Sick Around the World
April 15, 2008 8:16 PM   Subscribe

Sick Around the World, the newest documentary piece produced by PBS's Frontline asks: "Can the U.S. learn anything from the rest of the world about how to run a health care system?" Having previously shared a Pulitzer Prize with The New York Times, and produced such quality programs as Bush's War, this should be well worth a mere hour of your time.
posted by aheckler (144 comments total) 18 users marked this as a favorite
 
A single-payer model, or something very much close to it, seems to be a common theme with successful systems.
posted by Blazecock Pileon at 8:24 PM on April 15, 2008


My guess: "apparently not".
posted by pompomtom at 8:35 PM on April 15, 2008


T.R. Reid was interviewed on our local NPR station. Apparently he's from around here. It was interesting hearing about the project from him. Especially about how much we pay here in America. and how little we get for it. Or, the role of exceptionalism in American health care. It's also interesting to note that our health care system has not plan, it just happened. After listening to the interview, I really wanted to see this documentary. The interview is at this link. Scroll down to April 11. I didn't want to link to something that would open an audio player.
posted by Eekacat at 8:41 PM on April 15, 2008


One of the aspects I'm most interested in is the regulation (in some places) that health insurance cannot be operated for profit and that claims cannot be denied. So much of the costs weighing our system down are a result of the layer of bureaucracy (pre-authorization, review for medical necessity, challenging validity of claims) that has been implemented to serve as a set of roadblocks to paying claims. I think for a long time now the cost of justifying non-payment of claims has surpassed the cost of just paying them all at the outset--not to mention the ever-growing cost that providers must bear in order to deal with those roadblocks.
posted by troybob at 8:45 PM on April 15, 2008


I think the major issue is the concept of running healthcare as a for-profit business. Adequate healthcare is a basic human right as far as I am concerned, and turning it into a profit centre is somewhat distasteful.
posted by dirtynumbangelboy at 8:46 PM on April 15, 2008 [6 favorites]


The elephant in the room, no pun intended, is that Americans are just simply getting so fat and lazy that providing universal care would mean setting the bar pretty low as far as what would be covered for all comers. Anything else would bankrupt us inside a year or two. From a business standpoint, it would make tremendous sense to cover all comers up to a certain age, say sixteen or eighteen, then provide minimum care standards via community run clinics, staffed by RN's, NP's, PA's and a doc or two at most where the least well-off could be guaranteed minimal care for chronic diseases. And in a perfect world there would be a way to differentiate between "innocent bystander" diseases like multiple sclerosis or juvenile diabetes, and self-inflicted things like obesity and smoking or alcohol related illness. If you're smoking a pack a day you shouldn't be allowed to get a free screening colonoscopy.
posted by docpops at 8:48 PM on April 15, 2008 [1 favorite]


docpops, I wish the program (which I just finished watching) delved into just what you're getting at, with regard to self-imposed health issues. I'm willing to wager that the average Japanese, German or Englishman doesn't have any fewer vices than the average American, although their levels of physical activity are probably a bit higher than ours. If it were up to me to devise a universal health care system for the US, I'd fund a lot of it through vice taxes. Booze, cigarettes, crap/fast food, heck - anything with HFCS in it gets taxed out the wazoo, such that anybody intent on taking in those things in overly regular or indecent quantities would be subsidizing a generous portion of the care they would need later in life as a result.
posted by brain cloud at 9:00 PM on April 15, 2008


docpops, you should seriously watch this documentary. From your comment it is quite obvious that you haven't, and that you have your own preconceived notions about this. You might be surprised at what you see. Quite frankly, you sound like one of the Republican defeatists that say we can never have "socialized medicine" (a misnomer) because all the fatties, smokers, and buttfuckers will make it too expensive. Not to mention the poor people and all the damn immigrants.
posted by Eekacat at 9:01 PM on April 15, 2008 [1 favorite]


Graphs: U.S. Health Stats Compared to Other Countries. Somebody did a great job on that!
posted by Mayor Curley at 9:06 PM on April 15, 2008 [1 favorite]


Oh boy. First off, I would kill for a Universal system, so take your preconceptions and fuck off. And I'm sitting here waiting for the Frontline episode to start in 25 minutes.

I work in primary care. I see first hand, every day, thirty times a day on average, how the American mentality sees health care as an entitlement that should not simply treat serious illness, but should also cover $300 toe-fungus treatment and a $2500 cranial MRI for a migraine headache. Frankly, the closest model we have to UHC is the Oregon Health Plan, and I love it. I can practice good medicine, prescribe cost-effective drugs, and I have the best scapegoat in the world when I need to tell a patient who wants a $200 round of antibiotics for their cold that their plan won't cover it and they'll get over their virus naturally.

So I may be incorrect in my earlier assumptions, and I apologize if I sound defeatist. A better way to put it might be, instead, how do you take a society like ours, capitalist, over-entitled, not prone to taking responsibility for our own health, and train them to accept real limits? I think it could be done if you have someone with the right mixture of political will and ability to inspire the population, and after one or two generations it'll be the norm, I expect.

But, and I may find myself chastened in the next two hours, someone needs to explain to me how to care for 150 million obese sedentary people on limited funds when the trend is only worsening by the year and there isn't a dollar budgeted to teach elementary age kids how to eat properly.
posted by docpops at 9:12 PM on April 15, 2008 [6 favorites]


and eekacat, the buttfuckers at least tend to go to the gym as a rule. ;)
posted by docpops at 9:14 PM on April 15, 2008 [1 favorite]


I'm still not sure how we can create national health care constitutionally. . . it's certainly not included as a dominion of the federal government (and the connection to the commerce clause is as tenuous as in US v. Lopez). We would either have to amend the constitution or do it on a state by state basis (but states could freely enter into pacts with other states as far as overlapping coverage).
posted by Lord Chancellor at 9:15 PM on April 15, 2008


Ever since the Bush's War fpp, I have been a Frontline fiend.
posted by cowbellemoo at 9:20 PM on April 15, 2008


Ever since the Bush's War fpp, I have been a Frontline fiend.

me too.
posted by docpops at 9:20 PM on April 15, 2008


MC - that's a fascinating graph. More curious is the stat(s) on CT and MRI units. What's up with all the imaging in Japan?
posted by docpops at 9:22 PM on April 15, 2008


docpops, you'll see on the show. MRIs are cheap in Japan and they love them some imaging there.
posted by brain cloud at 9:26 PM on April 15, 2008


What's up with all the imaging in Japan?

Apparently, Japanese patients love technology. MRI's for some, miniature American flags for others!
posted by Mayor Curley at 9:27 PM on April 15, 2008 [3 favorites]


Good points. That's sort of funny. I bet we hand out a shitload more Dora stickers here than they could ever dream of.
posted by docpops at 9:29 PM on April 15, 2008


I'm an American living in Taiwan and I've got to say that the health care system here is eons better than America's. Admittedly, I'm a relatively healthy young male, so I wouldn't know how, say, leukemia treatment or triple bypass surgery would be different here, but for basic care, it rocks.

I can visit any doctor or dentist I want to, the facilities are up to first-world standards of cleanliness and professionalism, I can get an appointment with any specialist within a couple of days, and whatever meds they prescribe cost tens not hundreds or thousands of dollars. For instance, I once sprained my wrist in a scooter accident one Sunday, and I literally spent US$15 to get it X-rayed and checked up on at an emergency room. When I told some Taiwanese friends about that, they told me that it was unfortunate it had happened on the weekend and therefore I had to spend so much to visit the emergency room!

The cost is so cheap and the quality of care is so good, that people here find it unfathomable when I tell them that many Americans "tough it out" when they come down with anything less than cardiac arrest. (Indeed, I bet that people's willingness to go in for preventative care is a huge factor in keeping costs down.)

Even if absolute state-of-art treatment is marginally better in the States, I'd rather have 95% of the quality and 10% of the cost here.
posted by alidarbac at 9:45 PM on April 15, 2008


...how do you take a society like ours, capitalist, over-entitled, not prone to taking responsibility for our own health, and train them to accept real limits?

This is a function of an adequate public health system, which we have all but demolished. You can't introduce it into considerations of whether health care should be provided or covered, because the factors are too vague and numerous, and the guidelines are too inexact. Each individual responds to outside factors (and the infinite combinations of them) differently, and the last thing we need is guidelines that are so nebulous as to allow an insurer to withdraw coverage on any vague technicality.

I've known bodybuilders who were considered officially "overfat" by the military because their measurements fall out of the established standard for determining body fat. Take something as inexact as the BMI (body mass index) and apply similar standards to any number of others' vices that chap your hide, and you only further divert the healthcare dollar into fighting and defending those standards rather than providing actual care.
posted by troybob at 9:45 PM on April 15, 2008 [1 favorite]


A better way to put it might be, instead, how do you take a society like ours, capitalist, over-entitled, not prone to taking responsibility for our own health, and train them to accept real limits? I think it could be done if you have someone with the right mixture of political will and ability to inspire the population, and after one or two generations it'll be the norm, I expect.

Worth repeating. The more I examine this problem, the less doubt there is in my mind that the only durable solution to this problem is a single payer system based on rational, evidence-based prioritization made by Smart Doctors, totally tearing down the private insurance system. But the crucial question is *how?* I mean, it is so incredibly depressing when you realize that reason simply doesn't seem to matter in this debate. Hell, there shouldn't even *be* a debate. When there is growing consensus among the experts, why do Americans mistrust them so much? And what exactly is it that Americans are so afraid of?

I am watching Frontline right now, so far looks interesting...
posted by Slarty Bartfast at 9:47 PM on April 15, 2008


So the credits are rolling...is there more? Because if not, that was a pretty half-hearted effort to shed light on the real problems of instituting UHC in the USA. It was more of a dignified Michael Moore set piece, frankly. Not that I didn't learn something about the systems of other countries, but the real story is right here on US soil. I would expect more from Frontline.
posted by docpops at 10:01 PM on April 15, 2008


I work in primary care. I see first hand, every day, thirty times a day on average, how the American mentality sees health care as an entitlement that should not simply treat serious illness, but should also cover $300 toe-fungus treatment and a $2500 cranial MRI for a migraine headache

Right, so what we find is that in market based systems, health care will sort of eat up costs until we can't afford it anymore. People want open MRIs, expensive medication and full body scans. They want, in my opinion, over-care and are willing to pay for it. It has nothing to do with what is rational or empirical data on health care systems and satisfaction. No is just pure emotion. Sure the 4 year old girl whose family can't afford treatment anymore just wants to get out from having to sell their house, but this is an extreme situation, the kind of things a market-based system is notoriously bad with.

I think a redesign is bad from a logistical standpoint, I think there are ways we can try fixing our current system before trying to build one from scratch. At the very least it is much more pragmatic. Develop a regulatory structure so that private insurers start acting as a de facto single payer. If people want a plasma in their room with an open MRI, or $1500 diagnostic tests on a sprained ankle, let them. Sure it'll create a tiered system where the rich (or upper-middle class) get crazy amounts of service and pay $500 for toe cream or whatever, but we already have that, don't we?

Let Mr. Suburban Small Business Owner pay $2000 so he doesn't have to wait for his shoulder surgery. Let that finance the rest of us who can wait to get it looked at, and the large majority of us who wouldn't even go in because of costs.

Oh and let's get some of those stupid patent laws overturned. If some Brazilian manufacturing plant can produce drug x at cost, let me import it. These aren't designer bags. Give patents a year and then say play ball. There I just solved our healthcare problem.
posted by geoff. at 10:11 PM on April 15, 2008


I haven't seen the FRONTLINE special yet, but my understanding is that it was to be only a glimpse at systems in place in other countries (along with a book on the subject by Reid, I believe) to dispel some of the myths and assumptions that permeate our discussions on those systems.
posted by troybob at 10:11 PM on April 15, 2008 [1 favorite]




Assuming for the moment that the government has the power to implement such a system (given the unreasonable deference the federal government has received under the "necessary and proper clause" + "general welfare" + "commerce clause" trifecta has gotten so far, this is almost a certainty), we still haven't reached the most difficult questions. The single most important aspect of such a system - preventative care - is something that people can opt out of by sheer laziness. It is not only difficult to ensure compliance (think about the size and invasiveness of the bureaucracy involved), but morally questionable to: Is is all right to condition medical care on constant supervision of a person's activities? I have a real problem with taxing people to treat another individual's self-created emphysema, for instance. Simply because we can't prove that a given stupid activity was the sole cause of a disorder in a given case doesn't mean we can't make statistically reasonable inferences. I agree the U.S. healthcare system needs massive change, but I don't think we can get there - or ought to - without a major overhaul of attitudes. This brings us back to square one, because it isn't clear the government is empowered and/or well-positioned to undertake such a role. I'll be following this thread with great interest.
posted by Inspector.Gadget at 10:32 PM on April 15, 2008


I thought it wasn't bad. It had a pretty open agenda and wasn't trying to sway anyone in any particular direction. Examining alternatives can only help. Interesting that the system that most closely parallels our own situation (Switzerland) was also the most expensive one.

I still think the more interesting question here is not what we should do, but how can we get it done here. I kept thinking while watching it, yes that's good for Taiwan but they don't have a trillion dollar insurance industry that largely dictates the terms of the health care debate. They have a government that seems to look out for the well being of the people.
posted by Slarty Bartfast at 10:40 PM on April 15, 2008 [1 favorite]


If you're smoking a pack a day you shouldn't be allowed to get a free screening colonoscopy.


Huh, interesting. I wasn't aware that smoking caused colon cancer.

but should also cover $300 toe-fungus treatment and a $2500 cranial MRI for a migraine headache

Why shouldn't it? My plan--OHIP; Ontario Health Insurance Plan--covers pretty much anything that's medically necessary.

This is the problem: you see an MRI as a cost, because you were brought up in a world where medicine is a business. Those of us who live in countries that have civilized approaches towards health care see diagnostic tools as an investment.

I'm still not sure how we can create national health care constitutionally. . . it's certainly not included as a dominion of the federal government

My understanding of the US Constitution--please, someone, correct me if I'm wrong--is that it is roughly the same as every legal system based on British common law: if it is not explicitly forbidden, it is allowed. Is proper health care forbidden by your constitution?

The more I examine this problem, the less doubt there is in my mind that the only durable solution to this problem is a single payer system based on rational, evidence-based prioritization made by Smart Doctors, totally tearing down the private insurance system.

Welcome to Canada. Enjoy your stay. Please be polite. If it's not too much trouble.

But the crucial question is *how?*

Legislators who aren't owned by lobbyists? PS, how about outlawing the whole lobby system, or at a bare minimum requiring a lobbyist registry and to-the-penny accounting of where the money flows?

When there is growing consensus among the experts, why do Americans mistrust them so much?

20+ years of media shaping public opinion in order that they distrust anyone with a college education? Seriously.. the USA is the only country in the world where 'intellectual' is used daily as an insult. Think on that.

And what exactly is it that Americans are so afraid of?

See above. It's the collision of the American Dream (which I think is a lovely, wonderful ideal) with reality; in theory anyone can be anything, but in reality, there is a minority who are smarter than the majority. That doesn't sit well with Americans (I use the term to mean the country en masse, not individuals or even large but not majority groups) for some reason.

I think there are ways we can try fixing our current system before trying to build one from scratch.

That's not possible. Your current system is predicated on health care as a profit-making enterprise, which is largely at diametric opposition to health care as, y'know, the process of making and keeping people healthy.

Let Mr. Suburban Small Business Owner pay $2000 so he doesn't have to wait for his shoulder surgery.

In advance of a person who cannot pay, but medically needs the surgery first?

Let that finance the rest of us who can wait to get it looked at, and the large majority of us who wouldn't even go in because of costs.

It won't, and thinking that it will is...well... imagine a little bit harder and yes, Timmy, you can have a pet dinosaur of your very own. That's not meant as an insult to you, just talking about how the real world works.

Oh and let's get some of those stupid patent laws overturned.

Yes. Give pharma companies X years (it'll be arbitrary no matter what, so let's say 5) to have exclusive rights, and then BAM! it's over. Let the generics in to do it at a fraction of the cost while Big Pharma finds the next anti-itching-spleen medicine.
posted by dirtynumbangelboy at 10:42 PM on April 15, 2008 [21 favorites]


The single most important aspect of such a system - preventative care - is something that people can opt out of by sheer laziness.

Yes. They do that here, too. But that's the thing: paying taxes that pay for health care means taking care of your fellow human.

Put more broadly (and yes, I know, Libertarians will argue this--let's take it as read that I understand and categorically disagree with your arguments, so no need to go on about them), we pay taxes, some of which revenue goes to helping the weaker. Logically, those who are incapable of making rational healthcare decisions are weaker in some sense. Follow that to its conclusion.

but morally questionable to: Is is all right to condition medical care on constant supervision of a person's activities?

Of course not. See the use of the word 'universal' in Universal Health Care. Doesn't matter what you did; your body is broken, we will fix it. Everyone does dumb shit and there is no way to draw the line that is fair to everyone. You smoke? No lung treatment for you. You live in a polluted city? No lung treatment for you. Wait, what?

I have a real problem with taxing people to treat another individual's self-created emphysema, for instance.

And what about treating someone for their self-created carpal tunnel? You could have been a farmer. But we won't treat you for your self-created back troubles--you could have slung fries at McDonald's.

That's the thing about truly universal health care: It is blind. You have something wrong, it will be treated, that's the end of it. Inquiring about reasons is an artefact of the health-care-for-profit mindset.

. I agree the U.S. healthcare system needs massive change, but I don't think we can get there - or ought to - without a major overhaul of attitudes

Sometimes legislation forces the attitude change. See desegregation for an admittedly imperfect example.
posted by dirtynumbangelboy at 10:53 PM on April 15, 2008 [20 favorites]


I'm still not sure how we can create national health care constitutionally

Medicare seems to have done fine. Surely there's been at least one person since 1965 to press suit that Medicare is unconstitutional.

My understanding of the US Constitution--please, someone, correct me if I'm wrong--is that it is roughly the same as every legal system based on British common law: if it is not explicitly forbidden, it is allowed.

You're almost perfectly incorrect. In principle, the federal government can't do anything unless it can point to a specific grant of authority in the constitution. In practice, you'd be astonished at the wide array of ways that the federal government regulates interstate commerce.
posted by ROU_Xenophobe at 11:01 PM on April 15, 2008


"In 2003, Americans spent an estimated US$5,635 per capita on health care, while Canadians spent US$3,003... Canada’s single-payer system, which relies on not-for-profit delivery, achieves health outcomes that are at least equal to those in the United States at two-thirds the cost." What do wealthy, educated Americans living in Canada think?
posted by Blazecock Pileon at 11:15 PM on April 15, 2008 [2 favorites]


Is is all right to condition medical care on constant supervision of a person's activities?

Why not condition the provision of government-provided emergency services on the determination that the emergency did not arise from one's stupidity or carelessness?

It's easy to cheer about moral means testing when you get to pick the criteria. The hard part is realizing how many people have moral standards you don't live up to.
posted by troybob at 11:33 PM on April 15, 2008 [2 favorites]


dirtynumbangelboy just nailed it.
I feel enriched having read those two posts.
Thank you for that.
posted by Senor Cardgage at 11:54 PM on April 15, 2008


It's easy to cheer about moral means testing when you get to pick the criteria.

Had a sports accident? Lets not cover that: those sports are just too damned dangerous. What do those people think they're doing, climbing up mountains, whizzing down the damn things and otherwise throwing their bodies about at enormous speeds -- that's a recipe for disaster.

What's that you say? Injured while travelling at 50mph in a two ton metal box that sucks up natural resources at a rate of knots and pollutes the planet? I've never heard of anything so ludicrous? Let these fuckers use public transport or bicycles if they want health care coverage. Anything else is just too damned irresponsible.

And why the hell didn't that couple have a barrage of genetic tests before they got married? That would have prevented them from having those children with their awful diseases. Now they expect the rest of us to foot the bill for their treatment, when if they'd simply been responsible about their breeding habits, none of this would have happened.

What's more, I'm 53 and I've never had a day's illness in my life. Why should I be subsidizing all of these sick people? My insurance money should be spent on therapeutic blow-jobs as a preventative medicine that will reduce my stress levels and thereby improve my mental health. Send in the team of Thai 'nurses', stat!
posted by PeterMcDermott at 12:47 AM on April 16, 2008


When I read people on AskMefi worrying about insurance premiums and medical bills and suchlike, I really find it pretty heartbreaking, and I remain baffled that people can tolerate for such a system.

I'm in the UK, where the NHS often comes in for its own fair share of criticism. But let me tell you, if they shut it down and started up the American system tomorrow, they'd have to send the government off to some kind of bunker.

I say this as a friend: Americans, you are being fucking scammed.

(And however much tax I pay to treat people who should've known better than to smoke, drink and eat themselves into oblivion, I still won't be as scammed as you are. And then I'll go and see a doctor for free, to celebrate.)
posted by so_necessary at 1:12 AM on April 16, 2008 [7 favorites]


I'm disappointed that, once again, USians trot out a bunch of issues unrelated to providing humane health care.
Just set up a single payer system and get over yourselves. Those of you opposing it have blood on your hands of those suffering without care.
If you do it even half right it will cost you less than the current arrangement, and will result in improved services for the vast majority (including those who have good insurance now).
Why do USians find this so difficult to believe - yes, everybody else in the developed world is smarter than you guys at health care. You're better at making movies and software. We use your software, why don't you guys try a sane health system?
posted by bystander at 2:56 AM on April 16, 2008 [3 favorites]


exactly. user pays health is a fucking nightmare.

these sentiments about smokers, the unhealthy etc.. are simply typical US selfishness. get over it.. you have all been brainwashed by the corporate sector that living in squalor while the wealthy sttep all over you is 'the american dream'
posted by mary8nne at 5:43 AM on April 16, 2008


It IS the American Dream - for corporations and the rich. The rest of us are just fuel.
posted by Kirth Gerson at 6:14 AM on April 16, 2008


covers pretty much anything that's medically necessary

Well, yeah, if you don't count prescriptions or vision care, both of which are necessary for me or someone I know. OHIP just doesn't cover them—you have to get private insurance.
posted by oaf at 6:38 AM on April 16, 2008


Okay, hey, I'm a middle-class-ish American living in Canada since last August, and let me tell you what I think about the healthcare system here:

it completely, utterly, awesomely fucking rocks hardcore. I never want to go back. never ever ever. Please don't make me go.
posted by the dief at 6:38 AM on April 16, 2008 [1 favorite]


USians

What does this word mean? I speak English, but it's not part of the language.
posted by oaf at 6:41 AM on April 16, 2008


Public health-care is a complex subject, most discussions are anecdotal. There are some really good academic studies that show the "socialized" systems in Europe and elsewhere will eventually bankrupt the countries - it's the same problem we have with Social Security - the population ages, lives longer - not enough young people at the bottom to support the retired folks at the top where the majority of the costs are. I'm sure there are counter-arguments to this but clearly the US has the same problem with SS.
posted by stbalbach at 6:45 AM on April 16, 2008


I wasn't aware that smoking caused colon cancer.

If it does, you're doing it wrong.

(Or something metastasized.)


The US health care issue boils down to lobbying. But, really, is there any scenario in which an industry wouldn't lobby against a complete overhaul of the status quo -- especially an overhaul with the potential to severely reduce that industry's bottom line?

The question to ask is not, "Is health care reform a good idea?," but rather, "Should corporate interests dictate public policy?" Until the latter question is answered once and for all, the former is just debate club fodder.
posted by Sys Rq at 6:53 AM on April 16, 2008


Smoking is actually a significant risk factor for colon cancer, not that that was ever the point.

user pays health is a fucking nightmare.
Who, exactly is paying then? The 'Government' is you and me. The statistic in Frontline that was pretty impressive, to me at least, was that the average premium in Switzerland for health care was $735 per month. I don't know how average incomes compare but that is a tremendous amount of money for a typical family.

I'm playing devil's advocate, for the most part. I agree with what's been stated here - we have a strong moral obligation to provide care for everyone to a basic level. Perhaps I'm just depressed over the prospects of convincing an electorate, for once, to either vote in their interest (the working poor that need this the most but who won't pass a tax increase to save their own skin) or for what is ethically sound for us as a society.

My prediction? Big Business, in all it's venality, will actually force this issue once it threatens to bankrupt them. When GE, Exxon, Walmart, etc. see how much better off they would be under a single-payer system you may actually see the rhetoric factory work to spin this as something in the best interest of the average American, hopefully in a way that doesn't hand control back to the pharmaceutical industry like they did with Medicare.
posted by docpops at 7:16 AM on April 16, 2008 [1 favorite]


Did you know that in most countries, if you get sick or hurt, you just go to the doctor?

You don't think about "am I insured for that" or "I wonder if I have my co-pay" or even worse "it's not spurting/poking through the skin/causing you mind-wrenching agony, so let's wait and see if it gets better on its own."

It's crazy, man. You should try it.
posted by seanmpuckett at 7:23 AM on April 16, 2008


Put more broadly (and yes, I know, Libertarians will argue this--let's take it as read that I understand and categorically disagree with your arguments, so no need to go on about them), we pay taxes, some of which revenue goes to helping the weaker. Logically, those who are incapable of making rational healthcare decisions are weaker in some sense. Follow that to its conclusion.

Yes, the conclusion is that the government pays, and also exerts concomitant control over your life. It will start to control more of what you eat, what you drink, where you work, whether you exercise or not, and any other risk factor that affects your health. After all, you're "weak" and can't decide for yourself.

This may or may not be a bad thing. But "paternalism" includes both kindness and control (for your own good, of course).
posted by shivohum at 7:58 AM on April 16, 2008


There are some really good academic studies that show the "socialized" systems in Europe and elsewhere will eventually bankrupt the countries

Do you have a citation? I would honestly be interested in hearing this counter argument. Most of the studies floating around the medical literature point out the cost savings right now in moving to single payer. You are the honestly the first person I have heard say that the problem is that universal health care is not sustainable in the long term. On it's face, that sounds absurd, but prove me wrong.

My prediction? Big Business, in all it's venality, will actually force this issue


Sadly, I believe docpops has it exactly right. The dollar matters much more in America than humane policy. The health care issue is a *giant* problem for big business, at a time when our economy is really headed for a crisis. It's like an anchor that slows economic growth. Himmelstein (whose study I linked above) likes to quote a GM executive who says that GM is no longer a car manufacturing company, it is a health insurance provider that manufactures cars to subsidize itself. Something like $3000 of every car sold in the US goes to pay for employees' health care. That really starts to cut into the profits of a company that is already struggling.
posted by Slarty Bartfast at 8:24 AM on April 16, 2008 [3 favorites]


It will start to control more of what you eat, what you drink, where you work, whether you exercise or not, and any other risk factor that affects your health.

ATTENTION LIBERTARIANS: NO ONE IS BUYING THIS ARGUMENT ANYMORE

Unless you mean by "control" making sure your food doesn't contain poison or that your work place won't endanger your life.
posted by Slarty Bartfast at 8:29 AM on April 16, 2008 [3 favorites]


mary8nne: user pays health is a fucking nightmare.
docpops: Who, exactly is paying then? The 'Government' is you and me.

The differences are in administrative efficiencies. How many insurance companies and copay arrangements do you have to deal with each day, docpops? How much time does dealing with that cost your practice and interfere with your ability to see patients?

Single payer, government or some other private body, as opposed to individual user payers, would replace that mess with ONE form and almost no arguments over who pays. In Canada, at least, there's a list of what's covered and what's not, so no arguments over who pays for what treatment either. How much time, money and stress would that save you as a primary care physician?

Ultimately yes, the consumer/taxpayer foots the bill, but how they foot the bill, indivially as users or collectively through a single-payer matters a huge amount, and will matter most to people exactly in your position: the health care providers. I'm surprised you don't see that immediately. It's probably the largest benefit of the single payer system.
posted by bonehead at 8:35 AM on April 16, 2008


The differences are in administrative efficiencies.

Great point. I keep forgetting that, which is odd, since it was the one thing in Frontline's piece that kept causing my jaw to hit the floor when they quoted overhead statistics.
posted by docpops at 8:40 AM on April 16, 2008


ATTENTION LIBERTARIANS: NO ONE IS BUYING THIS ARGUMENT ANYMORE

SHOUTING DOESN'T MAKE YOU MORE PERSUASIVE. IT'S GOOD FOR KINDERGARTENERS THOUGH.

Anyway, this trend is already happening, as you can see in bans on smoking and trans fats. You can see it in organ donor situations, which are not market-based (since you can't buy and sell them) & deny organs to people who are alcoholics or otherwise abuse their bodies ("weak" people).

Indeed, you can read the entire drug war as an instance of trying to protect people from themselves. And why? In large part because society pays the costs of dealing with drug addicts. Now I'm not saying that our current system is a good way of dealing with them, but you can see why they are dealt with this way. If drug addicts didn't cost society anything, no one would care what they did.

It's inevitable that when Peter bears the cost of Paul's misbehavior, Peter is going to make damn well sure that Paul doesn't misbehave. To believe anything else is wishful thinking.
posted by shivohum at 8:44 AM on April 16, 2008




ATTENTION LIBERTARIANS: NO ONE IS BUYING THIS ARGUMENT ANYMORE

SHOUTING DOESN'T MAKE YOU MORE PERSUASIVE. IT'S GOOD FOR KINDERGARTENERS THOUGH.

Reasoned argument doesn't seem to work either. You have much less "freedom" because you are tied to a massively inefficient system that is trying to deliver a service that the vast, vast majority of people in this country consider essential. If you feel that having a harder time finding trans fats is somehow stifling your right to life, liberty, and the pursuit of happiness then I just don't know what to say to you. Canadians don't seem to mind their nanny state. If you want to make a big point of it, could you do it in way that doesn't stand prevent me from helping my patients?
posted by Slarty Bartfast at 8:59 AM on April 16, 2008


Are governments models of administrative efficiency now? I must've missed the memo.
posted by ZenMasterThis at 9:01 AM on April 16, 2008


You know, for all the griping about how the only arguments against universal health care are 'straw men' and totally illegitimate, I sure see a lot of people talking about the U.S. system in ways that aren't really connected to reality and the actual feasibility of implementing solutions from different countries over here.

I think the U.S. would be great under a single-payer system, if we had implemented it in the 1940s along with the rest of Europe. Unfortunately, that's not what happened. When people talk about just picking up a single-payer system that works well in another country--which has had 50 years to build up mostly-unified social agreement about how health care should be allocated as well as the political and organizational systems necessary to let it function--and transplanting it in the U.S., they sound just about as crazy as Ron Paul when he says that he'd like to abolish the Fed. It's the blind devotion to an idea you really believe in with absolutely no attention given to the practical implications of what the results would be.

I mean, you're either talking about:

(1) nationalizing an industry that represents about one-sixth of the GDP--that's huge, and whatever your feelings about the wisdom of nationalizing entire industries, there's no way that wouldn't be extremely wrenching to the economy as a whole, and even more so if we're going to jettison huge parts of it that are 'too expensive' or enact huge rate cuts on providers to start bringing our expenditures more in line with other single-payer countries; or

(2) instituting a single-payer system set on top of our current private delivery system, and having the government just directly reimburse hospitals, doctors and pharmacies for any medically necessary treatment (which, I must point out, doesn't even have the same meaning in the context of U.S. health care as it does in the countries with single payer systems). Of course, we tried that with Medicare in the 1960s, and the result was medical inflation that was routinely twice as large as inflation in every other sector, and costs doubling about every 7 years, threatening the very existence of the program. Medicare as it exists today is pretty close to the single-payer system that advocates say will be so much cheaper than our current system--but despite very low administrative costs, it's still projected to go broke very, very soon. Administrative costs savings, no matter how large (and at most, we're talking what, 20%?), cannot somehow get us out of the bind of needing to ration care and put limits on how much care any individual receives--and we haven't been able to implement that in our one experiment with a single payer system. What makes anybody think that extending a system like Medicare to everyone will solve that fundamental problem?

It is possible to strongly believe in the goodness of a certain way of doing things without becoming blind to the fact that you can't just drop it into another country and expect it to work the same way. Hell, I love me some democracy--I vote in the freaking election here, even the tiny ones for city council--and yet recognize that there might be some problems in just invading another country and trying to institute it there, ya know? Even with the best intentions, the intentional blindness to another country's entire history and current cultural context mean that it's probably not going to end up that well.
posted by iminurmefi at 9:06 AM on April 16, 2008 [6 favorites]


Are governments models of administrative efficiency now?

You can choose what political philosphy you want to believe, but it is a fact that Americans pay three times the overhead for healthcare delivery compared with Canadians. I would not hold up our model as a paragon of efficiency as we spend more per capita on heathcare than most European states, for example.

Even if Canada is the second-worst health care provider, nanny-state and all, our system saves more than $600 per person per year. Figure 250 million insured Americains, and that's at least 1.5 trillion dollars wasted every year to systemic inefficiencies in the Americain heathcare system (for the same level of care).

How many teachers would 1.5 trillion dollars pay for?
posted by bonehead at 9:13 AM on April 16, 2008


I really appreciate your comments, iminurmefi. I absolutely agree that the idea we could implement a well functioning single payer system in the US is pretty silly, despite it making the most sense on paper. But, I think it's useful to use it as a model for what an effective system would look like and the arguments people make against it are the same arguments that stifle practical reform, so it's a good jumping off point for debate. The real problem in this country is that people refuse to accept the revolutionary idea that Smart People could sit down and devise a solution that is in the best interest in the People and instead accept their slavery to a market system that benefits the Few.

Medicare as it exists today is pretty close to the single-payer system that advocates say will be so much cheaper than our current system--but despite very low administrative costs, it's still projected to go broke very, very soon.


Obviously, because Medicare *only* insures the elderly and disabled. And *even so* it actually works pretty well and there is literally no chance that we will see it dissolved. Imagine the profits the insurance companies make on insuring the young, healthy working people used to fund the care of people who are old and sick and there you have it: single payer.
posted by Slarty Bartfast at 9:25 AM on April 16, 2008 [1 favorite]


..nationalizing an industry that represents about one-sixth of the GDP--that's huge, and whatever your feelings about the wisdom of nationalizing entire industries, there's no way that wouldn't be extremely wrenching to the economy as a whole

Sure. But consider the fact that of that 1/6 of your GDP, about 1/3* is lost to inefficiencies compared with a universal healthcare system. So, in round numbers, 5% of the US GDP is being pissed away on unnecessary healthcare costs every year. That sounds like a fairly large wrench to the economy.

*From Blazecock's earlier post.
posted by Jakey at 9:25 AM on April 16, 2008 [1 favorite]


You have much less "freedom" because you are tied to a massively inefficient system that is trying to deliver a service that the vast, vast majority of people in this country consider essential.

Yeah, maybe. I'm just pointing out that if the government is going to give everyone free health care, you can be certain there are going to be strings attached, just like every other government grant, be it public housing vouchers, welfare, or medicare.

For instance, Canada has a pretty gigantic string attached to its health care system: the fact that it's illegal to seek private medical care. That along with waiting lists for many common operations means you had better take care of yourself, because if you don't, you might be waiting a long while to get your problem fixed.
posted by shivohum at 9:26 AM on April 16, 2008


6% of US GDP ~ $ 800 M
posted by bonehead at 9:30 AM on April 16, 2008


the fact that it's illegal to seek private medical care.

I think you are talking about private insurance, the rich still can pay for private care.

That along with waiting lists for many common operations means you had better take care of yourself, because if you don't, you might be waiting a long while to get your problem fixed.

I don't think there's data to support this statement. There is very little debate that Canadian get emergency care when it is emergent (this is a entire other discussion really). But if you are suggesting that people in Canada take better care of themselves because it is a hassle to deal with the consequences of unhealthy living that doesn't sound like a bad deal.
posted by Slarty Bartfast at 10:03 AM on April 16, 2008


" In Canada, at least, there's a list of what's covered and what's not, so no arguments over who pays for what treatment
either."

Who decides this? Is it the same for everyone in Canada?
At my place of employment, I can choose between 3 different plans, each one better for a specific lifestyles (kids/no kids, existing conditions, routine healthcare, lot of emergency room visits, etc).
I rarely go to the doctor, so I have what is essentially "catastrophic" insurance and I pay a lot less per month than my coworker, whose kids are always in for checkups, shots, etc. However, if I end up with a condition that requires monthly visits, it's going to cost me a lot more. The point is, I am able to get a healthcare plan that fits me.

How does it work in Canada? Presumably, you all pay for the healthcare via taxes. Is the "healthcare tax" the same for everyone? If I don't go to the doctor, do I get a bigger tax refund the next year? What if I want a treatment that isn't covered by the national plan? Do I sneak across the border to the south or what?
posted by madajb at 10:03 AM on April 16, 2008


The real problem in this country is that people refuse to accept the revolutionary idea that Smart People could sit down and devise a solution that is in the best interest in the People and instead accept their slavery to a market system that benefits the Few.

Well, despite being a pinko liberal in most ways, I guess I'm somewhat influenced by the Hayek critique; I think that with something as large and with as many moving parts as the health care system, even men (and women!) with the intentions of angels couldn't possibly have enough information to set it up in a way that won't eventually create weird incentives and cause the system crack under pressure. (I think Medicare is in some ways a good example of this--even though reimbursement rates for different procedures are set by a small group of Very Smart People, mostly doctors, the results have been a progressive move towards over-paying certain specialities and drastically under-paying primary care and diagnosticians, which probably has something to do with the shortage of primary care docs we're seeing.)

I should clarify that I'm not against universal health care--I'm actually very pro-UHC--rather, I'm pessimistic about a single-payer system working well in the US, in particular. I think the model implemented by Massachusetts that relies on insurance companies (and the variants suggested by Obama & Clinton) are probably the best way forward. I think this precisely because of what docpops noted above:

the American mentality sees health care as an entitlement that should not simply treat serious illness, but should also cover $300 toe-fungus treatment and a $2500 cranial MRI for a migraine headache.

If single-payer would have any prayer of working in the U.S., it would have to be paired with a serious national conversation on rationing, and the limits of what it would (could) cover. We'd have to take another look at explicitly deciding to cover / not cover things based on cost effectiveness, like other single payer systems do, rather than only being guided by medical necessity, which is a somewhat taffy-like concept that can be stretched much further than our resources can. My point is, if we can't even do that for Medicare now, when it's only covering a portion of the population, what is the likelihood we'll have those tough conversations once everyone is covered and there's even more people who would balk at limits on what sort of medical care they were entitled to?
posted by iminurmefi at 10:09 AM on April 16, 2008 [2 favorites]


There are some really good academic studies that show the "socialized" systems in Europe and elsewhere will eventually bankrupt the countries - it's the same problem we have with Social Security - the population ages, lives longer - not enough young people at the bottom to support the retired folks at the top where the majority of the costs are.

Citations, please?

If the "health care funding crisis" in those countries is as bad as the "Social Security crisis" here, I'm sure there's nothing to worry about.
posted by designbot at 10:11 AM on April 16, 2008


Indeed, you can read the entire drug war as an instance of trying to protect people from themselves. And why? In large part because society pays the costs of dealing with drug addicts. Now I'm not saying that our current system is a good way of dealing with them, but you can see why they are dealt with this way. If drug addicts didn't cost society anything, no one would care what they did.

Do you seriously believe that? The WOD functions as fundraising for law enforcement, as political capital for moralistic, hypocritical politicians, and as a weapon for keeping the have-nots in their place. It only has a goal of 'protecting' anyone in its marketing. The cost society pays in violent drug-related crime so far outweighs any theoretical cost of treating addicts that it's insane to even bring up the latter. That drug-related violent crime would not exist without the WOD. People who think outlawing drugs is a good idea completely ignore the lessons of Prohibition. I understand that you don't think the WOD is necessarily good, but it really doesn't have anything to do with the cost of addiction to society.
posted by Kirth Gerson at 10:18 AM on April 16, 2008


The statistic in Frontline that was pretty impressive, to me at least, was that the average premium in Switzerland for health care was $735 per month. I don't know how average incomes compare but that is a tremendous amount of money for a typical family.

a) Switzerland is the country with the health care system most like the U.S.

b) In the U.S., "The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,100 in 2007."
posted by designbot at 10:19 AM on April 16, 2008


Who decides [what's covered]? Is it the same for everyone in Canada?

Like the US, heathcare has been delegated to the provinces in Canada. Each province has it's own plan and there's a federal one for non-provincial lands, territories and the like. Effectively there are 11 lists of "what's covered". The lists are made up by the Minsitries of Health in each province. I don't know exactly how it happens, but there's a consulting board of some sort.

Is the "healthcare tax" the same for everyone?

No. Each provice has it's own tax rate. Some are higher, like Quebec, some are lower, like Alberta.

If I don't go to the doctor, do I get a bigger tax refund the next year?

Not in Canada. Your use or lack of use of the medicare system has no effect on the taxes you pay. Risk is averaged over the whole taxpayer population in each province.

What if I want a treatment that isn't covered by the national plan? Do I sneak across the border to the south or what?

You can get extra, private insurance for things that aren't covered. Commonly these are things like private rooms in hospital, instead of 2- or 4-occupancy wards, drug plans (precription drugs are not covered in Canada), optical and dental care plans.

People can and do go to the States for "optional" treatment, no sneaking necessary. This is mostly done for things like MRIs, which are in relatively short supply north of the 49th parrallel. Non-critical surgeries with long waiting lists, like joint replacements, are another common reason to go out of the country.
posted by bonehead at 10:20 AM on April 16, 2008


USians = people from the US in internet shorthand
Americans = people from the American continent, both North and South
posted by asok at 10:32 AM on April 16, 2008


"Like the US, heathcare has been delegated to the provinces in Canada. Each province has it's own plan and there's a federal one for non-provincial lands, territories and the like. Effectively there are 11 lists of "what's covered"."

Which one is the "best"? Do people move to, say, Vancouver, because it attracts the best pediatricians?

"No. Each provice has it's own tax rate. Some are higher, like Quebec, some are lower, like Alberta."

So presumably, there must be some healthcare shopping going on up there as well.
"Man, I'd love to live in Quebec for those short MRI lines, but the taxes are just killer".
posted by madajb at 10:34 AM on April 16, 2008



If single-payer would have any prayer of working in the U.S., it would have to be paired with a serious national conversation on rationing, and the limits of what it would (could) cover. We'd have to take another look at explicitly deciding to cover / not cover things based on cost effectiveness, like other single payer systems do, rather than only being guided by medical necessity, which is a somewhat taffy-like concept that can be stretched much further than our resources can. My point is, if we can't even do that for Medicare now, when it's only covering a portion of the population, what is the likelihood we'll have those tough conversations once everyone is covered and there's even more people who would balk at limits on what sort of medical care they were entitled to?


Aha! I think we basically agree. We *do* do this with Medicare to some extent. There are specific requirements that need to be met to get certain things done. $400 toenail fungus medicine is only covered if requirements A, B, and C are met. The thing about Medicare is that you are dealing with a population that is generally more needy and there's usually fewer arguments to be made that tests aren't necessary. Chances are, that 80 year old with a headache *does* need the cranial MRI.

But what drives medical decisions in a private insurance world is totally irrational. The patient wants the MRI for their back pain *now* because *now* is when they have insurance. But if the patient knows he'll be able to get the MRI if and when he needs it, he's less likely to demand it right now when it's not going to change any management decisions.

We need to get over this fear that we're not going to be able to cover everyone. We are already covering everyone, it's just that for 40 million of us we cover them when it's at a crisis point, when things are so much more expensive and we make them and their families homeless and broke to do it.
posted by Slarty Bartfast at 10:40 AM on April 16, 2008 [1 favorite]


But consider the fact that of that 1/6 of your GDP, about 1/3* is lost to inefficiencies compared with a universal healthcare system. So, in round numbers, 5% of the US GDP is being pissed away on unnecessary healthcare costs every year.

Jakey--I think that it's a bit of a leap in several ways to assert that spending 1/3 more means that it's all being lost to inefficiencies. First and foremost, that's definitely not accounting for differences in the underlying health of the population; while I'm a bit skeptical of the OMG OBESITY EPIDEMIC WILL KILL US ALL reporting, it is true that the U.S. has a higher rate of many chronic and expensive diseases than Canada. So we might expect that even if we outsourced our health care to the Canadians (now there's outsourcing that everyone can get behind, right?) we'd still pay more.

Secondly, you should note from that link that most health care providers in Canada are not-for-profit, and in particular most hospitals are not-for-profit. That's most definitely not where we are with providers in the U.S.; the past 20 years has seen an amazing consolidation of community hospitals into hospital systems, most of which are for-profit. How would that sort of payment system work when put on top of a largely for-profit delivery system? If it needs non-profit providers to function, how would we force private hospital systems and medical practices to convert to nonprofits?

Third, I think people look at those numbers and think the 30% extra must be administrative. That's much higher than I think any serious analyst of the health care system would claim. About half of the expenditures on health care in the U.S. are already funded by the government (at the state and federal level), and we have study after study showing that the administrative costs of Medicare and Medicaid are low--below 5%. The "medical loss ratio" for most health plans is 80% in a really good year, 90 percent on average, and over 100 percent in a bad year. So, the question is, where is that money going? I mean, by any measure we're spending between 80-95% of all of it on actual medical costs. Who decides which of that is "unnecessary"?

The last one is the heart of the problem: yes, we could save money by lowering administrative costs and paperwork to some extent, but the real savings would come from lower utilization. And that's in a system where we already have millions of people without insurance, so covering them while also lowering utilization would mean cutting some health care out of the system. I'm a big believer that there are inefficiencies in treatment, and probably lots of overtreatment going on in many places that isn't necessarily leading to better outcomes. My question is, functionally and politically, how are we going to cut out some of the utilization that is happening now? Are we going to say that certain things aren't covered (and sucks to be you if you need it)? On what basis would we decide what to cover and what not to cover? Are we going to have a limit on the amount that any one person can spend on health care in a year or over a couple of years? Are we going to limit how doctors are allowed to treat certain diseases? To some extent, I feel like saying that changing the payer will magically cause doctors, hospitals, and drug companies to provide fewer services is based on some really wishful thinking.

And again, the past 40 years have shown that for whatever reason, our policymakers are not able or not willing to grapple with these questions for Medicare, which is the single-payer system that we already have*. What is it that people believe will change about that equation when we bring more people into that system, other than making it even more politically difficult to enact limits?

*I'm not counting the VA, which is more like a nationalized system, where doctors are employed by the federal government. My sense is that few people in the U.S. are calling for a truly nationalized system; most want to extend Medicare to the entire population, where a private delivery system is funded by a public source.
posted by iminurmefi at 10:43 AM on April 16, 2008


Do people move to, say, Vancouver, because it attracts the best pediatricians? So presumably, there must be some healthcare shopping going on up there as well.

Not in my experience. There's some difference between the various provincial plans, but they are similar enough that I've never, ever heard that evan as a secondary reason for relocating. The usual, jobs school and family reasons are by far more common concerns. Heathcare options usually are not a topic for discussion in Canada. It's taken as a given like having police or community wellfare.

A far more serious concern for healthcare delivery is the difference between rural/remote and urban. Getting enough doctors to move to remote locations is really hard. This isn't unique to Canada: Alaska has similar problems.
posted by bonehead at 10:48 AM on April 16, 2008


Secondly, you should note from that link that most health care providers in Canada are not-for-profit, and in particular most hospitals are not-for-profit.

That's a stretch. Hospitals are government-run, but primary care (doctors, walk-in clinics) and many diagnostic test labs are for-profit private. They just have a single rate schedule from a single insurer.
posted by bonehead at 10:51 AM on April 16, 2008


bonehead, that's from the study linked to by blazecock pileon, which has in its intro:

Although both nations continue to rely largely on private funding for drugs, they now differ substantially in both the financing and delivery of physician and hospital services. With respect to financing, Canada has virtually first-dollar, universal public coverage of hospital and physician services. With respect to delivery, not-for-profit institutions provide almost all hospital services, and large for-profit organizations are almost entirely excluded from the provision of physician services. In contrast, the United States relies on a mixture of public and private insurance to finance health care, and leaves 16% of the population without coverage. Investor-owned for-profit providers play a substantial role.

Since hospital care is a very significant driver of health care costs ($1 out of every $2 spent, as I recall, though I'd have to look up a cite for that), it's a pretty big structural difference between the two countries. Just one more reason why (in my opinion) it's somewhat problematic to assert that we could just institute a financing system like Canada and end up in the same place.
posted by iminurmefi at 10:55 AM on April 16, 2008


Yes, the conclusion is that the government pays, and also exerts concomitant control over your life. It will start to control more of what you eat, what you drink, where you work, whether you exercise or not, and any other risk factor that affects your health.

Except, you know, in every democratic polity that's ever put a single-payer or nationalized health care system into place. But apart from all of them ever, yeah, this is a real danger.

Are governments models of administrative efficiency now?

Yes, quite often. The catch is that they tend to achieve very specific kinds of efficiency that might not map onto your idea of efficiency. The US military is tremendously efficient... at moving crud from one place to another, and at minimizing US losses. It's inefficient in other ways.

In practice, large federal bureaucracies like Social Security or Medicare are generally hugely efficient in terms of overhead, relying heavily on automation and on long-term, expert employees. I'm way too fucking lazy to go look up numbers, but overhead in these agencies is way, way lower than insurance company overhead + medical-office overhead to deal with those companies.

Who decides this? Is it the same for everyone in Canada?

Bureaucrats, under the oversight of provincial parliaments. It varies from province to province with, IIRC, some confederal oversight.

How does it work in Canada?

Everyone has the same single-payer plan. Employers often provide additional private insurance for things not covered by the provincial health care system -- private rooms, prescriptions, vision, dental, etc.

Presumably, you all pay for the healthcare via taxes.

You presume wrong. Some provinces fund them entirely from the mainline tax system. Others use a mix of taxation and user premiums.

Is the "healthcare tax" the same for everyone?

There isn't generally a "healthcare tax," or if there is, it (and user premiums) are relatively small part of funding. Most funding is through the general-purpose tax system.

So, no, the tax isn't the same for everyone.

If I don't go to the doctor, do I get a bigger tax refund the next year?

No, of course not. If you don't go to the doctor, do you get your insurance premium back, or get your employer's contribution in your paycheck? Also of course not.

What if I want a treatment that isn't covered by the national plan?

There is no national plan. Only provincial plans.

If you want something not covered, you do the same thing that you would do in the States if you want something not covered by your insurance company: either you try to get in on a research project if that's relevant, or you pay out of pocket, or you do without.

In practice, the list of things that's not covered by OHIP is almost certainly smaller than the list of what your insurance company won't cover, and both will center around things like cosmetic surgery.

Canada has a pretty gigantic string attached to its health care system: the fact that it's illegal to seek private medical care.

Not fully. There are cosmetic surgeons in Canada who AFAIK are fee for service.
posted by ROU_Xenophobe at 11:00 AM on April 16, 2008


Slarty Bartfast--Yes, we probably agree in large part on most of this stuff, although I think we might have different opinions on what is driving the over-utilization of services in some places. (I'd actually be interested in hearing what you think the cause of that is--where is the wasteful spending, and what's causing it? I've been doing some research recently into medical practice variation in Medicare in different parts of the country, and some of it is really surprising and challenges my pre-conceived notions about what is going on.)

Not sure if you have access to the NEJM, but this article from 2005 talks a bit about how the U.S. is one of the last hold outs in using formal cost-effectiveness standards to determine what services to cover. I don't doubt that CMS is trying to move that way surreptitiously, by instituting a bunch of roadblocks for treatments that are not very cost-effective, but as a matter of law the Medicare program is prohibited from taking cost-effectiveness into account when determining coverage. I wonder what it would take politically for Congress to change that.
posted by iminurmefi at 11:03 AM on April 16, 2008 [1 favorite]


What is it that people believe will change about that equation when we bring more people into that system, other than making it even more politically difficult to enact limits?

You mentioned admin and also overtreatment which are both clearly big contributors (i.e. it's easier to have rational mandates like "you don't need a $100 antibiotic for a cold"). There is also the cost of drugs which might be under better control in UHC system. But I think there are a number of inefficiencies buried in a disorganized, fragmented system. For instance a young guy without health insurance might not be able to get treatment for his alcoholism but when he's brought in unconscious to the ER with hepatic encephalopathy, the system supports his month-long stay in the intensive care unit. (I'm not naive enough to say that we'll all live healthier lives if we had coverage, I'm just saying that a lot of what I deal with all day long looks like this -- surely there are some dollars that could be saved if we dealt with health proactively). I guess what I am really talking about is prevention -- not just the colonoscopies and mammograms where we can measure the costs but all of the stuff that we all know happens that is harder to quantify.
posted by Slarty Bartfast at 11:04 AM on April 16, 2008


I think the U.S. would be great under a single-payer system, if we had implemented it in the 1940s along with the rest of Europe.

One of the reasons the Switzerland and Taiwan examples in the piece are so interesting is how recently they were implemented.
posted by xod at 11:09 AM on April 16, 2008


"You presume wrong. Some provinces fund them entirely from the mainline tax system. Others use a mix of taxation and user premiums."

What is a "user premium"? Is that like a co-pay? Or a deduction from your paycheck?


"If you don't go to the doctor, do you get your insurance premium back, or get your employer's contribution in your paycheck?"

No, but I have the option of spending less in the first place because I use less of the services.
And, actually, one of the plans offered by my employer does give you a rebate if you meet certain criteria. I don't use that plan, so I'm not up on the details.

"There is no national plan. Only provincial plans."

It was previously stated that there was a Federal plan to cover the Territories, etc. Is this not accurate?

" If you want something not covered, you do the same thing that you would do in the States if you want something not covered by your insurance company: either you try to get in on a research project if that's relevant, or you pay out of pocket, or you do without."

Or, you know, get different insurance. Something I gather isn't possible in Canada.
posted by madajb at 11:13 AM on April 16, 2008


Except, you know, in every democratic polity that's ever put a single-payer or nationalized health care system into place. But apart from all of them ever, yeah, this is a real danger.

I already talked above about the fact that in Canada you can't legally seek private medical care, and how this exerts pressure on you to take care of yourself, since you may be waiting a long time for many procedures in Canada.

In France and lots of other socialized countries, work weeks are often limited to 35 hours a week. You could read that as creating a lower risk of stress-related diseases - of course, it also has problematic economic effects.

I'm sure there are other examples of countries with socialized health care managing health risk by limiting citizens' choices. I'm not saying that on balance this may not be a good thing; I'm not sure.
posted by shivohum at 11:15 AM on April 16, 2008


It's quite sad that so many in this thread hold such rigid opinions as to why the richest, most powerful nation on the planet cannot provide healthcare coverage for its citizens, while every other civilized nation on the planet provides healthcare with nary a quibble. I guess we've reached the point where we can't, as a nation, take-on any big problem anymore.

The US is being shamed and laughed at by the rest of the world over this. Seriously.

On the program last night, I was very interested in Taiwan's story. They came to universal coverage very recently. They studied the healthcare systems in developed nations worldwide and then cherry-picked the elements they felt worked best and avoided elements they felt didn't work. They didn't take anything from the US system. The Taiwan representative was very quick to dismiss the idea of taking anything from the US system.
posted by Thorzdad at 11:32 AM on April 16, 2008


It was previously stated that there was a Federal plan to cover the Territories, etc. Is this not accurate?

No it is not, however, the terrirorial Federal plan covers a little more than 100,000 people, less than 1/3 of 1% of all Canadians. A lot of people forget the North. It's a national blindspot.

Or, you know, get different insurance. Something I gather isn't possible in Canada.

Not at all! It's a very common employment benefit to get supplimental heath insurance. This is for the things not covered, I mentioned above. The two big ones for most people are dental and prescription drugs.
posted by bonehead at 11:35 AM on April 16, 2008


I was less impressed with the Swiss example when it came to the premium. $735 a month is a big chunk of change for most families. It's on-par with what a family might pay (on the low end) for private coverage here in the US. Granted, it's all you would pay for healthcare, but it's still a large lump for working families to come-up with, month-after-month.
posted by Thorzdad at 11:37 AM on April 16, 2008


It's quite sad that so many in this thread hold such rigid opinions as to why the richest, most powerful nation on the planet cannot provide healthcare coverage for its citizens, while every other civilized nation on the planet provides healthcare with nary a quibble.

I guess we differ in our interpretations. What I see is a general concensus of need and desire and agreement that UHC is sensible, with the added thrill of expansive informed dialogue that seeks to raise potential obstacles and then proceeds, hopefully, to dismantle them. Anything less is just Pollyanna-ish circle-jerkery.
posted by docpops at 11:38 AM on April 16, 2008


What's dropped out of discussion, that was a big part of the health care plans of a few years ago, is a system of insurance plus pay as you go, that is known as High Deductible Health Plan + Health Savings Account. Too bad, because this combination could be a pretty effective way of handling health care expense for the majority of the U.S. population. And it's already in place.

The HDHP is what most people think they won't like about this combination, going in. But actually, it works well for well people, and for their doctors. And it can be made to work well even for families with kids. Funding the HSA portion is a hill to climb for poor people, but unlike cafeteria plans, you only climb that hill once in your life, and you don't have to climb it all in one year. Spread out over 2 or 3 years, that $5K HSA is affordable, even for minimum wage workers; moreover, by putting people substantially in charge of their health care spending decisions, it can be tremendously empowering, for folks who, too often, get little say in most insurance systems. As it stands, HDHP + HSA is not so good for chronically ill, poor people, but if the Health Saving Account part was augmented with direct means tested tax credits, even that could be made to work, I think.

What HDHP + HSA does do, right now, is cut out about 90% of the administrative cost of providing health insurance coverage. In the big picture of U.S. health care, that would be 90% of 22% of the total cost of health care delivery, if you use the FrontLine program's figures for administrative overhead in the U.S.

That's a lot of healthcare.

In my case, it's been a big win over the last 5 years. I'm a healthy middle aged man, whose major risk factors are a past history of smoking (I quit, again, a couple years ago), a family history of diabetes, and a life long weight problem myself (I dropped a lot of weight over the course of a year, 3 years ago, and have kept 85% of it off).

In the last 3 years, I've visited my doctor 4 times. I paid $60 for each office visit, out of pocket, and there was no insurance billing. Twice, I needed prescriptions of CIPRO. Once, it cost me $121, but Walmart came in with their $4 prescription list in Florida about 2 years ago, so the last time, I paid $4 for CIPRO. So, I've paid, over 3 years, $240 + 125 = $365 for health care, and never filed an insurance claim. But, I also got to pay with pre-tax dollars, because of the HSA. I even used HSP dollars for a contact lens exam and lens purchases, although I tend not to think of vision care as health care, myself. I could have paid for flu shots with HSA dollars, but they're only $10 at the clinic, so I "forget" to do that, every year. It just seems ludicrous to file paperwork for a sawbuck. In the same way, I've used HSA dollars for some dental work, but, although I could, I don't for 6 month cleanings.

My other economic benefit is that my HDHP premiums for those three years have been, in total, an affordable $4428, or a little over $100 a month. If I were paying for traditional Blue Cross/Blue Shield PPO program insurance (at $1000 annual deductible), my premiums would be over $800 a month, and my out of pocket costs wouldn't have been substantially any smaller. In other words, on the ~$5K balance I've kept in my HSA, I've gotten a "rate of return" of about 170% annually, in the form of affordable HDHP premiums, because I've had the good fortune to stay healthy, but my exposure, even if I'd gotten deathly ill, would have maxed out at a little over $5K, at least until I hit my lifetime policy cap on my HDHP, which is something north of $500,000.

Not one cent of my money, nor one minute of my doctor's time or his staff's time has gone to insurance paperwork. Nobody made any money keeping payment records for me. My record keeping average about 12 minutes a year. My access to medical care has been same day for 1 of my 4 visits, and next day for the other 3. I have stayed out of the ER system all together. I get free screenings for diabetes, cholestorol, and such at a clinic run by one of the big hospitals here, as a "community outreach"/marketing gambit, a couple times a year. This year, I'll pay a few hundred pre-tax bucks for a well person physical, to keep my doc happy. My next colonoscopy isn't due for another 5 years.

And I have no healthcare "gate keeper;" if I wanted, I could approach, directly, any specialist or alternative care provider I felt I wanted to see. I'd ask about their pricing, as I went in, just like I do when considering car repairs. And, just as I handle car repairs, I'd have a sensible negotiation of practical alternatives, and be a participant, because I was paying, in the care planning and outcome evaluation.

If this system is broken, I'm not seeing it. But I'm also not seeing anybody give it much of a chance, primarily, I think, because everybody seems to want "first dollar" benefits from their health care plan. But that's a chimera; as the FrontLine piece demonstrated, even in mandated insurance countries like Taiwan and Japan, somebody is paying those first dollar claims, and not making anything on the transfer activity. Once you get past the idea that paying someone regularly to take money out of your pocket regularly, to hand it over to someone else, if you need it later, isn't a service worth paying for, HDHP + HSA/HSP programs make a ton of sense.
posted by paulsc at 11:46 AM on April 16, 2008 [1 favorite]


First of all, yay, we haven't had this thread for weeks!
Second, welcome back DNAB.

Finally, as a Canadian who just moved to the US - I think most Americans simply have no idea how byzantine and complex the system is here. Just choosing a goddamn HMO was ridiculous. I had 7 health plan options. 7! This is my fucking life here, not the breakfast cereal aisle. Just heal me when something breaks, OK? And I fear for my sanity if anything major ever happens - arguing with doctors, dealing with billing agents, etc. Just imagine a world where none of that exists. None of it. You phone a doctor, you make an appointment, you get diagnosed, you get treated, you move on. That's it.

Also shivohum you are pretty much exactly wrong in every assertion you make about the Canadian system. It's illegal to operate a clinic that takes both public and private money. But I can seek private care and pay whatever I want for it. Why would that be illegal? And nearly everybody with a job in Canada has supplementary insurance. And things that re not covered - like what? Really, what are you talking about? What would not be covered? Experimental cancer treatments? I doubt most HMOs cover those either. Really, I'd love to know what a HMO, PPO or EPO would cover that OHIP wouldn't. Heck, my supplementary insurance program in Ontario covered therapeutic massage and naturopaths. Cigna, Kaiser and Blue Shield don't cover those - I checked.

Anyway I decided to move to the US because I thought it would be an adventure. How times have changed when mortgage lending and medical plans constitute adventure.
posted by GuyZero at 12:00 PM on April 16, 2008


If this system is broken, I'm not seeing it.

The problem is that you basically need a college degree to navigate the system. FSAs, HDHP, PPOs - does it never strike you as being too complex? Even FSAs have a lot of overhead associated with them. And you a) are essentially self-insuring via your HSA and b) basically have zero medical expenses to speak of. Wait until you get a hernia. My brother-in-law spent a week in a hospital with a combination lung infection and hernia. He paid nothing. How far do you think that would set you back?
posted by GuyZero at 12:06 PM on April 16, 2008 [1 favorite]


What is a "user premium"?

It's a premium you pay every month. It's the equivalent of the monthly deduction for health insurance, if you have that.

Or, you know, get different insurance. Something I gather isn't possible in Canada.

Go try to find insurance that will cover the procedures that OHIP won't. I will be surprised if you find any that cover, say, cosmetic breast augmentation.

I already talked above about the fact that in Canada you can't legally seek private medical care, and how this exerts pressure on you to take care of yourself, since you may be waiting a long time for many procedures in Canada.

Yes, clearly a wait time for nonurgent procedures is just a tiny step away from jackbooted thugs dragging you to the gym and forcing you to exercise at gunpoint while you eat only twigs.

The point is that no democratic country with universal health care has ever actually done the ridiculous totalitarian things that libertarians assert will surely happen if we ever dared adopt such a system. There are no Exercise Police forcing you to jog, anywhere. There are no democratic countries where you're legally forbidden from eating sticks of butter if you want.
posted by ROU_Xenophobe at 12:13 PM on April 16, 2008 [1 favorite]


"Just imagine a world where none of that exists. None of it. You phone a doctor, you make an appointment, you get diagnosed, you get treated, you move on. That's it."

This is pretty much how my every interaction with healthcare has been my entire life.
Of course, I did have to wait to see a specialist once, but it was only about 2 weeks for a non-critical problem, so it wasn't a big deal.
posted by madajb at 12:14 PM on April 16, 2008


" Not at all! It's a very common employment benefit to get supplimental heath insurance. This is for the things not covered, I mentioned above.
The two big ones for most people are dental and prescription drugs."

So the govt. plans only cover some drugs? Or only generics?
How much is a supplemental plan? Affordable for most Canadians?
posted by madajb at 12:16 PM on April 16, 2008


There are no Exercise Police forcing you to jog, anywhere.

Actually, yes there are. Mandatory military service in countries like Denmark, Finland, Germany, and Norway come to mind. Yes, of course they are instituted for other reasons too, but I'm sure public health benefits are on the short list of reasons of why they maintain these programs.
posted by shivohum at 12:21 PM on April 16, 2008


"... . He paid nothing. How far do you think that would set you back?"
posted by GuyZero at 3:06 PM on April 16

Catastrophically, my exposure in any year is a maximum of $5600, although my HDHP starts kicking in well below that. But those $5600 are pre-tax HSA dollars, so it's really more like $3000 "ordinary" dollars. And they're already in the bank, and earmarked. So, "out of pocket," a hernia is no additional hit to me, same as your brother-in-law, although I do have to climb the HSA hill again in the following year, if I use it all, to stay eligible for the HDHP.

And as I explained, the record keeping and claim process is dead simple. I don't know why you think it's so difficult that I'd "need a college degree to navigate the system." I pick a doctor I like, I pay him when I see him, and if I go to the hospital, I hand over my HDHP card, same as you, or your Canadian brother-in-law.

But I think your contention that your brother "paid nothing" is patently untrue, in that, even if no transaction dollars came out of his pocket at time of service, he surely pays for it in terms of higher premiums for insurance. Even in Canada, there's no free lunch.
posted by paulsc at 12:21 PM on April 16, 2008


paulsc, I remember that consumer-driven health plans were the next big thing that were going to save the system a few years ago. However, I think there's a couple of major problems with them that were never resolved:

(1) If it's truly going to save on administrative costs for all the "little" visits, then I would assume (and correct me if I'm wrong) that people paying out of pocket before they hit the deductible are not getting the lower, insurance-negotiated rate for services. Since the ability of health insurance plans to selectively contract with certain providers and extract price discounts (on the order of 50% - 60% off) in exchange for a steady stream of patients was one of the major factors in slowing health care inflation in the 1990s, I think it's worrying to move back to a system where consumers have to pay "list" price.

(2) Speaking of which, the idea that people are going to shop around and use the power of their checkbook to keep prices in check is based on the idea that information seeking is relatively low-cost. But the advent of HDHP didn't coincide with any legislative effort to mandate price transparency--not even some light consumer-protection stuff you'd expect, like mandating that hospitals provide a printed price list upon request--so the mechanism by which people are supposed to price-shop was never very clear to me.

(3) The biggest issue with HDHP as a silver bullet to eliminate waste in the health care system is the idea that the consumer - health care provider relationship obeys the traditional laws of economics, and that making patients responsible for costs would induce price competition on the part of providers. The literature on health economics has been filled since the 1970s with the various reasons why price competition never took hold; the one that seems most relevant here is that the locus of decision-making for health care expenditures doesn't lie with the patient, it lies with the provider. In fact, patients go to doctors precisely because they lack the relevant training to determine whether they need to purchase medical services, which types, and how much.

I don't doubt that consumer-driven health plans have been a good deal for you*, particularly if you're in good health. But as a systemic solution they leave much to be desired. I might be somewhat skeptical of the single-payer system as a good way to achieve UHC in the US, but I'm way more skeptical of HDHP as a solution to anything.

*Speaking of which, are you aware that HDHPs are getting a lot of criticism lately because their coverage is like swiss cheese: full o' holes? You might think that your liability is capped at $5,000, but I would be pretty shocked if that were true. Exclusions from coverage--which most people can't adequately evaluate when first buying insurance, as they cannot read the future to know what horrible disease they will catch--have really come back to bite some people in the ass. Make sure that you're as covered as you think you are.
posted by iminurmefi at 12:25 PM on April 16, 2008 [1 favorite]


But I can seek private care and pay whatever I want for it. Why would that be illegal?

According to the New York Times, "Accepting money from patients for operations they would otherwise receive free of charge in a public hospital is technically prohibited in this country, even in cases where patients would wait months or even years before receiving treatment."
posted by shivohum at 12:27 PM on April 16, 2008


The HDHP is what most people think they won't like about this combination, going in. But actually, it works well for well people, and for their doctors.

It works *ok* for you. I don't actually see how this is better for doctors since we still have to support the infrastructure that deals with everyone else's insurance. Visits with patients like you (basically healthy without any chronic diseases or acute major life changes) constitute about 10% of my visits. HSAs would be a significant barrier to care if you had even one chronic disease like diabetes unless you had a back up system in place for those patients. I do have to concede, I think about going to a cash out of pocket practice all the time. I can almost provide primary care for what insurance copays are now.

(One could also argue about the relative advantages/disadvantages of putting the patients' in charge of medical decision making. You and I probably do fine. But Joe Sixpack? Remember, ultimately no one is going to allow him to bleed to death in the street, we have to take care of everyone sooner or later, I would rather do it responsibly.)
posted by Slarty Bartfast at 12:30 PM on April 16, 2008


Actually, yes there are. Mandatory military service in countries like Denmark, Finland, Germany, and Norway come to mind. Yes, of course they are instituted for other reasons too, but I'm sure public health benefits are on the short list of reasons of why they maintain these programs.

You know, I was taking you half way seriously until this point.
posted by Slarty Bartfast at 12:32 PM on April 16, 2008


I understand that you don't think the WOD is necessarily good, but it really doesn't have anything to do with the cost of addiction to society.

Well, sure it does. The idea is that drug addicts are a weight, a burden on society. The (maybe mistaken) thought is that they are bad workers, bad drivers, bad parents, bad citizens. They injure their bodies (which needs to be paid for), are unproductive, and their judgment is screwed up. So the naive War on Drugs solution is simply to ban drugs, even if there are simpler and more cost-effective ways to address these problems.
posted by shivohum at 12:32 PM on April 16, 2008


"It's a premium you pay every month. It's the equivalent of the monthly deduction for health insurance, if you have that."

Ok. Would that be the same for every person in the plan?
posted by madajb at 12:34 PM on April 16, 2008


You know, I was taking you half way seriously until this point.

I assure you that if they bring a draft back to the US, public health will be one of the reasons for it.
posted by shivohum at 12:34 PM on April 16, 2008


(I mean the draft as a concept of mandatory military service, not necessarily going out into the field and fighting battles).
posted by shivohum at 12:35 PM on April 16, 2008


What HDHP + HSA does do, right now, is cut out about 90% of the administrative cost of providing health insurance coverage… So, I've paid, over 3 years, $240 + 125 = $365 for health care, and never filed an insurance claim… My other economic benefit is that my HDHP premiums for those three years have been, in total, an affordable $4428, or a little over $100 a month… Not one cent of my money, nor one minute of my doctor's time or his staff's time has gone to insurance paperwork. Nobody made any money keeping payment records for me.

It's a bit disingenuous to not include your premiums in the amount you've spent on health care. If you'd had the $800/month insurance, I'm sure you would have spent even less out-of pocket. That's a minor point, though.

I'm looking into HSA's myself, so I'm genuinely curious: isn't an HDHP still just a regular insurance plan with a high deductible? How does that cut out 90% of the administrative costs? If your insurance wasn't involved at all when you visited the doctor, how would they know when you met the deductible? How would you get the reduced rate of services that doctors provide to people with insurance?
posted by designbot at 12:37 PM on April 16, 2008


"... Make sure that you're as covered as you think you are."
posted by iminurmefi at 3:25 PM on April 16

I have. I am. :-) And I'd try to feel stupider in the future about going to the doctor, if there were any benefit in it, but there isn't, so for the foreseeable future, I'll just keep asking good men in white coats cost/benefit questions, and remind them that its me that is paying, and watch them smile, and put down their charts for a minute, and be surprisingly candid with me. It's that candor I'd miss most I think, if I went back to a PPO or HMO plan.

In point of fact, on going oversight and terms management are issues for all health care plans, aren't they? According to FrontLine, in Taiwan, they're borrowing from banks to keep their system afloat, while they debate price adjustments to raise enough revenue to cover the operating deficit. In Japan, more than 50% of hospitals are in the red. And in Germany, doctors are demonstrating for more money in the streets of Berlin.

Health care insurance and payment take constant vigilance, just like cars need oil changes.

But thanks for your concern.
posted by paulsc at 12:39 PM on April 16, 2008


According to FrontLine, in Taiwan, they're borrowing from banks to keep their system afloat, while they debate price adjustments to raise enough revenue to cover the operating deficit. In Japan, more than 50% of hospitals are in the red. And in Germany, doctors are demonstrating for more money in the streets of Berlin.

And in the US, we don't even get to debate what we're willing to pay for.
posted by Slarty Bartfast at 12:47 PM on April 16, 2008


"... How does that cut out 90% of the administrative costs? If your insurance wasn't involved at all when you visited the doctor, how would they know when you met the deductible? How would you get the reduced rate of services that doctors provide to people with insurance?"
posted by designbot at 3:37 PM on April 16

It cuts out administrative costs, because 90% of well people, in any given year, never file a HDHP claim, period. They operate, as I do, out of their HSA. They are self-funding their well care with pre-tax dollars. Thats a 19 to 40% built-in "discount" on services you never even have to ask for. But you're free to ask for discounts, and most billing offices give you similar rates as they give insurers. There's a lot of service you get with a smile when you pay cash :-).

As for "knowing when you've met the deductible," that's not a big thing to take care of, and most people do it themselves, as I do. In 12 minutes a year, I can drop my receipts and HSA claims in a folder, and if it gets to deductible time, pull 'em out and mail copies to the HDHP, with new claims that will exceed it.
posted by paulsc at 12:49 PM on April 16, 2008


An interesting discussion but it seems to be the larger points are falling to the wayside:

Americans pay more for less health care than any other 'first world' country while leaving 40 million of its citizens uninsured and another 30 million under-insured. Meanwhile, another 700,000 people will be bankrupted by medical costs this year.
posted by xod at 1:05 PM on April 16, 2008 [1 favorite]


HDHP + HSA is no magic bullet. You're still tied to horrendous monthly premiums. And this is what makes healthcare unaffordable to millions in the first place. They can't afford the insurance. The promise of tax-free savings doesn't mean piss if you can't pony-up the $800+/mo. for the policy. And then there's the huge deductible. $5000 for an individual isn't unusual.
posted by Thorzdad at 1:06 PM on April 16, 2008


So the govt. plans only cover some drugs? Or only generics?

Next to none. Prescriptions are your problem.

How much is a supplemental plan? Affordable for most Canadians?

They're provided by most employers and otherwise generally very affordable.

Actually, yes there are. Mandatory military service in countries like Denmark, Finland, Germany, and Norway come to mind.

Are you high? This would be a spectacularly stupid thing to do to lower health care costs -- take a population that's almost entirely healthy, and put them in much greater danger of the single greatest risk they face: accidental trauma. Not to mention that this clever public health plan misses a few people. Such as "women." And "pacifists."

"Accepting money from patients for operations they would otherwise receive free of charge in a public hospital is technically prohibited in this country, even in cases where patients would wait months or even years before receiving treatment."

This is just a peculiarity of Canada's politics of health care. It would be more accurate to say that it's entirely legal to pay for an operation and skip the queue; you just have to hop the border to do it. The Canadian health care system has always developed with the US next door to it, so they can afford to pretend to have the same plan for everyone.
posted by ROU_Xenophobe at 1:12 PM on April 16, 2008


" So the govt. plans only cover some drugs? Or only generics?

Next to none. Prescriptions are your problem."

Interesting. I wonder how much money that would save considering that lot of Americans take drugs like candy, a lot which is covered by insurance.
posted by madajb at 1:20 PM on April 16, 2008


"... I don't actually see how this is better for doctors since we still have to support the infrastructure that deals with everyone else's insurance. Visits with patients like you (basically healthy without any chronic diseases or acute major life changes) constitute about 10% of my visits."
posted by Slarty Bartfast at 3:30 PM on April 16

Well people tend not to visit doctors much. In this case, I think we can make an exception to the correlation/causation caveat. :-) UHC systems take advantage of this, by charging them nearly the same rates as chronically ill people, children, and others with greater health care needs. In "opting out" of that, HDHP + HSA people can be said to be acting selfishly, but OTOH, our expectations of medicine are usually much lower, and we tend to actually be pretty pro-active about prophylaxis, if we can be.

But wouldn't it be great, if you never had to force another patient visit into a billing code sheet, just to practice a little medicine? Sucks for you that you can't, and have to keep billing clerks on staff to stay in business. Because of unrealistic "first dollar" expectations by most of your patients (of their health care plans), I doubt you'll ever be able, not to, even if UHC is put in place.

"... HSAs would be a significant barrier to care if you had even one chronic disease like diabetes unless you had a back up system in place for those patients. ..."

As I said when I first jumped into the thread, HDHP + HSA isn't the be all and end all, as it sits, now, for everyone. Chronic illness and truly catastrophic illness categories are neither well served in it, as it stands. A person turned into a quadriplegic early in life, by an accident, is going to outstrip any health care policy sold in America's lifetime cap, period. And chronic patients represent real challenges, that are going to take innovation from the whole system to meet, although I do think that tax credits go a long way to targeting the big, identifiable classes of chronic care issues, like diabetes, high blood pressure and cancer.

"... I do have to concede, I think about going to a cash out of pocket practice all the time. I can almost provide primary care for what insurance copays are now."

My doc says the same thing, but in Florida, with his practice located in a retirement town, 99% of his patients are Medicare/BCBS folks. I'm such an oddball in terms of payment, that the billing lady actually asked me if I wouldn't mind giving her a check, instead of cash, last time, as she'd forgotten the key to the petty cash box at home, and they were having problems with the credit card terminal, the last time they'd used it. :-) So, I generated a bit of needless paperwork for my bank, at her request...
posted by paulsc at 1:21 PM on April 16, 2008


Are you high? This would be a spectacularly stupid thing to do to lower health care costs -- take a population that's almost entirely healthy, and put them in much greater danger of the single greatest risk they face: accidental trauma. Not to mention that this clever public health plan misses a few people. Such as "women." And "pacifists."

Physical education classes in grade school also expose kids to "accidental trauma." As does recess. People still argue for those things as if they had health benefits. The risk of accidental trauma may very well be worth creating cardiovascular fitness & lifelong exercise habits.

Plus, the history of physical education in the United States is heavily tied to being fit for military service, so it doesn't seem far-fetched that the relationship holds in the other direction as well.

That women are not included is just based on history, and is anyway sometimes not the case (see Israel), while pacifists are only a small portion of the population. The point is that it certainly seems plausible that for a lot of able-bodied men, military service is the "physical education" class of adulthood (in addition to being other things).
posted by shivohum at 1:30 PM on April 16, 2008


Physical education classes in grade school also expose kids to "accidental trauma." As does recess.

Physical education classes in grade school do not employ firearms, formal hand to hand combat, large power tools and other heavy machinery, automobiles, trucks, other heavy vehicles, helicopters, military transport aircraft, or explosives.

I wonder how much money that would save considering that lot of Americans take drugs like candy, a lot which is covered by insurance.

Canadians take medication too. Most people have prescription coverage, and even if they don't prices are much lower than in the US.
posted by ROU_Xenophobe at 1:36 PM on April 16, 2008


According to the New York Times...

You'd be surprised how little control the New York Times has over Canadian health care policy. Or maybe you wouldn't - please don't take the word of an American newspaper about how the Canadian health care system works over the word of a bunch of Canadians. I know very well what is and isn't legal in Canada, moreso than the Times.

But I think your contention that your brother "paid nothing" is patently untrue, in that, even if no transaction dollars came out of his pocket at time of service, he surely pays for it in terms of higher premiums for insurance. Even in Canada, there's no free lunch.

This is true but income tax is a sunk and constant cost; he had zero incremental costs for a fairly serious health condition. And, contrary to many pundits, the tax burden of an "average" person (me!) is only marginally higher in Canada. I paid an effective rate of ~33% in Canada and I expect to pay an effective rate of ~30% in California. Well, minus mortgage tax deductions but that's a different issue. It really is a less expensive system. Move to Canada if you need to prove it to yourself. I don't know what other arguments I can make to make the point any more clear. The quality is, on average, equally good and the cost is, across the board, less.
posted by GuyZero at 1:42 PM on April 16, 2008 [1 favorite]


From the World Health Organization:

Canada:
Total expenditure on health per capita (Intl $, 2004): 3,173
Total expenditure on health as % of GDP (2004): 9.8

U.S.:
Total expenditure on health per capita (Intl $, 2004): 6,096
Total expenditure on health as % of GDP (2004): 15.4
posted by xod at 1:54 PM on April 16, 2008


We started offering an HSA/HDHP for our employees (250 of us) about 3 years ago when our insurance premiums took a big jump. We still offer the typical HMO plan and only 2 people to my knowledge have taken advantage of the HSA. I think it's a fine option for people who are inclined towards a more hands-on consumer driven approach but the fact is that most people don't seem to want to choose this kind of plan.

I'm not totally opposed to the idea that we let the market have a shot at fixing things -- people complain about bringing socialism to the US but what we have now is the furthest thing from a health plan rooted in the free market so I can't really say whether the market has failed. Personally, I don't think the market really works well for essential services but a shift away from the status quo would be welcome. I just don't think the system realizes any global benefits of HSAs unless large numbers of people are flocking to them.

So my big question with all of this is simple really: what would be palatable and achievable to the American people? I think there's a number of ways we could go here and there some examples that exist that we could choose to follow. There's no real evidence that HSAs would work and there are examples of single payer systems that do work, so I gravitate towards a single payer system.
posted by Slarty Bartfast at 1:55 PM on April 16, 2008


"Canadians take medication too. Most people have prescription coverage, and even if they don't prices are much lower than in the US."

Indeed, but the coverage is separate from the "Universal Healthcare" being touted.
I'm simply wondering how the cost of U.S. Healthcare would stack up if drug costs were removed from the equation.
posted by madajb at 1:58 PM on April 16, 2008


"... Move to Canada if you need to prove it to yourself. ..."
posted by GuyZero at 4:42 PM on April 16

Thanks, but I couldn't even visit Canada, much less move there, for anything like my (knock on wood), health care costs of the last 3 years. And, even if I get really sick, I'd never be able to afford to get well in Canada, because of HDHP + HSA. It's just never going to cost me less, tax effected, than $3,000 to move to Canada. Where, apparently, I might have to wait to get a non-strangulated hernia repaired.

Here in the U.S., for a cash customer (or an HDHP + HSA nudnik like me), it's basically next day service, at your choice of hospital...:-) But if I break my neck, in the current U.S. system, I'd be happy to emigrate. Do you think Canada will have me, and provide life long 24 hour quadriplegic services, then? Because as much as I think of Canadians as a people (and I still think what the Canadian embassy did for some Americans in Tehran years ago deserves praise, and reflects tremendous credit on you, as a people, still), I think that might be stretching Canadian hospitality, some.
posted by paulsc at 1:59 PM on April 16, 2008


"... I just don't think the system realizes any global benefits of HSAs unless large numbers of people are flocking to them. ..."
posted by Slarty Bartfast at 4:55 PM on April 16

Granted. I'm not selling any form of health insurance here, over any other. I think HSA plans run smack into 2 pervasive problems with American attitudes, as follows. First, Americans don't feel they are getting a "benefit" from any form of health care plan, unless they see "savings" on every visit. Even if they pay more, in aggregate, they go, en masse, for programs that emphasize "first dollar" features, like "low co-pays" or "low deductible."

The second problem is Americans simply aren't savers. The idea of setting aside $5K as a cash reserve earmarked for health care, and only health care, is so foriegn to so many Americans, that they can never really understand anything about what that $5K buys them, in terms of financial return, much less simple independence.

Marketing might cure the first conceptual canyon, but frankly HSA programs distribute small money, quickly, to patients. As you say, it would take a lot of happy patients before you could let your billing clerk go, and until you could, you don't see money out of HSA, as a physician. So, you're "agin 'em." Understandable. For patients, once you've got your $5K in the bank, and your HDHP in place, your "benefits" are yours, and you get them, in the form of radically lower insurance premium costs, immediately, even if you stay well. So, there's no money going into marketing these programs for other people. The folks in the back of the bus rarely hear about them, and so, since 95% of their co-workers go with HMO or PPO electives, that's what they go for, too.

That's too bad.

"There's no real evidence that HSAs would work and there are examples of single payer systems that do work, so I gravitate towards a single payer system."

They were saying the same things about revenue collection and taxes, when somebody dreamed up the IRS and income tax withholding. :-) And we seem to be really happy, now, with all that. Should single payer come to pass, as it might, I look forward to just as great a rate of success at the hands of our new healthcare overlords...
posted by paulsc at 2:22 PM on April 16, 2008 [1 favorite]


Physical education classes in grade school do not employ firearms, formal hand to hand combat, large power tools and other heavy machinery, automobiles, trucks, other heavy vehicles, helicopters, military transport aircraft, or explosives.

And these are super-duper-dangerous to train with.

A plausible story, but I don't think it's true. I took an (admittedly quick) look at unintentional mortality statistics at the World Health Organization, and it shows mortality from accidents to be seemingly uncorrelated with whether or not the country has mandatory military service. I suspect the effects of whatever dangers you're talking about are swamped by other issues.

For 1999, for the 15-24 year old age group, the following numbers show deaths from accidental poisoning, falls, fire, drowning, machinery, and firearms, per 100,000:

Some countries with mandatory military service:
Denmark - 6.2
Finland - 14.3
Norway - 5
Germany - 2.7

Some countries without mandatory military service (but with single-payer health care):
UK - 5.5
Canada - 8.4

This is not super scientific, obviously, there could be plenty of other variables intervening, and mortality from accidents is different from injury from accidents - nevertheless, it doesn't look like there's much correlation here.
posted by shivohum at 2:37 PM on April 16, 2008


Sorry, the numbers I gave are only for males.
posted by shivohum at 2:38 PM on April 16, 2008


Should single payer come to pass, as it might, I look forward to just as great a rate of success at the hands of our new healthcare overlords...

Because health insurance companies, the pharmaceuticals and their respective lobbyists would never lord themselves over anyone.

Let's face facts: Despite having the most expensive health system in the world, the United States consistently fails to achieve better health outcomes than many democracies, including all of the examples presented in the Frontline piece.
posted by xod at 2:51 PM on April 16, 2008


paulsc, if you don't mind my asking, is the $5600 pre-tax for just yourself, or for you and a spouse, or family coverage? Does your employer kick anything in?

My health expenses are pretty low if I count my out-of-pocket expenses, but I take a couple of prescription medications for allergies that are pretty cheap after my insurance picks up the majority -- $40 for three months, and another that's $10 for a couple months. My employer picks up the majority of the cost for my plan, so I kick in something in the low two digits per month on top of that for my insurance choice. I pay $15 if I go to the doctor's office.

I think presenting yourself as a cash customer, even for small doctor office visits, is an amazing stretch because you can't break personal healthcare into single-use transactions. Even if you have a few issues (or pre-existing conditions, as they might be known as), you're going to get screwed if you lose your current insurance for even a short stretch. If you're self-employed, I might be stretching here, but if you were to lose your current job, you're going to get stuck paying for COBRA coverage, which is nasty. Then you either will get another job, which may or may not offer a HDHP plan, or you'll extend COBRA, go insurance-less, or get on a government health program, all of which have possible penalties.

The point of the health insurance game -- and treating it like a game, as we do in the US -- isn't to figure out who's getting the best deal, it's how to ensure that everyone gets a reasonable deal no matter the circumstances. Just because I have amazing insurance right now and a nice employer doesn't mean I won't be out on my ass tomorrow, or that things won't switch up.
posted by mikeh at 3:13 PM on April 16, 2008 [1 favorite]


I'm not totally opposed to the idea that we let the market have a shot at fixing things...

Except it's the market that put us in this situation in the first place. Or, more precisely, a market that effectively eliminated the pesky consumer from the equation. I have no faith that allowing the insurance and medical industries free-rein to fix any of this will result in anything to the consumer's benefit.
posted by Thorzdad at 4:02 PM on April 16, 2008


"paulsc, if you don't mind my asking, is the $5600 pre-tax for just yourself, or for you and a spouse, or family coverage? Does your employer kick anything in?..."

The $5600 is the legal maximum for 2008, for an individual, such as I. $11,200 for Self and Family enrollment.

I've been self-employed for awhile, now. But even when I was working as an employee of corporations, my needs might have been as well, or better met, at lower cost to me, by HDHP + HSA. The last time I worked for a company, and carried family BCBS, my portions of the premiums were 2.5x what I pay now for my individual HDHP policy. And my employer was picking up 60% of the total premium on that PPO plan. So, together, we were paying nearly 6x what I pay, now. And, I still had $15 copay office visits, and paid a lot more than $4 for common prescription medications.
posted by paulsc at 4:41 PM on April 16, 2008


Americans = people from the American continent, both North and South

That's not what the word means in normal parlance. It means "someone from the United States of America."
posted by oaf at 4:50 PM on April 16, 2008


There isn't generally a "healthcare tax"

There is in Ontario.

I already talked above about the fact that in Canada you can't legally seek private medical care

That's not fact, it's fiction.
posted by oaf at 5:03 PM on April 16, 2008


To people from North America, "American" means someone from the USA. Europeans sometimes use the word "American" as an analogue for "European" - it denotes a multi-polity region and not a specific country to them. This, of course, is tantamount to a declaration of war to a Canadian. I have no idea what Mexicans think of it. And I'm not sure if it applies to South Americans - but I'm not sure if Estonians are European either.
posted by GuyZero at 5:04 PM on April 16, 2008


There is in Ontario.

Well, yes and no. It's only since 2004 and since it's collected with your income tax it's effectively just another provincial income tax line item. It's not like OHIP is funded solely out of this one funding source - it's a way to increase income tax without increasing income tax. OHIP gets paid out of the general coffers and is therefore funded via provincial sales tax as much as by this premium.
posted by GuyZero at 5:09 PM on April 16, 2008


I think that might be stretching Canadian hospitality, some.

Per the CIC, if you were the spouse, common-law partner or child of a Canadian resident, you would be exempt from the "excessive demands" limitation. It may also apply in practice to parents as well - heaven knows that we accept a significant number of senior citizens as new Canadians who are sponsored by their children. However yes, you would be unlikely to be allowed to immigrate as a newly minted quadriplegic. Though that isn't exactly what the main issue is.

My point was just that you seem very convinced that the system you have set up is really great when it's actually pretty awful and complicated by the standards of most developed countries. You are in fact very sick - with Stockholm syndrome.
posted by GuyZero at 5:16 PM on April 16, 2008


One last comment, that I was going to include in my previous one, and then I'm out:

I think a lot of people who have PPO style medical insurance, that lets them choose a primary care physician, and other service providers, even from within a "network," are in for a rude awakening, once it comes time to use the major medical portions of their coverage. These days, there is usually an annual family deductible, which may be something like $2500 or even $5000, which you have to meet, as a 20% match of insurance payments, after you've already paid out for any co-pay or individual deductible, before your insurance goes to 100% coverage.

This recently surprised a neighbor of mine, whose 14 year old son was in a deck building accident last Thanksgiving. The boy shattered several bones in his leg, and had a series of orthopedic operations to correct the problems. So by the end of last year, about 1/2 way through the treatment course, the family was obligated for $5,000 of the boy's hospital and physician bills. Then, 2008 rolled over, and since the boy had been sent home for Christmas and New Years, and didn't go back for his final operation until February, another annual deductible period kicked in, and they are over $5,000 on the hook for 2008 treatments. All told, they figure to be down close to $15,000 when physical therapy and outpatient follow up is all taken into consideration. Granted, they are grateful to be down only this amount, considering that the total bills for this incident are around $90,000 now, and the kid is still on crutches, in a partial weight bearing cast, with more to come.

Going to the hospital, even with "good" insurance, is a serious financial hit to most middle class American families, and one that catches many off-guard, because they don't really plan for those costs, because they don't really understand their exposure. They are looking at recovery from the homeowner's insurance policy where the kid was helping, but that is looking iffy. And $15,000 is enough of a short term hit to this family, that they're selling their boat, and not taking vacations this year, among other cost saving measures.

I relate this, only because it's an example to stack against the HPHD + HSA exposure model, that I've linked previously. As always, the devil is in the details.

On preview:

"... You are in fact very sick - with Stockholm syndrome. ..."
posted by GuyZero at 8:16 PM on April 16

Perhaps. But what struck me about the Frontline report last night was that not any of the foreign systems they looked at, was, in fact, really "working." In Japan, more than 50% of hospitals are running in financial deficit, and the government is looking for ways to keep the major institutions afloat, without greater burden to the public, if that were possible. And Japanese doctors are hardly enthusiastic about capped pay for procedure, and rising workloads coming from an aging populace. Taiwan's system has the government borrowing from banks at the moment, and looking to raise consumer contributions to fund shortfalls, because they acknowledged that they set consumer contributions so low, that there is higher demand than they anticipated. And if you visit a doctor more than 30 times in 60 days, you get a "visit" from the health service people, who are going to discourage that behavior strongly. In Germany, the wait for services is 1 to 2 weeks for non-emergency care, and doctors are picketing in the streets of Berlin on pay issues. In England, there is on-going dissatisfaction regarding wait lists for surgical procedures, and a recognized over-utilization of primary care physicians. Cosmetic procedures are rarely covered, and procedures like organ transplants are carried out at lower rates, by far, than elsewhere in the world. In Switzerland, there is mandatory enrollment (you can't opt out of the national system), and it remains a barely popular system with only a slight majority voting it in, and continuing support in polls. Plus, it's shored up by cost savings that Swiss pharma generates from foreign sales of drugs, and by medical tourism. And all of these systems, as well as Canada's, have the "pop off valve" of elective private care for private pay, without which, dissatisfactions might be higher, still.

So, I'm just saying, to call the American system terribly broken in comparison to others, is to be the pot, calling the kettle black, in some degree.
posted by paulsc at 5:59 PM on April 16, 2008


If health-care institutions in Canada that receive public money are prohibited from receiving private money in addition, how the hell would I get treated if I were sick or injured? It's not like I do anything riskier than drive on the 401, but still…
posted by oaf at 6:14 PM on April 16, 2008


You know, I'm not sure how it works with visitors. I've never known anybody from out of the country who had to go to a hospital. The provincial health program all have reciprocal agreements with the caveat that you go home for any serious treatments. Foreign students, for example, have a special health insurance program as they don't qualify for OHIP (and I assume other provincial programs). But yeah, you'd get a bill, certainly. I'm not sure how that's handled in the legislation. You probably can't go visit a regular family doctor at all - no OHIP card, no appointment. It's the #1 thing they ask for. You'd have to go to an emergency room.

HEre's the information on non-emergency care at an Ontario hospital... basically they bill you. If it's emergency care I can only assume that like the US they treat you first and bill you later.
posted by GuyZero at 6:36 PM on April 16, 2008


You'd have to go to an emergency room.

I think that's a bad idea. If I'm on vacation and I feel moderately ill, my options are an emergency room (expensive for me, increases wait times for really urgent cases) or nothing. I don't think there's anything wrong with allowing people who are ineligible for OHIP to pay for an appointment for a primary-care physician.
posted by oaf at 6:45 PM on April 16, 2008




I'm not totally opposed to the idea that we let the market have a shot at fixing things...

Except it's the market that put us in this situation in the first place.


Oh my, I didn't want to let this stand. Yes, I completely blame greedy corporations for this mess and I am all in favor of a benevolent government, as the agent of the people, orchestrating a solution. It seems that one of the barriers to real reform however is the capitalist mantra "Let the market fix the problem" and the idea that any regulation or intervention by the government is inherently evil. My point is that if you think the market will really fix things, let's really have it -- the current system isn't consumer driven at all, in fact the deck is stacked to protect the insurance companies. How many people even have a choice?

We're at the point now where providing primary care costs less than the money required to support the insurance infrastructure and it almost costs less than many patients' out of pocket costs. From my perspective as a doctor, insurance is a bad deal all the way around: my patients are pissed off, I can't provide the rational delivery of quality care, and I get to spend half the day filling out forms. A purely market based approach where cash is exchanged between me and the patients who want to see me starts to look really attractive.

I suspect that as a society, people wouldn't like this very much. As was said before, Americans are only concerned with the up front costs and not necessarily what makes sense in the long term. Prevention would get tossed out the window and ERs would fill up quickly and people would die younger.

This has been one of the most civil discussions of this issue on the blue in some time. It's been a long day and I am going home. Thank you all!

posted by Slarty Bartfast at 7:13 PM on April 16, 2008 [1 favorite]


oaf: Apologies if USians confused you, but as "Americans" really does include people outside the USA, and the topic here hinges on the difference between at least two North American countries (CA and USA) I thought it was a reasonable descriptor.
I am 100% certain if I had berated "Americans" some Canadians would have jumped up and down at being tarred with the same brush.
posted by bystander at 1:34 AM on April 17, 2008


Well, since Mexico is really "The United States of Mexico", I don't think USian is specific enough either.
posted by Lord Chancellor at 2:03 AM on April 17, 2008 [1 favorite]


Perhaps. But what struck me about the Frontline report last night was that not any of the foreign systems they looked at, was, in fact, really "working."

In the respect that there does not exist a system where everyone is happy with what they pay and the care that they receive, this is true. In any system, regardless of payment method, there has to be a trade-off between what you are willing to pay and what care you get. This is a constant ongoing debate in pretty much every country with a semblance of a healthcare system. It's a tricky balancing act, and it's not possible to get it right all the time.

So, I'm just saying, to call the American system terribly broken in comparison to others, is to be the pot, calling the kettle black, in some degree.

Well, think about it this way: Imagine the healthcare system of each of the 20 richest countries was available as a scheme in the US. You can choose which one to join. For most of them, there is very little difference in measurable health outcomes or overall cost. The overall costs also include those other folks in the neighbourhood who can't afford to pay, so if you lose your job, there's no need to panic. Sometimes you have to wait in these schemes for non-emergency treatment, but everyone gets seen sooner or later.

But one scheme is different. In this scheme, you pay anywhere between 30-50% more than the others. The measurable health outcomes are pretty much the same as the others, except in infant mortality and life expectancy, where they're actually worse. Every year, there's a 0.5-1% chance that any member of this scheme will be bankrupted by medical costs not covered by the scheme. Anyone living in the neighbourhood who cannot pay is out of the scheme. Normally that's about 20% of the folks. Better not lose your job.

Now, which of these schemes would you elect to join?
posted by Jakey at 2:44 AM on April 17, 2008 [1 favorite]


as "Americans" really does include people outside the USA

Not as native speakers of English use it, no.

You can't invent words and declare that they're valid English words. Or else you're just a cafluble.
posted by oaf at 4:39 AM on April 17, 2008


You can't invent words and declare that they're valid English words.

1. Yes, actually, you can. It's kinda how the language works.
2. USians has been in use for years, all over the fucking place.

since Mexico is really "The United States of Mexico"

Yeah... except that no, it isn't. It's Estados Unidos Mexicanos in Spanish, and, on the rare occasion that it's anglicized, United Mexican States.


/derail
posted by Sys Rq at 5:28 AM on April 17, 2008


USian is a weird combination of LOLish netspeak and people who want to appear just sooooo fucking sensitive to concerns that nobody sincerely holds. I assure you that if you wander up to a Canadian traveler in Paris or London or wherever and ask them if they're American, they're not going to say "Why yes, I am American. I am from Canada," because even unicellular organisms know that "American" in that context means "from or in the USA."

Using USian to avoid this "confusion" is like using UKian to avoid the horrible, terrible confusion that "British" might cause, and the inevitable offenses. After all, Eire is also a British Isle, so citizens of the Republic of Ireland are also British, amirite?

I am 100% certain if I had berated "Americans" some Canadians would have jumped up and down at being tarred with the same brush.

Maybe. It's the internet, and people will pretend to take umbrage at all sorts of things they don't actually give a shit about, or will even develop fake outrage at things that don't sincerely bother them. This sort of person is going to find some reason to get pissed at you no matter what you say.

The sort of person who would get huffy about it is the sort of person who gets up in arms because white immigrants from South Africa shouldn't call themselves African-American.

posted by ROU_Xenophobe at 5:47 AM on April 17, 2008


Crap.

The sort of person who would get huffy about it is the sort of person who gets up in arms because white immigrants from South Africa shouldn't call themselves African-American.... and that's like a person getting up in arms because a ground beef patty from Pittsburgh is a hamburger and not a pittsburgher like it should be
posted by ROU_Xenophobe at 5:55 AM on April 17, 2008


Yes, actually, you can. It's kinda how the language works.

No, actually, you can't. It's not how language works.

posted by oaf at 6:11 AM on April 17, 2008


Bystander said... but as "Americans" really does include people outside the USA...

Your profile says you're from Australia. Australians use the word that way. I noticed at all the time when I lived there - people would say "You're American?" and I'd reply "No, I'm from Canada". And they'd say "Right, you're American!" People from the US and Canada do not use it this way. Argue about it all you want but that's that way it is. Different people mean different things when they say American. Aussies, expect people to get upset of you insist on using it that way.
posted by GuyZero at 8:14 AM on April 17, 2008


I really dislike "USian," partly because I can't figure out how to say it in a way that's not ugly. Is it "ussian," or is it "youessian"?
posted by Kirth Gerson at 8:49 AM on April 17, 2008


Except it's the market that put us in this situation in the first place. Or, more precisely, a market that effectively eliminated the pesky consumer from the equation. I have no faith that allowing the insurance and medical industries free-rein to fix any of this will result in anything to the consumer's benefit.

The thing is, though, that there's more than one way to think about "market solutions" to health care in the U.S., and almost none of them involve just setting the market free and totally deregulating everything. Among the health economists who think that market solutions would be a better way than single payer to reform the health system, there's two distinct schools of thought on what "market competition" looks like.

One is very pro-HDHP (the position that paulsc is laying out), "consumer-driven" and focused on competition on the level of individual providers: people will search out the individual docs they like best, and insurance will recede into the background (well, relatively--they'll be less involved in utilization review and selecting providers to contract with, although they'll still administer claims above a certain level). While I understand the appeal on the individual level for healthy people and for docs who are sick of paperwork, I personally think this will lead to a bit of a mess on the systems level, as I don't see how different it is from what the U.S. had in the 1940s - 1960s, except that many more of the institutional providers have consolidated into investor-owned businesses since then. Notably absent is any discussion about how to fix the fact that a lot of people can't buy insurance for any price, no matter how much they want to, because insurance companies don't want to insure sick people.

The other "market driven" approach involves reforming and regulating insurance markets to ensure that everyone has access to insurance on equal footing--a good example is Massachusetts and their "Connector," which allows any self-employed person or uninsured person to be a member of a really huge group from across the state, which hopefully gives individuals a bit more market power vis-a-vis insurance companies--and have competition between plans for enrollees. So rather than Joe Sixpack choosing between competing doctors for the best personal physician, he'd choose between plans that offered "systems of care." Insurance companies would contract not with individual providers, but with multi-specialty groups of providers, and each group would be pretty mutually exclusive; docs wouldn't be filling out and submitting 30 different types of claims, because they'd be part of larger groups that dealt with one insurance company. This was the ideal that managed care was supposed to evolve towards; however, you really only see it for a few plans, like Kaiser or Health Partners in Minnesota or Group Health Cooperative up in Seattle. All the other HMOs started operating like every other insurance company, just with more roadblocks (requiring referrals to specialists, utilization review of drugs, etc) to discourage people from seeking 'excessive' care.

They're definitely two totally different ways to think about market solutions to health care, and one of the ironies of the past 15 years is we got stuck with a hybrid (with a bit of single payer for some groups, like Medicare) that combines some of the worst aspects of each. The approaches--single payer, "consumer driven" health care, and systems-level competition--all have drawbacks, but the worst has got to be moving only halfway towards each and mushing them together. I'm not surprised that many (most?) people have given up on any hope of the market being anything but an impediment to good care, and I think that's a shame, although I certainly understand why.
posted by iminurmefi at 9:22 AM on April 17, 2008


There are some really good academic studies that show the "socialized" systems in Europe and elsewhere will eventually bankrupt the countries

revisting this thread. this comment is so absurd!

if yo uthink about it this way: the raw health cost to a country is somewhat fixed. The type of system has little real impact on the number of peopel who are sick at any given time (it may impact on the number of people who get treatment) but lets ignore that.

So we have either:
A) a government run UHC system which is essentially Not For Profit.

B) A private health care system which provides the same services* and makes a Massive profit for its owners.

now which one is going to cost the most to the people of the country (as a whole)?

*arguably the private ones may be making profits by NOT providing services to people who otherwsie would receive treatment.
posted by mary8nne at 5:05 AM on April 25, 2008


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