The Costs and Solutions to American Health Care

January 7, 2013 2:38 PM

Three excerpts from David Goldhill's new book on American health care:

Part One: Focus on Health-Care Costs Causes More Spending

Part Two: Obamacare Math Doesn't Add Up to a Healthier U.S.

Part Three: To Fix Health Care, Turn Patients Into Customers

Bonus reading! Goldhill's response to Atul Gawande's article on the future of medicine, posted here last year. [Gawande, previously]

posted by hopeless romantique (109 comments total)

A 2011 study by the RAND Corporation found that people with high- deductible health-insurance plans spend roughly 15 percent a year less than average on health care, even when the plan’s deductible is as low as $1,000.

So many hands being waved, so many questions glossed over.
posted by rtha at 2:48 PM on January 7 [16 favorites]

...the right is correct that we are unlikely to build a good, affordable system of care unless we leave most of it to market incentives.

[citation needed]
posted by justsomebodythatyouusedtoknow at 2:49 PM on January 7 [37 favorites]

If insurance is to pay half of these catastrophic costs, that suggests the deductible would average $30,000 -- obviously very high by today’s standards (but less so when you consider that the average insured household contributes well over $20,000 per year into our current system, even before considering deductibles and co-pays). It would make sense for this to rise with age, too, starting at $10,000 for younger people and capping somewhere around $50,000 for older people. Because all Americans would be eligible for health loans, no one would ever be unable to pay the deductible; rising deductibles would merely reflect the longer period of time that people would have had to accumulate health savings.

And that's where I stopped reading.

Sorry, but any proposal that puts an insurance deductible at just under half the pretax national median household income (and charges more to the people who need it more) is just staggeringly out of touch with reality (and ethics).
posted by schmod at 2:50 PM on January 7 [87 favorites]

anytime i read something on how the problem with a capitalism-based healthcare market is that we don't have nearly enough capitalism in it, i hear the NRA say that the reason we have spree killers is that we don't have nearly enough guns.
posted by gorestainedrunes at 2:50 PM on January 7 [125 favorites]

If we adopted any of the models used by the rest of the developed world, described in T.R. Reid's excellent Healing America, the U.S. would be WAY better off. Unfortunately, adopting any of these forces us to run into the brick wall of the world's most powerful political force, lobbyists. See also: OMG socialized medicine.

None of the other current healthcare models are perfect. But they are all better than what the U.S. has (third world excepted, which is a straight out-of-pocket model).
posted by mcstayinskool at 2:52 PM on January 7 [11 favorites]

Because all Americans would be eligible for health loans, no one would ever be unable to pay the deductible; rising deductibles would merely reflect the longer period of time that people would have had to accumulate health savings.

Never has such a horrible idea sounded so utterly bland.
posted by theodolite at 2:52 PM on January 7 [25 favorites]

I saw this movie before and Jude Law wasn't that great in it.
posted by GuyZero at 2:54 PM on January 7 [2 favorites]

...the right is correct that we are unlikely to build a good, affordable system of care unless we leave most of it to market incentives.

[citation needed]

I balked at that line the first time I read it too, but after reading it a second time I now interpret it as

...the right is correct that [bull-headed americans that will never accept anything that resembles "socialized medicine] are unlikely to build a good, affordable system of care unless we leave most of it to market incentives [, even when there are real-world examples of this happening elsewhere].

If that was the intended message, I will stipulate that point.
posted by mcstayinskool at 2:55 PM on January 7 [2 favorites]

David Goldhill is the president and chief executive officer of the cable TV network GSN.

This is the best post-article credential the author can muster to convince us of his authority and expertise on this subject?

And we wonder why our healthcare debate is so messed up.
posted by RonButNotStupid at 2:55 PM on January 7 [25 favorites]

This is the first in a series of three excerpts from his new book ...(snip)... to be published Jan. 8 by Alfred A. Knopf.
posted by XMLicious at 2:55 PM on January 7

...even when the plan’s deductible is as low as $1,000.

Um, for a lot of people a thousand dollars is a lot of money.
posted by octothorpe at 2:56 PM on January 7 [38 favorites]

Oops, the OP already notes that it's advertising for a book.
posted by XMLicious at 2:56 PM on January 7

FPP as free ad space for a book by someone with an opinion but no credentials?
posted by eustacescrubb at 2:58 PM on January 7 [8 favorites]

It's cool that the deductible steadily goes up every year as you become steadily more likely to get life-ruiningly expensive diseases, because hail satan
posted by theodolite at 2:58 PM on January 7 [88 favorites]

hopeless romantique: "Part Three: To Fix Health Care, Turn Patients Into Customers"

"Well, I have a cough, so I want an MRI!"
posted by boo_radley at 2:59 PM on January 7 [3 favorites]

I pay $0 deductible on my health care, and no monthly premiums. I also pay less taxes than many Americans. Why is the math so hard?
posted by blue_beetle at 3:00 PM on January 7 [20 favorites]

~...even when the plan’s deductible is as low as $1,000.
~Um, for a lot of people a thousand dollars is a lot of money.

True.
Unfortunately, a $1000 deductible is low. Damned low. Astoundingly low.

Healthcare will never be affordable in the US so long as all these reform schemes continue to saddle everything on the consumers' shoulders. The entities on the other side of the coin...providers, hospitals, manufacturers, insurers, etc...must accept lower wages and profits for any real, meaningful reform to work. Otherwise, this is all just rearranging deck chairs.
posted by Thorzdad at 3:02 PM on January 7 [8 favorites]

Defaced Money posted by spock at 7:53 AM

Secret and Lies of the Bailout posted by homunculus at 11:11 AM

The Red and the Black davidjmcgee at 12:42 PM

The Costs and Solutions to American Health Care kendrak at 1:54 PM

Given what Americans have accomplished the past 100 years relative to the rest of us, it seems like you don't fix your healthcare so you have another reason to talk about money.
posted by larry_darrell at 3:07 PM on January 7

They would pay their own deductibles, but they would also be entitled to health loans -- advances on their future contributions.

Health loans? Health loans?

Because dealing with a catastrophic medical event isn't already enough of a drag on your savings, future earning potential, and ability to pay for the costs of future catastrophic medical events. This guy is seriously proposing the equivalent of payday loans against your future benefits to pay for current emergencies.
posted by RonButNotStupid at 3:07 PM on January 7 [34 favorites]

The entities on the other side of the coin...providers, hospitals, manufacturers, insurers, etc...must accept lower wages and profits for any real, meaningful change to work.

I agree with this point wholeheartedly. I also think it cuts right to the core of the cultural fear many Americans have for anything like this: if healthcare entities were compensated less, we'd get worse healthcare because they'd all go off and be e.g. veterinarians or actuaries or plumbers. It would be just un-American to think that less $$ fed to this machine would result in anything but worse care. This is, of course, completely wrong, but it's why we continue to suffer this infernal system.
posted by mcstayinskool at 3:07 PM on January 7

Related: The Fallacy of Treating Health Care as an Industry (if by Related the Atlantic means "Meanwhile In Reality".)

Health care is not an industry. It's a human right.
posted by Potomac Avenue at 3:12 PM on January 7 [20 favorites]

So I skimmed through this article, and agree with all the criticisms that I've seen posted here. Did I miss the part where he explains why costs are so much lower in other countries as opposed to the US? Any analysis of US health care costs is woefully incomplete without such comparisons.
posted by Edgewise at 3:12 PM on January 7 [2 favorites]

This is exactly the sort of scheme someone would come up with if they were barred from examining any other system aside from the American one.
posted by klangklangston at 3:13 PM on January 7 [17 favorites]

Health care is not an industry. It's a human right.

[citation needed]
posted by H. Roark at 3:15 PM on January 7 [1 favorite]

cf Your soul
posted by Potomac Avenue at 3:15 PM on January 7 [30 favorites]

I'm just going to leave this here; the Guardian's Data Blog on comparative healthcare spending around the world. The US spends more, (both the government and citizens) than the UK, with its well established socialized healthcare system.
posted by His thoughts were red thoughts at 3:16 PM on January 7 [3 favorites]

Health care is not an industry. It's a human right.

Great! Let's dismantle the hospitals.
posted by thelonius at 3:18 PM on January 7 [1 favorite]

Part Three: To Fix Health Care, Turn Patients Into Customers

The fuck?
posted by Artw at 3:18 PM on January 7 [3 favorites]

Health care is not an industry. It's a human right.

[citation needed]

Here you go:

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, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. [Article 25, Paragraph 1; Universal Declaration of Human Rights]

posted by RonButNotStupid at 3:20 PM on January 7 [68 favorites]

At the other end of the spectrum -- let’s say all people 35 and younger -- individuals would be required to put some percentage of their pretax income into their health savings accounts. (The amount would probably be at least 15 percent.) They would pay their own deductibles, but they would also be entitled to health loans -- advances on their future contributions. This group, in other words, would be fully enrolled in the new system.

So, what you're saying is that you can fix the US healthcare system, and all you need is a 15% income tax increase to pay for it?
posted by Jehan at 3:21 PM on January 7 [15 favorites]

Here is the central problem I see in this article:

“My answer to those who argue for national health insurance or for a market-based system is to do both. Let’s provide national insurance to everyone but not for everything. Then let’s have individuals use their own health savings accounts to pay for those health-care expenses that aren’t catastrophic -- from routine exams to the management of illness and the infirmities of old age.”

This is easy to say, and it sounds nice. However, the problem with it is that this line between "routine care" and "catastrophic medical event" is a blurry one – and it's getting more blurred every year. Because of the current health care system's problems and the limits in who is covered for what, things that didn't used to be catastrophic now are. People with cavities just let their teeth rot and take a lot of aspirin and tough through it through rather than pay for a dentist; people who step on nails end up dealing with tetanus because they decided it was worth it to gamble by putting a bandaid on it instead of going in for treatment; people who get what turn out to be life-threatening illnesses don't go to the doctor right away but wait until they're at death's door. Not to mention the millions upon millions of women in this country that I have a feeling would never get pregnant if getting birth control didn't mean plunking down a chunk of change to see a doctor.

We are seeing this on a national scale today: if you guarantee care only in catastrophes, but demand that people pay otherwise, then people will not engage in preventative care, people will not catch their sicknesses before they become more serious, and everything will become a catastrophe. Which – it should be said – is one of the reasons health care is so expensive in the US. We've created a system where everybody is scared to do anything but wait to see the doctor, so every illness and every malady becomes exponentially more expensive to treat.
posted by koeselitz at 3:22 PM on January 7 [20 favorites]

Is this a joke?
posted by zouhair at 3:23 PM on January 7 [8 favorites]

I mean – the thing is, it's basically the exact same system we have today. Everybody knows that if they aren't about to die, they're gonna pay if they ask for health care; but if you're about to die, they have to help you. So everybody waits.
posted by koeselitz at 3:23 PM on January 7 [2 favorites]

Another big flaw in this system is the idea of health care loans. If the past ten years have taught us anything, they should have taught us that loaning money to people who probably won't end up being able to pay it back is a terrible, terrible idea; it was bad enough with housing, and I can only imagine how horrifying it would be to have a loan system motivated by the desire to be healthy and actually, y'know, go on living. It'd be lending at the barrel of a gun, really, and even those who are highly motivated not to borrow beyond their means would find themselves tempted, I think.

Health care spending accounts are almost as bad. If you're asking people to bank away money they could be spending on food or other stuff just for in-case medical care, you may as well just close those silly health care accounts and save the account maintenance fees. People won't do it. If you want to make sure they do, you'll have to force them to put money into those accounts, and then force them to keep it there. And guess what? That's just called taxing them.
posted by koeselitz at 3:31 PM on January 7 [18 favorites]

This is exactly the sort of scheme someone would come up with if they were barred from examining any other system aside from the American one.

Oh no! Stabler kicked down Canada's front door without a warrant, so now he has to prove that creepy old Mr. Pearson brutally slashed health costs without the fingerprint-covered Medical Care Act of 1966!!
posted by theodolite at 3:34 PM on January 7 [8 favorites]

Medicaid is already very expensive. In 2010, the states and the federal government spent a combined $405 billion on their Medicaid programs, up from $206 billion only a decade earlier.

(And what is it that drives up Medicaid costs?)

It doesn’t seem to make sense that a population that is getting richer,

(Well, 400 of them anyway.)

that has greater access to better food and cleaner water than it used to have,

that works in less physically dangerous occupations,

that doesn’t smoke or drink as much (ok, that might be true)

should need so much more health care. But Medicaid’s growth is an inevitable consequence of the undisciplined demand for care that pushes up prices.

There is so much wrong with just about everything this guy says that I don't even know where I want to start punching him in the throat. Leave it to a profit-hungry CEO to propose the model that got you into trouble in the first place as the solution to the problem that he caused.

And...health care loans?? WHAT, pray tell, is the collateral for THOSE? Or do they just become non-dischargeable like student loans, and all of a sudden suicide becomes a viable financial decision?
posted by deliciae at 3:38 PM on January 7 [23 favorites]

Wouldn't healthcare loans also mean "death panels"? I mean, you could just borrow millions on the never-never seeking some cure to a terminal illness, unless somebody stepped in and said "enough". The official agreeing to or turning down a loan would have to face the same old worries of rationing that systems like the NHS are often guilted with.

Even if it's not a terminal illness, who's to say that you're spending "too much" on healthcare?
posted by Jehan at 3:41 PM on January 7 [1 favorite]

Is this a joke?

Some of the participants are definitely laughing, all the way to the bank.
posted by FatherDagon at 3:42 PM on January 7 [3 favorites]

So, what you're saying is that you can fix the US healthcare system, and all you need is a 15% income tax increase to pay for it?

What's wrong with that? Americans seem to hate the idea of paying taxes, then take away everything that the taxes pay for. In Australia I know my taxes pay for good things: universal healthcare and Arrested Development reruns on the ABC. I get a tangible benefit, so I'm happy to pay higher taxes to help myself and others.
posted by Charlemagne In Sweatpants at 3:44 PM on January 7

David Goldhill is the president and chief executive officer of the cable TV network GSN.

This is the best post-article credential the author can muster to convince us of his authority and expertise on this subject?

He should have suggested a game-show component. Wheel-of-Chemo anyone?
posted by cosmic.osmo at 3:45 PM on January 7

cosmic.osmo: " He should have suggested a game-show component. Wheel-of-Chemo anyone?"

Chemo or Zima?
posted by boo_radley at 3:49 PM on January 7 [1 favorite]

Jesus fucking shit, this is horrible and dangerous nonsense.

I'm sure it will sell like hotcakes. Hotcakes with bootstrap molasses.
posted by Sidhedevil at 3:50 PM on January 7 [2 favorites]

Is there a term for linkbait when it occurs solely in a MeFi thread? I mean, what "conversation" is this post supposed to incite? A "what's not batshit crazy about this plan"? If so, I'm at a loss.
posted by Catchfire at 3:55 PM on January 7 [2 favorites]

What's wrong with that?

There's note wrong with it. But, I mean, if you're going to mandate that everybody puts aside 15% of their income for healthcare, you might as well eat the whole hog and build a universal system without any stupid idea of deductibles and health loans. National Insurance contributions in the UK are less than 15% (although with employer contributions too), and almost cover the NHS budget.
posted by Jehan at 3:55 PM on January 7 [3 favorites]

Jehan: “So, what you're saying is that you can fix the US healthcare system, and all you need is a 15% income tax increase to pay for it?”

Charlemagne In Sweatpants: “What's wrong with that? Americans seem to hate the idea of paying taxes, then take away everything that the taxes pay for. In Australia I know my taxes pay for good things: universal healthcare and Arrested Development reruns on the ABC. I get a tangible benefit, so I'm happy to pay higher taxes to help myself and others.”

Ah, but that's where you're wrong. In Australia, you pay a 1.5% income tax for your health care. He's talking about ten times as much, and it wouldn't even be guaranteed single-payer health care like you get in Australia. I'd be skeptical, but it might be worth it to pay 15% for good healthcare; hell, we Americans already spend about that much per person. But I sure as hell wouldn't do it for the crappy system this guy is proposing, which would be guaranteed to go in the same direction of creating more and more medical emergencies and making health care more and more expensive.

Listening to Americans talk about health care, a lot of times I know it's tempting to think we're just stingy, not wanting to pay for it through our taxes. But a huge part of the problem is the fact that our system is just structured horrifically badly for this. Hell, we probably pay double what you do in taxes for health care, and we get nothing but shit for it.
posted by koeselitz at 4:00 PM on January 7 [6 favorites]

In fact, there are workable capitalism based solutions, gorestainedrunes, just not any workable solutions the capitalists actually like, big difference.

In my experience, healthcare systems work when everyone uses the baseline system, certainly richer people can buy extra care, but any system fails when the upper middle class has their own separate system.

In Britain, there are separate public and private care streams that creates perverse financial incentives for health care providers, way better than the U.S. system, but still bad news, witness their teeth.

In France, there is an underlying capitalist aspect to healthcare providers in that providers are basically private practice, but the state provides fixed reimbursements for specific services. There are doctors who charge more than the government reimbursements, but afaik mostly only famous ones, i.e. the patients are consumers. Yes, rich people might hire a famous doctor, but they'd still be annoyed if the prices went up because the reimbursements went down for everybody.

In Germany, insurance companies are ultimately private companies, and everyone must buy insurance, but the insurers are tightly regulated. Why don't they hire lobbyists to weasel out of paying their bills? I'd suspect the influential people hold the same insurance policies as the poorer people, perhaps they hold additional policies too, but they'd still get pissed if their basic policy got worse.

You don't believe this makes a difference? I've never once heard about French or German doctors giving patients bad advice that benefitted the doctor financially. I've received such bad advice from a British dentist. I've family members who received such bad advice from American eye doctors. etc.

In any case, there are workable healthcare systems that "turn patients into consumers", but no workable system lets capitalists extract anything like the rents healthcare providers and insurers extract in the U.S.
posted by jeffburdges at 4:00 PM on January 7 [5 favorites]

This is so nonsense. As others have noted, we could run a national health service on less than a 15% set-aside from everyone's income. This is keeping the bath water of our shitty privatized over-bureaucratized system and throwing out the baby of actually getting people health care (including preventative health care, which is the reason rich people need, as a group, less emergency health care).
posted by Sidhedevil at 4:03 PM on January 7 [4 favorites]

could have...filled the room with a million dollars’ worth of hospital equipment leased for $15,000 a month

So what is that, a couple stethoscopes and an IV rack?
posted by telstar at 4:09 PM on January 7 [1 favorite]

Having just moved to the US I have learned there is one large hidden cost to the whole American health care quagmire; the consumer time sink in just figuring the system out. I've lost hours and hours sorting out my health care. It doesn't show up as a cost anywhere because I don't get paid for it or pay someone to do it for me but simply navigating and negotiating my health care arrangements is more difficult than any accounting I have ever had to do from tax returns to full business accounting. Plus, beneath it all is the nagging uncertainty that I may have made a mistake somewhere. So in addition to the thousands it directly costs me there are probably about another 30 hours or so of calling, emailing, reading and haggling. And I haven't had to use it yet.

I never had to ever even think about this stuff in Canada or in the UK. It was automatic.
posted by srboisvert at 4:11 PM on January 7 [42 favorites]

Unfortunately, a $1000 deductible is low. Damned low. Astoundingly low.

Relative to what, exactly? If it is "damned low" in actuarial terms, that is a good case that insurance is the wrong way to pay for medical expenses, because a thousand bucks is damned high relative to the amount of spare cash average people have on hand to pay for random disasters.
posted by Mars Saxman at 4:16 PM on January 7 [2 favorites]

I pay $0 deductible on my health care, and no monthly premiums.

Your monthly premiums are dignity and pride, and your deductible is your immortal soul!
posted by Nomyte at 4:21 PM on January 7 [1 favorite]

Turn patients into customers...that you can let die.
posted by emjaybee at 4:24 PM on January 7 [1 favorite]

The writer should immediately go to the hospital and get that fecal impaction taken care of. It doesn't take House MD to see that the guy is full of shit.
posted by humanfont at 4:26 PM on January 7 [4 favorites]

jeffburdges: “In fact, there are workable capitalism based solutions, gorestainedrunes, just not any workable solutions the capitalists actually like, big difference.”

Indeed. I'm not an expert – heck, I've never even been on a game show, much less run a whole game show network – but here's how it seems to me:

I have some sympathy for those who believe that a free market is the best way to lower costs. Free market competition drives providers to offer better deals to consumers; that's pretty clear. And it's certainly clear to me that we don't have a free-market health care system right now; nor do we have a "socialist" system. We have a kind of oligarchy where only the biggest players can afford the massive entry fee they have to pay in order to compete. These big players lobby to make sure regulation is arcane and confusing and costly enough to deal with that they won't have to face competition from smaller players. (It's disturbing when you contemplate how many industries in the US are like this now.)

The trouble is – it's not possible to institute a free-market health care system. Those big players will do everything they can to keep up the barriers to entering the market as an insurer; and since regulation of health care is absolutely necessary anyway, it won't be hard for them. It's the same with energy, frankly; we've tried in this country several times to "privatize" energy, but we just end up with a small number of energy providers who are allowed to monopolize city and even state markets.

So the only solution, I think, is to build some free-market action into a single-payer, individually-mandated, multiple-insurer system. Lots of countries do this; Israel, for example, has (I think) three different private insurers which compete for tax dollars which they earn on the basis of how many patients they can take on.

Honestly, one of the biggest benefits this has is that it drives providers to compete on care rather than on dollars. This is one of the biggest problems with the sort-of-free-market we've built now; since dollars are the main driver of competition rather than care itself, medical care takes on all kinds of awful and ridiculous dimensions. I have a friend who recently graduated from medical school, where the most sought-after specialty was dermatology, and family medicine people (which doctors treat the vast majority of patients in the US) are seen as second-class citizens. Why? Because in a medical system that values dollars above care, a rich person with an annoying rash is a much higher priority than a homeless person with a broken leg. This leads to all kinds of problematic situations, and (surprise, surprise) also serves to drive up costs overall.
posted by koeselitz at 4:27 PM on January 7 [4 favorites]

Hell, we probably pay double what you do in taxes for health care, and we get nothing but shit for it.

Confirmed. US government expenditure per person on healthcare is $4437, Australia is $2340 (USD, I think).

Australia also has a much lower proportion of private spending on healthcare (32% of all spending on healthcare, as opposed to the US's whopping 46.9%).

Yet Australia has a socialised heathcare system.
posted by His thoughts were red thoughts at 4:28 PM on January 7 [7 favorites]

If prevention is key to lowering healthcare costs, then we should give every incentive to see a doctor early, which challenges the notion of deductibles (and besides, healthcare isn't like ice cream, we don't need to discourage people from trying it). Also, new information is coming out that reveals that 1% of chronically ill patients account for 22% of all costs, and 5% of patients account for half of all costs. On top of it all, people who can't afford their emergency room bills mean that those costs are shifted to everyone else, while insurance companies make profits from not insuring them. Then drug companies lobby the states to prevent batch buying their drugs, to protect their profits. I think anyone should be able to see that healthcare is a problem the private sector can't fix.

I propose the idea of being able to take every penny we spend on preventive healthcare and crediting it to our taxes, even over many years. If all required healthcare costs were tax credits then everyone would be rushing to check out a potential health problem (including cavities, which illustrate the problem of escalating costs), and that way we would buy an insurance policy to cover the out of pocket after tax credits are used.
posted by Brian B. at 4:30 PM on January 7 [1 favorite]

I propose the idea of being able to take every penny we spend on preventive healthcare and crediting it to our taxes, even over many years.

That's a great incentive....provided you pay taxes that can be credited.
posted by RonButNotStupid at 4:33 PM on January 7 [1 favorite]

What surprises me is that there is so little discussion of the outcomes. You would imagine that the "best healthcare system in the world" would have the best outcomes, and I'm sure many people actually think so, but some quick googling shows it not to be the case:

Some examples: Infant mortality rates (i.e. dead babies), 34th place, between Cuba and Malta. Life expectancy, 38th place, between Cuba and Slovenia. Here is one where the US is actually high up: Breast cancer survival rates (but, for cervical cancer, it is much lower).

Here is an interesting blog post on health outcomes by country, probably based on this report. I was not able to find any really comprehensive comparisons of outcomes - something like Rosling's gapminder would be really useful for visualizing the information. (Like this, comparing Mexico and the US.)
posted by Baron Humbert von Gikkingen at 4:41 PM on January 7 [6 favorites]

What, exactly, is the point of growing and advancing a society if it isn't to get everybody higher standards of living and better health care? Anything else seems pointless.
posted by Benny Andajetz at 4:53 PM on January 7 [3 favorites]

I have some sympathy for those who believe that a free market is the best way to lower costs. Free market competition drives providers to offer better deals to consumers; that's pretty clear.

Maybe if a consumer's drive to deal with you is voluntary. But, why sweeten the deal when you know the "customer" has to come to you, no matter what?
posted by Benny Andajetz at 4:57 PM on January 7 [2 favorites]

What, exactly, is the point of growing and advancing a society if it isn't to get everybody higher standards of living and better health care?

More people making more money to shove into that corporate maw and be sucked into their depths, then shat out through the colon extentions called 'lobbyists' to insure the law makes greater requirements for each person to feed to the monster.

Anything else seems pointless.

Well, sure, you're not a monster, so to you it is, but to Cignazilla and BlueCrossdad and Kaiser X and its other kaiju of insurance, it makes total sense.'

I may be slightly sarcastic here.
posted by mephron at 5:02 PM on January 7

jeffburdges: In Britain, there are separate public and private care streams that creates perverse financial incentives for health care providers, way better than the U.S. system, but still bad news, witness their teeth.

What, you mean the best in the world?
posted by Mitrovarr at 5:05 PM on January 7 [9 favorites]

Mitrovarr, you're arguing with troothiness.
posted by jaduncan at 5:13 PM on January 7

Surely you mean 'toothiness'.
posted by His thoughts were red thoughts at 5:14 PM on January 7 [3 favorites]

koeselitz: This is easy to say, and it sounds nice. However, the problem with it is that this line between "routine care" and "catastrophic medical event" is a blurry one – and it's getting more blurred every year. Because of the current health care system's problems and the limits in who is covered for what, things that didn't used to be catastrophic now are. People with cavities just let their teeth rot and take a lot of aspirin and tough through it through rather than pay for a dentist; people who step on nails end up dealing with tetanus because they decided it was worth it to gamble by putting a bandaid on it instead of going in for treatment; people who get what turn out to be life-threatening illnesses don't go to the doctor right away but wait until they're at death's door. Not to mention the millions upon millions of women in this country that I have a feeling would never get pregnant if getting birth control didn't mean plunking down a chunk of change to see a doctor.

So much this. I'm a grad student, and nearly all of the grad students I know don't go to the dentist unless there's an active problem (and sometimes not even then). This can lead to a 7+ year gap in dentristry between when they get into college and get their first real job (at which point - maybe - they can afford it). Nobody does preventative medicine of any kind. People don't go to the doctor unless they have a problem they know won't go away on its own or they're at death's door. This can be really bad with appendicitis and meningitis and so on.

The worst part is, it almost doesn't matter if insurance covers these things. Insurance tries to screw you up, down, left, and right. You might have a covered procedure and an in-program doctor for a documented legitimate need and you'll still have to pay the ludicrously overpriced charges because you didn't turn around three times and spit before you filled out form 1323.a1. You never know if something is really covered until you try. So there's a huge incentive never to get preventative care.
posted by Mitrovarr at 5:18 PM on January 7 [18 favorites]

As a more cojent response.

Being a customer has basically no value unless you don't have to worry about the cost. If you are a customer then the service provider becomes a salesperson, and they focus on what they can sell you on top of the needed service. As evidence consider the following industries where you are a customer: auto mechanics, fast food, car dealers, airlines, plumbers, electricians, etc.

The observable evidence is overwhelming that single payer systems deliver better outcomes at a lower cost than private health insurance. We can easily prove this by comparing data from various systems. We are like the Soviet Union and Eastern Block in 1986 comparing the Western Economies to our own.

Since the passage of Obamacare we have seen the rise of healthcare costs slow dramatically. So yet again we see punditry try to trump reality. Remember when Nate Silver was getting attacked by Joe Scarborough because his statistical model failed to account for some truthy alternate reality. Same thing here.
posted by humanfont at 5:19 PM on January 7 [4 favorites]

I recently had the pleasure of being a health care "customer" after an accident that left me with over $100,000 in emergency health care bills. My plan has a $10,000 deductible, and I have spent countless hours on the phone trying to sort out the resulting billing mess. I can't imagine trying to do this without the skill set that I acquired thanks to a college education and my white-collar background.

The insurance and billing forms are completely impenetrable, and the providers routinely fuck up basic billing matters. I was attacked by a wild pig, was lacerated down to my tibia on both legs, nearly had my femoral artery severed, and the ambulance company used the billing code "VENOM".

Folks, there is no such thing as a venomous pig.

Market incentives don't work with healthcare, because competition only improves non-Kafkaesque markets.
posted by compartment at 5:22 PM on January 7 [23 favorites]

By the way, those of you dealing with medical debt may find The Debt Resistors' Operations Manual to be useful. According to the manual, credit reporting agencies are generally required to validate debt with a fee breakdown when asked, and it is virtually impossible for them to do so while remaining compliant with HIPAA.

See page 27 and Appendix C in the manual. I haven't had bills go into collections yet, so I haven't used this approach and can't personally vouch for it. But it has made me more comfortable when threatening to let bills go to collections unless providers are willing to negotiate a lower price.
posted by compartment at 5:34 PM on January 7 [5 favorites]

That's a great incentive....provided you pay taxes that can be credited.

True, there needs to be Medicaid, etc. But having a government thing called tax credit means that it can allow those people to use it or lose it for special incentives, which may as well be healthcare (and education) since these things should be encouraged to be consumed on demand, the sooner the better. And because it uses cash, it greatly reduces much of the infamous office overhead that American doctors have.
posted by Brian B. at 5:35 PM on January 7

compartment: “Folks, there is no such thing as a venomous pig.”

The only reason I'm slightly skeptical of your story is this remark, which makes it sound like you've never met a bill collector for a health insurance company before.
posted by koeselitz at 5:54 PM on January 7 [11 favorites]

...as we, here in NC, await the news that Pat McCrory is going to make us state number twenty-something to refuse Obamacare.

The system is so wrapped around its own axles there's not even an axle in there anymore. Where would we be if health insurance wasn't entangled with employers? I tried to decipher that in this mind numbing (to me) article about the history of insurance.
posted by yoga at 5:58 PM on January 7 [1 favorite]

Turn patients into customers and let them vote with their gangrenous diabetic feet.
posted by blue_beetle at 6:15 PM on January 7 [2 favorites]

Interesting link, Mitrovarr, but good luck finding dentist that'll accept NHS patients. Also, I suppose public policy must influence this considerably, perhaps the U.K. has policies that benefit that particular metric.
posted by jeffburdges at 6:36 PM on January 7

Goldhill seems to have a remarkable ability to draw the wrong conclusions from the right data. In the first paragraph in his October Atlantic article, he says this:

Unfortunately, the most common solution -- to improve efficiency through better central planning -- isn't working. Last week, a New England Journal of Medicine study that showed no impact on hospital-acquired infection rates from a Medicare program to penalize poor performers was the latest blow to administered process solutions in addressing health care's myriad issues of quality, cost, and efficiency.

The costs of infections increased, and the infection rates remained the same. Why on earth should it matter whether the customer was a private insurer, government insurer, or an out-of-pocket payer? It doesn't damn "administered process solutions", it damns the idea that market incentives improve patient outcome.

Of course, the actual situation is a little more complicated -- hospitals may have found it cheaper to futz with billing codes than to improve patient health -- but that too damns the for-profit health care system. If they were attending to billing codes rather than patients, it suggests that hospitals are willing to sacrifice patient health in favor of shareholder value.

"Markets markets markets markets." Repeating an idea does not make it a viable solution.
posted by compartment at 6:45 PM on January 7 [3 favorites]

There are 11 dentists within 5 miles of me currently accepting NHS patients. Check your area here.

This reminds me, I should actually go and get a check up... Gulp.
posted by knapah at 6:45 PM on January 7

koeselitz writes "Free market competition drives providers to offer better deals to consumers; that's pretty clear."

I don't believe that's clear at all. Health care, especially urgent healthcare, isn't something you can shop around for like a watch.

And I don't believe that allowing rich people to have better care than poor people is desirable for society even if it provides "better" deals for consumers.
posted by Mitheral at 6:49 PM on January 7

Mitheral, did you read my comment at all? That was my point.
posted by koeselitz at 6:53 PM on January 7

The thing about NHS dentistry is that it is nothing like the rest of the NHS, and so a poor guide to the strengths and weaknesses of the system as a whole. It's a bit like saying that not owning a car is normal in the US because lots of folk in New York don't own one.
posted by Jehan at 6:53 PM on January 7

This is a really terrible thread to read when I have a bad cold. I think I'm going to die now.
posted by happyroach at 7:15 PM on January 7 [1 favorite]

That's a great incentive....provided you pay taxes that can be credited.

That's not how tax credits work. Let's say I qualify for an $800 credit and I made $0 in the last tax year and have so far, paid $0 in taxes. When I file my taxes, I still get an $800 refund. This assumes that I have the presence of mind to file and claim the credit but that's a different issue.

A 2011 study by the RAND Corporation found that people with high- deductible health-insurance plans spend roughly 15 percent a year less than average on health care, even when the plan’s deductible is as low as $1,000.

So many hands being waved, so many questions glossed over.

This person with a high deductible plan spends less because right now I have pain in my wrist that might (but probably isn't carpal tunnel), a weird issue with a tendon in my ankle that has hurt for over a week, I tweaked my neck five days ago and have a hard time turning my head left, and I need to see an ENT to try and stop me from snoring so my wife can sleep. I should go see a doctor about all of these things but I keep putting it off because I'm afraid of how much it will cost. In the meantime, these things are causing plenty of lost productivity and I'm sure a host of other long-term problems.
posted by VTX at 7:15 PM on January 7 [3 favorites]

koeselitz yes I read your comment. Was the clear bit I quoted some kind of /hamburger line?
posted by Mitheral at 7:17 PM on January 7

Re NHS dentistry: the focus of UK dentistry is HEALTHY teeth, not cosmetic teeth, which seems to confuse US people.
In some societies, only teeth that are filed to points are acceptable, in others (like the US) only teeth that are forced into a regular curve are seen as good. Neither criteria are used in the UK.
posted by anadem at 7:24 PM on January 7 [6 favorites]

Health Insurers Raise Some Rates by Double Digits

The Health Care Act Was Never "A Good First Step"
posted by homunculus at 7:30 PM on January 7

Mitheral: “koeselitz yes I read your comment. Was the clear bit I quoted some kind of /hamburger line?”

I thought I made it clear that the part you quoted wasn't talking about health care at all. I was saying that, in general, free markets drive down prices because manufacturers compete for consumers. Do you disagree with this?

Note that I said at the beginning of my next paragraph that free market health care is impossible, so clearly I wasn't saying that free market health care is a neat thing.

And I'm totally confused by this:

Mitheral: “And I don't believe that allowing rich people to have better care than poor people is desirable for society even if it provides 'better' deals for consumers.”

I guess you're responding to this?

me: “... in a medical system that values dollars above care, a rich person with an annoying rash is a much higher priority than a homeless person with a broken leg. This leads to all kinds of problematic situations, and (surprise, surprise) also serves to drive up costs overall.”

What's weird is that you and I seem to be saying precisely the same thing here.
posted by koeselitz at 7:47 PM on January 7

My rule about health care reform: If your analysis doesn't make a single comparative reference to what other countries are doing, your plan isn't worth reading.
posted by vasi at 7:49 PM on January 7 [9 favorites]

Ah, but that's where you're wrong. In Australia, you pay a 1.5% income tax for your health care.

The Medicare Levy doesn't come anywhere near providing the revenue needed to run Medicare. 16% of the national budget is allocated to Medicare. Then my home state of Western Australia has 27% of its budget also allocated to the state healthcare system. Healthcare in Australia is a complicated interplay of state and federal payments.

Public healthcare is very much paid out of general revenue. Our top tax rate starts at $180K and is 45%. Dividends and capital gains are treated as earned income. We tax the hell out of mining and petroleum royalties. There's not a lot of places for the rich to hide. We also don't maintain a military capable of taking on the two next powerful armies combined.
posted by Talez at 7:59 PM on January 7 [6 favorites]

(Sorry for being fighty above, Mitheral; since you don't seem to be the only one who read my comment that way, I guess I was just not being very clear.)
posted by koeselitz at 8:27 PM on January 7

That's a great incentive....provided you pay taxes that can be credited.

That's not how tax credits work. Let's say I qualify for an $800 credit and I made $0 in the last tax year and have so far, paid $0 in taxes. When I file my taxes, I still get an $800 refund. This assumes that I have the presence of mind to file and claim the credit but that's a different issue.

Um, that's exactly how nonrefundable tax credits work. What makes you think it would be a refundable tax credit?
posted by one more dead town's last parade at 8:28 PM on January 7 [2 favorites]

Some insurers raised rates but since 2009 costs have risen by the lowest rate in 50 years. The transformation of an industry as big as the American health care system is going to take a long time and be extremely frustrating.
posted by humanfont at 8:51 PM on January 7 [1 favorite]

On another note, I've seriously considered discontinuing my status as an organ donor. Recently, it occurred to me that since no insurance I've ever had covered transplants, and no insurance I'm ever likely to have will, I've never been eligible to get one and probably won't ever be (if you can't pay they won't add you to the lists). I'm sure that 95% of the donors are in the same boat as me. Maybe that's why no insurance programs cover them, so the rich can hog all of the available organs.
posted by Mitrovarr at 9:39 PM on January 7 [1 favorite]

I'd call the articles' suggested fixes some kind of Rube Goldberg contraption, but that would be an insult to Mr. Goldberg.
posted by Napoleonic Terrier at 10:03 PM on January 7

Well, you could argue Canada uses this model, but with one key twist: the customer is the state.

Doctors in Canada are running private businesses with only one customer. They are paid set fees for each service, and the market ensures they are efficient as they don't want to make half the hourly rate by taking to long. As a customer, the state's goal is to pay enough to ensure time give to patients is adequate. Doctors also pay rent and admin staff and supplies out of their income, just like any other business.

Now, look at what is less regulated in Canada, the privatized pharmaceutical industry and you will find something that plays a major role in driving our health costs up in Canada. Thanks, free market and patent protection regulations under the WTO!

The UK actually ha s socialized medicine, a different model, and as noted, both are cheaper than the US model. Oh, except for the insurance companies.

Insurance beyond basic care (ie for prescriptions and dental) is often provided by member cooperatives in Canada (and the USA) so I'm surprised he didn't mention this model, which genuinely bridges competition with social purpose, but again, with a twist where customer is also owner.
posted by chapps at 10:48 PM on January 7 [1 favorite]

To add to what Talez said, the Federal Government also pings you with a medicare levy surcharge if you earn more than a certain amount depending on number of dependants etc but don't have private health coverage, as well as what they call the Lifetime Cover Loading (i.e. you pay more) if you don't have coverage by the time you're 31 or so.

They also subsidise 30% of the cost of health insurance, which has only just started to be means tested (starting, I think but not sure, at ~$85,000 for singles), and then only over the opposition of the Torries and the squealing masses of entitlement that comprises a substantial proportion of our middle and upper-middle classes.

All of this, except the means testing, was introduced by the previous Liberal-National Coalition, who hate red tape, excessive bureaucracy, and needlessly complex regulations; apparently.
posted by Hello, I'm David McGahan at 11:02 PM on January 7

Re NHS dentistry: the focus of UK dentistry is HEALTHY teeth, not cosmetic teeth, which seems to confuse US people.
In some societies, only teeth that are filed to points are acceptable, in others (like the US) only teeth that are forced into a regular curve are seen as good. Neither criteria are used in the UK.

Also, dentistry is free for kids under 18. Over that, even NHS patients have to pay.
posted by Summer at 3:16 AM on January 8

What is the easiest trick to lowering a price?

Volume discounts. This is one reason why single payer can beat down costs, because they basically *dictate* costs -- as long as they don't dictate a cost that will result in no fulfillment.

This is one of the reasons why group coverage through an employer is cheaper, per participant, than each participant would be in the open market. Single payer also has the advantage that you can't isolate the worst risks, condemning them to lack of resources, while profiting off the best risks. When that single payer is not in the business for profit, then suddenly, the profit motive is no longer important to it, but you can bet the cost motive is.

This is why when the GOP extended Medicare for seniors (Part D) they were *very* careful to put in provision that Medicare could not negotiate volume discounts with drug manufacturers. Why? Because the VA, for example, was paying $780 for a year's supply of Lipitor 20mg, and Medicare was paying $1120 and $1340, and the drug manufacturers knew that the vastly larger Medicare population would be able to negotiate even cheaper discounts. So, they made sure that Medicare couldn't.

Plus, Medicare cannot imposes a standard formulary, the Part D insurers do that, they all do it differently, and many times you find that generics aren't on the formulary (and thus, completely uncovered) while vastly more expensive name brands are. The VA does impose the formulary, and amazingly enough, they pay vastly less for the exact same drugs

So, amusingly enough, this plan wants to throw away that power to negotiate lower prices by grouping. Hmmm. Where's the market leverage there? What this plan is about isn't offering healthcare to everyone. It's about making healthcare profitable, and you know, the best way to do that is to make sure the highest risk groups, and the least healthy, cannot get it unless they can pay out of pocket.
posted by eriko at 4:38 AM on January 8 [6 favorites]

Just recently I got into it with a friend of a friend on facebook about healthcare. Their suggestion to solve the healthcare crisis in the country was to offer death benefits to the family members of someone who opts out of medical care for serious illnesses, terminal or not. So say your cancer treatment would cost 400,000. If you forego treatment, you're family would receive $100,000. This person thought that would solve everything. It was insane. That kind of lack of understanding of not only how health works (you don't necessarily die without treatment but you may end up costing MORE) and the unreasonable burden on the poor old folks to just die already amazed me. We have no hopefully of changing minds if these are the things the right are thinking up.
posted by [insert clever name here] at 5:00 AM on January 8

I've lost hours and hours sorting out my health care. ... Plus, beneath it all is the nagging uncertainty that I may have made a mistake somewhere.

Don't worry, it's not only you who may have made a mistake. As compartment noted, providers' billing offices routinely make errors in submitting claims. Then you get to spend more uncompensated time trying to get the insurer and the provider to agree that your treatment was covered. Also, I've had the wonderful experience of having the insurer deny a claim for a prescribed colonoscopy, then grudgingly agree to pay it when I pressed them. I believe that was a company policy based on the idea that some profitable portion of patients would not challenge the denials.

Making insurance companies responsible for health care is a profoundly stupid system.
posted by Kirth Gerson at 5:02 AM on January 8 [6 favorites]

Um, that's exactly how nonrefundable tax credits work. What makes you think it would be a refundable tax credit?

Every tax credit I've ever gotten has worked this way so I assumed that is what "tax credit" meant. What makes you think it would be a non-refundable credit? We're both making assumptions here.

Since I now know that tax credits may or may not be refundable, I think making it a refundable tax credit would be the way to go. We'd basically be making preventive care free in a way that should be an easier sell politically.
posted by VTX at 5:46 AM on January 8

It is my understanding that the provisions of Obamacare related to lifetime limits and caps now prevent insurance companies from denying transplant coverage. Also there are a number of medical procedures that rely on donor tissues beyond just the big ticket organ transplants.
posted by humanfont at 7:01 AM on January 8

Market incentives don't work with healthcare

Over-prescribing unnecessary, risky but more profitable healthcare procedures and services would seem to be another issue with market based healthcare.

Unnecessary C-sections more common at for-profit hospitals

For-profit hospitals performing more C-sections

The analysis challenges some common assumptions about C-sections, including that wealthier women are more likely to opt for a surgical birth.
[...]
of the five hospitals in California with the highest C-section rates, four were for-profit hospitals in poorer parts of Los Angeles County, where the African-American and Hispanic populations are above the state average.

“There are factors that are attractive to hospitals in terms of training and staff and facilities,” he said. “It’s a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need.” Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.

posted by Golden Eternity at 9:00 AM on January 8 [3 favorites]

That's outrageous. How can we support a system that allows people in need of medical care to disrupt schedules, create inefficiencies, and shave profits from our valuable shareholders? Terrible!
posted by rtha at 9:49 AM on January 8

My rule of thumb for any debate regarding reforming the US healthcare system: once you're talking about economic incentives, the fight's already over.
posted by dry white toast at 10:39 AM on January 8 [1 favorite]

May I add my one cent?

Here over the Atlantic Pond, the little, sunny, amicable, Mafia Spaghetti ridden Italy has its share of healthcare problems.

A few years ago a doctor was caught ordering absolutely unnecessary, expensive, risky surgeries - quite profiteable ones (both for the doctor AND for the hospital in which he worked). The fact that c-sections are distributed like aspirins was, comparatively, a petty offence worth a scolding.

Certainly the scumbag was guilty as hell (he knew exactly and willfully did what he did), but alas, "technically" he was the one and only guilty person, but the real elephant in the room was a whole incentive system setup to convince him into "doing whatever needed" to bring cash to the company. So the system was its accomplice (altought many a lawyer would tell me that a system isn't technically a juridical person that can be brought to jail - such as, for instance, a corporation - much less one could bring to jail a "tought model") and the very system was helping raising the next batch of scumbags.

What was changed since then? Almost nothing, cosmetic changes, some charges here and there. Much theathre, much "think about the children!", not much substance.

Alas, the much publicized planned change is for the worse, disguises as a solution - what is the proposed change? privatize it all! It's also a good deal now that austerity is in full force, we'll save billions of public spending!

Sure, as if an highly privatized system has worked so well for millions of Americans, afraid of getting a toothache because that may as well cost them a fortune, too poor for routine preventive medicine, and affected by the very exploitative gambling system that would like you to believe you MUST earn your health security LOTTERY ticket, as in:

1. will the doctor be trained well and not overstressed with 24h shift (they convinced doctos it's NORMAL not to sleep regularly!! eheh ) or do I get a dude who thinks his vicodine abuse makes him Dr. House?
2. will the insurance lawyer find a loophole and leave me hanging? I don't want to die!
3. will I get the best know treatements or will I be shafted...(paying $100 to receive a service that costs $10) ?
4. will I have enough money to fight in court, assuming I don't die during the proceedings?

Fuck if you know, you don't! It's fucking Las Vegas except you don't get to fully realize you are being scammed. How to fixit ? I don't know.
posted by elpapacito at 11:18 AM on January 8 [1 favorite]

Golden Eternity: "Over-prescribing unnecessary, risky but more profitable healthcare procedures and services would seem to be another issue with market based healthcare."

Yes, and I don't think the general public knows just how awful and pervasive the money problem is in health care. For instance, I know a certain children's hospital in Texas which makes most of its money on extremely wealthy parents who have babies that likely don't have any chance at a viable life, babies that will probably die soon anyway and who, even if they live, will be in pain the rest of their lives. With the miracle of modern science and a million dollars here and there, we can actually keep them alive a bit longer at least, even though those lives will probably be torturous at best. So it pays to talk up the 'there's still a chance, and we believe every life is sacred' line whilst happily taking the money of distraught parents. From what I hear, this causes a lot of moral difficulties for doctors, who know what bullshit it is.

The money problem is amplified in certain places and in certain ways, but I don't believe there's a large hospital in the US where it isn't an issue every single day. The situation I described above isn't even simple without money involved, but the money builds it into an execrable industry.
posted by koeselitz at 12:59 PM on January 8

Surprised no one's gotten into this, and forgive me if I missed it, but:

The whole idea of "health loans" represents the financialization of health care, beyond the degree to which it's already financed (i.e. you paying by credit card, etc.).

Lenders will, of course, generate fees via these loans, and what type of interest rates are we talking about? It's the new frontier for Wall Street, a means for lenders to make money while "filling a need" which can only result in more unpayable debt, as if those saddled with huge medical bills don't already have enough of that.

The American system if screwed, period. It's not going to be fixed, it needs to be razed and reworked from the ground up but that can never happen because the vested interests will never loosen their death-grip on the system.
posted by kgasmart at 1:28 PM on January 8 [1 favorite]

To fix healthcare, turn patients into customers.

No one has ever gotten into an ambulance and said "take me to the cheapest hospital in town."
posted by monotreme at 1:44 PM on January 8 [6 favorites]

Re: Health Loans
My local hospital (the only one in the county) already does something like "health loans". When you check-out, they hand you a bill and expect full payment (they don't do payment plans anymore). If you can't swing the payment, they refer you to a local lender (not a bank, but one of those storefront "acme consumer loans" places every town has). The lender has an arrangement with the hospital to provide loans to pay-off the balance interest-free for however many months their payment scale prescribes.

Miss a payment or be late, though, and you immediately get hit with retroactive interest payments. When I had my back surgery, I believe the interest rate would have been in the 18-23% range. Maybe more. Luckily, we never missed a payment.
posted by Thorzdad at 2:18 PM on January 8 [1 favorite]

As a balm for those upset by that appalling story of Italian doctors bilking the system with unnecessary c-sections I offer you Doctor's for Fair Taxation, Canadian doctors who want to pay more tax than they already do for our system. (I love this campaign!) and the Canadian doctors who have occupied MP Olliver's office to protest cuts to services for refugee claimants.

A far cry from our history, when some doctors Doctor's campaigned against our universal system and were concerned the state would override their judgement.

(It can be done, US friends! Rooting for you up here!)
posted by chapps at 2:51 PM on January 8 [3 favorites]

I thought that these two articles were, sadly, both timely and relevant to this thread.
posted by skye.dancer at 7:32 PM on January 9 [2 favorites]