Nationalization and Health Care

Can somebody explain to me why, exactly, nationalization has seemingly become The Vehicle for a healthcare system? There are a number of interesting state initiatives under consideration (or in the fledgling stages of implementation), and frankly, that’s about as wide an umbrella as I think can be efficiently managed.

I agree that the healthcare crisis is an enormous problem. I’m very interested in proposals and solutions — but I cannot get behind any plans that rely on the federal government’s management.

I’ve written more here.

         

Author: POLIMOM

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44 Comments

  1. I think, like most people, I would prefer any plan that works. I cannot understand the sentiment that you cannot get behind one general strategy over another. It’s a short-sighted limitation.

    The argument for nationalization comes while witnessing the near-total failure of our privatized system. That doesn’t imply privatized must fail and nationalized must succeed, but the reason is rather simple.

    I would be much happier if people were busy looking for solutions rather than setting ideology-based limitations, though we’re doing nothing the government isn’t doing already — which, conveniently, is nothing.

  2. I have another question to mirror Polimons. Can anyone tell me why nationalized health care CAN’T work? Let’s not forget that pretty much every other civilized nation besides the US offers nationalized health care (which does not, despite what some think, mean that private care is unavailable). I’ve never read anything to show me that Americans pay less for healthcare or are on average healthier than economically equivalent countries WITH nationalized healthcare. So then, what is so different about the US that would make nationalized healthcare un-doable? Why can’t the US pull of something that countries as different as Japan and Holland, can?

  3. Actually, in Quebec Canada, people were being sued for taking out private health coverage (even though they thought Canada’s coverage wasn’t up to snuff). I agree whole-heartedly with Polymom – the federal government is too large an umbrella under which we should put healthcare. Canada’s system is failing and any European country you can quote me about having a decent system (I’ll put aside my doubt on that) is only about as large as one of our states. (The Netherlands, not Holland, is 18 times smaller than the US; Japan is ~3 times smaller.)

    What is REALLY needed to reform healthcare is not nationalized (or even state-run) healthcare… its reform of malpractice (and related) lawsuits! Ask any doctor, nurse, or anyone else involved with the managing of healthcare – malpractice insurance and having to run extra tests to “cover your butt” are what is driving up the cost of healthcare.

    BTW – we do already have a National Socialized Medicine: it’s called the VA Hospital system. They already service 36.9 million (as of 1999) in outpatient services (1/3 the size of Germany’s population). From what we’ve seen of the quality of service, do you really want the Fed. Government in charge of more hospitals? Our other national system, Medicare/Medicaid never pays their bills on time. It usually takes months (if the doctor is lucky) to get their claims filled. Is it any surprise that healthcare agencies take it out on other people? They need to get their money somehow.

  4. Lynx and egrubs —

    The government that brought us FEMA is a bloated, bureaucratic nightmare already — jam-packed with conflicting, self-patronizing, and partisan interests. I have very little confidence in them, generally.

    More: The U.S. has a much, much larger, and more complex, population than Japan or Holland. More importantly, though, this country’s foundational concepts are radically different. Via federalism, we’ve arrived at a different place altogether.

  5. Problem is, Polimom, that there’s more than one problem with our present health care system and most of the proposed solutions are in conflict with one another. Problems include rapid rises in costs, the uninsured, and fear of becoming destitute as a result of a major medical crisis.

    The problem of the uninsured isn’t quite what the hype would suggest: a quarter of all of the uninsured live in just two states, Texas and California. They don’t account for a quarter of the nation’s population. Add just four more states and it accounts for half of the uninsured while their states’ population is less than half of the nation’s. In other words we’re looking for a national solution to what is actually a serious local problem.

    All of the other problems become worse as health care costs rise relative to wages. Few of the solutions proposed do much about rising costs.

    In answer to Lynx’s question: Gammon’s Law, i.e. the condition of outputs per input actually falling. It applies to both health care and education. Gammon’s Law was first discovered and enunciated in a study of British National Health, a fully nationalized system. Their costs are rising beyond their ability to pay, too.

  6. The government that brought us FEMA is a bloated, bureaucratic nightmare already — jam-packed with conflicting, self-patronizing, and partisan interests. I have very little confidence in them, generally.

    On this we agree. But if you expect one to have more faith in private health care organizations…

  7. Since the New Deal and particularly since the Great Society, people have ignored constitutional federalism and have looked often first and foremost to the “national” [sic; federal] government as the vehicle to solve all their problems or realize their objectives.

    Unconstitutionality aside, and also laying aside other things such as corporate federal charters (a Naderite fascistic dream), or other instances where leftists want to enlarge the scope of regulation or other controls so businesses and individuals cannot flee by changing states in the USA, the argument in favor of federal as opposed to state health care mirrors government versus private health care — elimination or reduction of the duplication of bureaucracies (though the single federal bureaucracy would grow very large), and the appeal of uniformity throughout the USA (same forms, same procedures everywhere).

    Also, the federal government is seen as larger and having more money (indeed, lefties see it as inexhaustible, something magical) than the state governments. Even state governments often look to (wish to exploit) the federal government.

    Those who want government health care (often using the dishonest, evasive term “single-payer” instead) rather than private health care claim that private care is unaffordable, they object to game-playing by insurance companies (which is all too real, too often), or object to what is in their view less than ideal or dreamlike about health care, with “costly duplication” of expensive services, not enough preventive care (though those most in need of it avoid it even when it’s provided), pay to health professionals and others in the field is “too high,” and so on.

  8. To start with an ideology rather than looking at a specific plan is short-sighted in the extreme.

    Privatization is, first of all, a misnomer. It would only be administered by private entities, while still funded by the government. If private insurers could do it on their own, they would have done it by now.

    On the one hand, then, you have a government bureaucracy, and on the other, you have a maze of private companies with their own mini bureaucracies and interests.

    There are pluses and minuses all around.

    Jumping to conclusions is the first sighn that we’re in trouble before we start.

  9. It was said:

    > I agree that the healthcare crisis is an
    > enormous problem. I’m very interested
    > in proposals and solutions — but I cannot
    > get behind any plans that rely on the
    > federal government’s management.

    Most (including I) expect to see federally provided health care eventually. I have warned others before — if we went from private to government health care we will only be changing the current set of problems we have for new problems. Only dupes believe it will be wonderful.

    The best warning, which I have given for years, for us is how the VA health care system has been. Person after person can tell you horror stories; in fact, “VA horror stories” is a cliche. Arguably some kinds of improvements have been made, in some places, in some cases. But VA (federally provided) health care is full of problems. The recent scandal with Iraq vets at Walter Reed is only the latest of decades of problems.

    In addition to VA health care problems, we must look ahead to what is being sought currently and what’s wrong with it. The Conyers bill (once again out from under its rock) is blatantly unconstitutional. This is aside from the lack of authorization granted to the federal government to provide health care to people in the first place. (What’s not granted is forbidden; the Tenth Amendment even repeats this for clarity.) What is specifically wrong with the Conyers bill is that it is an unconstitutional confiscation of property without due and adequate compensation. That bill wants to make medicine not-for-profit and take over facilities, but not pay owners for lost profits. This is outright theft. 20-30 years of (increasing) profits are due the owners if the government is expropriating the facilities.

    You can expect prohibitions on engaging in private medicine that duplicates anything specified as a federal health benefit in the Conyers bill, as a rule.

    People like Conyers want to keep health care nominally private. But what matters isn’t ownership, in the end, than control. Hillary Clinton’s fascistic HMO-”alliance” health care plan was a federal government takeover, and that is what is being planned here.

    The sickening part of the nominal-private-medical-provider scam by people like Conyers is that legally the providers can still be considered private, so there is no soverign immunity and the junk-lawsuit nonsense that is wrecking medicine now will continue. In fact, with federal takeover, we can even see ever-increasing malpractice insurance requirements to ensure more and more money goes to lawyers who deserve nothing.

  10. Polimon, I do appreciate the differences in origin and scale of the US, but I don’t quite see how nationalized healthcare can be rejected out of hand. BTW not all countries are as centralized as you might imagine. Spain has something quite close to a federalized system, with each Autonomy having nearly complete control over education, healthcare transport and police. Some regions are even allowed to collect and handle much of their tax load. There are national standards for education and healthcare, as well as a national police force and armed services. However Spain is much much smaller than the US.

    I don’t think that nationalized healthcare is the ONLY way to go, but I do think that public, free healthcare for all citizens is a must in any civilized nation. It makes no sense to me (as hard as C. Stanley has tried LOL) how Americans don’t question public schooling but do question public healthcare. Whether the system is local, state or nationally run, is secondary. However, if the system were to be state run, you would inevitably run into the issue of richer states with smaller populations getting better care than poorer states with large urban populaces.

  11. > Americans don’t question public schooling
    > but do question public healthcare

    Who provides it? (Admittedly there is federal intrusion, and there should be done, but public education is a local and state matter, where it belongs.)

    Part of the problem as well is what public health care there is — at the state level, it’s typically Medicaid people think of, and the classic welfare population. (Social Security and Medicare are welfare programs but the recipients aren’t commonly thought of as welfare beneficaries, even though that’s what they are.)

    Unless you’re involved with vets or you inquire into what is happening in the world around you (here in the USA), you may not be aware of VA medicine and its problems.

  12. Reasons while nationalized health insurance will not work:

    1. The government does not manage large workforces very well.

    2. The payscales would be set by the government. My guess is that the EEO coordinator would be vastly overpaid while the physicians would be underpaid. In a few years, all of the underpaid professions will have large shortages.

    3. The government would probably put a stop to new technology. It would be a cost savings for the government not to adopt new technology. Also, why would anyone want to go into biotech if the government is your only possible customers. Do you really want to reproduce the economy of the defense contractor in the healthcare area?

  13. I will guess that NONE of the posters here has a major life threating, long term illness. If you did, you would change your mind 100% on National vs. private healthcare. I have a major medical condition that I’ve been dealing with for over 20+ years. I see a doctor at least every 3 months, take a large assortment of medications daily, get my labs done at least 4 times a year, etc. Health care continues to get worse and the worse parts are the PRIVATE sector. I consistently have to fight with PRIVATE insurers who second guess my doctors and routinely deny me medications and tests my doctors have ordered. To all these posters here I say get a major illness. You will change your tune and be much less afraid of National health care. It ias the private system I fear–unless you’re rich. Then we have the best health care in the world. But for the majority of us who aren’t rich, a single payer system with Doctors instead of insurers in control is preferrable.

  14. Charles said:

    > Canada’s system is failing and any
    > European country you can quote me
    > about having a decent system (I’ll
    > put aside my doubt on that) is only
    > about as large as one of our states.

    Then when size comes to mind, we have to ask just how we are going to pay for health care for everyone, including all who forego it currently? The modern view is “Medicare for All” rather than trying to contrive some all-new system (Hillary’s new scheme as well as her outrageous behavior were primarily responsible for the 1994 election results). This means we get VA medicine for all in practice more than Medicare for all because the scope of government intervention will be increased along with the number of beneficiaries. But assume for a moment it will be similar in costs to Medicare (a frequent alternate model hawked by government health care supporters).

    Have people any idea of what our future costs of the “small” Medicare program we have now are going to be? I have warned people for ages about the coming problems with Social Security and Medicare. The programs’ Trustees report year after year about the problems (Social Security will start running deficits soon, which to intelligent people constitutes the time the system is truly getting into trouble, as has long been predicted; parts of Medicare have already been running deficits); if you look at the problems that will happen with Medicare now, how will we fund Medicare for All? (Making everything “mandatory” funding does not solve the problem; the funds that must be then spent still have to be found somehow, somewhere.)

    “while Medicare’s annual costs were 2.7 percent of GDP in 2005, or over 60 percent of Social Security’s, they are now projected to surpass Social Security expenditures in a little more than 20 years and reach 11 percent of GDP in 2080.”

    “HI could be brought into actuarial balance over the next 75 years by an immediate 121 percent increase in program income, or an immediate 51 percent reduction in program outlays (or some combination of the two). As with Social Security, however, adjustments of far greater magnitude would be necessary to the extent changes are delayed or phased in gradually, or to make the program solvent on a sustainable basis over the next 75 years and beyond.”

    “Part B of the SMI Trust Fund, which pays doctors’ bills and other outpatient expenses, and the recent Part D, which pays for access to prescription drug coverage … will result in rapidly growing general revenue financing needs-projected to rise from just under 1 percent of GDP today to almost 5.0 percent in 2080- as well as substantial increases over time in beneficiary premium charges.”

    “In 2006, the Social Security tax income surplus is estimated to be more than offset by the shortfall in tax and premium income for Medicare, resulting in a small overall cash shortfall that must be covered by transfers from general fund revenues. The combined shortfall is projected to grow each year, such that by 2017 net revenue flows from the general fund to the trust funds will total $487 billion, or 2.2 percent of GDP. Because neither the interest paid on the Treasury bonds held in the HI and OASDI Trust Funds, nor their redemption, provides any net new income to the Treasury, the full amount of the required Treasury payments to the trust funds must be financed by some combination of increased taxation, increased Federal borrowing from and debt held by the public, and a reduction in other government expenditures. Thus, these payments along with the 75 percent general fund revenue contributions to SMI will add greatly to pressures on Federal general fund revenues much sooner than is generally appreciated.”

    “currently projected benefit costs for Medicare and Social Security pose a far more serious long-term financing problem than is generally recognized. The shortfall of dedicated payroll tax and premium income will grow rapidly in the 2010 to 2030 period as the baby-boom generation reaches retirement age. Beyond 2030, the shortfall continues to increase rapidly due to health care costs that grow faster than GDP and because of the increasing life expectancy of beneficiaries. In 2005, the combined annual cost of HI, SMI, and OASDI amounted to about 40 percent of total Federal revenues and about 7 percent of GDP. These costs are projected to double to 14 percent of GDP by 2040 and then to rise further to 17 percent of GDP in 2080. Over the past four decades, the average share of total Federal revenues as a percentage of GDP has been 18 percent and has never exceeded 21 percent. Assuming the continued need to fund a wide range of other government functions, the anticipated growth in Social Security and Medicare costs would require that the total Federal revenue share of GDP increase to wholly unprecedented levels.”

    http://www.ssa.gov/OACT/TRSUM/trsummary.html

  15. Doubting Thomas said:

    > I will guess that NONE of the posters here
    > has a major life threating, long term illness.

    I have one. It’s not life-threatening yet, but…

    > If you did, you would change your mind
    > 100% on National vs. private healthcare.
    > I have a major medical condition that I’ve
    > been dealing with for over 20+ years.

    27 years and an unknown amount of time before that, and counting, in my case.

    And I don’t have AIDS or cancer; I’ve had enough problems as it is and feel really bad for the AIDS, cancer, etc. people.

    I also know fully well the games that the insurers play (insurance companies are the other thing besides lawyers pestering the
    doctors and ruining medicine currently — ask them; they’ll say it’s insurance companies and lawyers. In the case of insurers with the multiplicity of parties and different policies, many people are ready for a single, common health care program to replace it.

    As far as private health care, I wonder how many people are now not only upset with HMOs, but what they think of the new “middlemen” in the health care field such as “wellness providers” who counsel you as a social worker in government would to take your medications and live right, while also exchanging private personal medical information with your health care plan (the HMO). You realize, don’t you, that sooner or later the employers will grasp at the individual information that identifies high-cost versus low-cost employees. At that point I suspect government health care would become a certainty.

  16. Doubting Thomas wrote:

    > Health care continues to get worse
    > and the worse parts are the PRIVATE
    > sector. I consistently have to fight
    > with PRIVATE insurers who second
    > guess my doctors and routinely deny
    > me medications and tests my doctors
    > have ordered.

    You will experience similar problems under government health care, especially as inevitable cost controls are imposed in the years to come.

    Generics and lower-cost substitutions will dominate the formulary. Not only during the push for “HillaryCare” but at other times activists (who are on the Left) have said there is too much specialization, too much technical overinvolvement in medicine, too much effort (and money) being spent at the end of one’s life. You will see a pushing for “mercy killing” [sic], i.e., euthanasia, and an increase in its use in scope as well as frequency. You can expect one-size-fits-all algorithms and protocols for various patients and illnesses. You can expect the need for government pre-authorization for specialty care and inpatient care, with the overworked primary physicians still acting as gatekeepers. They will just be serving a different master.

    That it may be less money-conscious, at first, than profit-seeking private firms (who in fact may be greedy sometimes, as greedy as government unions), still doesn’t mean you won’t see it happen. You’ll see other changes as well, such as redirection of doctors from specialties and subspecialities to general practice (not limited only to medical school and residency openings).

    You will find decisions second-guessed under government health care, by government — by bureaucrats who know nothing rather than call center employees who know nothing.

    You will find some people who care less about you and their job as employees of government (especially if they are union members and especially well protected against disciplinary actions for misconduct or negligence) than they do now because at least they want your money rather than see it go to someone else.

    Some things may indeed become better. But it will never be ideal.

  17. [D]omajot wrote:

    > There are pluses and minuses all around.

    Yes, exactly. The grass isn’t greener everywhere on the government side.

    Floor yielded…

  18. Given that I’m writing this from my backyard in Texas, Dave Schuler’s comment has particular resonance for me. It’s been the subject of great (and extremely heated) debate in these parts, specifically as related to illegal immigration.

    But Texas is very much a “don’t tax me for any reason” state, and as far as I know, we’re not even discussing a state plan for mandatory coverage… as opposed to California, where they’re trying to address the issue.

    Furthermore, defining the healthcare crisis in terms of people with no insurance doesn’t really get all the way there. In my own case, our family (of 3) is paying over $800 per month, now, for insurance, because we’re outside the employer-provided / contributed benefit nets. Is this because we’re in Texas? Dunno…

    But ultimately, I think Dave (and others) had a point: there are specific areas and issues that can be pin-pointed, and if addressed, would provide dramatic relief.

  19. Wow. A lot of wind arguing against an ideology.

    One’s beliefs, jumping to insane conclusions, and partisan fearmongering outweigh others’ lives once again.

  20. egrubs –

    I’m not arguing for or against an ideology. I’m concerned about the vehicle.

    It’s bad now. Very bad. I don’t see anything that tells me the federal government wouldn’t perform in its usual dysfunctional way, and given the scope of this particular issue, how could that possibly improve things?

    I don’t know what the answer is, although I once wrote a post that included some ideas (here). Certainly the path we’re on is destructive. I’m just not at all comfortable with nationalized solutions.

  21. Again, I ask that someone tell me what, exactly, is different about the US that would make public healthcare not possible. I won’t get into whether it should be national/state/local, just that it be public. You see, this is not a theoretical issue, there are a multitude of examples throughout the world that can give you hard data as to what, exactly, a public healthcare system does, good and bad. There are countries that do it better, there are countries that do it worse. The fact some countries fail does not mean the idea is a failure, not when there are countries that succeed.

    That Public Healthcare isn’t ideal? Well no, of course not. Waiting lists for some specialties are very long and certain diagnostic tests are hardly ever mandated because of costs, though they would contribute to better health. Same goes for some drugs, which are better than those prescribed but are more expensive and therefore aren’t subsidized. However, I have never, ever, heard of a Spanish family falling into poverty because one of the children got cancer, even if the family was that of a bricklayer and a housewife. When a worker breaks his leg, he gets the “baja laboral” (full pay for a given time during incapacitation for work) and doesn’t have to sweat about the 250$ the emergency room charged his struggling family for the 15 minutes they took to set the bone. Senior citizens get all drugs 100% free, everyone else at 40% of real cost. Things sometimes get crappy, sometimes bad care, long waiting lists etc. can have tragic consequences. But that happens in private healthcare as well, and on top of it all you’re paying a lot of hard cash for it.

  22. Polimom said:

    > as far as I know, we’re not even discussing
    > a state plan for mandatory coverage… as
    > opposed to California, where they’re trying
    > to address the issue

    Be aware that some of the motivation behind some states’ plans is to put politicians in the news more than anything else. Also, consider what you may think of public sentiment toward these state plans and how they may be viewed as temporary or transitional until in the end we have federally provided health care in their place.

    [E]grubs said:

    > Wow. A lot of wind arguing against an ideology.
    >
    > One’s beliefs, jumping to insane conclusions, and partisan
    > fearmongering outweigh others’ lives once again.

    Definitely true about the “single payer” [sic] crowd and how they tend to mischaracterize the opposition. Or were you projecting or engaging instead in mischaracterization?

  23. lynx,

    The reason that socialized medicine would fail in the United States is that American make lousy socialist. America is too diverse, too individualistic, and too egotisitical for public healthcare to ever work. If you design a healthcare system to deliver a minimal level of healthcare to the poor, it will fail from lack of support for the middle and upper class. If you design a system for the middle class, it will probably fail to deliver heathcare to the poor.

    The best that anyone could hope to achieve is single payer with its own set of problems.

  24. [E]grubs said:

    Lowercase ‘e.’ On purpose. Thank you in advance for not correcting it again.

    If I were to give my opinion I’d only be rephrasing Lynx: Why can this not work, when others make it work? The answers I hear are assaults on groups, mischaracterizations, and excuses that “Because FEMA stunk, we can’t ever trust the government again.” None of these fly.

  25. It was said:

    > Lowercase ‘e.’ On purpose. Thank you
    > in advance for not correcting it again.

    It’s my perogative to avoid incorrect “english” and correct mistakes in what I’m responding to, whenever I so choose, just as I may interject additional text as needed to clarify things. “Thanks in advance” for your understanding, agreement, and wholeheartedly joyous approval (“not”).

    > If I were to give my opinion I’d only
    > be rephrasing Lynx: Why can this not
    > work, when others make it work?

    I’m not saying it can’t work, and in fact I expect federal health care to be a reality someday soon. (50/50 odds within 10 years; I used to say 20 for certain but now consider 10 years “downrange” as when we’re likely to see or have seen something.)

    But it won’t work as well as the advocates believe or claim. Nooooooo…

    > The answers I hear are assaults
    > on groups, mischaracterizations,
    > and excuses that “Because FEMA
    > stunk, we can’t ever trust the
    > [federal] government again.�
    > None of these fly.

    Bringing up the VA problems flies beautifully. The same is true for bringing up problems with Medicare, Medicaid, or for that matter other federal programs that feature a strong, dominant federal government presence such as the Post Office, Amtrak, etc. So is pointing out other problems with the existing system that some attempts at providing federal health care (Conyers) specifically fail to address or would perpetuate (keeping providers nominally private so the junk lawsuits continue and the Dims’ oft-#1 special interest group continues to feed itself at everyone else’s expense).

    That’s despite some (substantially small) minority claims that VA care has improved to the point where it’s the best in the nation.

    http://www.washingtonmonthly.c.....ngman.html

  26. Going back, with some trepidation, to the original question: Can somebody explain to me why, exactly, nationalization has seemingly become The Vehicle for a healthcare system?

    First, a clarification, nobody is seriously considering truly “nationalized” health cara a la Great Britain, wherein the government directly controls the medical deliver systems, the doctors, hospitals clinics, &c.

    I personally favor a “single-payer” system where all citizens are included in the same risk-pool, and where instead of payments to private for-profit insurance companies, fees are paid through (sorry polimom, I know for Texans it’s a four letter word) taxes on all citizens, and private service providers bill the administering government agency for services renedered.

    If you think about it as replacing the myriad private insurance companies with one large non-profit insurance company you’ll get the proper perspective.

    Another key point is that such a system would be mandatory insofar as that it would require everyone to pay into it. Which is not to say that everyone would have to use it, the rich could still buy more services, or faster, but it would provide a baseline for service to everyone.

    Advantages:

    A vastly larger risk pool. One of the problems with the current system is that it allows younger, healthier workers to opt-out. By spreading the risks to a much larger group of insured (everyone in the country) the cost per person would be dramatically reduced.

    Efficiency. I know this is tough for the anti-government types, but the duplication in beauracracy and paperwork involved in the current system is crushing. In fact a 2004 study by researchers at Harvard Medical School and Public Citizen shows that a singlepayer system could save an annual $286 billion.

    Portability. This should be a selling point to you free-marketers out there. The current system inhibits the rational flow of labor because some workers are obliged to stay in jobs they would not otherwise simply because their empoyer offers medical coverage. To limit such flow within state borders makes no more sense than would limiting the flow of goods.

    Competetiveness. In yet another bone for the freemarketers here to gnaw on, as has been increasingly noticed by US industry, in a global marketplace where many of our major competitors provide their own versions of nationalized healthcare, US companies, having to either provide such coverage, or risk worker attrition to those who do, are at a competetive disadvantage.

    I suppose i could say more, but I have to get to work. My company provided coverage doesn’t pay for itself y’know.

    Cheers, and thanks for a great discussion.

  27. Citizen Kang said:

    > First, a clarification, nobody is seriously considering truly
    > “nationalized� health cara a la Great Britain, wherein the
    > [federal] government directly controls the medical
    > deliver[y] systems, the doctors, hospitals clinics, &c.

    This is exactly what is being sought by many here in the USA. And this neglects the typical (zero-value) arguing point raised, that the federal government doesn’t necessarily own these things nor make doctors, etc., employees of the federal government. This is irrelevent. What matters is not ownership (be it only nomiinal in practice, or still the real thing), but control.

    “HillaryCare” was federalized health care, the Conyers bill is federalized health care, Physicians for a National [sic; Federal] Health Plan wants government health care, and the Conyers plan even has the federal government take over some facilities.

    > I personally favor a “single-payer� system

    That is weasel language. Who is the payer? Who is the monopoly you have in mind?

    > where all citizens are included in the same risk-pool,

    (“community rating”)

    > and where instead of payments to private for-profit insurance companies,
    > fees are paid through (sorry polimom, I know for Texans it’s a four letter
    > word) taxes on all citizens, and private service providers bill the administering
    > government agency for services renedered.

    That is the typical government health care scheme favored by many. By preserving (nominal) private status of the providers, junk lawsuits can continue to feed the lawyers.

    > If you think about it as replacing the myriad private
    > insurance companies with one large non-profit insurance
    > company you’ll get the proper perspective.

    Improper. As with Social Security and Medicare, it is not insurance, for growing old is not something that can be and normally is avoided, and preventive care is not the same as treatment if one is ill.

    > Another key point is that such a system would be mandatory
    > insofar as that it would require everyone to pay into it.

    Naturally, However,

    > Which is not to say that everyone would have to use it, the
    > rich could still buy more services, or faster, but it would provide
    > a baseline for service to everyone.

    Those who could do better outside “the system” would go outside the system (particularly in order to avoid waiting for services). Once people start going outside the system, they will reduce support for the system and be less motivated to pay for the system. Thus, typically the schemes that are proposed prohibit the private duplication of government-provided services. The proponents have thought ahread. Universality is a must, or more and more people will have less and less support for the government system as they leave it and desire less to fund it.

    “As in the Medicare program, private insurance duplicating the public coverage would be proscribed.”

    “Private insurance that duplicates the NHI coverage would undermine the public system in several ways. (1) The market for private coverage would disappear if the public coverage were fully adequate. Hence, private insurers would continually lobby for underfunding of the public system. (2) If the wealthy could turn to private coverage, their support for adequate funding of NHI would also wane. Why pay taxes for coverage they don’t use? (3) Private coverage would encourage doctors and hospitals to provide two classes of care. (4) A fractured payment system, preserving the chaos of multiple claims data bases, would subvert quality improvement efforts, e.g. the monitoring of surgical death rates and other patterns of care. (5) Eliminating multiple payers is essential to cost containment. ”

    http://www.pnhp.org/publicatio.....urance.php

    “Private health insurers shall be prohibited under this act from selling coverage that duplicates the benefits of the USNHI program. Exceptions to this rule include coverage for cosmetic surgery, and other medically unnecessary treatments. ”

    http://www.house.gov/conyers/news_hr676_2.htm#4

    1 SEC. 104. PROHIBITION AGAINST DUPLICATING COVERAGE.

    2 (a) IN GENERAL.—It is unlawful for a private health
    3 insurer to sell health insurance coverage that duplicates
    4 the benefits provided under this Act.

    5 (b) CONSTRUCTION.—Nothing in this Act shall be
    6 construed as prohibiting the sale of health insurance cov
    7 erage for any additional benefits not covered by this Act,
    8 such as for cosmetic surgery or other services and items
    9 that are not medically necessary.

    http://frwebgate.access.gpo.go.....ih.txt.pdf

    “The new advocacy group, Canadian Doctors for Medicare, [...] Chair, Dr. Danielle Martin, says a ‘duplicate system is basically anathema to Canadians.’ The paper itself concludes that in countries with a parallel private system, access is increased for a very small number of people but “significantly compromises access for everybody else.’”

    http://www.cmaj.ca/cgi/content/full/175/1/18-a

    “The Chaoulli decision opens the door to duplicate private health care insurance not only in Quebec, but also in some other provinces, notably Alberta. Duplicate private insurance is currently permitted in Australia, New Zealand and the United Kingdom. Such insurance, combined with doctors’ ability to engage in dual practice (that is, to work in the publicly funded system while at the same time practising in the private sector), has encouraged the development of a viable parallel private system for health care in these three countries. Duplicate private health care insurance has brought two substantial benefits: a wider choice of providers and faster access to care for those who can afford private insurance; and additional funding for capacity development in the hospital sector. At the same time, however, it has raised concerns about inequity of access and length of waiting times. It may be useful for Quebec and the other provinces to examine the lessons learned from the experience of Australia, New Zealand and the United Kingdom in order to maximize the advantages offered by duplicate private health care insurance.”

    http://www.parl.gc.ca/informat.....conclusion

    > Advantages:

    > A vastly larger risk pool.

    A larger pool of revenue payers as well as beneficiaries.

    > Efficiency.

    So it is claimed.

    > Portability.

    No doubt, especially if a federal program. This is the big seller. Few people stay long in one place any more.

    > Competetiveness.

    As long as the money’s not misspent somewhere else.

  28. Going back to the origins of why we are even talking about a national health care plan, we have to address the case of the currently uninsured.
    They are the poor, the young who choose to opt out and those who are priced out. These are people we are trying to bring into the system. If any of you have suggested a way to do that without involving the feds, I didn’t see it.

    As I see it, we are talking about an area that the market system can not address by itself.
    Many of you point out that governement programs are no good because of inefficient bureaucracies. So, private insurers can’t solve the problem, and government shouldn’t solve the problem.

    I hope you are not saying to forget about it, because as things are, you are already paying for the uninsured. When someone goes to an emergency room for a minor problem, you end up paying for it. It drives up prices and drains the resources of local communities, etc. You pay for a lot through Medicaid, too.

    We are not starting at zero cost to everyone. So, the resistance to looking for a way to spread the cost more inclusively and equitably is beyoind my understanding.

  29. Citizen Kang –

    Thanks for the detailed comment.

    The portability, and a greater risk pool, are elements that don’t require full nationalization, of course. Nor am I at all averse to paying (in the form of taxes) for healthcare. (No time like the present to mention that because I’m living here doesn’t make me a Texan. LOL)

    DLS — the links are helpful, too. However, we’re going to have to do something, ultimately, to solve this. There’s too big a net needed, and it’s likely that federal distribution of taxes — whether as payer (clearly not my preference), or as distributor to state / regional payers (better for me) — will have to be a component. Using FEMA was an easy example, but there are many, many more examples of ineptitude.

    Unfortunately, there are a number of states that come to mind that could conceivably handle things worse than the feds — hardly an improvement for their residents.

    Obviously I wouldn’t have asked the question if I didn’t have massive reservations — but I didn’t ask it idly, and I appreciate all of the feedback, very much. It’s a complex, but critical, issue.

  30. Citizen Kang has explained what’s called the “adverse selection” argument in favor of single-payer extemely well. Thank you (it’s why I’ve favored a single-payer system for 30 years).

    My own feelings about the proper strategy in healthcare reform is that, while single-payer is probably necessary, it isn’t sufficient and that in all likelihood we’re only going to get one bit at the healthcare reform apple this generation so we’d best be careful in getting everything we need this time around.

    Higher insurance administration costs aren’t the only source of the rise in healthcare costs. Unless rising costs is addressed beyond just reducing administration costs within a very few years we’ll be right back in crisis mode.

    Back to the fully nationalized medicine question. One of the reasons a fully nationalized healthcare system is impractical for the United States is that, unlike France, Germany, or the United Kingdom we have a very large, effectively open border to our south and commensurately high immigration rates. No country, including the United States, can afford both open borders and a nationalized healthcare system.

  31. [D]omajot wrote:

    > They are the poor, the young who choose to opt out
    >and those who are priced out. These are people we are
    > trying to bring into the system.

    Those who choose to opt out must be brought in against their will.

    > I hope you are not saying to forget about it, because
    > as things are, you are already paying for the uninsured.

    Not at all. (Not forgetting about it, that is.) Universality (effectively “community rating” if thiis actually were insurance) llowers the costs and makes them in large part external (or hidden) as well as reduces them on a per capita basis. That is one appealing argument in favor of government heallth care (for all citizens*).

    In fact, in theory it’s to my advantage to go with a government program because otherwirse I’d be denied or priced out of insurance. (I have been denied sometimes, and priced out in other cases. An example: mid-700 dollars per month for individual policy full of riders and exclusions and exceptions, and otherwise being denied insurance, to me,prices me out of staying in a certain location. I left that place.)

    * I said “citizens.” Illegal aliens don’t deserve the same kind or level of treatment.

  32. Polimom said:

    > DLS — the links are helpful, too.

    They point to places that can do a better job than I of exemplifying or explaning things.

    > However, we’re going to have to do something,
    > ultimately, to solve this.

    I predict federal health care provision within ten years (if not less) and in the longer term, strife as cost controls need to be imposed and we see rationing of care openly based in some cases on costs and on rationalization of this practice by academics glibly discussing “quality of life” and “best use of scarce resources.”

    > There’s too big a net needed, and it’s likely that
    > federal distribution of taxes — whether as payer
    > (clearly not my preference), or as distributor to
    > state / regional payers (better for me) — will have
    >to be a component.

    Agreed. The feds already assist with Medicaid and the states are demanding more federal funds for health care-related assistance as it is already.

    > Using FEMA was an easy example, but
    > there are many, many more examples of ineptitude.
    >
    >Unfortunately, there are a number of states that come
    > to mind that could conceivably handle things worse than
    > the feds — hardly an improvement for their residents.

    Every liberal at this very moment is screaming the T-name at you. (Vague Hint: Lone Star)

    With the hurricane, look at Louisiana and the city of New Orleans, for example.

    In addition to ineptitude, you’ll see a “magnet” problem if some states create health care plans that do become an attractive alternative to people elsewhere. As you may know from legal cases involving California, the states cannot disciminate against new residents from elsewhere by treating them differently when it comes to government beneifits. (That should also apply to other inequities of old vs. new residents, but I’ll stick here to health care and other welfare programs.) If states that can afford to attempt the programs and want to, do well, they’ll risk being swamped by new residents (or even new busiinesses if the plans make the businesses more competitive).

    Then, of course, if there are pull factors, other states (Texas?) might be motivated to suggest that people on welfare go elsewhere and get health care as well as better welfare payments if they want them.

  33. It was said:

    > No country, including the United States,
    > can afford both open borders and a
    > nationalized healthcare system.

    Careful. Now you’ll be called a “racist” even though adding health care to welfare benefits for all makes the USA an even bigger magnet (and tells the Mexican government we are an even better “safety valve”) and obviously would result in a cost increase.

  34. Well, just about every dire result possible has been mentioned within this thread. The way I see it, we have to start somewhere and adjust what we can as we go along. Let’s face it, the perfect solution to suit everyone is not going to happen; that’s something we have to face.

    Oddly, none of the doomsayers mentioned the two things that concern me the most.

    The first is preventative care (this may have been mentioned). It’s a low investment plan that can really reduce overall costs. Currently, it has low priority among insurers, especially when it comes to mental health.
    Again, we save pennies today only to pay mega bucks further down the road.

    The second is technology. This is usually cited as cost reducing, but I think it has a problematic side, as well.

    As new procedures are developed, the pressure starts to make them available to everyone. Every new invention creates an automatic market for it in exactly the same way that every new drug gets a ready-made eager consumer public.

    New technologies also extend life in both directions. Premies can be saved at earlier stages of develpment, but they often require extra medical care for years.
    On the other end, life can be extended by medicines and procedures to new outer limits of old age.

    Extending life in both directions has cost implications that no one is addressing. I’m sure I’ll be called a ghoul for even bringing it up. In fact, I’m as thrilled about new developments as anyone. But then I wonder: what will be the consequences, and does anyone have a plan to deal with them?

  35. Today I heard on the news about a report that says that when analyzed honestly administrative costs eat up 30% of health care dollars in the private sector in the U.S. The representatives of corporate medicine scream loudly denying it, of course.

    If my employers went three months without paying their bill for health insurance I’d lose my insurance. The insurance companies consider it SOP to take two or even four times that amount of time to pay doctors and hospitals. They don’t care if the bills get turned over to collections. They don’t care if the insured people can’t afford it and their credit rating is destroyed. None of that matters, only the profits to make Wall Street happy. Any actions can be rationalized in the name of stakeholder value. To show that you are serious about preventing specious claims being paid out you will spend more money on paperwork and multiple inquiries than you actually would lose by paying the claims. It goes on and on and on and the corporations involved show no signs of being interested in fixing it, just in maintaining the status quo so long as it means profits for them and good pay packages for the people in charge.

    I’ve dealt with both government systems and private ones. The government one was better in my experience. I have no doubt that others would have anecdotal evidence to the contrary. Not only would Texas do an abyssmal job in running a state based system but I have no doubt that my native Missouri, should it remain governed by the idiots currently in charge would do no better. Why? They don’t want to. I agree with the belief that when people who blame government for our ills or who have already decided that it is completely impossible for government to work well are in charge they will create a self-fulfilling prophecy. See the current administration for a sterling example.

    My suggestion would be for a non-profit corporation that would receive subsidies from the government and charge for insurance/care on a sliding fee basis. Think about the Post Office, the Federal Reserve or other institutions. Companies could help cover costs for employees but if someone loses their job they wouldn’t lose the ability to afford health care as well. It would also actually try and encourage research to look for ways to reduce costs. And something that just occurred to me is that perhaps they might be able to help single doctor practices be more economically viable, helping provide care for rural areas.

  36. Polimom,

    Quite the discussion on this topic. There seems to be a whole lot of ideology (egrubs preference notwithstanding), a whole lot of “faith”, and a whole lot of “selling” of preferred solutions. At the risk of taking the thread off in a whole different direction let me add my two cents.

    There are indeed many problems with our current health care system, but it is hardly so dysfunctional that we must throw the whole thing out and slap in a wholly different system–government run and/or paid for or not. There is also much worth preserving.

    Lynx said:

    “I’ve never read anything to show me that Americans pay less for healthcare or are on average healthier than economically equivalent countries WITH nationalized healthcare.”

    Lynx is not reading the right material. There is a vast body of literature describing the benefits of our decentralized, mostly private sector (i.e. doctor and insurance company) driven approach. Benefits include early (often first in the world) access to new drugs, surgical procedures, tests, and diagnostic equipment (think CAT scans and MRIs). Innovations diffuse relatively quickly in the US because of the competition between doctors, hospitals, and payers, and because we lack a single gatekeeper who decrees what is and is not “acceptable”. (The presence of a single gatekeeper for Medicare is one reason medical innovations are often made available to those over 65 years later than to those in private health care.)

    Before we throw away what we have, perhaps we should consider what would be needed to fix it. After all, the Pareto principle suggests that 80% of the problems might be fixable for 20% of the cost of fixing them all. So what are the major problems?

    Litigation: As discussed, our legal system is driving ever higher malpractice insurance rates and much medically unnecessary testing. Both increase the overall cost of medical care. Tort reform is an essential component of any health care reform. Going into this one in detail is another topic for another day. (Personally, I favor the Shakespearean solution, but that’s just me . . . )

    Uninsured/Underinsured (Part 1): As Dave Schuler pointed out, the problem is not evenly distributed across the country. A disproportionate share of uninsured people live in the (southern) border states. Controlling the border is yet another Federal responsibility done badly. (Add it to FEMA, Amtrak, the Post Office, etc. as another exhibit against entrusting the Feds with our health care system.)

    Uninsured/Underinsured (Part 2): Many of the uninsured are so because they are too poor to pay the premiums. For them, government assistance could be provided, either Medicaid or a basic private sector insurance policy voucher. It works with food stamps, why not health insurance? Those who are uninsured by choice, e.g. illegals, or 23 year old males who just know they are immortal, don’t have a problem. They have made a bet, and in any given year most of them will win it. Those who don’t will acquire rather large medical bills. Why should society cover their bet if they lose? Perhaps if they actually thought they might have to bear the consequences of losing the bet, they would bet differently.

    Uninsured/Underinsured (Part 3): Some say that the young and healthy must be coerced into a mandatory system and charged more than their health needs require in order to subsidize the older and less healthy. Why is that? Where is it written in the Constitution that the young and healthy owe a duty to subsidize the old and unhealthy? Or for that matter that the childless must subsidize other people’s children? Young workers are already getting the shaft on Social Security, are first in line to fight wars (at least if the likes of Rep. John Conyers manages to reinstate the Draft), and typically, start their adult life journeys’ with nothing–or with big college debts. Now they must be coerced into subsidizing their elders health care, too? Are they people or cows to be milked? (Hint: They get to vote, too!)

    Administrative waste: This is one cost that would be reduced or (possibly) eliminated if a single payer/provider system were imposed. If there were a common process for acquiring health care services, gaining approval, documenting what was done, etc., the savings would be vast. (Some of the savings might be offset by the inherent wastefulness of a monopoly, but let’s ignore that possibility.) Interestingly enough, inefficiencies exist not only on the payer side but also on the medical treatment side. The absence of a common format for medical records is a major cost for doctors and hospitals. Each hospital loves it’s own forms, procedures, and record keeping standards. This decentralization (fragmentation) does not serve the patients or the overall health care system well. However, imposing a government run system in its place is hardly the only solution. Much could be accomplished with government encouragement (or mandates) for medical record (and insurance claims processing) standardization.

    Like you, I don’t understand the rapturous enthusiasm for a government run replacement for our current health care system. Surely if we address the top 5-6 root causes of the problems with today’s system, we can keep the advantages it provides, while reducing the disadvantages?

    I’d like to think so, but maybe its just my ideology.

  37. What I don’t get is why it is considered ideological to ask to examine the actual flaws of the current system and see if they can be fixed without scrapping the system and starting over, but it’s not ideological to say that the current system isn’t working and therefore that proves that the public sector can do it better than the private? Who’s really being ideological here?

    Wilky gives an excellent discussion of the current problems, and almost none of these things would be likely to improve under a govt operated healthcare system. Those who have a kneejerk reaction to problems by saying that costs can be contained simply because the govt will cap prices are ignoring the realities of economics. If you take that approach, then something has to give. Set limits to spending and you are limiting the supply of healthcare; most Americans will not stand for that and will be unhappy with the results. But if the govt then tries to give Americans what they want (we want the best currently available medical treatment, plus innovations for new emerging diagnostic and therapeutic options, and we want it accessible when we want it and we want it for everyone, rich or poor; oh, and we also don’t want to limit awards for malpractice), then we’ll bankrupt the nation with the rising costs (particularly with our aging baby boomer population.)

    I think a key issue that’s overlooked when people say “It’s working in Europe, so why not here?” is that Europe’s system is able to benefit from the innovations of the American healthcare system. And again, if the US decides to go with a publicly run healthcare system, we’ll have to cap costs in some way which removes some of the profit margin that drives innovation. Of course, we might never know what new medicines might develop under a private healthcare system and not under a public one, but I think what we’d see over time is that we’ll no longer be making the medical advances in leaps and bounds as we’ve done for the past few decades.

    And Lynx, this is the crux of my argument about the qualitative differences between education and healthcare. We can accept a finite product for education and limits between what is govt provided for all vs. the extras that can be afforded by the wealthy. I don’t believe that we’re willing to accept those limits in healthcare and I think that a public sector system necessarily has limits.

    Don’t get me wrong though, I know there are serious flaws with the current system and I want to expand coverage for the poor. I think as wilky does, that this should be done via insurance vouchers for the poor. I also see a few other areas that could be fixed that wilky didn’t mention: expand the supply of physicians by allowing physican’s assistants to do more preventative and general healthcare, and by increasing enrollment in medical schools (some ideas here would include govt investment in the medical education system as well as govt grants for med students). And, portability of medical insurance would be very helpful and could be improved by one simple step: make individual health insurance premiums 100% deductible from personal income tax as it is for employers. Then if you aren’t happy with your employer provided policy or if you change jobs, you could shop for an insurance policy on your own and still purchase it with pretax dollars (I think that Polimom has discussed this idea in her previous posts).

    Having said all of that, I’ll also add that if govt healthcare is an inevitability despite all of my arguments against it, then I hope that we at least leave it decentralized instead of putting it under a federal umbrella.

  38. Domajot said:

    > Extending life in both directions has cost implications
    > that no one is addressing. I’m sure I’ll be called a ghoul
    > for even bringing it up.

    Not true. You’re not a ghoul (finances will always be finite, i.e., limited) and I have addressed this already:

    [activists will say] there is too much specialization, too much technical overinvolvement in medicine, too much effort (and money) being spent at the end of one’s life. You will see a pushing for “mercy killing� [sic], i.e., euthanasia, and an increase in its use in scope as well as frequency.

  39. Domajot said:

    > Oddly, none of the doomsayers mentioned the two things that concern me the most.

    Okay. Now I understand. Provided you were serious, you didn’t refer to what I wrote because I’m not a doomsayer.

    > The first is preventative care… The second is technology.

    “Those who want government health care (often using the dishonest, evasive term “single-payerâ€? instead) rather than private health care claim that private care is unaffordable, they object to game-playing by insurance companies (which is all too real, too often), or object to what is in their view less than ideal or dreamlike about health care, with “costly duplicationâ€? of expensive services, not enough preventive care (though those most in need of it avoid it even when it’s provided), pay to health professionals and others in the field is “too high,â€? and so on. ”

    “[activists will say] there is too much specialization, too much technical overinvolvement in medicine, too much effort (and money) being spent at the end of one’s life. You will see a pushing for “mercy killingâ€? [sic], i.e., euthanasia, and an increase in its use in scope as well as frequency.”

  40. CS,

    Show me some evidence that the existing system is actually capable of meaningful reform without the corporations screaming to high heaven about government interference since it’s blindingly obvious that they are only interested in taking baby steps that won’t really fix anything but provide some PR value. Vested interests have no interest in fixing the problems because they don’t affect them personally.

    As far as the idea of tax deductibility being enough to take care of portability why is it that some people can’t seem to grasp the concept that many people make so little money that a tax deduction or some other game with taxes does nothing for them in terms of being able to pay that monthly bill?

  41. The Master said:

    > Where is it written in the Constitution that the
    > young and healthy owe a duty to subsidize the
    > old and unhealthy? Or for that matter that the
    > childless must subsidize other people’s children?

    Nowhere. The losers will mis-cite the “general welfare” clause (which imposes restrictions on the power to levy taxes that Congress has been granted) and the worse-than-losers will mis-cite the Preamble.

    > Young workers are already getting the
    > shaft on Social Security, are first in line
    > to fight wars (at least if the likes of Rep.
    > John Conyers manages to reinstate the
    > Draft), and typically, start their adult life
    > journeys’ with nothing–or with big college
    > debts. Now they must be coerced into
    > subsidizing their elders health care, too?
    > Are they people or cows to be milked?
    > (Hint: They get to vote, too!)

    I have warned people before that eventually (10-20+ years from now) the taxpayers will rebel. Politicians are going to have to arbitrate and reconcile among two choruses of howls, the beneficiaries demanding ever more, and the taxpayers objecting to the excess and demanding relief.

    And if we introduce federal health care for all — we’ll probably need an all-new tax such as a VAT or a tax on motor vehicle fuels, the latter of which will outrage the western states. We may also see wealth taxation and an increase in the practice of “estate recovery” by government, which won’t be welcomed, either.

    Side note:

    Note the bitter irony and moral failure in the existing welfare programs. Those who have saved and lived their lives right must spend themselves down into poverty before they may be beneficiaries. Those who have not saved, lived badly, qualify promptly. This — ironically — can be used by universality proponents as an additional means of convincing voters to include everyone as beneficiaries. “If you’re paying for it, you deserve to benefit from it more than anyone else!”

  42. Jim,
    It’s up to voters to force the politicians to make policy changes that would fix the system even if special interest groups complain. To take just one example, trial lawyers aren’t going to voluntarily start seeking lower claims in order to lower malpractice costs, but legislators can and should impose tort reform.

    And my comment about tax deductibility of individual health insurance plans was that equalizing the deductions for personal taxation and business taxation would help because the whole marriage of insurance and employment began when the tax law was written to favor it. Businesses began offering health insurance as a perk because it could be payed with pretax dollars, so that the employer can give something 100% to the employee without Uncle Sam taking a cut. If people could purchase their own plan instead and still deduct the whole cost, then they’d be able to also purchase with pretax dollars but they’d have more choice in the matter (thus allowing for competition which insurance companies would have to respond to in order to keep customers).

    I didn’t say that this would make health insurance affordable to all, and I already stated that those who make too little money to afford it should be given vouchers by the govt.

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