Single Payer Shell Game

The Bureaucracy That Dare Not Speak Its Name

To hear its proponents describe it, under a Single Payer system of national health care the government wouldn’t even be involved. Apparently, even though such a system designates the government as the eponymous Single Payer who would pay everybody’s health care costs from tax revenues, the private sector will still be fully in charge as the government will neither run the hospitals nor employ doctors as they do in those creaky, decaying socialist countries. In fact, the hand of the government would be as soft as the milky fingers of a sixteen-year-old Lithuanian Virgin on her wedding night.

You’ll hardly notice.

Now look, I don’t have a degree in economics and I don’t belong to a think tank where I am paid to shill my particular brand of public policy. On the other hand, I have a little common sense and have kept my eyes open.

If you were to get in a scrap with a mean old junkyard dog and he managed to sink his teeth into your scrotum, from that point forward the dog is totally in charge. You may have the complete use of the rest of your body and even though, from a real estate point of view, the dog has laid claim to a fairly small portion of your property, where that dog goes you will go and you heart, mind, and soul will follow willingly.

Money drives medicine. Not a nurse empties a bed pan nor a surgeon repairs a hernia without money changing hands. This is so obvious that it is almost insulting to mention it. And yet the proponents of a Single Payer system seem to believe that, although the government would have its teeth firmly embedded where it counts in every medical decision, nothing but good could possibly result. It seems, at last, that our ruling elites have devised a system of total control which is appealing enough to convince the ignoratti but from which no blame could ever be extrapolated to government (who don’t actually run the hospitals or employ doctors, you see) when things go south which they inevitably will.

South they will go because the premises of socialized medicine (which is what a Single Payer system is except for a minor technicality) are all wrong and will do nothing to correct any of the perceived problems of health care delivery, most of which are overblown anyways.

First of all, price fixing always leads to scarcity as there has never been a government in the history of the world that fixed the price of a good or service above or even close to the market price. If you don’t think this is true, ask yourself why so many doctors refuse to take Medicaid patients. The answer is simple; because the real cost to treat a Medicaid patient is often more than the government’s fixed price. In a Single Payer system, the government might not own the insurance company but this is about as relevant as the government’s non-ownership of hospitals or non-employment of doctors. Under the Axiom of the Junkyard Dog, the government has the important parts (the funds) clamped in its jaws and it can dictate terms to the insurance company (what they can charge) and the health care provider (what they can bill). Because money is also a scarce resource, the pressure on reimbursement will always be down with nothing to resist it. Certainly not any pressure from the electorate, most of whom want a free lunch no matter how much it actually costs them and who are pandered to shamelessly on a regular schedule of elections.

Decreasing reimbursements would be fine to the ignoratti, of course, as those rich doctors and capitalist-tool insurance executives would finally get their comeuppances but if you think it is hard to get an appointment with your doctor now, wait until your doctor’s economic incentive is completely removed and see how the system which currently can get a wino to the cath lab in about an hour and a half would slow to a crawl. This would be because a Single Payer system increase demand, as people will take more of anything if it is cheap or even free, without doing anything to address supply. In fact, the decreased reimbursements to health care providers that would certainly ensue as the dog ground its teeth would decrease supply at the time demand was increasing.

Does our country even need universal health insurance and will adopting it make us healthier and decrease expenditures for medical care?

No and no.

First of all, nobody is exactly clear on the number of uninsured, who they are, and the significance their lack of health insurance. Forty million is a number thrown around a lot but as most of the elderly are covered under Medicare, all poor children and those from the lower middle-class are covered (or can be) under Medicaid’s Children’s Health Insurance Program, and many of the poor themselves get Medicaid, the forty million includes a fair portion of people who make the choice not to buy health insurance, either because they don’t need it or because they make a rational decision to spend the money on something else.

As we are a charitable people and it would be demoralizing to our society to have people dying for lack of medical attention, we need to have the so-called safety net to take care of people who simply cannot, through some combination of bad luck and personal choices, take care of themselves. But what if this number is only 10 million, not forty? Rather than have the government suck up even more money for redistribution in a highly inefficient, wasteful, and nonproductive manner, why don’t we just identify the 10 million hard-core uninsured and give them all health insurance with no strings attached. Seems to me that this would be several orders of magnitude cheaper than running what amounts to fifteen percent of our GDP through the Federal sausage stuffer.

There has, in fact, never been a government program whose costs have not risen well beyond even the wildest speculations of its critics and Single Payer would be no different, with its proponents 10 years from now opining that we have too many aircraft carriers and that the several trillion dollars spent on health care is not enough.

As to improving the health of the nation, well, I get attacked as a heretic for saying this but there is probably very little correlation between access to health care and health, especially as people who make health care a priority are the kind of people who would take care of themselves even if they didn’t have health insurance. Having a nice government health insurance policy will do absolutely nothing to get people to lose weight, stop smoking, exercise, and stop using crack, which, along with other poor lifestyle decisions are what really drives health care costs through the roof. This is readily apparent to anybody who works in a hospital. If it wasn’t for booze, cigarettes, drugs, 64-ounce Colas, Big Macs, and sedentary lifestyles, we would be all out of a job.

43 thoughts on “Single Payer Shell Game

  1. As a Canadian, I sincerely hope you in the states keep your system the way it is. This way, our rich will be able to jump the border and get treatment and reduce wait times for the rest of us.

  2. As a physician working in Poland, I agree with every single word of your post. We do have universal access to healthcare in my country. We have plenty of experience with the system and everybody hates it.
    My hospital is reimbursed for only a part of its costs, because the government is dictating the terms of the contract. The “contract renegotiations” each year take form of signing on the dotted line, take it or leave it. So we grind our teeth and submit.
    Everybody is entitled to everything for free, so many people just waste our time. People with IBS are routinely referred to gastroenterologists (!) and take up time slots, making people with severe Crohn’s wait six months for their follow-up visit.
    Physician’s wages are ridiculously low (I won’t name the figure as it could make you fall off your chair) and still we are made to feel that we are responsible for “generating cost to the hospital”. Yes, because not only do we have to be paid (although they are working on it), but we order all those expensive tests and procedures.
    I really enjoy visiting American medical websites… and I do not wish the Single Payer System upon you. Yes, it is nice to know that, at least somewhere else in the world, medicine can be a free profession.

  3. Well-said, young Panda.

    The junkyard-dog-hanging-on-to-your-scrotum analogy is perfect; a beautiful metaphor for the real “Golden Rule” (TM).

    “He who has the Gold, makes the Rules.”

  4. You might not want to post so soon after post call days. Saw a few atypical errors.

    If you don’t think this is true, ask yourself why so many doctors refuse to take Medicaid patients. The answer is simple; because the real cost to treat a Medicaid patient is often LESS than the government’s fixed price.

    Single Payer would be no different, with its proponents 10 years from KNOW opining that we have too many aircraft carriers and that the several trillion dollars spent on health care is not enough.

    And yes, I do have better things to do…I just don’t feel like doing them.

  5. You no that WordPress doesnt’ have a spellccheker, rite?

    But I appreciate your sharp eye and the corrections have been noted.

  6. Maybe you haven’t been paying attention, but that ol’ dog already cradles your sensitive scrotum in his slavering jaws. That dog’s twin canine teeth are called “Medicare” and “Medicaid.” (god I love to abuse a metaphor)

    Enjoy EMTALA much? That’s a medicare mandate. How about JCAHO? Medicare, too. HIPAA? You got it – Medicare. The RVU system and the lovely threats of audits to docs who don’t document their review of systems? Say it with me – Medicare! I hope you are looking forward wth joyful anticipation to the P4P guidelines coming down the tracks like a steam locomotive, ’cause they’re Medicare, too.

    The point is, single payor has a number of possible downsides. Increased government intrusion into the medical practice environment is not one of them – it already exists. The biggest downside is the likelihood that the government’s monopsony power would predictably drive down the costs of services, and that budgetary pressures would guarantee that the pressure on physician reimbursement would increase.

    You do make a number of less significant errors of fact – you ask, “why don’t we just identify the 10 million hard-core uninsured and give them all health insurance with no strings attached,” but there already is such a program, and it is called Medicaid and reimburses at 10 cents on the dollar and increases wasteful utilization of medical services — especially the ER.

    You also imply that a significant number of the uninsured simply “choose” not to buy insurance. Not so, and moreover, just as with car insurance mandates, there is a far question of whether it should be allowed — to “go bare.” Cigarettes and sedentary lifestyles are drivers of healthcare spending, but colon cancer and breast cancer and type 1 diabetes strike the virtuous as well as the foolish, and if you are uninsured and unlucky and get stricken, society will have to pick up the tab. How much more efficient to have prevention and disease management avilable to all?

    And you also ignore the substantial cost savings from the efficiency of scale, streamlining of beauracracy, elimination of CEO payouts, etc, which would accompany a single-payor system.

    I’m not saying single-payor is all that and a bag of chips. I’m on record as preferring alternative means for providing universal coverage. But it’s not without its merits.

  7. I’m not sure whether you are disagreeing with me or agreeing with me. Either that or you are making the argument that since, as a society, we have put one foot into a big pile of shit we may as well go ahead and put the other one in to.

    I also don’t understand how you could get the idea that I approve of EMTALA, Medicaid, Medicare, or any kind of socialism to which we are subjected as I most certainly do not. On the other hand these things are a fact of life and, “as your people, Sir, are a beast,” it’s not likely that they will ever go away.

    And I don’t know how anybody can use the words “streamlining” or “efficiency” in the same sentence as “governement.” Government serves a legitimate purpose and there are some functions that government probably needs to organize but “efficiency” and “streamlining” are impossible in an unaccountable bureacracy. We may elect our leaders, you understand, but the bureaucrats stay the same. Ask yourself how easy it is to fire a government employee and there is your answer to government efficiency.

    The single most important purpose of any bureacracy is self-preservation and expansion. If you don’t yet kow this I don’t know in what monastary you have spent your life.

    As for things like CEO payouts, whatever. That’s just a red herring and the kind of rhetoric I warned you folks that I won’t tolerate as it skirts the usual goofiness one might find on the Daily Kos.

    As for colon cancer, breat cancer, and diabetes, it is true that they strike the virtuous but from my experience, limited as it may be, the great majority of morbidity in our society is directly lifestyle related. (Obesity, smoking, drugs, alcohol, and various combinations of these with a complete disregard for physics…i.e the snowmobiler at night drunk without a helmet.) Again, I don’t know if you agree or disagree with me. Like I said, people need to have a major medical policy to cover unforseen illness or bad luck. Smoking for 40 years and spending a couple hundred thousand a year for ICU visits is willful self-destruction and has nothing to do with luck…or bad genes.

    Not that we shouldn’t take care of these people but the idea that these kind of patients would have had a different course has they only had access to primary care is ludicrous. Hell, our ICU is full of people who had access to GM health insurance (I’m in Michigan), at one time the best possible health insurance that money could by, and other than their ability to pay, there is no appreciable difference in their morbidity or mortality compared to the uninsured in the same age and class.

  8. And I never said I wanted “universal coverage.” You said it. I said that people should be responsible for their own health care, buying a major medical policy and paying for regular doctor’s visits out of their own pockets, fer’ Chrissakes.

    I’m on record as saying “Fuck universal coverage.”

    My hospital fronts almost $12,000 bucks per year to pay for my family’s health insurance. A major medical policy would cost a third of that. If they gave me the difference even paying for routine things there is no way thay my family of six burns $8000 a year in health care. I go to the doctor once a year. My kids maybe go twice. My wife has her annual exam annually. Some prescription meds, some antibiotics here or there, doesn’t come close to $8000. If we had to pay the whole cost we might even eschew some doctor visits although my wife has a good sense of when the kids need to go and when they don’t.

  9. Vjay, what on earth are you talking about? I’m open to criticism and suggestions but you have to be more specific.

  10. Politically, I believe the answer is simple and lies with the Libertarian party.

    The next best option I’ve been able to think of is a system that fully funds preventive care like vaccinations, routine screening, physicals, and education only.

  11. Oh Holy Hannah—get ready for a rant:

    Dr. Panda Bear said:
    “First of all, nobody is exactly clear on the number of uninsured, who they are, and the significance their lack of health insurance…”

    My answer: Are you out of your frigging mind? We are ALL VERY CLEAR on who doesn’t have insurance and its significance! It’s a huge percentage of middle class working adults! NOT the kids/adults on Medicaid and NOT the elderly on Medicare—but the vast majority of the country, which is middle class adults, aka the “working poor”. We who work for employers who do not provide health insurance or else those who are self-employed!! (Would you like me to do a poll here in Podunk and give you the percentage? All you have to do is count the people in the ER and do a simple calculation using the population of the middle class adults of the town—and that’s about 40-50% around here!) And the significance is that they either let their health go to pot or else they just SUFFER, both financially or physically. I know people who have had to declare BANKRUPTCY because of a 3-day hospital stay.

    Next, Dr. Panda Bear said this:
    “Having a nice government health insurance policy will do absolutely nothing to get people to lose weight, stop smoking, exercise, and stop using crack, which, along with other poor lifestyle decisions are what really drives health care costs through the roof. This is readily apparent to anybody who works in a hospital. If it wasn’t for booze, cigarettes, drugs, 64-ounce Colas, Big Macs, and sedentary lifestyles, we would be all out of a job.”

    My reply:
    What are you, the “Lifestyle Police”? If you didn’t want to take care of people with the above habits then WHY did you go to medical school in the first dang place? If you want to take care of people who live perfect lifestyles, then you need to find a way to magically jump into Truman’s world or else that Walgreens commercial— because it ain’t here in reality, man. Here in this country we are human.

    I’ll SWONEY the next time I hear a dang doctor spout off about people that do that kind of stuff. In fact, I want to see YOUR last physical exam, YOUR grocery list, and YOUR last labwork. Then we’ll see who’s perfect around here.

    Okay, rant over. I will now return you to your regularly channeled programming…

  12. First of all, I come out of the middle class (and am certainly, by economics, in the lower middle class right now) so I know a little about what goes on and I will match my middle-class street cred’ against anyone. You have got the wrong guy if your rant is directed against the evil rich.

    Second, you didn’t read my post before you went off on a rant. A typical middle-class family does not need expensive health insurance. In fact, what drives up the cost of insurance is the absolutely inexplicable expectation that every single thing be covered to the point that people even become irate to make a 20-dollar copay.

    It is this mentality that drives the yearly cost for a comprehensive health insurance policy for a family of four into the 12 to 15-thousand dollar range. What people really need is a high deductible or major medical policy to protect them against a catastrophic medical expense, not the realtively trivial expense of a pediatrician visit for an ear infection. This kind of thing needs to be in the family budget, just like food, clothes, rent, and entertainment. The fact that it is not says a little about the sense of entitlement that exists where medical care is concerned.

    As I said, the working poor and lower middle-class can get their children insured for free under medicaid. In my state, Louisiana, the poorest state in the Union, the income cutoff is about $36,000 for a family of four.

    In Louisiana $36,000 a year is actually a pretty decent salary and what I made at my first engineering job so spare me the hysterics.

    The other point that you missed is not that we shouldn’t take care of the fat, the addicted, the stupid, and the careless but that no Single Payer, Multiple Payer, I Pay You Pay, No Pay To Play, or any system of socialized health care you care to mention is going to make a dime’s worth of difference in the general health of the nation and if anything, health care costs will actually increase as the last remaining vestigial incentive to be healthy is removed forever.

    As far as declaring bankruptcy after a hospital stay, you must have a very aggressive hospital because our patients wouldn’t pay if they had the money (which some do) and there is nothing the hospital can do but send a bill every now and then which is promptly thrown away.

    Go back and re-read my post. And get a hold of that jerking knee before you rant. At least refute something rather than just ranting at how uncaring I am.

  13. First of all to the OP, one doesn’t need to believe that the government should take money through taxes in order to pay for people’s poor lifestyle choices in order to go into medicine. I’m really not sure why people believe that going into medicine requires leaving ones logic and moral base at the door in order to accept a strange combination of politically correct social propaganda and a vague sense of wanting to “help people” without actually evaluating the best way to help people.

    To Panda. Great point on the price fixing. I’d like to add that it would be inevitable that prices that are capped would be below market, because if they weren’t, the price would just fall below the cap and it would be irrelevant. However, fixed prices can drive prices up, which of course is what happened in many cases during the great depression and is why milk costs about 4x as much as a dozen eggs today. Of course, this would decrease access by and large, or those inefficiencies would simply be passed elsewhere in the economy in a single payer system, diminishing tax revenue and personal income. Also, as witnessed by the power of the dairy farmer over the chicken farmer in the above example, he who has the ear of his congressman will dictate price far more than what actually fairly or efficiently distributes resources.

    Nothin’ but love for ya.


  14. There are so many errors of fact in your post that I’m just going to refer you to two sites where anyone can get reliable and valid information about the demographics of the un-insured, the under-insured and the basics of single payer (which IS NOT socialized medicine).

    The Physicians for a National Health Plan (PNHP) website is extremely informative around the single payer issue, and the Kaiser Network website provides one-stop shopping for statistics on the insured, payment, healthcare costs, sources of reimbursement, physician reimbursement, etc. It allows you to subscribe to a variety of health policy updates, and the topics covered will give you a borader and deep health policy perspective.

    I’m not sure if commnets allows for html, so I didn’t include urls. They are on my blogroll, if you have trouble accessing the sites.

  15. You are not in reality, man.

    Few of the working people I know in Podunk qualify for Medicaid. The only people I know who get Medicaid around here make minimum wage. The average wage around here is just above minimum wage–enought to put most people out of the reach of Medicaid or the ability to afford a private insurance policy.

    Sure, we had the insurance people come parading into our office to see if they could sell us a policy—but they left quickly after stating that none of us qualified because of past treatment for diabetes, blood pressure issues, or a weird Pap smear. Even the Aflak people denied my diabetic friend one of their little policies.

    And as far as your statement about people simply “throwing away their hospital bills they can’t pay”—my best friend, an uninsured RN, is currently fighting the hospital over just such a thing for her child’s hospitalization. She regularly sends a small payment— and then gets a call from the hospital saying they are “rejecting” that payment as it’s too small! They are hassling her every week. AND SHE’S TRYING TO PAY THE DANG THING! She is too responsible to “throw away her hospital bill”. Not everybody is a “deadbeat”, you see.

    And about your statement of “entitlement” and bitching about $20 co-payments. I NEVER hear people bitching about $20 co-pays. I do hear people with insurance BRAGGING and BOASTING that they only have to pay a $20 copay.

    And ANOTHER thing. I resent you calling people “fat”, “careless”, “addicted” or “stupid”.

    Who are you to say such a thing? How much do you weigh? If you’re fit and have a decent weight, let’s ask that question in 10 years and see what you say. And have you ever done anything “stupid” or “careless”? I bet you have–many times. Good God, you’re judgmental.

    And addicts? I’m a recovering alcoholic and I’ll tell you what—I’m human too and I resent being ridiculed simply because I belong to category of people who have a miserable disease that has nearly a 75% kill rate. Where is your compassion, Dr.? It was a recovering doctor who helped give me the hope and courage to try sobriety one more time (after many failures)–and now I’m sober. My question to you is, do you have a family member who is addicted? If so, would you want them ridiculed by a doctor as being “an addict” in the same sentence as “the fat and the stupid and careless”?

    And I don’t have a “jerking knee”—and I read quite well. I am simply one who believes in standing up and defending the weak and infirm (whether it’s their own “fault” or not) because they may not be able to speak for themselves. I am a nurse who tries to understand humanity and help– instead of criticize or judge.

    Your statements smack of arrogance and generalizations. And I believe that patients are INDIVIDUALS. You need to walk a mile in their shoes before you start making generalized statements about their intellect, their abilities to get insurance, their incomes, their “carelessness”, or their addictions.

    And I don’t think you’re uncaring. I think you’re naive.

  16. Interesting post, Panda. Though I’m a liberal on many issues, I have to disagree with those who want to enact a single payer system for many of the reasons you’ve mentioned.

    In the undergrad Medical Sociology class I foolishly signed up for this semester, the professor constantly rants about the “lavish lifestyle” of doctors and asks “how much must the doctors be charging if they can afford these huge mansions?” This is the mindset of many uninformed people who would be more than happy to see ‘those rich doctors’ get what’s coming to them. Of course, when I point out that physician charges make up only a small fraction of total healthcare costs, that physicians take on substantial personal financial and health risks, and that all workers deserve compensation commensurate with the value of their service, the sociology professor and the class are not interested. I don’t think the American people are interested either.

    Of course there is truth to the point that healthcare costs for the individual have gone up, and that healthcare has become more difficult to access for some as corporations have cut healthcare benefits. But, is enacting a HUGE, EXPENSIVE government program the answer? I couldn’t agree with you more that a smaller, more targeted government program to help the lower middle class uninsured would be far better for physicians and ultimately the country.

  17. Wow Panda, you sure hit a nerve with this blog. You would have thought you were talking about killing babies and raping sheep or something. I read your blog all the time and this was by far the most comments I have seen. I still enjoyed it! Thanks again and keep on a posting!

  18. To Bohemian Road Nurse –

    Just curious, don’t you think you’re being pretty judgemental of Dr. Panda by calling him judgemental when you don’t even know him? Pot. Kettle. Black. Enough said there.

    Also, I don’t think you are in reality. FACT: I make 32,000 a year right now (about $15/hr, far above minimum wage) and have a family of 4. My kids are now on medicaid. So you don’t have any clue what you’re talking about.

    I don’t think Panda is “ridiculing” fat people, addicts, etc at all. All I think he’s saying (correct me oh wise Panda if I am wrong) is this: If you want to smoke, drink, eat big macs all day, and so on then fine. I’ll even treat you for the problems that those vices cause. But don’t expect me to foot the bill for your irresponsibility.

    Allow me to tell you a true story – I have a friend from high school who is a fairly “smart” guy as far as brain power goes. I love the guy to death, but the fact of the matter is he’s about the laziest person you will ever meet in your life. He works ten hours a week for his uncle (literally) and lives in his parents’ basement (seriously). He spends almost all of his time drinking and bowling. I keep pushing him to do something with his life, but he has flat out told me that he’s happy making $100 bucks a week and spending it on booze while his parents pay for everything (we graduated in the 1990’s by the way). Please understand, this guy is entirely capable of working and supporting himself but he just flat out doesn’t want to. He has a variety of health problems and expects to be taken care of even though he does nothing. On the other side of the coin, I work full time overnights to support my family of 4 while going to school full time during the day, in hopes of attending medical school in a couple of years. I am careful about what I eat, and do not smoke or drink.

    So can you please explain to me why I ought to be obligated to subsidize his health care? Can you please explain to me how my opposition to doing so makes me a bad person?

    So to recap: yes, low income and lower middle class folks DO ABSOLUTELY qualify for medicaid, with the cutoff in most states being mid 30,000’s a year for a family of 4. Look it up – google it or something, this is not my opinion, it is an absolute fact. It also covers diabled folks, and there is Medicare for older folks. Who does this leave? The middle class. Whom, as it has been pointed out, could afford health insurance if our country would be smart enough to realize that health insurance needs to be about “major medical” rather than paying for every little doctor’s visit.

    These are the facts, sincere apologies if they rain on anyone’s parade. The truth of the matter is, you can be a caring and compassionate person even if you don’t support the notion of government picking the pockets of responsible folks to pay for those who are not.

  19. Panda, you have brought up wonderful arguments and stated them as eloquently as a health policy professor with a bit of flavor!
    How can you morally justify a health care system which spends the most of any nation per capita but falls short of most other Western nations in terms of health outcomes?
    The American Health system as a whole is a failure. We have an inefficient system thats bleeding benjamins. Our per capita health expenditures are twice that of the UK and 3 times that of New Zealand.
    Our government subsidizes a pseudo-national health system by giving corporations huge tax breaks so that they will provide health insurance to many American employees. What about those squandered dollars? Isnt that our tax money paying for other peoples insurance?(Sounds pretty socialized to me)
    What about the enormous amount of cost shifting that occurs when an uninsured patient(one of the 15% of uninsured Americans as elucidated by multiple studies that were robust and published in peer reviewed journals) walks into the ER and requires treatment? Who pays for him/her? The hospital? Or are the costs shifted to the the insured patients and medical staff who pick up the tab through higher bills and lower pay. The money has to come from somewhere.

    The general theme here is that the current system is quite wretched and needs vast reform. Huge amounts of money are being spent with pretty poor outcomes relative to other countries.
    In addition I think its immoral to deny health care to the uninsured. Health care can be meaningful and prevents disease and disease progression.(Unlike a patient waiting eternally to make an ER visit for a cancer which progressed to stage IV instead of having regular checkups and screenings to catch it early).
    I understand that your strongly against a single payer system but what is your opinion on providing Medicaid for all? What are your thoughts on Medicare for all? Perhaps such systems would still preserve physician autonomy while providing necessary care to the needy.
    I refuse to accept that the status quo system is what we should live with, just as I refuse to accept the current system of residency is what should stay with us.
    I think it would do us well to uphold the constitution in this case and promote the “General Welfare”, the health of our fellow citizens, instead of brushing them off with broad strokes which insult them as idiots who are completely responsible for their health as if other factors (societal, genetic, cultural) are not in play.

  20. health care is really expensive. i hope no one has a heart attack.

    How can we have a free market and cover everyone with pre-existing health problems? It’s impossible. Those people will always be denied insurance or be paying insane premiums. But if the insurance companies were forced to cover those people, the free market wouldn’t exist.

    And if we had only the government’s hand in health insurance, patients would be waiting 6 months for knee surgery while doctors are getting paid $95K/year. That would suck.

    So there is no real solution…….

    except what we have now–> a mix of private and government health coverage. this way the gov can cover the poor/lazy (that’s right I said it) and the wealthy/responsible can get slightly better health coverage by paying for it.

    I believe that medicare reimbursments are fucked up though. decreases? inflation is roughly 3%. If nothing else, reimbursment should increase with inflation. What the hell is the deal with decreasing reimbursements? Doctors aren’t working faster and faster, seeing 300 patients a day. The system is not becoming more efficient, it’s static. This isn’t a car, it’s a service, services do not get cheaper the way consumer products do, they get more expensive as the value of the dollar decreases.

    I know this effects FM the most. Those FM docs need to get off their asses and start contributing to some lobbies so they can fight the declining medicare reimbursments.

    What the hell is wrong with the gov’t?…they are not working in a free market. They are voted in by the majority of votes and you can’t readily remove them. They are trying to make the majority of people happy so they can stay in office. The problem with this is the majority of people are not on doctors, so doctors get the shaft.

  21. Yan–you say that the USA spends the most on health care yet doesn’t have the results of other nations. Maybe US citizens have extremely unhealthy lifestyles and that leads to poor health outcomes. Perhaps all our spending is creating the best health outcomes we can get considering the poor state of our citizen’s health.

  22. Health care is so expensive here because we WANT it to be. We’re willing to pay all this money in order to never be told that grandma’s 93 year old life ain’t worth a 10,000 dollar operation. It’s a stupid question to ask why we pay more money without getting substantially better results: because we have expectations that ALL measures will ALWAYS be available, even if they’re minimal in terms of what they can offer.

    Anybody who supports single payer without admitting that that would have to change is just a bold faced liar, plain and simple. It worked in other countries because they started it before the modern era of technology really started, so there was never an expectation that grandma was going to veg in the ICU for a month and eat 10k in hospital bills. I wish y’all the best of luck in trying to take away that entitlement from the 85% of Americans with health insurance to give it to the other 15%. I foresee great success.

  23. The current problems with health care doesn’t really have a clear cut good vs. bad guys. As a previous poster stated, the raising cost is caused by the expensive care that is demanded by patients….and why shouldn’t patients want to spend thousands of dollars to save their beloved grandmother? I would.

    The problem is that our current system was setup decades ago when health care costs were lower, and hospitals didn’t spend $100k on a dying patient which they can’t really turn around or toss out the window or pull the plug on.

    Now, the raising cost of health care means more and more costs are being felt by patients who were brought up with the idea that health care shouldn’t be costing so much (because it didn’t used to).

    What’s the solution? Well, a single-payer system, from an economic point of view, is inefficient because the government will have a monopoly on health care. Good for people who currently have crappy/nonexistent, bad for the majority who still have decent health care.

    Americans don’t want to let go of their (mostly) good health care, yet they also fear being one of the 40 million without care, or become the millions more struggling with health care bills. (Top three reason for declaring bankruptcy is medical bills).

    I think the solution is to allow for most people to keep their private insurance but to have basic universal care for anyone who can’t afford it.

    Vaccinations, preventive checkups etc should be automatically given because of the enormous savings in terms of human and monetary costs.

    I like something similar to the MA plan. You are required to have private health care if you make over a certain amount to pay for your own health care to cover, minimally, catastrophic health care costs. For those that makes below a certain amount, basic care including catastrophic care would be provided.

    This means unequal health care, but I think it will allow for people who can afford it to have good health care, and for those that don’t to also have health care. And the cost of health care is lowered b/c most people are covered in some way.

  24. After reading my previous post, I realized I should have proofread it before I hit ‘submit’. I wanted to add that the current system is different from the one I advocate in that I want the level of income level to qualify for gov’t basic health care to be raised so that the working poor, and those doing crappy jobs without benefits will not lose their their health care if they lose their jobs.

  25. Huge, HUGE +1 to how the good Bohemian is being equally judgmental (and easily offended, it seems).

    Loved the post; I thought it made some decent points, and would wonder if it wouldn’t cause additional issues down the line when all these premed, potential doctors like myself see what the medical field turned into and go, “uhhh, yeah, no.” Lots of poo flinging on SDN over that sort of thing.

  26. I’m going to mostly agree with Panda, but I really think aflak got it right: part of the reason universal health care will not work in America is because the quality of care here is so good. Universal access /= everyone having access to the absolute most cutting-edge care for rare conditions with low success rates. Ditto long-term fights against inevitable death for the elderly.

    Any sort of easily accessible healthcare system would have to focus on the ‘easier’ stuff: preventative medicine (which is where access really becomes an issue) and emergency/’bad luck’ care.

    Practically everything is cheaper if its caught early — that includes ‘lifestyle’ diseases like alcoholism, obesity, etc. If it spirals out of control because a person chose not to access this (hypothetically) cheap and easy preventative care system, then it’s tough shit and you’ll have to pay for it yourself. But, should you have the bad luck to get hit by a car, be exposed to a virulent strain of something, have a rapid onset of cancer, etc., there would still be a safety net.

    Insurance is a numbers game. MOST people will not need expensive medical care if they (a) take care of themselves and (b) are lucky. (A) is more likely to happen if there’s a trained professional keeping an eye on you. A family practitioner really needs to be an advocate as well as a health coach for his or her patients–that’s the whole point of long-term relationships. (B) can never be sorted, but the results can at least be attenuated. A successful system could be cheap but only if it played the odds correctly, and understood the economy of disease: catching things early is just good business sense, and keeps the odds of expensive medical care down the road a lot lower.

    But yeah, in Europe socialized medicine took hold before everyone expected guaranteed results for really messy health problems. THIS IS TOTAL SPECULATION BUT: I’d wager that many Europeans are, if not sanguine, at least a little more rational when it comes to expecting extremely specialized, extremely expensive healthcare.

  27. my (school) insurance doesn’t work like this, and i’m pretty woefully uninformed about other plans BUT: are there plans that lower your deductible/payments for MORE visits to the doctor? like, rewarding you for preventative/maintenance visits? it may cost them a bit more, but it also means that you’re actually less likely to claim on something later, when eleventh hour care will drive the prices through the roof?

    i mean, i would never buy a used car without looking at the repair/maintenance records. if someone got regular oil changes, etc., i would be willing to pay a little more, even if there were a few catastrophic (but repaired) accidents/scrapes with luck. I’m struggling a bit to map that to insurance, but I think you get the idea—families/individuals that make health a priority (as evidenced by a good relationship with their FP) are a better bet for an insurance company.

    Also, as an aside: what is the profit margin in the insurance industry? I imagine they’re huge, but I’m just spitballing and am ready to assume the worst. Why hasn’t anyone started a non-profit insurance company that assumes all the risks of a private company but that reinvests its profits in lowering prices instead of lining pockets? This would encourage a larger customer base, which, in the long run, is a much more fiscally sound strategy than making big bags of money and gouging your customers.

  28. What’s the point in even discussing health care costs in a country where a quarterback is worth more than the pediatric cardiologist who saved your kids life?

  29. Are you serious when you say that most of the 40 million people who don’t have insurance choose to spend it on something else? Have you actually practiced medicine yet? A lot of these people are working people in jobs that hardly pay enough to pay the bills, let alone some expensive insurance policy. Come to my ER and work a few shifts and you will see who doesn’t have insurance.

  30. Most working families don’t need an expensive insurance policy. What they need is to budget money for routine medical expenses.

    It is the expectation that so-called “health insurance” cover everything that drives up the cost, that and the fact that like any insurance scheme, the payers are subsidizing not only people who actually get sick but, indirectly, those who pay noting at all.

  31. What’s actually worse, is that if you attempted to give care at an equivalent price and quality to what they have in Europe, you’d get the pants sued off of you. Maybe we could allow for some quality variation based on what people could pay, so that the poor people could actually afford something, rather than bankrupting everyone in an attempt to give everyone’s grandma the $150k ICU stay. This sort of crap IS the result of the meddling the govenmenr has already done in the healthcare system.

    P.S. The government doesn’t generate a profit. Everything it pays it takes from someone else who earned it. Talk amongst yourselves.

  32. Let’s step back a bit and ask ourselves the real, core philosophical question here:

    Is health care a right, in this case, something that the State must guarantee the provision of (e.g. Education)?

    If you answer “No” you will agree for the most part with what was said in this post and advocate that the payment and distribution of health care remain in private hands.

    If you answer “Yes”, then you will quickly realize that the US system does not guarantee the provision of this “right”. Denial of a right is evil, and so, you will seek a solution; Single Payer is one way to begin to address it.

    I don’t think we should talk about Single Payer so much as a solution to our financial woes in medicine, but instead as a moral question. For example: Is education a right? It appears to me that American ideology says “Yes”, and hence our expansive public school system. We need to determine what the American ideal is on Health Care as a Right, and then find a solution from there.

    Personally, I do think we have a right to health care, and so I advocate in favor of Single Payer solutions. But I wouldn’t waste my time arguing with Panda or anyone else about the details of Single Payer without first asking the core question.

  33. Interesting post. I still have to read your next two followups before I can comment meaningful, but I wanted to remind both you (Panda) and Bohemian Road Nurse that while Medicare is quite standardized across states with respect to eligibility requirements, Medicaid is extremely heterogeneous. Thus, comparing Medicaid in Podunk vs. Louisiana (hooray, Louisiana, where I’m also training) is like comparing apples and oranges (if I’m not mistaken, I think Louisiana has, for some time, had quite broad definitions for eligibility for Medicaid, unlike many more restrictive Medicaid programs elsewhere).

    Nonetheless, in Lousiana, no matter how penniless you are, it’s virtually impossible to be covered under Medicaid if you’re older than 18 and male, since Medicaid (+CHIP) is predominantly a program for low-income women and children.

  34. Losrivas,

    You said “Is health care a right, in this case, something that the State must guarantee the provision of (e.g. Education)?”
    Excellent point, one that needed to be brought up here, and I thank you for doing so.

    As it’s primarily a moral question, it’s quite difficult to supply a concrete yes/no answer to that question. However, I’ll try.

    There is a difference between a so-called positive right and a negative right. You intelligently used a ‘negative right’ example to compare healthcare to, as healthcare is quite obviously a negative right.

    For those who aren’t clear on the difference, a positive right exists in a vacuum – ie, life, liberty, pursuit of happiness, peacable assembly. These rights exist unless someone takes them away from you. Negative rights exist because someone gives them to you – ie, the right to military protection, the right to use our highways, the right to police and fire protection. Therefore, calling them a ‘right’ means someone else is forced to provide these goods and services to you. In nearly every case, the good or service is provided for by the government and the providers of said right are then paid a wage for their services.

    I have not taken any position on which right is good or bad. These are just the definitions.

    In the case of healthcare, EMTALA has clearly stated that healthcare is a right to all, though the government hasn’t funded that right. It has merely stated that hospitals must provide healthcare to the sick, and who pays for it isn’t the taxpayers problem.

    Can you imagine the government saying to the Marines, “Go storm that bunker, but we’re not going to pay you for it, nor will we give you bullets. Good luck.”? Notice the disconnect here. We’ve already answered the question “Is it a right?”, but haven’t taken the next necessary step, paying for it.

    I’ll also take on the example of education. A fine example of another situation where the government has stepped in and made a mess of things. We make the guarantee to our citizens of a high school level education if they want it. This is woefully inadequate to actually make them productive members of society, and our government can’t even provide -that- successfully. Please take a moment to read some statistics of how educated our high school graduates are, weep, and then come back to my post.

    Compare that to *higher* education in the USA. It is predominately private enterprise (somewhat supported by tax write-offs and the like that government freely distributes to any large corporation paying taxes on US soil), and also enormously successful in educating, reputable, respected around the world, and making huge profits to boot.

    Private enterprise provides goods and services more efficiently than the government does – if you disagree with this, I cannot convince you, but please look at this rationally.
    Therefore private enterprise is better suited to provide ‘negative rights’ to our population. If the government truly believes the good/service to be required for the common good, they must pay for it while mandating it’s necessity – but pay private enterprise. The highway departments do this when building roads.

    Is a basic level of healthcare a right (which is what EMTALA now requires)? Yes, no, who cares? It’s already being given, it’s already required. I say the government needs to pay market wages for what it requires to be given.

    Anything else, you *should* be responsible for yourself and utilize private enterprise to get the goods you want. That said, hold insurance companies accountable. Their reserves are enormous, a way of hiding profits. They cut risky individuals from their policies in ways that are almost illegal. Force them to play fair. That’s what a government should do, protect capitalism and the free market.

  35. Pingback: Apollo, M.D. » Blog Archive » Why won’t Social Darwinism just die?
  36. Pingback: Health Care BS » Blog Archive » Is Single-Payer Health Care Socialized Medicine?
  37. I’m an R3 ER resident in Canada and I find some of the assertions here simply false. We have a single payer system in Canada that, barring a long line (~6 month) for elective things like knee replacements and cataracts, works quite well. I don’t think there need be pressure on physician income: for many specialties incomes are equal or (for ER) better than in the US.

    We don’t have to spend hours arguing with managed care companies, we don’t ask for a bill for anything, ever… and our health outcomes are much better. Our GDP spend on health is only 10% versus your 17%. Where we do have people running to the US for care, its for those elective surgeries I mentioned, faster MRI scans, or for largely futile end stage cancer therapy.

    There are better economies of scale, no large corporate bureaucracies, better health regional planning (such as city-wide cath lab networks)… we don’t hoard heart patients to make money off them. ER’s aren’t yet the only primary care clinic people can go to except in some areas where GP’s are scarce.

  38. Whoa Dude. Six months might not be a long time for a knee replacement (although if you need a knee you might think it is) but it is a long time for chemotherapy and other time-sensitive interventions. I recall a lawsuit brought against the Canadian government quite recently for this very thing.

    As for “largely futile end stage cancer therapy,” well, that’s sort of my point about socialized medicine. There is no way in your country or in Europe many of the patients that we routinely keep alive for years past their expiration date (for things besides cancer) would ever get that far. Whether this is a good or a bad thing is a subject for another debate but our “never say die” philosophy is motivated by our best impulses. I have patients living fairly decent lives who have had seven or eight stents, quadruple bypasses, colostomies, and other costly interventions who would have been dead at 65 in France.

    So don’t give me this crap about the superiority of your system. Like I said in another article, it’s a great system until you really need something, then it blows and hard.

    As for our increased costs, I would hazard to say that much of the difference is in the defensive medicine we practice due to the highly litigious nature of American medicine and I am 100% in agreement with any criticism you care to level in that regard.

    As for better outcomes, no one really has any idea what spending or access has to do with it. Japan pays less on a per capita basis then any other indusrialized country for health care and they have the healthiest population. We happen to have a culture where unhealthy lifestyles are more prevalent than in yours but to blame this on the system is to have the tail wag the dog. Our people are not unhealthy because health care is so expensive, rather health care is expensive because so many people are unhealthy.

    And don’t kid yourself. You must not read your own papers because even your government has trouble paying for your cradle-to-grave socialism and the price you pay is decreased standard of living, decreased economic opportunity, and decreased social mobility as you live in a high-tax, low productivity nation. The urge to turn our country into a model of yours is inexplicable to me except that a lot of people would love to live in Freeloader Heaven.

  39. Interesting position. Can’t say I totally disagree, but in Ontario, with public health care, the wait time between seeing a specialist, and the date for having my Knee replacement done was 2 months. I elected to take it later rather than interrupt my vacation, so it turned out to be 3 months, 9 days.

    Good treatment in hospital, out in 4 days. Follow-up care at home, and it comes out of my tax dollars, not savings account. I’m still recovering and chronicled the whole thing at if anyone is interested.

    Great Blog btw. Good look at medicine from the inside.


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