Thus, we have a kind of free market in our healthcare system and it has produced the largest costs and quality is mediocre because care you can't afford is not high-quality (because what you get is no care).
Well, it is a "kind of free market," I suppose we can concede. However, you can't write the current funding set up, off as merely physician vs. payer competition. This sort of cabal - with nearly 50% of funding coming from a single payer[
1], almost all other sources setting their prices off the reimbursement rates of Medicare, and without any price/reimbusement transparency - would never be allowed by the SEC in the private sector for any other industry.
And it is difficult to argue that, in a true free market sense, something like an emergency craniotomy isn't
UNDERVALUED.
Not true. Every American is free to pay whatever physician to get care, as long as they are in agreement (physician accepting patients, etc.). If you want to see an out-of-network physician, go for it; it will come out of your own pocket as in a free market.
A lovely notion, and reasonably true right now. But even if we avoid single payer and go to a two-tier system it isn't a terribly realistic notion. You start increasing the tax-burden to fund public health care and it prohibits people from seeking out and paying for their own private care.
Well, 46 million Americans have the opportunity you are talking about. They aren't doing very well.
Two points about inflating the number of uninsured.
1) 46 million is a easy and well repeated number for the media. However, a huge number of policy wonks concede that the Current Population Survey directly understates those with coverage at any time time[
2] [
3]. It is likely they under report those enrolled in Medicaid and because of the way the question on insurance is posed get negative responses from those currently insured but have had been uninsured in the past year (it is a point in time survey)
Everyone should go look at KaiserEDU's tutorial on the difficulties in
Counting The Uninsured. The
CPS is the major survey for counting the uninsured with several smaller ones including
MEPS and
SIPP.
2) Undercounting the uninsured doesn't tell half the story however. It speaks nothing to those who choose to forgo insurance or about the lack of personal responsibility amongst patients in this country.
Yes there are ALWAYS antecedal stories about the single mother who pulled herself up by her bootstraps and then loses the farm because her son gets a brain tumor. Heart tugging but simply not part of the facts. And yes more than 30% of the uninsured are below the poverty level (which is in and of itself a joke of a measurement of true cost of living anymore, I admit) [
4]
Those being conceded, non-partisan respected estimates put the percentage of uninsured who are either a) able to afford insurance or b) eligible for public assistance (mostly Medicaid) and aren't enrolled at more than 40% [
5] [
6].
The bleeding heart counter argument is that ANYONE uninsured is too many. Who cares if the numbers are inflated, is what you're probably saying right about now. Maybe, but it is important to understand the true magnitude of the problem so we can know how outraged to be.
Let me make it clear, it is difficult to put my personal greed at the heart of my opposition to further government subsidies -- I've got my track record and ideals to the contrary. My distinction, and I don't think it is hair splitting, is that whatever I feel my moral obligation to the less fortunate I refuse to put it on anyone else. Which is exactly what any form of wealth distribution does. Public funds need to be used only for items beneficial to nearly all. And while, as it is for everyone determining what taxes should be spent on, the definition of what nearly all means is very subjective I can say that the bar needs to be very low and health care certainly doesn't fit under it.
Also, before we start blaming the goverment for everything in Katrina, keep in mind that many people chose to live there despite the fact that it is near/below sea level and next to the ocean. Many people chose to stay even though they were told a hurricane was coming. While the government can do many things, in a free society people are free to make unwise choices (as many in NO did).
You're playing into the 'personal responsibility' crowd's hands. And I'm not merely taking about those who get lung cancer with a 15 year smoking history. Another two points to make:
1) This is probably the sickest country in the western world. What I mean by that is that independent of health care access or quality this country is sick. In 2006 Banks, et al found that independent of coverage status Americans were sicker than their English cousins [
7] [
8]. The PI's conclusion in interviews? Lifestyle factors, especially in childhood were to blame on America's poor health.
This country is the fattest in the western world [
9]. And it has one of the longest histories of growing obesity. It has one of the highest rates of trauma and violent injuries. The point is the casual relationship isn't we spend more and get less (which isn't actually a relationship at all) it is we live unhealthy by choice, so we're sicker, because we're sicker we spend more on health care, and because we're sicker we die sooner. Those increased costs drive insurance premiums and leave more American uninsured.
Don't get me wrong, America runs one of the least efficient health care systems in the world. This explanation, at most, contributes a relatively small part to America's health care expenses. But it is significant, and whatever the size of that contribution shouldn't people be taking some personal responsibility before they ask for hand outs?
2) This country has the most consumer debt in the world. More than 2 trillion dollars [
10]. The Urban Institute's analysis of those who could afford health insurance (cited in Health Affairs above) didn't even consider this. As I already admitted above, more than 30% of the uninsured fall below the poverty line, so this discussion doesn't include them.
Plenty of evidence exists that this isn't survival debt, it is merely Americans not living within their means. Americans are working to pay off the dimes they spent on that new television or pair of shoes or tupperware and yet at the same time they're clamoring for health care reform with further subsidization of their health care expenses? They can't even show the common sense or strong will to cut up that pre-approved credit card offer so that they might have some money to budget for their health care expenses.
This is an example of a growing entitlement culture. I mean, for all the lavish praise laid on universal health care, in many ways why would we want to follow europe down this road of socializm and guarantees. Take a look at what an entitlement culture has done to their unemployed figures...but at least those unemployed don't have to worry if they get sick I suppose[
11].
No, this complaint doesn't apply to all but it does change the frame of the debate. If you concede the above then back off your single payer talk. Start discussing a public assistance program with strict eligibility rules based on income...call it Medicaid-For-All. Then we can have a discussion, with those who should be able to afford insurance out of the picture.
It is often not a matter of being able to afford good health insurance. Millions of Americans do not qualify for individual coverage at all due to pre-existing conditions such as diabetes, obesity, or other issues. They can't buy it at any price if their employer did not provide it as group coverage. Take Blue Cross Blue Shield for example. When you apply, they ask you your height and weight. Those who are obese don't qualify for that company's health insurance ... that's 30% of the population that doesn't qualify right there. On top of that, my 1 & 2-year old boys are perfectly healthy and not obese (per their pediatricians) and they do not meet the height and weight requirements. Fundamentally, private health insurance companies have a profit motive, not a public health motive. Only the government is in a position to strongly advocate care and ultimately manage healthcare with help from the private sector and significant input from its citizens.
A legitimate common complaint. Although I can't find nor have I ever seen any numbers on this, which makes me dubious, because people cite it all the time.
If this is your primary complaint then stump for mandated community rating for private insurance. Sure, I might not like over government regulation of the insurance industry, but I promise myself and just about every other libertarian would buy it more than a single payer idea.
Without the government's help, many industries would be utterly destroyed by foreign competition, patent violations, fraud, etc.
What? There's no globalization of health care. If your point is that government is already involved in the market so why shouldn't it be in health care...well the answer is easy. There's a huge difference between the way the market SHOULD work and the way it must pragmatically work. If the government doesn't HAVE to be involved in health care
to protect it, then it shouldn't be. No one wants to leave our manufacturing industries out to dry, so we look for ways to assist them. But in an ideal world China would let its currency float so its export products weren't artificially cheap, etc.
In fact, I advocate a two-tier system, with a single payer (ala Medicare that covers everyone, but with copays) and optional additional/supplemental private coverage. In this way, everyone has at least access to healthcare, and if it is a priority and they have the means, they can spend more of their own money to get additional care.
As I said above, this is an inadequate compromise. Proponents of a two-tiered system should not pretend it is the best of both worlds - covering all while protecting liberty. Increased tax burdens prohibit many of those who want private insurance from affording it in a two tier system. The UK has a private insurance market which is not very utilized. It is my contention that the lack of utilization is due to inaffordability, not with satisfaction with the National Health System. Indeed, in 1999 only 61% of UK residents were satisfied with the NHS [
12].
Obviously the UK's tax burden is large and its socialized system puts unique pressures on the private insurance market. But it is certainly an example of what can happen to the reality of 'private insurance choice' in a two tier system with a large tax burden.
Sorry to be so aggressive about this. Maybe I'll go back and edit my message for a better tone. I'm a firm believer in using objective facts when it comes to problems like this. If you would just give objective information a try, I think we could make more progress in a discussion like this.
Well, maybe you'll take my response a little more seriously.
http://www.nchc.org/facts/coverage.shtml
"Nearly 82 million people - about one-third of the population below the age of 65 spent a portion of either 2002 or 2003 without health coverage (1).
"In 2004, 27 million workers were uninsured because not all businesses offer health benefits, not all workers qualify for coverage and many employees cannot afford their share of the health insurance premium even when coverage is at their fingertips(4).
"Millions of workers don't have the opportunity to get coverage. A third of firms in the U.S. did not offer coverage in 2004 (2).
Almost assuredly all facts derived from the Current Population Survey and other census bureau surveys. Not a criticism, just a point. As cited above you should go check out some critiques of them...although they only lower the magnitude of the problem. The problem still remains the elephant in the room.
"Getting Everyone Covered will Save Lives and Money
"The impacts of going uninsured are clear and severe. Many uninsured individuals postpone needed medical care which results in increased mortality and billions of dollars lost in productivity and increased expenses to the health care system. There also exists a significant sense of vulnerability to the potential loss of health insurance which is shared by tens of millions of other Americans who have managed to retain coverage. Every American should have health care coverage, participation should be mandatory, and everyone should have basic benefits.
Sadly this misses the point, as does basically my entire post up until now.
For all I've cited and all you've cited, the argument over government funded health care is really one of political philosophy and morality.
Libertarian proponents may get side tracked, or more likely are scared of appearing heartless, and go out and cite all sorts of figures or make all sorts of arguments trying to display the free market as a pragmatic solution.
I concede right now that single payer and socialized medicine system, while sacrificing choice and increasing waiting times, are cheaper and in terms of common imprecise measures (don't get me started on comparing infant mortality and life expectancy figures...what a joke) of health care quality are at least equal with the American system or a true free market system.
I concede that the safety net in this country is inadequate to provide the uninsured with the same medical attention and quality that the insured have, and that the uninsured die at a higher rate and with live their lives with a lower quality of life.
And after those concessions, I wipe the tear away and promise to do my personal best to correct those WITHOUT FORCING SUCH ON ANYONE ELSE.
I simply cannot defend wealth distribution. Correcting inequalities is simply not the role of government. There's several winding roads I can take to come to this conclusion. Lets take an obtuse one.
A) A progressive tax system and government funded health care redistributed wealth.
Everyone can agree to that.
B) Wealth distribution denies some of liberties.
IF, you believe in property rights then you almost have to agree with this. Implicitly you're choosing some right to a quality of life level over property rights.
C) The quality of life level or the level of health care guaranteed is subjective.
There is a huge amount of indefensible subjectivity in determining wealth redistribution. Oh you get this health care covered but not this other procedure. Oh you get health care but not a roof over your head.
At first it seems like a pragmatic determination, because you don't have the monies. But remember if you wanted to you could go and take more money in taxes. What you've done is weighed property rights against the rights to health care and come up with a scale - oh it is okay to take this much from the wealthy to guarantee this much health care for everyone, but it isn't okay to take more than that.
There are of course
reasons you made the choices on the tax rate and on which procedures would be covered and on how many MRI machines there would be or why you spent the money on health care rather than on housing the homeless. There are economic and social factors in this determination but from a solely philosophical point of view the determination (no matter what it turns out to be) is subjective and illogical. At least in my mind.
The only seemingly sound and defensible positions are either a) no redistribution of wealth or b) equal redistribution of wealth guaranteeing all the same quality of life.
I've made a circumstantial argument (probably with many fallacies in it) which concedes that complete redistribution of wealth has a logical road to it. Throw out the idea of individual property rights and throw in some collectivism and you have ideal communism. Short of you advocating that, I think government subsidized health care has to be condemned.
---------------------
1) Wall Street Journal Graphic From CMS Data
2) Urban Institute On Counting The Uninsured
3) Heritage Foundation On Counting The Uninsured
4) Kaiser Family Foundation, "Health Insurance In America"
5) Health Affairs Blog
6) Health Affairs Article (Subscription Required)
7) USA Today On Study
8) Study In JAMA
9) Forbes' Fattest Countries
10) MSN On Consumer Debt Circa 2003
11) Challenge Magazine On Europe's Unemployment...All The Way Back In 1998
12) European Foundation National Health Care Systems Satisfaction
