it anyway, so a utilitarian, ethic, and humane concept would be to give equal opportunity to health care to everyone, and not make it a money issue, but a health issue, something which is equal for everybody, like education, and the law (I don't see you privatizing, for instance, the police force, even though one could hire a force to protect their village, or whatever and perhaps those mercenaries would preform better than the current squads, but ultimately, that is debatable).

[Virgil]

Virgil - Businesses may listen to what the customer wants but they also have to provide profits for their shareholders. Disgruntled shareholders expecting a payout of profits quickly affect decisions made by the Directors.
What I found was that the average health insurance company has a 6.4% profit, which is not really much. You'll see some years where these companies had a growth of triple digit growth in profits, but that's growth from a relatively low number. Look at the total profits over time. And some insurance companies, mine for instance, is a non-profit, which keeps the for-profit companies costs down and competitive. The 6.4% is surely enough to make up for lack of competition in a single payer plan.

Kasie, much has been said about the US system, but of the people insured, 93% were satisfied with their plan (Rassmusen poll done last year). What we have is a hole in our coverage. Because our coverage is mostly linked to employer providing insurance, the elderly covered through a government plan, and poor peoplle are covered through welfare programs, what we have is a hole in coverage for those that work jobs that don't offer health insurance. That's the problem usually associated with the US system. And of those, most are either well off enough finacially to buy their own and don't, or they are uninsured for less than a year at time for whatever transient reason. We have about 8% of the population that is chronically uninsured. And keep in mind, no one is denied emergency health care. That's why a good portion that can afford it decide not to buy it out of their own pocket.

Of the systems I have looked through, one of the best (and best would be defined as people satisfaction) of the European models is the French system. They have a balance of government and private health care insurance. That is essentially the same as the US model, our gov't system covering the elderly and the poor. You could read about the French systems here:
http://www.medicalnewstoday.com/articles/9994.php
and
http://www.npr.org/templates/story/story.php?storyId=92419273
Sure both the US and French models are more expensive than the single payer gov't systems, but that's because we don't ration. Some people call the rationing more efficient. Well, when it comes to my family's health, I couldn't care about efficiency. Sometimes efficiency is counterproductive. Sometimes it delays diagnoses, while it goes through likely causes first. If a serious health issue was in question, I don't want to queue up. I want service now and I want choices. I want to pick my doctors, pick my hospitals, pick my medical facilities. I want to pick a plan that suits my needs, not one for a whole mass of people.


The electorate is indeed quite finicky and, in the UK at least, it wants a Health Service that works and if it perceives that the incumbents at Westminster are not ensuring the efficient provision of that service, it has a potent recourse - the ballot box. There's nothing a political party fears more than losing votes and a rumoured threat to the Health Service is a sure way to cause a swing to the rival faction. (I speak of the UK here, of course.)
I don’t know how politics works in your country, but in my country there is mostly a fixed amount that government takes in and it’s not easy to raise taxes. People don’t go for that. Given that gov’t already takes in half ones pay check, when you figure everything gov’t grabs at, and given that the average person needs the other half to make ends meet, there is no political consensus to raise taxes normally. Even Mr. Obama (as Liberal as he is) ran on a platform that said he was going to cut taxes for 95% of the people. (Of course I don’t believe that, but that’s another story.) So even a Liberal has to promise tax cuts. Given that gov’t has a limited tax base, it has to make cost/benefit decisions: roads, police, fireman, teachers and education, military, welfare programs, environmental stuff, regulatory agencies, buses, trains, the list is endless. Who is going to take a cut if a cut for more money is going to be diverted toward healthcare? Will people cut back on education? Are teachers suddenly going to take a pay cut? If crime is suddenly a problem, will you not fund police more? Won’t the electorate hold politicians account for bad service, for high crime, for uneducated children? So in essence, politicians make cost/benefit decisions not just on healthcare, but on a totality of things. Well, that’s not the in the best interest of health care. The best cost/benefit analysis for you as an individual is done by you, for what your needs are.


And if it was a pure market system, the doctor himself would be free to prescribe to get a better pay, the pharmacist could charge more, as could the supplier, the doctors all hike up their prices, the quality be dashed in order to provide more cost efficient products, procedures hurried to cut wait times, etc. That's the market model - you must look supply side as well.

The government still is using laws to regulate the field, if not pay for it - you might as well get them to pay for the procedures too, as happens here. Sure there are flaws, but in the end, most people are going to be unsatisfied customers without it anyway, so a utilitarian, ethic, and humane concept would be to give equal opportunity to health care to everyone, and not make it a money issue, but a health issue, something which is equal for everybody, like education, and the law (I don't see you privatizing, for instance, the police force, even though one could hire a force to protect their village, or whatever and perhaps those mercenaries would preform better than the current squads, but ultimately, that is debatable).

It's not a pure free market. The gov't is regulating. But you want the best balance of free market for people to have choices and gov't on the other side to regulate practices. (By the way, that's out of Adam Smith, but I'm not having a debate over the merits or lack of merits of socialism.) Given that the high dynamism in the health care sector (constant reseach and development and new procedures and equipment, more diagnoses, all of which drive the inflation rate of health care costs) and given a more aging population, then some regulation is required for people to not fall through the cracks of constant transitions. If the health care industry ever plateaus with innovations then even more free market would be in order. Not sure that will happen in my life time.

[Nick Capozzoli]

I would. The insurance companies are answerable to customers. If you are in business and you are competing you listen for what the customer wants. The electorate is quite finicky. It would prefer tax cuts, it prefers social programs, it would prefer good roads, it would prefer a slew of things. Actually it prefers more than it's willing to pay for. In the absense of competition, gov't will make decisions based on a plethora of needs. I don't know about you but I think every country in the world has budget problems. It will attempt to satisfy as many of those requirements as possible and therefore not fund them fully. And you have no recourse. If you're not happy with a particular service from a solitary provider, and they decide they will not spend money on that particular service, where do you turn? In a competing environment, I can choose another insurance company or appeal to the gov't. Once the single provider, and that single provider is the gov't, makes a decsion you have no recourse.

Virgil,
You said that quite well...thanks for putting it so succinctly. Also, to answer Kasie's question re preferring insurance companies to the state, the way it works in the US is that the state makes rules about medical care and if you are denied by an insurer's UM program, you can appeal in Civil Court or by arbitration. It's a kind of checks and balances that is lost if the state takes over all aspects of medical care



1:Over this part of the world, we're big on social responsiblity resting on society rather than the individual and we have the best human rights and social policy systems on earth. You can argue lots of things, but NZ has been the world leader in every "soft socialism" policy extant - from universal suffrage to human rights to gay marriage to social security for single mothers, we rule!

2:Over your way, the history is far more insistent on individual responsibility, and political parties tailor their policies accordingly.

Re #1:I agree with you about NZ! I really love your country,and people. I've thought about places I'd like to live outside of the USA, and NZ is tops on my list. As regards civil rights histories, no place is perfect. We have our Native American and African slave populations, NZ has the Maories, and Australia has the aborigines... who were all mistreated. I don't object to "socialism" per Se, and I think that all good people should be socially responsible.

Re #2: I thought that New Zealanders and Australians were historically big on individual initiative and responsibility, just like us Yanks. Maybe we were a bit bigger on it, since we fought our way out of the Commonwealth. Either way, I do know a bit about your UHC, and I'd be happy if we could construct a system that worked as well. I'm not sure that we can, because the USA is a much bigger and diverse country.;)




1:Let me get this straight - you would rather rely on an insurance company, which is in business to make profits, to pay for your medical care than on a nationalised system where the government is answerable to the electorate for its management of public funds?

2:btw - 65 is more likely to be the starting age for a hip replacement rather than the cease date - surgeons in UK are reluctant to take younger patients because of the likelihood of having to perform repeat operations when the replacement joint wears out: length of service is reckoned on average to be twenty years.

Re #1: The government of democracies is indeed answerable to the electorate. There is a potential fly in this ointment, and it is that people vote their own interests. This is important when it comes to financing servives through taxation. The Founders of the US limited the vote to free male property owners who paid taxes. That has changed over the years since 1776. It is no longer a requirement for franchise that voters pay taxes. In the US today, in many jurisdictions, we are reaching the point that a majority of voters pay less in taxes than they realize in state sponsored welfare benefits, and fewer and fewer citizens are paying more and more of the welfare bill. What is to stop people who pay little or nothing in taxes to legislate that the "rich" pay more and more of their income to support welfare programs for the rest? The guys who wrote The Federalist Papers were keenly aware of this conundrum. One reason that we have a 2/3 voting requirement to impose new taxes is concern about this issue.

Re #2:

I'm not sure what the exact NHS "cease date" for hip replacements is, but I know that they have specific UM criteria for such surgeries, and they involve the age of the patient, and also involve consideration of cost/benefit analysis. I also know that the NHS has specific rules regarding renal failure and dialysis vs. kidney transplants. I have a particular understanding of the NHS protocols for treating acute stroke and heart attack, since I am a neurologist here in the USA and I've communicated with my colleagues in the UK (and Canada) about this.:)

Nick

[TheFifthElement]

I see I wasted perfectly good typing time.

[kasie]

No, you didn't, Fifth - I read it! I knew most of what you had written but I could not have set it out so succinctly - thanks again.

Thanks, too, to Virgil, for setting out the situation in USA - that should clear some misunderstanding, certainly on my part.

And Nick - I don't suppose it could be said that, as a provider, you have a certain partisanship in the argument, could it ? :) I suppose I too, as a consumer, have a certain partisanship, not least because of what you might call Folk Memory - the man who has been called the Architect of the National Health Service, an MP named Aneurin Bevan, came from the same small town in the coal-mining valleys of south-east Wales as my parents. He was an ex-miner himself, a former colleague of my uncles, in fact, and when he was given the job of constructing the NHS as Minister of Health, he used the Miners' Welfare Scheme that was in use in his home town as a model for the national scheme. He remembered the dire straights that sickness produced in communities where there was often unemployment and in receipt of low wages at the best of times and used the voluntary insurance scheme as the basis of the National Insurance scheme that was introduced in 1949. (He fell out with the Labour Party not long afterwards because they realised very quickly the financial implications of a completely free-at-point-of-use scheme and introduced charges for spectacles and dental care and he would not agree to the necessity for these charges.) I grew up with tales of the hardships of life in Thirties' Wales and still shudder at the thought of returning to those times, so I suppose I for one would oppose any suggestion of removing the NHS (and not just because I've paid into it all through my working life with the understanding that the service would be there when I needed it.) If you want a picture of this life, you can read about it in The Citadel by A J Cronin - Cronin was a doctor in the same town at the same time as Bevan was growing up and though it is a fictional account, undoubtedly adjusted for dramatic effect, it is, according to my parents, a not unrealistic assessment of the situation. (Cronin was my mother's doctor when she was a child - he was a dour Scotsman and, I suspect, scared her with his abrupt manner.)

[Nick Capozzoli]

And Nick - I don't suppose it could be said that, as a provider, you have a certain partisanship in the argument, could it ? :) I suppose I too, as a consumer, have a certain partisanship, not least because of what you might call Folk Memory...

Actually, and you'll have to take my word for this, I don't feel I have any "provider partisanship."

I grew up in a working class family in the Bronx, and lived in the "projects." I actually went to high school and was on the HS debate team with that gal who Obama just nominated to the US Supreme Court, and I shared a lot of her "liberal" ideas. I also worked as a plumber before I went to med school, and paid my way through college and med school by working in that trade.

So I am sympathetic to the medical needs of working class folk. I do believe that no one should be denied medical care just because they can't "afford" it.
My father died at home of a heart attack in the early 1970's. I'm sure he could have gotten better care, but he didn't. He was just a poor working class guy, and that's the way it was back then. Medicine has advanced a lot since then. I could be bitter about it, but what would be the point? This is a complex issue.

Yes, I am a "provider." I'm a licensed and board certified physician. Does that make me "partisan?" I hope I can still be objective, and I think I am.;)

Nick

[Taliesin]

One of the problems with the "if you got money, you can afford to go to a doctor, otherwise, sucks to be you" is that the doctors don't have very many clients, which forces them to raise the cost of their service (or move somewhere else or cut corners), which means that healthcare becomes unavailable for another bunch of people etc - in general, a a positive feedback system going to the wrong direction.
Mind you, I don't know whether there exists such a system anywhere, so I am just babbling.

Here, the system seems to be that if you work and pay the social tax (or if you study or are under 19 years old or retired or...) then you usually can go to the doctor and get doctored, but sometimes the queues are quite long - well, one can also pay extra to get the service more quickly. I haven't been to a doctor for a long time so I can't really comment much on it, but it seems that the doctors are a bit underpaid and tend to emigrate - not sure, though whether that's the fault of the system or the current government so I'll shut up lest I say something about current politics.

[kasie]

Sorry I didn't get back to you yesterday, Nick - I was at the local hospital, having tests done! I mention that not for sympathy but because as you may have realised I am a pensioner, I no longer pay into the NHS, but I paid all through my working life and so there is no question that I would be eligible for this treatment, whatever it turns out to be, and I have not had to wait very long for it: I saw a consultant within three weeks of seeing my GP. Had I gone down the private route, I might have seen him within a week, but if my condition had been really serious, the NHS would have worked on a similar time scale. (The C word gets you to hospital so fast your feet scarcely touch the ground - that's in Wales, btw, the Welsh Assembly has jurisdiction over the Health Service and often goes down a different route from Westminster.)

How far do you think the sheer size of USA population in comparison to UK or France, for example, has an influence over thinking about Health Care provision there? I ask in light of Virgil's note about the number of people not liable for payment - I don't know how that percentage compares with UK: pensioners, as I said, are deemed to have paid throughout their working lives and the scheme, unlike other private insurance schemes here (I'm thinking of things like private health insurance or life assurance) does not cease cover when payment of premiums cease. Contributions (as they are deemed, rather than premiums) are good for the life of the payer and are on a scale - I forget the percentage of wage/ salary payable at present, but it is capped as far as the employee is concerned, though not as far as the employer is concerned, and begins at quite a low wage. As Fifth pointed out, it is money that can only be used for health services and cannot be diverted elsewhere.

I must say that given your family's experiences I am quite surprised that you do not support a form of universal health care though other posters have emphasised that emergency health care is not denied when needed.

[Nick Capozzoli]

Kasie,

The US population is around 1/3 of a billion, which is pretty large. We are not a a homogenous population, ethnically, religiously, or otherwise, unlike say Japan or China, or even Italy or Sweden (though the European countries are getting less homogenous these days). This certainly presents "challenges" to UHC and other socialist systems. We often forget that the Nazi's were socialists...and one of their platforms was "racial" homogeneity...

I think diversity is good, up to a point, that point being when it interferes with democratic government and "peaceful coexistence." Just look at the Balkans, which have given us the word, "Balkanization." The US has always operated under the idea of "assimilation." We are supposed to be a "melting pot" nation. I still like the ideal.

[kasie]

Thanks for the info, Nick, but the bit about homogeneity has rather lost me - we have a pretty diverse society in UK too, what with our colonial past and current membership of the European Union. And how did the Nazis get in her? Socialist? Not exactly what is said on the tin, perhaps?

[islandclimber]

though I will admit to my own dire aversion to politics and government, I will say this...

the idea of lower taxes should be absurd to anyone who is in the lower 50% or more of the income bracket... the only possible reason I could see a low income person supporting lower taxes is in the hopes that someday they will make more money and get to keep more of it... for a person making less than, say, $30,000 or so a year which is the vast majority, well a 2% tax cut saves them almost nothing, as opposed to the enormous amount of revenue the government no longer takes in, and the enormous cuts that will have to be made to (of course) social services/education/health care/arts and culture/etc. I have no problem in saying it is fine to believe in lower taxes, that is everyone's right, but to suggest that lower taxes benefit the lower class is absurd and is why in countries without Universal Health Care of some sort, even alongside Private Health Care (which I think is fine as long as everyone is still paying tax dollars to support public health care), well often people on at the bottom are left without adequate health care coverage due to insurance that doesn't cover much, or unable to afford insurance at all...

some countries (and to avoid falling into modern politics I will just say northern haha) have what North AMericans would consider excessively high taxes, but they also have incredible social programs/ outstanding education systems/ great universal healthcare/ etc...

and here is where one gets into the Socialism/Capitalism argument... and in theory poor people, if they were educated well(poor education for the impoverished is another part of strong capitalism) would never choose Capitalism unless thinking of the American Dream that someday they may get rich too and then high taxes suck... but the large majority of not so educated people will never understand this and will think the 2% tax cut that puts $500 in their pocket will be more beneficial then Universal Health Care, then much cheaper University education, then better social programs... for that $500 a year that the majority of these people will save won't even begin to cover the losses in social programs that the 2% tax cut brings, but someone saving $20,000 a year on a million dollars, or large corporations saving millions in taxes, well it sure benefits them as the savings easily offset those things... I guess that's why we're all so afraid of a truly educated proletariat...

Don't get me wrong here, I am not a communist, but I am not Capitalist either.. to be honest I abstain from politics and elections/etc.. I don't believe there will ever be a system that truly works, so I don't really judge... I am just trying to state what I believe is pretty much fact. However whatever somewhat democratic system is in place, is just as good as any other in my opinion, for they all have flaws, and all hurt someone...

I will say Universal HealthCare is nice though, although I don't use it, and don't believe in modern medicine for myself...

[JBI]

The whole idea of lower taxes is absurd anyway - the only major Developed country to not have socialized health care is the US, and quite frankly, compared to Canada, they pay more for Education, more for Healthcare, and, ironically enough, more in taxes as well. Strangely enough though, the incarceration rate in the States is also 7x that of Canada, so perhaps all the money just gets pumped in there.

[islandclimber]

I've always thought, that although the harsh conditions of a Siberian Style Gulag are a bit absurd, the current prison system of having prisoners do nothing productive and tax dollars support prisons, etc.. well it's absurd... I know this is a whole different topic, but I would suggest that inmates be employed inside prisons in doing something productive for society, and in so doing be paid for it and have deductions come out of those paychecks for living expenses... I mean, the fact that someone in prison is much better off (physically at least, for no price can be placed on the value of liberty in the mind I guess), than someone who can't get a job and is living on the streets, well it seems silly...

that's the other question with regard to the whole socialism/capitalism question... capitalism is supposedly the theory "each according to ability"... socialism more dips into a happy medium between Communism and capitalism where each according to ability also has to coexist alongside each according to need... now this is just brushing the tip of the iceberg... but capitalism has gone so far beyond "each according to ability" that it is ridiculous... capitalism has become for the most part (with exceptions of course), each according to birthright... for if it was truly "each according to ability" things such as estates, and inheritances would need to disappear, pay scale would need to be more suited to what each member of society provides for that society... should a chartered accountant make more than a police officer? should a stock broker make more than a fireman? etc. etc.... although you could say I am looking at the "ability" question all wrong here, but the problem is that in capitalist society 95% of the wealth is in the hands of 5-15% of the population, and it remains that way with very rare additions to the group and disappearances from it, as wealth passes from generation to generation in these families regardless of ability, skill, and competence...

[Nick Capozzoli]

Since we're talking about taxes, what about this fly in the ointment of democracy...i.e. that people will tend to vote "their own interest?"

The Founders of the USA felt that only those who paid taxes (mainly propery owners) should be allowed to vote. The reason for this was that only those who paid taxes should get to vote on how taxes were levied and spent. In the USA we currently allow any citizen (with a few exceptions, like convicted felons) to vote. Most jurisdictions require a "supermajority" (usually 2/3) to levy taxes. There has been a movement to lower this to a simple majority requirement to make it easier to levy tax increases/

Here is the problem for democracies: What happens when the majority of franchised voters "consume" more in goverment welfare benefits than they pay in taxes? How would you expect such voters to vote when there is a question like "Should we increase taxes on the rich?(i.e. other folk who pay taxes) to pay for some welfare benefit that I (someone who doesn't have to pay for the benefit) wants....

How do you think such people are going to vote? Sure, they are going to say, "Raise the taxes on those rich bastards!"

Think about this for a minute.

Nick