Respectful Insolence

When flame meets straw (man, that is)

It gives me no pleasure to do this, but sometimes even friends let loose with such jaw-droppingly bad arguments that it is impossible for me not to redirect a bit of the old Respectful Insolence in their direction. So it was earlier, when I saw an unreasonable article by an otherwise reasonable guy sneak into my newsfeed. If you want to see an example of a bad analogy, watch Dr. Kevin Pho have at it in a post entitled We’ve Tried Single Payer Health Care, and It Has Failed.

Quoth Kevin:

Based on an agreement in 1787, the government is responsible to provide free health care to Native Indians on reservations. And, as you can see from this scathing story from the Associated Press, that promise has not been kept.

It is a horrible story about how badly underfunded and run the Indian Health Service (IHS) is, certainly a story worthy of comment. Unfortunately, Kevin uses the story as an excuse to indulge his dislike of anything resembling a single payer system by laying down one of the worst arguments I’ve ever seen anywhere (and I do mean anywhere):

And, after Haiti, where in the Western hemisphere do men have the lowest life expectancy? It’s on Indian reservations in South Dakota.

The primary reason, not surprisingly, is lack of money, compounded by a difficult time recruiting physicians and other clinicians. Indeed, many Indian health clinics cannot “deal with such high rates of disease, and poor clinics do not have enough money to focus on preventive care.”

So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.

Because the IHS is just like a Medicare-for-all type solution to the problem of the uninsured.

This is nothing more than a massive “guilt by association” argument, along with a nice straw man. The straw man in Kevin’s argument is the assumption that anyone has ever proposed anything resembling the IHS as health care reform. The shorter (guilt by association) version of Kev’s argument goes:

  • The IHS is underfunded and poorly run. It is a government health care program.
  • Therefore any government funded health care program that Congress can come up with is likely to be just as bad.

Unfortunately for Kevin’s argument, there is no inherent reason to assume that this will necessarily be the case, and Kevin is drawing historically ignorant inferences. After all, it’s not as though the government doesn’t have a 200+ year history of making promises to Native American tribes and then breaking them, is it? It couldn’t be, could it, that this is just another example of a broken promise in a long line of broken promises? It couldn’t be that the enormous burden of chronic disease and profound poverty, not to mention the consideration that the reservations are considered to be nations with varying degrees of sovereignty, could it? But, no, to Kevin, the sordid history of how the U.S. has mistreated Native Americans as demonstrated by the failure of the IHS to provide adequate care on the reservations is damning evidence that single payer health care would, if implemented, fail. To Kevin, the IHS is an attempt at single payer insurance and damning evidence that it has “failed.”

It must be nice to be able to ignore so blithely all the factors that make this comparison specious at best.

Of, course, it’s odd that Kevin briefly mentions the V.A. system early in his post, as though it were as bad as the IHS. It’s not. In fact, the V.A. routinely delivers excellent care. If I were a V.A. doc, I’d be profoundly insulted by that insinuation.

There are certainly reasonable arguments to be made against a single-payer system, but, unfortunately, Kevin’s isn’t one of them. As for me, I used to think a lot like Kevin in that I was profoundly opposed to any sort of single-payer plan. Even so, I’ve said it before, and I’ll say it again. We already have government-run health care in the U.S. It’s here; our system is not a free market and has not been one ever since I first entered medicine back in the 1980s. The government in essence sets what physicians and hospitals can charge for any procedure through Medicare reimbursement rates, and the third party payers use that as a baseline to negotiate their rates of reimbursement with hospitals. Indeed, we have the worst of both worlds. We have in essence a government run system that doesn’t provide the the one benefit that, whatever its inherent faults and shortcomings, any government-run system should be able to claim over a private system: universal coverage.

The longer I see the dysfunction in the system the less able I become to defend it. I’m sure that practicing in one of the most economically depressed (if not the most economically depressed) region of the nation probabably hammers home the problems in our health care system. Perhaps that’s why I no longer fear single-payer the way I used to.

Comments

  1. #1 spudbeach
    July 6, 2009

    Orac, I see your point, but let’s cut Kevin a teensy bit of slack.

    The problem is that it’s relatively easy to start a single payer system, but hard to actually run it. The political will to fund it can be lacking, just like having the political will to fund adequate infrastructure maintenance (care to look at our bridges?). Funding for the IHS is even harder to get.

    Most of the horror stories I’ve read about Canadian and British health care have been “Oh my gosh, we had to wait ages for a band aid!” type things. If government was willing to spend more money, and people were willing to pay more taxes, those stories would mostly go away.

    Would adequate funding be a problem in the US? Would republicans / liberterians / etc. actually like paying taxes if they thought they were getting something? Somehow, I have my doubts.

  2. #2 Rjaye
    July 6, 2009

    Thank you, thank you, thank you, Orac, for this post. For Dr. Pho to use the Indian Health Service as an example of a failed “single payer” system ignores so many issues with the example it was clear he was grasping at straws.

    The mismanagement of that system is well known to anyone who has to deal with the tribal health centers, and that the system would work if it had appropriate funding and management. Given the lack of political will of the federal government to clean up a corrupt system also shows some of the deeper ideological and racial issues of how the tribal system is “organized.”

    Whether we like it or not, we can go single payer with a clear vision, or end up with a screwed up single payer years later because we let the “market” decide for us…and be managed by privatized interests with a higher overhead than if it were managed by the government, and with fewer people served.

    And about the VA…you are right. There are good VA hospitals, and we need to make sure those that are remain so, and to improve the bad hospitals. I’d also like to see even more improvement in the VA, because in my opinion we owe it to our vets.

  3. #3 antistokes
    July 6, 2009

    Well, I’m not sure what health care system the Germans have, but I got my toothache sorted out damn quickly (walked in to an office of MY choice, they made me an appointment for the very next day, and 40 min.– maybe about 3 min. total in the waiting room, too– and 10 euros later, no more toothache).

    My US experience with dental care was for the dental office to outright lie to me about my health care coverage, and then sue me for the full amount ($2,0000) when, as it turns out, I was not covered for the procedure.

    Quite frankly, the Germans have have half my paycheck, if I get treated decently when I’m in significant pain.

  4. #4 Eric Lund
    July 6, 2009

    So an underfunded, poorly run health care program has poor outcomes. In other news, water is wet, bears defecate in the woods, and Generalisimo Francisco Franco is still dead.

    That the IHS is a government-run program is not relevant. They could turn it over to a private contractor, and it would still be just as bad, if not worse. In fact, we have already done a similar experiment with the general health care system: it’s a poorly run (though admittedly not underfunded, which is part of the problem) system that produces mediocre outcomes even without government “help”. Short of Republicans/Libertarians making a creative effort in this direction (a well-founded fear, as spudbeach suggests), I have a hard time envisioning how a government-run system could be worse.

  5. #5 Tyro
    July 6, 2009

    If he wants to use life expectancy as a proxy for the effectiveness of a nation’s health care, it is dishonest to ignore the fact that the US is 50th in the world, behind every western nation except a handful of Baltic states and only just beats out Albania, Cuba and Libya.

    There may be some valid arguments against single-payer but to imply that it will reduce life expectancy is not one.

  6. #6 Luis
    July 6, 2009

    Thanks, Orac. I had considered just sending Kevin an email with a FARK meme in it: “False equivalence is false.”

    And it is. I normally love the guy’s work, but this was just strange.

  7. #7 Greg
    July 6, 2009

    This post is a bit long, sorry but it’s important that people know the truth about what is going to be the biggest lost opportunity of this century if you don’t get a public option for health care…

    I’m an American living in Canada for the last six years and I can say from experience that the system up here is fine. Look, for those of you who are unsure it’s because you’ve fallen for the same propaganda as most other right-wingers, which is based on cherry-picked anecdotes of people who have had poor experiences. The vast majority of Canadians are happy with the system. Sure they would like things to move a little quicker for non-emergency procedures, but over all the system works and no one would ever give it up. In fact it’s considered one of the greatest achievements of the last century. Pierre Trudeau, the prime minister who pushed through the Canada Health Act, has been consistently voted the Greatest Canadian in yearly polls. That should say a lot about the system.

    Anyway here is a link to an article that sums up some of the myths about the Canadian system, it’s pretty accurate depending on what Provence you live in I’ll copy the meat of it below.

    http://www.denverpost.com/recommended/ci_12523427

    Myth: Taxes in Canada are extremely high, mostly because of national health care.

    In actuality, taxes are nearly equal on both sides of the border. Overall, Canada’s taxes are slightly higher than those in the U.S. However, Canadians are afforded many benefits for their tax dollars, even beyond health care (e.g., tax credits, family allowance, cheaper higher education), so the end result is a wash. At the end of the day, the average after-tax income of Canadian workers is equal to about 82 percent of their gross pay. In the U.S., that average is 81.9 percent.

    Myth: Canada’s health care system is a cumbersome bureaucracy.

    The U.S. has the most bureaucratic health care system in the world. More than 31 percent of every dollar spent on health care in the U.S. goes to paperwork, overhead, CEO salaries, profits, etc. The provincial single-payer system in Canada operates with just a 1 percent overhead. Think about it. It is not necessary to spend a huge amount of money to decide who gets care and who doesn’t when everybody is covered.

    Myth: The Canadian system is significantly more expensive than that of the U.S.Ten percent of Canada’s GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada’s. Part of the reason for this is uninsured and underinsured people in the U.S. still get sick and eventually seek care. People who cannot afford care wait until advanced stages of an illness to see a doctor and then do so through emergency rooms, which cost considerably more than primary care services.

    What the American taxpayer may not realize is that such care costs about $45 billion per year, and someone has to pay it. This is why insurance premiums increase every year for insured patients while co-pays and deductibles also rise rapidly.

    Myth: Canada’s government decides who gets health care and when they get it.While HMOs and other private medical insurers in the U.S. do indeed make such decisions, the only people in Canada to do so are physicians. In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.

    There are no requirements for pre-authorization whatsoever. If your family doctor says you need an MRI, you get one. In the U.S., if an insurance administrator says you are not getting an MRI, you don’t get one no matter what your doctor thinks — unless, of course, you have the money to cover the cost.

    Myth: There are long waits for care, which compromise access to care.There are no waits for urgent or primary care in Canada. There are reasonable waits for most specialists’ care, and much longer waits for elective surgery. Yes, there are those instances where a patient can wait up to a month for radiation therapy for breast cancer or prostate cancer, for example. However, the wait has nothing to do with money per se, but everything to do with the lack of radiation therapists. Despite such waits, however, it is noteworthy that Canada boasts lower incident and mortality rates than the U.S. for all cancers combined, according to the U.S. Cancer Statistics Working Group and the Canadian Cancer Society. Moreover, fewer Canadians (11.3 percent) than Americans (14.4 percent) admit unmet health care needs.

    Myth: Canadians are paying out of pocket to come to the U.S. for medical care.Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care. Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is.

    Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.Princeton University health economist Uwe Reinhardt says single-payer systems are not “socialized medicine” but “social insurance” systems because doctors work in the private sector while their pay comes from a public source. Most physicians in Canada are self-employed. They are not employees of the government nor are they accountable to the government. Doctors are accountable to their patients only. More than 90 percent of physicians in Canada are paid on a fee-for-service basis. Claims are submitted to a single provincial health care plan for reimbursement, whereas in the U.S., claims are submitted to a multitude of insurance providers. Moreover, Canadian hospitals are controlled by private boards and/or regional health authorities rather than being part of or run by the government.

    Myth: There aren’t enough doctors in Canada.

    From a purely statistical standpoint, there are enough physicians in Canada to meet the health care needs of its people. But most doctors practice in large urban areas, leaving rural areas with bona fide shortages. This situation is no different than that being experienced in the U.S. Simply training and employing more doctors is not likely to have any significant impact on this specific problem. Whatever issues there are with having an adequate number of doctors in any one geographical area, they have nothing to do with the single-payer system.

    And these are just some of the myths about the Canadian health care system. While emulating the Canadian system will likely not fix U.S. health care, it probably isn’t the big bad “socialist” bogeyman it has been made out to be.

    It is not a perfect system, but it has its merits. For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system. Her $35,000-plus surgery is finally scheduled for next month. She has been in pain, and her quality of life has been compromised. However, there is a light at the end of the tunnel. Aunt Betty — who lives on a fixed income and could never afford private health insurance, much less the cost of the surgery and requisite follow-up care — will soon sport a new, high-tech knee. Waiting 14 months for the procedure is easy when the alternative is living in pain for the rest of your life.

  8. #8 Becca Stareyes
    July 6, 2009

    Another case of confounding variables. I mean, if you mention both the VA and IHS as ‘health-care programs run by the US Government’, then you have to argue why one works better as an analogy for a hypothetical single-payer program as the other. You can’t just briefly mention the one that mostly works, then go into great detail into the one that fails, without explaining why the one that fails is the better case.

    antistokes @ 3
    The one thing I took away from my flirtations with Libertarianism and my father the economic conservative was ‘you get what you pay for’. Personally, I’m willing to pay higher taxes to ensure good health care and education systems in this country — and also yell at people until it gets done. Both for my nearest and dearest, and because I hope to be a professor someday and having healthy, well-educated students will keep me healthy, paid and not wanting to kick the system because I am teaching remedial math instead of astronomy.

  9. #9 antistokes
    July 6, 2009

    Personally, I’m willing to pay higher taxes to ensure good health care and education systems in this country

    My own personal solution is to a) have less people and b) have more money. (/kidding….not a real solution, but it would be a nice one…)

  10. #10 Carolyn
    July 6, 2009

    Greg @ 7: The “Greatest Canadian” winner who championed the single payer system was Tommy Douglas (never prime minister, but the federal NDP leader at the time, and Saskatchewan leader who first introduced it there), not Pierre Eliott Trudeau. Indeed, the prime ministers who got medicare rolling were Deifenbaker, and then Lester B. Pearson, whose government finally passed the act. Trudeau is Mr. “Just watch me” and “The state has no place in the bedrooms of the nation”.

    But what you say rings true. Things here aren’t perfect, but generally, they’re not bureaucratic.

  11. #11 Alison Cummins
    July 6, 2009

    As a Canadian happy with her health care, I say: Thanks, Greg!

  12. #12 Greg
    July 6, 2009

    Carolyn,

    Fair cop, I was briefly watching last years “Greatest Canadian” show and got them confused, plus I haven’t studied my citizenship manual yet, guess I better devote extra time to it… :)

    ~Greg

  13. #13 bureaucrat
    July 6, 2009

    If we limited ourselves to policy interventions that have worked on Indian Reservations, we’d be left with well, nothing. Although, I suspect that has more to do with the government’s shameful and sordid history with Native Americans than anything else.

    I have government run health care. It’s pretty darn good. The United States Congress in their infinate wisdom decides what is covered and what is not covered. The saving grace is that they have to live with whatever they decide to so it’s mostly reasonable. Now it’s not a single payer system, since I get to pick one of the many plans under the Federal Employee Health Benefits Plans (FEHBP).

    I think its a model worth looking at because the US isn’t likely to adopt anything that would put all the health insurance companies out of business immediately. They are going to have some role, like administering plans, probably in some level of competition with each other to keep our free market friends happy. (The level of competition among plans based on advertising is fierce!)

    Since federal employees pay part of their coverage it’s not a perfect analogy. People can and do pay more because they value different things in their coverage. On the other hand, I went to a higher per month cost plan this year, but ended up with significantly lower out of pocket expenses total because of how that plan structures specialist visits and perscription drug copays.

    Giving people the most basic coverage (which under FEHBP is pretty good) and leting people make choices about what they want or need after that could go a long way to asuaging fears that people have about say not being to able to choose their own doctor or get a referral to see a specialist of whatever.

  14. #14 Travis
    July 6, 2009

    Greg, I have to say I agree with everything you say. I am Canadian and have had nothing but good, or at least reasonable experiences from our health care system.

    I am a student, if I have a minor problem that does not require immediate attention I can usually see a doctor on campus within a few days, if I was actually sick I could get in that day easily.

    Recently I had a minor problem, it did take a while to see a specialist but it was a minor problem, I was not in any pain, it was not going to kill me. The only paperwork I have had to fill out was a 2 page form about my history when I got to his office which I did while waiting to go in. The only other thing I have had to do was supply my medicare number, no worrying about money or anything. By the end of the exam, we talked about the surgery and I signed off on it, and within a week I had a date set for it for three weeks later. In a week I go for the surgery, I have not had to worry about money, proving to an insurance company it is required, or anything like that. Of course it leaves me to worry about the procedure itself but I prefer that to worrying about anything else.

  15. #15 D. C. Sessions
    July 6, 2009

    If I were a V.A. doc, I’d be profoundly insulted by that insinuation.

    And if you were an IHS doc, you’d have every right to be flaming furious.

    I have more contact with IHS than most, since I do volunteer EMS work on one of the Apache reservations. The IHS staff that I know are some seriously dedicated and hard-working people, and I say this after living with a Level One NICU nurse for 25 years. That sets a pretty high bar.

    The trouble is, dedication and hard work will only get you so far in the face of massive problems and minimal resources.

  16. #16 scote
    July 6, 2009

    This flame is long overdue. Kevin MD has long been a knee-jerk, ideological foe of Single Payer health care. It is one of the areas where he doesn’t let the facts interfere with his opinion. And there is the fact that Kevin MD deliberately writes up controversial posts to his blog to gin up traffic, as he has admitted to me in his blog comments, so it is hard to take what he writes seriously.

    Kevin MD is engaging, but the idological knee-jerk posts turned me off and I’ve kicked him off my blog roll in favor of engaging writers who still stick to science and facts, like yourself.

  17. #17 Joseph C.
    July 6, 2009

    For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system.

    Somehow I think they should do better than 14 months for someone who has presumably paid into the Canadian system their entire working life.

  18. #18 rrt
    July 6, 2009

    Greg (or others with an idea):

    I’ve heard that comment about the US’ 31% overhead vs. a potential 1% (or very very low) overhead before, and it doesn’t smell right. I suspect they are not being fairly calculated. Do you know how they are determined? My biggest suspicion is that many of the US overhead expenses are being offloaded in the “public” model onto the government in general–in other words, that both the US and Canadian systems ultimately pay for the same thing (say, office space) but that it’s not being counted for the Canadian system.

    I’m also having a hard time with believing that this is functionally true:

    “In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.”

    Isn’t that at least partially contradicted by quotes like these?:

    “…services that are deemed medically necessary, not experimental…Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is…”

    How is it decided what is medically necessary? What waits are prudent? How urgent is urgent enough? Your physicians aren’t making these decisions purely on their own opinion with no governmental/health system influence…are they? I’m also a little confused about the lack of physicians affecting availability of care in rural areas. Why wouldn’t training more physicians solve the problem? Again, my suspicion here is that the lack of physicians could have something to do with them not being attracted to the field due to things like rates of pay, although I wonder if I’m missing something simple, like “it’s geometrically impossible” or something.

    Please understand that I ask these questions from the perspective of someone who VERY much wants something like the Canadian system. I’m all for this. But I think these might be details that are being glossed over, and I’d like to understand them better. And I completely agree with several others’ worries: My biggest fear overall is that if we try this, we won’t have the political will to carry it through. I fear we’ll grossly underfund it, whining about taxes the whole way through. It hurts me a LOT to say I don’t have the faith in my fellow Americans to believe we’ll do this right.

  19. #19 Landru
    July 6, 2009

    A little outside of your usual oeuvre, but good post on an important topic. It bears noting that the US is nearly alone among industrialized nations in not providing health care for its citizens as a fundamental right. It also bears noting that a number of semi-industrialized countries that suffer a lot of American scorn (Cuba, for instance) have, by many measures, significantly better health care than we do.

    Not entirely sure I agree with you about the VA, but it’s certainly true that the VA system is not universally bad, and it suffers from the same sort of anecdotal jibes as any other system, hospital, or practitioner, so as much as I like to type out bloviations and see them on the Internets, I’ll shut up about that.

    It is refreshing to see this from a doc who has to be making a nice living as a doc (this is not intended as a value-laden characterization, nor is it meant to suggest that you are driven by money). Thanks, Orac.

  20. #20 Chris
    July 6, 2009

    As a New Zealander I find it mind blowing that American’s pay for their own healthcare (meaning that so many of you are entitled to none of the most basic care because you cannot afford it). Our healthcare system isn’t perfect, but at least if I injure myself or become ill, I know there’s a bed for me and it wont cost me anything.

    I also love that if I cause an accident, I’m at absolutely no risk of being sued if I cause the other person injury, but can also sleep at night knowing that if they’re out of work they will still receive 80% of their wages. No fault accident cover FTW.

  21. #21 Michael Ralston
    July 6, 2009

    rrt: A significant portion of the 31% in American healthcare goes to advertising, and another significant portion goes to a bunch of insurance-company bureaucrats whose job it is to try to drop people from the plan for attempting to make use of it.

    Medicare, by contrast, has a 3% administrative overhead.

  22. #22 Travis
    July 6, 2009

    rrt, I don’t know the details of it, I should contact one of my doctor friends and ask them how they decide what needs to be done when and where, and when things are needed, but I do not believe there is any government person sitting there with a stamp saying yes or no to a procedure being done, but I do not know what the doctors themselves have to go though. All I know right now is that my experience is that I go in, the doctor says I need to get something done and it happens.

    From having listened to news about the health care system here for some time I think one of the large problems about getting doctors to go to rural areas is simply that they are rural areas, not that the pay is poor. I believe there are some initiatives that are out there trying to get doctors to at least stay in rural areas for a few years after they finish.

    Anyway, I hope someone knows a little more about this. I will have to go do some reading as all I remember now are fuzzy reports from the news.

  23. #23 rrt
    July 6, 2009

    I understand, Travis…but my point is that surely there’s someone in the system who says to the doctor “um…no, you can’t give Mr. Simpson Dimoxinil to keep his brain from freezing.” Somebody’s gotta be drawing some lines besides the frontline doctor, and I strongly suspect that someone is either “the guvmint” or is very strongly influenced by it (say, by saying “here’s the money you get to spend this year…figure it out!”) That could be a problem. I’m guessing that Canada and others have some interesting ways mitigate the risk, but I bet the risk is still there.

    And thanks, Michael Ralston. That helps, but still, I knew that already. I’m wanting to know just how much is “wasted” overhead, and how much overhead on the government side (if any) is being hidden. Are we REALLY spending 28% of our healthcare dollars ONLY on things like profit, marketing, executive compensation, Committees of No and needless duplication of effort between competing companies?

  24. #24 shoshidge
    July 6, 2009

    I’m living in Calgary and would like to thank Greg for setting people straight on the truth about Canadian health care.
    I am very happy with our system, in spite of it’s minor shortcomings.
    Some of the histrionic scare mongering that goes on when the issue of any degree of socialized health care comes up makes for hilarious reading for us up here in ‘Soviet Canuckistan’
    The very disingenuousness of it should make people suspicious.
    Also, why always compare to Canada? Our system may be superior in most regards to the American one but that doesn’t mean it’s the best. How about France, Germany Denmark, Australia, Japan, Korea etc?
    Their models might fit America better than Canada’s, but, i suppose, given that they tend to favor hybridized systems, combining the best of socialized and capitalized health care, they don’t have the capacity to give paranoid libertarians the kind of nightmares that Canada’s system does.

  25. #25 Ian Musgrave
    July 6, 2009

    Denialism blog did a whole series of posts looking at actual objective data on the performance of “single payer” systems.

    UK, Canadian and New Zealnd systems http://scienceblogs.com/denialism/2009/05/what_is_health_care_like_in_th.php for comparison Australia http://scienceblogs.com/denialism/2009/05/whats_health_care_like_in_aust.php, following the links at Denialism blog will also show you comparisons for the Netherlands, France and Germany.

    Bottom line, better outcomes for overall mortality and morbidity for a lower cost but longer waits for elective surgery (except NZ, Germany, Netherlands).

  26. #26 Jud
    July 6, 2009

    I had the pleasure (yes, really) of using the Canadian health care system after spraining an ankle. Walked (well, limped) in the front door of the hospital, walked out 45 minutes later having in that time gone through intake, been x-rayed, had the films read, been expertly Ace-bandaged, then gone through billing where, since I was not a citizen, I was billed the princely sum of $60 Canadian (about $45 U.S. at the time) for my treatment.

    OTOH, yes, I did know someone with a painful shoulder problem that required orthopedic surgery for which he waited the better part of 7 months.

    Then there was the fellow with terminal lung cancer for whom the Canadian system would (quite justifiably) do nothing beyond palliative care, who private paid a minor fortune to a San Diego facility for an experimental treatment, then died a month or two later. (I forget at the moment what insanely large share of Medicare’s total expenditures on medical care is spent on treatments that occur during the last year of life. One thing we can do to substantially reduce U.S. health care costs is work to cure our American obsession with living forever.)

    The Canadian system has the decided advantage of universal coverage (as our Kiwi friend says, it’s unbelievable – a sin, really – that we deny health care to those who need it simply because they happen to be poor or lack insurance for some other reason, or we require hospitals to take on the burden of treating them for free). However, I don’t think the Canadian system will fly in the U.S. as a political matter, having heard wealthy Canadians pin their 50% marginal tax rates on the health service.

    It won’t have to fly, though, since single payer isn’t what anyone in the executive or legislative branches appears to be proposing ATM. As Orac says, pure straw man.

    Last bit, on administrative costs. While I think the 3% admin cost for Medicare uses some creative accounting and CMS’s power as an agency of the federal government (e.g., private insurers must pay up to 4 times industry standard rates to receive electronic claims from Medicare, so Medicare’s costs to process those claims will look quite low), not atypical legal “loss ratio” requirements for private health insurers are 65 or 75 percent, meaning 25% to 35% of the premium dollars the insurer receives can be spent on something other than paying benefits.

  27. #27 Mark P
    July 6, 2009

    I, like Chris above, am from New Zealand. The state health care system is a no-go area for politicians. To remove it would be to consign a political party to decades of non-election.

    New Zealand is a relatively poor country, and we do our health care on the cheap. As a result many rich people top up their coverage with private.

    I have also lived in France. It spends about the same amount per person as the US, but gets a far, far better service.

    There is only one reason for a rich country to avoid single-payer health care: the bogey-man of “socialism”, which seems to so scare people in the US. As Orac says, what you get instead is a system that is both expensive and inefficient, just in order to keep your idealogical purity.

  28. #28 D. C. Sessions
    July 6, 2009

    However, I don’t think the Canadian system will fly in the U.S. as a political matter, having heard wealthy Canadians pin their 50% marginal tax rates on the health service.

    I’m a damn long way from wealthy, but as an empty-nest single my marginal tax rate plus what my employer and I pay for insurance add up to pretty near that much.

    If I made less, it would be a lot higher. That family of four trying to get by on $50,000 (median houshold income) with $10,000 insurance and $3500 FICA, plus Medicare, and we haven’t gotten to the income tax yet …

  29. #29 Kevin B
    July 6, 2009

    Here’s an arguement for why the IHS is a model to consider: http://www.marktrahant.com/MarkTrahant.com/The_premise.html

    We should be careful to make healthcare outcome-based rather than process-centric. Consider this from the link above:

    “There has been considerable improvement in American Indian and Alaskan Native health since the IHS was founded in 1955. One study found: “In the first 25 years of the program, infant mortality dropped by 82 percent, the maternal death rate dropped by 89 percent, the mortality rate from tuberculosis diminished by 96 percent, and deaths from diarrhea and dehydration fell by 93 percent. The improvement in Indians’ health status outpaced the health gains of other U.S. disadvantaged populations.”

  30. #30 Calli Arcale
    July 6, 2009

    The main problem with the analogy is that IHS isn’t a single-payer system — it’s damn near a “no-payer” system. The clinics do the best they can, and there are some incredibly dedicated physicians and nurses working in the system, but it’s like trying to put out a wildfire with a straw. They just don’t have the resources.

  31. #31 Phoenix Woman
    July 7, 2009

    Of, course, it’s odd that Kevin briefly mentions the V.A. system early in his post, as though it were as bad as the IHS. It’s not. In fact, the V.A. routinely delivers excellent care. If I were a V.A. doc, I’d be profoundly insulted by that insinuation.

    No kidding. And if Kevin knows about the IHS, then he certainly knows about the much bigger VA — which has ever since Bill Clinton fixed it up been recognized as the best health-care provider in the US.

    As for the IHS, its problems have a lot more to do with how Native American issues in general are shoved under the rug than about single-payer specificially. For Kevin to single out IHS while pretending the VA doesn’t exist is symptomatic of extremely dishonest cherry-picking on his part.

  32. #32 Michael Simpson
    July 7, 2009

    Thanks Orac, great article. But special kudos to Becca…I’m so tired of these myths about how bad the system is in the UK and Canada. It’s as if the right wing would rather believe that health care for a few is good, when in fact, we have a disastrous health care for many, and it’s bankrupting individuals and the country.

    And kudos to Phoenix Woman. The VA system is getting a lot of bright energetic young physicians, and is well run. Is it perfect? Well know, but I’d say the same about Kaiser or UHC or any other health plan.

  33. #33 Michael Simpson
    July 7, 2009

    Actually my special Kudos go to Greg. Not that Becca said anything wrong, I just moved one post down in reading the author of the Canadian healthcare myth posting. My bad.

  34. #34 Daniel M
    July 7, 2009

    If it hasn’t been said already, shame on you – the response to the idea that single-tier, single-payer healthcare would be as bad as the IHS is, is that it’s probably far more likely to bring UP the level of medical care that Indians have access to.

    right now, you have indians sitting in the back of the bus. They’re still there.

    do you like the taste of that? I don’t, and I’m not even in the same continent.

    I think everyone should be entitled to the same level of universal healthcare, then there wouldn’t be this drop-off of funding for second- or third-class people whilst the priviledged upper-class rich folk get their hangnails seen to whilst sipping champagne straight from their hospital bed attended by hordes of private nurses.

    I jest with hyperbole, but surely you get my point – erase the need for health-care providers to be, first and foremost, money providers, and let them be healthcare providers instead, and whilst you’re at it, make sure that everyone who needs to get to a doctor can, and doesn’t end up filling up the ER unit after waiting until they really, really have to.

  35. #35 DLC
    July 7, 2009

    Orac, the guy deserved it. Bad Logic and faulty reasoning.

    For you “single payer” fans, a couple of questions:
    first: can you explain please the difference between “single payer” and “socialized medicine” ?
    And second: what happens to the insurance companies ?
    Are you really suggesting that (for example) Humana competes with Government in direct competition? I think we all know who’s going to win that one.

    Note: No, I’m not trolling for an argument here or asking for a flame war, I’m just asking because I’d like to see it explained.

  36. #36 Epinephrine
    July 7, 2009

    What stuns me is that in a land so concerned with “rights” that the right to medical care isn’t considered universal, and that there isn’t a socialis(z)ed system for health. The Canadian system certainly isn’t perfect – for example, dental care should be covered and isn’t (it’s not like we’re lacking evidence as to how dental health affects your health), and eyeglasses aren’t covered either despite the necessity of being able to see. As well, both the USA and Canada consider university education a privilege for the wealthy, and have made it increasingly elitist, rather than considering it a right, and funding it as countries like France do.

  37. #37 Dianne
    July 7, 2009

    A problem with the US-American system is that it is actually more expensive in terms of public money spent than any other health care system in the world. According to the Economist, the US spends more public money on health care than any other country (I think Switzerland was next but don’t remember for sure.) So introducing universal health coverage could actually decrease health care expenditures and possibly (after the inevitable initial investment was over) actually _decrease_ taxes.

  38. #38 Robin Levett
    July 7, 2009

    @DLC:

    first: can you explain please the difference between “single payer” and “socialized medicine” ?

    Yup.

    “Single payer” is a system that works pretty much everywhere in the first world, and in parts of the developing world, to produce better health outcomes across the population than the US system.

    “Socialized medicine” is what certain USAans like to call single payer systems to paint them with guilt by association with the term “socialist”.

    Am I right? Do I get a biscuit?

  39. #39 D. C. Sessions
    July 7, 2009

    And second: what happens to the insurance companies ?

    That’s capitalism for you — times change. Some you win and some you lose.

    Insurance companies understand that shit happens, Baby.

  40. #40 Joseph C.
    July 7, 2009

    “Single payer” is a system that works pretty much everywhere in the first world,

    Except in Britain, of course, where they actually have socialized medicine in the sense that the government owns hospitals and directly employs those who work in them.

  41. #41 Pablo
    July 7, 2009

    I know that people complain about waiting times for non-critical procedures in Canada, but I can relate that a few years ago when I was suffering from an underarm rash and needed a derm consult, the earliest appointment I could get was in 6 weeks. This was for an active rash that was driving me crazy.

  42. #42 Tyro
    July 7, 2009

    @DLC

    first: can you explain please the difference between “single payer” and “socialized medicine” ?

    I don’t know what “socialized medicine” is. Is that where a government flunky must approve each of seven copies of a request to apply a tongue depressor or is it like “socialized police force” and “socialized firefighting”, some BS name that demagogues use to imply Uncle Joe himself will come back and take their guns?

    Seriously though, read Greg’s FAQ. Under single payer in Canada, doctors generally work for themselves in private businesses and submit claims for their services, the big difference is that there is only one “insurance company” to reimburse them.

    And second: what happens to the insurance companies ?

    They wither and die or, more likely, they accept government handouts. Which reminds me, what is the difference between “socialism” and “US-Style Capitalism”?

  43. #43 Natalie
    July 7, 2009

    I’m also a little confused about the lack of physicians affecting availability of care in rural areas. Why wouldn’t training more physicians solve the problem? Again, my suspicion here is that the lack of physicians could have something to do with them not being attracted to the field due to things like rates of pay, although I wonder if I’m missing something simple, like “it’s geometrically impossible” or something.

    As Greg mentioned, lack of physicians in rural areas is a problem int he US as well as Canada, so at the very least one cannot chalk it up to the healthcare system. My suspicion is that rural areas generally don’t have enough of a population to support a full-time physician, since the population of the rural US has been steadily declining since the 50s. I don’t know if Canada is experiencing similar demographic shifts, but it wouldn’t surprise me.

    Somebody’s gotta be drawing some lines besides the frontline doctor, and I strongly suspect that someone is either “the guvmint” or is very strongly influenced by it (say, by saying “here’s the money you get to spend this year…figure it out!”) That could be a problem. I’m guessing that Canada and others have some interesting ways mitigate the risk, but I bet the risk is still there.

    The question I have for you is, do you think this doesn’t happen in the US? The person drawing the line here is an insurance company employee, but they are drawing a line nonetheless. Is that better than Congress doing so, and if so, why?

  44. #44 Alexis
    July 7, 2009

    Actually, not all European countries use single payer: they use mandatory private insurance or a hybrid.

    As for who decides what treatments are available: I don’t know Canada. I lived in the UK for several years (moved back less than a year ago). NICE approves all new treatments, using a cost-benefit analysis (leading to the high profile cancer drug rejections, or the infamous Avastin/Lucentis problem).

    On top of that, individual primary care trusts can decide to fund, or not fund, certain treatments. This leads to a phenomenon called the “postcode lottery” where you can get something in one part of the country, but not another. IVF would be a classic example, with pretty much every trust having its own criteria for how many cycles they will fund (anywhere from 0 to 3) and who they will fund it for. The situation is complicated by people suing, for Herceptin for example. There are other mechanisms for controlling costs, eg GP drug bills–there are guidelines for prescribing to keep the costs down.

    The NHS has a lot of targets, for both hospitals and doctors; this also affects treatment choices and can cause other issues. For example, several years ago the government decreed that patients should be seen by their GP within 48 hours. Many surgeries promptly made it next to impossible to schedule appointments in advance and started relying on “emergency” phone up on the day appointments, so they could meet the target. The NHS is used as a political football, and it shows.

  45. #45 PhilB
    July 7, 2009

    From what I recall from stories around Colorado, getting physicians into rural areas is a proplem for several reasons. Among those, PCP practice in general pays significantly less than specialization and probably moreso in rural communities. New doctors facing six figure med school bills would have incredibly hard times just paying their med school debt.

    I’ve heard stories on NPR of some communities and clinics actually resorting to offering to pay off medical school debt in its entirety in exchange for 5 year commitments to work in local clinics.

  46. #46 Greg
    July 7, 2009

    To the the question of administrative costs of the Canadian system; I honestly don’t know the accuracy of the 1% figure but it is the one that seems to pop up a lot when I googled it, as well as the 3% for Medicare, so I think it’s correct within a margin of error. That said, even if it was 10x that amount it would still only be 10%, a third of the US system.

    To the question of:
    “In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.”

    Isn’t that at least partially contradicted by quotes like these?:

    “…services that are deemed medically necessary, not experimental…Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is…”

    How is it decided what is medically necessary? What waits are prudent? How urgent is urgent enough? Your physicians aren’t making these decisions purely on their own opinion with no governmental/health system influence…are they? I”

    I’m not a Dr. so I can’t say from personal experience, however my good friend is a senior Dr at an ER in Ontario and I asked him. He told me that 99% of the time it’s not an issue, you order the tests the patient needs and schedule the procedures they need. Those tests and procedures have been examined and reviewed by doctors and administrators within the system to determine how well they work, as are new procedures. In the few cases that a procedure or test is too new or experimental that it hasn’t been reviewed, or found to be ineffective, it can be denied.
    As for wait times there is a metric based on a variety of factors but mostly on medical necessity, basically if there is a wait – how long can you wait without getting worse compared to others in the system. It’s not first come first served, or whoever has the best insurance or the most money get to go first, regardless of necessity.

    It’s a sane, reliable and equal system.

    There have also been some questions out there about the Canadian system being underfunded, and European systems as well. Well this is really more of a political problem rather then the systems. When something works well for long enough and is not used by everyone everyday, people begin to take it for granted. They don’t think where the money is coming from when new politicians start calling for tax cuts to get or stay elected. So over time fractions of a % are removed from each budget, never enough to make a huge difference, but enough to cause hospitals to put off some things a bit here, cut a position there. After a while, wham, all of a sudden the system is underfunded and people start complaining that wait times are “out of control!”, the system is broken! It’s never your fault for expecting something for nothing or being more interested in that few extra $s you saved the last few years in taxes than the services those dollars buy.

    The fact is that services cost resources and those resources are represented by money. As a society we can either all chip in and get a good system for everyone, or stay with this Old West style let the strong (rich) survive and the weak (poor) suffer. Today you may be rich, tomorrow you may not be, or worse your kids and their kids my not be as lucky as you are right now. You have to decide and you have to act. Tell you elected representative what you want, and tell their challengers as well, because nothing motivates a politician more than the threat of loosing an election.

    Also I can’t take credit for my previous post, I did not write it , I just linked to the article and then copied it here as well.

  47. #47 rrt
    July 7, 2009

    Don’t misunderstand me, Natalie, I know we have those line-drawers in the US. That’s partly why I assume a national comprehensive system would also have to have it. But I think Greg’s source is misleading (somewhat accidentally, I think) about that. I’d rather not let it be unexplained, as I think that would let opponents define it. No, I’m not suggesting Congress would draw lines worse, but I think we should be clear that someone will be drawing them. In reality I doubt Congress would draw many lines at all; they’d probably delegate most of that to an agency. One of my biggest priorities would be to make damn sure we fund that agency adequately and keep their decisions open and public.

    Rural doctors make a lot more sense to me the way you put it. That’s kinda like rural electrification: we can do it, but it would have to be subsidized. A lot, potentially.

  48. #48 catgirl
    July 7, 2009

    Personally, I’d rather have health care run by elected government officials than by insurance company bureaucrats. Most people do not have any control over their insurance company, since it usually provided by the employer. People have no power to change what they don’t like. Their only choice is to find a new job. If elected people are in charge, we would have more power to do something about it. Of course I’m not naive and I realize that our government has plenty of flaws. But at least we would have the power to vote, and that’s more than we have now.

  49. #49 D. C. Sessions
    July 7, 2009

    I can relate that a few years ago when I was suffering from an underarm rash and needed a derm consult, the earliest appointment I could get was in 6 weeks. This was for an active rash that was driving me crazy.

    That’s about the same story one of my co-workers had, except she’s in Arizona with private insurance. Active phase of intermittent rash, see you in six weeks for the earliest dermatological appointment.

    Busy specialists are busy, period.

  50. #50 Erika
    July 7, 2009

    @41, I don’t know where you are, but at my HMO in Wisconsin I have to wait 3 months to see a dermatologist. I don’t know if they have emergency slots for people w/ melanoma, but for your garden-variety rash, or unknown skin whatsit, you have to wait.

    Regarding the rural doctor shortage, there are a lot of things that go into it, and just turning out more MDs isn’t going to solve it. One problem is that there are relatively few rural med schools and residency programs–so by the time someone interested in practicing in an underserved area gets through 8 yrs of schooling, they’re used to living in a city, and are much more likely to stay where they are. Another issue is retention–the average rural practitioner stays somewhere 7 years before moving on, usually to a larger venue. A number of med schools are trying different ways to train their graduates to go into rural settings. One technique is to choose students more likely to go into–and stay in–a rural setting, which means recruiting students who grew up in rural areas, and possibly went to smaller, less prestigious schools. UM-Duluth, UW – Madison, IU-PUI, UI-Rockford (I think), and U. Washington all have programs of this sort, which focus on giving students rural training experiences at some point in their career–some brief, some immersive. (Lots of other schools, too, but those are the ones I can think of off-hand.)

  51. #51 catgirl
    July 7, 2009

    I’ve almost always had to wait for months to see any specialist. Most of my waits are longer than 6 weeks. I remember being completely shocked when a cardiologist could see me in 2 weeks, and my doctor explained that’s because it was sort-of an emergency. And I live in the United States with private insurance. Anyone who complains that universal health care makes you wait is either completely unaware that private insurance makes you wait even longer, or they are just plain lying.

  52. #52 catgirl
    July 7, 2009

    I don’t know what “socialized medicine” is. Is that where a government flunky must approve each of seven copies of a request to apply a tongue depressor

    No, that’s exactly what the United States has now if you replace “government flunky” with “insurance company flunky”.

  53. #53 Robin Levett
    July 7, 2009

    @Joseph C. #40:

    Except in Britain, of course, where they actually have socialized medicine in the sense that the government owns hospitals and directly employs those who work in them.

    It’s actually rather more complicated than that. Our GPs, and dentists (outside hospitals), are mostly either in practice on their own account or employed by such a practice.

    Inside hospitals, I accept that pretty much everybody is salaried, although not exclusively employed, by the NHS. Having said that, there exists a significant private hospital sector, and the NHS will in some circumstances pay for private treatment.

  54. #54 Joseph C.
    July 7, 2009

    It’s actually rather more complicated than that.

    I’m well aware of this, but my intention was just to give an example of what would classically be considered socialized medicine as opposed to a single-payer model.

  55. #55 chris
    July 7, 2009

    It doesn’t surprise me that Kevin is making a straw-man argument against single-payer government-sponsered health coverage. Many of the people I have heard or read opposed to single-payer systems are physicians. Somewhere in the discussion they always manage to invoke the specter of “socialized medicine” and most of them use the current system’s failures, particularly shrinking profits and rising costs to claim that a single-payer system is a bad idea. They also raise all the usual myths of long lines, lack of availability of technology, too few specialists. Given that physicians in private practice have a better understanding of their costs than most people, it is hard to make a cogent argument defending single-payer coverage when the opposing argument is made by presumably knowledgeable individuals. Obviously, not all physicians believe these things but the ones that do are vocal and carry a lot of clout.

  56. #56 Dianne
    July 7, 2009

    No, that’s exactly what the United States has now if you replace “government flunky” with “insurance company flunky”.

    Having worked with government flunkies (VA system) and insurance company flunkies, I’ll take government flunkies any day. Why? Because government flunkies couldn’t care less. Give them their paperwork and they’re happy and won’t interfere further or try to block you from getting what needs to be done done. Insurance flunkies on the other hand are actively trying to keep you from ordering expensive tests or procedures even when they are clearly indicated and always on the lookout for a way to avoid paying for any medical care at all. I’m sure that they get paid based on how many claims they block. So I’d rather have the conservative’s worst nightmare of universal care than the current system. (And if you ask me “So why don’t you move to Canada?” the answer is “Because I can’t find a job in my area there.” Yep, turns out Canada’s not begging for doctors after all.)

  57. #57 LovleAnjel
    July 7, 2009

    @41

    I had to wait six weeks to see a derm for suspicious moles, and when I checked in for my appointment they told me the referral hadn’t come through yet. The receptionist called whomever and got on their case about it right then (bless her). I still had to wait two weeks to get in.

    I also had to wait 6 weeks to get a breast lump checked out.

    Good thing the biopsy results were normal!

  58. #58 gpmtrixie
    July 7, 2009

    Finance gal here – I had to see if this 31% administrative expense percent is right. Disclosure – I work for a fairly large not-for-profit health insurance company, so I know my company’s data.

    I looked at the most recent annual reports for 4 of the top 5 public health insurance companies (sorry it’s late and I couldn’t get to all 5). In total these 4 companies cover about 85 million people. Throw in my company and you’re up to about 90 million. I had to do some estimation because to calculate this percentage the right way, you can only look at insured business. Many of the large companies in the U.S. self-insure and pay only an administrative services fee to the insurance company (i.e. they pay their own claims).

    For the 5 companies including mine, the admin cost % ranged from 9-14% and this includes profit.

    I also read that the 31% comes from one oft-quoted study that is contradicted by many others whose percentages are more in the range of what I calculated.

    Even though I would likely lose my employment if we went to a single-payer plan, I would be in favor of it if someone had a plan that will work. Medicare is not the answer. I’m sure you’re all aware that the fund is projected to run out of money in 2017 unless either costs are cut or taxes are increased or both. What most people don’t realize is that private insurance probably subsidizes Medicare. What hospitals and doctors can’t get from Medicare, they make up on the private insurance side.

    One person mentioned the FEHBP for federal employees as a model for the whole country. This is actually a reasonable proposal.

    I am not a conservative by any stretch of the imagination, but I have the knowledge of the industry to know that most of the solutions proposed will not work without restricting care or raising taxes, or mostly likely, both.

  59. #59 DLC
    July 8, 2009

    For those who replied to my questions re single payer, thanks.
    I don’t necessarily agree that having government run it will fix health care, but I acknowledge that it’s one possible solution. Another one might be making some changes in the regulation of the industry. As it is right now I’m not sure having an insurance company own a hospital isn’t a violation of the anti-trust laws. (as an example)
    Another issue I keep thinking about is costs of such things as drugs and supplies.I remember seeing a bill back in 2000 for an outpatient procedure that included 96.00 for 3 bags of IV saline. $96.00 ! for what is essentially sterile water with salt added. this is idiotic.

  60. #60 Paul Murray
    July 8, 2009

    It is very typical of conservatives to cut funding for the cleaning of public toilets, and then to complain that public toilets are filthy.

  61. #61 rrt
    July 8, 2009

    DLC: skipping the gory details, I know what you mean. I have some similar personal anecdotes, but in my case I’d add that besides inflated prices, I think there are some fundamental attitudes that must change, such as preferences for disposable equipment vs. sterilizable reusable equipment.

    gpmtrixie: thanks. Would you have a link to the sources you used?

  62. #62 Patient
    July 8, 2009

    “first: can you explain please the difference between “single payer” and “socialized medicine” ?”

    There is no difference. If you have the former, you WILL eventually get the latter by default.

    See:

    http://online.wsj.com/article/SB124597297859757163.html

    and
    http://www.economist.com/blogs/freeexchange/2007/04/in_the_name_of_innovation.cfm

    and

    http://online.wsj.com/article/SB124649425934283347.html

    and finally:

    http://online.wsj.com/article/SB124562948992235831.html

    They make the case against single payer/socialized medicine better than I could.

    I can understand the appeal of a single payer system, but the fact remains that our system is unique in that it allows for choice, even if that choice “costs us” in a number of ways. People may think that they want the government to make those choices–until the government actually does. Then, people will want the freedom to choose something else—and at that point, they won’t be able to anymore.

    We should never give up our rights and our ability to have a choice. Any system that doesn’t allow for that is socialism, plain and simple.

  63. #63 gpmtrixie
    July 8, 2009

    rrt: I used info from either the 2008 10K’s or annual reports of United Healthcare, Cigna, Humana and Wellpoint. The other biggie is Aetna that I didn’t get to. Each of these companies present their data a little differently, so you have to read through the financial details. If possible, I used medical health care only. Most of these companies have other lines of business that it’s sometimes tough to tease out of the data. The math is as follows:

    - Determine the ratio of fully-insured business to total based on members served. Operating expenses and profit are presented in total, so I used the member ratio to determine the portion related to fully-insured business. This assumption is not perfect, because typically fully-insured business costs more, mainly because there is more likely to be brokers involved and thus commissions.

    - Add operating expenses (sometimes called Selling, General & Administrative), depreciation and amortization and operating profit. I used net operating income before interest expense and taxes, so this is conservative in that it includes a higher number for profit (i.e. yields a higher %).

    - Multiply the first by the second to get the portion of administrative expenses and profit related to premium revenue. This assumes operating expenses and profit are proportional to membership. See first item for why this is not perfect.

    - Divide this result by premium revenue.

    Here’s a wikipedia article that talks about health care in the U.S. in general, but has a section on admin costs…

    http://en.wikipedia.org/wiki/Health_care_in_the_United_States

    Note that all the other sources listed have a range from 11% to 15%. If you want, you can discount all but the CBO, since AHIP and BCBSA are industry groups, but Wellpoint is the largest Blue Cross and Blue Shield plan and I calculated 10-11% for them in 2008.

    Relaxing my math muscles now ;-).

  64. #64 D. C. Sessions
    July 8, 2009

    I remember seeing a bill back in 2000 for an outpatient procedure that included 96.00 for 3 bags of IV saline. $96.00 ! for what is essentially sterile water with salt added..

    It’s not quite that simple. Anything going straight into your bloodstream has to be free of pyrogens (among other things) and there are other safety-related non-reducible overhead issues. That by no means accounts for all of the total, though.

    The canonical example is the $<large figure> bill for an aspirin tablet.

  65. #65 Tyro
    July 8, 2009

    @Patient (62)

    I can understand the appeal of a single payer system, but the fact remains that our system is unique in that it allows for choice, even if that choice “costs us” in a number of ways.

    And which choices do you suppose that you have which Canadians do not?

  66. #66 Dianne
    July 8, 2009

    the fact remains that our system is unique in that it allows for choice

    Choice of…what? Insurance company? Doctor? My only personal experience with universal health coverage comes from living in Germany (which has one of the longest running universal health care systems in existence and yet the society only collapsed when it deviated from the principle and didn’t cover some people). In any case, my experience with the German healthcare system was…well, I won’t say pleasant since it involved shots, antibiotics, and dilated eye exams at various points, but I will say that the doctors and other medical personnel were efficient and courteous and that I never waited longer than a week for an appointment. Also I chose who I saw (sometimes randomly, but never mind that), not my HMO or the infamous “faceless bureaucrat” from the government. In fact, if they’d get off their butts and start including immigrants in AOK I’d call it a pretty good system on the whole.

  67. #67 Robin Levett
    July 8, 2009

    @Patient #62:

    From your first link:

    If a public plan is inserted into private insurance markets, the American health-care system could rapidly evolve into a single-payer system, which would have devastating effects on R&D for new medical technology.

    This last seems to me to be absolutely untrue; perhaps you could provide some evidence of its truth?

    My understanding (I looked into this some time ago) is that any extra income per unit in the US market as opposed to the European market is pretty much absorbed by extra marketing costs in that market (particularly direct to patient advertising). It emphatically doesn’t go to extra R&D spend.

  68. #68 Greg
    July 8, 2009

    I can understand the appeal of a single payer system, but the fact remains that our system is unique in that it allows for choice, even if that choice “costs us” in a number of ways.

    Ummm, I chose my doctor and I can even get a second or third opinion at no cost to me. I trust my doctor to refer me to a decent specialist, but on one occasion I didn’t like the guy and asked to see another doctor, and I got one without any hassle or cost.

    All of this costs me about the same in taxes as I paid in the US. So I’m not sure where you are getting your information. I’m getting mine from experience and from looking at my pay stubs.

    If a public plan is inserted into private insurance markets, the American health-care system could rapidly evolve into a single-payer system, which would have devastating effects on R&D for new medical technology.

    You’re missing something here. Everything still gets paid for under a single payer system, only you cut out the people skimming off the top. Dr.s, procedures, drugs, etc. still cost money and the system still pays for all of that, and the companies who develop and sell those things still get payed for all of it too, so why would R&D slow down?

    Look, for less of their GDP than what the US is paying now Canada and Europe cover 100% of their populations, and all of them pull it off pretty well. Single payer systems have some issues, but none of them insurmountable, and for what the US is paying it should have everyone covered with the best service of anyone, but it doesn’t – not even close. Aren’t you ashamed of not being able to do/have better? What happened to USA #1? I guess you think working out a better system is just too hard for America, so you’re happy to settle for less…

    Greg ~ an American in Canada

  69. #69 Dianne
    July 8, 2009

    which would have devastating effects on R&D for new medical technology.

    I don’t see how. Drug companies spend about the same amount on R and D in Europe and the US. The difference in R and D comes from the presence of the NIH which provides a huge amount of funding for research in the US and for which no comparable institute (at least of similar size) exists in Europe. So it’s the public funding part that makes the US a better place to do research, not the private investment. How would universal health care affect that?

  70. #70 Patient
    July 9, 2009

    @65

    “And which choices do you suppose that you have which Canadians do not?”

    A well known phenomenon of Canadian health care is that whenever someone does not want to wait for a procedure, or couldn’t get a procedure like an MRI for example, they would come across the border to get that procedure in the US. If we go to single payer, then that phenomenon will not exist any longer, because the same types of restrictions will exist on both sides of the border.

    I also have the choice to buy whatever health care I want, assuming I have enough money to do so. If I don’t like a plan, a doctor in my plan, or the coverage I am getting, I am free to buy anything I want as long as I pay for it myself. If I want to see the top neurosurgeon in my area, the only thing that separates me from an appointment with him is the amount of money that he will charge me. No one is describing a system where we will still be able to do that. It is only a recent development in Canada that allowed for this practice of being able to “go outside” of the plan–I can not speak to how well it is working for them at this point, but I have read of some problems with having to enact these types of changes to what many on this thread have termed “great healthcare”.

  71. #71 Patient
    July 9, 2009

    @66 Diane

    “In fact, if they’d get off their butts and start including immigrants in AOK I’d call it a pretty good system on the whole.”

    I am glad you had a good experience with their system, but as you point out immigrants have a pretty tough time over there, so there is still a lot to be desired. Don’t forget that what the US government is attempting to do may in fact cover immigrants, and that can present another load of problems and costs that the Germans (and others) still haven’t owned up to even with all the “great healthcare” they claim to have.

    Your experience also may be one of a day to day type of condition and not something chronic and complex; I wonder if the same “satisfaction” would apply if you had a hard to diagnose condition where you needed to seek out multiple specialists, and treatment was complex….the bicycle is a great form of transportation, unless it is snowing outside, then only a 4 wheel drive will do.

  72. #72 Patient
    July 9, 2009

    @ 67 Robin:

    This last seems to me to be absolutely untrue; perhaps you could provide some evidence of its truth?

    I thought the second link provided some further explanation of this–but I will dig around and try to find something else that directly addresses the concerns you raised.

    @68 Greg:

    “So I’m not sure where you are getting your information. I’m getting mine from experience and from looking at my pay stubs.”

    I am getting it from here:

    http://www.city-journal.org/html/17_3_canadian_healthcare.html

    and here:

    http://theconverted.wordpress.com/2009/03/13/the-problem-with-canadian-healthcare/

  73. #73 Robin Levett
    July 9, 2009

    @Patient # 71:

    I thought the second link provided some further explanation of this–but I will dig around and try to find something else that directly addresses the concerns you raised.

    No, the second link didn’t help you. It argued from theory that “gubmints will use monopsony buying power to drive drug prices down”; he didn’t address practice, which is that (i) accounting for additional advertising spend in the US market, drub prices in US and Europe are broadly equivalent, and that (ii) in the UK at least R&D spend is a specific component of the negotiated price and is set at levels that (as I recall), in some respects, subsidise the US market in this respect.

    Tl;dr – the extra income from the US market is spent on extra advertising, an unnecessary inefficiency, not R&D.

  74. #74 Jud
    July 9, 2009

    “Are you really suggesting that (for example) Humana competes with Government in direct competition? I think we all know who’s going to win that one.”

    It amazes me that Senators and Congresspersons can say this sort of thing with a straight face. It happens in Medicare right now. It’s called Medicare Advantage (Medicare Part C), consisting of private plans that compete with government-run Original Medicare (Parts A and B). Medicare Advantage covers over 10 million people. The companies in the Part C business, **including Humana**, are doing very nicely, thank you.

  75. #75 Tyro
    July 9, 2009

    @Patient,

    If we go to single payer, then that phenomenon will not exist any longer, because the same types of restrictions will exist on both sides of the border.

    There aren’t any restrictions in Canada! People are free to open MRI clinics and offer for-pay services just as in the US. However it isn’t economically feasible to do so because the health system is universally enjoyed by the rich and poor alike.

    Yes, there are occasionally a couple people each year which garner a lot of attention because they jump the queue but the US has the same group of people doing the same thing – flying to China or Mexico for experimental surgeries or even Steve Jobs flying to different states to get faster access to organ transplants. The wealthy or eccentric will always try to game the system, but it’s as foolish to trash the entire Canadian system because of these few people just as it would be foolish if I said the entire Californian system was terrible because Jobs had to leave to get a transplant.

    So yes, if you’re in the top 0.01% of the population, you may find that your ability to throw money at the problem are diminished and to hell with everyone else.

    If I want to see the top neurosurgeon in my area, the only thing that separates me from an appointment with him is the amount of money that he will charge me. No one is describing a system where we will still be able to do that.

    Again, the wealthy may find their ability to game the system is undermined. Screw ‘em.

    But if you have a problem that genuinely requires access to a top neurosurgeon, you can see them in Canada, all it takes is for your doctors to recommend you. If your doctor doesn’t want to do that, you can seek other opinions. It gives everyone who needs it the chance to get access to the top medical people, and not just the richest of the rich. I’d say that actually increases choice.

  76. #76 Greg
    July 9, 2009

    @Patent

    So I read those two articles and then checked where they came from. The first one is an self named Anarchist blog. I’m not sure how reliable a site that promotes anarchism is when speaking about government policies, but even the author of the article had to admit:
    “The biggest problem with Canadian style universal health care is that, for most people, most of the time, it works well enough. Yes, that’s right, it actually works.”

    The second article is on the City-Journal which, it you take even a moment of research is owned by The Manhattan Institute, a neoconservative think tank who’s tag line is “The Mission of the Manhattan Institute is to develop and disseminate new ideas that foster greater economic choice and individual responsibility.” pretty much sums up their motivation for knocking down a public system. **

    I did notice that this these articles did say that the current US system is basically a failure ~ “There’s no question that American health care, a mixture of private insurance and public programs, is a mess.” but didn’t seem to offer a better one.

    I appreciate that you are unconvinced and a little frightened about a single payer system, and if you’ve got a better idea then don’t hold back, let us all know what it is.

    You write like the lucky few who have the money to have a premium plan, or you’ve not, like tens of millions of Americans, have had the misfortune to find that their plan isn’t as good as they think. But if you are going to be part of a decision process that is going to choose the health policies (ie. Vote) for an entire nation for the foreseeable future, then you should get your information from more reliable sources.

    Good luck to you, I hope you don’t loose your job, or have to see your children or grandchildren without coverage because they didn’t get as good a job as you did, or a friend that got turned away because he had a pre-existing condition, or any number of practically arbitrary things that insurance companies toss people for. Because thats whats happening right now, as you debate “choice” 10′s of millions of people are living in fear of financial ruin if they are unlucky enough to get sick or injured. The system isn’t perfect but above doesn’t happen in Canada, and Canadians know that a bit of waiting is and the occasional hassle is a small price to pay for that kind of piece of mind.

    ~Greg

    ** ~ Something I’ve noticed about the whole freedom to choose thing: people tend to miss that when there is health coverage for everyone, no one has to worry about loosing their insurance if they want to choose to change employers. Right now how many people want to change their job or are afraid to ask for a better (fairer) wage, but can’t afford too because they fear loosing their insurance? Having the power to choose without fear is real freedom, and everyone should have that, not just those who by luck or chance are able to pay for it.

  77. #77 Joseph C.
    July 9, 2009

    There aren’t any restrictions in Canada! People are free to open MRI clinics and offer for-pay services just as in the US.

    This is not true. There are restrictions on privately-delivered care in Canada and they vary from province to province:

    http://www.vancouversun.com/Health/Health+minister+says+private+surgery+clinics+okay+with+limits/1730220/story.html

  78. #78 Tyro
    July 9, 2009

    Joseph C,

    There have been many fights over this as provinces like Alberta try to undermine the Health Care Act. The issue is generally not whether it’s possible to open private clinics but whether these private clinics can bill the government for the procedure while requiring extra private funds (though there are occasionally other spats). As you see from your own article, there are many private clinics open already and operating legally.

    You may be right that there are restrictions placed on them so that the health care system doesn’t fragment, I don’t know all of the details.

  79. #79 Joseph C.
    July 9, 2009

    I don’t know all of the details.

    Neither do I. Such is the nature of fragmenting the control across the various provinces. But I think it’s far from being completely open season for MDs to operate private practices.

    I can’t see it making much sense to tell the wealthy that they cannot buy private care outright (aka no public money whatsoever). If anything, this should take some burden off of the public system. Though I suppose there is then the concern of having enough providers to support the needs of the public system.

  80. #80 blana de euglena verde
    July 9, 2009

    “We should never give up our rights and our ability to have a choice. Any system that doesn’t allow for that is socialism, plain and simple.”
    no, any system that doesn’t allow for that is totalitarianism. Socialism is an economic doctrine.

  81. #81 Daniel M
    July 10, 2009

    as much as people rave about poor service from the NHS (and there will always be people who complain, and there are lapses), ask anyone if they’d like to pay for it just like the US system, and they’ll invariably shout oh jeez no.

    to think (they say), we could have this sort of poor service and have to pay through the nose for it, too!

    Seriously, the US healthcare system is the shame of the developed world – when it works (ie, if you don’t really need it OR have a good healthcare provider AND they allow you access to ALL the medical know-how you could need) then it works great.

    When it doesn’t work, or doesn’t work very well (which is most of the time) you get denied treatment, end up paying hundreds of dollars for an x-ray, thousands of dollars to get told that yes, you have a cough, here have some antibiotics, or get stiffed for 80%+ of the bill (which, due to the wacky way it’s all put together will cost you most of a thousand dollars for even the minimum of care).

    People end up going to ER because they couldn’t or didn’t seek help for a cough, or an infection, or some stomach pain that turns out to be a burst appendix – and what could have been a short in-out job ends up being weeks of treatment, running to tens or hundreds of thousands of dollars because they just had to get that MRI or CAT scan or ultrasound or…you get the picture.

    I’ll take the NHS any day.

  82. #82 Craig
    July 10, 2009

    People who relay anecdotes about Canadians traveling to the U.S. for health care should also remember that Canada is a *very big* country with a few small metropolitan areas that are very far apart.

    If you are in rural Saskatchewan and need to see a specialist who is not available locally, it is cheaper to go to Minneapolis than to Toronto or Vancouver. This is basic realism, not a failure of the system.

    I’m one of the lucky few who is both very health and still could afford to pay for my own medical care if I needed it. I still prefer Canada’s system, if only because there is no reason to consider personal finances when faced with a life or death decision.

    I’ll go even farther and say that I don’t particularly care that my taxes are subsidizing the medical care of the less fortunate. Why shouldn’t they? I was less fortunate myself once, and may be so again.

  83. #83 Greg
    July 10, 2009

    @Patient
    We should never give up our rights and our ability to have a choice. Any system that doesn’t allow for that is socialism, plain and simple.

    First, as someone else pointed out, you need to look up what Socialism is. But thats beside the point.

    If the US adopts a single payer option, which is what most people want, you can still buy your precious private health plan. In fact it will probably save you some money because private insurance will have to be able to compete with the public option. The single payer option being floated in the US right now is not funded by taxes, it’s funded by premiums just like private plans are, only everyone can buy in and no one can be denied because of of a pre-existing condition.

    The costs of this public insurance option would be covered by keeping the premiums low enough to entice as many people as possible to sign up, spreading the costs of care out so broadly makes it affordable (this is pretty much how private care works too). The savings are realized by eliminating the profit motive and the extra layers of bureaucracy created by having dozens of providers (or is it hundreds?). Un-like private plans which make their profit mostly by saying no, if you eliminate the need for profit, you don’t have to say no to everyone.

    To further reduce costs the government will have some incentive to pass laws and regulations to limit gouging by pharmaceutical companies, and other for-profit health related industries (which will likely also lower the cost private health plans).

    The government will have to determine what care is and isn’t covered and they will likely use the Medicare model, which is pretty good from what I’ve read. In any case private insurance does this as well, only they have no incentive to keep people healthy, be transparent, or fair, their priority is profit. They will also likely have to beef up the DOJ to add agents to monitor and investigate Dr.s and Hospitals to keep them from gaming the system, something they also do for Medicare, and that will have to come out of taxes, but fines will cover those expenses. It’s not going to be as good as the Canadian system, in my opinion, but it will be better than the current US system.

    So really whats the point of blocking the single payer option? It seems like a win win.

    I copied this from thedailybanter.com, it sums up the feeling of a lot of people in the debate:

    People are, in fact, dropping dead here due to a lack of affordable, reliable healthcare. They’re being abandoned on the street. They’re being denied coverage and care. They’re going bankrupt and losing everything just because they had the bad luck of losing their job and then getting sick. And the Republicans are telling us that this is the best system ever, even though our infant mortality rate ranks 29th, our life expectancy ranks 42nd (so much for “pro life”) and our healthcare spending is the highest among industrialized nations.

    We have an opportunity to turn all of that around, though, with a strong public health insurance option. In fact, 70 percent of us want it. But if certain wingnuts and Republicans don’t want affordable, guaranteed health insurance, then they don’t have to sign up. They’re welcome to continue to defiantly roll the dice with their private plans. And good luck with that, by the way. Just don’t punish the rest of us with this self-defeating Palin-ish ignorance.

    So don’t screw the rest of us, let your representative know that you’re ok with a public option, but you plan on keeping your private insurance anyway.

  84. #84 Joseph C.
    July 10, 2009

    And the Republicans are telling us that this is the best system ever, even though our infant mortality rate ranks 29th, our life expectancy ranks 42nd (so much for “pro life”)

    There are too many confounds, like lifestyle factors and violent crime, for infant mortality and life expectancy to serve as a direct score card for the health care system.

  85. #85 Robin Levett
    July 11, 2009

    @Joseph C #84:

    There are too many confounds, like lifestyle factors and violent crime, for infant mortality and life expectancy to serve as a direct score card for the health care system.

    Hmmm; since when are “lifestyle factors” divorced from the healthcare system? We expect a decent healthcare system to provide the information necessary to enable us to avoid unnecessarily unhealthy lives.

    More generally; are these really such dramatic confounds? Are you really saying that USAan society is so much more violent, and its lifestyle so much more unhealthy, than the countries ahead of it on the lists? Do the Republicans really want to go down that line of argument? How does that compare the claim (from anti-vaccine sources) that it is the introduction of a healthier lifestyle that has caused the dramatic drop in rates of infection with vaccine-preventable diseases?

  86. #86 Joseph C.
    July 11, 2009

    Hmmm; since when are “lifestyle factors” divorced from the healthcare system? We expect a decent healthcare system to provide the information necessary to enable us to avoid unnecessarily unhealthy lives.

    All health care people can do is carry out the research and deliver the information. What people do with the information is entirely up to them.

  87. #87 Robin Levett
    July 11, 2009

    @Joseph C #86:

    All health care people can do is carry out the research and deliver the information.

    But do they – deliver the information, that is? If the USAan lifestyle is that much more unhealthy than 49 other countries, either your population isn’t getting the message, or they’re uncommonly resistant to it.

    How about the other half of my comment?

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