I was pleased to see president Obama deliver this address yesterday:

I was even more pleased because he has gathered the traditional opponents of healthcare reform around him and has convinced them to commit to reform in the US system. This is a positive sign. However, I’m concerned because, as with all political debates that challenge a dominant ideology – in this case free-market fundamentalism – we will soon see the denialists come out of the woodwork to disparage any attempt at achieving reforms that may result in universal health care coverage. This has, in fact, already begun, and typical of the tactics they selectively mention the British NHS. If you care to read a balanced article on the history and function of the NHS, you’ll probably agree it is wrongly demonized. What you will also see is that the denialists will ignore a few key facts which include:

1. The United States is the last industrialized nation that lacks a universal healthcare system. Once again, thanks to obstructive policies led by the free market fundamentalists, the US is trailing the rest of the world.
2. The US spends more per capita on healthcare than any other nation in the world.
3. Despite spending more, we get less. We have tens of millions who are uncovered – which does not mean they do not receive healthcare at all. They instead are treated in ERs, urgent care centers, or receive substandard care, and the state ends up picking up the bill anyway. So even without a planned universal health care system, you end up picking up the (higher) bill because the state has a vested interest in protecting hospitals from the economic collapse that would occur if they had to pick up the tab on every impoverished patient who doctors are ethically and legally obligated to treat.
4. Many national healthcare systems work. We will not hear about this from the ideologues who will soon harangue us with cherry-picked horror stories of long wait times and underfunded hospitals. You will likely not hear about Sweden or Italy or France, and I promise you will never hear them talk about Australia. For them to do so would be to admit to defeat of their fundamental premise that universal health care can not work.
5. Failures of national health systems are not related to universality but instead are due to chronic underfunding by government. If the British spent as much per capita as we did, they wouldn’t have the shortfalls in manpower and beds that they do.

We will of course hear a lot of chest thumping from the thick-browed morons about how the US is already perfect and can not learn anything from the rest of the world. We will hear how every other system in the world is imperfect, and that is why any reform is impossible. We will hear how this will lead to communism and socialism despite the fact that every other industrialized nation in the world has universal healthcare and amazingly they didn’t all go commy. In short, we are about to hear a bunch of denialist garbage designed to delay, to obstruct, to block, and drag down any meaningful action in healthcare.

But before that happens, let’s have a more balanced discussion on what a universal healthcare system could look like in the US.

Any discussion of changes in the US medical system must begin with a statement of principles guiding reforms in the system. Let’s start with some of the principles I would include, and I think most of us could agree on:

1. Universality: The major obstacle currently facing US medical care is 47 million uninsured, a proposal for reform must begin with a plan for universal coverage. Access to primary care is cost-effective and must be the basis for a medical system designed to serve the needs of the populace as well as to serve as the gateway to specialized services.
2. Health Care Reform: Health care can not be sustained with expensive interventions, tests, drugs, inefficient administration, and treatment protocols which have limited evidence of efficacy. There would need to be a reform of medical practice, ICU and end-of-life care, compensation for medical errors and patent law to prevent excessive costs of drugs. Finally, an emphasis on “best practices” must guide medical intervention as health care must be based on the best available science in order to be efficacious and efficient.
3. Portability: Health care must be available to individuals regardless of employment status, is consistent with the mobile culture of the US population, and allow for easy sharing of medical information between providers.
4. Justice: Health care that is universal must also endeavor for just distribution of resources, and address disparities in health care.

Universal health care in the US faces obstacles of expectations of patients for high quality care, and excessive expense from high tech modalities and testing. However, an inexpensive baseline of care should be available to all consisting of primary care, prevention, and treatment of chronic conditions that will save costs by preventing over-utilization of ERs and emergent treatment of preventable medical conditions. Ideally, a government-administered insurance program would be created with a progressive premium structure based on individual income. Low income subscribers would be subsidized by the government based upon income similar to the Massachusetts system. Patients could either pay, based on a progressive scale, for governmental insurance plans tailored to individual needs, or opt out/expand their coverage using a private insurer. Governmental insurance, which historically has lower administrative costs, could then compete with private insurance to decrease costs at the same time high-quality care is provided. Universal insurance would also have the advantage of increasing the pool of subscribers. Requiring uninsured who can afford health care to buy into the system would help to decrease premiums overall. Further, it would test the accepted wisdom that privatization is superior to governmental programs. If the governmental programs are indeed superior, then they will naturally evolve to replace private insurance for most patients’ needs. Finally, a government-administered program would have the advantage of increased accountability through transparency and input through the political system to address inequalities and deficiencies in care.

Affordability of such a universal system is problematic in the United States considering the current cost of medical care in the US which is not currently commensurate with quality based on international surveys of medical systems. The major obstacles to affordability include costs of pharmaceuticals, cost of malpractice insurance, use and overuse of expensive imaging modalities, excessive costs of care at the end of life, and inefficiencies in medical administration increasing overhead costs.

The first step in addressing affordability would be reform of the patent system. Currently, drug manufacturers are able to patent drugs which don’t represent significant innovation over previous chemicals. Incentives must be created to restore a pattern of drug innovation in pharmaceutical R&D, and appropriate use of pharmaceuticals by the population. First, all direct to consumer advertising must be banned, as it is in all other countries, to prevent the irrational over-utilization of pharmaceuticals, disease-mongering by pharmaceutical companies, and promotion of more expensive brand-named drugs over more inexpensive, and sometimes superior alternatives. Second, the patent system must be reformed to create graded-levels of protection for new pharmaceuticals based on the level of innovation the drug brings to the market. New classes of drugs would enjoy the longest protection from generic competition (20 years). Sibling drugs would enjoy shorter protection (5-10 years), and preparations which are combinations of existing drugs (e.g. hypertensive combinations), purifications of existing drugs (e.g. Nexium), or using existing extended release technology will not enjoy patent protection and may be made by generic manufacturers.

Malpractice insurance is a source of great expense for physicians, increasing overhead and failing to resolve disputes between patients and doctors in a fashion that is satisfactory to patients, physicians and society. While lawsuits for negligence or misconduct should be allowed to protect patients from harm, lawsuits for expected complications and other negative outcomes of medical care that is standard of care should be discouraged. This could be done by creating victim compensation funds that are funded by a surcharge on medical care commensurate with the known risks and expected costs of complication of medical interventions. Thus when more complicated and risky procedures are performed, the expense of insuring for negative outcomes would be built into the cost, and access to the compensation fund would then require a patient to waive their right to pursue compensation in court. This would help shift the burden of cost of medical complications off of doctors and the legal system, decrease costs by avoiding expensive litigation and legal fees, and prevent adversarial interactions between patients and the medical system.

ICU and end of life care is a leading source of waste in medical expenditures, but reform is complicated by the inability to predict when medical care is truly futile, and issues of equality and justice in the provision of medical care. However, significant reductions in overuse of medical care at the end of life could be obtained by increased patient education, the requirement of patients in a universal system to provide a living wills, and better adherence to evidence-based guidelines in ICU care. Unfortunately, extended ICU stays and aggressive interventions at the end of life have become a routine part of the process of dying. Public education about the reality of end-of-life care could create awareness of the invasiveness, pain, cost and frequent futility of extensive ICU stays. While many patients feel it is their obligation to “do everything” for their loved ones, a better understanding of the pain, indignity, and reasonable expectations for improvement involved in intensive care may help people avoid medical interventions that are futile. Further, a universal health care system, combined with the electronic medical record, will allow for universal application of living wills, and more time for patients to discuss with their physicians and decide what kind of interventions they want at the end of life.

Higher emphasis on evidence-based guidelines on the efficacy of interventions in different populations will provide physicians with higher quality information on when medical care is appropriate or futile in the treatment of patients near the end of life. Universal healthcare, and electronic medical records, will facilitate the collection of such data, and help ensure its application in ICUs. However, physicians also have a professional responsibility to decrease useless and redundant testing and prevent overuse of expensive imaging modalities when the results will not impact treatment decisions. This must not be accomplished using the current insurance company method of creating punitive paper work or peer consultation that places physicians in the position of begging for permission to use their medical judgment. Instead, guidelines on when imaging modalities and labs are appropriate and useful must be generated and physician use or overuse of resources should be monitored with possible remediation if poor use of resources is suspected.

Importantly, a standardized, universal electronic medical record (EMR) must be created that will allow physicians to easily share information, protect patient confidentiality and maintain integrity and high information quality. The government does not need to mandate a single front-end service to access such records, but, a panel of medical and software engineering experts should be convened to decide on a universal standard for storage of medical information in a single database. A record must be designed that would allow multiple programs to interpret the records so a competitive market of software designers could create a variety of efficient and user-friendly systems, differential access based upon need to access the information (administrators and insurers would have limited access to private data, physicians full access), and a high-level of data encryption and protection of private information, a high level of data integrity (a tiered system of access for correction/modification of the record to prevent errors). This is similar to the successful model previously used by the government for the searching of SEC records by law firms using private software such as that designed by Thompson, Lexis, and EDGAR to access a government database with uniform record design. Finally, this record must be transparent and programs designed for the records must agree to be open access as “there is no security in obscurity”. EMRs, well-applied, would decrease the cost of medical administration, decrease overhead, prevent errors, allow for better data-mining for scientific study, and make transfer of information between providers more efficient.

Portability of medical care must be ensured as the culture of the US is highly migratory. Not only do US citizens typically change jobs frequently, but they rarely stay in the same state or region of the country for their entire lives. Medical care must be ensured despite employment status, or region of the country in which the patient lives. The EMR is critical for portability, as is universality.

Finally, the principle of justice must be applied to medical care as the United States still struggles with inequalities among healthcare for its citizens related to race, sexuality, and poverty. Provision of care must be decided based upon science and evidence, but also must be monitored for just allocation of resources, and disparities in access and quality of care. The nature of political systems is to reward those who are politically powerful. In this country that would tend to generate a system designed to benefit wealthy, older, white men. Thus before a system is even implemented it must be studied for the differential impact of resource allocation for women, minorities, homosexuals, and immigrants. One must approach the application of medical care with the realistic expectation that inequalities will inevitably be built into the system. Such inequalities must be constantly sought out and corrected, ideally with an independent panel of experts consisting of physicians, legal experts, bioethicists, and community leaders that will monitor and address such inequalities when they arise, not if they arise.

Comments

  1. #1 Interrobang
    May 12, 2009

    You’ll also never hear the UHC opponents (or pretty much anybody in the US) talking about Canada’s system, except to perpetuate the same tired canards and gross falsehoods. (They sure do love to compare wealthy urban US patients to Canadian patients who live so far north their communities don’t have road addresses; they have map designations, and the only way in or out is an airstrip. I only wish I were making that up.)

  2. #2 Zeroth
    May 12, 2009

    A very thorough outline. The problem is many of those things would be implemented half-heartedly, and so it would fail. The free-market fundamentalists have been so loud and pervasive, that even here in Canada, we think there’s something wrong with our health care system. Thanks to Sicko(despite a lot of the mistakes in it), people are changing their minds on our system.

    My favorite thing to do when debating(hopefully publically) a free-market fundamentalist, is to ask about Britain’s Industrial Age, with laissez-faire economics applied, what happened? Child labor, consistent abuse of people of all ages, poor medical care, poor products… and so on. The free-market makes things worse, just makes the divide wider. I haven’t met a fundamentalist yet that has an appropriate answer beyond that it wasn’t free-market fundamentalism because they didn’t have advanced economic knowledge then. (Moving the goalposts!)

  3. #3 D. C. Sessions
    May 12, 2009

    Importantly, a standardized, universal electronic medical record (EMR) must be created that will allow physicians to easily share information, protect patient confidentiality and maintain integrity and high information quality.

    I have yet to see a public discussion of EMRs that addresses the fact that these objectives involve tradeoffs. In particular, “easily share information” is in direct tension with “protect patient confidentiality.”

    Obviously, it’s possible to screw up on multiple fronts: a system that blocks collaboration while leaving patient data unprotected. It doesn’t follow that we can have the best of both.

  4. #4 Brian D
    May 12, 2009

    I would be wary of any Republican being ‘convinced’ on healthcare reform, simply because that’s exactly what Frank Luntz told them to say. We’re still dealing with the messaging fallout of his environment memo after several years of inaction and an administration change.

  5. #5 jacksmith
    May 12, 2009

    PRIVATE FOR PROFIT HEALTHCARE IS AN OXYMORON!

    As congress debates fixing Americas current private for profit healthcare disaster, global embarrassment, and national disgrace. The question is not weather we will have a public option. But rather what kind of public option we will have.

    America is the only country in the developed world that has a GREED DRIVEN! PROFIT DRIVEN! IMMORAL! UNETHICAL! PRIVATE FOR PROFIT! healthcare delivery system.

    As a result, hundreds of thousands of you are needlessly killed by your healthcare delivery system in America every year. And millions of you are crippled and injured. America is the only country in the developed World that does not have a NOT FOR PROFIT, PATIENT PROTECTING, government managed healthcare delivery option for all it’s people.

    America currently has the most costly health care system in the developed world. And the lowest quality of healthcare in the developed world. And the most dangerous, deadly, and FEARED! healthcare delivery system in the developed world.

    America is the only healthcare delivery system in the developed World that does not cover all it’s people automatically. And America has the most difficult healthcare system to access in the developed World.

    Contact your representative and tell then that a single payer, government managed healthcare option is a must for everyone that wants it. Tell them that you demand that the public option be the finest in the World.

    Tell them it should be available to everyone that wants it as a HUMAN RIGHT! Tell them it should be the easiest to access in the entire world. Tell them it should have the highest quality, with the greatest patient protections in the entire world. Tell them coverage should be automatic for everyone that wants it unless they choose to opt out. Tell them it should be the most affordable in the World. And tell them that NO ONE in the public option is to be reported to a credit agency, or driven into bankruptcy for unpaid medical bills just because they got sick, for FREEK’EN SAKES!

    Tell them, none of the requirements above are negotiable. Tell them, that we are prepared to remove them from office. Tell them, we will rain down the political FIRES OF HELL! on any of them that would betray the American people. Or continue to compromise the life, health, safety, and National security of the American people for the GREED DRIVEN, PROFIT DRIVEN! private for profit Healthcare Industry.

    TELL THEM NOW! AND PASS THE WORD ON.

    God Bless You

    Jacksmith — WORKING CLASS

  6. #6 MarkH
    May 12, 2009

    Actually Jacksmith, quite a few countries have profit in their healthcare systems. I might talk about a few in the coming days. Australia, for instance, I believe has the ideal system for the US to copy. It creates a parallel government insurer that competes with the private. Insurers there have learned to offer a different product, designed to give people the option of buying coverage above and beyond what is universal. Similarly in Britain there is private healthcare if you opt out of the system.

    Profit doesn’t need to be removed, and we don’t necessarily have to go single-payer. I doubt Americans would ever accept such a system even though I believe it would be ideal. What needs to be removed are the kind of profit-seeking behaviors that harm patient care. We must incentivise insurers to provide better care, and if they don’t they’ll get slowly replaced by government services.

    Ultimately what I think of as an example is the post office. We all have basic mail service. Government provides universal, fast, cheap basic service to all citizens. If you want to ship overnight, or have some other specialized service like Fedex or UPS offers, then you contract with them for those needs. But everyone needs a mailbox. Well, everyone needs a doctor too. Governments can do universality and corporations famously suck at it. The consensus has shifted to recognize we need universality. It costs more not to have it. It’s also unjust, painful and ugly. We want a healthcare system that reflects our values. Our values fortunately have evolved to the point where we believe it’s wrong for people to suffer without healthcare just because they’re poor. We also, however, value capitalism. Our healthcare system, whether you like it or not, will have capitalist aspects to it. It will drive profit. I find that sad, but inevitable.

  7. #7 Zeroth
    May 12, 2009

    JackSmith: Its people like you that make things worse, just as much as the blinkered free-market fundamentalists. Polarizing the discussion does absolutely no good to progress. They point at people like you, and go, “SEE! COMMIES!”

    Even if you aren’t, such a polarized, threatening message does nothing but subvert the debate to something pointless. Rather the debate should be about the pros and cons of universal health care, with every attempt to avoid political ideology. Politics has no place in health care, which makes it unfortunate that the politicians control health care.

    And frankly, you sound like a crank. It doesn’t matter if its a message democrats may believe in, you still may be a crank. Are you willing to evaluate the evidence honestly?

  8. #8 bob koepp
    May 12, 2009

    Good, reasonable suggestions about overhauling the health care system, but with one glaring omission… You haven’t addressed the “consumerist” mindset that infects the system, where far too many people want the latest, the sexiest, and the costliest healthcare they can induce providers and payors to deliver, and lots of it. I’m not saying demand is the most important factor in causing the disaster that we call a health care system, but a workable, sustainable solution to our problems can’t ignore this variable.

  9. #9 MarkH
    May 12, 2009

    Bob,
    I would say my recommendation to eliminate direct to consumer advertising addresses that to a significant degree, but not completely. We are the only country in the world that does not ban DTCA outright. New Zealand tried legalizing it for a few years, and their costs skyrocketed. It was a dramatic, negative effect.

    Doctors fall victim just as often to the desire for the new and sexy. Surgeons tend to be even worse. To some degree, the EMR suggestion helps with this, as it allows one to identify and correct overutilization through effective data aggregation.

  10. #10 TLP
    May 12, 2009

    If you ask a free market fundamentalist what he thinks about the current system, he will say that it’s an over-regulated mess that has nothing to do with free markets.

    The US economy has as much to do with Free Markets as the Holocaust had to do with Darwin’s Theory of Evolution.

  11. #11 catgirl
    May 12, 2009

    The only argument I have heard against universal healthcare is that there might be rationing of healthcare. But this is already happening with our current system, where people can lose coverage just by being sick for too long.

  12. #12 MarkH
    May 12, 2009

    Ah yes, the “no true Scotsman” of economics. When something goes wrong because of the free market, one can always point to some level of regulation and say it’s regulated not free. The only true free market is one in some imaginary anarchical state.

    This is total nonsense. The current medical system is a patchwork of payers, true. But it’s fundamental nature is that which supports for-profit insurers, for-profit hospitals, for-profit clinics and doctors, and for-profit drug companies. This, compared to a true socialized single-payer such as Great Britain in which the government is the employer of most doctors.

    We have a market. It’s not a laissez-faire one, thank Jebus, but it is one in which corporate interests wield the power and patients do not. Patients are treated as customers who will somehow magically make the system more efficient by the invisible hand of the market. This of course does not happen. Instead we have the most inefficient healthcare system in the world, especially compared to the single-payer models. The idea that deregulating the system would make it better would therefore seem foolish, especially considering historically how we got to this point. All those regulations are there because of abuse of the free market that got people screwed. Our current economic crisis? A deregulation error. The great depression? A no-regulation error (let’s hope the Randites don’t invade now to blame the Fed).

    The anti-regulation argument is ignorant of history. The period before regulation was not an era of goodwill and fuzzy bunnies. It was one of poison drugs, uneven development, abuse of workers, abuse of consumers, monopoly, despoiling the environment…name the abuse, that’s why we have the regulation. When government steps in because the market consists of fraud and lies (e.g. pharmaceuticals pre-1940s) the libertarians then have the temerity to suggest the FDA somehow harms the market. The only reason we have efficacious drugs at all is because of regulations forcing companies not to lie about efficacy! Because of government regulation of the market!

    There is a matter of degree here, we can have over-regulation as well, but that is not the problem with the medical system today. Trust me. I’ve seen it. I’ve treated the patients. I’ve seen the insurance system at work. I’ve sat with the doctors spending hours of their time yelling at the insurers over the phone to get necessary tests or to be reimbursed for reasonable services.

    What I’m arguing for isn’t regulation but a redesign of the system that includes a free market for services over a universal baseline. Corporations will never provide us with universality unless they are forced to. Justice and morality demands a universal system. The values of the people of this country will no longer support people going without medical care (not that they truly do anyway, we have universality in our ERs but the cost is not acknowledged or dealt with properly). The problem needs to be addressed and there is no free market solution to it.

  13. #13 D. C. Sessions
    May 12, 2009

    Ah yes, the “no true Scotsman” of economics. When something goes wrong because of the free market, one can always point to some level of regulation and say it’s regulated not free. The only true free market is one in some imaginary anarchical state.

    And then only for a very brief time until its inherent instability leads to one form or another of power concentration. The basic math of a free market only works as a small-angle approximation when all market actors are small and numerous. (Tragedy of the commons and related game theory apply. The fundies really don’t deal well with cost externalization.)

    Another problem is that “free market” analyses embrace failure as a necessary part of its operation. Do the math and that means children starving in the streets — which, for economic good or ill, we have as a society rejected as unacceptable.

  14. #14 MarkH
    May 12, 2009

    Rationing does occur. It’s just a scare word anyway. It’s not meaningful.

    When an insurance company denies a service because they say it’s not indicated, even after a physician prescribes it, that’s rationing. They’re saying they don’t think it’s indicated, usually based on a cost-benefit analysis. They are superseding your physicians opinion to save themselves money. If there were no rationing you could see a doctor any time you want, get any service you want that is medically indicated. If you had back pain you’d get an MRI without having to wait 6 weeks and getting physical therapy. But the insurance companies know they can get away with that requirement and that PT is cheaper than MRIs, so they force you down the cheaper pathway. You wouldn’t believe what hell it is trying to get an emergent MRI of the back and actually get it paid for. Or to get a PET scan, holy crap! They use punitive paperwork to scare any doctor out of getting one, even when medically indicated. Or how about the use of co-pays to drive patients away from expensive, but necessary interventions?

    The system is rationed, but the system of rationing isn’t transparent and isn’t based on medical necessity or physician input. There is no system of control, and attempts to regulate the behavior through state medical boards or state regulation have usually failed. They game the system to deny as much care as possible without getting sued or generating such outrage they end up in a newspaper. That’s the current system. It’s far more perverse and inconsistent than any system of rationing that could be devised.

  15. #15 D. C. Sessions
    May 12, 2009

    OT: Mark, you might want to update your profile.

    Congrats, Dude.

  16. #16 pdxtran
    May 12, 2009

    As a Japanese-English translator, I was once hired to translate the autobiography of the founder of a Japanese pharmaceutical company. He admitted that drug companies the world over make most of their profits in the U.S., where they are allowed to advertise drugs to consumers and where there are no restrictions on prices.

  17. #17 SimonG
    May 12, 2009

    Re: 8/9 – consumerist attitude
    People here in the UK like to whinge about the NHS. I think many people’s opinion of it is a bit biased, because they don’t have much contact with it except for relatively minor things. Those people I know who have had serious problems usually speak highly of it.
    One thing which helps to keep us content is a feeling of ownership. This is our health service, and the doctors and nurses are noble people who want to help their patients, not simply employees contributing to the bottom line of some big corporation.
    (OK: all health professionals are saints and angels, but in a private system their somebody else’s saints and angels.)

  18. #18 Paul Murray
    May 13, 2009

    Australia, for instance, I believe has the ideal system for the US to copy. It creates a parallel government insurer that competes with the private.

    Well, that system is a creation of the Howard government. Private insurers are subsidised in that if you earn more than a certain amount and do not have private insurance, then an extra medicare levy is applied over and above the standard 1.5% (or whatever it is). About a grand or so per year in my case, I think.

    Personally, I don’t have private insurance for two reasons:
    1) I don’t trust for-profit healthcare. They are in the business of taking your money and then denying you cover.
    2) I’m proud to pay extra to support the public system. I like to think that the money goes more-or-less directly to the less fortunate.

    But many don’t feel the same. Without the penalty rates for higher-income earners, without the cream-skimming incentive, private health insurance would vanish. And good riddance.

  19. #19 cm
    May 13, 2009

    MarkH said:

    The values of the people of this country will no longer support people going without medical care (not that they truly do anyway, we have universality in our ERs but the cost is not acknowledged or dealt with properly).

    But they *do* truly do go without health care for just the reasons you so perfectly state in the other comment about rationing. They also go without health care because they do not seek it because they know the incredible stress associated with getting something approved, or, much worse, getting a charge corrected after a billing error.

    I myself try to use health services as only absolutely necessary because I really live in dread of the prospect of another 10 month battle to correct an obvious billing error. I have directed my European wife to only get her annual woman’s physical on visits to Europe because last time she did I was on the phone with the insurance company for an hour–IN THE DOCTOR’S OFFICE–trying to get the right “code” for her incredibly standard visit. When the office manager asked the insurance rep finally, “Well then, what code DO we use for this procedure?” the rep said, “I can’t tell you, but if you tell me codes I can tell you if that will be reimbursed.” It was like we were playing a game, it was completely demoralizing.

    And people know this, and they don’t have the option to get care elsewhere, and they avoid doctors like the plague.

  20. #20 S. Sepp
    May 13, 2009

    I think one thing that seriously has to be considered is that a “universal health care” system would best be brought in on the state, not the national level.

    Consider Canada’s system, for example: though the Federal government funds a considerable portion of the system cost, and provides some regulation, it’s ultimately up to the individual Provinces to determine their spending models. There are two advantages to this:

    a) The system is a lot easier to manage. Canada’s largest province, Ontario, is only about 10m people, but the population was perhaps half that when the system was introduced. Coordinating a system for 300m or so people would be nigh impossible without making it a bureaucratic and ineffectual mess.
    b) There’s room for experimentation. Different funding models can be tried, different services and organizational structures attempted, all without risking the entire system. If Manitoba tries some innovative idea and it flunks, only a small part of the system is harmed (and can quickly be recovered). Likewise, if the experiment works, the other Provinces can adopt it. With a national system, every change you make puts the entire system at risk.

    And the political wrangling on the state level can be easier. If the federal government were just to say “Hey, we’re willing to partially fund any state system”, I’m sure quite a few willing participants would come up. Those states would very quickly gain a substantial competitive advantage as employers would no longer have to provide as much insurance coverage. Laggards with Republican governors would soon grow ashamed and they’d be drawn by economic factors into the system. Again, this is sorta what happened in Canada – Saskatchewan was the first adopter, and its successes quickly brought the other provinces in line.

  21. #21 Johnmayer
    May 13, 2009

    If you are uninsured and does not have insurance, you should check out the website http://UninsuredAmerica.blogspot.com – John Mayer, California

  22. #22 Scott from Oregon
    May 13, 2009

    Europe has SYSTEMS, not one system. Each nation has its own system, and its citizens are responsible for how effective the system is.

    Some work well, some work like crap.

    The US should let each state create its own opt-in system. Get it out of the “one-size-fits-all” behemoth that a universal system implies.

    Each of these systems could be aided in funding by things that bring in revenue to those particular states already– logging revenues in Oregon, for example. Tourism revenues in Hawaii. Cheese tax in Wisconsin…

    So you opt-in, pay a premium to be “in”, and leave independent insurers (and maybe facilities) in direct competition.

    This way, you get some protection against rampant waste and bad service built in, you get 50 different entities trying 50 different systems (with systems that work best getting copied by the poorer systems) you get a more direct feedback loop as patients can go to their legislators to complain instead of fighting through a single, heavily lobbied rep in Washington who can ignore you if he/she wants, and you don’t remove what drives American inventiveness and incentives for R and D (making money).

    If you are out of state and use a hospital, you use your state card and your state is billed by the other state accordingly. Over-billing is tampened by the fact that there may be reciprical patients. You ripped me with your bill, I’ll rip you with mine…

    America is full of people who just don’t want the federal government in everybodies business. There was a fourth Amendment for a reason. It is in the heritage and psyche of Americans to be independent and not herded into any one pen, no matter how earnest the pen keepers.

    Universal health care is just one of those well-meaning systems that promotes the view that the government can do better than free markets.

    It never has, and never will.

    Your state could have a great parallel system up and running THIS YEAR!! What are you waiting for?

    Besides, didn’t anybody tell you? The US is BROKE, and cannot pay back the money it has already borrowed from the rest of the world. We are the largest debtors in the history of everything. Time to suck it up and go to real work…

  23. #23 LanceR, JSG
    May 13, 2009

    Universal health care is just one of those well-meaning systems that promotes the view that the government can do better than free markets.

    It never has, and never will.

    With due respect, and noting that I agree with your basic point about each state having its own plan, horsefeathers. This is the sort of free-market fundamentalism that got us into this mess.

    Free markets screw people. Badly. Always have, always will. Unfettered capitalism is only good for the top few percent, and everyone else is hosed. It’s been tried repeatedly, and it always has the same results. (CF Victorian England, Argentina, Antebellum America, etc., etc., ad nauseum).

    That said, 50 individual state plans, with federal funding rather akin to Medicare, under some federal oversight agency, would probably work better than a cookie-cutter one-size-fits-nobody plan.

  24. #24 David Marjanović
    May 13, 2009

    Europe has SYSTEMS, not one system. Each nation has its own system, and its citizens are responsible for how effective the system is.

    First intelligent thing I’ve ever seen you write.

    Universal health care is just one of those well-meaning systems that promotes the view that the government can do better than free markets.

    It never has, and never will.

    Same denialist argument you always write.

    The evidence is right in front of your eyes that some things work better for everyone if they’re not done for profit.

  25. #25 Scott from Oregon
    May 13, 2009

    “Free markets screw people. Badly. Always have, always will. Unfettered capitalism is only good for the top few percent, and everyone else is hosed. It’s been tried repeatedly, and it always has the same results. (CF Victorian England, Argentina, Antebellum America, etc., etc., ad nauseum).”

    I won’t debate this point with you, but I will leave you with this observation. The freer the markets, the greater the gains in health remedies, procedures, and machinery.

    The greater the state control, the worse systems get.

    It is no great secret why Putin is warning America not to go down “that path”.

    Where would you rather live. North or South Korea? USA or USSR? East Germany or West Germany?

    For all of the warts, the free market is vastly superior to state run economies. Look it up.

  26. #26 LanceR, JSG
    May 13, 2009

    False dichotomy. There are entire worlds between “free markets” and “state run economies”.

    The freer the markets, the greater the gains in health remedies, procedures, and machinery.

    Again, horsefeathers. Practically all medical advances in the US have come from government funded research. Corporations are not willing to put out money for research that may pay off in ten years.

    I know it’s comforting to think that free market capitalism will cure all that ails us, but it just ain’t so.

  27. #27 SamuelK
    May 13, 2009

    It’s so sad and true about chronic patients not being able to afford healthcare. I did some research online and stumble across a new search engine that finds generic prescriptions within your ZIP code. It’s called Medtipster. I volunteer at a local community rec place and often hear stories from elders about skipping dosages and choosing grocery over medications. I started referring Medtipster to my friends and some of them have saved money and time from the website

    http://www.medtipster.com recently launched an early version of its drug price comparison Web site. Consumers type in their drug name, dosage and ZIP code, and can find prescription drugs available on discount generic programs and where they can find them in their neighborhoods. The site will eventually offer users information on scheduled immunizations, health screenings and mini-clinics in their area; recalls and warnings; an “Ask the Pharmacist” feature; and an online community in which individuals can share information.

  28. #28 Confederate Right Winger
    May 13, 2009

    I would like to see a health care system that is fair. Right now hospitals are in business to make money. They should be there to help people, not make huge profits. I was in the hosptal last year and later found out that I was charged $4.00 for a Tylenol. I could bought a whole bottle for that.

    I say we start charging doctors $250,000 for a gallon of gasoline and we should charge hospitals a tax on the profit they earn.

    We could literally sue hospitals for armed robbery. After all, the surgeon is holding a sharpe knife and did rob me by taking excessive amounts of money from me to get rich instead of helping me. Is that not robbery?

    Also I do not want socialism here. It does not work. I do not want to wait in line to get robbed. It’s bad enough waiting a few hours. if Obama’s socialist plan comes into effect, I’ll have to wait months to see a doctor. Screw that, I’ll go herbal and sue the government for state mandated suicide.

    Government needs to get out of health care, out of the auto industry, and out of our lives. They can all kiss my hairy white confederate butt cheeks.

    Behind, hospitals, trial lawyers, and crakckpot quack doctors, government is our real problem here. Insurance companies do not help either. If 100,000,000 people all of a sudden refused to pay their medical bills, taxes, and insurance policies, America would be better off. Maybe we could rid ourselves of thee frauds and perverts in the medical system and the federal government. What would they do, arrest 100,000,000 angry armed people?

    Yes the health system needs work, but some of these two bit good for nothing quacks who are in it just for the money should be hanged at sunrise the first time they deny someone care that cannot afford their outrageous and unethical rates of greed.

    There was a 12 year old boy who died froma tooth infection that went to his brain. His mother was on Medicaid and no dentist would pull the tooth becuase they thought Medicaid was not paying them enough money.

    If I were president doctors like that would disappear – preferrably to an asian slave labor camp.

    It’s two bit scum sucker fudge packers like that nimrod that gives healthcare problems. If he didn;t like his pay, he should hjave chosen a different profession. There needs to be a law that is strictly enforced that says any doctor who willingly refuses to treat a patient becuase of the financial situation can legally be stripped of his/her medical liscense for life and/ or a $250,000 fine or 50 years hard labor in a foreign prison.

    They should get the same treatment as their patients.

    ———–

    Socialism is not the answer. Getting rid of greedy crackpot doctors is!

    There are good doctors out there, but there are some greedy ones as well.

    If socialism is implemented here I hope it breaks the country in half. Secession is the only answer then. Then we can let the moonbat looney bins have their socialism while we real Americans (not Europeans) have a real country without liberalism, Darwinism, and all other leftwingisms.

  29. #29 Confederate Right Winger
    May 13, 2009

    Also, Remember Hillarycare? That was a mistake! Think Obamacare will be better? It will be infinitely worse!

    I remember my mother having cancer and having to drive 2.5 hours to get chemo just becuase the idiot insurance HMO people dictated to us where we could and could not go to get treated.

    Communism anyone?

    How about if I go where I please to any doctor I wish, and you pay the bill becuase I pay my premiums for you to do so and if you don’t I’ll wrap a great big club around your fat hog head.

    That was the only way to get by in those days and under universal un-health care it will be even worse.

    Socialism can stay the hell in Europe becuase we are America and we do things out own way. Screw socialism and those who worship at the alter of dictatorships who introduce it. I hope they all fail miserably and no one will help them.

    Universal health care will be the death of America. Watch and see. I hope we have enough Republicans to block it or call for presidential impeachment if it passes. We cannot have a dicator wannabe telling us where we can and can’t go to the doctor and for what reason. That is reason enough to kick butt and take names.

  30. #30 LanceR, JSG
    May 14, 2009

    I remember my mother having cancer and having to drive 2.5 hours to get chemo just becuase the idiot insurance HMO people dictated to us where we could and could not go to get treated.

    Communism anyone?

    **headdesk**

    This is not communism, socialism, or government healthcare. This is a classic example of “cancer stage capitalism”. This is precisely the sort of thing that is driving the current push for universal healthcare.

    I am always amazed at the people who “don’t want some gubmint burra-crat making my healthcare decisions”, but are apparently content to have accountants making those same decisions.

    For-profit healthcare will *always* sacrifice patient needs for corporate profit.

    Anyone wanna take bets that “Confederate Right-Winger” is more concerned about the color of Obama’s skin than he is about any substantive policy issue? Anyone? Bueller? Bueller?

    **crickets**

    Didn’t think so. Dude, turn off Faux News and read something. You might learn something.

  31. #31 Dana H.
    May 14, 2009

    Health care is a need, not a right. The government has no right to force some to pay for the medical needs of others, nor to dictate to doctors the terms on which they may offer their services. This is the most fundamental, moral argument against “universal” health care enforced at the point of a gun.

    My young daughter would most likely not be alive if we had had a complete government takeover medicine in this country (as opposed to the partial takeover we have now, between Medicare, Medicaid, and mandates too numerous to mention).

    A good article on the subject can be found here: http://pajamasmedia.com/blog/health-care-reform-vs-universal-health-care/

  32. #32 LanceR, JSG
    May 14, 2009

    Health care is a need, not a right.

    WTF?

    You are arguing against a “complete government takeover medicine”, which I believe has *never been proposed*. Do try to argue the actual case, not some strawman that Faux News puts out. Your “enforced at the point of a gun” betrays your talking point bullshit.

  33. #33 MarkH
    May 14, 2009

    Health care is a need, not a right. The government has no right to force some to pay for the medical needs of others, nor to dictate to doctors the terms on which they may offer their services. This is the most fundamental, moral argument against “universal” health care enforced at the point of a gun.

    .

    This is one of those statements that really makes me pull my hair out. This is the ideal result of the denialist information campaign – people who think that universal = forced.

    We already have universal healthcare. We just treat lots of people emergently for problems that could have been solved with good preventative medicine and a visit to the family physician. We just have a system that lets the problems reach a critical state that then forces doctors to act based on their ethical obligations. If you come in with a critical problem, we are obligated to treat you, it’s our ethical responsibility. The state then picks up the tab so that the ethics of medicine doesn’t cause all hospitals to fail.

    We already pay for most of what’s being argued over. We just pay more, when it’s too late and harder to do good. This isn’t about medicine at the point of a gun, which is just about the stupidest thing I’ve ever heard. We’re already delivering much of this care! We already treat these people, and not because we’re forced to by a gun but by the ethics of our profession. This is about creating a sensible infrastructure that addresses problems before they’re critical. That ensures when our citizens get sick they don’t wait for it to be an ER problem.

    So, in our system, the responsible, insured taxpayer is already paying for universality and access. It’s just we wait until the problems require admission to a hospital to do so. This is foolish. It’s inefficient. It’s medically unsound. It’s unfair. And it’s unjust.

    The facts are that the universal systems universally cost less per capita than ours. The fact is preventative treatments and seeing people before the ER is not only medically superior, but cheaper than waiting for people to become critically ill. The fact is, we are the only country in the world not to do this, and we pay more for health care than anyone else in the world. The fact is that countries that have done this, didn’t go commy, they just spend less on healthcare than we do.

    Take your obnoxious ideology and shove it. We’re looking for pragmatic answers to a problem. Not ideological rants.

  34. #34 Dana H.
    May 14, 2009

    The true “denialists” are those who evasively try to deny that force is involved in government control of medicine — including the massive level of control we already have. E.g., you state, “So, in our system, the responsible, insured taxpayer is already paying for universality and access,” as if this is a law of nature, rather than the forcible taking of the wealth of the responsible for the sake of the irresponsible (or simply unlucky).

    That you write, “Take your obnoxious ideology and shove it” while accusing *me* of engaging in a “rant” would be amusing if it weren’t all too typical of the quality of “argument” put forward by statists when confronted with principled disagreement.

  35. #35 Dana H.
    May 14, 2009

    For anyone here who may have a sense of humor, there is an entertaining parody at the AFCM web site that begins, “One of the great scandals of our age is the fact that America spends more on food than any other nation…”:

    http://www.afcm.org/nationalizegroceries.html

  36. #36 LanceR, JSG
    May 14, 2009

    Oh, there it is. The “Nuh-uh, *you’re* the denialist” tripe.

    Currently, you pay for the uninsured in higher premiums, higher medical costs, and decreased access. This is inevitable. Getting serious about universal healthcare, including preventative care, would actually *decrease* costs for everyone involved.

    Principled disagreement would be one thing. What you’re pushing is ill-informed talking points full of fermented moose piss. Your “joke” from Americans for Free Choice in Medicine is typical of the level of response we see from your side. No real discussion, no actual rational thought, just inanity, lies, and fearmongering.

    Principled disagreement? You keep using that phrase. I do not think it means what you think it means.

  37. #37 cm
    May 14, 2009

    LanceR, you said, in response to Dana H.

    Currently, you pay for the uninsured in higher premiums, higher medical costs, and decreased access. This is inevitable. Getting serious about universal healthcare, including preventative care, would actually *decrease* costs for everyone involved.

    I think you are missing Dana H.’s point.

    Dana H. doesn’t want to pay *anything* extra if it is going to help *other people*. So, in his/her view, health care costs could be really low in this country if we just only treated those who arranged health care through private entities. There would be ZERO additional burden due to paying for and treating the uninsured, because they would not be treated unless they had cash in hand. If not, they would simply get ill and often die. It would be laissez-faire medicine, and let the bodies fall where they may (and let private body-collecting companies make a entrepreneurial buck hauling them away).

    Get it? It takes a frame shift to really be able to see Dana H’s view. (If you now have, may I offer you a motion sickness bag?).

  38. #38 LanceR, JSG
    May 14, 2009

    @cm

    You’re probably right about Dana’s real point, not that you could ever get a straight answer about that from any of them. My overarching point is that, in *any* system, even the most laissez-faire, let them die if they can’t afford care abomination, there are added costs. Someone has to pay for the poorhouses, debtor’s prisons, etc. Even if it’s just in lowered wages and lowered quality of goods from using slave labor in these places.

    Even more important, we have direct evidence of what happens in that sort of system. We replay that evidence ad nauseum every single Xmas season. Christmas Carol, anyone? England in Dickens’ time *was* that laissez-faire “paradise” of which they speak so lovingly. IIRC, even Scrooge, that paragon of libertarian virtue, lived a pretty crappy life. Amongst all his high-blown talk of “excess population” and the virtue of thrift, he went back to his cold, dark rooms, ate his cold supper, and retired to his cold, threadbare bed.

    We see this every year, and even the hardest among us cheers Scrooge’s transformation at the end. After the last package has been unwrapped, and the last bit of leftover turkey has been put away for casserole, some people go out into the world and get in touch with their inner Scrooge every day.

    It’s sad, really.

  39. #39 Dana H.
    May 14, 2009

    Those who fear bodies in the streets as a result of free market medicine should study their history. Before 1965 and the onset of Medicare and Medicaid, there was no “crisis” in medicine, no problem with access to health care (with charity able to cover those who could not afford it), and obviously no corpses piling up in the streets. It is only since the advent of those programs and countless other laws that mandate the conditions insurance must cover, that prohibit interstate insurance coverage, that give preferred treatment to those abominations called HMOs (see HMO act of 1973), etc. that a “crisis” has developed.

  40. #40 LanceR, JSG
    May 14, 2009

    Again, horsefeathers. There has been a “crisis” in healthcare ever since the modern healthcare system began in the 30s. Stepping into the Wayback Machine…

    Roosevelt wanted to create medical insurance plans, and pushed a Medicare-like proposal. Republicans in Congress wanted no such beast. The compromise was our current employer-based healthcare system, which immediately began to stink up the joint.

    It’s comforting, I’m sure, to blame socialized medicine for all that ails us, but it just ain’t so. Put down the Faux News crack pipe and read some history books.

  41. #41 LanceR, JSG
    May 14, 2009

    Again, horsefeathers. There has been a “crisis” in healthcare ever since the modern healthcare system began in the 30s. Stepping into the Wayback Machine…

    Roosevelt wanted to create medical insurance plans, and pushed a Medicare-like proposal. Republicans in Congress wanted no such beast. The compromise was our current employer-based healthcare system, which immediately began to stink up the joint.

    It’s comforting, I’m sure, to blame socialized medicine for all that ails us, but it just ain’t so. Put down the Faux News crack pipe and read some history books.

  42. #42 cm
    May 14, 2009

    LanceR:
    Although I am on your side–I’d like to have a single payer taxes-funded universal health care in the U.S.–I still don’t think you are fully grokking the DanaH. side of it. In order to make this clearer, I am switching on Dana Mode now: [accessing...Dana module imported...]

    You say that somebody has to pay for the poorhouses and debtor’s prisons? Why? Who says we must have poorhouses and debtor’s prisons? Why not just slums, like much of the world has already? And if there are to be debtor’s prisons, let them be funded not by tax dollars, but by private investors who think they can make money on imprisoning these people, perhaps by extracting, as you said, slave labor from them.

    If slave labor causes the price of wages to go down, all the better for the private holders of means of production! Who said high wages is necessarily a good thing? If you are so lazy or incompetent to be stuck as the one on the receiving end of a low wage, that’s YOUR fault. No one is forcing you to work for a factory or mill that offers low wages, that’s your free market choice.

    What I won’t stand is some government entity telling me how it ought to go and what I have to do, and enforcing it at gunpoint. If the country becomes a hacking, whooping, miserable slumland dotted with oases of the rich, so be it. It is FAIR that way, because no one MADE it be that way, it just GOT that way. It is what God, or fortune, or luck, or whatever, willed, but it is not what the bureacrats in Washington said it should be.

    But, I submit, it won’t get that way, anyway. When the magic hand of the free market is unshackled, soon enough prices for health care services will find their market value, and that value will be fair and appreciated by any people hardworking enough and clever enough to have the money necessary to pay it. Quality of service will also greatly improve to the working of free choice, since people will opt not to go to a doctor with unsatisfactory service. If, due to their own misfortune, incompetence, or laziness, the sick do not have enough money to afford a good quality doctor, well, maybe that will light a fire under them to get on the stick and go out there and make some real coin so that next time it won’t happen to them.
    Sure, sometimes people will simply be unlucky, they will have recently been robbed blind and then hit by a breadtruck and lie bleeding in the street, but, you know what? That’s the breaks. You can’t MANDATE health and security for all your citizens and then force me to pay for that. I think my own chances are pretty darn good for avoiding that thief and that breadtruck, and so I will pay for health services as I see fit, and not cough up a red cent for the poor dumb schmuck who is either too lazy or dumb or unlucky to fare as well as I will.

    [exit Dana mode...rebooting...]

    I also think the Charles Dickens point was a non sequitur. Scrooge was a miserable bastard because he was isolated, ungenerous, and miserly, but none of these traits are necessitated by a laissez-faire system. One can imagine a rich person in a laissez-faire system who interacts much with poor people, gives copiously to charity, and spends money on lavish turkey banquets for all, but who still resents the “bureacrats in Washington” TELLING HIM HOW he has to comport himself. Right?

  43. #43 trrll
    May 14, 2009

    The fact is that in terms of objective measures such as infant mortality, the US does a worse job than those nasty developed countries with “socialized” medicine. See here, for example

  44. #44 Dana H.
    May 14, 2009

    I’ll ignore the ad hominem snark and focus on a serious point:

    “The compromise was our current employer-based healthcare system, which immediately began to stink up the joint.”

    I actually agree with this, and did not mean to imply that the Johnson programs of the 60s were the first or only government intervention in health care. It’s just that the extent of intervention greatly increased from that point on.

    The preferential treatment of employer-provided health insurance has indeed been destructive. But you don’t have the history quite right. In the 1940s, wage increases were restricted by government dictate, but firms were permitted to offer health insurance as a tax-free benefit. It is this more than anything else that led to the current state of health care being tied to employment.

    The term “crisis” is massively overused today. So, while I agree that many of today’s problems have their roots in programs created decades ago, I hardly think that “crisis” can legitimately be used to refer to the state of health care then. Even as bad as things are in our semi-free/semi-socialized system today, I’m not sure it’s a “crisis” (though I could be convinced otherwise). WWII was a crisis. The subprime meltdown was/is a crisis. I don’t know about a system in which 80% of people claim to be happy with their health care.

  45. #45 bob koepp
    May 14, 2009

    Lance is wrong about the origins of employer-based health insurance, which means Dana is wrong to agree on this point. Employer-based health insurance was instituted because employers wanted to retain skilled workers but were unable to increase their wages in a time of wage and price controls. So instead of wage hikes, they provided “non-wage” benefits.

    Not that this is even relevant to the current mess…

  46. #46 Confederate Right Winger
    May 14, 2009

    Actaully univerals does mean forced becuase the government will make health nsurance cheaper. That sounds great, but then all other insurances go out of business and the only one left standing is … big government dictatorship healthcare. That’s been the whole goal all along. Global warming, universal healthcare, etc. is all about control. Nothing more, nothing less.

  47. #47 LanceR, JSG
    May 14, 2009

    That’s right, Confederate Winger. It’s all about control. Sure. Now put the tinfoil away, the nice orderly has some pudding for you before your night-night meds.

  48. #48 LanceR, JSG
    May 14, 2009

    Okay, on further reading, Bob Koepp is correct, and I was misinformed. Sorry about that!

  49. #49 Dana H.
    May 14, 2009

    “Dana is wrong to agree on this point. Employer-based health insurance was instituted because employers wanted to retain skilled workers but were unable to increase their wages in a time of wage and price controls. So instead of wage hikes, they provided “non-wage” benefits.”

    Er, isn’t that what I said (albeit more tersely)?

    And the point I was agreeing with Lance on was not the exact history of the policy, which I corrected him on, but that the policy has been destructive — specifically (though I’m sure Lance would disagree with this part), that it’s yet another example of the destructive effects on health care of government controls.

  50. #50 cm
    May 15, 2009

    Dana, I’d agree with your post #49’s rebuttal of Bob. But I don’t agree with your larger point. Seeking clarity on some statements you made:

    Health care is a need, not a right.

    Why? Who says? What if I say it is a right? How do we arbitrate that? What things do you think are rights?

    The government has no right to force some to pay for the medical needs of others, nor to dictate to doctors the terms on which they may offer their services.

    Again, that word, “right”. What does the government have a right to do?

  51. #51 Ryan Dolley
    May 15, 2009

    Speaking as one of the 50 million uninsured, who lacks health care due to the unfortunate confluence of my graduation from college and the total meltdown of the world economy due to a pathetically short-term free market outlook, I can say that I feel more and more everyday that health care is a right.

    Specifically, I feel it with the growing ache in my left testicle that I am simply unable to pay a doctor to look at, much less pay for any sort of procedure necessary thereafter.

    But I guess them’s just the breaks. If I’m infertile, I’m infertile. If I die, I die. At least nobody took Dana’s money at gun point.

  52. #52 cm
    May 15, 2009

    Ryan, look into options.

    Home Depot (if they are hiring, and I realize they might not be) supposedly does health insurance benefits for 24 hr/week workers. Look into health services for low-income people. There are sometimes community clinics that charge a reduced rate or sliding scale. Sometimes doctors can do a hardship case for less.

    How did you pay for college? Is there parental help? If so, is it at all possible they can help with getting some initial look-over for your concern?

    Google will no doubt help. Don’t just assume you can’t get help. Read up first. Be careful of the pre-existing condition issue, though (in that, if you pay for initial treatment out of pocket but it establishes you have a pre-existing condition, later you will have trouble getting any insurance unless maybe through a group plan, but that requires employment).

    Don’t give up that easy. Early treatments for problems is always better than later. Damn good luck to you.

  53. #53 Dana H.
    May 15, 2009

    cm, thank you for asking some serious, polite questions, free of snark. I will answer as best I can in a short space.

    “‘Health care is a need, not a right.’

    Why? Who says? What if I say it is a right? How do we arbitrate that? What things do you think are rights?”

    A right is a sanction to free action in a social context. You have the right to free speech. You have the right to pursue your happiness. You do not have the right to steal your neighbor’s cow, or to bash in his skull. Neither health care nor any other benefit at someone else’s expense can be a right, because it requires violating the rights of others to obtain it. Any legitimate right can be exercised alone on a desert island.

    As for, “Who says?”, this gets to the foundations of political philosophy. John Locke (I think) originated the idea of rights arising from man’s faculty of reason. In the Declaration of Independence, Thomas Jefferson enumerated various rights and stated the Lockean view that the purpose of government is to secure these right. In my opinion, Ayn Rand gave rights a sound moral foundation, which they had lacked previously. You’ll have to read the works these thinkers if you want their full arguments.

    “What if I say it is a right? How do we arbitrate that?” The same way we arbitrate disagreements over any other intellectual dispute. You give your arguments; I give my arguments; we each judge to the best of our ability who is right, and then we live our lives accordingly. If we’re lucky, we live under a system of government in which neither of us can attempt to coerce agreement from the other.

    “The government has no right to force some to pay for the medical needs of others, nor to dictate to doctors the terms on which they may offer their services.

    Again, that word, ‘right’. What does the government have a right to do?”

    Per the Declaration of Independence, the purpose of government is to secure the rights of those within its jurisdiction. In my view, this is the only purpose of government (because any other alleged purpose ends up subverting this primary purpose). Strictly speaking, the concept of “rights” applies only to individuals, not to governments. But loosely speaking, I’d say that government has the right to do what is required to carry out its function of protecting individual rights — specifically, maintaining the military, the police, and the courts, along with a few auxiliary functions.

  54. #54 cm
    May 15, 2009

    Dana, thanks for your answers. Some responses…

    A right is a sanction to free action in a social context. You have the right to free speech. You have the right to pursue your happiness. You do not have the right to steal your neighbor’s cow, or to bash in his skull. Neither health care nor any other benefit at someone else’s expense can be a right, because it requires violating the rights of others to obtain it. Any legitimate right can be exercised alone on a desert island …. In my opinion, Ayn Rand gave rights a sound moral foundation, which they had lacked previously.

    Without being able to go through the arguments of Ayn Rand or Jefferson or Locke now, I would just say that I find any definition of rights arbitrary. I have a feeling that Ayn Rand’s defense of her view of rights attempts to avoid any arbitrariness and to derive her concept of rights from some kind of axioms (knowing Objectivism a bit), but I also suspect that I wouldn’t buy her arguments in the end. But I could be wrong.

    You’ll have to read the works these thinkers if you want their full arguments.

    Sure. Again, this is just not the time in my life for me to do that.

    “What if I say it is a right? How do we arbitrate that?” The same way we arbitrate disagreements over any other intellectual dispute. You give your arguments; I give my arguments; we each judge to the best of our ability who is right, and then we live our lives accordingly. If we’re lucky, we live under a system of government in which neither of us can attempt to coerce agreement from the other.

    As per above, I suspect–though am not sure–that arguments cannot reveal rights to be anything more than good societal heuristics–not that good societal heuristics are anything to take lightly. My larger point is, I don’t think the idea of a “right” is a useful concept. It strikes me as somoething of a cognitive de-railer. I am reminded of the phrase, “The divine right of kings”, “endowed by their Creator with certain inalienable rights”, etc., and these both strike me as bare assertions, not sequalae from some kind of undeniable social or metaphysical truth. For these reasons, I am not sure basing any discussion of health care in terms of “rights” is the best way to go. That said, I am sure I too have used the term in my discussions, as it is a natural way for Americans to think and speak.

    But loosely speaking, I’d say that government has the right to do what is required to carry out its function of protecting individual rights — specifically, maintaining the military, the police, and the courts, along with a few auxiliary functions.

    Well, that’s nice and clear. Your point about reserving the word “right” for individuals is granted, so if we change “right” here to “justified authority” or something, then again it strikes me as it just boils down to assertion. You say the government only has the justified authority to protect basic individual rights–let’s sub that out to “non-harming others freedoms”, because that’s the rights you list. Fine.

    For what it’s worth, my view is different. Sorry, this may not cleanly transition from the former point… I feel that when one has a large nation, government can serve a very useful and helpful role in regulating or running aspects of it beyond mere law enforcement. These are things like public education, roads, funding science, anti-trust, etc., which we have now in the U.S. The reason I feel the government (and keep in mind that can be at local, state, or federal level, and that the government is made up of citizens) can do some things better is because it has, when it is working well enough, properties that private entities do not have: stability over time; no profit motive, accountability, oversight, and internal review; the ability to create mass action; good geographic coverage; etc. I sometimes think these are the very things that people with something like your philosophy DON’T like about government.

    In the case of health care, I just have trouble seeing how it can be a good idea to make health a profit-driven industry. People make health care decisions often at the point of a sickle (the Grim Reaper’s) and so it is not really a typical free market choice, like carpeting or even food. There are also so many ways in which insurance industries can collude, or obfuscate, or catch weak or ill people on technicalities, and they HAVE done this and ARE doing this. If the free market worked to optimize health insurance, why hasn’t one great company come to dominate the industry and has near universal praise as reasonably cheap, accurate, fair, modern, etc.? Why have I heard so many stories–and experienced three myself–about the maddening incompetence or deception of these companies?

    In the cases I have experienced, there was no role for the government to hamstring the proper execution of our privately-entered-into contract. The multibillionaire dollar company managed to do that on its own, and it robbed me of many hours of my time and patience over 10 months.

    Thanks,
    cm

  55. #55 cm
    May 15, 2009

    (pardon a couple of nutty typos above, my favorite being “The multibillionaire dollar company”)

  56. #56 MarkH
    May 15, 2009

    Dana, the reason for the anger and snark is because my ideology is that all ideology is stupid. I don’t care about first-principles ideas of what works on a desert island. I don’t care about centering the healthcare system on a minority’s idea about what rights are or how the world works. And certainly, if I were to choose such a minority view, it wouldn’t be that of libertarians, or the ideological abortion of Randian fantasy.

    Rights do force other people to act. Your right to a trial requires people to serve on a jury as a basic example. But this is all besides the point. I don’t care about ideology. I don’t even want to hear about how the world should work according to the sick fantasies of the laissez-faire capitalists, or the persecuted populism of other commenters like Jacksmith.

    We have a problem. It needs a solution. The world has left Laissez-faire capitalism behind. Get over it, it didn’t work, no civilized society maintained its precepts for long. I don’t want to hear libertarian nonsense or marxist nonsense. I want to hear about ideas that work.

    All over the world, socialized healthcare systems work to deliver medical care. People in these countries (every single industrialized nation but ours) get medical care usually gauged to be superior to ours at the same time its universal. I don’t want to hear about how this hurts your poor ideological feelings and makes Anne Rand roll over in hell or wherever she is. I want to hear about realistic solutions that don’t amount to “If I were dictator I’d do X”.

    That’s why I react with anger to this nonsense about the warped view of libertarians on rights. Because it’s a thread hijack. No one cares what you think about rights. No one cares about the libertarian vision of a healthcare system(none). We want healthcare, we want it to be universal, we elected people with that goal in mind, and libertarianism is a political worldview on the trash heap of history. It’s irrelevant, obstructionist, and of no help in this discussion.

  57. #57 Alessandro Riolo
    May 15, 2009

    Dear Mark,
    I think a point that should be expanded is that made by S. Sepp, about employers improving their competitivity in UHClands.
    I cannot see USA, or any other developed country for that matter, being able to compete on cost with the likes of China or India any time soon.
    I would be tempted to say that at the moment I cannot see this happening during my life time, actually for the lenght of the lifespan of anyone alive at this exact moment.
    Barring black swan unavoidable catastrophes, or avoidable ones (i.e. wars or a crash of a major currency), the competitive cost advantage of those countries is here to stay.
    As pointed by your article, USA is the only seriously developed coutry which has not yet got a UHC system in place.
    Companies producing in all the direct concurrent of US companies don’t have to care directly for the health costs of their employees, if not marginally.
    They do it indirectly, obviously, but as the cases of GM or Chrysler will show you, direct liabilities ammassed caring from big employers may bring down massive companies, if not entire productive sectors.
    Is there really a long-term benefit for the average taxpayer in this sort of policy?
    Personal experience and rational thinking tell me there is not, and I think the times we are living through are showing us towering evidence that is not the case.

  58. #58 Dana H.
    May 15, 2009

    MarkH: I didn’t come here with the intent of hijacking the thread. In fact, I only came to your blog to read your post on the obesity meta-study, which I found interesting, and then I followed the link here. But after my initial comment, I was bombarded with responses that I thought deserved replies. At this point, I’ve probably said enough, so I’ll bow out after these final remarks.

    (As an aside, I find absurd the view that “all ideology is stupid.” Everyone has an ideology. Your ideology is your world view. The only question is whether you hold it consciously and explicitly, or as a set of hidden, unquestioned, and most likely self-contradictory assumptions.)

    I’ll make one last point for those who think that an individualist philosophy has nothing concrete to offer for our current problems. To anyone not already blindered to alternatives to universal, government-controlled health care, please consider the following small steps that could be taken to increase access and decrease the cost of medicine:

    1. Remove the preferential treatment of employer-provided health care — e.g., by making all medical bills and insurance payments fully deductible for everyone.

    2. Remove restrictions on the coverage that insurers must offer, allowing people to pay for only the coverage they need and not for things they don’t want (or can cover out of pocket). Allow insurers to compete across state lines.

    3. Allow tax-free medical savings accounts, permitting people to buy high-deductible catastrophic coverage while paying for routine care out-of-pocket.

    There are certainly additional reforms I would advocate, but these would be a good start.

  59. #59 Pseudonym
    May 18, 2009

    Paul Murray:

    Personally, I don’t have private insurance for two reasons:
    1) I don’t trust for-profit healthcare. They are in the business of taking your money and then denying you cover.
    2) I’m proud to pay extra to support the public system. I like to think that the money goes more-or-less directly to the less fortunate.

    I do have private insurance for two main reasons:

    1. Dental work currently isn’t covered by Medicare. My private insurer has dental clinics that are convenient for me to get to, and preventative work is 100% covered. (This will probably get fixed soon, but until it is, I find this is a good trade-off.)
    2. Eye checks are covered by Medicare, but my private insurer will happily fork out for a new pair of glasses every year for everyone in the family.
    3. We are a single-income family, and even though I’m in good health and haven’t spent so much as a day in hospital since I was born, I think that it’s a good trade-off for me to buy the ability to “jump the queue” should I ever need elective treatment.

    I’m also proud to support the public system, but for me, buying private insurance aids that by freeing up a hospital bed in a public hospital for a very small proportion of my money. I don’t believe in a two-tier health system, but this way I contribute my fair share overall.

  60. #60 Dentist Melbourne
    May 26, 2009

    While some wonder if the government can now afford to move forward with comprehensive health care reform next year, others wonder if the government can afford not to proceed with significant changes. Health care reform can be expensive (Barack Obama’s plan is estimated to cost $50 billion to $60 billion a year). Still, health care has strong ties to the economy. Today, 46 million Americans are uninsured, and health care costs continue to rise at an alarming rate.

  61. #61 Dentist Thornhill
    September 16, 2009

    Employer-based health insurance was instituted because employers wanted to retain skilled workers but were unable to increase their wages in a time of wage and price controls. So instead of wage hikes, they provided “non-wage” benefits.

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