White Coat Underground

In his latest comment, Philip H has accelerated my reluctant discussion of health care reform. In fact, it was Philip who bullied me into writing about this topic in the first place. I’ve been avoiding wading into this mess, but being on the front line, it’s in my face every day.

What he says in his latest comment is this:

[T]he idealogical leap PalMD is asking for is a good one, but it misses the mark. The leap we need to make is that healthcare is not a good, like Cheerios, or cars, or flatscreen tv’s, that exists in anything like a free marketplace.

Commenter Donna B. makes a tangent assertion, that in fact health care is, “a service, a good to be purchased, and is therefore not a “right” as such (she also does not have a problem with government subsidizing or being involved in some way, so don’t stomp all over her without reading her full words).

If health care isn’t a “good” in the sense of “commodity”, and it isn’t a “right”, then what is it?

There are people much more knowledgeable than I when it comes to what a “right” actually is. I think it’s safe to say that we don’t all share a common understanding of what a right is; given that, it’s not surprising that we don’t all agree on which things are rights. But I think we can end up a little distracted when we focus too much on the question of whether health care is one of these “right” thingies.

Philip and Donna have highlighted a commonly held idea that health care is either a “right” and a “commodity like any other”. It may, in fact, be neither one.

Health care is not a commodity like any other. It is more akin to water and food than to Cheerios. Sure, you can choose not to purchase or use it, but eventually you will need it, and to go without it poses a mortal danger.

But if it is not a simple commodity, neither is it clearly a right. Here in the U.S., it certainly isn’t an enumerated right. So if health care is not an explicit right, could it still be a “right”? What would it mean for health care to be right?

Remembering that I’m not an ethicist, I don’t think that simply calling it a right requires the government to provide it. The government cannot impede you from printing what you will but it doesn’t have to provide you with a printing press. But what about airwaves and bandwidth? Must the government make these available?

This brings up another distinction—health care services, vs. health insurance. We might be able to agree that everyone has a right to access to health care services (whatever that right to access may mean). But if the only way we provide access is via purchased health insurance or limited government benefits (except in emergencies) then we are denying people not only insurance, but access as well.

As a nation we value, among other things life, liberty and the pursuit of happiness (explicitly!). These things, along with prosperity, are not possible without good access to modern health care. If this access is granted only by employment, the purchase of insurance, and limited government programs, we are denying access to a large segment of our population. I don’t think it matters much if we call it a right or a rutabaga—we cannot maintain our values without a commitment to providing at least a basic level of health care to all. If we cannot provide this via the current employer/individual/government system, then it’s time for a change. There seems to be a fear of this change, but in this case, fear of change may literally cost us our lives, fortunes, and sacred honor.

Comments

#1 wazza
August 19, 2009

The difference here is that free speech is a negative freedom, one you can have without using, while good health is a positive freedom, one that must be continually maintained. If the government is to fulfill its duty to you (under the Universal Declaration of Human Rights), it must make sure that you can get health care. Simply staying out of the way so that you could get it if you wanted it bad enough to sell one of your children for it isn’t enough.
#2 David
August 19, 2009

Another way to look at it bypasses the issue of whether it’s a right. In an advanced society, healthcare must be part of a shared social contract.

Healthcare is fundamentally not like a commodity in that very few individuals truly purchase healthcare. Consider heart transplant following viral myocarditis, a lifetime of dialysis for renal failure, or brain surgery for drug-resistant epilepsy. Almost nobody in our society can afford these treatments out of their own pocket. Instead, we pool our resources, each pays a share, and those unfortunate enough to suffer the disease get the benefit. Nobody would support a cruel system in which only 1% or less of society could ever receive such treatments (in which case the treatments would disappear for lack of practice and missing economies of scale).

The only kind of healthcare that could exist in a truly free-market system is rudimentary well care and payment for brief encounters for self-limited conditions in basically healthy people. The chronically ill, mentally impaired, elderly (retired), and orphaned children would never receive healthcare in a free market system.

So healthcare is fundamentally a shared purchase. We pay into a pool and take out what’s needed. The pool may be run by insurance companies or by government, but the concept of a shared enterprise is basic.
#3 Donna B.
August 19, 2009

The part of me that is purely argumentative would point all toward the water rights wars of the west. And that part of me would also contend that food is a commodity, including Cheerios. It is something one must seek out, pay for or barter for, even if the bartered item is a food stamp card. (One does give up something to gain access to a food stamp card, ie, a certain dignity and the “right” or “opportunity” to earn more money next month.)

Then there is that purely Southern part of me that believes* that hospitality (which shares a root with hospital) is the sharing of whatever food and shelter one has. A “true” Southerner breaks out the best for company, whether it be wine, spirits, food, or bedding. We are historically populists. And Jacksonians… so there is that to consider too.

But these things are social constructs, not inherent or absolute legal rights. My comments about rights are more along the legal line. A right does not exist in a vacuum. There is always an accompanying duty or obligation, and it is not always put upon the person the right is bestowed upon.

Where health care is concerned, that duty or obligation is so obscured that I think it negates the right. One reason for this is the unsettled nature of the science behind currently evidenced-based medicine (ie, future evidence can change it and it would not be in the public’s interest to inhibit further learning). Another is how comparative effectiveness does not correspond in exact ways with evidence-based medicine. If 15% of the population does not respond to the most effective medicine comparatively, denying or delaying their access to what works for them is essentially “un-insuring” them.

Put another way — if health care is a right, I have an obligation to take no risks and Pal has a duty to provide services. Further complicating that is what constitutes a risk and what constitutes a service, currently and in the future.

To me, enshrining health care as a right would constitute an unreasonable restriction of action (or choice of inaction) on my part as well as an unreasonable obligation on Pal’s end.

*I am not saying that y’all damned Yankees don’t do this too, just that it’s stressed as not only being socially acceptible, but socially required in the South.
#4 daedalus2u
August 19, 2009

To answer Donna’s assertion that because health care requires labor and supplies it can’t be a “right” because that implies an obligation for someone else to supply it. The same goes for police protection, protection of property rights and such. That can be privatized and has been in places like Somalia, but there are drawbacks to a free market approach to police protection.

Public financing of police is part of the shared social contract that David mentions. If you have good police, they don’t always need to be doing a lot of stuff. If you don’t have good police (like in Somalia), then who ever is the first warlord to get weapons and take from everyone else becomes the de facto government.

Paying for the police to maintain the arbitrary property rights that are also part of a shared social contract are usually ignored by libertarians. Property rights only exist because of a shared social contract that they do exist. If the social contract breaks down because too many people are starving, then property rights break down too.
#5 Donna B.
August 19, 2009

Actually daedalus2u, I mean no such thing. Police are, by definition, an arm of the government. My assertion is that health care providers should NOT be an arm of the government and one of the fears I have of single payer (government) is that they might become such against their wishes.
#6 Ramel
August 19, 2009

Donna B. what about other emergency services? Most places have fire and rescue sevices paid for by the taxpayer how is that different from heath care? The first muninciple fire service was only formed in (I think) 1824, before that it was all private insurance and if you didn’t have it the fire fighters would stand and watch you house burn down (just to make sure it didn’t spead to a house that was insured of course).

And police being an arm of the goverment by definition is either the view of an anarchist or a supporter of a police state. They are supposed to be a public service in most places, although they usually end up as de facto enforcers for the government.
#7 Donna B.
August 19, 2009

Ramel — all government services are “paid” for by taxpayers. The government has no other source of revenue, does it?

As for municipal fire departments, those were not created or “sold” as government services. That they were eventually taken over as providing for the good of all is actually quite reasonable.

Police being an arm of government follows the rule of law, not that of an anarchist. It is by and through our constitution that police cannot extend their power beyond that of the government. The Constitution is our protection against a police state.

An anarchist does not recognize any government. Or do I misunderstand?
#8 Donna B.
August 20, 2009

Perhaps we are getting close to something here. Fire departments essentially respond to keep damage from spreading. They cannot do a damned thing about what has already burned.

This is not a good analogy to health care, unless the analogy is to contagious disease. Fire departments exist primarily to put out fires to prevent them from spreading and causing additional property damage. One buys insurance on property to cover losses to that property. Those who loan money on property often require that insurance be purchased on the property to protect their investment. About 1/2 mile up the street from me is a vacant lot. There used to be a house there and the foundations and landscaping are still visible. The homeowner decided to cancel their insurance after the mortgage was paid off because they were no longer required by the mortgage holder (not the government) to have it.

The house burned because of an electrical short while they were on vacation. They lost everything but the value of the land. How is that comparable to health or health insurance?

Had these people continued to pay property insurance, they would have been made “whole” in some way or another. Health insurance cannot make that promise no matter what premium one pays or if their government pays the premium for them.

Health insurance essentially cannot be compared to other insurances because we, as a society, are not able or willing to put a value on health or quality of life. We do put value on a life itself through life insurance and wrongful death lawsuits, but those are no more comparable to health insurance than is fire insurance.

Perhaps an even more fundamental question than “what is health care” is “what is health”?
#9 Ramel
August 20, 2009

First off all modern fire departments do fire and rescue work (including things like cutting people out of cars, and appearing on local news rescuing kittens from drains), but they also do preventative work including education and consultation work (for example the school I went to paid a nominal sum every few years for an inspection by the local fire service for insurance purposes). Many services also have experts who assist in arson investigations. There is alot more to it than putting out fires.

The point of the analogy however is an example of a service that used to be privately run based on insurance that became a publicly funded service because of the benifit to society. I could just have easily used education or the police service to make the same point.

Police being an arm of government follows the rule of law, not that of an anarchist. It is by and through our constitution that police cannot extend their power beyond that of the government. The Constitution is our protection against a police state.

This is heading off topic a little but never mind. The fundemtal question when considering the police fore is this: Do the police exist to protect and serve the civilian population, or do they exist to enforce the will of those in power on the population. If they exist entirely to enforce the will of the government then you have a police state. An anarchist is against any use of governmental power so will always treat law enforcment as opression, and was included as something of a joke.
#10 Ramel
August 20, 2009

Blockquote fail…
First paragraph in the quote was Donna B’s, second was mine.
#11 Dave
August 20, 2009

Donna-
Would you agree that health care is more of an infrastructure issue than one which markets left to their own devices can properly address? Most infrastructure projects involve the private sector, to build the roads and schools, supply the military, etc. What is your opinion of Medicare? How has it caused our healthcare system to become a branch of the gov’t? Does it not pay private doctors and hospitals? (Ok, so it pays far less than things actually cost…it needs improvement for sure.)

It is embarassing that the US can’t do a better job at healthcare. It’s time to cut the crap, and make Medicare available to anyone who wants it. A larger, younger, healthier pool will address solvency issues, and it will increase efficiency and patient outcomes by increasing access to primary care for millions of people. It is more cost effective than letting insurance co’s reap huge profits yet provide no value, forcing those without access to postpone treatment until critical and utilize ED’s as a last resort. The private insurance model is rationing by exclusion, and a hidden tax on anyone paying insurance premiums. These costs of the current system exceeds that of offering Medicare to all, and would force insurance companies to, you know, compete, instead of profiting by denial of coverage. It might force them to provide the service they are ostensibly in business for. The only thing at risk by opening Medicare to all who want it is corporate profits and political bribe money.
#12 Dave
August 20, 2009

Sorry for the rant. Just sayin’, who cares if it’s a right, providing access to all is simply the right thing to do.
#13 Donna B.
August 20, 2009

As a willfully illiterate html person… no points off for screwy blockquotes.

All those functions that fire departments do still fall under the function of preventing property damage and loss of life. Is loss of life under those circumstances comparable to health? I say no.

That does not mean I denigrate the positive impact to society of publicly operated fire and emergency services. I am, in fact, in awe of the good they do. First responders have my utmost respect and EMTs are, IMHO, miracle workers. I have no problem with firefighters, EMTs, and first responders being government funded because there is no doubt in my mind the serve the public as whole.

But I do not think those people provide health care. Unless you want to define health care as emergencies only. I don’t.

Ramel — what I did not make clear (or you failed to understand) is that protection of property is not the same as health care. The value of property depends on many variables — its age, size, historical value, amenities, desirability… etc, all based on a dollar amt. The value of a human life is not considered strictly on its dollar amount except in torts of wrongful death or injury where there is an arbitrary amount placed on life, an actuarial amount placed on the future value of that life, and amount placed on its emotional value.

None of those things are relevant to health. Western societies (not only the U.S) put a value on life by measuring not health but future value. It is a legal extension of property rights to a value of “average” health in the future.

Such reasoning has no actual bearing on current health, the preservation of health, or the prevention of health problems.

As I’ve previously stated, I support ideas and mechanisms that extend health care coverage to the uninsured. I do NOT however, extend that support on the basis that it is a public good… I see no evidence (except for vaccinations) where it is. I support it because I believe it is humane and I do not want people to suffer, especially children.

An anecdote that covers various scenarios of opinions is one that I personally experienced. My daughter, after hours of labor was diagnosed as needing an emergency caesarian section. The baby’s heartbeat could not be found, the mother had suffered preeclampsia for 3 weeks.

I overheard a few conversations… one between my daughter’s doctor and his colleague concerning the use of the OB operating room by a fellow obstetrician they called the “king of c-sections”. The patient that the “king of c-sections” was operating on was an illegal alien.

My daughter was taken to a main, regular, whatever you want to call it, OR within 45 minutes after her OB said an emergency c-section was needed. Dammit… that was at least 30 minutes after grandma’s limit. (Oh who am I kidding…it was 44 minutes.)

What I cannot muster up is a ill feelings toward the illegal alien delivering a baby. This woman had climbed 9000 ft of mountains to deliver her baby in the US, so he/she would be a US citizen… and I admire that sort of attitude. That the OB she got by luck of the draw thought she needed a c-section is not her fault. Though my daughter’s OBs made fun of her OB for order “yet another emergency c-section”… maybe he was right this time.

My daughter and my granddaughter survived the slightly delayed c-section. I hope the illegal and her baby did well also. I don’t know for sure because there was a border patrol agent stationed at this woman’s door…

That was insulting to me for several reasons. First, a new Momma ain’t gonna be trying to escape. His presence denied the citizenship of the child, and… finally it was just demoralizing not only for me, but surely for the mother.

To his credit, the border patrol agent seemed embarrassed to be there.

I remain angry at the possibility that the doctor for the illegal alien decided on an c-section that was unnecessary. I do not, however, hold this against the illegal mother. It was not her choice, it was her luck of the draw.

I admire the mother who climbed 8000 ft and hiked to a point where she was picked up by the border patrol at 9 mos pregnant. What kind of guts, courage, and desperation did that take? Yeah… I am ambivalent at best about illegal immigration.

But how does this relate to health care? Is the care for the newborn U.S. citizen or his illegal alien mother? Does it matter?

I was one of many willing to hold my newborn granddaughter to my chest so that she might feel my heartbeat and the warmth of a human body. No one was allowed near the infant of the illegal alien. This is NOT right.

Although I consider myself a conservative, I also know that I am a softy. When I could hear cries from the illegal alien’s room, I was not allowed to enter. I was not allowed to offer comfort to either the infant or the mother and his hurt me.

I have gone way off topic here, but in essence only 1/2 off topic as I have addressed in this post infant and mother care… though even only the surfaces of those.

Care for the elderly and disabled… let it be another topic.
#14 MikeB
August 20, 2009

Donna – you’ve clearly signalled your political/ideological opposition to public healthcare, but I’m not sure your argument with relation to other emergency services come close to standing up.

Fire Insurance dates from at least the 17th century – if you were insured, the company brigade hopefully came and put the fire out. If you were next door, hard luck. This made no sense to anyone, since a fire was a threat to all, which is why fire services gradually became a government service, paid for by taxes.
Now you can argue that fire services exist to protect property (they certainly do), but the first thing you hear during any fire lecture is to get out, because your property can be replaced, you can’t. Lives matter. In the same way, when the emergency services (which you pay for out of your taxes) are cutting you out of your car after a smash, are they concerned with you or the car? Hopefully you. Your taxes are already providing healthcare, of the emergency kind, which is something you have no problem with.

You argue that ‘Fire departments essentially respond to keep damage from spreading. They cannot do a damned thing about what has already burned’. Actually, they hope to prevent fires breaking out in the first place (which is why fire regulations and inspections exist), and save as much as possible if one breaks out. Which is a pretty good description of healthcare.

You think that human life should come down to more than just dollars (agreed), but then turn round and say that ‘health’ is not a public good (apart from helping small children with vaccinations), unlike the fire service. This doesn’t really make sense.

Good healthcare, like good sanitation, is a public good. It reduces infection (with swine flu about, this becomes even more important), reduces costs (the costs of the uninsured or under insured have to be paid by someone, which will be those able to pay), and reduces the likelihood of catastrophic financial loss to the individual or business.

Your daughter gave birth to a healthy daughter, presumably at about the time she was supposed to. In your terms, that was not an ‘emergency’ (although the C-section was). If she had had to give birth a month or two before, or there had been a complication, would it have been an emergency? Yes? No? Or in both cases, would she have simply needed healthcare?

Reading through your previous posts you really quite like the idea of some sort of healthcare safety net for the poorest, plus some way to administer vaccinations, etc. But you have convinced yourself that to go further would somehow mean that ‘health care providers’ would become an ‘arm of the government and one of the fears I have of single payer (government) is that they might become such against their wishes’.

If you want something which is a better safety net than you currently have, then support the ‘public option’. From the viewpoint of the rest of the industrialised world, this is hardly radical. You still have private healthcare, your hospitals are certainly not under government control, and frankly, you will still pay for more for healthcare than the rest of us.

I have a question for you – how much did your daughters stay in hospital cost? I’d like to know, because I’d like to compare it with the cost of my first child’s birth (also a very long labour and a vontose into the bargain). Also have a look at the costs of this man’s broken leg http://www.guardian.co.uk/society/2009/aug/19/nhs-healthcare-america – comparing the US and the UK, who got or gets a better deal?
#15 Philip H.
August 20, 2009

PalMD,
Sorry to come across as a bully. I just disagreed with you that you had nothing (as a practitioner) to contribute to the policy part of the healthcare reform debate. You’re on the front lines of the issue, and that makes you MORE likely to propose a solution that works then I could, as a practicing fisheries oceanographer.

I have not really considered the “Right to healthcare” as described here, but it is an interesting take. More thought then I have time to give here . . . .
#16 R E G
August 20, 2009

Maybe a fellow Canadian could help me out with the legal details… It’s a long time since I wrote the quiz on this one.

We don’t have an actual legal “right” to healthcare. We have a guarantee of universal access to healthcare. Therefore, if I need a kidney transplant and don’t get it, I can’t whine to the courts. If however, anyone bumps me from a transplant list for a financial reason, there would be hell to pay.

All the healthcare provided by my province must be available to everyone equally. Medical procedures like cosmetic surgery are not provided by the province. They are paid for by the patients. Certain items commonly thought of as “medical”, are not on the approved list. The one that surprises most people is the ambulance fee. The ride from your door to the local hospital is $75.00. The ride in the fancy helicopter to the specialist hospital is paid by the province.

My conclusion, after reading so much on this topic, is that the real difference is cultural. We just don’t see medical care as a commodity in a marketplace. In our minds it has become a right.
#17 Dianne
August 20, 2009

I’m not sure if this adds to the discussion of health care and the need for a public option or not, but it occurs to me that health care is a relatively unique good/service for another reason: the average consumer of health care has virtually no way to judge whether he or she is receiving good quality care or not.

Take the following scenario, for example. First, from the patient/consumer’s point of view. Patient, a 50 year old man, has been feeling tired for several months. He goes to Dr. A who performs a simple test and finds a problem. She then prescribes a simple medication to correct the problem identified. A few weeks later the patient feels great, basically well. Suppose instead of Dr. A he went to Dr B instead. She did the same test, got the same result, but instead of prescribing a pill she ordered a series of uncomfortable and invasive tests which led eventually to a recommendation for a major operation and possibly a long series of further treatment later on. Which doctor did the better job?

Everyone knows that’s a trick question, right? Here’s what happened from the medical point of view: The initial test in both cases was a complete blood count. It found that the patient was anemic with parameters suggesting iron deficiency. Dr. A prescribed iron. This will work-the iron deficiency will go away if you give enough iron and the patient will feel better. However…why is a middle aged man iron deficient? He almost certainly doesn’t have heavy menses*. A common -and life threatening- cause of iron deficiency anemia in a middle aged man is colon cancer. So Dr. B’s suggestion of a colonoscopy, an invasive, unpleasant test, is the logical one to make, particularly in the absence of other symptoms which might suggest a different problem. In the scenario above, a colon cancer was found and resection with possible chemotherapy afterwards was suggested.

So, the first doctor made the patient feel better, but left a time bomb in his body. The second made him feel worse initially but took care of the underlying problem. From the medical point of view it’s clear which one did better. And, eventually, it would be from the patient’s point of view as well. But it’d be very tempting for a patient to go with plan A initially. Especially if Dr. A were consulted first…how is someone without a medical background supposed to know when fixing the symptom is not enough? Add to that the fact that being right doesn’t guarantee a good outcome (suppose the patient had hemorrhoids and the colonoscopy caused a perforation–bad outcome even though it was the right thing to do.)

Even looking at the statistics isn’t necessarily enough. Suppose the mortality rate for a particular procedure is 1% at hospital A and 3% at hospital B. Is A or B better? It depends. B may be taking higher risk patients. Or it may just have poorer infection control. No way of knowing without a fairly sophisticated examination of the data (which probably won’t even be available to patients) and, again, the averages don’t guarantee that things will go well for any particular person.

So, health care isn’t like cheerios. It isn’t even like food**. It’s a difficult, complex commodity and service which has to be purchased almost on faith. I’m not sure what moral to draw from all this, except that it makes treating health care like any other consumer product seem even less sensible.

*Though I can come up with a scenario…suppose he’s a pre-op transsexual with uterine fibroids.
**Not but that food probably has its scary, difficult to evaluate side too. I tend to take the agricultural inspectors’ work more or less on faith. Hope that’s not too big a mistake…
#18 Ramel
August 20, 2009

Donna, it may just be my socailist tendencies showing through but the way you talk abaout the protection of property not being the same as health care, it’s hard not read as “the government should protect stuff people own, but it should leave people to fend for them selves”. The main purpose of any government service should be to work for the good of public, not their stuff. For example if a house burns down when nobody’s home it sucks for the family that live there, a house burns down with the family inside then its an absolute tradgedy. That’s why fire and rescue services come so close to the top of the hero scale, and then their only serious competition is from the medical profession and the police (N.B. police vary massivly between areas, hero value may vary considarably).
#19 Donna B.
August 20, 2009

MikeB — I have not convinced myself of anything quite yet, except that I do not want to see health care become a legal right. That does not mean I don’t want to see some kind of universal coverage.

I have no idea what my daughter’s hospital stay cost, but I do remember what we paid when she was 30+ years ago: $2800 to the hospital and $750 to the doctor. I had another child the next year and he cost almost a $1000 more — same doctor, same hospital, but one day less spent there. If costs have continued to rise at the same rate, a non-complicated delivery would be around $30,000. I would guess my daughter’s was at least double that.

The link you provided does not really make the NHS sound all that great except that it was ‘free’. The staffing problem sounds horrible and since it takes fewer staff to run a ward than individual rooms, that’s just going to get worse in the new hospital.

It highlighted very well the problems that Medicare has and that’s one reason why I’d hate to see this whole country put on something similar.

One thing I didn’t understand was the 9 month waiting list for the MRI when it was obviously available. That really doesn’t make sense to me. While I know somebody is going to say that at least it was available to everyone whether they had money or not — it seems quite unfair under a national system like the NHS for it to be available within a week for what sounds essentially like a bribe. I can understand why he felt ashamed.

Overall he actually made the NHS sound worse than what I thought it was and didn’t quite make Medicare sound as bad as I think it is.
#20 Donna B.
August 20, 2009

Dianne — you have a point, but we already do treat it as a commodity. It can’t be had without raw materials and labor no matter how complex and unique it is.

I think your post goes a long way in describing what health care is and how it sometimes does not result in the patient ending up healthy. This is actually part of the reason I don’t think health care can be a right — it is too ill-defined. Defining it enough to make it a right would be too limiting in a way.
#21 Dianne
August 20, 2009

Overall he actually made the NHS sound worse than what I thought it was

Absolutely no one is seriously proposing an NHS style health care system in the US. Obama is proposing something closer to the Swiss model. Anecdotally, the Swiss model seems to work fine (aka my mother lives in Switzerland and has had no trouble with it.)
#22 daedalus2u
August 20, 2009

What! Obama is going to force Swiss style health care on us? Obama will force us to wear lederhosen in order to get health care?

http://www.funhousetheatricalcostumes.com/swbageleco.html

Oh the humanity!
#23 Donna B.
August 21, 2009

Dianne – I haven’t said that an NHS system is being proposed. I have said I have no idea what is being proposed! What I was replying to is the defense (or defence) of the NHS system.

One thing that I oppose is extending Medicare to all because Medicare is not that good. The best thing I can say for it is that it is better than Medicaid or no insurance at all.

Perhaps the fact that it is better than no insurance at all is enough to offer it to the uninsured, at least those who are able and willing to pay ~$100/mo for Part B. Raise that premium to ~$130/mo for Part D prescription coverage. Is it worth it? No doubt… but not if you don’t have an $130/mo to spend after food and shelter.

I know there are huge numbers of people who make too much money to qualify for Medicaid, but not enough to buy health insurance on the open market.

And I do not like this at all.

I have a son who is on SSDI and a brother who is on SSI and medicaid. My brother is a prime example of those who — in my opinion — do not deserve government help. He’s got a degree from Columbia for pete’s sake… the fact that he’d rather drink than work irritates the shit out of me even though I recognize that alcoholism is a disease. He still manages to piss me once a week at a minimum. (Yes, he’s the one taking the doggie homeopathic arthritis medicine mentioned in another thread.)

My son has SSDI, Medicare, and Medicaid. You’d think with all those he’d be well covered. But no… He has incurred this year alone over $4000 in Medicare co-pays and is less than $10 under the limit for his Medicaid coverage which only pays his part B and D premiums. While we try to help him as much as we can, we can’t quite afford to pay those costs for him. He’s also incurred over $3000 in debt for dental care… Medicare and Medicaid cover none of that.

His budget is overwhelmed with $10, $15, and $20 payments to cover his co-pays.

Medicare and Medicaid do NOT work. Extending them will actually make some people worse off as it will obligate them to pay for things they previously could have obtained for free as non-insured.

This is similar to the gap that exists for families that no longer qualify for all kinds of help that are essentially penalized for trying to help themselves.

Our entire welfare system is screwed up, not just the health care part of it.

It appears to me that the system is designed to keep some people down regardless what they do to try to bring themselves up. Where I disagree with many “progressives” and “conservatives” is how this works.

Do I have a solution in mind for these problems? Nope. But the one thing I can say is that I’d rather be poor in a prosperous country, like the US, than be poor anywhere else.

We ain’t perfect and we can do better… but I hope that we don’t end up throwing the baby out with the bath water.
#24 eddie
August 21, 2009

Perhaps you could consider, when thinking in terms of rights or commodities, the difference between a want and a need. The NHS core principle is care that is free at the point of need.
This means that you can consider emergency care as in a different category from cosmetic surgery. The assessment of need is not always that clear-cut.
Another area which the NHS finds problematic is with pharmaceuticals in situation where the patients’ need is clear, but the effectiveness is in some doubt. There has been a lot of astroturfing around this.
#25 DLC
August 21, 2009

health care isn’t really a product, but a service. And, because the alternative to ‘buying’ that service is often death, dismemberment, disfigurement or permanent disability, it is not a “Free Market.” One simply cannot go and bargain with a hospital. Do any of you think you can walk into your doctor’s office and demand to be treated for only $40.00 ?
or 20 ? your doctor will likely tell you to go pound sand.
And should you be in an emergency care situation, you really don’t have much choice in where to go. not like you can stop having that heart attack and wait until prices come down.
#26 MikeB
August 21, 2009

Donna – I’m sorry that you thought the NHS sounded less than great. Its certainly true that there is under-staffing, partially caused by mistakes some years ago in relation to staff training, and partially caused by the needs of an ageing population (something all western countries are going through, including the US). The buildings are not always perfect, either, although a rebuilding programme is gradually sorting this out (a shame they are through PFI, but there we are). As for the MRI scanner, I came across a similar situation when I was working for the NHS, but overall waiting times were very low. Having spent over 5 years working for the NHS, I am perfectly aware of its flaws, but also recognise its strengths.

And that was the interesting thing about the article. Not only was the author very happy with the care he got on the NHS, reading through the comments shows a pretty good picture of the NHS, as well as a large number of people using both systems and complaining at the huge cost of the US system. In the same way that the NHS gets about 85% approval ratings from its users, Medicare gets 56% of its users rating a 9 or 10 on a 1-10 scale http://healthcare.change.org/blog/view/happy_birthday_medicare_–_the_most_popular_kid_on_the_block , far better than the private insurance plans. You may not particularly like Medicare, but overall its users do.
There is actually a system which gets NHS type approval ratings in the US – run and paid for by government – for the military http://www.huffingtonpost.com/jon-soltz/hey-dont-save-me-from-gov_b_264098.html . It means in effect that the US military is socialist and loving it…

I asked about costs because that was the thing that came over most clearly both from the article and the comments. The costs associated with the US system can be so overwhelming that they either wipe people out, or stop them from getting the healthcare they need. If you estimate your daughters stay in hospital to be $60,000, and the average wage in the US for 2007 was c.$40,000, your basically talking a couple of years just to pay that bill, unless you have insurance. Our bill for our two kids? Nothing. And the health visitor came around for weeks afterwards (particularly for our first child) to make sure everything was OK. Think what else you could do with $60,000. Even in Switzerland.

I think that REG is right, its a cultural thing, along with a dose of ‘Whats the matter with Kansas?’ Your not going to have the NHS, nor the Canadian or French systems, and you probably won’t want them. If your lucky, you might get the Swiss system. But that alone will help huge numbers of Americans,including your family and save you all some money. Whats not to like?
#27 mrcreosote
August 21, 2009

Theodore Roosevelt, 26th President of the United States, from CITIZENSHIP IN A REPUBLIC Speech at the Sorbonne Paris, France April 23, 1910

We can just as little afford to follow the doctrinaires of an extreme individualism as the doctrinaires of an extreme socialism. Individual initiative, so far from being discouraged, should be stimulated; and yet we should remember that, as society develops and grows more complex, we continually find that things which once it was desirable to leave to individual initiative can, under changed conditions, be performed with better results by common effort. It is quite impossible, and equally undesirable, to draw in theory a hard-and-fast line which shall always divide the two sets of cases. This every one who is not cursed with the pride of the closet philosopher will see, if he will only take the trouble to think about some of our closet phenomena. For instance, when people live on isolated farms or in little hamlets, each house can be left to attend to its own drainage and water-supply; but the mere multiplication of families in a given area produces new problems which, because they differ in size, are found to differ not only in degree, but in kind from the old; and the questions of drainage and water-supply have to be considered from the common standpoint. It is not a matter for abstract dogmatizing to decide when this point is reached; it is a matter to be tested by practical experiment. Much of the discussion about socialism and individualism is entirely pointless, because of the failure to agree on terminology. It is not good to be a slave of names. I am a strong individualist by personal habit, inheritance, and conviction; but it is a mere matter of common sense to recognize that the State, the community, the citizens acting together, can do a number of things better than if they were left to individual action. The individualism which finds its expression in the abuse of physical force is checked very early in the growth of civilization, and we of to-day should in our turn strive to shackle or destroy that individualism which triumphs by greed and cunning, which exploits the weak by craft instead of ruling them by brutality. We ought to go with any man in the effort to bring about justice and the equality of opportunity, to turn the tool-user more and more into the tool-owner, to shift burdens so that they can be more equitably borne. The deadening effect on any race of the adoption of a logical and extreme socialistic system could not be overstated; it would spell sheer destruction; it would produce grosser wrong and outrage, fouler immortality, than any existing system. But this does not mean that we may not with great advantage adopt certain of the principles professed by some given set of men who happen to call themselves Socialists; to be afraid to do so would be to make a mark of weakness on our part.
#28 Deen
August 21, 2009

@25 DLC: on top of that, health insurance is also not really a free market: it only works if you have a large enough pool of insured to spread the risk over. You can’t really have a small mom-and-pop health insurance company, or be a small health insurance upstart. And the bigger the pool, the better it works. Therefore, health insurance markets will always be dominated by a small number of large monolith companies.
#29 Coriolis
August 21, 2009

Woah, that’s a really well said piece by Theodore Roosevelt. If only modern republicans were anywhere even close to his intellect.
#30 Donna B.
August 22, 2009

As far as Teddy Roosevelt goes, he was a progressive as progressives of his time are now defined. See:
http://www.princeton.edu/~tleonard/papers/otherbel.pdf

Health insurance as we are talking about today differs from all other insurances in that it attempts to insure things that are likely to happen instead of catastrophic things. For health insurance to cover such things as wellness and prevention, it’s guaranteed the costs are going to be incurred and we might as well look at them as pre-paid rather than insured.

I ran across a comment on another blog (can’t remember where) that suggested health care can’t be a commodity because humans can’t be a commodity. I found that odd, but thought-provoking.

eddie, #24 — Back when Hillary was trying to get health care reform passed, I sat down to try to figure out what basic health care services should be offered as a “right”. It was basically a never-ending list because if you see health care as a right, whatever treatment *might* do good is a need to that particular person.

In some ways our current system of charity might provide more of those excruciatingly expensive treatments to more people than a more equitable system of rationing would. It’s something to consider. I think of St. Jude’s and the Shriner’s hospitals when I say this.

MikeB, #26 — I totally agree that the people most satisfied with their healthcare in the U.S. today are military. What you may not understand is how much the military depends on the infrastructure of the rest of the U.S. healthcare system to provide that.

I have Tricare. I am very grateful that I do, but it doesn’t eliminate ALL problems. I am limited to seeing whatever PCP I’m assigned to. Getting an appointment is MAJOR headache because if there are none available the day you call, you must call again the next day. You can’t book one ahead of time. You must use the assigned physician unless you are more than 100 (crow flown) miles away from home. Visits to the ER are routinely not covered unless you are admitted.

Granted, someone who has been in the “system” as long as I have can learn the ropes and bypass a lot of these rules, but for the average Tricare patient, it’s not a cakewalk.

I remember one day in particular needing an appointment to get treatment for a sinus infection. I’d been trying for over a week, and finally got the help of several friends. We all dialed over and over again as soon as the appointment line began taking calls. It took more than an hour to get anything other than a busy signal (5 cell phone users with speed dial!) and that resulted in being told that there were no appointments available and to call back the next day.

Can we say “access” problem?

I think the elephant in the room may be that we expect too much, both as patients and physicians. Medicine really can’t do everything the newspapers say it can and patients are much more likely to go their own way than follow a physician’s advice… which may or may not serve them well depending on the presenting problem. Though it’s not common, I’ve had physicians suggest treatments that are definitely NOT in my best interest. And, being human, I’ve ignored excellent advice.
#31 Caledonian
August 25, 2009

That does not mean I don’t want to see some kind of universal coverage.

That leads to its own problems, Donna B.

There is a great deal of talk about “affordable insurance for everyone”, but that’s an absurdity. The nature of insurance guarantees that policies cannot accept anyone who wants to be covered AND cover all conditions. In total people must pay in at least what is paid out, and generally the most equitable way to arrange that is for each individual to pay according to the risk that they’ll draw on the insurance. People who are guaranteed to have medical expenditures therefore cannot have them be covered by any plausible insurance program.

In the public mind, “health insurance” now refers to a payment program that covers the cost of medical expenditures. Making participation in this program “affordable for everyone” is impossible, because people who don’t contribute will have to be covered by others who pay far more than the services they get are worth to them. And that’s not even touching rationing, which is inevitable.