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One Deep Reason Why the US Does Not Have a Sane Way to Pay for Health Care for All

2017 June 30
by Mandos

(PLEASE CHECK THE BYLINE ABOVE. YES, IT’S MANDOS AGAIN.)

Single-payer is proposed by many as the most ideal way to reform the payment/insurance process for health care in the US, for reasons with which I mostly agree, based on personal experience. The Canadian experience is drawn up, again mostly appropriately, as part of the evidence-base for this view. But if one is going to use Canada as an example, it is important to understand, in some detail, how single-payer was accomplished and what lessons this has for the US.

Canada has single-payer health care, but it did not come out of nowhere. It came from a left-wing government in the province of Saskatchewan, and it came after quite a dramatic fight, including a strike by medical doctors, who were its fiercest opponents.

The history of opposition to Saskatchewan was documented in a very detailed and high-quality MA thesis from 1963 by Ahmed Mohiddin Mohamed at the University of Saskatchewan, which, as far as I can tell, is the authoritative original history on opposition via media to the Saskatchewan single payer plan.  Mr. Mohamed (I am unable to locate his present-day particulars or even if he is still alive) managed to get his hands on a treasure-trove of documents from various “players” not that long after the original events.

That opposition involved a great deal of media and propaganda, including astroturf organizations called “Keep Our Doctors” (KOD) committees. It is important to note that even if a lobby group is “astroturf” in the sense of being supported by vested interests, it is not the case that the people who run it, work for it, support it, etc., don’t have genuine beliefs in line with activities of the group. The KOD committees actually and genuinely originated with mothers, particularly rural mothers, who had the vaunted “personal relationship” with their local doctors and the ideological belief that their doctors would be justified in leaving Saskatchewan and abandoning their patients if they were forced into a monopsony. The song should be familiar to Americans — professional liberty and all that. Their local doctors convinced them that the Saskatchewan government would be responsible for denying them access to health care.

Of course, not only were they egged on by their own doctors, eventually medical organizations and ideological businessmen got into the game via their wives and organized province-wide KOD committees, radio propaganda, etc. The public focus and concern of all the protest and propaganda were very simple, as above: Professionals should have the right to choose their working conditions, and the pricing power that single-payer insurance gave government effectively made the government the dictator of doctors’ working conditions, and the ordinary Saskatchewan patient would suffer from this in various ways.

There is one important feature, however, of the anti-single-payer campaign: All the Saskatchewan government’s antagonists went out of their way to agree that people who could not afford access to medical care themselves, should still receive it. Their counterproposal was instead that there be voluntary regulated insurance, and the government would instead use its funds to pay the premiums of those who could not afford it. Doctors would charge patients directly — remember, we’re talking about a health care system that involved direct cash payments — and patients would submit the bills to the insurance agency, if they didn’t just want to pay the cost themselves. The medical associations agreed then only to charge poor patients what the insurer would pay out, so that poor patients would not have to swallow the costs.

The problems with this are obvious, of course. The Tommy Douglas government didn’t buy it, and proceeded to institute single-payer and break that doctors’ strike. The rest is Canadian history. But what is remarkable, and what I would like to emphasize, is that at no time did anyone make the public argument that the indigent should simply go without care.

In point of fact, the Canadian health care system still has ideological opponents in Canada, both among doctors and rich patients who think their wealth should allow them to skip the queues that do indeed sometimes result from the monopsony more easily than they do now (by going to the US). The difference is that it is still not possible in Canada to admit in public that you don’t think that those who can’t afford it shouldn’t have access to quality care. Almost all domestic Canadian attacks on single payer acknowledge the need for universal coverage, even if their proposed solutions won’t work as well as single payer.

That is a deep and fundamental difference with the United States of America and its health care debate.  Admitting to a belief that someone should suffer medically for lack of funds does not put you beyond the pale of politics. I lived in the US during the Obamacare debate and had many acquaintances who expressed envy of the Canadian system under which I had lived my life previously; but I also had acquaintances who were willing to at least entertain the right-libertarian argument that property is an essential characteristic of being, and that to dilute my property for someone else‘s life — is a theft of my life. And they could make that argument in polite company and not be shunned.

To me, that is the most fundamental barrier preventing humane health insurance reform in the US. I find it difficult to believe that the US will achieve a single-payer health insurance system until nearly all opponents of single-payer, down to the college libertarian level, still feel obliged to make a halfway sincere-sounding argument that their preferred reform idea will pay for universal access to affordable care. From what I see in the health care debate in the US, that day is not here yet, although the discomfort that the Republicans have in trying to find a way to delete Obamacare suggests that some progess has been made; people are uncomfortable with taking away what has been given, and what has been given is at least some insurance for some of the uninsurable. But if arguing to leave some uninsured is socially acceptable, then that will usually be the path of least resistance.

90 Responses leave one →
  1. July 1, 2017

    It will happen, mostly because it is now so clear. Remember the Republicans were running on a counterfactual: they were going to pay for all healthcare – just not in the same way as Democrats. several Democrats were actually wanting some percentage to not pay – because you can get so much more at out of everyone if some percentage are seen to be deliberately not paying, and suffer the consequences.

    Because remember that is why people wish to not have certain people covered – they die, and are seem to be dying because they don’t have enough faith for health care. It’s actually the same reason that NATO tells people that you don’t need protection from the Soviet Union. ( Again – fascism is not as bad as Naziizm, which is by the Spanish lived under the system for a long time afterwards)

  2. someofparts permalink
    July 1, 2017

    Canadians would do well to prepare for the day when you will have to protect yourselves from the murderous citizens of the U.S. Barbaric inhumanity is a feature, not a bug, in this place.

  3. Carla permalink
    July 1, 2017

    This is a profoundly important piece, Mandos. Thank you.

    The argument you put forward also resonates deeply with what has happened to public education in the U.S. It has gone from being our gift to the world, to becoming a pariah that is viewed as sucking the blood, primarily in terms of local property taxes, out of middle-class homeowners–too many of whom now see nothing wrong with turning local school systems over to private, profit-making corporations that collect those same tax dollars and stash them in the pockets of billionaires. All so that little black, brown and other undesirable children will be “educated” more “efficiently.”

    The sheer stupidity of it is stunning.

  4. Hugh permalink
    July 1, 2017

    It has been hard to get universal single payer/Medicare for All into the public discourse because virually the whole of the elites of the Establishment have refused to even mention it. This was especially evident back during the Great Healthcare Debate of 2009-2010 which culminated in the enactment of Obamacare. Single payer was taken off the table at the outset. Obama belittled it in the few mentions he made of it as essentially unAmerican. The few single payer advocates who showed up at Congressional hearings were arrested and carted off as a bunch of extremists. At the same time, there was a big, and effective, push to co-opt progressive sites on the net with both money and the promise of a vague, ill-defined “public option”. This was so successful that progressive sites like firedoglake became some of the biggest and most virulent opponents of progressives advocating universal single payer. So universal single payer never hit the mainstream.

    Fast forward to 2016. Bernie Sanders who voted for Obamacare ran on Medicare for All, but the media and the Democratic party marginalized him, and his platform with universal single payer even more. The idea was popular in so far as it got out, and it did get out more than during the 2009 healthcare debate, but still only at the edges of the mainstream. Nowadays you will hear the occasional, rare mention in passing of some kind of universal system, but these tend to be brief and even vaguer than those accompanying the old “public option”.

    John Conyers has proposed a bill HR 676 on universal single payer each year which has never gone anywhere lost in the media and the Establishment’s ignoring of it. Sanders was supposed to come up with some kind of an analog of this, but Sanders being Sanders he will only strike while the iron is cold. I mean here we are in the middle of this big healthcare debate where one bad healthcare plan Obamacare is failing and the alternatives to it: Trumpcare 1/Ryancare and Trumpcare 2/McConnellcare are exponentially worse. So where is Sanders? Where is Sanders’ bill? Nowhere and so the code of omertà in our public discourse on healthcare remains largely intact.

    It is not so much that Americans don’t want universal single payer. It is that our so bought and corrupt Establishment, parties, media, and President refuse to even discuss it.

  5. Ivory Bill Woodpecker permalink
    July 1, 2017

    Hugh, and others like him, vastly overestimate the moral and intellectual development of my tribe (non-elite white Murkans).

    Too many of my fellow tribesfolk will accept uncertainty, or absence, of medical care for themselves just to be sure those “lazy” dusky-hued folk aren’t getting any money from the “gummint”. My “affectionate” term for my peers of this sort is “Stupid White Folks”.

    The Hughs of the world will cite a googolplex of “scientific”, “accurate” polls to the contrary, but where are all those allegedly enlightened souls when Election Day comes? The Democrats abandoned social democracy because they saw what that got them in 1972. Where was the alleged majority of enlightened people then?

    Granted, the Cruelty and Treason Party (oh, excuse me, Republican Party) does cheat, nowadays with help from Mommie Dearest Russia, but would the cheating work, in the face of a vast majority of enlightened citizens, if such a majority existed?

  6. Dan Lynch permalink
    July 1, 2017

    “We must rapidly begin the shift from a “thing-oriented” society to a “person-oriented” society. When machines and computers, profit motives and property rights are considered more important than people, the giant triplets of racism, materialism, and militarism are incapable of being conquered.” ~ Martin Luther King
    .
    Note that FDR’s proposed 2nd Bill of Rights did not call for single payer. FDR never specified how he would deliver health care, because he knew that the delivery system would have to be negotiated with Congress. What FDR said was that health care was a basic human right.

  7. July 1, 2017

    Dan Lynch: dingdingding! That’s the central strategic issue: getting people to agree that health care is a human right. Once that is done (and in the USA, it’s very much not done), it becomes simply a matter of how to pay for it, of which there are multiple options depending on the overall shape of your society and culture.

    One day I will describe my culture shock when I moved to the USA from Canada on this point. That culture shock, including a health event that took place within the first six months of my stay in the USA — originally expected to be permanent, but then, turned out not — more or less shaped my opinions on the subject to this day. Both that single-payer is the right answer specifically for American society, even if it really isn’t the only way to deliver universal care, and that it was very much not around the corner, simultaneously. I think it is now closer than it was then, partly thanks to the on-going tumult around Obamacare.

  8. Tony Wikrent permalink
    July 1, 2017

    I have reached the conclusion – and am developing the argument – that the most powerful destructive mechanism resulting from USA devolving from a republic to an oligarchy, is the withering of the classical republican (not Republican) civic trait of public virtue. The notion that the greatest good for the greatest number will result from the freedom of all to pursue their own self interest, strikes at the very foundation of what a republic is supposed to be. What made the USA as a mercantalist state radically different than England and other European states, was the constitutional mandate to promote the General Welfare. Conservative and libertarian philosophers both have openly attacked that mandate, and are therefore clearly identifiable as enemies of the republic.

    A major problem, of course, is that they have managed to convince enough Americans of their argument against the General Welfare. Worse, they have convinced enough people that selfishness is a virtue. Which is the basis of the difference in health care debate between USA and Canada which Mandos identifies here.

    Ian has argued that political philosophy needs to be renewed in terms that newer generations can understand. I do not disagree, but I think a proper appreciation the USA as a republic means, in terms of the historical break from feudalism and monarchical and ecclesiastical authority, is important to 1) appeal to whatever residue of republicanism remains in the American people; 2) show that the claims of conservatives and libertarians to be patriotic are entirely illigitimate; 3) show that there is a vital difference between republicanism and capitalism, and that capitalism developed after USA was founded in no small part in contradiction to republican ideals; show that republicanism is in some ways more amenable to social democray than capitalism.

  9. July 1, 2017

    This is a profoundly important piece, Mandos. Thank you.

    The argument you put forward also resonates deeply with what has happened to public education in the U.S. It has gone from being our gift to the world, to becoming a pariah that is viewed as sucking the blood, primarily in terms of local property taxes, out of middle-class homeowners–too many of whom now see nothing wrong with turning local school systems over to private, profit-making corporations that collect those same tax dollars and stash them in the pockets of billionaires. All so that little black, brown and other undesirable children will be “educated” more “efficiently.”

    The sheer stupidity of it is stunning.

    And yet, totally human, in a lot of ways. I met a high-flying medical specialist in the USA, in private practice. Made enormous amounts of money from this. And very proud of what he did for humanity — saving lives and all that, and believed that he deserved his wealth. He knew about the Canadian system. He said that Canadians would be idiots to give it up and let the American insurance business have a window to wedge their way into Canada. But he would definitely fight the implementation of universal care schemes in the USA — obviously, because it would destroy his pricing power.

    The implication you can get from this is that he basically knew that people went without care in order for him to be wealthy. But he didn’t consider himself a bad person for it — he saved lives. The further implication you can get from this is that lives are indeed measurable in dollars of personal wealth. You can bet that this thinking is widespread among specialists in private practice (as opposed to family physicians — there’s a class difference here similar to that between biglaw partners and public defenders)

    The twist is: he himself passed away later of an incurable disease, after using his accrued wealth to extend his life possibly by a few years via experimental treatments available to him only via his wealth and connections. So how does one judge him? He did what he needed to do to escape his disease a little longer. By accruing wealth he could only have accrued because of inequality in the US health care system…

    (By the way, Canadian specialists are not poor by any means but the extent of their art purchases are not going to compare…)

  10. July 1, 2017

    Outstanding essay. Well said.

  11. July 1, 2017

    I read Mr. Mohamed’s thesis, actually, several months ago, and this post had been percolating in my head since then, but I wanted to see first what the Republicans would actually try to do before writing it. Actually I do regret that I cannot find out what became of Mr. Mohamed (there are people of the same name who are clearly not him, that combination of names seems to nevertheless be quite common) — if he is alive I would like to have asked him what he thought of the debate in the USA on this point, although since that was written in the 60s he may have moved onto other things and not be thinking about it.

  12. Sub-Boreal permalink
    July 1, 2017

    Happy Canada Day!

  13. nihil obstet permalink
    July 1, 2017

    There is an enormous difference between widespread attitudes in the 1970s and the 2010s. And yes, the cause of the difference is leadership and propaganda. The economic problems of the 1970s, including wage stagnation and general stagflation, oil shocks and the like, gave the nasty rich the opportunity to define people’s personal problems as resulting from a government that attends to the general welfare. The Powell Memorandum of the early 1970s is one of the documents of the propaganda plan. By then, most politicians were from the comfortable middle class and didn’t react with sufficient “That’s stupid and evil.” Those who did, I remind you, ended up dead.

    We are social animals. Despite our love of the myth of the brave individual standing alone against error, we want acceptance, standing, and status within our group. We tend very strongly to adopt the opinions of our society. That’s why propaganda is powerful. It does work. And it should, or else we would not have the bonds of agreement and affection that make us human. The current U.S. fetish of selfishness and cruelty towards others was carefully developed and advanced. We need to develop and advance an outlook of solidarity explicitly. As long as we grant the premises of innate human selfishness, we won’t get there peacefully.

    I see it as being like the fight for civil rights in the 50s and 60s. The conservatives all either argued that the races liked being separate and problems non-whites had were their own fault or argued that we needed to take it slow because you can’t legislate morality. It took leadership and force to integrate public institutions and require equal treatment for all races. In 1960, it wasn’t really an insult to call someone a racist. In 1981, it was, as Lee Atwater explained in his infamous southern strategy interview. Although we have not reached a post-racist Eden, public accommodations cannot refuse service based on race and employment cannot overtly be denied on the basis of race. These things came about because of strong leadership and work, not because we continually agreed that some legal racism was OK as long as it was better than the status quo — we didn’t integrate schools by arguing that it’s an advance to let a few black children sit in the back row of the classroom.

    And that’s the issue with health care and general welfare. Supporting a system that excludes our neighbors because of their financial position is perpetuating it. I see failure for any leader to argue for universal health care not as pragmatic reform but as moral failure.

  14. Rich permalink
    July 1, 2017

    Pricing power is an illusion.
    All in all this post is too important too ignore.
    This paragraph is by my estimation, best.
    “That is a deep and fundamental difference with the United States of America and its health care debate. Admitting to a belief that someone should suffer medically for lack of funds does not put you beyond the pale of politics. I lived in the USA over the Obamacare debate and had many acquaintances who expressed envy of the Canadian system under which I had lived my life previously; but I also had acquaintances who were willing at least to entertain the right-libertarian argument that property is an essential characteristic of being, and that to dilute my property for someone else‘s life — is a theft of my life. And they could make that argument in polite company and not be shunned.”
    I am a medical specialist in this United of States. My practice “caters to concierge” care of the poor, imprisoned, indigent, disenfranchised, immigrants and the uninsured. I stand more ER call than all the other doctors credentialed in my specialty at this medical center combined. And for that I am demonized by colleagues and peers because they perceive I am somehow stealing their property and setting a bad example to impossible to emulate. And not the least, the administrators of the hospital demand even more from me while routinely under-miscalculating my pay. However, I’m not credulous to the notion many of my disenfranchised patients “think” they’re taking advantage of a stupid white guy who must have done something wrong in his career or else he wouldn’t be practicing in this place.

  15. Herman permalink
    July 1, 2017

    It is true that single-payer will face massive opposition, not just from the hated insurance and pharmaceutical companies but from the popular physician’s lobby as well. All of these interests know that any viable single-payer system (or any universal system, for that matter) will have to get costs under control and that will reduce their income.

    Some supporters of single-payer do tend to downplay this powerful opposition and try to argue that most Americans are enthusiastic for single-payer which I find to be too sanguine. The Left sometimes underestimates the selfishness and cruelty of the American public and the profound lack of solidarity that pervades this country. All you have to do is look at the various arguments against universal health care :

    1. I have good insurance already. I worked hard and have a good job and part of my reward is good insurance so why should some lazy failure get the same health care as me without working as hard?

    2. I don’t want to pay for anyone else’s health care, they should pay for it themselves. Personal responsibility!

    3. I take care of my health. I exercise and eat right and don’t have bad habits. Why should I pay for people who have made bad lifestyle choices?

    4. If you reduce big pharma income they will be less likely to innovate.

    5. If you reduce doctor income fewer people will want to become doctors, especially if they are really smart and can go into another higher-income profession like finance.

    6. Single-payer will put huge numbers of people in the insurance industry out of work.

    7. The government will control my health care and tell me which doctors to see.

    8. Health care rationing will be needed along with long wait times.

    9. The government will fund contraception and abortion services. I don’t want my tax dollars going for things I find morally reprehensible.

    I am not saying that I agree with the above arguments but these are the arguments that will be blasted constantly if it ever looks like a robust single-payer program has a possibility of passing. And these kinds of arguments tend to work best with the kind of people who vote regularly in every election: upper middle-class types. This is the true Republican base, not the white working-class. Many working-class people don’t vote regularly or don’t vote at all, which is a major problem for any left-wing political movement including the one for universal health care.

    That being said, I do agree that Obama didn’t even bother to fight for a public option, much less single-payer, and that Obamacare has proven to be a totally inadequate fix for our health care problems. Bold leadership is important. We used to have liberal lions like FDR and LBJ who were willing to do the right thing and support policies that were unpopular with the rich and even many ordinary Americans because it was the right thing to do.

    Today we are stuck with the weak neoliberal Democrats who claim that they have to be as moderate as possible because otherwise they will get destroyed politically. But after 8 years of Obama-style centrism the Democrats are at their weakest point since the 1920s with the Republicans in control of all branches of the Federal government plus a majority of state governments. So technocratic centrism is not even working on the cynical terrain of political expediency which was always its supposed strength.

  16. Synoia permalink
    July 1, 2017

    …the right-libertarian argument that property is an essential characteristic of being, and that to dilute my property for someone else‘s life — is a theft of my life….

    Single payer is a single risk group medical insurance. An individuals medical risk is spread over the greatest number of people.

    Because there is single payer, the medical providers are cost-constrained. That is Doctors cease to become rich.

    In addition the Medical Schools then loose their pricing power, because there would be a consequent demand for free higher education, and this consequence would ripple through US higher education, and it’s very well paid administrators.

    Single Payer remove a keystone of the US rent extraction system. When removed a considerable part of the rent-extracting arch, the neo-liberal arch, collapses.

    This is a way forward:

    Make California’s SB 562 (single payer bill) a ballot initiative. However SB562 needs a companion funding law.

    There is a proposal for a 2.3% gross receipts tax coupled with a 2.3% sales tax. This proposal is a wicked regressive tax burden.

    A progressive tax would be a modification of the CA income tax , and include ALL income, earned, capital gains and whatever other income else exists.

  17. bruce wilder permalink
    July 1, 2017

    That’s the central strategic issue: getting people to agree that health care is a human right. Once that is done . . .

    Politics is not a problem to be solved by the deus-ex-machina of “when everyone agrees in principle with me, me, me”.

    Political opinion is human ambivalence writ large onto the community. If you look closely, you can see that pretty much everyone is for and against almost every everything; individuals hold within themselves unconscious, unsystematic every opinion, every sentiment and resentment. They admire and envy, love and hate and on and on. That the matter and antimatter of human unconscious feeling gets resolved into some net expression in human personality or philosophy is mediated by society, because in passions and their expression, as in any other production of social cooperation, we specialize. We adopt roles and our ambivalence gets projected out into the group and the community, where one person expresses love of vanilla, the next defends chocolate. Our actual individual tastes may be a muddle, but we will construct a persona that resolves them sharply, just to argue them, to pass the time and have society.

    “health care is a human right” is a fine sentiment and can be sold as a consumer good of sorts — an opinion that lots of people can like to have, and people do tend to like the opinions they conspicuously pretend to have — but it is never going to be a deep conviction of a majority, let alone a sufficient guide to policy. At best, it will be convincing to a plurality, around which a coalition might be rallied. But, people are going to bring many perspectives and interests to any complex policy issue. They are going to be knit together to support political action by ambiguity that leaves their differences aside. It is not true that people come to agree on the reasons for some policy; they agree to the policy, when they come to not care so much about their different reasons. (cf mandos re: the rhetoric of lambert of naked capitalism)

    the tough part — as I am sure was the case in enacting Medicare in Canada — is overcoming a noisy opposition willing to create dread “conflict”. It is the major PR weapon of employers in most labor-management disputes. Most people hate the noise of political conflict and they hate even more the raw exposure of conflicts of interest. No child wants to think a parent is not to be trusted, though every child rightly suspects that is sometimes the case, and the conflicts of interest between parent and child are the most highly fraught of “political” issues and form the deep psychological foundation for all understanding of politics. The idea that one’s doctor is in it for the money has to be some serious scary! I would not underestimate how easy it is for determined reactionaries, deluded in their libertarian bubble, to overplay their hand.

    the progress of neoliberalism began with a left that was tired of fighting the good fight on behalf of the lower orders and ready to give that up for a better funded existence. the liberal idea of a common interest in the general welfare and public good was revived, but, of course, in a subversive form of lesser evilism (yes, the same lesser evilism that mandos thinks we should manfully embrace as a test of our moral discernment, because it shows we won’t “trivialize” differences in outcome at the margin by pointing out differences in kind traceable to architectural principles). So, conflict was dissolved in de-regulation, breaking unions and became public-private partnerships, but i digress. now at what is hopefully the end of neoliberalism (and not the end of civilization, but who knows?) our politics must reabsorb the idea that politics is, at base, about conflict. hopefully, we can revive a politics of managed conflict without resort to guillotines and pitchforks, though again, who knows?

  18. c1ue permalink
    July 1, 2017

    The author makes the common error of equating “coverage” with “health care”.
    The reality is that American health care is not affordable even under Obamacare mandates, and the reason is that America doesn’t have a single payer system to force the rest of the health care sector to charge reasonable prices (or at least have a clear option with understandable and accessible information).
    The only way to maximize the benefit of health care spend – whether private or public or both – is to drive down costs. Mandated insurance “coverage” does not do this.
    Those who make a 10% or 1% level of income in America don’t recognize this as a problem, but cost is the real issue.

  19. July 1, 2017

    Interesting to note that at the time of writing his thesis, Ahmed Mohiddin was on Scholarhip at USask from Kenya, sponsored by the Rockefeller Foundation. (PDF pg. 168 http://assets.rockefellerfoundation.org/app/uploads/20150530122236/Annual-Report-1965.pdf)
    As a political scientist in Uganda, he wrote a book called (1981) African Socialism in two countries (https://www.amazon.com/African-Socialism-Countries-Ahmed-Mohiddin/dp/0389201707) and had been cited in books such as Simon Reid-Henry’s The Political Origins of Inequality: Why a More Equal World Is Better for Us All and Ali Mazrui’s The Pan African Commonwealth, with whom he wrote: Rapid Development and the Crisis of Empathy, the African Perspective.
    He wrote and spoke frequently with the African socialist intellectual Tom Mboya as well.
    He was ecturer in the Department of Government at the University of Nairobi and later a Professor Makerere University College, Kampala. I believe he passed in 2013

  20. Albertde permalink
    July 1, 2017

    Never forget that Canada has a federal structure and that health care is under provincial jurisdiction. So there is no sure thing as a monolithic Canadian Medicare system. The Federal government promised to pay 50% of the costs back in the ’60s but they never have. In fact, PM Justin Trudeau just cut the Federal government’s contribution, forcing the provinces and territories to negotiate individual deals.
    That is the negative side to this. The positive side to this is that no unilateral action by the Federal government can take away medicare.
    Re the US, I find the individual states unimaginative and worthless.

  21. July 1, 2017

    And right on time, the media delivers. Right-wing columnist Bret Stephens in the NYT:

    You do not get to insure your house after it’s on fire. Why should Americans have the unalienable right to wait till they get sick (at least during open enrollment) before buying health insurance?

    *facepalm* He is literally saying that if you couldn’t afford health insurance, you should die. And he is saying this in the NYT.

    (His solution, by the way? Health savings accounts!)

  22. Hugh permalink
    July 1, 2017

    Here are a few healthcare facts. In 2015, about $3.2056 trillion was spent on healthcare in the US. According to Physicians for a National Healthcare Program (PNHP) who support universal single payer, 64.3% of this came from tax funded sources, i.e. the government.

    Another fact: the government’s Centers for Medicare & Medicaid Services estimated $338.1 billion of that $3.2 trillion or 10.5% of it came from out of pocket expenses. So when we talk about private healthcare insurance costs, we are probably talking about something in the neighborhood of 25% of healthcare expenditures in the country.

    I think that if people knew the numbers, they would understand they were being conned, by their leaders, by the media, and above all by the insurance industry. But the con is precisely to keep this information from them, to keep them focused on lots of bright shiny objects and false political debates (Obamacare vs Trumpcare).

    As c1ue says, insurance isn’t care, and the real issue is the numbers.

  23. July 1, 2017

    Thanks Brian, that’s very interesting. I knew he would have had an interesting career.

  24. July 1, 2017

    I think that if people knew the numbers, they would understand they were being conned, by their leaders, by the media, and above all by the insurance industry.

    I do not share your confidence that people, when confronted with the evidence that they are being conned at such a scale, would react the way you seem to think that they would react.

  25. July 1, 2017

    Re: Bret Stephens. Well … yeah. It’s a bit odd he should say such a thing, given that the BCRA (Senate version) does away with individual and employer mandates, thus de facto actually encouraging those who can’t afford insurance to take the risk of not being covered (presumably in the name of “freedom” and “choice”). But there’s a lot of cognitive dissonance floating around these days.

    Interestingly, the tide of public support for single-payer appears to have turned in recent months. An Economist/YouGov poll in April 2017 showed 60% support/strongly support expanded Medicare for All, v. 23% oppose/strongly oppose. The wording matters, of course, but in a more recent poll in June, even when the question made it clear that the program would be funded by taxes, 44% v. 31% were in favor.

    It’s going to require superb strategy and expert tacticians to bring Medicare for All about, but if you follow your senator or representative’s FB comments, as I do, you see that more and more commenters are chiming in with “Forget the ACA, forget BRCA. Medicare for All, now” – at least that’s what’s transpiring on Richard Durbin’s (D-Minority Whip) page. H.R. 676 was submitted in January 2013, and it now has more than 110 co-sponsors. A similar bill is anticipated for the Senate.

    There are two core arguments in favor of single-payer, one moral (which is basically the one the Democrats are employing in the Senate), one economic — single-payer is cheaper long-term and gets better overall results in terms of morbidity and mortality. For those not persuaded/persuadable by the moral argument (that health is a human right), the economic one may ultimately prove more compelling.

    Extremely interesting post, and equally-interesting comments. Thanks.

  26. paintedjaguar permalink
    July 1, 2017

    Mandos – “I think it [single payer] is now closer than it was then, partly thanks to the on-going tumult around Obamacare.”

    This is the opposite of the truth. There was strong public sentiment way back in the early 90’s for comprehensive reform, as it was obvious even then that reform was necessary. But the Clintons and other conservaDems managed to strangle that possibility for another quarter century. This time around, Obamacare was deployed to suck up all the oxygen in the room, keeping topics like single-payer on the fringes. And once passed, the institutional inertia of an existing system continued to do so, as was the intent.

    In spite of what Mandos claims, it is still not socially acceptable in the US to advocate just letting people suffer or die. Those who do advocate such policy commonly get around public sentiment by carefully avoiding certain facts and topics and by mischaracterizing how the current healthcare “system” actually works (see “Emergency rooms have to treat everybody!”). And naturally by also appealing to the self interest that our tiered and rationed system promotes. Note that Dems who emphasize insurance “coverage” and preserving non-universal tiered healthcare, use these tactics just as often as their fellows in the GOP. It’s quite easy to see this in operation, without entering into speculation about motivations.

    This isn’t to deny that there is a well-funded and organized industry turning out propaganda in favor of selfishness and atomized society – Herman’s listing above of their most common healthcare arguments is pretty good, but those arguments didn’t arise in a vacuum. The AMA famously spent ~$4 million in 1945 to quash Truman’s proposal for US national healthcare – an exorbitant amount at the time.

  27. Carla permalink
    July 1, 2017

    painted jaguar said: “There was strong public sentiment way back in the early 90’s for comprehensive reform, as it was obvious even then that reform was necessary. But the Clintons and other conservaDems managed to strangle that possibility for another quarter century. This time around, Obamacare was deployed to suck up all the oxygen in the room, keeping topics like single-payer on the fringes”.

    Yeah. I was there. I became a single-payer activist back in the late ’90s. We said at the time that the Clintons had set universal health care back 20 years. Little could we have imagined that in 2017, post-Obamacare, friends of our family afflicted with cancer would need GoFundMe donations to help with the cost of their care. Disgusting, despicable, disheartening, dehumanizing, degrading, deplorable… y’all can fill in any other “D” word you find that fits.

  28. July 1, 2017

    paintedjaguar: I think your analysis is profoundly wrong for reasons I have mentioned many times ad nauseum The fundamental issue is: how is American society so susceptible to this. The fact that it was so susceptible is the evidence that single-payer was not around the corner, suddenly snatched away. It’s all the evidence you really need.

  29. July 1, 2017

    Re: Bret Stephens. Well … yeah. It’s a bit odd he should say such a thing, given that the BCRA (Senate version) does away with individual and employer mandates, thus de facto actually encouraging those who can’t afford insurance to take the risk of not being covered (presumably in the name of “freedom” and “choice”). But there’s a lot of cognitive dissonance floating around these days.

    It’s not odd that he says it, and there is no cognitive dissonance in him. The content of the BCRA doesn’t matter here. He wants to propose health savings accounts to satisfy a fetish. He wants to denigrate the moral basis of universal care. What the BCRA or AHCA propose is fully besides the point. He can do this, and remain at the heart of American media, without a glimmer of the disgust of others driving him away from his position.

  30. July 1, 2017

    Politics is not a problem to be solved by the deus-ex-machina of “when everyone agrees in principle with me, me, me”.

    Certainly not, you are right. That principled agreement, which is necessary to proceed, must be built through certain kinds of effort. Effort that takes into account the opportunities that present themselves as they do.

    the tough part — as I am sure was the case in enacting Medicare in Canada — is overcoming a noisy opposition willing to create dread “conflict”. It is the major PR weapon of employers in most labor-management disputes. Most people hate the noise of political conflict and they hate even more the raw exposure of conflicts of interest. No child wants to think a parent is not to be trusted, though every child rightly suspects that is sometimes the case, and the conflicts of interest between parent and child are the most highly fraught of “political” issues and form the deep psychological foundation for all understanding of politics. The idea that one’s doctor is in it for the money has to be some serious scary! I would not underestimate how easy it is for determined reactionaries, deluded in their libertarian bubble, to overplay their hand.

    Perhaps. I think/hope that the current BCRA fight might turn out to be one of those moments.

  31. July 1, 2017

    nihil obstet:

    We are social animals. Despite our love of the myth of the brave individual standing alone against error, we want acceptance, standing, and status within our group. We tend very strongly to adopt the opinions of our society. That’s why propaganda is powerful. It does work. And it should, or else we would not have the bonds of agreement and affection that make us human. The current U.S. fetish of selfishness and cruelty towards others was carefully developed and advanced. We need to develop and advance an outlook of solidarity explicitly. As long as we grant the premises of innate human selfishness, we won’t get there peacefully.

    I see it as being like the fight for civil rights in the 50s and 60s. The conservatives all either argued that the races liked being separate and problems non-whites had were their own fault or argued that we needed to take it slow because you can’t legislate morality. It took leadership and force to integrate public institutions and require equal treatment for all races. In 1960, it wasn’t really an insult to call someone a racist. In 1981, it was, as Lee Atwater explained in his infamous southern strategy interview. Although we have not reached a post-racist Eden, public accommodations cannot refuse service based on race and employment cannot overtly be denied on the basis of race. These things came about because of strong leadership and work, not because we continually agreed that some legal racism was OK as long as it was better than the status quo — we didn’t integrate schools by arguing that it’s an advance to let a few black children sit in the back row of the classroom.

    I grant you, for the most part, that the American cultural gestalt and the place of libertarian selfishness in it is not an accident and was at least in part nurtured deliberately, although aspects of the history of the USA make it an inherently fertile territory for that ideological fruit.

    But let’s look at your example: look at the state of integration today. Look at the need for Black Lives Matter. A lot of progress was made during the time you mention, but the deeper issue of the cultural and psychological place of “blackness” has not been settled in the USAmerican consciousness, with material effects that we see this very day.

    That tells me that actually, what had been accomplished was, yes, great and important — but incomplete. And you can bet that much if not all of the civil rights leadership would see it that way. And part of what has not been accomplished is in the area of personal emotion, culture, and yes — you were probably expecting this by now — “identity”. The thing we’re supposed to set aside as we fight for better economic conditions and less war in this world…

    And that’s the issue with health care and general welfare. Supporting a system that excludes our neighbors because of their financial position is perpetuating it. I see failure for any leader to argue for universal health care not as pragmatic reform but as moral failure.

    Oh, it is a moral failure…but on whose part? People do not react in the profound way that the health care debate needs them do when merely confronted with a stern moral teacher. They especially don’t react that way when it comes to what they’ll put into a ballot box. So my suspicion is that there is a more complicated path that must be walked before people vote in such a way that politicians committed to *proper* health care reform, as Canada’s Tommy Douglas was, achieve power at a level in the system required to institute single payer.

  32. Peter permalink
    July 1, 2017

    @Hugh

    The straw man you are trying to create with your numbers may work well for people wanting an easy target to throw their shiny objects at but I think the insurance industry is limited to 20% overhead costs.. Calling people stupid and slow is the typical liberal way of addressing people who don’t quickly lap up the thin gruel forced onto them.

    The people you are trying to propagandize and demean are the about 50% of the population who get their private insurance through their employer and some older data I read said that 50% of individuals paid nothing for their insurance while 30% of families paid nothing , the rest paid a fraction of the actual costs.

    If you are looking for someone who is suffering under a burden from private insurance that would be the business community that pays much of the costs including payments into the large existing single payer section of our health system.

    The fetish like single mindedness of some people advocating single payer as a cure-all or even that it’s necessary seems to defy sanity. Over 90% of the people in the US are insured and it seems a bit insane to destroy the system that works for 50% of the people to get coverage to the 5% that can be reached.

    Germany has universal multi payer health insurance with controls on doctor/ hospital prices and it works well, better than Canada or the UK. Patients don’t have to wait 18 weeks for a GP appointment or die in a hospital hallway waiting for service. Some people think that only Statist solutions can work, even when they don’t, and concentration of power is desired to force compliance.

  33. July 1, 2017

    Peter: I know about several European systems, including the German one. The German one is not free-market by any stretch of the imagination, and it’s not all done via price control. Within a certain income band, which is calculated to represent the bulk of the population, employed people are obliged to buy into public health insurance schemes. Yes, there are many of these schemes, but they’re all basically identical — some may offer a small benefit for prescription glasses, some may offer courses in eating your vegetables, etc. Their overall domination of the German health insurance market is effectively a monopsony in all but name. They exist as separate entities largely because of the way the German welfare state developed. They are gradually merging, and it is only a matter of time before there are only a handful left.

    Above a certain income, a minority of people can opt out of the public insurance funds, and instead buy US-style medically underwritten insurance. It is, however, for many people unwise to do so and more expensive than the public insurers, and you cannot easily buy back into the public insurance scheme if you do that. Consequently, the private insurance market gets smaller and smaller, raises premiums, and shrinks further. The logical conclusion of this is a single payer system.

    However, Germany has very good outcomes without literally having single payer. That is partly because Germany, as other European countries do, focus on other aspects of public service provision and quality of life.

  34. July 1, 2017

    Another way of putting the German system is “employment-based public oligopsony”. The employment-based part is the big difference with single payer as such — the German system is developed for geographically sessile, highly organized industrial and agricultural workers. For a settler society “on the move” as we traditionally have in North America, a direct move to single payer is more culturally appropriate. As it was in Canada.

  35. John permalink
    July 1, 2017

    Basic Calvinist view: God ordains your suffering and your money. If you are poor and can’t get healthcare, marvel in the glory of it. If you are rich….God ordained it. Betsy deVos knows God’s plan made her rich. If the serfs can’t get health care or education, it’s just part of the Plan.
    I’m fairly certain Canada doesn’t have so much Calvinist indoctrination.

  36. Peter permalink
    July 1, 2017

    @M

    I think there are about 130 sickness funds in Germany who handle the day to day business of the health care system. I skipped, while you missed, the fact that they are all nonprofits which saves much money while keeping the operations decentralized. The German government does what it does well, collect taxes, write regulations, subsidize the poor and keep the sickness funds financed.

  37. paintedjaguar permalink
    July 2, 2017

    Single payer was never “just around the corner” as Mandos puts it, and in 40 years of debate I’ve never heard anyone at all claim that it was. Believing it’s an achievable goal if actually put “on the table” is not at all the same thing (ie, not a straw man).

  38. Merasmus permalink
    July 2, 2017

    Oh good, now Mandos is insulting the very people of the United States as having some intrinsic cruelty and/or stupidity. How about the fact that single payer consistently shows majority support in polling? You can go the heart of Trump voting coal country and find significant support for it. The reality is that there hasn’t even been anything resembling a real healthcare debate until very recently. A large number of people didn’t (and many still don’t) even know what single payer is; that it’s a thing that could be done. The chief obstacles are a media that has for decades refused to even allow the idea of an alternative to the private insurance model to be discussed, and a political establishment, especially the supposed left-wing party, that actively squashes any move in a better direction. This literally just happened again in California. Single payer failed there because of a liberal politician, not because of some deep-seeded Calvinist impulse in the American psyche.

    You’re claiming there’s some sort of cultural defect that won’t allow Americans to adopt a more socialist system, when the reality is that common Americans have little say in what the elites do.

  39. Jessica permalink
    July 2, 2017

    Rich,
    Thank you for your service, which genuinely deserves thanks.
    Jessica

  40. jackiebass permalink
    July 2, 2017

    The attitude you describe was instilled in peoples mind for decades using propaganda. The term used is personal responsibility. It has turned the US society into a me centered society where you owe nothing to anyone including the government. A person shouldn’t pay any taxes because the money they earn is all theirs to keep. What is strange is that these people expect to get things from the government but they shouldn’t have to pay any taxes to be used to provide these things. In fact they believe that the government should only provide those services they need. Unfortunately people believe almost everything they are told without actually looking at the evidence. The saying that if you say something often enough people will believe it is true. Even if proven false about 40% will still believe it’s true. Divide and conquer is one tactic used to accomplish this agenda.

  41. July 2, 2017

    Oh good, now Mandos is insulting the very people of the United States as having some intrinsic cruelty and/or stupidity.

    It’s not intrinsic in some kind of “fundamental property” sort of way. Different countries have different cultural histories, which lead to different outcomes. These are far from immutable, they just take effort and sometimes just cultural drift over time to change.

    How about the fact that single payer consistently shows majority support in polling? You can go the heart of Trump voting coal country and find significant support for it.

    *sigh* I’ve dealt with this many times. Going up to people and saying “do you want X?” is not really useful political evidence when you’re talking about a complex, hierarchically structured representative democracy. Political culture sets priorities on a ranked list — mediated through representatives who are explicitly not elected to fulfill a particular list of policy preferences, but to mediate priorities through the system, based on their own views and character. Sufficient Americans are unwilling to elect people who make sane health reform a priority. By sufficient, I mean, taking into account population distributions, constituency sizes, etc, etc.

    The reality is that there hasn’t even been anything resembling a real healthcare debate until very recently. A large number of people didn’t (and many still don’t) even know what single payer is; that it’s a thing that could be done. The chief obstacles are a media that has for decades refused to even allow the idea of an alternative to the private insurance model to be discussed, and a political establishment, especially the supposed left-wing party, that actively squashes any move in a better direction. This literally just happened again in California. Single payer failed there because of a liberal politician, not because of some deep-seeded Calvinist impulse in the American psyche.

    It failed because a liberal politician thinks that it won’t be remembered that he nixed it when people vote. Much if not most of the time, they are right.

  42. July 2, 2017

    I think there are about 130 sickness funds in Germany who handle the day to day business of the health care system. I skipped, while you missed, the fact that they are all nonprofits which saves much money while keeping the operations decentralized. The German government does what it does well, collect taxes, write regulations, subsidize the poor and keep the sickness funds financed.

    I did not miss it. What do you think “public health insurance scheme” means? The operations are decentralized in that there is a lot of duplication, some of which has been eliminated “under the table” through a comprehensive network health IT scheme involving patient smart cards. The 130 gesetzliche Krankenkassen are only a fraction of how many there used to be, because it was organized by workplace.

    Major life events can be a bit of a bureaucratic headache in this system, for example transitioning to running your own business or becoming an artist on commission involves complicated bureaucratic operations on the part of the individual. It’s a system that evolved around the idea that most people would work their entire lives in one auto parts factory (or whatever), and that the “extra” services that auto workers need are going to be different from the ones that, e.g., meat packers are going to need. But even among the 130 there’s a handful of “elephants” that contain large swathes of the population (e.g. TK, AOK, Knappschaft etc) — anyone can join any fund that operates in their Bundesland. This is a system that will eventually evolve to a single-payer scheme, or a multi-payer-in-name-only scheme.

  43. Noirette permalink
    July 2, 2017

    Before Obama-care was instored a team of health specialists from the US visited Switzerland (where I am) to study how the Swiss system worked, as CH is the only country in the world that has a so-called ‘all private insurance’ system which delivers supposedly acceptable ‘western’ HC in a ‘fair’ manner. (The ‘fairness’ is a no-brainer, it is achieved by the tax payer paying for those who can’t pay the premiums.)

    Once the team discovered that to make this system work, complete and total cost control is necessary (1) they simply left! They thanked the Swiss authorities profusely – the Swiss had been very flattered by this visit – but said they had urgent matters to attend to back home.

    1. Each and every medical (hospital, nursing, etc. ..) act /service, is fixed at x cost. Insurance cos., for the ‘basic health insurance’ are so tightly controlled and surveilled by the Gvmt they have almost no leeway. They can charge y, in structure abc, but not more. The insurance cos., in principle, are not allowed to make money from the basic insurance, only a ‘markup’ (2 – 3%) for the ‘administrative’ cost is allowed.

    Switz. adopted the system roughly described by Mandos as rejected by the Canadians. The Swiss appear happy with it. In the past 15 years there have been at least 9 popular initiatives to change it. A few came from the ‘far right’, in fact from insurance cos./ libertarians, others went in the direction of ‘single payer’ in various ways. All were refused, the libertarian ones most strongly. So an uneasy compromise based on a certain kind squeamishness or ‘image’ (nobody dies in the streets or from treatable disease in lovely Switz.!) and a rough pragmatism, which includes the attitude ‘this works for now..’

  44. paintedjaguar permalink
    July 2, 2017

    Mandos – “Political culture sets priorities on a ranked list — mediated through representatives who are explicitly not elected to fulfill a particular list of policy preferences, but to mediate priorities through the system, based on their own views and character.”

    You’re likely right that this is the view of the average politician. I guarantee that it isn’t the understanding of average American voters, who absolutely think they are voting for specific policy preferences. That’s because we are constantly being told that we live in a democracy, however much that claim differs from the facts of the matter.

  45. July 2, 2017

    You’re likely right that this is the view of the average politician. I guarantee that it isn’t the understanding of average American voters, who absolutely think they are voting for specific policy preferences. That’s because we are constantly being told that we live in a democracy, however much that claim differs from the facts of the matter.

    The average voter (however you determine what an “average voter” is) does not think that s/he is voting for a list of specific policy preferences. The average voter has a complex combination of preferences that include occasionally judgements on policy. What matters, however, is how the system is constructed, which is quite intentionally not to allow direct expression of policy preferences delivered via the ballot box. Representative democracy — isn’t.

  46. July 2, 2017

    Noirette: I checked a few years ago and found that Switzerland has the highest per-capita health care costs in Europe as well as high administration costs. Is that still the case? Yes, the Swiss system is the closest one in Europe to the American system, but is based on minute price control.

  47. July 2, 2017

    Back when Dear Leader was getting Congress to pass his health coverage abomination bill, at the same time, Rep John Dingell (D-MI) tried to introduce his 19 page long single payer bill. Pelosi killed it in committee so it never had a chance, instead we got the budget wrecking Obama Care.

    Over 2,300 pages, it must have so much pork in it that when squeezed, bacon fat drips out.

    We were better off pre-Obamacare, when my insurance only went up 6-10% per year, instead of the 20% increases. Couple more years of this crap and I’ll have to choose between my mandated health care and my mortgage payment.

  48. Peter permalink
    July 2, 2017

    @M

    Bureaucratic complexity is what comes with Statist concentration of administration and the self -employed and artists have been part of Germany society forever. The only difference I can see for these people is they must pay all of the healthcare tax while employees only pay one half.

    This is a universal public health insurance program but the delivery of services is accomplished with a corporatist structure putting people to work in the private sector locally and avoiding more centralized and remote government apparatchiks. I doubt the German system will change much and they will continue to avoid single-payer because their system works and its customers are generally happy with its product. Their corporatist approach to controlling health services prices through all party negotiations is where the money to continue the system is saved.

  49. July 2, 2017

    Peter: You are mistaken if you don’t think the German system will change. It does *work* for the most part, so it will change slowly. But because of the nature of health care as a “product”, the outcomes will always trend either towards a British-style NHS monolith and a monopsony, and I prefer the latter. The key affix is “mono-“. In the German case, the diversity of the insurance market, both the gesetzlich and privat components of it, trends monotonically downwards.

  50. Peter permalink
    July 2, 2017

    @M

    It’s a good thing that the average health insurance customer in the US doesn’t need to fear the loss of their good to excellent health coverage because some politicians and statists activists tried to sell them some snake-oil. Some of the political parasites will continue to spout the single-payer mantra during the election cycle but with California rejecting it, it’s done for now.

    Hoping for the disillusion of the successful German system so they can join in the failures of the single-payer systems seems warped. Most of the single-payer advocates seem to have some agenda other than satisfied customers and a reasonably well functioning system.

  51. July 2, 2017

    anti-Mandos:

    You missed something!

    Mandos:

    Not in any way which is significant. (explains details)

    anti-Mandos:

    Stop cluttering the issue with facts!

  52. July 2, 2017

    The argument I make about Heath Care is based on what happened in Montana with it’s power utility, Montana Power. Montanans owned their power plants and they had one of the cheapest power bills in the country. In 1997, shenanigans ensued. TheRepublican governor Marc Raciocot convinced the duffers in the legislature to privatize it. Now we have really expensive power. The linemen that worked for Montana Power lost most of their pensions.
    So when I argue this issue, I say, “I love the free market. I love freedom. But some things need to be protected from the grifters, the takers, the hustlers. Power to run your business and health care for workers should be separate from the so called free market. Thoughts?

  53. July 2, 2017

    Great article on the US medical system and civil rights movement.
    Tl-dr: Medicare was a major driver of desegregation, and the AMA desegregated in 1968.

    https://www.theatlantic.com/politics/archive/2017/06/the-fight-for-health-care-is-really-all-about-civil-rights/531855/

  54. Peter permalink
    July 3, 2017

    @Maven

    Montana still has one of the lowest electric rates in the country which is mostly determined by fuel costs and the prices are set by a state commission not the power company, a regulated monopoly.

    Many states have big problems with underfunded retirement plans and defined benefit plans are becoming rare. It’s possible some of the money from the sale of the utility was used to cover retirement plan costs but the newer employees will have to make do with a defined contribution plan.

    I brought in the German health insurance system because it is a hybrid that works well in the most important ways by controlling costs and producing happy customers. It is a universal public system that uses a corporatist free market appearing but non-profit structure. This seems to help them to avoid some, but not all, of the glairing problems of the single-payer examples we are told to follow. This wiser approach also appears to avoid much of the politics that a statist system is part of and the less politicians involved the better for everyone.

  55. July 3, 2017

    Peter:

    It is an illusion, and it works well – but it is still an illusion. I for years work for one member of the bio-circuit, and the were clear on ways of taking advantage. And part of that is that they are small loophole they want to convince the American public that it is the natural order of things. It’s not, it’s having the loopholes remain in force – and expanding them when there are certain occasions to do so.

    Which is why the rest of the developed world doesn’t have these problems. They have other problems, but the US takes many of them off the table.

  56. July 3, 2017

    Peter: For a couple of the years in which I was living in the USA, I had truly “Cadillac” health coverage, coverage that allowed me to take trivial problems to the best clinics — the rest of the time I had “pretty good” coverage. I would still unhesitatingly replace the entire US insurance system with a single payer system, if it were in my hands.

    The German system does not look like the free market, by any stretch of the imagination. What could be more “statist” than declaring that people within particular income bands *must* purchase particular kinds of insurance? Practically all the gesetzlich insurers charge about 15% of income, give or take 0.1% or so — the moment they leave a narrow band, they’re doomed to a death spiral that results in their consolidation into another public insurer. (A consolidation which is well under way — Germany once had several hundred insurers, and you couldn’t quickly switch between them like you can now.)

    The German system also has huge duplication — why should there be multiple storefront operations for registration and multiple Vorstände for something that is strictly regulated and looks precisely the same at your doctor’s office no matter whether you’re with Barmer or AOK? And so on and so forth. I mean, German doctor’s offices are required to use the same IT systems that do exactly the same thing with the same patient smart cards no matter the logo on the card. It’s as “statist” as anything. The free market is not even intended here, it has to do with the history of German labour movement in heavy industry, among other historical, highly “statist” politics.

    Other European countries with mixed multi-tier systems are even further down this road. So I merely take it that your theoretical opposition to single payer is of a piece with your other political obsessions — for no underlying factual reasons.

  57. Peter permalink
    July 3, 2017

    @M

    You have shown clearly if unintentionally why we don’t want Insane Emperor Mandos making decisions about our health system. I don’t think your Stalinist health mandate would be welcomed by the 50% of Americans who enjoy high quality coverage with little or no cost. I imagine our private insurance policies look luxurious to people in many single-payer systems. 75% of Canadians need to purchase additional private health insurance to bring their coverage up to our standards.

    It’s telling that the activists selling this and other top down solutions need to divert attention from the known failures of and useable alternatives to these systems and project coming catastrophe.

    All of this theater is being staged and scripted promoting the punishment of half the people in the country to bring coverage to the last 5% of uninsured that can be covered. As Mandos has shown this is not rational but based on some political or overly emotional agendas.

  58. July 3, 2017

    LOLwut

  59. Noirette permalink
    July 3, 2017

    Yes Mandos the HC costs are *extremely* high. This is *partly* because in Switz. all costs are very high, salaries are high, rents are high, food is high.

    A full time employee at the discount supermarket Lidl (like Wallmart?) earns 4,000 CHF for 13 (paid) months per year. That is about 54 K US dollars p year, without overtime / bonus / etc. — Admittedly, they are the discount store who pays the best.

    A nurse earns more, but not that much more…from (lowest) 5K per month to 7K or more per month (depending on qualifications, posting, seniority, extra tasks.)…that is stretching to like 85K or more US dollars p y. (I quote that to show that the medic. field is better paid but the difference is much smaller than elsewhere.)

    Docs we won’t go into, more, much more, and very variable. Some may earn for low-level not full-time 50K, others 200K, etc. (In the public service.) Professional cleaners in CH earn about 4 times what cleaners in France earn. About pharma prices I can’t say, the comparisons are dodgy, too complex, change all the time, etc. Other med costs reflect this ‘high’ trend, etc.

    A kilo of prime beef “filet” in Switz. costs more than 100 US dollars.

    So the ‘high costs’ have to be figured in function of Purchasing Power Parity, and not in the ‘absolute.’ Still the present system (imho) is not good. A general agreement (though of course it depends what you count as ‘HC’ or not – super ramp to the emergency? wheel chairs? spas? aspirin? police ambulance? phisiotherapy for sprained knees? dental?) show that the public / potential patients pay, through insurance, about 70% of the costs with the rest falling on the taxpayer in opaque ways.

  60. gnokgnoh permalink
    July 3, 2017

    @P
    “50% of Americans who enjoy high quality coverage with little or no cost…” Uh, no.

    I am in senior management in a non-profit, and my company offers quite good health insurance with one of the best employer-supported programs around. They pay my premiums. I pay for my wife and kids, exceeding $1,200 per month = $15K+ per year. Even with a very good plan, our co-pays and other out-of-pocket costs exceed $4-5K every year, primarily because my youngest daughter has serious asthma and allergies (Epi pens!). I try to partially cover those costs using a health savings account (HSA), which simply shifts more of my costs to the taxpayer. My premiums go up every year, by about the same as pre-ACA. Many employers only pay half or even less of their employees’ premiums.

    I strongly advocate and fight for any form of single payer or Medicare for all, both for myself, because my brother is a musician with two kids, who struggles on a daily basis with medical and dental care, and because I care deeply about the common good.

    Your argument against politicians, if taken to mean political interference, is your best argument. I agree. That’s exactly what we have now. Single payer, using a distributed delivery model (AKA Germany), might work, but the lack of a very tight regulatory market will ensure many of the current problems with extreme differences from state to state.

    Your argument that the “private market” is better is unprovable at best, and counter-factual. The rapid destruction of diversity and competition in the corporate world is exactly how we continue to pay much less for everything than it actually costs. A small business cannot escape the external costs, except at the edges. A monopoly can, and, as a monopsony, can strip the supply chain of every ounce of fat. Walmart = single payer.

  61. cripes permalink
    July 3, 2017

    Oh, lordy.

    Peter is worried about the terrible failures of single payer systems like Canada, despite better health outcomes across the board at half the cost. And a private health delivery system.

    He worries about the 50% of Americans with “great” health insurance being sacrificed to pay for those with none at all.

    He worries that in a single payer system patients would still need supplemental insurance for all that frilly stuff, but is unfazed we are now forced to buy 100% insurance–plus yuuge out-of-pockets–or go without health care entirely. And no cost controls at all!

    Last but not least, he worries about the “Stalinists” and “statists” who will force a collective (shudder) health system bureaucracy (which we don’t suffer now) and to share his little crust of bread with the unwashed.

    Why not just drag out the Hitler shibboleth and be done with it?

    I’m not sure why he even comes here, except to disrupt, but access to health care brings out the worst of ugly class chauvinism in American society and deserves both rebuttal and ridicule.

    Is he AMA-financed Hasbara?

  62. July 3, 2017

    > Peter is worried about the terrible failures of single payer systems like Canada, despite better health outcomes across the board at half the cost. And a private health delivery system.

    If he is, he is in the wrong place.

  63. cripes permalink
    July 3, 2017

    Oh, and to the poster above who says health care as a human right will never be accepted by the majority, I must ask: are you channeling Hillary Clinton?

    Health care as a human right is absolutely accepted in at least 58 countries, especially advanced economies but also 11 in Africa. It is a UN charter right:

    “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

    This “segregation now and forever” kind of thinking gets on my nerves.

  64. Peter permalink
    July 3, 2017

    @Gnok

    Thanks for the personal example of someone who pays nothing for their health insurance. You have at least three dependents so your family insurance costs seem reasonable even though your daughter’s preexisting condition probably increases them. I wonder if your NP NGO is subsidizing those policies also even though they don’t pay it all. Co-pays were imposed to reduce overuse of the system and the other charges you mention reflect the high cost of care in your situation compared with lower premiums.

    I hope you don’t believe that single-payer will reduce your overall insurance costs or provide better coverage, Medicare only covers 80% of costs. The 10% savings from eliminating profit from the insurance system won’t change the fact that you will be required to pay for your and your families health insurance, the full amount, that is reflected in private policies. You will be taxed more to help cover unfortunates and businesses will stop viewing health insurance as a fringe benefit and resist higher taxes on top of what they already pay for public health.

    I didn’t mean to make a subjective argument about the private market but did hope people could see the objective results produced by the German system. Their using non-profits is one source of their success but their corporatist regional negotiated medical services pricing is where their large cost controls are accomplished. Some people think that the centralized statist system can exercise its power to control costs but we have already seen that power neutered for political reasons in the case of drug prices the government pays but could have reduced. Walmart uses its power over Chinese sweatshops while the US faces the AMA, wealthy doctors and powerful drug companies.

  65. July 3, 2017

    > Thanks for the personal example of someone who pays nothing for their health insurance.

    Everyone pays for health insurance – it’s called “taxes”. Are you this moronic naturally – or do you have to work at it? You are arguing against the Austria – and they are madly conservative.

  66. Hugh permalink
    July 3, 2017

    Peter is a troll, folks. And the first rule of troll control is “Don’t feed them.” Never take them seriously. Make fun of them if you must, but the best policy is simply ignore them.

    It is like trying to have an honest discussion with someone who believes the Earth is flat, or that climate change doesn’t exist, or isn’t man-made. If someone believes these kinds of things, or is paid to say they do, or just wants the attention, the one thing you are not going to get is a real discussion. You will get word salads, specious arguments, personal attacks, and alternative facts, but a substantive discussion? No.

  67. July 3, 2017

    Not only is he a troll he’s a snowflake. Alas my entire stock-in-trade is troll-feeding. It’s so addictive I made a career of it.

  68. cripes permalink
    July 3, 2017

    “Co-pays were imposed to reduce overuse of the system”

    No, they were imposed to reduce the medical payments and increase profits of insurance corps. Reduced utilization is a side bennie.

    USians have one of the lowest utilization rates – at 3.1 doctor visits per capita.
    Canada? 7.6
    Turkey? 8.3
    Russia? 10.2
    South Korea? 14.9

    When a putative “viewpoint” is so infesting with neoliberal Rand Corp propaganda, it’s an endless process to refute it all. Sigh…

    I also feed dicks at the lake.

  69. cripes permalink
    July 3, 2017

    Ducks, that is.

  70. cripes permalink
    July 3, 2017

    “we have already seen that power neutered for political reasons in the case of drug prices the government pays but could have reduced.”

    Admittedly true.

  71. July 3, 2017

    Nothing to admit; that problem is also a risk in regulated multi-payer systems. The prices are still set by stakeholder negotiations — the public negotiator can be subverted for political reasons just the same, it is public expectation that prevents this from occurring.

  72. cripes permalink
    July 3, 2017

    (I admit) that can happen in government-administered systems, too.

  73. Peter permalink
    July 3, 2017

    @Cripes

    I think you just showed that copays work as intended in the US reducing unnecessary office visits. I think the Germans also use them for the same reason and there is no profit incentive there.

  74. cripes permalink
    July 3, 2017

    Wow.

  75. Stephen Douglas permalink
    July 3, 2017

    Thank you for that stirring recounting of 2008.

    This is 2017.

    Maybe you haven’t been watching Fox. No one is saying anymore that it’s cool to let people who ca’t “afford” health care die.

    They are trying to skirt around the issue by saying that the new plan will allow us all to choose what is “right” for us. I think that a part of that approach is signaling to the young who don’t want to be “forced” to pay for care that they, at their young age, don’t think they will need.

    And then there’s Dr. Rand Paul saying we don’t want socialized health care.

    He would be wrong, of course. Everybody now wants some kind of socialized health care.

    It’s not okay anymore to say let ’em die. Don’t be so negative, bud.

  76. cripes permalink
    July 4, 2017

    Flat-Earther.

  77. Blissex permalink
    July 4, 2017

    «health care as a human right will never be accepted by the majority»

    Arguments including “health care as a human right” usually disgust me because of their rancid hypocrisy: human rights don’t stop at the USA (or Canada) border, and if you think that poor people in majority-white USA (or Canada) have a “human right” to have their health care paid for by those who can afford it, please campaign for the human right to health care of poor people in the majority-colored rest of the world, like Sudan, Bangladesh, Guyana, Cambodia by extending Medicaid and Medicare to those countries, paid for by raising your taxes to 70-80% of your income.

    Single payer in Canada and other countries is not based on “human right” arguments, because it extends only to citizens, sometimes residents, and for example usually excludes visitors. It completely ignores the “human rights” of those outside the borders and many inside the borders.

    It is based instead on the right-libertarian argument that it is a voluntary bargain of mutual advantage:

    * Being a group purchase of an insurance pool against both the risk of becoming ill, and the risk of becoming too poor to pay the insurance premium, based on reciprocity.

    * Being a large scale group purchase it has very low administrative and overhead costs with respect to smaller scale arrangements, and is therefore good value for money.

    * And nobody is forced to take that bargain, because it is always possible to take personal responsibility and reject that bargain by leaving Canada and shopping for a better deal among hundreds of other countries that offer a wide range of citizenship products.

  78. Blissex permalink
    July 4, 2017

    «Everybody now wants some kind of socialized health care. »

    Well, a minority of social darwinist don’t, but in general yes. But the issue is not wanting some kind of socialized health care, it is paying for it.

    Many/most conservatives are not monsters, they don’t rejoice because the poor suffer and die because they cannot afford health care. They are really sorry for that, and wish very piously that this never happened, and wish that there was universal health care for everybody including the poor.
    They just don’t want to be forced to pay for it with their own money (while they are very happy to force everybody else to pay, often with their life, for the protection of their properties and liberties).

    The ideal conservative single payer system is one that is funded by voluntary tax-deductible contributions, so every contributor has the pride and satisfaction of contributing by their own decision, and those who opt to contribute to their personal or church-based health-care insurance pool can do so without penalty.

    The argument I use about that is that such is already the case in Canada, because everybody have the right to leave that country and paying for the single-payer system of Canada is thus entirely voluntary.

  79. Blissex permalink
    July 4, 2017

    «Many employers only pay half or even less of their employees’ premiums.»

    No employers pay even a cent of their employee’s premium (or social insurance contributions etc.). Oh please, that is so blatantly obvious. To an employer all direct costs associated with that employee are part of the pay package. Labels like “employer’s share of the insurance premium” are only used to fool the gullible (and many are gullible).

  80. Blissex permalink
    July 4, 2017

    One of the more interesting aspects of the story is that Saskatchewan (a fairly poor rural state) created by itself, first nearly universal hospital single payer in 1946, and then full social medical insurance in 1962 as reported here, but no USA state has done so until recently, and yet there have been Democratic majorities in many rich states for decades.

    For example why didn’t California or Minnesota create medicare-for-all many decades ago? That is the really big question. If Saskatchewan could do it over 50 years ago, why not California or Minnesota?

  81. Peter permalink
    July 4, 2017

    @Bliss

    The history of Saskatch’s UHC system is interesting and their small population and large exports may have made it possible. California was a different creature even then and both parties have used HC as a political football in the US.

    I do grow weary of the phony rhetoric about poor people dying because of no healthcare. Our truly poor and disabled numbering about 70,000,000 are covered by Medicaid. Think about that number which is almost twice the population of Canada. This mass population, through no fault of their own, will never contribute much if anything to support any medical system so other people must pay for their care and their numbers continue to grow.

    The hypocrisy in these pleas for the dead and poor to push single payer tries to hide the fact that the remaining 5% of the population that can be insured is neither truly poor nor dying. From what I have seen many people in this group can pay for their insurance but don’t want to because it is expensive and would interfere with their other consuming habits.

  82. Blissex permalink
    July 4, 2017

    «The history of Saskatch’s UHC system is interesting»

    Also because as F Hayek predicted correctly that was just the beginning of the “Road to serfdom”, and eventually the whole Canada went for socialized medicine, and so on and little by little on that road, and 50 years later Canada has become a vicious soviet hellhole :-).

    «the remaining 5% of the population that can be insured is neither truly poor nor dying. From what I have seen many people in this group can pay for their insurance but don’t want to because it is expensive and would interfere with their other consuming habits.»

    Even assuming that such claims are right, in a democracy the 5% don’t have a right of veto over the majority; for example I am pretty sure that over 5% of the USA voters were against big government big spending to invade Iraq, “because it is expensive and would interfere with their other consuming habits”, yet they were steamrollered by the majority to pay for it.

    And since the USA does not have exit visas, if that 5% thought that single payer was not in their best interest they could take personal responsibility and shop for a better bargain in one of the many countries that have no socialized medicine system.

  83. Peter permalink
    July 4, 2017

    @Bliss

    Canada may have avoided the pitfalls of statist socialism by using a provincial system decentralizing what has become a uniform mediocrity in healthcare.

    The 5% I mentioned would be the most likely to support single-payer, in the US, they have the most to gain while the 50% who have private insurance have the most to lose. If this majority received true accurate information on what single-payer would do to their costs and coverage I doubt many would support it. Right now people are being fed shallow hype and virtue signaling which does produce conditioned responses from many people.

    I see you’re a member of the Canada love it or leave it extremists barking at people who have no chance of changing their system but dare to question its failures. Canadians seem to be busy digging up tar-sands and increas9ing CO2 sales to the US to help fund their basic health care.

  84. July 4, 2017

    And since the USA does not have exit visas, if that 5% thought that single payer was not in their best interest they could take personal responsibility and shop for a better bargain in one of the many countries that have no socialized medicine system.

    Not quite how the world works. Even poor countries don’t necessarily let ordinary people from richer countries simply settle there. One’s “shopping” opportunities may be quite limited.

  85. doug permalink
    July 4, 2017

    Peter does not give a shit about the poor…and their lack of access to healthcare. He claims they get all they need via medicaid, which is total bullshit, which I suspect he knows also.

    Thanks to those who added to the discussion with an honest effort.

  86. Blissex permalink
    July 4, 2017

    «Even poor countries don’t necessarily let ordinary people from richer countries simply settle there. One’s “shopping” opportunities may be quite limited.»

    Well, from a right-libertarian point of view “let ordinary people from richer countries simply settle there“ is simply ridiculous: why should a country be forced to give away something valuable for free? Indeed “ordinary people from rich countries” cannot just walk into a shop and take an LCD TV and walk out of it. Shopping for a better citizenship bargain is like everything else for a right-libertarian: you can purchase what you can afford.
    Right-libertarians in Canada for example if they want to escape the soviet hellhole that Canada has inevitably become after decades of socialized medicine and all the other steps on the “Road to Serfdom” 🙂 have a choice of a wide range of residence products at all affordability levels: it costs several millions to get residence in the Principality of Monaco, and probably only a few thousand in a brown envelope for places like South Sudan. Of course often price reflects value even as to residence and citizenship products.
    And what if some “ordinary people from rich countries” cannot afford to purchase the residence product from the country they would prefer? Well, they if they can’t afford to buy the luxury model of LCD TV they want, the shop has no duty to give it to them for free, and they will have to make do with a cheaper model.

    For a right-libertarian residence or citizenship in a country is simply like a membership product in a club, and some will be free, and some will charge a joining fee, some will charge a yearly fee, some both, some fees will be small, some will be large. Shop carefully…

    That applies for example to shopping for the preferred level of state taxation in the USA: if you want to get the job opportunities in Massachusetts you got to pay that state’s residence product’s local taxes, you can’t say “Oh yes I would like to live in Massachusetts but I’ll pay only Texas level taxes”.

    So I really cannot see why 5% of USA voters should be able to veto single payer when they can take personal responsibility and “choose freedom”.

  87. Blissex permalink
    July 4, 2017

    «residence or citizenship in a country is simply like a membership product in a club»

    Actually perhaps a closer analogy is with a cable TV or mobile phone “membership” in a “plan”. There may be entry, yearly, exit fees for “membership”, and several cable TV or mobile phone companies offer different “plans” at different levels of affordability. If you don’t like your current “plan”, switch to one you can afford. Switching may be expensive, may be inconvenient, you may not get exactly the deal you want, but you can take personal responsibility for your choice of “plan”.

  88. Blissex permalink
    July 4, 2017

    And if “membership” in a country is like a mobile phone plan, single payer healthcare is like a flat fee plan for “unlimited” minutes/GB. If your current mobile company offers you only that plan, switch to a company that offers a “by the minute/GB” plan if that suits you more and you can afford it.

  89. Peter permalink
    July 4, 2017

    @Doug

    Your short comment left me wondering if you are just a simpleton or what some conservatives call a poverty pimp. Further comments might help to clear up that confusion.

  90. Peter permalink
    July 5, 2017

    I suppose I could apologize for forcing Hugh to produce these repetitive, childish outbursts of cheap shots but he offers a too easy target to resist. I can’t decide if he has comprehension problems or is intentionally misapplying data for his agenda.

    The numbers he uses seem accurate but then he takes the Medicare/Medicaid estimate of $330 billion spent out of pocket, apparently for the whole system, and uses it to create some fiction about private insurance. Medicare has a 20% out of pocket cost and Medicaid has a varying OOP depending on the state and none of these payments go to insurance companies but directly to service providers. Many people on Medicare need to buy private insurance to protect them from the 20% OOP costs that can bankrupt someone on limited fixed income.

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