I genuinely wish to know

Matt Y. writes:

…the forces of progress are fated to an arduous generational struggle against the health care industry [TC: not just private insurance?] and there’s not much to be done about it.

Now I can understand the view that market forces are doomed to failure in the health sector and that government is the best of a bad set of choices.  That is not my opinion, but I grasp why someone might believe that.  I wish to ask all you single-payer advocates — in absolute terms — how good (bad) do you think it will be?

Let’s rate "the paper clip industry" as a 9 out of 10.  Paper clips are pretty cheap and usually they work.  Let’s rate the better federal agencies as a 6.5 out of 10.  Let’s rate HUD as a 2.5 out of ten.

How will national health insurance do, keeping in mind that U.S. doctors do not wish to have their wages cut, Americans want the right to choose their doctors, and the U.S. is a huge, messy, decentralized, federalistic country with lots of cheats and massive, hard-to-eradicate inequalities at many different levels.

I give it about a 3.  How about you?

And what are your views on the likelihood of today’s flawed system improving without drastic single-payer reforms?


How well does the Veterans system do? Medicaid? Medicare? Foreign health care systems? Those could give us some idea.

Single-payer health care in the US? I think it will be just like government schools.

Upper middle class neighborhoods will have GREAT services - maybe 9 out of 10. There will be professional managers who will get fired if performance, as measured by service quality, isn't up to snuff.

Poorer folks will get whatever model you think Marion Barry would provide. I predict that health clinics in populist-leaning cities, like their schools, would be run as job programs for the politicians' constituents instead of service providers - maybe 2 or 3 out of 10.

Rich folks will still go to private doctors just like they send their kids to private schools.

Single-payer is not primarily about controlling the cost of care; it's about expanding coverage. The hope is that we could current shift spending on redundant administrative systems to spending on medical care for currently uninsured people.

If, under single-payer, we were to continue to spend 16% of GDP on medical care, the idea just might work. If the single-payer agency were well-run, it might achieve 6-7 out of 10, which is probably about how most people with good coverage rate their insurance now. (If the single-payer agency tries to reign in costs, all bets are off.)

The problem (as kebko senses) is how such a system deals with changing technology. Without market signals, how does such a system decide which new treatments should be covered and which shouldn't? How does it decide when people would be happier to spend a larger fraction of their income on medical care and when they would prefer to spend less? Under a single-payer system, there is a real danger that such questions remain unanswered or mired in poltics, standards of care stagnate, and customer satisfaction declines.

We already have socialized healthcare (most people have their healthcare paid for by someone else, half of it is paid for by the government, sounds socialist to me).

So the question isn't whether socialized healthcare is better than free market healthcare, but whether a different socialized healthcare system might be better and more cost effective than the mess we have now.

It also is interesting to consider what might happen if healthcare were de-socialized.

I am with mike on this on. I don't see how the US system will be so much worse than actual existing state run medical service systems that do pretty well. Ask the Canadians to rate their system.

1. If (as David says) "redundant administrative systems" are a significant factor in health care costs, why don't we see a wave of mergers among insurance companies? You don't need a government to get economies of scale.

2. Medicare and the VA benefit tremendously from innovation financed by private insurance payments. I don't care about cheap paperclips today, I care about whether 30 years from now iPhones will be cheaper than paperclips.

3. Having said that, I really love the French system. I had to spend most of two weeks with a sick family member in a French hospital once. The buildings were old and the smoking lounges were weird, but the doctors were the equal of top American standards, and the cleanliness and infection control was far, far superior. There is a case to be made that the single-payer systems are more effective in dealing with the externalities of spreading infections.

I have a condition called Otosclerosis which causes progressive hearing loss. Fortunately, it's easeily fixed with surgery. The usual treatment is to do each ear separately, the second 6 months after the first, with regular doctor visits in between.

I'm insured through my wife's employer. We had blue cross (CA) HMO. It took EIGHT MONTHS for me to see the surgeon from when we started the process. My surgeon has to play games with insurance company rules (like having people admitted for surgery as outpatients before the surgery, then changing their status to inpatient after the surgery, even though an overnight stay is medically necessary. He also, had to write a prescription in which he claimed I was alergic to some medication to prescribe me his preferred treatment. If he didn't, the insurance company would have wanted me to take medication which damages the ear.)

Yeah, the current system works great.

Now throw in a new wrinkle: My wife's employer is changing insurers effective Jan 1st. I have to go through the whole referral process AGAIN to continue seeing the doctor who is in the midst of treating me.

Tell me why we don't want single payer again. I think giving the current system a 3 is awfully generous. If I had 3, I think I'd be happy. I had much better service when I was on unemployment 5 years ago. Hell, I've had better service for Jury Duty, paying tickets, doing anything at the post office. Dealing with health insurance is probably the worst encounter in my life. Anyone who says otherwise, has probably never used their insurance.

Do people think the problem with the current system is market failure as opposed to regulation? In any case, at least with the current system new treatments are constantly being invented. Even if you think there would be an immediate improvement in the quality of care, this may come down to discount rates again.

don: Don't forget that single-payer is about extending coverage, not improving the quality of coverage. Single-payer could just mean that a lot more people get to have the crappy experience that you did. For some people, that would be an improvement. For many others, it would be a significant reduction in their standard of care.

DK: You have a good point about administrative costs. It may be that heavy state regulation of the insurance industry discourages mergers. I don't know for sure. I do know that advocates of the Clinton-era single-payer plan claimed that they could cover the uninsured out of administrative savings.


The state of health care in New York City supports your claims. Massive expense. Low quality. Heavy political control. Large scale fraud. Google Dennis Rivera. Ugly at best.

I hope its MUCH better than the VA. From today's "The Hill":


"A secretly recorded meeting of researchers working for the Department of Veterans Affairs indicates that the department did not take seriously congressional requests intended to safeguard the personal and medical information of veterans.

"“If you want to know what’s the real purpose of the data call, read Machiavelli. It’s about power, it’s about Congress saying, ‘VA, you’re accountable to us,’† one Veterans Affairs official, Dr. Joseph Francis, says on the tape. “We’re not asking people to do an A-plus job on this report.†

"“Congress is actually rather angry at the VA because we’ve been technically breaking the law for a decade,† Dr.Francis said. “In 1996 legislation was passed called the Clinger-Cohen Act that really set the timing for all agencies to follow certain types of business principles in IT [information technology] procurement and IT management, including cyber security. We’ve basically ignored that"

"It really illustrates that, to the researchers at the VA, the veterans are guinea pigs and are there to promote the research, which is used in turn to promote researchers’ careers.†

The source claimed that high-level researchers at the department are not sufficiently concerned about the vulnerability of medical information because of financial stakes tied to their research.

You know, after having sat with my wife through the 2.5 year ordeal to get the federal government (Social Security) to recognize her post-car-accident disability, I have little faith in the government to deliver or manage services to/for individuals on an efficient basis.

Put me down for a 1.

"I think that healthcare is special"

A lot of people do, but I can't help but suspect (strongly) that this perception arises from the fact that health care is already massively socialized in the US (as well as pretty much everywhere else in the advanced world). A lot of the familiar, and peculiar, practices which we associate with medicine and which prompt us to consider medicine "special" may arise, not from causes intrinsic to the field, but from causes originating in government meddling.

Do we really have any comparable examples of a free market in health care in a first world country, one without massive government intervention all over the place? Examples of first world countries are: the US, Canada, the UK, France, Germany. For starters. Does a single one of these have anything approaching laissez-faire in health care? If not, then how do we really know what a free market in health care in an advanced country would look like?

My opinion is this: it will run a whole gamut ranging from 2.5 for the poor to maybe a 6 for the middle-class. I agree with someone who said earlier that it will be just like public schools. That said, I think the whole healthcare system is a broken mess and although the insurance companies take the flak most of the time(deservedly so), the biggest reason for this is the whole doctor mafia under A.M.A. and other trade groups. The market forces are never allowed to work in the health care industry here in the US because the inital barrier is set too high and expensive.
I will explain why. The entry level barrier for somebody to become a doctor is extremely high both in terms of time spendt in the medical school and the expense. First you need to have a four year college degree in pre-med and only then you get into medical school for about six years including the internship. That's roughly 10 years after highschool for somebody who diagnoses and treats ordinary ailments. Where's the need for that? So obviously for somebody to go through such a system the incentive needs to be higher pay which is payed by the consumer. Let's compare it to the doctors in India (you'll see a lot of them in most hospitals here in the U.S.) They go to school and study what is called M.B.B.S after high school. It takes six years to mint a new doctor and that is including the one year internship. He is allowed to practice. If he chooses to specialize he will spend some more time in graduate school but the important thing is the entry is not as high as it is here. Now, are we getting the best quality doctors because of they go to school ten years and lay those costs on consumers? I doubt it because a large number of doctors here had studied in India. Now, for these doctors from India who only studied for six years there's a clever way of increasing their costs. For them to practice here there are a lot of obstacles in place like clearing a great deal of exams before they are allowed to do anything. My point is, doctors as a group,like teachers have taken the whole system apart to suit them and rose costs by cutting down on competetion.
Instead of all this convoluted system of government paying for insurance to pay for the high cost of healthcare, let's say we tweak the policy saying people from reputed schools in India and elsewhere be allowed to practice here without any entry barriers like the M.L.E exams. Further let's say, we have a course designed for doctors who will be allowed to practice healthcare after five or six years of medical school after high school but will do only basic care. The costs will automatically drop.

Now the likelihood of the system improving is very slim, just like the public school system( the culprits over there are the teachers). Unless the system as a whole collapses I don't see a better way.

Since much of this is personal and anecdotal, let me add my $.02. These days I do have health insurance and yes, sadly I use it. For me personally, the system is an 8-9. However, that doesn't make me any advocate of the status quo.

There are plenty of people at the margins with little or no health insurance. If they get sick, they will either pay the bills out of pocket (at rates higher than insurance companies are charged) or just default. They will get treated, but the process is a mess.

Some number of years ago a friend asked me if she should take a full time job with benefits at lower pay (she was temping at ImClone, earning considerably more). My advice was yes, you should. Fortunately she did. Later she got very sick and needed extensive and expensive health care. Her case is difficult. However, she has received good care at little out-of-pocket cost to her. What if she had stayed temporary?

Conversely, I have a niece with no health insurance. Her choice. She is young and playing the health care lottery. She could pay for health insurance (she earns enough), but chooses not to. If she gets sick, she will probably dump her health care costs on the taxpayer. For her it is a “heads I win, tails the public looses† transaction. Completely irresponsible.

The system is also hugely wasteful. I could mention Terri Schiavo, but let me provide a personal note. A few years ago, my wife and her girlfriend came down with viral meningitis (one got it from the other, direction unknown).

The girlfriend was treated here in the US at a total cost of $15,000 which included several extremely painful procedures. My wife has taken care of in Sweden (we were traveling). The total cost was $1000 (health care isn't free for Americans) and no tests were run. She was given powerful drugs to reduce the pain and make her comfortable.

The American medical system runs on a "cost is no object" premise driven by revenue generation and fears of MedMal. Of course, the insurance companies try to constrain the process, but they have been fighting a losing battle since the HMO wars of the late 1990s. Actually, they have generally surrendered to be honest.

How does this relate to single-payer? My guess is that it will result in even greater outlays. The Democrats know they can't even try to implement such a scheme if it imposes health care rationing from the outset. They won’t even try.

The medical establishment will use single-payer as a bottomless pit to feast on. Of course, some administrative savings will be realized and drug prices might be lowered via negotiation. However, the underlying "cost is no object to providing proper care" mindset will now have the Federal treasury to devour.

Well I have health insurance and my wife and I use it a lot with few problems. Though since we switched to an insurer with a lower premium -- my employer gives us a choice, my wife has been aggravated by having to get referrels. But overall, my biased opinion is that I'd rate it fairly high, around 7.

I have a hard time seeing the case for a greater role for a single payer system. Mostly for the reasons already mentioned. Personally I doubt that a single payer system would reduce administrative costs as much as the widely publicized study from a couple of years ago claimed. If having one form to fill out -- instead of a different form for each insurance company -- creates efficiencies and cost savings, why not not give anti-trust exemptions (if needed) so the insurance industry can adopt it. Forms are already standardized for mortgage applications, etc. So why not health insurance? Why would it be necessary to have a single payer to adopt such reforms? (sorry I don't recall the names or authors of the study.)

I'm glad the Canadian reader likes their system. Evesdropping from the U.S. side of the border, I don't see that it's any better than ours. Last month I heard on the CBC that a Toronto man was suing for discrimination because Ontario's health care system doesn't pay for PSA tests. Even though the PSA test is a superior test to other forms of detecting prostate cancer. Plus the system won't pay for -- how was it put? -- post operative items related to prostrate cancer (O.K, the E.D. drugs) even though they pay for things after a woman has surgery for breast cancer.

Several years ago when the Ontario premier announce the budget, he mentioned that 5,400 more heart surgeries were included in the budget. If I was the X+5,401 person to need heart surgery, I wouldn't be happy.

All goods are scarce and need to be rationed. Will a single payer system be a better way to ration?

During the debate over the Clinton heath plan, NPR's "All Things Considered" ran a piece discussing whether or not skydiving, rock climbing, downhill skiing, and other risk taking activities should be banned. The conclusion, I think, was of course we shouldn't. But just the idea that people are even considering it is sad.

Peter Schaeffer -- you're probably right about Canada spending closer to 10% of GDP on health care than the 7.7% I cited. I was surprised it was so low, but it came from a Reason magazine article which was highly critical of the Canadian system so I thought it was safe to break my rule about believing statistics in editorial pieces. Your numbers are probably more reliable.

As for emergency rooms, it probably depends on where you live. I'm lucky to be in a large city with many medical clinics open late seven days a week, so there isn't much reason to go unless it's actually an emergency. I was there recently because a family member needed surgery, and they were top notch. I imagine it's quite a different experience if you show up with the flu.

Daniel -- I wouldn't believe the rhetoric on heart surgery. Politicians love to announce things like that, but that doesn't make it true. He probably figured out the cost of a heart surgery, and increased the budget by 5,400 times that number.

I agree with your rationing comment. But I'd suggest in some ways our rationing is more effective. For example, I was recently prescribed the generic form of a medicine which isn't available in the US, instead the US has a patented version with the same active ingredient (it's patented because the molecules can be either right- or left-handed -- please don't ask me what that means -- and only the right-handed version is biologically active. The Canadian version of the drug has both, so the patent has expired; the US version only has the right-handed molecule so it is patented. The US drug costs eight times more, but no one's ever done a head to head study to see if it's any different or more effective. I suspect because the drug company wouldn't like the expected result, but I might be too cynical. Still, I suggest this is an example where the Canadian system is more efficient.

The PSA example from Ontario is harder. It's troubling that the government decides the test isn't medically helpful as a general screening device rather than the men themselves. But even in the US men with insurance aren't faced with the right question (is a PSA test worth more than $X to me), they decide if they want a free or cheap test. A piori it's impossible to know which system will lead to a more efficient outcome.

I don't think there's any question that the top 10% of people get better health care in the US than Canada, and that it's the other way around for the bottom 10%. The difficulty is for the 80% in between.

As someone who came from Canada a few years ago to the US, I have to say that Nathan's take seems spot on. Personally, I preferred the Canadian system by a long shot - while you sometimes had to go through rigmarole to get certain stuff done, there was far less of it than I've faced while trying to deal with insurance companies here. Not to mention, a far lower burden of paperwork. Obviously, one can't extrapolate general claims well at all from a single case - but I did find it pretty good, and also better than Germany, where I've lived too (I understand that France is better still by a long shot, but haven't lived there for long enough to be able to say).

Universal health care could work as catastrophic insurance. At the other end, the government could expand the amount of free and low cost clinics. (Doctors used to make rich people pay more, and gave free care to the poor, before government intervened. That's not a bad model.) The postal service is a good example. It's decently run, but it doesn't carry all the mail anymore. A lot of people choose FedEx and UPS. Give people a safety net, but allow the free market the chance to provide healthcare without 75,000 pages of regulations and hours upon hours of paperwork. The big problem, I think, is that people believe health care is a right, and that everyone should receive the same service. Whereas, the free market would provide better service to all, but at differing levels of quality. Also, try to sue the government when they kill you through negligence.

I give today's system about a 5. The lieklihood of today's system improving without drastic governmental reform is virtually zero. There are two reasons. First, there are so many darn stakeholders with conflicting interests (taxpayers, patients, insurers, providers, government). Second, I don't see on the horizon advances in medical technology that will make the current way of treating patients obsolete - those dramatic technical changes have often assuaged the need for drastic reforms.

Kevin Drum comments:

Let me take a stab at this. Under Medicare, doctors are paid pretty decently, patients get to choose their doctors, and the system currently operates in the United States, messiness and all. So the short answer is that we don't really have to guess at this: national healthcare ought to work at least well as Medicare. And surveys indicate that the group of people who are most satisfied with the healthcare system in the United States are.....

The elderly. Who all use Medicare.

I don't know exactly what number to put to this, but a system that provides good quality care, gets high marks from its customers, covers everyone, and operates at a cost no higher than private healthcare seems like a pretty good deal. Maybe not as good as the paper clip industry, but surely at least a 6 out of 10.

And now a reverse question: how would Tyler rate the patchwork system we have today?

Oh, and if you want government services that work, try electing people who actually believe in government, instead of the corporate whores who've been looting the pantry for the last six years...

Hermit, that's interesting, because a (lefty, single-payer supporting) friend who just moved to Canada cannot find, in the entire city of Toronto, a doctor who is accepting new patients. Friends who have lived in rural areas don't get to choose their doctors, because there are too few to speak of "choice". Have you actually tried choosing your doctor, or is this a theoretical belief?

JMHO but initially, I think a government run system would be a solid 6 or 7. The problem would be how would the system develop over time? I have serious doubts that medical advancement would be achieved at the same rate without competition between providers. Currently we have doctors, hospitals and services competing for our insurance dollars and it produces advancements. If we had one provider with zero competition, I seriously question future advancements and the future quality of service.

I don't see a change in health care changing the pace of improvements in health care. Right now most new treatments are NOT a results of market competition, they're a result of academic research.

What market competition has done is do things like create a CURE for sleeping sickness which was never manufactured until it was discovered that the same drug also had cosmetic benefits.

"Right now most new treatments are NOT a results of market competition, they're a result of academic research."

Drug companies spending billions on research into new drugs for things like cancer probably would beg to differ. Some of these companies are *sponsoring* academic research, and therefore *that* academic research *is* a product of market competition.

"What market competition has done is do things like create a CURE for sleeping sickness which was never manufactured until it was discovered that the same drug also had cosmetic benefits."

Well, with that comment you suggest strongly that you don't actually know what you're talking about and are merely regurgitating the selective accounts and absurd exaggerations of the street.

--"If not, then how do we really know what a free market in health care in an advanced country would look like?"

The closest you can come is probably to compare the comparatively lightly regulated dentistry and vision health care markets to the general health care market. This would have the added benefit of giving the difference across largely the same customer base.

I can imagine that lightly regulated healthcare would be great for proceedures of the same scale as those performed by dentists and eye doctors. I don't know how well this would scale to catestrophic or chronic problems.

Let me clarify: not one soul other than the receptionist would look at me until I had paid the almost $400 up front. Essentially I had to pay that much just to get into the Emergency room waiting room.

I must be one lucky bastard. Do most people really have endless paperwork to deal with? If I'm sick I go to the doctor. My company (I'm in energy) pays for whatever I need, less a co pay for which I'm billed via the mail. I don't have to fill out a darn thing.

That's how my parent's insurance was. That's how my insurance has always been (with three different health plans from three different companies). My wife, who's worked for several non-profits, has had a similar experience.

My only gripe is that I wish my company offered a catastrophic only product (of course, I could always choose to work somewhere else). I don't need my insurance to cover normal doctor visits or drugs; I need to it to cover terribly expensive, major (life threatening) procedures. The later is the kind of thing that could put my family at risk, and that's what insurance is good for.

Health insurance needs to be more like auto insurance. I don't expect Geico to change my oil, do I? Of course not.

"I'm looking at potentially having a medical treatment INTERRUPTED because my wife's employer changed health insurance plans. That doesn't happen with single-payer."

A government problem. Why is US health care tied to employers? No good reason, other than tax incentives created by the government. We don't expect our employers to cover our auto insurance. Or home insurance.

And this is doubly bad considering the mobility of the US system. We move around and change jobs comparatively often...

Well, my uncle's best friend's sister's cousin's girlfriend went to the doctor with a stomachache and came back with two heads. And they charged her $10000 per head!

If data really were the plural of anecdote, this thread would be a fantastic example of data. Unfortunately, it's just a bunch of bloviating.

Jane Galt -- No, it wasn't GERD. I don't remember the name of the generic any more, but the prescription version in the US is Lunesta.

Will Gore said: A government problem. Why is US health care tied to employers? No good reason, other than tax incentives created by the government. We don't expect our employers to cover our auto insurance. Or home insurance.

No doubt this is partly true, but I think you're overlooking the role of adverse selection, which is a huge problem for medical insurance. Single payer is one way to get around this, but insurance through large employers is almost as effective. The trouble is as soon as you let individuals pick whether they want to sign up for insurance or not, you're not going to get a good risk profile.

Let us review what we know:

1) Most other major industrialized nations either have single-payer plans or government run plans.

2) Most, if not all, of those plans cost considerably less than the US system, and the populations of those nations often have longer life spans and lower infant mortality rates (to name two measures of performance).

3) Medicare has significantly lower administrative costs (on a per-patient basis) than any private insurer.

4) By most objective measures of quality of care, the VA system is the best health care provider in the US

5) Private insurers have strong incentives to:
a) Deny coverage, whenever possible, to those mostly likely to need it, and
b) Deny payments, whenever possible, to those who are covered.

6) Those who need care but have no insurance spend their own money (and perhaps that of their family) until they are broke, and then either we pay for their care from our taxes, or they die.

A) Single-payer plans exist that can do much, much better than we are doing now.

B) I see no fundamental reason why the US Government cannot create a single-payer plan that far outperforms what we have now.

C) Whether or not we do so depends upon the political process

I think John Rogers said it best:

It's wrong for you to lose your house if you kid gets cancer

I tore my ACL while I was living in Sweden in 2004. I got into to see a doctor within a week, who informed me that I could get it surgically repaired, in about 1.5 years. That's when I left Sweden.

--"I don't know how well this would scale to catestrophic or chronic problems."

I guess it depends on your definitions. Speaking as someone who nearly went blind at age three thanks to a vision problem, I tend to think that there are certainly catastrophic and chronic vision problems around. And that I've had a lot less hassle getting them dealt with and controlled than I have with my (also chronic) allergies, at least before loratadine went OTC.

--"Why is US health care tied to employers?"

As you say, tax incentives. A relic of a historical oddity, and a government program that (no surprise) never got repealed after the problem it was meant to address went away.

Another good argument for a constitutional amendment requiring an automatic sunset provision on all federal laws, perhaps? I've always liked the idea that they'd have to review the books every so often and specifically, and individually, pick which ones were worth keeping and which weren't worth it.

2) Most, if not all, of those plans cost considerably less than the US system, and the populations of those nations often have longer life spans and lower infant mortality rates (to name two measures of performance).

This is a bit misleading for several reasons. First the reasons why the United States spends more on health care that most other countries is largely because we tend to use more cutting-edge technology than most countries (IIRC only Japan uses more high technology than the United States) and we tend to be more willing to spend money on “heroic measures† for things like end-of-life care and premature babies both of which are enormously expensive. As far as the infant mortality rate goes, the United States unlike most countries includes stillbirths in our infant mortality rate statistics and they account for about 40% of our numbers (per the March of Dimes Foundation). Remove that 40% so we’re using the same methodology of nearly every other country and we’re in the top ten. Life expectancy in the United States is largely a result of life style choices (e.g. obesity driven by diet and exercise) and to an extent ethnicity (Asians in developed nations tend to live longer just as they tend to have a lower infant mortality rate) rather than the availability of health care.

3) Medicare has significantly lower administrative costs (on a per-patient basis) than any private insurer.

This is also misleading because Medicare doesn’t use activities based costing like private insurers which means that the administrative support it receives from other federal agencies (e.g. the IRS serving as its accounts payable department, DOJ performing its legal services, the civil service administration performing its HR work) aren’t costed into its administrative overhead as it would be in a private insurance company.

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