Health Service Sociology
July 28, 2009 1:19 AM Subscribe

An article of an american sociologist about being sick in Europe.
posted by - (150 comments total)

This post was deleted for the following reason: Poster's Request -- goodnewsfortheinsane

Meanwhile in the US: "Keep your government hands off my medicare!"
posted by delmoi at 1:37 AM on July 28, 2009 [3 favorites]

I'm not sure what the objections will be to the type of health care depicted in the link, but I am sure somebody will make them.
The USA seems incapable of progressing on any healthcare model used internationally, presumably for nationalistic reasons. In Australia or the UK, where the 'free' health care is somewhat rationed there is the option to pay out of pocket for immediate care. Emergency or critical care is never rationed, and any use of the national system just requires the presentation of a health card.
In both systems there is the alignment of interests to delivery best quality patient care mentioned in the article.
It seems pretty straight forward to people outside the USA, I must say.
posted by bystander at 1:41 AM on July 28, 2009

After 2 years in the U.K. I still stop at the dr.'s door and want to pay my copay -- it's such a learned behavior. My first visit, I actually waited at the receptionists desk and asked "is there anything I need to do?"... she heard my accent, smiled and politely said no.
posted by sundri at 1:52 AM on July 28, 2009 [6 favorites]

The German health care system really is nice. They need more doctors, particularly in the rural areas, but it works pretty well.
posted by cmonkey at 2:07 AM on July 28, 2009

This is a badly written article, full of nothing but anecdote. He feels the need to repeat his thesis every couple paragraphs - yes, separation of payment and treatment = good.

This struck me as odd:

Nor do patients face “rationing” of services in this system–apparently, the kinds of “socialized medicine” horror stories that Americans hear so often when we start talking about health care reform are drawn primarily from models like the NHS in Britian. Based on accounts from NHS patients, doctors and British politicians, that horror seems well-founded.

Why does he feel the need to slam the UK's NHS? The two links are to an NHS doctor - who obviously cares for his patients and wants to do better - and to a politician - who is trying to milk an edge-case for his own ends. The UK actually scored higher than Germany on the list that he keeps mentioning!

Germany only made it to 12th on that list, but still–in nearly three years here, I have never heard a peep against the health care system..."

Again, selective anecdote by someone who strikes me as very uninformed on this issue but was excited enough about not having bill-collectors nag him in the German hospital that he felt the need to spin out that small observation into an entire article.
posted by vacapinta at 2:14 AM on July 28, 2009 [5 favorites]

The thing about the British NHS is (a) resources and (b) triage. During the 1980s and most of the 90s it was starved systematically of investment. When the Labour government was elected in 1997 they turned a firehose of money on the problem ... and ran into the underlying problem that a caregiving organization is labour-intensive, and the skilled labour to use the money effectively just wasn't there (after decades of starvation). The result today is a mish-mash: lots of shiny new hospitals and clinics, a pipeline that's only just beginning to deliver the extra trained professionals to make them work, and most of the surplus money going on administration (the politicians' response to not understanding why the NHS, despite a money fountain up its arse, wasn't getting healthier: more auditing).

Triage ... resources in the NHS always go to the acute emergency cases: there's no waiting list for heart attacks or strokes, you go straight to the front of any queue. This leaves folks waiting for a hernia operation or minor surgery under-prioritized compared to a system where they can wave cash for priority treatment (although you can still opt for private treatment in the UK; again, it's single-payer, not single-provider).

Finally, when hearing horror stories about the British NHS, always ask who's bearing the bad news. A large chunk of the right-wing press serve owners who are inimical to the NHS and would love to see it replaced by a private insurance system -- American style, natch. (Ditto horror stories about the EU, from the British press.) The term "self-serving agenda" needs to be checked for applicability ...
posted by cstross at 2:21 AM on July 28, 2009 [18 favorites]

You guys!

Every other healthcare system in the world is cheaper than your healthcare system. No other healthcare system is as expensive as your healthcare system. You can switch to any other healthcare system and it will cost you less money. Your healthcare system is the most expensive one in the world.

But your debate is about how much any alternative will cost. There's a serious disconnect there.

The UK NHS historically got less money than other European healthcare systems, and we have higher levels of poverty, so you should expect it to do worse than, say, the French or German healthcare system. You should probably be looking at the French one, which is about one-third cheaper than your system and is probably the best in the world.

Again, once again, your healthcare system is the most expensive of any healthcare system. Any other one is cheaper. You have a "free ride" - you can pick any healthcare system, from the best (France) to the cheap (UK) and you'll still save hundreds of billions of dollars.

Healthcare expenditure as % of GDP
posted by alasdair at 2:39 AM on July 28, 2009 [39 favorites]

Why does he feel the need to slam the UK's NHS? The two links are to an NHS doctor - who obviously cares for his patients and wants to do better - and to a politician - who is trying to milk an edge-case for his own ends. The UK actually scored higher than Germany on the list that he keeps mentioning!

He is basing his judgment on "accounts". That means the fine tabloid journalism of the UK mixed with political infighting. Notice he says patients do not "appear" to face rationing of services in Germany. Which is to say they still do but it is just less noticeable to him which suggests a particular obtuseness on his part since presumably he would have had his care rationed when he could no longer pay.

Also note that his much vaunted premise breaks down the moment there is a billing conflict. At that point the Doctor and his assistants are on the phone dealing with a bureaucracy. In this case I imagine the bill difference was in his favour. How would it have gone if it were the other way around? Would he still have felt an alignment of interests?

The NHS has it's huge flaws (undertrained staff but that is more about abysmal English academic standards across all fields, bizarre regional differences in treatment availability and phenomenally shit public relations) but I would take it any day over the German system and absolutely over the American system. It beats the Canadian standard of care that I grew up with by including the cost of medicines in the coverage and as near as I can tell the rationing is mostly intelligent and effective.
posted by srboisvert at 2:44 AM on July 28, 2009 [1 favorite]

The German healthcare system is far from perfect, but I am thankful for not having to fear going to the doctor because I won't be able to afford it. I've had a few dealings with doctors and hospitals and I was impressed with the care I was given. It has almost always relatively hassle-free.

Some friends and their older parents have had some quite serious ailments. I haven't heard of anyone being denied any required treatment. I'm not saying it doesn't happen, but I haven't heard of it. I did see a documentary a few years ago about a guy who was privately insured who was getting the run around about a cancer treatment he required. I'm not sure how it was resolved.

Germans love to bitch and complain about their healthcare system and some of it is warranted. All human-designed systems are going to have problems and deficiencies, but I think most Germans would appreciate what they have a lot more if they could experience American health care for any amount of time. Also, Germans just like to bitch.

There are many factors in my life right now that keep me here in Germany. The healthcare system is one of them. I will never entertain the idea of moving back to America if the healthcare system there doesn't get fixed.

I don't understand how people, many of them on the "christian right", can stand in the way of fixing this problem. From a christian viewpoint, it is a moral imperative to fix this. Helping the sick and downtrodden? What would Jesus do?
posted by chillmost at 2:55 AM on July 28, 2009 [1 favorite]

Notice he says patients do not "appear" to face rationing of services in Germany. Which is to say they still do but it is just less noticeable to him which suggests a particular obtuseness on his part since presumably he would have had his care rationed when he could no longer pay.

Of course, because he doesn't actually have German health insurance - he pays out of pocket for everything, which is not how the system usually functions. Rationing in that context is different from rationing of health care for people who do have German insurance, which I've never experienced or even heard about anecdotally. If you have links, please share.
posted by cmonkey at 2:57 AM on July 28, 2009

My brother is a doctor in Germany, and there absolutely is plenty of bureaucracy, it's just that it's the healthcare providers, not the patients themselves, who get to deal with it.

Nevertheless, although the German system is flawed, and relatively expensive, it's nowhere as flawed or expensive as the American one.

Also, what one has to learn about this is that there are many ways of providing for universal healthcare: from multi-payer, multi-provider healthcare with compulsory health insurance and cross-subsidies for the least well-off, like in the Benelux countries or Germany, to a single-payer, more-or-less-single-provider system, like the UK's NHS, through single-payer, multiple-provider systems like in France.
posted by Skeptic at 3:12 AM on July 28, 2009 [1 favorite]

Meanwhile in Oz we're discussing adding universal dental care to the existing universal medical and upping taxes to do it.
posted by Wolof at 3:14 AM on July 28, 2009 [5 favorites]

I don't understand how people, many of them on the "christian right", can stand in the way of fixing this problem. From a christian viewpoint, it is a moral imperative to fix this. Helping the sick and downtrodden? What would Jesus do?

The poor don't need health insurance; they can just pray for recovery. This praying is often done at Ma's beside in the ICU, as she's racking up tens of thousands of dollars in useless procedures and resuscitation efforts because "brain death" isn't in the Holy Bible. "Gawd will work a miracle." We actually heard this in a real ICU a few weeks ago.

Invoking the Bible to refute any Christian Right policy is putting the horse before the cart. "It's all in how you interpret it." Medical professionals have an particularly good view of this sort of nonsense, I'd wager.
posted by Maximian at 3:24 AM on July 28, 2009

I just translated some academic work on rationing in various health care systems, including Germany's. My understanding is that there is rationing everywhere, including Germany; here it is done largely on the doctor's individual conscience, and it is very hard to gather any data about it because rationing is strictly illegal. My own experience: I had some minor orthopedic problems recently, and asked a doctor for physiotherapy. He said physiotherapy wasn't necessary for young healthy people like me. I paid for my own physiotherapy out of pocket (20 Euros per half-hour) and I'm pretty sure it did help, but I'm also pretty sure that the doctor was right that it wasn't necessary. Still, it counts as rationing -- denying a patient beneficial care is rationing. I'm certainly not resentful about it though, and no-one with serious shit like cancer is denied necessary care.

Also I'm not sure why he neglects to mention the co-payment -- you pay 10$ for your first visit that quarter. So if you already went to the doctor once in the past three months, you don't have to pay anything. But still, they certainly have a cash register right there in the doctor's office. (It is true that they have no credit card machines.)
posted by creasy boy at 3:26 AM on July 28, 2009 [1 favorite]

Today, it looks like six pivotal centrist members of the Senate Finance Committee, who talk about some issues for a whole day (poor them! imagine how tired they must be!), have decided that, no, actually, we won't have a public option, or an employer mandate to provide coverage or subsidize it.
posted by mdonley at 3:28 AM on July 28, 2009

I can't imagine a cash register in my GPs reception.
posted by A189Nut at 3:36 AM on July 28, 2009

Why exactly is it immoral to let it slip to a patient that the care they receive costs money? Why shouldn't Americans understand that when we go to the doctor, the Medical Office Assistant, Nurse and Physician must be paid and receive benefits, there is rent for the building, equipment and supplies, medical waste to dispose of and malpractice insurance to pay. Healthcare is expensive. Provide safety nets at all levels for those who cannot afford to pay, but why create the illusion that this is a free service? Word(s) of the Day: Moral Hazard.
posted by njbradburn at 3:44 AM on July 28, 2009 [1 favorite]

We in the USA are being cheated. From one of the links in the article:

In France, the sicker you are, the more coverage you get. For people with one of 30 long-term and expensive illnesses — such as diabetes, mental illness and cancer — the government picks up 100 percent of their health care costs, including surgeries, therapies and drugs.

France has made an unusual guarantee that every cancer patient can get any drug, including the most expensive and even experimental ones that are still being tested, says Dr. Fabian Calvo, deputy director of France's National Cancer Institute. This kind of access is why the French — unlike Americans — say they are highly satisfied with their health care system, he says.

"It's a feeling of safety — that if you have a big problem, you could have access to the good therapy," Calvo says.

When compared with people in other countries, the French live longer and healthier lives. Rodwin says that's because good care starts at birth. There are months of paid job leave for mothers who work. New mothers get a child allowance. There are neighborhood health clinics for new mothers and their babies, home visits from nurses and subsidized day care.

The Cost Of Care

It's expensive to provide this kind of health care and social support. France's health care system is one of the most expensive in the world.

But it is not as expensive as the U.S. system, which is the world's most costly. The United States spends about twice as much as France on health care. In 2005, U.S. spending came to $6,400 per person. In France, it was $3,300.

To fund universal health care in France, workers are required to pay about 21 percent of their income into the national health care system. Employers pick up a little more than half of that. (French employers say these high taxes constrain their ability to hire more people.)

Americans don't pay as much in taxes. Nonetheless, they end up paying more for health care when one adds in the costs of buying insurance and the higher out-of-pocket expenses for medicine, doctors and hospitals.

[Emphasis mine].

How long will we put up with this? Insurance companies are making huge profits on our suffering and deaths. They are the problem. We should end their interference in our medical system.

There are worse things than taxes. We live with one of those things, and we don't have to.
posted by Kirth Gerson at 4:01 AM on July 28, 2009 [9 favorites]

There is a moral hazard argument. In Australia, old age pensioners (and some others) don't have to pay anything for ambulance transport - this has lead to a poster in the back of the ambulance showing a taxi and reminding people an ambulance isn't one.
Similarly, in some areas, particularly in regional areas, there are only doctors who charge a co-pay. Since the system discourages this, it requires the patient to pay 100% of the fee up front (typically $40ish) then they can claim a rebate of the scheduled fee (about $27). Because some low income people do not have $40 free they present at the hospital instead, which adds an unnecessary drag on resources.
Overall though, these quibbles are small beer compared to the costs, inequities and distortions in the USA system.
posted by bystander at 4:10 AM on July 28, 2009 [1 favorite]

"It would have been a drag in any context, but trying to get help in a foreign language, in a country that is not exactly warmly disposed toward foreigners, made the whole situation very difficult."

if she expected the doctors to go all Mengele on her, like "Sieg Heil, Frau Patient! Now please show me your proof of Arian ancestry before I can start the treatment", it's no wonder that she was pleasantly surprised.
posted by kolophon at 4:26 AM on July 28, 2009

I don't think the experiences and references of the author say what he thinks they say. He's either picked those aspects that support his suppositions and ignored anything that doesn't, or else he just hasn't done his research very well. Still, it seems like more evidence that even the misguided are coming to see that change to the current US system is inevitable, and that the move should be towards a more equitable and care-focused service.
As for the NHS-bashing in the article, it should be noted that those who have had cause to use the NHS have a significantly better perception of the state of the service than those who have not. It's a bit of a national hobby to beat on the NHS, especially in the press, and this attitude seems to have leaked abroad. But when push comes to shove, you find that any overt threat to the service is met by a level of resistance that makes Heston's "cold, dead hand" seem like a positive invitation. (Ongoing privatisation by stealth notwithstanding)
posted by Jakey at 4:28 AM on July 28, 2009 [2 favorites]

I've been living outside The United States for over a third of my adult life, and health care is one thing that concerns every expat when the subject of repatriation come up. How on earth could anyone seriously consider reverting from a fully covered European system to America's capitalism-run-amok style of "too poor to pay you die"?

I talk with my friends and family back in the states pretty regularly, and notice that any discussion of health care in general and present proposals specifically almost always includes the word "socialism" or one of it's variants, almost always as a pejorative.

I have to admit I don't fully understand why that word is used by otherwise reasonably intelligent people, except to speculate its a code word the vested interests are employing to direct necessary debate, in a direction beneficial to their interest, NOT the public's.

Recently I was talking to a friend back home about taking a position in Paris, a city that (unbeknownst to her) I've lived in several times before. She became agitated, warning me breathlessly that if I moved to Paris you might become a SOCIALIST and if that didn't happen (oh! is there a test?) you'd definitely become MORE LIBERAL.

Now she's otherwise very well educated, an RN so I don't really understand why folks are so blinkered back there when it comes to how other developed and even some developing nations approach health care. This attitude is almost not invented here, but taken to a very, very illogical extreme.

I've got a buddy in The United States now whose wife needs a liver transplant. Not because of drink or drug, but due to a well known disease she's been struggling with for years that gradually destroys the organ.

While they can get some of the operations initial costs mitigated, he's looking at ongoing fees of some $1,000 a month (possibly more?) to purchase the drugs she'll have to use the rest of her life. My otherwise very laid back friend is quietly panicking, but to understand why you've got to know what their future will look like. He already does.

The ranch they've worked all their lives to acquire will ultimately be gone. Of course before that their meagre savings will be gone. As will my buddies future prospects at just enjoying life as he approaches 60 years of age, working a second job to insure they've got the necessary funds for her medication. I bet over a sufficiently long horizon their marriage will crumble; although I hope not as I don't doubt their love for each other, but this terrible illness and her post operation life with its incessant demands will insert a major stress factor into their relationship.

I've done business, significant on the ground business in 28 countries and lived for extended periods in half a dozen developing and developed nations. I've seen how a wide cross section of other countries handle the health care question.

And something untoward is going on when some African nations treat their citizens better than America does.
posted by Mutant at 4:33 AM on July 28, 2009 [58 favorites]

"It would have been a drag in any context, but trying to get help in a foreign language, in a country that is not exactly warmly disposed toward foreigners, made the whole situation very difficult."

I noticed the same thing, and I was going to say "to be fair, she might live in Dresden for all we know", but she seems to live in Cologne of all places. I don't think you get to claim disadvantaged minority status as a fucking white American academic living in Cologne.

Also: how do you manage to have a job in Germany and not have health insurance? She must've worked really hard at that.
posted by creasy boy at 4:49 AM on July 28, 2009 [1 favorite]

Sweet Jesus, Mutant has gone socialist! ;-)
It is a source of wonder to me that even with ex-pats telling the USA the system is broken, even with the figures showing the costs are ridiculous, even with people fucking DYING because they lack insurance, there are still americans who will argue that because of some minor failing of alternative systems there is no possibility of change.
Perfect is not just the enemy of good here, it is hunting down the good so you keep living with costly, ineffective (across the population) care.
posted by bystander at 4:50 AM on July 28, 2009

If we don't get health care reform by the 2010 elections, I'm going to start voting out every single incumbent, Democrat or Republican or other. We The People want reform, we need reform, and they're there to implement solutions for us. If they can't or won't do it, then maybe someone else will.
posted by jamstigator at 5:15 AM on July 28, 2009 [1 favorite]

Interesting that due to the timing of this post it has a lot of non-US based users commenting, and a general tone that healthcare must be reformed. Even in US daylight hours there are usually only a few holdouts, but it interests me that there is such consensus from people that have experienced alternatives. But I still don't expect it will influence any change.
posted by bystander at 5:30 AM on July 28, 2009

As an American ex-pat in the UK, I could go on and on about how the healthcare here feels like a minor miracle compared to the US - and I say this as a professional who was insured to the hilt. But, I'll just link to Happy Dave's heavily favorited comment about the experience of his American wife with NHS.
posted by vacapinta at 5:41 AM on July 28, 2009

Word(s) of the Day: Moral Hazard.

Hey, guys! We here in America can't have sane healthcare. We can't have a system like every other country in the developed world. Yes, they practically all live longer, healthier lives than we do, and they pay less to boot, but we can't have that. It would be a moral hazard!
posted by dirigibleman at 5:42 AM on July 28, 2009 [1 favorite]

njbradburn - I know there are costs. It's the (excess) profit that I find difficult
posted by A189Nut at 5:45 AM on July 28, 2009

Letting people suffer and die so insurance companies can keep raking in the cash is apparently not a moral hazard. Please explain.
posted by Kirth Gerson at 5:47 AM on July 28, 2009 [1 favorite]

I can begin to get a picture from some comments here how the rest of the world, and not just those crazy, leftist countries in Europe (and of course add to that Canada and Australia) run by freedom-hating socialist regimes, must think when they read about what an unmitigated disaster our health care "system" is, and how completely unwilling we are to even think about doing anything better than what we currently have. It's unbelievable to them. It's unbelievable to me.
posted by blucevalo at 5:50 AM on July 28, 2009

Imagine a national debate as important as healthcare being orchestrated this dumbly.
posted by Fupped Duck at 5:50 AM on July 28, 2009

We'll get there eventually. I hope. Maybe.

I find the whole debate increasingly discouraging, in part because of where I work (health policy think tank kind of place), so I'm surrounded by informed, intelligent discussion and written analysis all day and then I listen to the radio on the way home, or watch the news, and see the rest of the country apparently freaking out over OMG SOCIALISM or something. The July health tracking poll we just posted (I did not write it or anything - all I did was put it up on the site) has some depressing numbers, for instance.
posted by rtha at 5:51 AM on July 28, 2009 [1 favorite]

I have a question for people from the USA. In the UK, there has been a slow shift in the NHS from being a place where sick people are treated towards being a place to prevent health problems in the first place. Is this happening where you are? I can't see insurance companies enjoying such a world...
posted by Helga-woo at 6:02 AM on July 28, 2009

I shake my head. Universal healthcare should be as controversial as oatmeal.

I've been insured all my life, with a variety of health insurance vehicles. Some good, some sucky, but I've never had to worry about getting sick.

Even though "I got mine" I still see the benefit of everyone else getting theirs.

As for those who worry about rationing, really? Your insurance company doesn't make you jump through hoops, with referrals, and second opinions and the telephone nurse holding your care in the balance?

Everything that those against Universal Healthcare in the US warn against, we already have, in spades, with our current model.
posted by Ruthless Bunny at 6:10 AM on July 28, 2009 [3 favorites]

Letting people suffer and die so insurance companies can keep raking in the cash is apparently not a moral hazard. Please explain.

"Moral Hazard," as the definition behind the link explains (and I paraphrase), is when people are insulated from the cost of something, allowing them to behave in a way in regards to that item that they might otherwise not behave if they had a real stake in the cost of the item. See bystander's comment. But I'm not disappointed that a few of you have lunged onto my "Why is it immoral?/Moral Hazard/Oh the morality! lobs. ;>
posted by njbradburn at 6:27 AM on July 28, 2009

telephone nurse holding your care in the balance

We finally got my husband health insurance last year (I still live without -- can't afford it*), and we read through all the literature they sent on how to use the stuff. They are adamant -- ADAMANT -- that we have to call them before he goes to the emergency room so they can determine the best course of action, and if we don't call first, they will refuse to cover it, no matter what the problem is. Like I am going to have the time to call them first when he's having a heart attack or some other emergency situation to see whether or not they think he should go see a doctor immediately. It's ludicrous.

And it isn't some weird plan either. It's actually not all that terrible, and it's from one of the major insurance companies, but the rules and hoops one has to jump through to use it means, he never uses it and doesn't even want to use it, so it ends up being a waste of money and there just to make sure if he does fall over with a major problem, I won't be left holding too much debt if he doesn't make it and might get to keep the house.

* We are part of that lower middle class that always seems to get screwed on health care. Too much income to make use of any of the public options or clinics and not enough money to insure both of us or just go to the doctor when we need to go. It looks like we'll be getting screwed again.
posted by Orb at 6:35 AM on July 28, 2009

njbradburn: I'm guessing many people here (at least myself) agree more with the last part of bystander's comment:

Overall though, these quibbles are small beer compared to the costs, inequities and distortions in the USA system.
posted by vacapinta at 6:35 AM on July 28, 2009

In the UK, there has been a slow shift in the NHS from being a place where sick people are treated towards being a place to prevent health problems in the first place. Is this happening where you are?

No. Our system tends to the opposite approach, since the gatekeepers of the money spent on treatment seem to believe that they might have to let more of the money get past them if they tried to keep people healthy.

I call that a moral hazard. Whether it fits some economic definition to do so is of no interest to me.
posted by Kirth Gerson at 6:42 AM on July 28, 2009

I think the good thing about the US system would be availability of specialists (I can only see a gyno on the NHS if I'm referred by a doctor) but this is only for those with money.

I've had two very bad experiences on the NHS - one of which very nearly resulted in my dying due to misdiagnosis - but that is in a lifetime as someone with a chronic health condition needing a LOT of doctor visits. What shocks me most about the US system is that contraception is not free - despite my mother's GP actually saying that 'women are a drain on the health service', what kind of capitalist country essentially causes women to have unwanted pregnancies and all the complications and costs involved because the Pill is $30 a month?
posted by mippy at 6:45 AM on July 28, 2009 [1 favorite]

This means that when you visit a doctor in Germany, the whole event is aligned around care from start to finish.

Nonsense. Just as in any other country, it's about making money, or rather, about minimizing the effort the doctor has to put into you in relation to the fixed amount of money he's getting from the insurance for treating you. The fact that you don't haggle with your doctor about money in Germany doesn't change these basic motivational structures.
(It might be different if doctors were paid for healthy patients, but this is not the case, at least not in Germany.)

"Nor do patients face “rationing” of services in this system"

Dubitable. I have been subject to private German health insurance (great) as well as in the "gesetzliche" Kasse (not so great) and I've experienced pronounced differences between the two. As a Kassenpatient (i.e. person without private insurance) it is virtually impossible to find good doctors for certain problems. You have to wait for appointments for months, Doctors send you away because they're in a rush, etc.
Also, the total separation of medical and financial stuff he describes is a thing of the past. German doctors nowadays let you pay directly at their desk for stuff that is medically advisable but not covered by insurance, and they're also trying to sell you stuff that's medically dubious but brings in cash.

Obviously these are minor flaws and the German system is not as bad as the totally crappy American system ("Help, my head fell off, do I really need to go to the doctor???"), but we're not in medical paradise here either. Many doctors are very unhappy about the changes over the last years (cost cuts which basically boil down to rationing), and many doctors think the German system is not going to work for much longer and the quality of treatment is already suffering in some areas because of rationing.

All in all, the author certainly has a point, but still the article has a strange propagandistic vibe...
posted by The Toad at 6:49 AM on July 28, 2009 [2 favorites]

Healthcare is expensive. Provide safety nets at all levels for those who cannot afford to pay, but why create the illusion that this is a free service?

Surely the same applies to policing and fire-fighting services?
posted by Kiwi at 6:50 AM on July 28, 2009 [1 favorite]

Surely the same applies to policing and fire-fighting services?
Indirectly, actually. Those are public services paid for by the our taxes (as crazy as I often come off, I'm not actually a Libertarian ;>).
posted by njbradburn at 6:58 AM on July 28, 2009

My wife and I (both Americans) have been living in the UK for the last couple of years while I've been getting my master's, and will (with any luck) be staying here for another three years or so while I do my PhD.

We're both late thirties/early forties with a pre-existing condition or two between us. Basically, if some kind of public health care doesn't get passed in America, we're not coming back.

I don't care if I have to run out the clock on residency by getting two more degrees, or if I have to fake my death, change my name to something like "Nigel Mainwaring-Smythe" and get a British passport...we're staying in a country with sane ideas about how to treat sick people.
posted by Mr. Bad Example at 6:59 AM on July 28, 2009 [2 favorites]

Re moral hazard, in any free system there will be free riders. Since no one likes to be sick (discount whichever psychiatric condition opposing this view), it's doubtful that people will get sick on purpose to get free treatment. Therefore the free riders will be unreasonable people with minor complaints or people with ailments that can be endured without having much of an effect on their quality of life. Rationing solves it.

Also, I thought that what was immoral was not giving treatment to those who can't afford it, not the part about letting them know the costs regardless of whether they're paying or not.
posted by lucia__is__dada at 7:02 AM on July 28, 2009 [1 favorite]

Do Americans have universal health care for children?

For those in the fight for health care reform in the United States, that should be the focus. Apply the wedge strategy to that, and see what results. Pick an age, any age. Free health care until you're old enough to vote. Free health care until you're old enough to drive. Free health care until you hit puberty. Free health care until you go to school. Doesn't matter which age you pick, just choose one.

Just imagine an opponent trying to argue against that. All this "too expensive" or "socialism" or "personal choice/responsibility" or "government bureaucracy" talk instantly torpedoed with a picture of some four-year-old girl with cancer. "Sure, it might mean an extra quarter off your paycheck, but don't you think little Molly here should reach her sixth birthday?" A politician running on that platform can deflect all those critics saying universal health care subsidizes poor lifestyle choices.

Who can argue against protecting the children, the youngest and most vulnerable? And once that's established, and Americans experience it firsthand, health care will go from socialist to human right pretty damned fast.
posted by GhostintheMachine at 7:04 AM on July 28, 2009 [11 favorites]

don't you think little Molly here should reach her sixth birthday?

Maybe Molly's parents should get better jobs. Welcome to the USA, where we'd rather bankrupt our own families with medical bills than treat even one poor person with dignity.
posted by uncleozzy at 7:10 AM on July 28, 2009 [15 favorites]

alasdair: Every other healthcare system in the world is cheaper than your healthcare system. No other healthcare system is as expensive as your healthcare system ... But your debate is about how much any alternative will cost. There's a serious disconnect there.

This is true. However, I'm not sure the mainstream debate is about systemic change. Particularly if the bill goes to conference without a public option, we're basically having a debate about whether to throw more money at the status quo or not.

The factor that makes NHS at all affordable is its use of salaried physicians instead of the fee-for-service system that predominates here in the US. While a handful of organizations are switching off fee for service - the Mayo Clinic, Kaiser Permanente, etc - and while our politicians treat these organizations as miracle workers, there is no serious conversation about eliminating fee-for-service and thus no serious conversation about systemic change.
posted by l33tpolicywonk at 7:19 AM on July 28, 2009 [1 favorite]

GhostintheMachine: Do Americans have universal health care for children?

Short answer: No.

Long answer: Since the late 90s, the US has a system called SCHIP through which states and the federal government pay for health care for poor children, up to 150% - 350% of poverty depending on the state (why on earth we don't just reassess our poverty benchmark is a whole nother conversation). When the Democrats regained control of the legislature in 2006, one of the first ideas on the table was expanding the program. Huge opposition from center and right wing politicians, who were concerned about the program covering the undocumented (even though they pay taxes, Americans assume all undocumented immigrants are free loaders. It's actually the other way around) and about personal responsibility, blah blah blah. It took a few years, but they finally expanded the program a little under Obama. It's an effective program, but what it doesn't take care of are the many middle-class families who are underinsured or still can't afford insurance. So, no.
posted by l33tpolicywonk at 7:26 AM on July 28, 2009

Do Americans have universal health care for children?

Some states have this, including California. Or, correction, did, before draconian budget cutting made all health care to children, poor people, and the elderly a disposable resource.
posted by blucevalo at 7:27 AM on July 28, 2009

For those in the fight for health care reform in the United States, that should be the focus. Apply the wedge strategy to that, and see what results.

Those advocating a wedge strategy should look at Medicare and Medicaid.
posted by vacapinta at 7:30 AM on July 28, 2009

The US opposition to state-funded health care seems to be rooted in the sort of punitive Calvinist belief system that holds that prosperity is a virtue, failure a moral failing, and that the greatest sin is to take something one is not entitled to. This was well documented in Joe Bageant's "Deer Hunting With Jesus".
posted by acb at 7:32 AM on July 28, 2009 [3 favorites]

Here in the UK, people are fairly realistic about the NHS. We know it has problems and limitations and could always be better. We grumble, pontificate and sometimes suffer. It's like talking about the weather, except we can blame politicians.

But there's also a strong awareness of how it could be an awful lot worse, with our nightmare scenario closely matching the US system. And we shake our heads in dismay and pity when Americans throw around terms like "socialised medicine" or claim you can't afford to care for the poor.
posted by malevolent at 7:40 AM on July 28, 2009

But it is not as expensive as the U.S. system, which is the world's most costly. The United States spends about twice as much as France on health care. In 2005, U.S. spending came to $6,400 per person. In France, it was $3,300.

To fund universal health care in France, workers are required to pay about 21 percent of their income into the national health care system. Employers pick up a little more than half of that. (French employers say these high taxes constrain their ability to hire more people.)

I don't see how both of these paragraphs from the article quoted in this comment can be true.

How can France spend only $3300 per person, but workers have to pay 21% of their income? The average income in France is almost $25,000. 21% percent of that is $5250. So, the average worker is already paying almost 60% more than what the country is spending on them?

Something is very wrong with everyone's numbers, possibly including mine.

We apparently have considerably fewer doctors per capita than all of the countries whose healthcare system ours is usually compared against. Likewise, the US has considerably fewer hospital beds.

That suggests that the problem is in fact a very simple one with a simple Economics 101 solution - increase the supply of doctors and hospital beds and the price will fall. That's basic economics.

But that begs the question why we have so few doctors and hospital beds in the first place. Is it really so difficult to get into medical school? Or is the process so expensive and arduous that people decide to do something else? How difficult is it to be come a doctor in France? How many years of college and medical school. In the US it takes something like 11 years including the average residency. (Compare that to 7 years to become a lawyer). Might that be a source of the problem?
posted by Pastabagel at 7:40 AM on July 28, 2009

Nate Silver weighs in on the Baucus Bill.

If this proposal passes into law, it will be an unmitigated disaster. Just when you thought things couldn't get worse, Senate asshats have figured out a way to do just that.

Fucking criminals, the lot of 'em.
posted by Benny Andajetz at 7:41 AM on July 28, 2009

They are adamant -- ADAMANT -- that we have to call them before he goes to the emergency room so they can determine the best course of action, and if we don't call first, they will refuse to cover it, no matter what the problem is...

Orb,
That one is an absolute cracker, isn't it?

They eventually dropped that chaotic demand from our plan here in NY.
It was one of the first terrifying bits of small print I had to learn (when we moved from the UK) and I thought I was on top of it.

Then came the day when my eldest son was handed on by our pediatrician to a referred specialist (pointlessly, fortunately - no, we did NOT require a plastic surgeon to deal with a possible tiny scar on our son's chin from his fall from a rope swing!) who happened to be working in the emergency room that afternoon & who suggested we meet him there, rather than at his office, for a five minute consultation one afternoon.

We were then charged $2,000 plus for an "unauthorized" emergency room visit.

It took, maybe, ten letters from me before the insurers relented.

I know anti-reformers would point out that, in the end, I overcame the obvious unfairness of the charge.

But it took hours and hours of anxiety and full-on fury...just such a fucking waste of time.
posted by Jody Tresidder at 7:43 AM on July 28, 2009

But it is relatively easy to be a health tourist to the UK.

I don't buy it. I think this is daily-mail scare mongering at its worst. Not that there aren't isolated cases, of course.

The UK gets about 22M visitors a year. I dont know the exact number of tourism pounds that represents but I'm sure its in the billions. The cited figures here are a drop in that ocean.

And the figures never seem to add in the money thats *made* from some of these overseas tourists. The practice I go to is right near the British museum. Almost everytime I go in there's some American dropping by then asked to pay £10 to be able to see a doctor for 5 minutes.
posted by vacapinta at 7:47 AM on July 28, 2009 [3 favorites]

How can France spend only $3300 per person, but workers have to pay 21% of their income? The average income in France is almost $25,000. 21% percent of that is $5250

Thats not how to take averages, Pastabagel. Unless of course that "average" represents a mean of a perfect bell curve, which I doubt it does.
posted by vacapinta at 7:52 AM on July 28, 2009 [1 favorite]

Jody: Yup, a waste of time for you, and a waste of money for the insurance company (and thus the people paying for its insurance) due to some employee(s) having to deal with your ten letters.

And I may try to remember to call them before I take my husband to the emergency room, but if he's clutching his chest having a heart attack or one of his limbs is at an odd angle, I may very well forget during the excitement, and then I'll have to argue with them afterward about the necessity of not waiting until morning.

That's what really cracks me up about all the talk of how health care will be rationed. It already is. There are many gate keepers between people and doctors and treatments right now, and some of us (myself) have been rationed right out of health care altogether.
posted by Orb at 7:59 AM on July 28, 2009

But there's also a strong awareness of how it could be an awful lot worse, with our nightmare scenario closely matching the US system.

This statement bothers me because the problem with the healthcare system is the US is the financial side, not the care. Unless you are talking about edge cases (which would never apply to you), health care in the US is excellent. As in, the doctor discovers a problem on Monday and you are getting surgery on Thursday. It costs a shitload, and that's usually what the complaining is about, not about waiting for access to care, or access to the latest medical technology, etc.

But something else frustrates me, which is why the US is near the tops charts like child maltreatment deaths, plastic surgery, obesity, circulatory disease deaths, cancer deaths, abortions, but we are way down on the list for life expectancy, practicing doctors, math proficiency, science, literacy, etc.

It's like on every measure, the US is fucked up. To me that suggest a single common underlying problem. Why the fuck are so many Americans overweight? Why are we getting so much plastic surgery? To make our fat bodies more beautiful? What the hell is wrong with our culture? Why could we land on the moon and do all the other things in 1969, but we can't do anything at all in 2009?

I refuse to solely blame politicians, because they reflect us. The President, who is supposed to revolutize healthcare for us, IS STILL A SMOKER. Lead by example you fucking moron. If Bush could quit drinking and doing coke, why can't this guy quit cigarettes? And politicians don't make us by doritos and stuff our faces with treats. Goddamit this pisses me off.
posted by Pastabagel at 7:59 AM on July 28, 2009 [1 favorite]

vacapinta: you don't buy that it's easy, or you don't buy that it's a problem?

I don't think anyone is disputing that "tourists" add more economically than they take away. But that's not the point. The point is whether a) certain people come to the country specifically to use the NHS and b) whether the NHS is as efficient at charging non-eligible patients as it should be.

In both a) and b) I think it is the case. I'd agree that a) is probably blown out of proportion by the Daily Mail et al, but bearing in mind that the government doesn't even track eligibility for use of the NHS and several GPs don't require proof of eligibility before signing up patients it's a highly porous system.
posted by MuffinMan at 8:01 AM on July 28, 2009

MuffinMan: I dont doubt that a) is true but I haven't seen any compelling figures that its a real problem. Most people throw out cash numbers to "prove" its a problem but I'm saying that needs to be compared to how many people are passing through here in the first place.

Raw monetary numbers rarely have any actual meaning and when you see them in isolation it is because they are intended to cause outrage not provoke actual intelligent conversation. They need to be compared to other things such as the total NHS operating budget before they start to acquire meaning.
posted by vacapinta at 8:06 AM on July 28, 2009

How can France spend only $3300 per person, but workers have to pay 21% of their income? The average income in France is almost $25,000. 21% percent of that is $5250. So, the average worker is already paying almost 60% more than what the country is spending on them?
Won't this be because the spending is per person but the taxes are onlly levied on those in work, i.e. not everyone (includes children, retired, unable to work etc)?
posted by Abiezer at 8:10 AM on July 28, 2009

To fund universal health care in France, workers are required to pay about 21 percent of their income into the national health care system. Employers pick up a little more than half of that.

The bold part is the part you missed. The employer covers more than half of it soin reality the average french worker is only paying 10% or so. At least as I understand it. A French person should be along to correct us both presently.
posted by minifigs at 8:14 AM on July 28, 2009

njbradburn - you miss the ethic that applies. My experience in the UK is that people are very well aware of how the cost of the NHS is met and go out of their way not to abuse it. Moral good, not hazard.
posted by A189Nut at 8:24 AM on July 28, 2009

... several GPs don't require proof of eligibility before signing up patients it's a highly porous system.

When I entered the UK and every time I've moved, I've had to register with a new GP. And each GP needed my National Insurance number, proof I was living permanently within their catchment area, and the details of my previous GP so they could fetch and confirm my records.

If the system is "porous", I seem to always be living in especially impermeable locations.
posted by outlier at 8:27 AM on July 28, 2009 [1 favorite]

Count me in as another American expat who won't return to the US to live unless health care is fixed.

I've said much of this before, but the issue is so important I want to repeat it: Here in France, we can choose our doctors, from GP to specialists, and we can also choose our hospitals, clinics, etc. Government health care covers about 80-90% of general costs; most employers offer private "third-party" insurance that covers the remaining percentage. My employer, for instance, has 20 euro/month insurance that also covers dental and opthalmological at 100% (with reasonable limits for both). This means, for instance, that I can get one free pair of prescription eyeglasses every year, up to a limit of 500 euros for the frames.

One of the key issues for me is pregnancy and childbirth. Here are a few stats, taken from Wikipedia's list of countries by infant mortality rate. The first number is the infant mortality rate, and the second is the under-five mortality rate:
USA: 6.3 and 7.8
Cuba: 5.1 and 6.5
Slovenia: 4.8 and 6.4
Canada and the UK: 4.8 and 6.0
France: 4.2 and 5.2
Iceland: 2.9 and 3.9 (they have the best numbers)

In France, pregnant women have 3 sonograms and blood tests (one per trimester), with a three-hour blood test around the 4-month mark. All covered at 100%. Anything beyond that's deemed necessary is also covered 100%. Mothers-to-be get 6 weeks of paid vacation legal minimum before their birth date -- it can be extended, for instance if the pregnant woman lives more than an hour's commute from her offices. They then get 10 weeks after giving birth. Fathers get 11 days of paid vacation (18 days if they're father to twins or more). Postpartum exams are covered. Parents are given allocations familiales depending on their need; all get a basic "starter" minimum of several hundred euros. There are also allocations to help cover childcare if/when the mother returns to work. Mothers have the option of working 4 days a week instead of 5; fathers can now do this too (but only one member of the couple can do this, and there is a sort of "salary cut" in that a few — less than 10 — vacation days are removed if they choose the "4/5 work week" as it's called).

All this and per capita, we pay half what Americans do, as previous commenters have mentioned. Here are some more stats for good measure.
posted by fraula at 8:33 AM on July 28, 2009 [8 favorites]

vacapinta: compared to overall NHS budget it may well be on the small side, although, again, the NHS simply does not have a proper mechanism to check eligibility at either a primary of acute trust level and IMHO will underestimate actual costs. National expenditure is slightly misleading because the impact is felt most keenly where immigration/tourism is heaviest. I would concede the problem is likely irrelevant in the Hebrides, or Cornwall, for example.

Bearing in mind this is hospital-related costs only, for example, the average London hospital wrote off £3.5m over 5 years as bad debt, of which around 2/3 is from foreign nationals. This number does not, for obvious reasons include undetected fraud (i.e. an individual passing themselves off as someone else, or faking eligibility).

Is that a lot? It depends, I suppose, on what you think a hospital could have done with that money.
posted by MuffinMan at 8:33 AM on July 28, 2009

When I entered the UK and every time I've moved, I've had to register with a new GP. And each GP needed my National Insurance number

But they don't as an emergency patient, where "emergency" doesn't translate as anything particularly urgent.
posted by MuffinMan at 8:36 AM on July 28, 2009

The President, who is supposed to revolutize healthcare for us, IS STILL A SMOKER. Lead by example you fucking moron. If Bush could quit drinking and doing coke, why can't this guy quit cigarettes?

If I was the president, I would be reaching for a pack of unfiltered Camels right now.
posted by squalor at 8:37 AM on July 28, 2009 [2 favorites]

The USA seems incapable of progressing on any healthcare model used internationally, presumably for nationalistic reasons.

No, it's purely to protect the profits of insurance companies, who own enough of congress to stop any real progress. The gridlock on this issue has nothing to do with nationalism, it's all about capitalism.
posted by exhilaration at 8:38 AM on July 28, 2009 [1 favorite]

Unless you are talking about edge cases (which would never apply to you), health care in the US is excellent. As in, the doctor discovers a problem on Monday and you are getting surgery on Thursday.

I'm not sure what you mean by an edge case. It depends on the nature of the problem that the doctor discovers whether you get surgery on Thursday. If it's catastrophic, maybe. If not, probably not. If it's a primary care physician discovering the problem and not a specialist to whom he or she has already referred you and to whom you must go to get super-duper approval for the surgery, even more probably not.
posted by blucevalo at 8:38 AM on July 28, 2009

If Bush could quit drinking and doing coke, why can't this guy quit cigarettes?

That's a big if.
posted by blucevalo at 8:39 AM on July 28, 2009 [6 favorites]

Seems like the main question to answer is whether health care (preventive or otherwise) is a right or a commodity.

If it's a commodity, then the U.S. health care market is working about like it should; that is, the owners of the commodity (insurance, providers) charge what the market will bear, and those who cannot afford the market price are screwed.

If it's a right, then allowing it to be treated like a commodity is the problem, and the insurance companies should be dissolved and physicians should work for a government agency or agencies. Those who make money from providing health care or being a middleman in the process are screwed.

The debate is straightforward enough - who gets screwed?

It's been my experience that individuals (human or corporate) with money tend to get screwed less.
posted by Pragmatica at 8:58 AM on July 28, 2009 [1 favorite]

moral hazard!
Look, every time we have one of these threads there is a dude who comes in with this. I don't know if you've actually thought this through, but think about it:
Why would anyone go to the doctor unnecessarily? Even if it is free. I really doubt that there are enough hypochondriacs to make a difference. Not only that, but primary physicians are not the major cost drivers of health care. The primary drivers are major surgical procedures, long term pharmaceuticals and expensive diagnostic tests. All things that will only be performed when doctors deem them necessary.

Here is another thing - moral hazard only applies if the participants in the game are rational, but:
obesity is a major driver of individual health care costs, therefore you would expect that in the countries where health care is not provided universally there would be less obesity. So why are Americans fat and the French, Dutch and Germans skinny. Where is your moral hazard effect?
It would appear that people do not take future health care costs into account when they make decisions about their lives, therefore there is no moral hazard effect.

The bold part is the part you missed. The employer covers more than half of it soin reality the average french worker is only paying 10% or so. At least as I understand it. A French person should be along to correct us both presently.

To be honest, this doesn't actually matter. The employer may transfer the cash, but it is the employee who pays for it in real terms (because their nominal income will decrease). Still, the French seem happy with their system, so more power to them.
posted by atrazine at 9:01 AM on July 28, 2009 [1 favorite]

Moral hazard is an important concept because it ultimately can protect us from tyranny. We all need to have some skin in this game, if you will. Voices demanding "I NEED THIS!" are sometimes a lot louder when someone else is paying for it.

So I take it you were opposed to a government bailout of AIG and friends?
posted by Combustible Edison Lighthouse at 9:36 AM on July 28, 2009

Malcom Gladwell on the myth of moral hazard.
posted by mullingitover at 9:40 AM on July 28, 2009 [1 favorite]

Moral hazard is an important concept because it ultimately can protect us from tyranny. We all need to have some skin in this game, if you will. Voices demanding "I NEED THIS!" are sometimes a lot louder when someone else is paying for it.

I see you decided to make the point even more general and abstract than it already was (the fight against tyrrany? really?) while failing to address the specific argument, which has two parts: 1) if I go to a German doctor here demanding surgical procedures I don't need, I'm not going to get them, and 2) why would I even do that in the first place?

So how does the "moral hazard" argument apply specifically to health care? What hazard are you worrying about?

I'm not sure that the relative weight of the French doesn't have more to do wth their culture of walking versus ours of driving than healthcare systems, but anyway...

That is exactly the point of his argument. The only "hazard" would be that people who don't have to pay for their care out of their own pockets would start "needing" a lot more care, thus sandbagging the whole system. In fact, we've seen that people who don't pay for their own care generally need less care and the system runs more smoothly. So what "hazard" are you worried about exactly?
posted by creasy boy at 9:43 AM on July 28, 2009

njbradburn: 'Moral hazard is an important concept because it ultimately can protect us from tyranny. We all need to have some skin in this game, if you will. Voices demanding "I NEED THIS!" are sometimes a lot louder when someone else is paying for it.'

Uh, we're born with skin in this game. I'm always amazed at the people who think that universal coverage will mean that people take recreational trips to the doctor. I have great coverage and I still avoid the doctor's office like the plague. Meanwhile...

From Malcolm Gladwell's article:

The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

posted by mullingitover at 9:54 AM on July 28, 2009

Who can argue against protecting the children, the youngest and most vulnerable?
Me. Maybe I'm an ogre, but I don't see why a child's health/life is more valuable than mine, or my husband's or my brothers' or parents'. I do believe, however, that just about every U.S. state has a plan that covers children whose parents don't have insurance.
posted by Oriole Adams at 9:56 AM on July 28, 2009

I do believe, however, that just about every U.S. state has a plan that covers children whose parents don't have insurance.

Not anymore they don't.
posted by blucevalo at 9:58 AM on July 28, 2009 [1 favorite]

How can France spend only $3300 per person, but workers have to pay 21% of their income? The average income in France is almost $25,000. 21% percent of that is $5250. So, the average worker is already paying almost 60% more than what the country is spending on them?

workers &sub population.
posted by ROU_Xenophobe at 9:59 AM on July 28, 2009

So how does the "moral hazard" argument apply specifically to health care? "Moral hazard" is used in re: healthcare all the time--I learned the term in a HC finance textbook. Specifically, payors and providers are concerned about people booking an appointment to see a dermatologist for a zit because, why not? You have free healthcare. Taking your baby to the pediatrician for a diaper rash because, why not? You have free healthcare. I was an administrator for the Richmond EMS system, and we had the 911 system used as a taxi a few times a day ("Self Pay" patients who refused to fill out the forms for Medicare and became Bad Debt for the city's Ambulance Authority). It is this kind of behavior that a certain amount of cost awareness can modify.
posted by njbradburn at 9:59 AM on July 28, 2009

And BTW, that's the kind of behavior I'm asked to subsidize in a universal plan.

And we should all be on the lookout for tyranny ;>
posted by njbradburn at 10:05 AM on July 28, 2009

atrazine , I'm not sure that the relative weight of the French doesn't have more to do wth their culture of walking versus ours of driving than healthcare systems, but anyway...

Moral hazard is an important concept because it ultimately can protect us from tyranny. We all need to have some skin in this game, if you will. Voices demanding "I NEED THIS!" are sometimes a lot louder when someone else is paying for it.

Absolutely that probably is why the French are thinner, but I was trying to make the following point:
The demand for healthcare is pretty inelastic, obviating any moral hazards.
Even if the 'raw' demand was not inelastic - that is, people suddenly demand a great deal more care once it becomes free - the actual spend will be. The reason for this is that the most expensive procedures are ones that are only available to those who need them.

Although moral hazard is an important thing to consider whenever something is provided free to individuals and paid for by the public as a whole, I just don't think that it applies to inelastic goods.
posted by atrazine at 10:07 AM on July 28, 2009

I think the good thing about the US system would be availability of specialists ... but this is only for those with money.

And, of course, those with money could continue to see specialists. But they think it's fundamentally unfair (and OMGUNAMERICAN/SOCIALIST/etc.) to pay taxes to provide for universal health care for other people IN ADDITION to paying their own way.

I think that's the nut we have to crack to make this happen. Maybe an opt-out system where rich folks can go their own way without paying into the national system. It then becomes a non-issue for them in my mind -- more like, "you guys wanna do what now? yeah have fun with that..."
posted by LordSludge at 10:16 AM on July 28, 2009

I see the healthcare debate in the US as fundamentally linked (in a negative way) to the American Dream. The belief that anyone can work hard enough and therefore become rich. Sadly, that isn't really the case. The US has a pretty good rate of social mobility, but there are still solidly entrenched privileges and class structures.

If the power holders/decision-makers believe that the only reason someone can't afford healthcare is because they've not worked hard enough then of course they're not going to want to pay - with their hard earned cash - for those lazy bums. This is very much not the view in most countries that already have universal healthcare, where the attitude is more that anyone can be unlucky enough to be poor, anyone can get sick, and everyone should help those that are/do.
posted by knapah at 10:17 AM on July 28, 2009

Regarding the profit motive in the American health care 'system,' Bill Moyers interviewed a former Cigna executive a few weeks ago whose job it was to manage PR for the insurance giant. Worth watching/listening, even though it's pretty disturbing stuff (at least to me).
posted by scdjpowell at 10:21 AM on July 28, 2009

I don't mind foreign nationals using the NHS, as long as we have reciprocal agreements with their systems, or they are UK taxpayers, or they pay.

I don't mind foreign nationals using the NHS, as long as they keep cleaning the wards, and lifting the beds, and treating the patients, just as they are at the moment.
posted by mippy at 10:22 AM on July 28, 2009 [3 favorites]

njbradburn: "Specifically, payors and providers are concerned about people booking an appointment to see a dermatologist for a zit because, why not?"

A better example is the many more people who aren't going to the dermatologist to get their unusual mole checked out because, oh yeah because it costs a lot of money that they don't have.

But hey, so a bunch of poors died of preventable malignant melanoma. At least we kept those freeloaders from getting free medical attention for their zits! Now if you'll all kindly get off my lawn.
posted by mullingitover at 10:23 AM on July 28, 2009 [3 favorites]

No. Our system tends to the opposite approach, since the gatekeepers of the money spent on treatment seem to believe that they might have to let more of the money get past them if they tried to keep people healthy.

...Because if you skip the preventative checkups, you save the upfront costs -- and there's every likelyhood that the ~~victim~~ customer will have moved on to another ~~sucker~~ health insurance provider by the time it becomes a real problem and the back-end costs rack up. And with the new insurance provider, it'll be a pre-existing, non-covered condition anyhow, so the only one left holding the colostomy bag is the customer.

And they get to die and go to heaven! It's a WIN-WIN!!
posted by LordSludge at 10:27 AM on July 28, 2009

Specifically, payors and providers are concerned about people booking an appointment to see a dermatologist for a zit because, why not? You have free healthcare.

njbradburn: I live in the UK, and therefore have healthcare that is free at the point of use (note: not free, and most people here don't call it "free" and are well aware of how it's funded). I cannot make an appointment with a dermatologist directly - I have to have a referral from my GP. My GP would not refer to the dermatologist for trivial reasons.

If I had lots of zits and were concerned about them, I'd go see my GP and take it from there (she may or may not recommend a referral to a dermatologist - that's more or less her decision and not mine, though I could ask).
posted by altolinguistic at 10:27 AM on July 28, 2009 [1 favorite]

Even if the 'raw' demand was not inelastic - that is, people suddenly demand a great deal more care once it becomes free - the actual spend will be. The reason for this is that the most expensive procedures are ones that are only available to those who need them.

Yes, hence the rationing. But you'll still have the babies with rashes (or, in my experience, old pensioners who run to the doctor at the slightest pain and mostly to have something to do in the morning and someone to chat with). So, maybe the problem is not so much the cost but the bottleneck created where it might be difficult for someone who really needs it to get an appointment. But that's why you charge small fees (eg in Portugal I believe is 5 euros per appointment) to moderate access to people who otherwise would engage in the behaviors njbradburn is talking about.

It's surprising how even such a small fee works wonders. It's a bit like the metafilter 5$ thing.

I don't understand something. People who are against universal health care are against it because no system will be perfect? Lots of countries have free health care and have more or less success, but ultimately, no matter how inefficient or how many little tricks you have to implement to curb abuse, it's worth it not to see your fellow citizens suffer because they don't have money.
posted by lucia__is__dada at 10:33 AM on July 28, 2009

[P]ayors and providers are concerned about people booking an appointment to see a dermatologist for a zit because, why not?

Because going to the doctor or going to the hospital is NOT FUN. The moral hazard argument works for free sodas or free movies or public grills or public bikes because those are all things that people want to do -- and they'll do those things even more if they're free. With very few exceptions, the analogy just doesn't hold water for health care because NOBODY gets bored and goes to the ER for a free round of probing. It's way EASIER to just pop that zit yourself than to go to the ER, wait 5 hours (behind people with, you know, actual emergencies), fill out 5 forms, and finally see a doc to lance it (OMGNEEDLE!!) for you.

ERs suck. Hospitals suck. Doctor's offices suck. We go there because we have to, not because it's fun.

Come on, a little common sense!!
posted by LordSludge at 10:37 AM on July 28, 2009 [2 favorites]

mippy: I don't get your snark. Foreign nationals work in the NHS. What does that change, exactly?
posted by MuffinMan at 10:43 AM on July 28, 2009

...it's worth it not to see your fellow citizens suffer because they don't have money.

This does not seem to be universal. Some people here claim to be OK with seeing those who are so shortsighted as to not have adequate insurance suffer and die. No - I am not exaggerating. I had that conversation yesterday.
posted by Kirth Gerson at 10:44 AM on July 28, 2009 [1 favorite]

Because going to the doctor or going to the hospital is NOT FUN.

You'd be surprised. I'm sure they don't think it's fun, but there are lots of panicky people who rush to the doctor or ER rooms at any instant because they can afford to be panicky since they don't have to pay. This isn't new, it's human nature and it has been dealt with in many countries where health care is free (the fees I mentioned but also pre-screening at hospitals where they even send people back home with a reprimand for being silly).

What's amusing in this moral hazard conversation to me is that I've had complete private medical insurance and I've been without it. I used to go to the doctor much more often (for trifles that I otherwise would ignore) when I had private insurance because I felt I had to get my money back. But when it comes to using public health care I'm much more ethical about it...
posted by lucia__is__dada at 10:48 AM on July 28, 2009

Since the moral hazard is clearly so hazardous, I'm waiting to see some cites from countries with universal health care that show that their doctors' offices and ERs are being overrun by people coming in to have zits looked at and what those costs are.

And I would like to see some cites that compare that cost to the cost of having a huge portion of your population (~45 million uninsured people in the U.S.). Uninsured people often wait until something is really, really wrong, then go to the ER, where it's more expensive to treat them than if they'd gone to the doc early on.

Are there such cites? Because I'm seeing people argue that it's a DANGER but I'm not seeing any numbers from places like the UK or Canada or France.
posted by rtha at 11:18 AM on July 28, 2009

But hey, so a bunch of poors died of preventable malignant melanoma. At least we kept those freeloaders from getting free medical attention for their zits! Now if you'll all kindly get off my lawn

This is basically what mystifies me. I can understand being in favor of universal health care, but still wanting some sort of copay system to mitigate "abuse". But to use "moral hazard" as a reason to oppose universal coverage? I don't know how to interpret that other than to assume that you're more bothered by people getting "too much" health care than not enough. The kid who gets more antibiotics than he needs because his parents are worrywarts is more of a concern to you than the kid who gets no asthma medication because his parents can't afford health insurance. What the hell?
posted by Combustible Edison Lighthouse at 11:19 AM on July 28, 2009 [1 favorite]

"But what about the moral hazard?" = "I am an elitist". Translation: I am capable of wisely using the health care system, but everyone else is not.

Our leaders, by and large, are beholden to business interests that don't give a fuck wheteher people live or die. That's bad government. That's bad business. That's bad citizenship. That's bad, period.
posted by Benny Andajetz at 11:41 AM on July 28, 2009

Are there such cites? Because I'm seeing people argue that it's a DANGER but I'm not seeing any numbers from places like the UK or Canada or France.
I've heard anecdotes similar to what lucia_is_dada writes above: some pensioners visit their GP more out of loneliness etc. than actual health need, but have seen doctors write that they don't see it as too far removed for mental health care anyway. It's not brought the system crashing down though can be a drain on collective resources - on a swift search there's this from 2000 although it seems to be something of a rewrite of a pharmacy press release (who obviously have a vested interest getting you into their shop). The NHS Direct phone line set up not long before that has at least partially successfully addressed the issue.
TBH whatever the truth of the matter it's certainly vastly over-blown as an objection - any funding/resource problems the NHS might face will be because of larger demographic trends I believe, not the dreaded freeloaders. Anyone making the moral hazard argument beyond a concern for efficiency in a universal system is missing the wood for the trees or casting around for a fig leaf for what are patently not economic or rational objections - after all, if they're in the US they're defending the most expensive, worst-access healthcare in the developed world.
posted by Abiezer at 11:43 AM on July 28, 2009

But to use "moral hazard" as a reason to oppose universal coverage? I don't know how to interpret that other than to assume that you're more bothered by people getting "too much" health care than not enough.

It's been estimated that 40% of ER patients in Portugal are false emergencies. I wouldn't call it conscious freeloading (more like extreme anxiety mixed with hypocondria plaguing a whole country but that's another matter). Would I like to see free health care disappear from my native country because of these ridiculous numbers? Not at all. Is health care a huge burden on a small, poorish country and on everybody's taxes? Yes. Do I understand that in face of mass hysteria fueled by the prospect of freebie treatment you need to impose fees and pre-screenings and phone lines and god knows what more? Yes, and I still think it is a million times better than not having health care at all. That's how good it is. But then again I don't believe poor people are poor because they're losers so that might make a difference.
posted by lucia__is__dada at 12:08 PM on July 28, 2009

Vocabulary problem: Can someone help me find a word for someone so small-minded and mean that they would voluntarily withhold a benefit for the vast majority on the off-chance that it might be abused by a small minority? Thanks.
posted by maxwelton at 12:16 PM on July 28, 2009 [1 favorite]

An interesting experiment for any American to try:

Drive to the Canadian border.

Cross it.

Pick the nearest bar, diner or coffee shop.

Ask everyone in there

1) How they feel about the health care system ("The Conservatives are ruining it", "It took me 6 months to find a GP who was accepting patients", "My aunt had to wait 9 months for her knee surgery and then they canceled on her twice").

2) How they feel about changing to an American private-insurance model.

Listen carefully.

The only place you'll be able to find someone who *wants* the US system will be Alberta, where they all wish they lived in Texas, but they're too wussy to move there.
posted by jrochest at 12:18 PM on July 28, 2009 [2 favorites]

I'm sort of hoping I won't live past a certain age, because I don't know how we'll support ourselves here in the US since pensions are a thing of the past and my husband's 401K seems mighty unreliable. I'm not keen on having to take a billion pills a day either or having tons of surgeries.
posted by anniecat at 12:36 PM on July 28, 2009 [1 favorite]

I'm sure they don't think it's fun, but there are lots of panicky people who rush to the doctor or ER rooms at any instant because they can afford to be panicky since they don't have to pay.

In most cases, I would WANT those panicky people to go the ER. Chest pain? Might be heartburn, might be heart-attack. Slipped in the bathroom and knocked yourself out for a sec? Eh, you might just have a lump on the head. Or you might have a closed-head injury that will kill you if not treated. That mole on your back might just be a mole. Or it could be cancer. At some point, you're asking unqualified people to make medical decisions -- many times on matters that require early detection for good survivability. They really should see a doctor, and promptly.**

Of course I don't want people coming in for hangnails, but I can't see that happening. Little stupid things like that are way less work to deal with it yourself than hit the ER. There will be fringe abuses, such as people taking the ambulance for a minor injury, but please god let's not let those relatively rare exceptions dominate the conversation!

** What really, really, really sucks is to be holding your friend who just knocked herself out and is having weird abdominal pain and trying to console her that she'll *probably* be okay -- because she's uninsured, has $12 in the bank, and can't afford an $8000 ER visit on her $19k/year salary. Because, you know, she probably WILL be okay. Or... maybe she'll die in your arms. I'm not a doctor, and neither is she -- how the fuck would I know???
posted by LordSludge at 12:55 PM on July 28, 2009 [2 favorites]

Moral Hazard!
=
We can't care for the public's health at the risk of their souls!
?
posted by Catch at 12:59 PM on July 28, 2009 [1 favorite]

Ended up idly reading around some of the points raised by the old BBC article I linked and not that the Dr Fradd quoted is popping up now in a rather dubious way.
posted by Abiezer at 1:15 PM on July 28, 2009

Specifically, payors and providers are concerned about people booking an appointment to see a dermatologist for a zit because, why not? You have free healthcare. Taking your baby to the pediatrician for a diaper rash because, why not? You have free healthcare.

Hm, that's an interesting thought. More people will go to the doctor, and earlier, because why not? And so the market will demand more doctors and facilities to handle the additional traffic, meaning that medical schools will make more money and more people will be working as doctors. Since medical schools and doctors pay (a lot of) taxes too, that'll add a bit more money into the system, and the influx of new doctors will make prices go down overall, reducing the burden on the system that our taxes pay for. Meanwhile, people seeking out medical care earlier and having to wait less (after the new doctors and facilities enter the system) means lower worker absenteeism and higher productivity all around, meaning more income overall -- and so more money into the system via taxes.

So I think you've just convinced me that this is a very good thing, sir, not a very bad thing.
posted by davejay at 1:18 PM on July 28, 2009

California finally passed a budget, and the governor signed it. After he lined-out stuff like:

$80 million from child welfare programs;
$61 million in county funding to administer Medi-Cal, California's version of Medicaid;
$52 million from AIDS prevention and treatment;
$50 million to Healthy Families, the low-cost health insurance program for poor children;

Meanwhile, [f]rom July 1, 2008, to June 30, the [UC Davis] university health system was left footing the bill for $165.7 million in charity services - up from $96.9 million the year before.

I wonder what could happen when you cut funds to help people get insurance? They'll just stop going to get medical care, right? That's how that works, right?
posted by rtha at 1:33 PM on July 28, 2009 [1 favorite]

Some of you worry way too much.

Look, here's how it'll work out: We won't get sensible or humane health care in the USA, sure.

But it's not so bad.

In order to distract us, the insurance companies will be forced to make more commercials featuring smiling senior citizens and children playing in fields of flowers lit by golden sunlight. An actor with an avuncular voice (some regions will see a version with a motherly voiceover instead) will assure us that the Insurance Company cares deeply about every single one of us while soft string music plays. I love those commericals!

And then my Senator and Representatives who sold me down the river will make commercials where they promise that they're fighting hard for me. Me, personally! And they don't even know me!

Then Television will produce more shows about young, attractive doctors from assorted ethnic backgrounds whose chief flaws are that they all care too much about helping people, even to the detriment of their love lives. Why, they'll never even hint at bad stuff like people being bankrupted by medical bills or people being denied treatment by insurers! When you get the occasional scene featuring the pretty young woman doctor and the sensitive but rugged looking male doctor having a furtive encounter that somehow ends in hilarity, why should you waste time worrying about issues?

To sum up, it's all good. Let's let our elected officials continue to enjoy a system they wouldn't dream of allowing the mortals to partake of. They are our betters after all.
posted by lord_wolf at 1:38 PM on July 28, 2009 [4 favorites]

Why is health care deemed different from say, paved streets or military services? Is providing tax-supported macadam socialism? Probably. But I am not frightened. Perhaps socialism should be the operating system for a society.
posted by Cranberry at 1:42 PM on July 28, 2009

Maybe I'm an ogre, but I don't see why a child's health/life is more valuable than mine, or my husband's or my brothers' or parents'. I do believe, however, that just about every U.S. state has a plan that covers children whose parents don't have insurance.

"As the United Ways of California point out the children's health care cuts are going to ensure the wider spread of H1N1 flu this fall. Children are one of the primary vectors of swine flu, and without access to health care we will see a more intense and more deadly flu epidemic when school starts this fall."
posted by rtha at 2:01 PM on July 28, 2009

Then Television will produce more shows about young, attractive doctors from assorted ethnic backgrounds whose chief flaws are that they all care too much about helping people, even to the detriment of their love lives.

I love those chirpy pill ads and insurance conglomerate shills and doctory TV shows too. In the best combination of all worlds, Noah Wyle and Sandra Oh prescribe you a big bottle of Cymbalta and Alan Alda as Hawkeye Pierce makes a clever Groucho Marx-y joke and all of these quibbles about "moral hazard" and "the road to socialism" vanish in a wondrous multi-hued haze.
posted by blucevalo at 2:34 PM on July 28, 2009

Bill Kristol: Government healthcare is the best healthcare (around six minutes in.)
posted by minifigs at 3:11 PM on July 28, 2009

chillmost: Also, Germans just like to bitch.

What. The. Fuck?
posted by Dysk at 3:24 PM on July 28, 2009

chillmost: Also, Germans just like to bitch.
What. The. Fuck?
posted by Brother Dysk

In chillmost's defense, at least in southern Germany, where I've lived, I found this to be true, too. Not in that especially fatalistic Viennese way (the Sterbevereine, the importance of saving up for a big ol' funeral, the way most people here in the US treat weddings, etc), but more in the "grumbling as a fun activity" way...

Perhaps not very diplomatically phrased, but apt. Doesn't mean I don't love Germany -- I'd move back in a heartbeat -- but it was kind of funny how my coworkers, etc looked at the world compared to me (and I'm a pessimistic beeyatch).
posted by bitter-girl.com at 3:31 PM on July 28, 2009

minifigs: But according to Bill, the rest of us non-soldier Americans don't deserve such health care. I'm happy we have a military to protect us, and I'm happy to pay taxes so they can get whatever they need, but to suggest that anyone not in the military doesn't also deserve good health care kind of sets up two classes of citizens, doesn't it? Those who are both willing and capable of serving in the military and those who aren't.

I pretty much got sick to my stomach last night while watching that part of the interview. Bill Kristol is a disgusting man.
posted by Orb at 4:43 PM on July 28, 2009

Bill Kristol is a disgusting man.

Little-known fact: Bill Kristol comes from a long line of lizards.
posted by Kirth Gerson at 5:00 PM on July 28, 2009

maxwelton: Can't help ya there, becauase I'm not trying to withold care from anyone. I am first in favor of qualifying uninsured patients for existing safety net programs that they may not yet be enrolled in (SCHIPs are a good example of an underutilized health insurance program for children), then look at the needs of the population groups who remain uncovered and get them covered. Period. Yes, it is a conservative (in the lower-case meaning of the word--that is, incremental--and perhaps incidentally in the uppercase meaning of the word) approach. It also reflects a core value that I realize I share with few on the blue--that is a sincere belief that this move might be more than just a step toward Socialism */shudders, but that it could alter some fundamental aspects of American society. I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation. So mock away at my fear of tyranny ;> Most definitely not small minded. And most assuradely not mean.
posted by njbradburn at 6:02 PM on July 28, 2009

outlier: When I entered the UK and every time I've moved, I've had to register with a new GP. And each GP needed my National Insurance number, proof I was living permanently within their catchment area, and the details of my previous GP so they could fetch and confirm my records.

It's pretty porous. I lived in the UK without a visa for going on ten years. Once you can find a GP willing to see you as a visitor, you are on his or her books. I saw an excellent GP for six years, had two ER visits for haemorrhagic miscarriage, a hospital transfer, an in-patient stay, and a return to a day bed on the GYN ward for a D&C without ever getting a bill. Oh, and a referral to the community mental health team and ten visits with the best shrink I've ever seen, including $300 an hour fancy NYC shrinks.

I never got a bill for any of it.

The most important contrast for me, however, is that whilst bleeding on my bedroom floor, I never once considered not going to A&E. I didn't worry about the money, because I knew any bill they sent me would be reasonable and one I could pay over time without destroying my credit. (Not getting a bill was a bonus.) Far more importantly, I didn't sit at home and die because I was afraid seeking medical attention would get my illegal ass deported.
posted by DarlingBri at 6:05 PM on July 28, 2009

I worry about the loss of social mobilty, for example
Well then the Economist had bad news for you back in 2004. it's been retrenching capitalism that's achieved that, not creeping socialism.
posted by Abiezer at 6:19 PM on July 28, 2009 [1 favorite]

I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation
You believe denying people health care motivates them to innovate and create? I don't share that belief, and I don't understand why you would think that.
Surely the motivations for financial success are very significant ignoring any healthcare aspect. Which people will be more innovative/creative due to fear of catastrophic health failure who wouldn't be innovative/creative anyway? Surely the number must be very small. Wouldn't the number be dwarfed by those unable to innovate/create because they or their families have untreated health issues?
Wouldn't removing the chain of health insurance from employment foster more entrepreneurship? I don't have to consider for a moment any health consequences of a change in jobs or quitting to start my own business because we have societal health care in my country.
Can you explain a little better?
posted by bystander at 8:14 PM on July 28, 2009

I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation.

That's pretty standard conservative (small "c") thinking, and understandable.

It's been my experience, however, that when you really examine these constructs they are more illusion than anything. While the Horatio Alger "rags to riches" story happens from time to time, it's exceedingly rare. We don't enjoy the highest standard of living on the planet because we are conservative and democratic; we enjoy it because we created the largest, most powerful middle-class on the planet. That economic engine was the direct result of the American Labor Movement - workers stood up and took their due.
Hardly a conservative win.

As for drive to get ahead and the catalyst for innovation and creation, which do you think is more important: the social system an individual lives in, or a good mind, education, and restless intellect? Creative people create. Innovative people innovate. A system that nurtures that definitely helps things along, but it's not necessary. Besides, a more "socialized" medical delivery system is not a huge threat to our existing lifestyle. In fact, I see the possibility that removing to a large degree the worries many people have concerning their medical needs could actually make our society more productive and creative.
posted by Benny Andajetz at 8:31 PM on July 28, 2009

The only place you'll be able to find someone who *wants* the US system will be Alberta, where they all wish they lived in Texas, but they're too wussy to move there.

Not that it's particularly germane to this discussion, but on behalf of myself and every other Albertan I know well enough to have discussed health care with, I'd just like to note that jorchest doesn't have the slightest fucking clue what he's talking about right here.

By which I mean that one of the more remarkable aspects of Alberta (which in certain self-satisfied corners of the country it's become kind of fashionable to slag off in generalizations so broad they'd embarrass a Klansman) is that even despite its alleged Texophilia et al., even in Alberta you'll find essentially no strident or sustained opposition to universal healthcare.
posted by gompa at 8:32 PM on July 28, 2009

Benny Andajetz, let me fix that for you:

We don't enjoy the highest standard of living on the planet. Full stop.

(Assuming "we" to be 'citizens of the United States of America' or something similar, here, neither your post nor profile specify, though context does suggest)
posted by Dysk at 9:00 PM on July 28, 2009

(SCHIPs are a good example of an underutilized health insurance program for children)

Which is why more and more states are instituting waiting lists, or cutting money from the programs, or both. Awesome.

Those existing safety net programs are the first on the chopping block when times (like these) get tough for states. Do we decide that corporations or the wealthy should get by on one or two fewer loopholes? No, because that would be raising taxes! Oh noes!

Instead, we tell disabled people, and poor people, and kids, to get to the back of the fucking line. Again.

Neat.
posted by rtha at 9:07 PM on July 28, 2009

I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation. So mock away at my fear of tyranny

Okay, I'll mock.

You worry about social mobility. How would single-payer or other universal health care reduce social mobility (except downward social mobility from massive debt, or from untreated diseases)? If anything, social mobility should be greater under universal health care. Universal health care would reduce the number of parents who have untreated illnesses and who drop into poverty from medical expenses. Reducing those means that their children's circumstances remain much better, vastly increasing their chances of doing well educationally and setting them up for the mobility you claim to want. You want social mobility? Then you want kids in stable households, well provided-for, getting solid educations. All of which would increase under universal health care.

You worry about innovation and creation. How many people are out there now toiling away at some office job instead of striking out on their own because they need the job for the health care benefits? How many people want to to join an exciting startup but can't because they or their spouse or their child has what would become a Pre-Existing Condition? You want innovation and creation, you absolutely want universal health care so that people are free to join startups or start a small business or whatever without being irresponsible for their families. You want innovation and creation, free people to concentrate on what they're good at instead of having to spend some big chunk of their time being half-assed health insurance specialists.

I mean, my God, do you even think about what you're saying, even a little bit, before you repeat the talking points? Are you so utterly oblivious to the entirely backwards nature of the claims you're making?
posted by ROU_Xenophobe at 11:38 PM on July 28, 2009 [6 favorites]

gompa:

There are, indeed, sane Albertans, and I feel deeply for you, I really do.

"certain self-satisfied corners of the country "= Saskatoon.

"he" nope, not that either.
posted by jrochest at 12:46 AM on July 29, 2009

I had a long chat with a conservative (Republican) friend about needle exchange programs. She mentioned many of the same codewords used in this thread: moral hazard, social mobility, socialism. I started asking questions about why she opposed needle exchange programs, when they reduced HIV transmission. But they're junkies, she said. You're encouraging them. It's our tax dollars. OK, so forget the junkies - what about the innocent wives and husbands of the junkies that will get HIV? If needles will prevent HIV transmission to non-junkies, will you support that? But it's setting a bad example to give syringes FOR FREE to people who are doing that to themselves. So, you're willing to let innocent people die of HIV because you're worried that bad people might get something for free, and we will be rewarding sinners by preventing them from getting diseases.

The response was silence, an unstated yes.

Insurance company propaganda about healthcare parasites tap directly into validating this belief system: I would rather let my family and friends die bankrupt than allow BAD PEOPLE to get nice things FOR FREE.
posted by benzenedream at 1:43 AM on July 29, 2009 [3 favorites]

Coincidentally, BBC4 showed an excellent documentary last night called "The NHS: A Difficult Beginning" (BBC iPlayer). From the blurb:

...the National Health Service very nearly did not happen at all. In the months leading to its launch it was bitterly opposed - by the Tory Party and the national press. But its most vicious and vocal opponents were the very people its existence depended on - surgeons, nurses, dentists and Britain's 20,000 doctors.

It was intriguing to see that the arguments posed against the inception of the NHS featured many of the same canards being trotted out today in the US: A bureaucrat between you and your doctor, a straightjacket on the medical freedom of doctors, the thin end of the Marxist wedge, moral hazard etc. All of these have proved completely untrue in the UK and, at least to my knowledge, in any other democratic country with socialised healthcare.

It's a source of constant amazement to me that these topics are even under debate in the 21st century. This is not a bold social experiment. There are almost as many flavours of socialised medicine as there are OECD countries. Most of them have been running for 50 years or so. All of them are cheaper (as a whole), and most of them are better (as a whole) than the current US system. If you are not in the top 1% or so of wealth owners, nor a fee-for-service health provider, nor HMO, then it's abundantly clear that you are better off under a socialised healthcare system. How the US insurance sector, government and media have managed to convince the majority of the population otherwise for so long is beyond me.
posted by Jakey at 1:52 AM on July 29, 2009 [1 favorite]

benzenedream: Insurance company propaganda about healthcare parasites tap directly into validating this belief system: I would rather let my family and friends die bankrupt than allow BAD PEOPLE to get nice things FOR FREE.

I completely and utterly fail to understand this mindset, this perspective on things. The sheer disregard for human life, the utter lack of compassion or empathy strikes as being practically sociopathic. And yet, it's remarkably prevalent in the UK, and (as far as I can tell) even more so in the US.

And Jakey, I reckon it's this very attitude that allows specific interest groups to convince people of a position that, were it not for people's irrational knee-jerk response to the notion that someone, somewhere, might get something for free that they didn't "deserve", would be considered unfounded and irrational.
posted by Dysk at 2:40 AM on July 29, 2009

Yeah, people get all hung up on "deserve." But as my granny used to say "If we all got what we deserved, there wouldn't be many of us here." The whole point of an enlightened society is that we should endeavour to rise above such base instincts and prosper as a whole. The cynicism and disregard of others shown by those who are coordinating the opposition to such a basic proposition as universal healthcare is breathtaking, even to a jaundiced 21st century political eye. The BBC programme I linked to above mentioned a speech made by Nye Bevan (regarded as the founder of the NHS) on the eve of the launch of the service, talking about the Tory party who had opposed it:

That is why no amount of cajolery, and no attempts at ethical or social seduction, can eradicate from my heart a deep burning hatred for the Tory Party that inflicted those bitter experiences on me. So far as I am concerned they are lower than vermin. They condemned millions of first-class people to semi-starvation. Now the Tories are pouring out money in propaganda of all sorts and are hoping by this organised sustained mass suggestion to eradicate from our minds all memory of what we went through. But, I warn you young men and women, do not listen to what they are saying now. Do not listen to the seductions of Lord Woolton. He is a very good salesman. If you are selling shoddy stuff you have to be a good salesman. But I warn you they have not changed, or if they have they are slightly worse than they were.

I hold the money men in charge of the fight against socialised medicine in similar regard as Bevan did the Tories.
posted by Jakey at 3:53 AM on July 29, 2009 [1 favorite]

What's interesting is that Bevan's comment there is as relevant today as it was then (just substitute 'David Cameron' for 'Lord Woolton'), except that the other party is very nearly as bad now.

(I voted Green in the MEP and local elections, but let's not kid ourselves - we have a broken system with two real choices, particularly when it comes to parliamentary elections. Not that I'd ever vote labour, or am even eligible to vote in parliamentary elections, mind.)
posted by Dysk at 4:01 AM on July 29, 2009

One of the things that hasn't come up in the thread yet is that it is too easy to access socialised healthcare in the UK.

I'm all for the NHS. I don't mind foreign nationals using the NHS, as long as we have reciprocal agreements with their systems, or they are UK taxpayers, or they pay.

But it is relatively easy to be a health tourist to the UK. And it shouldn't be, which sounds heartless but is no less calculating than individuals who abuse the system. It's free at the point of care, but clearly not free to fund.

More background here, here and here. Estimates range from £60m-£200m per year, but given the levels of checks, (and apologies for coming over all Daily Mail) I doubt if that is accurate.

Just to put this number into perspective, I work for an NHS department. That's one department for one (admittedly big) hospital within the NHS.

Our expected annual income for the department? Just over 60m. £200 million wouldn't come close to covering the directorate's annual budget, and there are half a dozen directorates within our two-hospital trust.

Yes, there is a leak. But by NHS standards it's peanuts, and stopping it would cost far more. (We'd effectively need a dedicated full-time person in each hospital A&E room checking IDs. Say three posts per hospital at £25k/year each (including overheads) for 24 hour coverage = £75k/hospital. Say 1000 hospitals in Britain and you're into the £75 million range just to add sufficient bureaucracy to the system to piss off all the legitimate patients. F**k that!).
posted by Francis at 7:34 AM on July 29, 2009 [3 favorites]

But it is relatively easy to be a health tourist to the UK. And it shouldn't be, which sounds heartless but is no less calculating than individuals who abuse the system. It's free at the point of care, but clearly not free to fund.

You're quite correct, it is no less calculating. In fact, it's a damn sight more calculating than some bloke going to the hospital A&E because he got injured, and getting some fixin' he wasn't technically legally entitled to. It's also an unhealthy obsession (that the Danes, or at least the Danish system, seems to share) with making sure nobody gets anything beyond their deserts, to the point of implementing counter-measures that are significantly more costly than the problems they're meant to fix.
posted by Dysk at 8:14 AM on July 29, 2009

I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation.

This opinion, once again, forgets what we're talking about. We're not talking about free cars, free boats, free vacations, or free clothes -- sure, you give those away, and hey why should I bust my ass trying to get ahead?

Rather, we're talking about free health care. I know LOTS of people that are working a shitty, low-paying, dead-end job -- pretty much the antithesis of "innovation and creation" -- just for the health insurance. They're locked in. They absolutely cannot strike out on their own, because they have diabetes, or have had cancer and fear it will recur... whatever. This is what the system of private health insurance has doomed them to.

National health care would remove the yoke, freeing those with medical conditions (or fear of medical conditions) to pursue their dreams.
posted by LordSludge at 8:17 AM on July 29, 2009 [5 favorites]

LordSludge: "National health care would remove the yoke, freeing those with medical conditions (or fear of medical conditions) to pursue their dreams."

This is the most straightforward explanation of why we'll never get universal healthcare.
posted by mullingitover at 9:19 AM on July 29, 2009

Yep, the yoke's on us.
posted by Kirth Gerson at 10:04 AM on July 29, 2009

This is the most straightforward explanation of why we'll never get universal healthcare.

Really? I don't get it. Who does this serve?

I think the biggest reason is that people with enough money to afford private health care see any sort of nationalized health care as a step backwards from their perspective. And if they're paying their own way anyhow, why should they pay into the public system? For them, national health care would be a tax increase without benefit and really does smack of socialism -- you're taking my money to benefit other people. This demographic tends to be disproportionately powerful, socially and politically, so they're disproportionately able to drive the national discourse.

Then you have poor people who want to believe that they are a part of the Rich People Tribe, so they support whatever policies help the rich people because "Hey, I'm one of them!! Never mind I make $19k a year -- at least I *look* like them..." And they vote accordingly.

And, of course, you have the entrenched business interests (closely tied to "rich people") lobbying to keep their companies alive and profitable. I'm all for profitable business, but health insurance companies too often run a parasitic business model that adds little value. I can see doctors being afraid that they will suffer pay cuts -- and it may be a legit concern. What has the pattern been in other countries? 20% pay drop? No effect? What??

I dunno... There's a lot of emotion running on the subject, including my own, but I'd love to address the concerns seriously rather than simply brush them aside and say WE REALLY REALLY WANT THIS!! I tend to think the pro national health care argument will still hold up well under scrutiny.
posted by LordSludge at 10:24 AM on July 29, 2009 [1 favorite]

Serious question: Is national health care in the U.S. economically feasible if we allow (rich) people who prefer to pay their own way to opt-out? (i.e., prove you have your own insurance that meets X and Y standards, and you can take a tax cut)
posted by LordSludge at 10:28 AM on July 29, 2009 [1 favorite]

French system has been created in the aftermath of WW2. To some extent, you have to be a socialist to believe that it is going to work fine. But you don't have to be a socialist to benefit from it (as stated here, "All residents in France are obliged by law to have health insurance").
With such a system, there is little to wonder at when the balance sheet ends up in a terrible state. But even with a deficit of more than 20 billion Euros as of 2009, some say that it is still worth it.
Actually, many people think that the health insurance system hasn't to be balanced. We just have to pay what health is worth, which means, to make up for the losses of the system, however high they may be. Because not doing so would induce much more damage, even if we are to forget a more humane point of view, and consider only the possible economical or social outcome.
posted by nicolin at 10:38 AM on July 29, 2009 [1 favorite]

I worry about the loss of social mobilty, for example, the drive to get ahead, the catalyst for innovation and creation.

Access to health care helps social mobility far more than having uninsured people go to the emergency room for care and go bankrupt as a result. Health care is a huge issue for employers and the lower and middle classes. It is a giant benefit for everyone but the insurance companies if we adopt universal care.

Finally, are you willing to sacrifice 40,000 lives a year for the sake of theories about social mobility?
posted by krinklyfig at 10:57 AM on July 29, 2009

And if they're paying their own way anyhow, why should they pay into the public system?

What many of them forget is that they're not actually paying for it on their own. If they get it through their employer - and even rich people often have employers - then their part of the premium is taken out pre-tax. It is, in effect, subsidized by the government, and since the government is run on taxes, which the vast majority of us pay - well, they're subsidized by us.

And they're already paying into a public system, both directly and indirectly. Some people seem to think that nobody's paying for uninsured people, and if there's a single-payer system that would eliminate the state of being uninsured that that would be awful because OMG my money is going to pay for someone's irresponsible lifestyle!!1! or something.

But we're already paying for uninsured people. We're just doing it in a very inefficient and extremely expensive manner. It costs us all too much already. Y'all have seen this latest AskMe, yes? This is shameful, what we do to people.
posted by rtha at 11:04 AM on July 29, 2009

So bottom line: Would their total cost, including taxes, go up? Down? About the same? (Could they opt-out and get the "about the same" option?) This is the real sticking point. All this fuss and bother about "moral hazard", etc. is only so much disingenuous window dressing.

Hey I'm on-board, have been for years. I'm not the one we need to convince.
posted by LordSludge at 3:20 PM on July 29, 2009 [1 favorite]

Are there any Swiss MeFites out there who can comment on their system? Mort Kondracke has a piece in Roll Call that looks interesting to me. But then, as established above, I am a small-minded ogre. ;>
posted by njbradburn at 4:10 PM on July 30, 2009

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