Why We Need Universal Health Insurance

by hilzoy

Kate Michelman tells a horrible story in The Nation. In 2001, a horse fell backwards onto her daughter, paralyzing her for life. Then her husband was diagnosed with Parkinson's. Michelman and her husband had health insurance and long-term care insurance; her daughter did not. Between her daughter's expenses and what her husband's health insurance did not cover, they had "all but exhausted our savings." Then her husband's balance began to deteriorate. They scheduled an appointment, and then:

"We pulled up to the main entrance of the hospital after the two-hour drive from our home near Gettysburg, Pennsylvania. My husband opened his door, grabbed the roof of the car and began to pull himself out as I walked around to help him. I was too late. In an instant--time slowed enough for me to see the danger but raced ahead too fast for me to reach him--he lost his grip and fell to the concrete, shattering his hip, breaking his femur and causing internal bleeding that kept him in the hospital for months.

My husband is a retired college professor, and what the teaching profession lacks in salary it often makes up for with generous benefits. His health insurance would cover most of the emergency costs related to the fall--the surgeries, the hospitalization, the drugs. But in the astronomical sums the cost of medical care often entails, "most" is not a reassuring word. Months later, as his discharge from the hospital drew near, I sat in my living room looking at the bills piling up on the table. The co-pays, uncovered care and other costs had already reached $8,000, and we had virtually nothing left. (...)

The fraying financial thread by which we were already hanging was now certain to snap. When I heard the awful sound of my husband's body hitting the concrete outside the hospital, I knew the modicum of independence to which he had clung for so long was gone. He was discharged into an assisted-living facility, where most of the cost was excluded from both his private long-term-care insurance and Medicare. At $9,000 a month, the bills accumulated quickly.

Recently, we decided to bring him home, although the doctors would have preferred that he stay at a facility with full-time supervision. But this was a mathematical decision, not a medical one: we do not have the money it costs to keep him there. I had already stopped working, to care for him; our savings are nearly depleted; and his pension is not nearly large enough to pay the bills.

Today he needs nearly round-the-clock professional help at home--less than the cost of the assisted-living facility but still far more than we have. I have spent recent weeks looking for a job that can add at least enough to my husband's pension and our Social Security benefits to cover the cost of his care. It is a dilemma familiar to so many women--finding work that can pay for care but also leave time for providing it.

The time is drawing near when, job or no job, the expenses will simply be more than we have."

Read the whole thing. 

I have never understood why Republicans are not behind universal health insurance. Though I don't agree with them, I can see the argument for not providing help for problems that are in some way people's own fault, or that might lead to big problems with moral hazard. But health care isn't like that. While some illnesses are due to people's choices, many are not. When you get sick, you can be ruined financially, whether  or not you have been prudent. When acts of God ruin like hurricanes or earthquakes ruin people's lives, we step in to help. I have never understood why health care should be different.

Comments

[Linkmeister]

Ms. Michelman might want to change the gender reference in that paragraph you clipped: I'm male, have been caring for my mother for 10 years, and am about out of money. I too am looking for a job; in my case, one that will pay my health care and auto insurance premiums so I can continue to care for her.

It's a situation which plays no gender favorites.

[Jesurgislac]

Well, I guess if everyone agrees the US needs universal health insurance, the best argument to have is whether a journalist on another publication should have been allowed to say "so many women" when some men are full-time carers too....

[Awesom0]

I have never understood why Republicans are not behind universal health insurance.

Their argument for doing so seems to go a little something like, "Blah, blah, blah...Europe...blah...blah...blah...Taxes...blah...blah...blah...keep off my lawn you damned teenagers."

[Linkmeister]

Jesurgislac,

Oh, never mind. The point I was trying to make was that Michelman's problem is widespread and goes beyond stereotypes.

[chris y]

I have never understood why Republicans are not behind universal health insurance.

1. their leaders are too heavily invested in the existing structures;
2. they don't actually believe that bad stuff is going to happen to them;
3. a significant minority of them are sociopathic whackjobs.

But you knew that, didn't you?

[Jesurgislac]

Link: The point I was trying to make was that Michelman's problem is widespread and goes beyond stereotypes.

True. But there's not a lot Hilzoy or anyone on this blog can do about Michelman's choice of phrasing, is there? Which is my point.

There are more women functioning as unpaid carers than men (this is true in the UK, at least): but obviously no one, regardless of gender, should be in the position of going broke trying to keep up with the cost of medical bills while providing full-time care.

I have never understood why Republicans are not behind universal health insurance.

Because universal health insurance gives people more independence from their employers and encourages adventurous small-business entrepreneurs, which are both things Republican policies oppose, favoring employer control over employee welfare, and favoring large-scale corporations over small independent businesses. Plus, traditionally most Republicans care for the problems of the very wealthy far more than they do their own problems, and the very wealthy tend to have good health insurance and not to have the same difficulties over co-pays.

[ReasonableCitizen]

"I have never understood why Republicans are not behind universal health insurance."

Start with this: What is the good of being rich if the poor have what you have? Phones, TVs, homes, cars, retirement money, healthcare.

End with this: Why work for IBM, Xerox, GE, et al, if you can have the same benefits and a more satisfying job working for your local grocery store, food pantry, newspaper,or auto body shop?

The Republicans believe that healthcare is a luxury reserved for those who can afford it. It is not for those who need it.

[Brett Bellmore]

"Because universal health insurance gives people more independence from their employers and encourages adventurous small-business entrepreneurs," at the expense of robbing them of independence from the government, which in the long run is a much more serious thing to be dependent on. Private businesses at least don't routinely threaten to shoot people who cross them.

Liberals get all upset about 'big business', and your answer is always the biggest, nastiest business around.

[Brett Bellmore]

I mean, let's be serious: Health care is a finite resource, and people are mortal. Even in a perfectly run system, people are going to die due to that latter fact, and people who could have been saved are going to die due to the former.

If you're upset about the fact that sometimes poorer people die when a treatment wealthier people could have afforded would have saved them, you know what? You could bankrupt the entire world trying to provide everybody the best care, and still not succeed, so the only way to prevent that is to deny people health care they can afford to pay for.

That's pretty nasty, wanting people to die who could pay for the life saving treatment out of their own pocket. But it happens in countries with nationalized health care.

You really care, you ought to be more concerned about the factors that make health care more expensive for everyone, like an FDA approval process that's slower than other nations', but not any more effective. Or the regulatory bias against preventative medicine. Or the way concern about 'doping' denies people who aren't involved in competitive sports treatments which would vastly improve their quality of life.

But that would involve the government intervening less, not more, wouldn't it? And it's pretty hard for you guys to admit the government is frequently the problem, not the solution.

[Dan S.]

"But it happens in countries with nationalized health care."

Cite?

[Dan S.]

"Private businesses at least don't routinely threaten to shoot people who cross them."

Somebody's not up on their past & present labor movement history (although to be fair, that often - for example, Shell in Nigeria - involves government threatening or outright killing people on behalf of/with the assistance of private businesses).

[Dan S.]

"I'm from the health insurance company, and I'm here to help you" - it would be absolutely terrifying, if it wasn't so utterly unbelievable.

[Jesurgislac]

Brett: at the expense of robbing them of independence from the government, which in the long run is a much more serious thing to be dependent on. Private businesses at least don't routinely threaten to shoot people who cross them.

Huh. You know, we've had the National Health Service in the UK since 1948. 61 years. If the provision of universal health insurance led directly to the government routinely threatening to shoot people, I think we'd have noticed by now.

That's pretty nasty, wanting people to die who could pay for the life saving treatment out of their own pocket. But it happens in countries with nationalized health care.

No, Brett, it doesn't.

Or the regulatory bias against preventative medicine.

The chief bias against preventative health care in the US system is the sheer quantity of people for whom their only access to health care is the If you think preventative health care would be a good idea, you should be shouting for a national health care system... that's how you'll get it.

[Jesurgislac]

for whom their only access to health care is the ER.

(I guess Brett showing up to flail about guns and government and how the government wants TO KILL EVERYONE but benevolent corporations don't, is the Republican defense.)

[Dan S.]

" . . .is the Republican defense."

It's pretty offensive, that's for sure.

"You could bankrupt the entire world trying to provide everybody the best care,

I'm not sure best is the goal. Decent care, perhaps. World, tradeoffs, etc.

" I mean, let's be serious: Health care is a finite resource, and people are mortal. Even in a perfectly run system, people are going to die due to that latter fact, and people who could have been saved are going to die due to the former."

Yes, so let's not do anything to make the situation somewhat better, because status quo and unreachable perfection are the only two possible options.

" . . . at the expense of robbing them of independence from the government"

Well, I'd agree that the Michelman family is radically freer under the current system, at least according to the definition put forward by Joplin (1971). Why don't you try to contact Mrs. Michelman and share your argument with her? I'm sure it will provide her with much-needed comfort.

[ReasonableCitizen]

The entire Federal Government, all State governments, and many of the municipal governments have paid healthcare. I don't hear them complaining.Why is government healthcare so bad, hmmm?

[chris y]

Jes, it's an article of faith among Republican opponents of UHC that you cannot get private medicine/insurance in countries which have it. You can show them the evidence, but you can't get them to believe otherwise, in the same way that you can't get a similar constituency to believe that Iraq had nothing to do with 9/11.

[magistra]

If you're upset about the fact that sometimes poorer people die when a treatment wealthier people could have afforded would have saved them, you know what? You could bankrupt the entire world trying to provide everybody the best care, and still not succeed, so the only way to prevent that is to deny people health care they can afford to pay for.

The UK has a national health service. It also has private health insurance and the option for anyone to buy any kind of private healthcare they want (here or overseas). So you are simply wrong on that.

If you read someone like Andrew Sullivan, he will admit that there is always healthcare rationing in any system. He just wants it to be done by the market rather than the government. Why? Because he and Brett think that it's better that poor people die of curable diseases (in a free market system) than that there is the smaller possibility that prosperous people (like Sullivan, I don't know about Brett) die of curable diseases because of NHS rationing.

I would accept that there are a small percentage of people who do better with US healthcare than universal equivalents: those with the best forms of private insurance and no really expensive diseases. 90% or more of the rest of the population are worse off. But when the 10% include so many of those in positions of influence, it's not surprising that nothing much changes.

[John Thullen]

All of us, including Ms. Michelman and her unfortunate family, should gird our loins for the rancid ugly bile that is going to erupt from the some on the Right against her in the coming weeks.

[Jesurgislac]

chris y: Jes, it's an article of faith among Republican opponents of UHC that you cannot get private medicine/insurance in countries which have it. You can show them the evidence, but you can't get them to believe otherwise

So basically, Brett will continue to believe that it's impossible to get private health care in the UK even if I link to sites like www.BUPA.co.uk and www.lookforhealth.co.uk? Interesting.

in the same way that you can't get a similar constituency to believe that Iraq had nothing to do with 9/11.

Well, the difference is that "Iraq had nothing to do with 9/11" is a concept requiring a little bit of thought and understanding to follow. But "Britain has private health care/private health insurance" doesn't require any thought or any understanding beyond the effort to click on the link and believe that people wouldn't just make those sites up just for a spoof.

Indeed, private health insurance is much better (according to comparisons I have read) in the UK than in the US, because in the UK, private health care competes with the NHS: it has to be distinctly better than the NHS in order to convince people to pay up - and where Brett's fear just falls over and looks stupid, is that private health care is generally only able to offer the "better than the NHS" tag if it's not anything major, not life-threatening or disabling, because it's the awkward zone where it won't kill you to wait but it will be uncomfortable while you wait, that people do tend to make use of private health care if they can afford it.

[Doctor Science]

What I *really* don't understand is why the Small Business Association and similar groups aren't totally on the UHC bandwagon. Speaking as someone who's been part of a very small business for 8 years now, the need for affordable health insurance is a constant worry, and one of the biggest barriers to starting a business. It would be completely to small businesspeople's advantage for access to health care to be separated from employment, so why aren't they for it?

[Francis D]

I mean, let's be serious: Health care is a finite resource, and people are mortal.

Granted. So why are you backing the single most inefficient system in the developed world? A system on which your government(s) spends more per head than the British government spends to run the NHS. A system that is more bureaucratic than any nationalised system anywhere. And a system that is simultaniously the most expensive in the world and only the thirty-seventh best?

Even in a perfectly run system, people are going to die due to that latter fact, and people who could have been saved are going to die due to the former.

No one is arguing with you. But when your argument is "We can't have a vast improvement because it's perfection or nothing" you might as well give up now.

If you're upset about the fact that sometimes poorer people die when a treatment wealthier people could have afforded would have saved them, you know what? You could bankrupt the entire world trying to provide everybody the best care, and still not succeed, so the only way to prevent that is to deny people health care they can afford to pay for.

But what we are worried about is that people die from diseases in America when every single civilised country in the world (and on this subject you are not civilised) has

That's pretty nasty, wanting people to die who could pay for the life saving treatment out of their own pocket. But it happens in countries with nationalized health care.

Depends on the implementation. Not in Britain it doesn't. (The closest you can find to it happening is where people can afford topups but not the entire treatment can't get the treatment they can't afford).

You really care, you ought to be more concerned about the factors that make health care more expensive for everyone,

Yes. Take the insurance companies out and pull all their charters. They are nothing but a pointless level of bureaucracy that no sane system has. The NHS's administrative overheads are paltry compared to the great lumbering behemoth of red tape that is private provision of healthcare using a

like an FDA approval process that's slower than other nations', but not any more effective.

If that's to do with drug approval, that will actually lower costs.

Or the regulatory bias against preventative medicine.

If that's true it's a major factor. But given how knowledgable the rest of your post demonstrates itself to be I'm going to have to demand a source for this claim.

But that would involve the government intervening less, not more, wouldn't it?

No. It would involve less pointless private sector bureaucrats. It would involve block negotiations with pharmaceutical companies (which really bring drug prices down for the NHS).

And it's pretty hard for you guys to admit the government is frequently the problem, not the solution.

Oh, government is frequently the problem. In this case the government's unwillingness to kick the private sector and say that it will either provide a civilised standard of care nationally (which shouldn't be hard given the resources put into it) or it will be nationalised.

But it seems impossible for you to admit when the private sector is running demonstrably the single most inefficient system anywhere in the world. It is hard for you to admit that every single medical system in North West Europe (and for that matter many other places) are cheaper and better than the US system. In part because they have more (and more useful) government intervention. It seems impossible for you to admit that no government anywhere has managed to come up with a more bureaucratic system and one more focussed on denial of treatment to patients than the existing insurance based model of healthcare in the US.

And until you admit that you are continuing to deny reality.

[lightning]

If there was a way of ensuring that black people didn't get it, we'd have had national health care by 1970. In discussing politics with conservatives, I've seen more pure naked racism on this subject than perhaps all others combined.

[ThisJohn]

At first John Thullen's 8:24 seemed like a non-sequitur, but I think I get it:

He means people will claim her grief is divine punishment for her NARAL activities

[JadeGold]

I have never understood why Republicans are not behind universal health insurance

Really? Guess what? There's gambling going on in the backroom at Rick's Café Américain. Shhhh.

Could it be the campaign funding by the health insurance lobbies?

On another level, GOPers tend to believethe value of a citizen is measured by his or her wealth. 'Good' citizens can afford adequate healthcare--'bad' citizens cannot.

[ScentOfViolets]

Today he needs nearly round-the-clock professional help at home--less than the cost of the assisted-living facility but still far more than we have. I have spent recent weeks looking for a job that can add at least enough to my husband's pension and our Social Security benefits to cover the cost of his care. It is a dilemma familiar to so many women--finding work that can pay for care but also leave time for providing it.

This is something the military can do. A young person going in not only does close-order drill, learns how to read a map, etc, but can also visit shut-ins on a regular basis, or chronically ill people and perform basic nursing tasks. Four years of that will get you some sort of extra education gratis, along with health benefits and a sense of connection.

What's not to like?

[ajay]

I mean, let's be serious: Health care is a finite resource

Republican admits that some resources may be finite. Film at 11.

[Woody]

Granted. So why are you backing the single most inefficient system in the developed world? A system on which your government(s) spends more per head than the British government spends to run the NHS. A system that is more bureaucratic than any nationalised system anywhere. And a system that is simultaniously the most expensive in the world and only the thirty-seventh best?

It's teh Capitalism. If there is a resource and there is a finite limit on it, then it is more efficient--it is more profitable-- to let the 'market' to determine the price.

Profit, rather than public good, welfare, or conscience, is the dominant motif.

As long as the parasites of the Insurance Industry are in the equation, the health of the 'people' will be auctioned off to the highest bidder.

We do NOT "need" better insurance. We need full, cradle-to-grave, single-payer, public health care. Nothing else, nothing less, is morally permissible or should be acceptable...

[Observer]

When I run stories like this by my GOP/Fox News family members the answer is consistently, "That's tragic of course. Life can be very unfair. These things can happen but that doesn't mean I should have to pay for it through taxes. That's why there are charities."

Of course there are rejoinders. But the problem is it's a circular discussion, complete sealed, and completely illogical when seen in its entirety.

But that is the mindset and it plays well with the corporate incentives to lawmakers - it's exactly why the "Harry & Louise" ad played so well across so many voters.

Personally I cannot think of anything since fire, the wheel, the printing press, and the internet that could do more to boost human creativity and productivity than portable universal health care plan. Millions of insured as well as uninsured would be freed up to take more risks, leave dead end jobs, explore new sectors if they weren't trapped.

[Marc]

ThisJohn: Yup. I'm surprised that someone hasn't already claimed that Michelman is facing the wrath of God; they did the same when the grandchildren of someone associated with abortion clinics died in a plane crash.

[Barbara]

We live in a country where our health care system is so barbaric that I can actually sit here and feel lucky that when my father was diagnosed with cancer we knew the diagnosis and the course was definitively terminal. As a result, we never had to choose between caring for him and staying solvent. I can't believe we still allow this. My father died almost 15 years ago.

[ThirdGorchBro]

If we were talking about nationalized health care, I would agree with Brett. But national health insurance does not mean government-run health care, and would almost certainly be an improvement over our current system.

[Davis X. Machina]

If there was a way of ensuring that black people didn't get it, we'd have had national health care by 1970.

SS only got through Congress when originally passed (1935?) by excluding most domestics and agricultural workers.

Wonder who they were....

[ericblair]

" . . . at the expense of robbing them of independence from the government"

This is a key point, and there are different meanings to the Inner and Outer Republican parties.

To the Outer Party, this is simply a slogan: "government" health care today, and it's Borg implants tomorrow. I've lived in Canada and in the US for long periods of time, and as far as healthcare goes, I certainly feel far more free in Canada where you don't have to worry about losing your coverage with your job and fighting with insurance companies who don't want to pay. Americans accept a level of Kafka-esque healthcare bureaucracy that would send Europeans into the streets with rocks. In single-payer plans, you have a voice at the ballot box and in the streets: in a private plan, you've got nothing.

To the Republican Inner Party, Freedom simply means Nothing Left to Lose for the unwashed masses. The Republican leaders want to make sure that their followers expect nothing out of government, so they'll be fine when that's what they get. The leaders have made it clear that their vision of government is a mechanism for directing money and power to their elite circle, so any justification for giving nothing to the rest of the population will work.

"Independence from government" to the leadership means that the population can independently sink into poverty and misery while the government independently makes its friends rich.

[stonetools]

Its interesting that I'm reading this post now. I am unemployed and looking for a job right now and of course uninsured. I had a previously scheduled appointment for a physical exam set for today. I had to weigh between paying full cost for the appointment versus husbanding my dwindling financial resources.
I postponed the appointment, of course, even though I have some problems that I know damned well that a doctor should look at.

Ms Michelman's situation is uncommon (though not all that uncommon. I know that hundreds of thousands, if not mullions, of people made the decision I made and as a result, some will end up in emergency rooms next because their problems , initially easily treated, redevelop into life threatening illnesses.

Why do Republicans oppose national health care? pretty simple . They cannot plan further than their next contribution from AMA ands drug and insurance companies. I cannot see any other reason.

In the meantime, Singapore and Thailand( supposedly Third World countries) have national health insurance and the US doesn't . Bizarre.

For those who care concerned about effficency, this is what Wikipedia says about SINGAPORE's health care system:

Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[42] Singapore currently has the lowest infant mortality rate in the world (equaled only by Iceland) and among the highest life expectancies from birth, according to the World Health Organization.[43] Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt.[44]
http://en.wikipedia.org/wiki/Universal_health_care#Singapore

If frikkin' Singapore ( a country not much bigger in size than Washington, DC) can get it right, then there ain't no excuse for the big old USA to fail on this.

[bob mcmanus]

As I understand, Obama main emphasis in his own proposals are on reducing health care costs and increasing efficiency, in order to increase the profits of the insurance companies and corporate programs. I was not aware that Obama was seeking, or had any interest on a single-payer program or a "public option" in order to increase competition for the insurance companies.

Will what Obama has proposed, for instance, really help Ms Michelman to a significant degree? Please provide details. I also realize there may be more generous possiblities out of Congress, tho in the interest of controlling deficits, we may get a veto or another alliance with Blue dogs.

Of course, we might try to impeach the enabler of war criminals, the President for Goldman-Sachs.

[Point]

There's a lot of terms that get thrown around when talking about health care reform in this country -- universal health care, socialized medicine, nationalized health care, government (run) health care, single payer -- each meaning something different, but all too often get confused and blurred together, especially (but not solely!) by conservatives. (Brett being one example.)

What we need to is to make our health care system less expensive (for both the people and the government) and more accessible, while at least preserving our capacity for medical innovation and the like. If we can do this in a way that achieves universal health care, all the better, but if the pursuit of UHC compromises this basic goal of overall improvement to the system, it may be worth making it a longer term goal.

Which is a long way of saying, support the Obama Health Care Plan.

[Slartibartfast]

Hmmm...thought I fixed this.

[mightygodking]

You know, we've had the National Health Service in the UK since 1948. 61 years. If the provision of universal health insurance led directly to the government routinely threatening to shoot people, I think we'd have noticed by now.

Jes, when Brett talks about the government shooting people, he's speaking Libertarian, wherein the government only exists as a method of coercion and blah blah blah Rand-cakes.

It is important to bear this in mind, because the evidence re: effectiveness of socialized medicine is so overwhelming at this point that truly dedicated libertarians have no other argument other than going to the Well Of Libertarian Principles (freedom, freedom, and more freedom on Sundays!) and pretending that the marginal harm caused by forcing people to pay for socialized medicine is greater than the marginal harm caused by letting people die of horrific diseases and maladies.

Which is idiotic, but, again - libertarians, et cetera.

[Point]

Bob

Just so you know, Obama's plan does provide for a public option in his insurance exchange program. There are two such options for how a plan would work.

http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/04/16/deparle-two-options-for-public-plan.aspx

"Will what Obama has proposed, for instance, really help Ms Michelman to a significant degree? Please provide details."

Mrs Michelman is being hurt financially by the burdensome co-pays accompanying her husband's care. This is a confluence of two faults in America's health care system -- the inflationary cost of care, and the high level of underinsurance (what a plan with such high co-pays essentially constitutes) that comes with so much lack of coverage (itself resulting, in large measure, from high prices -- it's a cycle).

Obama's HCP brings insurers into a regulated market, whereby they will compete with each other and a public plan, not to monopolize the healthy and the wealthy (as they do now) but to expand overall coverage. This will reduce both premiums (in conjunction with other reforms, like EHR) and co-pays (as a percentage).

[Jesurgislac]

ThirdGorchBro: If we were talking about nationalized health care, I would agree with Brett.

And you'd be just as wrong.

Look, the NHS is far from perfect. I've worked for it (briefly, some time ago) my brother worked for it, I have several friends who worked for it - and obviously, literally everyone I know in the UK has been treated by the NHS at some point in their lives. There are things the NHS could do better. But it is as far removed from Brett's fantasies as it is far ahead in every measurable factor except cost from the US system.

bob mcmanus: As I understand, Obama main emphasis in his own proposals are on reducing health care costs and increasing efficiency, in order to increase the profits of the insurance companies and corporate programs. I was not aware that Obama was seeking, or had any interest on a single-payer program or a "public option" in order to increase competition for the insurance companies.

Correct. Obama is running scared on this. Either that, or he really is too right-wing to appreciate the benefits of a universal health care system.

mightygodking: when Brett talks about the government shooting people, he's speaking Libertarian, wherein the government only exists as a method of coercion and blah blah blah Rand-cakes.

I understood that. I was mocking Brett.

[Brett Bellmore]

The government DOES only exist as a method of coercion. It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector. Coercion might not be all the government does, but it's all the government does that somebody else couldn't do just as well.

[bob mcmanus]

Just so you know, Obama's plan does provide for a public option ...point,11:59

Two posts from Uwe Reinhardt (via Ezra Klein) at the NYT, revisited this morning to be sure my impressions were correct.

Defining Health Care Reform

"...helping low-income Americans" would not have helped Michelman so much. I see little else in Reinhardt's description except vague goals and ideals toward IHC.

Health Reform without a Public Plan

In the previous two posts, I sought to explain why the public health insurance plan that Barack Obama had firmly promised during the presidential campaign appears to have become a deal-breaker in President Obama’s quest to sign a genuinely bipartisan health reform bill later this year.

...Reinhardt

[Uncle Kvetch]

All of us, including Ms. Michelman and her unfortunate family, should gird our loins for the rancid ugly bile that is going to erupt from the some on the Right against her in the coming weeks.

We're going to find out she has really, really nice countertops in her kitchen?

[Francis D]

The government DOES only exist as a method of coercion. It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector. Coercion might not be all the government does, but it's all the government does that somebody else couldn't do just as well.

Even if you accept Brett's claim above (hint: it's bollocks - see regulation, accountability, economies of scale, and other factors (including lack of bureaucracy in the case of healthcare)) then it's irrelevant. Because the government does not bring one thing to the table that the private sector does: a positive incentive to screw every last cent out of the general population that it can get.

Your life is worth more to you than your money. Which gives healthcare providers an amazing amount of leeway to screw their clients using impliments such as a 6" diameter drill tipped with a surgical steel bit. And if the insurance companies screw their clients in such a manner (as they do) they know they can externalise the costs as it's either the government or the community that would have to pick up the pieces for the poor bastards who have been made destitute due to healthcare costs. On the other hand, the incentive for the government to screw the population on healthcare is only passive apathy not active profit (in which someone with a particularly steady hand with the drill gets more money) - the government is going to be one of the groups picking up the pieces and people with a steady hand with the drill certainly aren't going to be directly rewarded.

The incentives for private healthcare (and private water supply and private roads and privatising quite a few other things done by the government) are quite simply perverse as far as the general population is concerned.

[Jesurgislac]

Brett: The government DOES only exist as a method of coercion. It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector. Coercion might not be all the government does, but it's all the government does that somebody else couldn't do just as well.

All right... all right... but apart from better sanitation and medicine and education and irrigation and public health and roads and a freshwater system and baths and public order... what has the government done for us?

[Catsy]

Brett: I mean, let's be serious: Health care is a finite resource, and people are mortal.

In order: no, it's not, and yes, but so what?

Health care is no more a finite resource than legal counsel, emissions checks or any other service that the government provides. It is finite in the sense that the service must be funded, like roads and the military and everything else, but it is not finite in the sense that we will run out of it. This is a red herring.

As for the observation that people are mortal... in earnest, is this even an argument of any sort? Reducing the mortality of its population is one of the first obligations of any government.

Liberals get all upset about 'big business', and your answer is always the biggest, nastiest business around.

Brett, if you're ever looking for a reason why so little of what you say gets taken seriously, comments like these are a good place to start. I don't see any sign that you actually think things like this through as opposed to simply throwing them out there because they sound good as one-liners.

The aspects of "big business" that liberals tend to get up in arms about arise from the harm done by the unregulated pursuit of profit. This is especially toxic in the private health insurance industry, in that the business model of any insurance company is based on denying coverage whenever they can get away with it. It is inherently, by every imaginable definition, exploitative.

Government may be "big" (a vague, relative term at best), and it may share some structural and bureaucratic similarities with business, but they key point is that the government is not and should not be concerned with profit. Absent the driving need to deny claims in order to support the bottom line, the focus can be on providing the best care possible.

That's entirely setting aside the benefits of free preventative care and checkups. There are a legion of conditions that are much cheaper and safer to deal with if caught early, and the uninsured or under-insured usually cannot afford this kind of preventative care--which costs us all more in the long run. But please don't try to score cheap points with nonsensical comparisons between government and business.

[joel hanes]

At first John Thullen's 8:24 seemed like a non-sequitur,

Huh. I thought it cut to the heart of the question at issue :

I have never understood why Republicans are not behind universal health insurance.

The Republican moral calculus is founded in the invariable conviction of the privileged Calvinist that people get what they deserve, and runs something like this:

1. ) I have paid healthcare.

2. ) Therefore, I can be certain that I, personally, morally deserve to have paid healthcare (othewise it wouldn't have happened).

3. ) Those other people do not have paid health care.

4. ) Therefore, they must somehow not morally deserve to have paid health care. Had they been better, had they been more hard-working or foresighted (or more like my admirable and deserving self in some other way), they would have paid health care.

5. ) Therefore, efforts to provide those other people with health care [watch this part closely] are designs to provide healthcare to those who do not deserve it.

6. ) Which is a The Bad Thing -- call it "socialized medicine" or call it "cadillac-drivin' welfare queen", but the anathema in the Republican moral calculus is someone who gets something they don't deserve.

7. ) Which cannot possibly describe anyone has already demonstrated that they deserve privilege by having it.

The final link, the one that will make it morally OK for Republicans to target Ms. Michelman with spiteful remarks, goes like this :

8. ) Ms. Michelson must somehow deserve the bad things that have happened to her.

[Phil]

It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector.

Except we don't get to vote on who is and isn't in charge of private sector companies.

[JadeGold]

The government DOES only exist as a method of coercion. It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector. Coercion might not be all the government does, but it's all the government does that somebody else couldn't do just as well.

Libertarians are like adult Goths; it's a desperate cry for attention.

[Warren Terra]

I really think Brett needs to calm down and reassess his views of government. I mean, I get that he's a conservative and skeptical of government, but lately he's been expressing a truly visceral loathing of government in terms that are at least metaphorically violent; in the last few days he stated that taxes are rape, a view that manages to be profoundly unfair to victims of rape, to acquiescent taxpayers, and to public servants, whatever Brett thinks of them; and in this thread he refers to government as being an operation that will "routinely threaten to shoot people who cross them."

There are genuinely thuggish forms of government that take without consent and are not responsive to their publics and indeed use overwhelming levels of violence at little provocation. But even in these debased times, the American democracy is not such a government, and referring to it in these terms will only suggest that the person doing so is paranoid and unreasoning in their outlook, likely leading to the disregarding of any less extreme points they wish to make.

[russell]

It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector.

It doesn't have to make a profit.

[...now I try to be amused]

The incentives for private healthcare (and private water supply and private roads and privatising quite a few other things done by the government) are quite simply perverse as far as the general population is concerned.

A private oxygen supply is the logical conclusion of all this. I'm sure it's been a feature of a dystopian science fiction novel or two.

[John Thullen]

We must privatize government coercion and find the most efficient means to ration the sanctity of life.

[jonnybutter]

I have never understood why Republicans are not behind universal health insurance.

There are ideologocial-ish reasons Republicans have always opposed uni health insurance (enumerated above), but the GOP is so 'de-coupled' these days from their own ideology that you can almost bank on the fact that if the dems were on the floor of the congress and on tv day and night railing against uni health insurance in the US, GOP pillars would be railing FOR it (disingenuously so, as ever, but still). Obama could come up with a school crosswalk safety initiative which cost $0, and the Opposition would figure out a way to be against it. The GOP - not to say all Republican voters - are simply not to be taken seriously, not even enough to wonder why they are not in favor of UHI.

[gwangung]

We must privatize government coercion and find the most efficient means to ration the sanctity of life.

Blackwater...I mean, Xe....

Seriously, I think folks should tease out what truly in inherent to government and what belongs to behavior of large collective. On a very local level, one can even VOTE one's self into government and decision making powers. That's not an option available in the private sector.

[Simon K]

As someone who has experienced both the British and American healthcare systems, I'd like to make a couple of points to those of you singing the praises of the NHS. Don't get me wrong - I think its an excellent system - but it could be improved and its drawbacks make and interesting contrast with those of the US.

The NHS is incredibly cost-effective, in terms of health outcomes per $ spent, but the total level of spending is low, and increasing the level of spending (as the labour government did over the last 10 years) has only improved health outcomes at the margins. If you're at those margins (eg. you were on the waiting list for a hip replacement) the result is a fantastic improvement, but it hasn't benefitted most of the people who were paying for it.

The US system in contrast is astonishingly, mind-bogglingly expensive. It cost nearly $3k for my brother to stay overnight in a hospital because he passed out in a bar, for the usual reason people pass out in bars, and they weren't taking no for an answer. That's damned expensive for "he's drunk, put him in a room and we'll keep an eye on him until someone sober comes to get him". In the UK he'd have been triaged to the back of the line so many times he'd have sobered up before a doctor saw him, which would have been vastly more cost effective, really, wouldn't it? Total cost, 10 minutes of a nurses time, around $200.

But, and this is the important but, for those who can afford it the US system does produce much higher levels of service and much better health outcomes. It was undoubtedly more pleasant for my brother to be put in a semi-private room to work off his hangover than to spend his evening in the emergency room waiting area. But more seriously, there are critical, potentially fatal conditions, especially in the elderly that are more survivable in the US than in the UK.

This is the key question, then - what counts as "value for money" in healthcare, especially value for government money? Because there's really no way to compare the value of providing reasonable, but not necessarily pleasant and definitely not always state-of-the-art, care for everyone, versus provided excellent, hi-tech, pleasant care, for those who can afford it?

Because in neither system does the consumer really get to pick their service level. In the US the insurer will exclude various things, but what is covered is inevitabily provided at the highest possible standard, with all possible technology, because we're in this crazy situation where it creates less liability for the insurer to deny coverage than it does for them to cover only a non-state-of-the-art treatment. In the UK no conditions are excluded from NHS treatment, but the care you get is (at least in theory) carefully calibrated for cost-effectiveness by an organization called NICE (yes really - National Institute for Clinical Excellence - somewhat like the NIH). While the standards on which this is done are public, its doubtful much of the public really understands them.

Some people mentioned the private insurance system in the UK. It exists mainly to cover things that the NHS won't cover - some kinds of chronic care, some elective procedures, and so on. The level of service is usually much higher - private rooms versus a bed in a ward, more time with more expensive doctors etc. But its very much a luxury good and its purpose is to complement, not replace, the NHS. Most NHS hospitals also provide private care, and most NHS doctors also have private patients, so there's a great deal of overlap between the 2 - they're not really seperate systems, but a main core system and a "top up" system. If you have a heart attack in your nice room in the private hospital while recovering from elective surgery, you'll quite rapidly find yourself back in an NHS ward, because the private system, such as it is, isn't rigged up for acute care. In some cases you can even mix the two - for example you can have your baby delivered by an NHS doctor and/or midwife but pay the hospital for a private room. My point here is that you can't actually compare the US private system with the private top-up system to the NHS in the UK - the UK has virtually no private acute care, and very few fully private hospitals or practitioners. The private system could not exist as it is without the NHS, but the NHS effectively "crowds out" the private system from certain lines of business.

But there is a place where the 2 systems have a lot in common, and its the key point of failure for almost any healthcare system, and that is long-term chronic care. Tragedies like the one hilzoy described occur everywhere - its only the exact consequences that differ. Here unexpected healthcare costs lead to financial ruin. In the UK the same medical condition would leave only the taxpayer out of pocket, but the health outcomes would almost certainly be less good. That means, when it comes down to it, shorter life expectancies for people with these conditions, either because of wait times, or simply lower-tech treatment methods. The truly staggering costs of the very best care for long-term but survivable chronic illnesses are a huge problem for everyone, and its a problem no system solves well.

[Brett Bellmore]

Warren, I've always had a visceral loathing of government as an institution. If it's coming out a bit more lately, it's because it appears to me that our government is finally starting in on the transition from "occasionally symbiotic" to "open predation", which even the best, (Least worst, anyway!) of governments are susceptable to.

Take the TARP fund: It's now official, you don't get to pay the funds back if the government would rather you remained in debt to it, and thus dancing to it's tune. (And, remember, some of those institutions didn't get to refuse the funds in the first place!)

I think we've passed the tipping point, where the power of government relative to the private sector has grown so much that there's no effective countervailing force. Something is going to vanish in the next few years, that's never coming back, and I mourn it.

"It doesn't have to make a profit."

Neither do private charities. For profit business isn't the entire private sector.

[Jesurgislac]

Shorter Brett: "There's just something about that boy Barack I don't like."

[Fraud Guy]

I think we've passed the tipping point, where the power of government relative to the private sector has grown so much that there's no effective countervailing force.

Better tell the Goldman boys, ma; they're gonna have to get out of the Treasury by nightfall!

[Warren Terra]

Brett, I'm not sure I agree with you (and I am sure I don't know enough about TARP to effectively disagree with your characterization), but I do think your most recent comment is massively more compelling than any of your previous metaphorically violent emotional outbursts.

Similarly, I do not approve of, or find rhetorically effective, Jes's response to your recent comment (especially ascribing to you the use of the incendiary term "boy"), though - again - a more reasoned comment expressing a closely related position (explaining the similarities between the economic and government power policies of the current administration and those of its recent and its earlier predecessors, for example) might stand an excellent chance of convincing me.

[Gary Farber]

"Private businesses at least don't routinely threaten to shoot people who cross them."

Private businesses aren't run by people chosen through election, by the people, of the people, and for the people.

Why do you hate democracy, Brett?

[Jesurgislac]

Simon K: As someone who has experienced both the British and American healthcare systems, I'd like to make a couple of points to those of you singing the praises of the NHS. Don't get me wrong - I think its an excellent system - but it could be improved and its drawbacks make and interesting contrast with those of the US.

That's a very fair analysis, Simon (FWIW, my brother, who has worked as a doctor in several different European nations, reckons the French system is the best one, and the NHS is among the worst in Europe, speaking from the point of view of the ordinary doctor in the system).

ut there is a place where the 2 systems have a lot in common, and its the key point of failure for almost any healthcare system, and that is long-term chronic care.

My great-aunt died a few years ago (seven or eight years ago now): and one thing which impressed me about the system of care wasn't so much the intensive care unit where she ended up after her first heart attack, six years before she died: it was the care and support she got from the NHS afterwards but also from various local authority services to help her stay in her own home until she died, so long as she kept saying that was what she wanted to do. Obviously she couldn't have done it without family and neighbors, but we couldn't have done it without the multiple local services that turned out to be provided at low or no cost, once you knew to look for them: the local authority where my great-aunt lived had figured that almost any level of at-home service was cheaper than round-the-clock care in a nursing home, if the person in need of care - and her family - wanted to stay out of a care facility and was able to do so with help. (As I said at her funeral: she was determined to die in her own home, and she got her way to the end: she was good at that.)

So I possibly have too shiny a view of the services available for long-term chronic care, simply because the only close experience I have had of them has been pretty good - complicated and emotionally difficult at the time, of course, but manageable. Then again: it was manageable because my great-aunt was pretty compos mentis almost to the end, and even at the end, she might not be able to remember what she had for lunch, or if she had had lunch, but she was still very much herself. We were all slightly dreading what would happen when/if she got to the point where she couldn't function at home.

[Brett Bellmore]

Since you insist on asking, because democracy is a sad, sad substitute for freedom. On a statistical basis, I suppose we might prefer that the majority oppress the minority, rather than the other way around, but shouldn't we really prefer that nobody gets oppressed?

[Sebastian]

"I have never understood why Republicans are not behind universal health insurance."

Can't speak for Republicans but I can try for conservatives.

It depends on what you mean by 'universal health insurance'. I'd prefer universal catastrophic health care insurance for instance.

First, there is the question of innovation in health care. Certain types of universal health insurance would squash it. I would want to avoid that for the most part. I would suggest that 'universal health care' pay for only treatments older than a certain number of years (7-10) unless the new treatment is cheaper than the old treatment.

Second, there is a question of what care will be paid for. If we want health care to be cheaper we are going to have to develop an ethos that doesn't involve spending tens of thousands of dollars on lots of people's last 6 months of life. That is going to be a very hard sell.

Third, and this is a slightly different topic, I'm becoming increasingly disenchanted with the "Shorter X" format. It is sort of ok when the shorter version really a non-ridiculous reduction of the argument. But, using it to not-very-cryptically Brett a racist is not acceptable.

[Warren Terra]

I realize that it's a tiny point, a little bit of trivia in the vast ocean of complexity that is a health system, but I was quite struck a few years back when my grandfather spent a couple of years dying of congestive heart failure and was sent home with a device I'd never heard of before, an oxygen generator. This was a (moderately noisy, unfortunately) bix heavy box that you plugged into the wall and that supplied an enriched flow of oxygen to a mask, so he could rest near it without having to worry about exhausting or changing oxygen tanks.

As I said, I'd never heard of such a machine, and so I Googled around a bit (not actually finding all that much). But one very small fact that I did find stuck with me: when a Briton is prescribed an oxygen generator on the NHS, they are also given a tiny stipend that pays for its (extremely modest) electricity usage, lest they feel financially burdened by this contribution of their treatment to their bottom line.

As I said, it's a single little factoid, and it's a negligible amount of money. But it also speaks to a philosophical outlook about how you try to provide medical help that is quite different from what we see here in the US.

[Warren Terra]

I suppose we might prefer that the majority oppress the minority, rather than the other way around, but shouldn't we really prefer that nobody gets oppressed?Of course, our democracy, as constituted, contains protections for the civil liberties of unpopular minorities and combined different forms of representation and some supermajority requirements that can together give larger minorities significant influence.

More importantly, the question is not whether "we really prefer that nobody gets oppressed", wihch I hope we can agree on, but how to express that desire in a system of government. On this subject, I refer you to Churchill:Many forms of Government have been tried and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.

[russell]

But, and this is the important but, for those who can afford it the US system does produce much higher levels of service and much better health outcomes

Simon, thanks for your thoughtful comment.

What I'd like to say about the specific point I quote here is that, as I understand it, under Obama's or any other imaginable plan, those who can afford it would still be able to buy a better level of service than whatever is offered as the universally or near-universally available standard.

In this country, it is quite common for people to forgo necessary care and die, or to be forced into bankruptcy by unexpected accident or illness. Quite common.

As far as I know, nobody is trying to take "cadillac care" away from wealthy people. If you have the money, live it up.

As I understand it, the goal folks are trying to accomplish is to make access to basic health care available to as near to everyone as we can manage.

If you're rich, I'm sure you will still be able to buy excellent care for yourself, and I'm sure that enterprises looking to attract high-demand talent will continue to offer high-end health benefits as part of a deluxe compensation package.

We're just trying to make it possible for pluggers to not, frex, lose their homes if, again frex, they get cancer, or a spouse or parent ends up needing 24/7 care. Those things happen everyday.

[Catsy]

Neither do private charities. For profit business isn't the entire private sector.

Are you seriously suggesting that any kind of private charity would be able to provide a functional and universal alternative to either for-profit or government-funded health care?

Really?

I will eat my words if you can describe for me a plausible way in which any nonprofit charity could sustainably provide even basic preventative health care--yearly checkups--for 300 million people. I defy you to even try. Please show your work; argument-by-assertion is not acceptable.

[Matt C]

Hilzoy,

You are completely wrong here, economically speaking.

Of all the Medicare beneficiaries who receive coverage under the plan, diabetics -primarily Type II adult-onset - comprise about 10%

Yet of all the Medicare expenditures made as part of this coverage, diabetics account for nearly 40%!.

Do the math.

Type II diabetes is primarily caused by the patient, due to obesity (and old age). This is not lukemia, or Parkinson's, or name-your-random disease.

The vast amount of expenditures does not go to antibiotics or guaze pads or scalpels. It goes to expensive cardiovascular and orthopedic interventions in our fat, old, and dying populace. Yet you want to spend more.

[J.M.]

Given that most Republicans and conservatives are strong supporters of the military and its internal workings, you would think there would be a lot of opposition to the government-run Veterans Administration, which provides comprehensive health care to veterans.

I'm not trying to argue that the VA is an example of outstanding health care in all respects, but if universal care is good enough for our war heroes, how can it be so bad for the rest of Americans?

[Catsy]

Sebastian: If we want health care to be cheaper we are going to have to develop an ethos that doesn't involve spending tens of thousands of dollars on lots of people's last 6 months of life.

I don't agree that that necessarily follows. What you're describing is one possible balance of priorities. There are others.

First, the thing that bloats the cost of our current system the most is administrative overhead. Every serious plan I've seen addresses that in some fashion.

Second, I don't see how it's useful to start with the assumption that you're going to have to provide worse care. Making health care cheaper is certainly a big priority, but I would argue that given the choice between making it cheaper and making it universal, the universal part wins. And again, I still think this is a false choice.

[russell]

"Since you insist on asking, because democracy is a sad, sad substitute for freedom."

I don't mean to pile on, Brett, but if you really want to live in your ideal world you're going to have to move to some other country. I'm not asking you to go, I'm just pointing out that whatever it is you're looking for, you're not likely to find it here.

Maybe somewhere back of beyond -- the UP, somewhere up in the Idaho panhandle, out by the Four Corners somewhere, way up in some shaggy corner of the Appalachians.

If you go that way, bring your gun. You'll want it.

If you want to live around other people, you're going to have to accept limits on your own, personal freedom. There ain't no way around it.

Good luck.

[laxel]

Doctor Science: What I *really* don't understand is why the Small Business Association and similar groups aren't totally on the UHC bandwagon. Speaking as someone who's been part of a very small business for 8 years now, the need for affordable health insurance is a constant worry, and one of the biggest barriers to starting a business. It would be completely to small businesspeople's advantage for access to health care to be separated from employment, so why aren't they for it?

Good question. After a little digging on the National Small Business Association site, it seems like they want to make carrying health care mandatory but keep the industry private... give tax incentives. While the link above is broad talk of reform, it appears they are also specifically urging members of Congress to co-sponsor HR 1470.

To be honest, I don't know how representative the NSBA is of anyone other than the most active of small business owners. Their claim that they represent 70 million people in the U.S. who are either small business owners or employees of small business owners seems, well, slightly self-aggrandizing. Forced to wager an answer to your question, I would guess that NSBA operates as a lobbying arm of, again, the most active small businesspeople, and their efforts only represent the interests of a small subset of those 70 million.

It should also be noted that they are coming out hard against EFCA.

[gwangung]

Since you insist on asking, because democracy is a sad, sad substitute for freedom. On a statistical basis, I suppose we might prefer that the majority oppress the minority, rather than the other way around, but shouldn't we really prefer that nobody gets oppressed?

Enforcement and recognition of those freedoms (particularly in this country) has been through the judicial process, which has engendered cries of judicial activism.

I'm not certain you're putting two and two together and recognizing how connected freedom and prevention of the tyranny of the majority actually are.

[Sebastian]

"First, the thing that bloats the cost of our current system the most is administrative overhead. Every serious plan I've seen addresses that in some fashion."

Are you certain? My understanding was the the two main price differences between our health system and most European ones is 1) doctor and nurse salaries, and 2) end of life care.

[Yukoner]

Catsby:
I don't see how it's useful to start with the assumption that you're going to have to provide worse care.

A point that should be made over and over. There are a lot of interlocking sets of priorities and different balance points between them. One of the most obvious is targeting spending on preventative care. A lot of that spending pays long term financial and health dividends.

[Gary Farber]

"The government DOES only exist as a method of coercion. It brings nothing else, AT ALL, to the table, when approaching a problem, which isn't available to the private sector. Coercion might not be all the government does, but it's all the government does that somebody else couldn't do just as well."

This is, of course, total nonsense. The government does countless things that are necessary to be done for the good of endless common people which can't be done by private industry because there's no profit in it.

See, for example, the history of rural electrification, rural postal service, supplying emergency room services for the uninsured, the food stamp program, Medicaid, providing an Air Force and military, giving police protection to the poor, running public schools for those who can't afford tuition, etc., etc., etc.

Most of the point of government is to do that which other entities can't/won't do.

[Jesurgislac]

Can you actually cite doctor salaries in the US versus doctor salaries in (for example) France or the UK, nurse salaries ditto?

End-of-life care costs are likely so far dependent on a multitude of other factors that I'm not sure it's reasonable to compare between France and the US: average life expectancy is noticeably better in France, which suggests that regardless of what the US spends in the last six months of life, France's overall healthcare for the whole of a person's life is better.

But first, I think you'd have to show that the entire monstrous addled bureaucracy of US healthcare is somehow cheaper to run than the more streamlined versions elsewhere...

[Tony P.]

Since you insist on asking, because democracy is a sad, sad substitute for freedom.

Yeah, just as libertarianism is a sad, sad substitute for solipsism.

--TP

[Doctor Science]

Sebastian:

I don't see how administrative costs -- especially the costs of dealing with insurance companies, and also their profits -- can *not* be a major component of US medical costs, in excess of spending in civilized countries.

If we had single-payer, universal, no means test health care, we wouldn't be spending money for:

1. people at insurance companies (including doctors) evaluating whether they'll pay a given claim. Turning it down, arguing with patients, arguing with doctors.

2. people in doctor's offices (including both nurses and doctors) arguing with insurance companies. The small family practice I go to -- 3 MDs, a couple of physician's assistants -- has 3 full-time equivalent nurse admins solely for dealing with insurance companies. That's not counting the people who work at the front desk and in the records room.

Hospitals have entire departments to do this. There are about 4 pharmacists at my local drug store, at least one is on the phone to an insurance company at any given moment.

3. Time spent by patients (like me) and human resources departments arguing with doctors and insurance companies, trying to get promised or implied coverage. Time spent by HR and business people debating what insurance coverage to get, on hold with insurance agents, writing letters, etc. Filling out forms, sending them in, filling them out *again*.

4. Insurance company profits.

[Gary Farber]

"I really think Brett needs to calm down and reassess his views of government. I mean, I get that he's a conservative and skeptical of government,"

Brett's not a conservative; he's a libertarian. He's always used this language, which is typical of immoderate libertarians.

For the extreme libertarians, government is nothing but a jackbooted heel coming to shoot them and take away their freedoms. Weird, and blind, but that's their view.

Regrettably, their noise and numbers swamps from view the relatively small number of sane libertarians (see, e.g., Jim Henley, Julian Sanchez, Radley Balko, etc.).

[Catsy]

The great Catsby? :)

Are you certain? My understanding was the the two main price differences between our health system and most European ones is 1) doctor and nurse salaries, and 2) end of life care.

Pretty certain. I've seen data for this multiple places, but the only link I can find on short notice is this.

1. higher prices for the same health care goods and services than are paid in other countries for the same goods and services;

2. significantly higher administrative overhead costs than are incurred in other countries with simpler health-insurance systems;

3. more widespread use of high-cost, high-tech equipment and procedures than are used in other countries;

4. higher treatment costs triggered by our uniquely American tort laws, which in the context of medicine can lead to “defensive medicine” — that is, the application of tests and procedures mainly as a defense against possible malpractice litigation, rather than as a clinical imperative.

1. Salaries figure into this somewhat, but the real culprit here is bloat from drug company patent monopolies and kickbacks.

2. My point. Single payer would take a huge bite out of this, but our system is so abominably lousy with red tape that there are plenty of efficiency savings to be realized from solutions short of that.

3. I don't view this as necessarily being a bad thing. Many high-tech treatments have value added that make their increased cost both reasonable and a good value. Some are bloat. Not everything that's high tech and more expensive is wasteful.

4. A problem that has more to do with our legal system than it does with the method of providing health care per se. But again, not always a bad thing: I'm of the school of thought that when in doubt, it's better to get checked and tested than not--as I pointed out upthread, many many conditions are more cheaply and effectively treated if caught early.

[Gary Farber]

"A private oxygen supply is the logical conclusion of all this. I'm sure it's been a feature of a dystopian science fiction novel or two."

In The Moon Is A Harsh Mistress, prior to the revolution, you had to pay "air money" to the Lunar Authority. I don't recall offhand if it was stated how this was handled after the revolution.

However, custom says you give air to anyone who can't afford it, until they can pay you back:

[...] “All our customs work that way. If you’re out in field and a cobber needs air, you lend him a bottle and don’t ask cash. But when you’re both back in pressure again, if he won’t pay up, nobody would criticize if you eliminated him without a judge. But he would pay; air is almost as sacred as women. If you take a new chum in a poker game, you give him air money. Not eating money; can work or starve. If you eliminate a man other than self-defense, you pay his debts and support his kids, or people won’t speak to you, buy from you, sell to you.”

TMIAHM is, for those unaware, generally extremely highly regarded by most libertarians. It's also actually one of Heinlein's best books.

[Catsy]

Bah, blockquote got eaten. The following is quoted from the article I linked:

1. higher prices for the same health care goods and services than are paid in other countries for the same goods and services;

2. significantly higher administrative overhead costs than are incurred in other countries with simpler health-insurance systems;

3. more widespread use of high-cost, high-tech equipment and procedures than are used in other countries;

4. higher treatment costs triggered by our uniquely American tort laws, which in the context of medicine can lead to “defensive medicine” — that is, the application of tests and procedures mainly as a defense against possible malpractice litigation, rather than as a clinical imperative.

[Catsy]

Speaking of blockquotes, how feasible (or desirable) would it be for the ObWi mods to add a bordered blockquote style to set it off from comment text a little better? I'm thinking of something like the one they use at DKos, which is both unobtrusive and effective.

I'll be happy to provide the CSS if necessary.

[Mark]

"When acts of God ruin like hurricanes or earthquakes ruin people's lives, we step in to help."

You can step in all you like. You have no right to force me to pay for other people.

There are 2 ways to obtain medical care:

By voluntary means (paying for it yourself, insurance or charity) or by coercion.

Interesting that most liberals would never point a gun at someone to get something for themselves, but it's okay if Barney Frank or Obama does it for them.

Why don't you liberals be honest and admit that the government operates like the mafia? Pay up or bad things will happen to you.

Kindly tell me the distinction between taxation and theft. And spare me your ends justifies the means utilitariansim.

[Warren Terra]

blockquote got eaten.

You, too? I thought I'd just managed to do something really dumb twice in one comment, above ...

[Warren Terra]

I'd really like to see how the fire department and the police operate in Mark's world ...

[Mark]

"I will eat my words if you can describe for me a plausible way in which any nonprofit charity could sustainably provide even basic preventative health care--yearly checkups--for 300 million people."

Why would any charity have to provide basic preventative health care for 300 million people? Most Americans can afford to pay for it themselves. Low cost providers like Wal-Mart charge as low as $59 for a basic checkup. Also, yearly checkups are a waste of money for most young and healthy people.

And again, this is the liberal utilitarian argument. It's okay to coerce people for a good cause.

[Simon K]

Jes - thanks for your follow-up. I agree with your brother on the perspective of ordinary doctors. As I've seen it operate the NHS is hell on earth for junior doctors and nurses, and sadly there is almost no such thing as a senior nurse any more. There's no job security, the hours are horrible, and the pay is terrible. Doctors, once they acquire seniority, have a much easier life, partly because they can then take private patients.

Local authority health services are distinct from the NHS, although obviously closely related. They can be excellent, and they can be terrible because there is still some difference between jurisdictions. The British don't take well to federalism - it creates inequalities than people don't like - so I'm not sure how long this will last. But that kind of care isn't quite what I was thinking of - I was thinking more in terms of things that would require health professionals over long periods of time eg. degenerative illnesses, serious mental health problems, and so on.

russell - Although I may have sounded down on it, I actually think the trade-offs in the British system are made better than they are in the US one. But its very reflective of a difference in values between the two political systems - the British like equality of provision, Americans generally want the best for themselves. The tradeoffs in the NHS wouldn't be sustainable here, which isn't to say some kind of mostly-single-payer system wouldn't be - it would just look different.

That said, the issues with state provision aren't limited to Cadillac (or Rolls Royce) levels of care. That's why I threw in the remarks about my brother's bachelor party experience (my bachelor party, as it happens ...). The difference permeates the whole system - the NHS will give anyone cost-effective treatment for anything, the US system will give those who can pay, or who are insured for whatever it is that's wrong with them, the very best care available. The ethos is quite different, and it pervades the whole way healthcare is administered. In the US its impossible to get low-cost care even if your only problem is mildly excessive alcohol consumption. In the UK its impossible to get the very best care technically possible for certain conditions.

I should explain that last point because I wasn't totally explicit about it before. When a single payer buys almost all healthcare based on a uniform assessment of its cost effectiveness, anything that it chooses not to pay for automatically has very few customers. It therefore becomes more expensive and in many cases totally unavailable. This doesn't just mean cadillac levels of care for the rich and old, it means (for instance) certain malaria medications for travellers, certain vaccination regimes for children, and so on.

Its essential to see the tradeoff here clearly: The UK system achieves universal coverage very efficiently, at the expense of measurably poorer health outcomes for all patients, compared with the US system. Those poorer health outcomes are politically acceptable in the UK because they occur only at the margins - those who are extremely unwell, extremely old, extremely young or extremely rich have measureably smaller life expectancies.

I don't think that particular tradeoff would work in the US. In particular the old and the rich (and the old and rich) have much more political clout here. I don't know the details of the French system, but since it more freely allows mixed state/private payment for care, it might well be more politically acceptable in the US.

[Jesurgislac]

Simon K: Those poorer health outcomes are politically acceptable in the UK because they occur only at the margins - those who are extremely unwell, extremely old, extremely young or extremely rich have measureably smaller life expectancies.

Though FWIW, the UK does have better life expectancy on average than the US. (It's not nearly as marked between the UK and the US as it is between the US and France, though - and I seem to remember it's fairly recent.) The UK also has a lower infant mortality rate and a lower maternal mortality/morbidity rate than the US.

[Mark]

Warren,

Try reading some Murray Rothbard or Hans Hoppe. They describe in great detail how an anarcho-capitalist system would work.

We know how the police operate in our system already. Millions arrested for victimless crimes, people tasered to death, constant police lying, coverup of police crime, etc. Nice, huh?

Private fire departments could operate on a prepaid insurance basis or you could pay for services after the fact.

Just because something is not commonly done now, does not mean it is impossible. I'm sure people in the former Soviet union wondered how they could possibly eat if government run grocery stores were abolished.

[Catsy]

You can step in all you like. You have no right to force me to pay for other people.

Sure we do. There's even a name for it. Starts with a T. I'm pretty sure there were some wild parties recently complaining about it. It'll come to me.

I await your description of how we have no right to force you to pay for other people's roads, other people's defense, or other people's schools, or other people's public defense attorneys, or...

There are 2 ways to obtain medical care:

By voluntary means (paying for it yourself, insurance or charity) or by coercion.

Tweeeet. False dichotomy, 10 yard penalty.

Interesting that most liberals would never point a gun at someone to get something for themselves, but it's okay if Barney Frank or Obama does it for them.

If you want to tilt at windmills by complaining that you have to pay taxes to fund FEMA and Interstate 5, that's your hobby and it's your right to waste your time and money on it. Mine is Legos. But when it comes to the right of the federal government to raise taxes to fund programs for the common good, that ship sailed a long time ago.

Kindly tell me the distinction between taxation and theft. And spare me your ends justifies the means utilitariansim.

This question is so silly as to defy description. And responding to it is probably a waste of time. But for the sake of any would-be-libertarians out there who might think this sophistry clever: the difference is law.

Taxation and theft both constitute taking property or value from one person or entity, and giving it to another. In this they are similar, just as a cop shooting an armed suspect and the armed suspect shooting the cop both involve using a firearm to take the life of another. But few people would argue that the cop--assuming that this was a lawful shooting--committed murder. Even fewer would argue that the suspect shooting the cop was not.

The reason for this distinction is that one act falls within the boundaries of what we, as a society, have agreed is lawful, and one does not. One is an action that, while regrettable, generally makes us safer and more secure as a society, the other does the opposite. There are all sorts of things that are good when lawful, bad when not, even if on some level the underlying action is the same. Context--and law--matters.

Just so, while few people like paying taxes, and even fewer agree with everything their taxes pay for, there is near-universal agreement that taxation per se is a legitimate power of the state. I don't like paying taxes, but I recognize that they pay for civilization. You might have heard of it. We live in one, and taxes make that--including the worldwide network on which you're currently regurgitating this pseudo-Randian garbage--possible.

You don't have to like it. But FFS, "how are taxes different than theft?" is on the intellectual level of "if God loves us, why is there evil?" Been there. Done that. Moved on.

[b-psycho]

Hilzoy: if you want to hear an anti-state argument on health care that doesn't begin & end with "corporations YAAAAY!", here's one.

I'm actually fine w/ the general concept of collective provision for this type of stuff in principle. What I don't get is why the discussion is limited to government vs mega-corporations, when they're just two sides of the exact same coin. How 'bout neither?

[Simon K]

Jes - You're absolutely right that overall life expectancy, infant mortality and so on are better in the UK. I meant to emphasise that the UK acheives measureably lower health outcomes compared with the US *for those with access to the healthcare*. The qualifier is very important. Obviously the 50m Americans who don't have routine access to healthcare, and the larger number whose access is constrained or intermittent, have a substantial impact on the overall statistics.

And why is this thread turning into another incarnation of the same discussion of anarchocapitalism that's been flitting around the internet since the days of green screen terminals? We're not going to reach any different conclusions this time ...

[Warren Terra]

Mark, there are excellent reasons why public services are charged to the entire public and not charged after the fact to those who use their services; for one thing, if you only paid the fire department after you had a fire not only would the fire department's incentives be all fouled up but most likely you'd be unable to pay the costs of the fire. And If I am unwilling to pay the fire department, I guess my neighbors have got some problem, huh?

And I really don't want to live in a world where people only go to the police if they're wealthy or if they're certain their situation is sufficiently bad to justify the additional expense incurred by contacting the police. It's bad enough having the police we've got now, with all their problems, especially if you're poor, or black, or gay; I don't look forward to needing the police and being prevented by my own poverty or even directly outbid by the people who've wronged me.

P.S. I've helpfully hyperlinked the above word "neighbors" because exponents of libertarian philosophies so often seem to have trouble with the concept.

[Sebastian]

Catsy I'm more skeptical of your understanding now than I was at the beginning.

"Salaries figure into this somewhat, but the real culprit here is bloat from drug company patent monopolies and kickbacks."

Even taking away 100% of the drug cost in our medical system saves you only like 10% of the cost. (See for example here And I don't think you believe that drugs cost $0 even after the research has been paid for. So if we are only getting rid of the patent monopolies and kickbacks, I suspect that your mindset about where the real savings are is skewed.

It is kind of like Republicans saying that they are going to balance the budget by getting rid of earmarks. Either you don't understand how big the budget is, or you don't understand how big the earmarks are.

[Warren Terra]

We're not going to reach any different conclusions this time ...

Quitter!

[Gary Farber]

"Neither do private charities. For profit business isn't the entire private sector."

Setting aside that private charities can do relatively little compared to governments, due to their relatively tiny sizes, private charities can't pay out more than they have coming in; government, on the other hand, can run various endeavors at a loss. (Yes, yes, by having jackbooted agents ruthless put guns to the heads of kittens and children of taxpayers, etc.)

"Since you insist on asking, because democracy is a sad, sad substitute for freedom."

Freedom to be bankrupt and die from lack of health care, or merely suffer greatly, is a poor substitute for the benefits of democratic government.

Glossing the not-small distinctions between democracy, especially a democracy with various guarantees of individual rights, and dictatorship is an unbelievably huge gloss.

Really, Brett, if you feel so strongly that you lack "freedom" (and what is it, exactly, specifically, that you lack so badly that it compares to the lacks of hundreds of thousands, if not millions, of people in situations comparable to Kate Michelman's?), why don't you move to a more free country? Which one do you think is more free? If there is one, why not move? If there isn't one, why do you think that is the case?