Single Payer Dreaming

(The third time’s a charm as they say. Again, from the tone of many of my emails, not all of them as polite as you would imagine coming as they do from people who make it their business to be compassionate, I can see that many of you are still not getting it. Let us try one more time to show those of you who worship at the altar of public policy, any public policy, that your gods are mererly hollow brass castings which, although they make mystical noises when the wind blows a certain way, are as empty as a French Army recruiting office after the Germans have invaded.-PB)

Potemkin Health Care

Before the United States can have anything approaching the obvious perfection of European-style universal health care, our people are going to have to learn some good manners. While I am a fierce patriot and love America before all other countries, I cannot help but to admire the urbanity and the insouciance with which Europeans obligingly die before they can become a burden to their nanny states.

In truth, I am ashamed to report that where Americans, in a typically boorish fashion, will insist on hundreds of thousands of dollars of medical care to preserve their shameless lives beyond the point where it would be convenient for society, in Europe not only are many procedures and medications unavailable to patients over a certain age but some of those elegant continentals have even hit on the money-saving idea of offering a couple of hundred guilders worth of euthanasia drugs to politely eliminate those who might otherwise become a burden.

The problem with offering universal access to health care, which should be obvious to anyone with good manners, is that there is an almost inexhaustible demand for it. Maybe you, oh loyal and patient reader, don’t think about this as you are no doubt a veritable Hector or Andromache, in the prime of your life and about to conquer the medical world, but the old and the infirm, with stunning bad manners, do want their hips replaced, their coronary arteries vigorously scrubbed, and their expensive sojourns in the intensive care unit. Sadly, there is no end to their demands as they clamour for more and more precious health care, grimly hanging on just for spite until at around 90, eighty if we’re lucky, their bad manners finally catch up to them like their mothers from the turn of the last century said they would.

It’s shameful. The demand may be inexhaustible but the supply cannot possible keep pace. Certainly not now where, with typical American insensivity, we structure our society around merit and allocate services to those who earn them and certainly not under a single payer system where there is no restraint on demand whatsoever…except that it is to be hoped we learn some European style-good manners.

And quickly, too, because lurking in the demographic shadows is a huge bolus of rapidly aging baby-boomers, perhaps the most self-centered generation our country has ever produced, and they, of all people, will not go quietly into that good night…at least not unless shuffling off of your mortal coil becomes a hip-and-trendy lifestyle choice. It will be the largest eat-and-run the nation has ever seen and somebody is going to have to pick up the tab.

So, it may come to pass that our country adopts a single payer system in our impossible quest to provide high quality health care for all. The result will be pretty much what anybody who thinks about it could predict. We will have a lovely little health care system that looks nice, sounds nice, and finally wins us the adulation of our charming European friends that many of us so ferverently desire. But please don’t have the bad manners, the unmitigated gall, to get sick and require anything that can’t be provided at a simple visit to your barefoot doctor. You will find your marvelous access is nothing more than a creaky rationing scheme and your shining medical city on a hill is really a Potemkin Village.

42 thoughts on “Single Payer Dreaming

  1. I think for the 4th go around, you should probably just post “SINGLE PAYER SUCKS” followed by a supply-demand chart with arrows showing the incompatability of insatiable demand for cheap care and how lowering the price via the single payer will lower the supply.

    Or perhaps a picture of a midget in a kiddie pool flipping the bird would get the point across better.

  2. Panda, of course you’re correct in your statement about the “inexhaustible demand” problem.


    We are waist-deep into computability theory and intractability. Problems that are solvable in theory, but cannot be solved in practice.

    And so far, the whole universal health thing looks to me like a problem with no solution. (But I hang onto the hope that someone will figure it out…)

    Also, the “inexhaustible demand” thing is inherent in the very cells of the brains of our population. It would take an act of God to change the mindset of our country’s population…

  3. No one will figure it out because there is nothing to figure out. There is not enough medical care to give everybody all that they want whenever they want it and any Single Payer, Multiple Payer, or No Payer system is just a shell game distracting the electorate from the true costs which they will pay, one way or another either out of their pocket or from the costs of a stagnant economy that makes them serfs to the nanny state.

    May as well admit that medical care is a scarce, rationed commodity and fight like hell to keep the current system from being mangled in the federal sausage stuffer, making it even more scarce and more rationed for everybody, not just the between 10 and 40 million citizens who have to wait on plastic chairs for their health care.

  4. I can’t believe I just found your blog. You are saying exactly everything that I have come to conclude after practicing medicine for 17 years but say it much better than I ever could.

    I can’t remember the study or analysis but something like 1% of the population consumes 50 percent of the healthcare dollar and half of the health care dollar is spent in the last 6 months of life.

  5. I cannot help but to admire the urbanity and the insouciance with which Europeans obligingly die before they can become a burden to their nanny states.

    Ironically, of course, their average lifespan is longer than ours. The US does indeed have the shortest lifespan in the OEDC, I think. Certainly lower than most of Europe’s.

    Oh, and most European countries do not have single payor systems. Most have a combination of public-private funding. All seem to get far better results per dollar (pound/euro/kroner) spent than we do. Oh yeah, and they all have universal coverage for all their citizens.

    So, where’s the down side again?

  6. Shadowfax: Is it… the mandatory government rationing? Ah yes, I believe it is! Move to France and demand your 90 year old father receive a CABG. What’s that you say? They LAUGHED at you? Well, surely the UK will provide you with some Remicade for those achin joints. What’s that they said? Take some ibuprofen and use a cane because there are mandatory caps on the number of patients receiving anti-TNF drugs? Oh, well. If America was founded on one thing, it’s the idea that “from each according to his means to each according to his need”, so save a plastic chair for me, comrade.

  7. Hey Panda, I’ve always enjoyed your blogs and insight, but I was wondering how you explain the higher life expectancy found in some European countries, especially considering how quickly they’ll drop their elderly. I guess it could have something to do with population homogeneity or better lifestyle. Well, I’ve run through my quota of commas and run-ons; I look forward to hearing back from you.

  8. [i]Ironically, of course, their average lifespan is longer than ours. The US does indeed have the shortest lifespan in the OEDC, I think. Certainly lower than most of Europe’s.

    Oh, and most European countries do not have single payor systems. Most have a combination of public-private funding. All seem to get far better results per dollar (pound/euro/kroner) spent than we do. Oh yeah, and they all have universal coverage for all their citizens.

    So, where’s the down side again?[/i]

    First off, not all European systems are alike. The UK system, for instance, is in shambles.

    Second, you are comparing small highly homogeneous populations to a very large, highly heterogeneous one. Further (and this is what Panda alluded to in his earlier post), Americans engage in high risk activities to a greater extent than Europeans. (I will barely mention that much of this is, uhmmm… limited to the dependency class). The difference is (again as Panda pointed out) that Americans demand that the consequences be treated medically. Believe me, this is not the case in Europe. Beyond a certain age, you can forget about invasive interventions, unless you have the money to go private.

    European medical systems do have a single advantage over the US ‘system’: cheap access to primary care and preventive medicine.

    In this respect, they are much better. No question about it. But, when it comes to secondary or tertiary care, there is no comparison.

  9. Though I am nowhere near as eloquent as many of the posters here, I’d like to suggest that one of the main reasons for the difference in the expected lifespan in the US and that in many European nations could be examined by looking at the number of fast food restaurants per square mile. As a generalization, the European mindset has a much healthier attitude towards food and life in general (with some argument to the contrary regarding tobacco use) than the general American mindset. Read just one report on how restaurant portion sizes have changed over the last 50-60 years.

    Also, one of the reasons that the US spends more on healthcare than, well any other country is that we DO have what amounts to unfettered access to the latest technologies, drugs, etc. I can not site the study, but in a presentation I sat through recently, there was data to suggest that one of the biggest complaints of doctors in some European countries is difficulty accessing the latest technologies, etc. The countries were all those with socialized medicine (or some form thereof). The data showed this was far less a concern for US doctors. However, I think this is just one factor that ought to be considered before trying to make comparisons between how much the US spends on healthcare and how much other nations do. Sure, we can spend less on healthcare – but I’m not sure many Americans are going to REALLY want to accept what they would have to give up in return.

  10. About 30 years ago I was asked, as president of our county medical society, to give an interview on how to cut health care costs. I spoke on the same points raised by some of the comments above. Quit smoking, quit overeating, and give up some of your risky behaviors. The six year old killed in a motocross accident contributes to our lower life expectancies, as does the crack baby and the patients who do not avail themselves of the available prenatal care.

  11. I was wondering if someone with more knowledge could explain if I am correct in my thinking on this point. Is it true that since we have different criteria for considering what is an infant death versus still birth than the european countries, if this could be bringing down our life expectancy. Because if they are counting premies that we try to keep alive in our life expectancy it would dramatically affect the numbers bringing the average down.

  12. Hang on folks, the life expectency in the United state in the year 2000 was 77.1 years.

    USA: 77.1
    France: 78.8
    Greece: 78.3
    UK: 77.1
    Germany: 77.4

    Are we really going to get that worked up over a less than 0.3 year difference in average life expectancy between say, the United States and Germany? I’m not even sure of the statistical significance here. It’s not as if we’re comparing France and Chad, after all.


    Japan: 80.7 Highest
    Malawi: 37.6 Lowest

  13. Much of our care is also symptomatic, which doesn’t factor into life expectancy, but it has an awful lot to do with life. Joint replacements and such. Also, most of our European colleagues have no problem using our drugs and interventions that our “evil” drug companies contrive. We are bearing the costs here. The US essentially funds the vast majority of private medical research. If we stop paying, it will disappear. Far from the statements you get from most, maybe we should demand that the Europeans dump the price caps and let those who are benefitting from the medicines actually compensate those who made them.

  14. Not to mention that Europe enjoyed a post-war boom which was partly fueled by money that would have otherwise gone to defense if they weren’t under the expensive American military umbrella protecting them from a deluge of Soviet Armor which would have otherwise stormed deep into Europe to liberate ’em to a higher form of socialism.

    In case you folks haven’t been paying attention, our European cousins are starting to feel the need to tighten the old welfare belt a little. Combined with the massive influx of third world immigrants who are nothing like their homogenous hosts, who knows what Europe will look like in fifteen or twenty years after they have worked through (or not) some of the social problems that we are now getting a handle on.

  15. Panda, I’ve just found your site. You’re my new best friend. Thank you for so eloquently espousing the deceit that’s currently taking hold of this country.

  16. Infant,

    You should probably do more research into how those numbers are put together and the differences between how different countries measure infant mortality. It’s different everywhere. Apples and oranges.

  17. Living in a democracy means accepting the rule of the mob. There are more of them than there are of you (Health care professionals) and they’re going to take what you have to give until there’s nothing left (Which is to say, until all our doctors are from India like all our tech support). Politicians just want their cut, and who can blame them? If we weren’t all already so short sighted the immense funds devoted to treating the effects of smoking, obesity, and stupidity would easily cover all our health care needs.

    You can’t stop the government taking this power, although you might slow it down a little. Best of luck. In your next life, be a politician; it’s better to be the shark than the food.

  18. The US isn’t a true democracy. It is a democratic republic. Individuals have rights that the government isn’t supposed to take away. A quick look at our constitution would probably make you notice that the federal government isn’t allowed to do anything that it isn’t explicitly given the right to do. Read the 10th Amendment. Since healthcare isn’t listed in the constitution, logic would tell us that this would require a constitutional amendment and not simple mob rule. However, I’ve long ago given up trying to argue what the constitution actually says. The founders of this country had enough foresight to try and stop the broad federal takeover of everyone’s lives. Unfortunately, most people today are much more interested in sound bites than a unified theory of government and a legal definition of its actual function.

  19. “Politicians just want their cut, and who can blame them?”

    Are you kidding? I can blame them and so should everyone. I didn’t vote so I could be invited to bend over and take it like a woman, pick my pocket, ruin the healthcare system, and steal my land so a shopping mall can be built. I’m longing for a Boston Tea Party but instead of tea, we toss the politicians into the harbor. My first choice is Hillary and her universal health care takeover bid when Slick was in office.

  20. OK.. what about a compromise. We offer universal healthcare, but we pay for it with a huge tax on alcohol (gotta keep those drunk drivers cared for, and pay for all of those liver transplants) and a hefty tax on processed foods (that oughta cover the diabetics). Throw in a few more taxes on cigarettes, porn, cars…

    Wait.. you didn’t want to PAY for universal health care?

    Realistic solution: require every employed person maintain a reasonable standard of insurance (for catastrophes, not necessarily for routine maintenance) and fund a subsidized plan for low-income persons. Oh, and just to deal with that red herring of malpractice costs – as a condition of receiving this subsidized care, recipients agree that any malpractice claim will be heard by a neutral body of experts with no lawyers present.

  21. Malpractice suits and their cost to health care is not a red herring. I’m going to address this in a future article but it’s not so much the cost of awards made to patients as it is the cost of defensive medicine. I believe the numbers, which are as fuzzy as anything else when it comes to calculating the enormous costs of health care, are that the cost of defensive medicine adds anywhere from 140 to 250 billion dollars.

    I know for a fact that we order many tests, images, consults, and the like which are not strictly speaking medically indicated because we have taken risk aversion to ridiculous levels. Everybody knows, for example, that a CT of head is not necessary for everybody who presents for lightheadedness but I believe that everybody get one, even if the history and physical exam don’t warrant it. The fear of litigation makes cowards of us all.

    Every CBC we order on an kid who presents for mild viral enteritis, a self-limiting illness in 99.999 percent of otherwise healthy children, costs forty bucks. And we see a lot of patients like that. It adds up. In a perfect world, I would just say, “You know, take your kid home, give him some ginger ale, and if he doesn’t get better in a day bring him back…but for now, don’t waste our time. He has no fever, he’s eating and drinking, and he’s not acting funny. Go home.”

    But we can’t do that, exercise medical common sense, I mean, for fear of litigation.

  22. Defensive medicine is, indeed, ridiculously pervasive. It affects almost EVERY decision. I was talking to an oncology attending the other day about additional treatment for certain mets. He said straight up that he really thought the data indicated it didn’t help with survival and he wouldn’t do it. He then went into the patient’s room and said that he really couldn’t say whether or not it helped, that some people opted for it and some didn’t. End result: patient opted for a $20000 course of treatment with no evidence of improved survival.

    I asked him why he equivocated on it and he said that without ironclad evidence that it didn’t help, saying that he thought it didn’t help was leaving his ass wide open to lawsuits, that he tried to present the data in a way that didn’t expose him to liability. That was 20 g’s dropped in 15 minutes. Welcome to US Health Care.

  23. forty bucks for a CBC? it costs all of five here.

    MiamiMed: those price caps you refer to aren’t price caps. they’re a refusal to subsidise a particular medication unless it is as cost-effective as its competitors. imagine insurance companies telling pfizer that viagra won’t be covered unless it costs less than 15c per pill; pfizer can take it or leave it.

  24. Aflak, that link is just plain depressing. I’m sure the insurance companies would be happier if the poor bastard would accomodate everyone and simply die. Won’t be too long before our survival percentages begin to match those of France, England, Austrialia, New Zealand and Canada. Rationing indeed.

  25. Matthew,
    No shit. But the information reported by the CDC and WHO is a better measure than the, oh, nothing, that you have provided.

  26. *chuckles* I was waiting for someone to point that out about Matthews’ sources (or lack thereof), thanks Infant Mortality.

    I find it ironic that all of the reasons for medicine being so expensive seem to be: 1) high-risk behavior such as processed food, smoking, drug abuse, alcohol abuse, etc. 2) defensive medicine and 3) end-of-life care.

    Let’s examine this. As far as number one goes, are you at fault for any health problems you may incur from habitually eating fast food, smoking cigarettes, snorting crack, or any other obviously unhealthy activity? Yes. Regardless of what you may think, or what the sociologists may preach to you, you are responsible for your actions.

    Concerning number two, this should be quite simple. Frivolous lawsuits in general have become completely ridiculous. I don’t like government involvement in anything, because they usually seem to screw everything up, but I do think the government needs to reign in frivolous lawsuits; especially in medicine. Unfortunately, this contribution to the cost of health care has the most vague solution, since if you restrict litigation, then instead of having patients yearning to steal their doctor’s wealth to enrich their own lives for free, you would have health care workers who would shrug their shoulders when a mistake is made because they know that they are protected. It seems as if in the absence of one extreme, another extreme arises. Of course, before lawsuits got out of control in the first place, I don’t recall hearing about any era where doctors became the proverbial Mad Hatter with a chainsaw, but then common sense is far more elusive these days isn’t it?

    Let’s see…number #3…first of all, who do you think is paying for your $50,000 end-of-life bill, if you don’t, after you die? I won’t say this as a factual statement, because I’m not entirely sure, but it wouldn’t surprise me if the children ended up paying it. Secondly, let’s create a scenario that probably happens far too often. Jim is a 80 year-old male patient who is diagnosed with leukemia. He is told that he has one year to live. Him and his family decide to try to prolong his life by another 6 months and burn up $75,000 in the process. Those extra 6 months? Well, including the year he was initially given beforehand, they were spent in agonizing pain of course because medicine is not to the point where it can play god, therefore, Jim dies regardless and in far more pain since it took a vast amount of technology to stretch his life out that extra short amount.

    Should the institution decide when people die? Hell no. That’s where it starts to degenerate into socialized health care. Should people stop being so selfish and start thinking big picture? Yes. If people start to realize that they will have to die eventually, and if they try to prolong it then it will only hurt everyone else (including them through suffering), then perhaps they will be willing to go more peaceful. Ask yourself a question. Do you want to die in the hospital while intubated, strapped to a life support machine, in an impersonal hospital gown, or do you want to die at home on your own terms? We don’t get to choose when we die, but most of the time, we can choose how we die.

    So if you believe in the rabid animal that is socialized health care, why don’t you put your money where your mouth is, and take a small percentage of each paycheck and dump it in a glass jar, and never touch it. You don’t want to do that? Well, too bad, because a small percentage of your income is going to dissapear if health care is socialized. You can argue, bitch and moan, and make claims with no sources *cough* all you want, but at the end of the day, Panda’s right: you will pay for socialized health care. Because you can be damn sure the government won’t want to foot a bill that large.

  27. For your information, only the patient (and spouse, of course, because the law regards the couple as one economic unit)is responsible for ICU bills and if he dies, unless the hospital can get the money out of his estate they are out of luck.

    You cannot send a bill to the daughter who “want’s everything done,” more’s the pity.

    That’s the goofy thing and I believe I have mentioned this before. We give the families of the warm dead complete autonomy to decide what and how much medical care to administer and we keep flogging away until biochemistry tells us to piss off, the meter running all the while. And yet, we don’t make them responsible for the money. Surely if they are knowledgable enough to make decisions regarding critical care they are responsible enough to know the cost and the value of the care they are ordering. (because they order futile care as surely as I write the orders in the chart).

    The problem is that “autonomy” has been carried, like most things in our lunatic age, much, much too far. Maybe it is paternalism to think that you, as a doctor, know what’s best for the patient…but…and please sit down those of you with weak hearts…we are doctors and we do know what’s best for the patient. Keeping your 90-year-old mother alive with her heart just quivering enough to keep the pain centers of her brain perfused is wrong. Not only should we have the authority to tell the patients this but in many cases, we should also have the authority to tell the patients, “We’re not going to keep flogging Grandma while you work out your guilt and attachment issues. If you want to keep her alive and I believe she isn’t in any pain, then write the check every day. If not, I’m going to do what I think is right.”

  28. Reigning in ridiculous law suits isn’t more government. The Malpractice System IS government. The courts are government. Malpractice is based on legislation that defines what it is. Without such legislation, there is no malpractice.

  29. I’m not going to tell you that I have all the answers on how we should pay for health care in our country, but I want to make an observation about some things being said in regards to this post. I keep hearing people say that they are not in favor of the government rationing health care, and that people will have to wait a long time before they can receive care. News flash, folks, I have insurance, but I can’t afford the copays, and I have to wait to a long time to get referals, appointments, and test, and that’s only when I can afford to pay for for those services. The insurance industry is doing a fine job of rationing my care, and I think I would have better access to care if the government got involved. You can roll your eyes at me and call me a “liberal,” but I get steamed when I hear people tell me how much worse things would be with a single payer system, when I can’t afford to go see the doctor.


  30. My dear, everything is rationed all the time by one method or another. The most efficient way is to have the free market allocate goods and services based on supply, demand, and production which is a system, as the government is already highly involved, we do not have. You also have not read my articles except through the prism of your own emotions on the subject. You will not get shorter waits once you have to compete with more people who now will have equal access who are competing for roughly the same amount of service.

    Even the supporters of European-style health care admit that their is much tighter rationing (waits, denial of services or procedures, age cut-offs) than we have in the United States where even the uninsured, I assure you because I see this every single day, receive top notch medical care whether they can pay or not…and quickly, too.

    You’re an RN and you can’t afford your co-pay? Good Lord, I could understand not being able to pay for a major hospital stay out-of-pocket but a lot of people drop more for a night out on the town than they do for their co-pay. You probably make more than I make, I have a huge debt for medical school, and I can afford my copay.

    That’s one of the problems. Nobody feels it’s right and they view it as an affront to pay anything at all.

  31. Motherjones said:
    “I think I would have better access to care if the government got involved.”

    You mean like they run the post office, Walter Reed Hospital, the DMV? The government is the most inefficient entity going because they’re politicans, not business people and know nothing about running businesses.

    While free enterprise doesn’t guarantee perfection, it’s the most efficient system going because people have choices. There are incentives for creating new innovations. Involve the government and you create an artificial supply and demand whose price indexes aren’t anywhere near reality.

  32. The patient’s view on what is fair to pay depends largely on where she is in the treatment process. My sense, after 20 years in hospital finance, is that “money is no object” while the patient is sick or in pain. The outrage over the high cost of care usually does not materialize until after the patient has recovered.

  33. Motherjones wrote
    ” News flash, folks, I have insurance, but I can’t afford the copays, and I have to wait to a long time to get referals, appointments, and test, and that’s only when I can afford to pay for for those services.”

    Just wondering if you have a cell phone, Cable TV, internet connection, or even carry automobile insurance…none of which are necessities in life.

    If you have any of these luxuries, and still think your copay for your doc visits is still too high… you need a serious reevaluation of your priorities, not a new health care system.

    How much would you complain about the copay (deductible) if you wrecked your car? Most likely, you’d budget it into your expenses for the month(s), but as soon as its YOUR OWN HEALTH, it becomes someone else’s responsibility to provide it to you for free. Why?

  34. “…we structure our society around merit and allocate services to those who earn them…”

    Your whole blithely ironic little satire hinges on this statement, this comforting falsehood. You have to believe this rationalization in order to hold the views you do and still regard yourself as a good person. Those who get sick or die because they go untreated under our profit-driven system deserve their fate; they are deserving of sickness or death because they lack merit. They have not earned the rewards of health and life. If that were not true, you would be a barbarian, a ghoul who regards the lives of others as worth something less than your own. You would be merely dressing your privilege up as virtue.

  35. Where did you get the idea that I feel the need to regard myself as a good person?

    I’m betting you’re not actually in the medical profession. Dude, nobody gets sick and dies in our country for lack of medical treatment. This is a myth. As long as we have EMTALA everybody who comes to the hospital gets the works. I know because I am at the cutting edge of EMTALA and I have never, in six years and eight different hospitals, four of them in the poorest state in the Union (Louisiana), seen anybody ever turned away for anything, even things that in a more rational world we would turn away paying customers.

    I repeat, you are mistaken, you don’t know what you’re talking about, and you are reading my blog through the lens of your own bias, looking for an excuse to get indignant.

    I will wager you that an elderly, demented, alchoholic, homeless, crack-addicted indigent fellow with colon cancer can get the appropriate therapy faster in our country than he can in any European nation you care to mention…if he could even get therapy at all which is kind of the point of my little satire.

    Bring your indignation to heel, please. “Profit driven” is not a bad thing. Do you think I’d be working like a slave for hamburger-flipper wages if there wasn’t a chance of eventually making a decent living? Would anybody?

    And I am a barbarian. “Ghoul” is a little much but I am most certainly looking to rape and pillage the world for the benefit of my female and cubs. But since you may one day benefit from my willingness to take care of you for free (because most of my patients wouldn’t pay thier bill if they could) what’s your problem with that? Do I contribute any less to society because I don’t clap and sing Kumbayah?

  36. Privilege.

    Man, you come do my next manual disimpaction of some 400 pound lady and you may need to come up with a new definition for privilege.

    I believe you are confusing me with some liberal compassion whore making more noise than productive work.

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