Universal Health Care & Personal Health Concerns

On a pandagon thread about socialized medicine, a commenter called Catty writes, “I know 2 die-hard libertarians that are now universal health care supporters. Funny how problems like multiple sclerosis and cancer can change people’s minds.”

I have always supported universal health care, but jesus fuck she’s right.

A couple weeks ago, I started having some strange symptoms. Last week, I went to the ER to speak to a physician, and she said the things I didn’t want to hear — namely, that my symptoms were consonant with two bad diagnoses: diabetic neuropathy and multiple sclerosis.

I have since been to my regular physician who is not nearly so concerned. I am still being checked for diabetes, but she’s holding off on the MRI to diagnose for multiple sclerosis for now. We’re first looking into other possible causes which are much more benign, such as hypothyroidism, advanced anemia, migraine, and anxiety.

I am an incredibly privileged woman. I’ve never been without health care. My health insurance is incredibly good. I pay $5 for doctor visits, and $5 for medications. I’ve always known that my health insurance was great, but I don’t think it’s ever really hit home for me how much uninsured people have to pay for their health care — not just going into debt, but going bankrupt, becoming homeless, and sometimes having to make the difficult decision to let themselves or their loved ones die from treatable illnesses.

Another commenter called Jodie relates the following story, “My 27 year old brother in law developed an intense headache on a Thursday, dx’d as brain tumor after an MRI, had surgery, went to intensive care, had chemo, and died prior to the next Thursday. Cost after insurance: $280,000 (at last count, I don’t think all the bills are in yet)… That bill was amassed in less than a week.”

Note: After insurance.

Other commenters discuss surgery for marrow transplants coming in at $250,000, refills for cancer drugs being in the thousands of dollars, a course of treatment for a major illness costing hundreds of thousands. Canadian commenters relate how relieved they are to live in Canada, after considering the ramifications of the major illnesses in their lives should they happen to have been American and uninsured. When a parent, a sibling, and another close relative are sick, often the whole family can’t find enough money to fund health care for all of them, even when they go into debt. They must choose bankruptcy or death.

Treatment for uninsured people is abominable. Uninsured people often have no choice but to obtain their health care through emergency room visits, which are phenomenally expensive. Pandagon commenters report paying $300-1,200 for emergency room visits, for things as routine as obtaining antibiotics for a bladder infection. One commenter notes that his $320 physical meant that he had to put off paying his bills for a month.

Facing debt, uninsured people often put off going to the doctor until their dieases have progressed beyond treatment. Worse, if they do go, they may be ignored. Pandagon recently reported incidents of uninsured people being left to die in hospital emergency rooms.

In the emergency room at Martin Luther King Jr.-Harbor Hospital, Edith Isabel Rodriguez was seen as a complainer.

“Thanks a lot, officers,” an emergency room nurse told Los Angeles County police who brought in Rodriguez early May 9 after finding her in front of the Willowbrook hospital yelling for help. “This is her third time here.”

The 43-year-old mother of three had been released from the emergency room hours earlier, her third visit in three days for abdominal pain. She’d been given prescription medication and a doctor’s appointment.

Turning to Rodriguez, the nurse said, “You have already been seen, and there is nothing we can do,” according to a report by the county office of public safety, which provides security at the hospital.

Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone’s apparent indifference.

Arriving to find Rodriguez on the floor, her boyfriend unsuccessfully tried to enlist help from the medical staff and county police — even a 911 dispatcher, who balked at sending rescuers to a hospital.

Alerted to the “disturbance” in the lobby, police stepped in — by running Rodriguez’s record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

At the same hospital, in 2003, “20-year-old Oluchi Oliver waited hours to be admitted to the hospital with crippling stomach pains, according to his family. After 10 hours, he collapsed dead on the floor. No one noticed, his father, Akilah Oliver, said.”

I had a brief hiccup with my insurance coverage the day I decided to go into the ER, and it looked like I might not be covered at all. (Now, I’m covered by two health care plans.) I almost didn’t go in. My mother told me I had to go in, that they’d find a way to fund it if I were sick. We are extremely well-off for the United States, but I doubt that even we could find a way to pay $250,000 if I didn’t have insurance and needed a marrow transplant.

I’m watching my reactions as I read this Pandagon thread. I am so scared. I probably don’t have MS. I’m repeating this to myself as a mantra. My other mantra involves facts about MS. If I do have MS, I have all the indicators of a good prognosis. I am young, white, and female. If I do have MS, it’s extremely likely that I have the type that remits, instead of the type that progresses until you die. Hell, 15% of people who have MS never suffer a second attack.

And there are drugs! One of my fiance’s professors told him about two people she knows with MS, who were diagnosed in their thirties, and who now, in their fifties, have been kept symptom-free with drugs. I called one of my friends who is in medical school, and he told me to remember that both MS and diabetic neuropathy require lifestyle changes, but may not affect life quality.

Even in the worst case scenario, I’ll be okay. That’s not enough to keep me from worrying or being depressed, but it’s good news. Nevertheless, I’m a basket case as I wait for my blood test results.

I can’t imagine how much worse it would be if I didn’t know how I was going to pay for the medical expenses of my doctor visits, my blood tests, my MRIs, my visits with the neurologist and/or dietician. Without insurance, would I be able to afford those drugs that could keep the multiple sclerosis in check, preventing me from losing the use of my limbs, my speech, and my brain?

I don’t understand how anyone can oppose universal health care. A libertarian in that thread is spouting off strange talking points. Some are demonstrably false. Countries with socialized health care do not have more bureacracy than we do; they have less, because hospitals don’t have to deal with insurance claims. They don’t have longer wait times than we do. They don’t force patients into predetermined courses of treatment. The cost in taxes is more, but studies have shown that while taxes are higher in many countries with socialized medicine, the American middle class ends up screwed with their lower tax rate — because we have pay not only our taxes, but we also have to pay through the nose to privately fund things that countries like Sweden provide for free. We end up paying a huge amount more, just so we can claim that we have lower taxes.

One of his talking points is that he doesn’t feel he should be forced to help people who are less fortunate. Does he understand that he’s talking about people who will die without his help? Help that he will benefit from, because he as a middle class American would pay less if taxes were higher but provided more services? Someday, he may have a medical emergency, and god forbid he should be denied his insurance. He may bankrupt himself and his whole family. If he chooses to finish treatment, he might lose his home. We might force him, as we force others, to choose between the basic necessity of shelter, and death.

Meanwhile, he can’t even imagine those scenarios. Over and over again, he talks about the undue burden that would be placed on him if he had to help other people. He can’t imagine himself in their shoes. If he can imagine their pain, he doesn’t care. What a strange, frightening lack of empathy. What a limited view of the world.

My empathy is heightened right now, because of course this medical issue has me sensitized to issues of my own mortality. It’s odd to move from the life in which I thought of myself as healthy, to the life a few days later when I realize that I could have a progressive and debilitating illness.

I don’t want to be going through this. I want to feel safe and well again. Hopefully, my diagnosis will be benign, and soon I will be feeling safe and well again. Even if I have MS, I am sure that eventually my sense of weakness, fear and vulnerability would dull, and my illness would become just another part of my life. That’s another thing I’ve been repeating to myself for the past couple weeks. Studies show that paraplegics are just as happy one year after their injury as they were before it occured. People are amazingly adaptive; anything can become ordinary. If they are equally happy after that, then I will surely be equally happy even if my diagnosis is MS.

I am so amazingly lucky to be worrying only about my health. If I were worried that I was about to bankrupt my loved ones, and that I wouldn’t be able to afford life-saving care, this painful experience would become a constant waking nightmare. Any person who would wish that on other people is both monstrous and lacking in empathy.

This entry posted in Class, poverty, labor, & related issues, Disabled Rights & Issues, Economics and the like. Bookmark the permalink. 

331 Responses to Universal Health Care & Personal Health Concerns

  1. 301
    Jamila Akil says:

    Sylphhead Writes:

    To Jamila, Nick, and David Gratzer, I provided a study that, among other things, queried Canadians on their own experiences with their health care system. 3.5% reported that waiting times had resulted in an unmet health care need*. Three point five percent. However of a ‘little’ problem, however much of an ‘oh, that too’ you consider the nasty side effect of the American system whereby a significant number of people go uninsured, know that it is precisely 15/3.5 = 4.2857 times the problem that waiting times are for Canada.

    How many people are uninsured is not as important as how many people are going without care. In the United States just because you don’t currently have any insurance does not mean that you go without care. There are thousands upon thousands of illegal immigrants who will show up at hospitals in the US this year and get care that is just as good as the people who show up at the exact same hospitals with insurance. There are millions of poor people in America who are eligible for Medicare but are not insured because they have chosen not to be. There are millions of people in America who make over $50,000 a year and choose to forgo insurance because they don’t want to pay for it or because they don’t see a need for it; after all, if something serious happens to them they will not be turned away from a hospital.

    “Uninsured” is not a synonym for “not receiving medical care”.

    “Single-payer systems — confronting dirty hospitals, long waiting lists and substandard treatment — are starting to crack”

    Again, that would be a first, given that so far in human history, many, many countries have made the switch from private to public health care, while none so far have moved from public to private.

    There is often a first time for everything. UHC is a relatively recent development on the world stage.

    “One often-heard argument, voiced by the New York Times’ Paul Krugman and others, is that America lags behind other countries in crude health outcomes.”

    Krugman mentions disability adjusted expectancy and potential years lost – adjusted, controlled measures taken by the medical community as definitive, which is more than I can say for the extremely problematic measure Gratzer… cites.

    According to this press release by the WHO the US is ranked #24 for DALY From the press release:
    The WHO cites various causes for why the United States ranks relatively low among wealthy nations. These reasons include: 1) In the United States, some groups, such as Native Americans, rural African Americans and the inner city poor, have extremely poor health, more characteristic of a poor developing country rather than a rich industrialized one; 2)The HIV epidemic causes a higher proportion of death and disability to U.S. young and middle-aged than in most other advanced countries. HIV-AIDS cut three months from the healthy life expectancy of male American babies born in 1999, and one month from female lives; 3) The U.S. is one of the leading countries for cancers relating to tobacco, especially lung cancer. Tobacco use also causes chronic lung disease; 4) A high coronary heart disease rate, which has dropped in recent years but remains high; 5) Fairly high levels of violence, especially of homicides, when compared to other industrial countries.

    In previous posts on this thread I have referred to reasons number 1 and 2 to explain why the US ranks so low on many national rankings, but also notice reason number 5. In post #287 I also made note of the extremely high incidence of homicide and unintentional accidents in the US which lowers our DALY. What can a health care system do to stop gun violence?

    Just so you know, I think Paul Krugman is an idiot. The man’s arguments have been ripped apart on NRO more times than I care to mention.

    As for infant mortality, it’s hard to square Canada having comparable rates with the US only until it adopted UHC, or similarly differing maternal mortality rates, without UHC looming in as a major factor.

    I believe this is your second time making this statement. Please provide a link that says Canada’s infant mortality and maternal mortality rates were similarly to the US until the Canadians adopted UHC. If you have already provided the link and I overlooked it previously then apologies on my part and please point out which post it was on.

    It could be that Ohsfeldt and Schneider’s work was perfectly legitimate and has addressed my concerns. It merely needed a better man than Gratzer to vouch on its behalf. But I’ve seen too many statistics – adjusted in the ways that I’ve described – before I can allow this one further into the mix.

    You can always go buy the book by Ohsfeldt and Schneider and you can also read the WHO study on DALY rankings ( see above) that the press release refers to.

    This article is excellent and briefly makes me forget that I hate TNR. I’ll quote the relevant parts.

    I’ve already talked about many of the factors that the article brings up which make US health care look bad so I won’t readdress them, however I will talk about the ones that haven’t already been discussed.

    “Look at Japan. It has universal health care. It also has more CT scanners and MRIs, per person, than the United States.”

    And yet we still have Japanese people coming to the US for cancer treatment

    “It’s true that the European countries tend to have less technology (although Germany and Switzerland appear to be comparable or at least very close.) But their citizens get more of something else relative to Americans: Face time with doctors and time in hospitals. Take France, for example. As New York University’s Victor Rodwin has noted, on a per capita basis the French get more physician office visits and more drugs than their American counterparts.

    1) Americans make fewer trips to their doctor per year but spend more time with their doctor per visit. Thirty percent of American patients spend 20 minutes or more with their doctor on a visit compared to 20 percent and 5 percent spending more than 20 minutes with their doctor in Canada and Britain, respectively.

    2) More time in the hospital does not necessarily equate to better care. If a person is in the hospital and they are healthy enough to be at home instead ( and there is no increased risk of negative health outcomes from being home) then the extra time spent in the hospital is a sign of inefficiency. The result is a waiting list for hospital treatment, which you see plenty of in Canada and Europe LINK

    3) According to OECD Health Data 2002, France spent $290 per capita on drugs ( the highest per capita) and the US was right behind with $283; Japan was a close third at $281. Not very much of difference, eh?

    When a woman in France gives birth, she gets to stay in the hospital for an average of nearly five days — even if it’s a perfectly normal delivery. In the United States, on average, a woman with normal labor and delivery gets to stay less than two.
    Why the difference? The big reason is that private insurance in this country has squeezed inpatient time to the bare minimum, while universal coverage in France has preserved longer periods for convalescence — just as it has in other countries. The Germans get almost as much time as the French.”

    See my point #2 directly above. If there is no increased risk of adverse health outcomes for mother and child by going home after 2 days versus going home after 5 days–why not increase it to 8 or 15 days while we’re at it?–then for a patient to stay in the hospital longer than they need to is a sign of inefficiency, a waste of hospital resources that is keeping someone from entering the hospital who probably needs to be there more than the post-partum mother.

    I had a baby and was ready to go home the next day but the hospital wouldn’t let me take my baby with me, so I stayed in the hospital because my baby was there and my insurance would pay for me to stay another day or two.

    But this is what UHC’s do very well: overspend on healthy people while forcing many sick people to wait for care.

    “……..But Americans on the whole are no less likely to die of the disease [prostate cancer] than Germans on the whole — and the same is true for most of the other well-developed countries in Europe. In fact, the percentage of the population that dies from prostate cancer is remarkably consistent between the United States and the most advanced European nations.”

    From a link that Dianne provided: “In Germany, survival was significantly higher for patients with stomach cancer, whereas survival was higher in the US for patients with breast, cervical, prostate, colorectal and oral cavity cancer. Among the most common cancers, age-specific survival differences were particularly pronounced for older patients with breast, colorectal and prostate cancer……This comprehensive survival comparison between Germany and the US suggests that although survival was similar for the majority of the compared cancer sites, long-term prognosis of patients continues to be better in the US for many of the most common forms of cancer. Among these, differences between patients with breast and prostate cancer are probably due to more intensive screening activities.”

    “The Swedes are more likely than Americans to survive a diagnosis of cervical, ovarian, or skin cancer; the French are more likely to survive stomach cancer, Hodgkins disease, and non-Hodgkins lymphoma. Aussies, Brits, and Canadians do better on liver and kidney transplants.

    I can concede that due to variations in screenings and other preventative measures no country is the greatest at catching and treating all forms of cancers.

    But the fact that countries with universal health care routinely outperform the United States on many fronts……..

    And the US routinely outperforms other nations with UHC on just as many, if not more, fronts.

    …. and that, overall, their citizens end up healthier

    Their citizens are not any healthier overall and in cases where they appear to be healthier it has virtually nothing do with supposedly having a better health care system.
    .

    You don’t see their citizens choosing between prescriptions and groceries, or declaring bankruptcy, because of medical bills.”

    I do see many of them dying on waiting lists, suing their governments to opt out of treatment under the UHC, traveling to the US or other countries for treatment ( if they can afford to), complaining to their representatives that the health care system needs major reform, and the list goes on and on…….

  2. 302
    sylphhead says:

    Here are the two links from earlier, fixed; the one dealing with treatment in general, and cancer specifically.

    Also, before we go any further, I’d like a straight answer to my proposal in post 299. Yay or nay?

    “So who are you going to believe, the commonwealth fund or the WHO?”

    Jamila, you are saying one of two possible things here, both of which are misunderstandings of the scientific process.

    First, given a dispute between two teams of researchers, there’s no tiebreaker for the team whose commission came from an institution with greater name draw. If a physics team from Stanford finally proved that the Higgs boson existed while another team from U of Washington proved something that upset the original hypothesis, we don’t say that ‘well, STANFORD must be right’. This is an ad hominem in the purest sense. (Besides, wasn’t it WHO who so insidiously included breadth of government involvement in a ranking of health care quality? You impugned them on that, and I agreed, but now it seems bygones are bygones?)

    Second, if two studies come up with results that are diametrically opposed, it doesn’t follow that at least one of them must have been fundamentally flawed in some way. Especially outside of the hard sciences, it’s entirely possible for the researchers to have been perfectly methodical and fair and yet for them to get different results; in a case like this, usually this means the things being compared are close enough that a slightly differently worded variable (say) in the methodology could swing the results. If two findings oppose each other this way, the right question isn’t to bet on which horse; science isn’t a dogtrack. Just to start you off, the right questions to ask how the methodologies differed (note again that the perceived prestige of the institution that commissioned the study is not counted under ‘methodology’), under which circumstances are one of the two methodologies more applicable, etc.

    There is a third possibility, actually; you just may be accusing the Commonwealth Fund of being plain old untrustworthy. Even if you were to do this, which I doubt you’re doing, the time for it has long since past given that you quoted from them yourself back in your own post 192. (Remember?)

    “Once again, I have no idea how you managed to come up with that conclusion from a study that only compares metropolitan areas in Canada and the US.”

    If the Toronto-Honolulu study bothers you, then the cancer link I provided on top of this post expands the net to Detroit, not to mention that cancer is included in the table from a study I referenced earlier:

    http://www.openmedicine.ca/images/8/table3.png

    It’s actually part of a series that included a string of American metropolitan areas; three more are included here.

    Now, corroborating sources are always nice, but in any case I’d like to point out that even the Toronto-Honolulu connection by itself is far better than any evidence that has been posited the other way. Tanner, Gratzer, et al. will have to account for that graph I linked to on post 299 before they can continue to claim what they do about cancer survival in America and Europe.

    “I have no idea where you came up with conclusion from because it definitely wasn’t in the link you provided.”

    Hmm. Yes, it appears so. I do remember recalling a study along those lines during the course of this debate, but I apparently didn’t link to it and mislabeled a somewhat different link. The McMasters link on top of this post mentions Canadian superiority over America given the same diagnosis; perhaps the study I remember reading was the expanded version of the same? Consarn it, organiseur extraordinaire, I ain’t.

  3. 303
    Dianne says:

    And yet we still have Japanese people coming to the US for cancer treatment

    That’s ok. We also have Americans going to Japan for cancer treatment. (Admittedly, a Japanese American going to Japan for stomach cancer treatment. The US does stomach cancer very poorly. ) I’m afraid my reference is personal and therefore I’m not going to give any confirmatory details so feel free to believe I made the whole thing up if you’d prefer.

  4. 304
    Dianne says:

    Sigh. I knew that abstract was trouble. Read the full Gondos et al article. The conclusions are quite different from what you expect. There are a number of confounders that make the equation of higher 5-year survival with better care questionable.

    First, stage at diagnosis is generally higher in Germany compared with the US. They aren’t doing enough screening (mammograms, colonoscopies, etc). This is changing, but the results of these changes won’t be obvious for several years. If you compare stage specific survival, most of the difference disappears. Second, patients in Germany had a tendency to be older and older age is associated with worse prognosis in almost all cancers. Third, we’re pretending that the data from the US is representative of the Us, but it may not be really. The SEER data is a collection of data from areas in the country that have really good databases. But an area with a good database is also an area that is likely to have good cancer care. It isn’t proven to be a factor, but might well be. Finally, survival was actually higher in Germany for many of the most chemotherapy sensitive cancers, including non-Hodgkin lymphoma, testicular cancer, the leukemias (no subdivision was done), and multiple myeloma (though the differences are stated to be non-significant, although they are quite large in some cases. For example, a 58.7% 10-year relative survival for NHL patients in Germany versus 53.3% in the US. Though HIV rates may confound this…)

    An interesting way to test the question of whether new treatments come into use more or less quickly in a universal health care system might be to look at changes in survival in chronic myelocytic leukemia. There was a major breakthough in CML treatment in 2001 and the majority (>90%) of patients with CML who receive the new treatment will survive >5 years. So looking at changes in 5-year survival might be an interesting proxy for use of the med. Not sure you could get enough numbers to be significant though. CML is relatively rare. Sigh. Back to the drawing boards.

    Incidently, I notice that the only model for a non-universal healthcare system that anyone has used is the US. But the US is exceptional in a number of ways, including having one of the best publicly funded research programs in the world. Why not look at other countries without UHC as well. For example, South Africa. It’s an industrialized country with a high functioning economy but, at least traditionally, without UHC (this may have changed…if anyone knows maybe they can correct me.) Outcomes are not so good though. Anyone have other examples?

  5. 305
    sylphhead says:

    “How many people are uninsured is not as important as how many people are going without care. In the United States just because you don’t currently have any insurance does not mean that you go without care. There are thousands upon thousands of illegal immigrants who will show up at hospitals in the US this year and get care that is just as good as the people who show up at the exact same hospitals with insurance. There are millions of poor people in America who are eligible for Medicare but are not insured because they have chosen not to be. There are millions of people in America who make over $50,000 a year and choose to forgo insurance because they don’t want to pay for it or because they don’t see a need for it; after all, if something serious happens to them they will not be turned away from a hospital.

    “Uninsured” is not a synonym for “not receiving medical care”.”

    I’d advise you not to underestimate the reality of being uninsured. But aside from that, the last statement is salvageable; indeed, uninsured does not mean that you don’t receive medical care, ever, at any point. But then, neither does being on a waiting list mean that you don’t receive medical care; especially since much of the waiting lists are filled with elective procedures. Both, however, are serious impediments to getting adequate, timely care. I’d argue that, even leaving aside the numbers I’ve brought up, being uninsured is worse than being on a waiting list. But then, I don’t need to. There are far, far more Americans whose access to care is impeded by lack of insurance than Canadians on a waiting list. The study I linked to compared only Canada to the US, but I’d expect the situation to be similar with the other Anglophone nations with UHC, and rather better in Continental Europe and East Asia.

    Also, note that even my earlier math was being too generous. 15 is a lowball estimate; I’ve heard estimates as high as 18.5, and note that this percentage is rising, not falling. Leaving that aside for now, we should at least include the 1 percent of Americans who cited waiting lists as an obstacle to receiving treatment; while a nation like Canada has only waiting lists as a problem, America has both the uninsured and its own waiting lists. So that wonky number should be at least 16/3.5, which I won’t go through the trouble of calculating in my head again.

    “1) Americans make fewer trips to their doctor per year but spend more time with their doctor per visit. Thirty percent of American patients spend 20 minutes or more with their doctor on a visit compared to 20 percent and 5 percent spending more than 20 minutes with their doctor in Canada and Britain, respectively.”

    Read the link I provided on post 299, hyperlinked “More on waiting lists”.

    “2) More time in the hospital does not necessarily equate to better care. If a person is in the hospital and they are healthy enough to be at home instead ( and there is no increased risk of negative health outcomes from being home) then the extra time spent in the hospital is a sign of inefficiency.”

    True, but the same is true of technology. If you have two competing private hospitals situated within the same section of the city, they will both buy PET scanners, MRI’s, and the like. Since resources are finite, that’s less money to spend on, say, general practitioners, of which there is a shortage in the US. If the two hospitals were public and did not have to compete, they could arrange for the one, ‘bigger’ one to get the machines – there’s no need for two hospitals in the same district of the same city to have expensive machines imported that will only be used on a small minority of patients – while one specializes in general care. In this case, more technology is the inefficiency.

    In fact, that same article mentions that measuring inputs – be it technology or time spent in the hospital – is problematic for these reasons. It then goes on to discuss outputs.

    “If there is no increased risk of adverse health outcomes for mother and child by going home after 2 days versus going home after 5 days”

    Might I remind you that both maternal and infant mortalities are significantly higher in the US?

    “I do see many of them dying on waiting lists, suing their governments to opt out of treatment under the UHC, traveling to the US or other countries for treatment ( if they can afford to), complaining to their representatives that the health care system needs major reform, and the list goes on and on…….”

    Am I reading this right? The reason why the article mentioned that last part was to say that, it’s damn near impossible to set apart any one developed country in the world as providing better treatment overall. The article is saying that, in the event of a gridlock, the banana goes to UHC, because it doesn’t saddle us with the moral complications of the uninsured, financial insecurity and medical bill-induced bankruptcies, needed procedures being delayed by insurance companies trying to squeeze out the last ounce of profit, etc. etc. Do you dispute this? If Americans nationwide were polled with this same questions (if quality of treatment was basically even, and the remaining drawbacks to both are the following…), what do you think they’d say, on the average?

    Also, Americans sue their health providers and doctors. Americans complain to their representatives about health care reform. Americans secretly buy drugs from Canada. Though I’m sure that the first are ‘nuisance lawsuits’, the second are ‘hysteria and demagoguery’, etc. etc. That, my friend, is a double standard.

    (EDITED FOR CLARITY)

  6. 306
    sylphhead says:

    Jamila, your links don’t work – I tried reading the WHO press release, but I got an error 404. Are you typing your responses first on a word processor, then copying and pasting onto the comment box? If so, you’re going to have to retype the hyperlink code; the same thing happened to me.

    That being said, I’d like to address the five points given by the press release (yes, I realize you didn’t pen them, a WHO official did; that doesn’t make them correct).

    Only (5) is something legitimate to consider as a factor that excuses American health care, given that gun violence is indeed completely outside its realm. (2), (3), and (4) are far less sound; every country has, for reasons of history, culture, geography, climate, demography, etc. a number of ailments that affect it acutely. The US isn’t the only one. Also, given that already we’ve found that Canadians smoke more, and Europeans drink more and have more sex, do we really want to go down route (3)?

    (1) is just outright ludicrous. If you want an urban/rural split that would really cast a wrench into the whole apparatus, visit Italy sometime – first the north, then the south. Visit Germany, starting from the West, and then to the former East Germany, and see how much ‘parity’ has been achieved. Visit Canada, starting from the big cities that hug the 37th parallel and the St. Lawrence River, then going gradually upward, where you visit all the First Nations Reserves and population density so sparse it takes three hours’ drive in a trailer or pickup truck to get to a hospital. Visit South Korea or Japan, where the cultural gap between urban and rural is so high that young adults in the city set the fashion for electronics and clothing accessories for the rest of the civilized world whereas in the countryside many still live as if contact with the West had never been made, worship the old folk gods, and distrust modern technology, including medicine. Ay yi yi.

    “Incidently, I notice that the only model for a non-universal healthcare system that anyone has used is the US. But the US is exceptional in a number of ways, including having one of the best publicly funded research programs in the world. Why not look at other countries without UHC as well. For example, South Africa. It’s an industrialized country with a high functioning economy but, at least traditionally, without UHC (this may have changed…if anyone knows maybe they can correct me.) Outcomes are not so good though. Anyone have other examples?”

    For a variety of reasons, I *wouldn’t* consider South Africa a fully developed country and so perhaps throwing it in the bin with non-UHC is unfair. However, you’re right in that the US is unique in being the most powerful country, the most resources and the wealthiest, etc. etc. Having one example stand in for a principle leads to some imbalance. For instance, one could pick and choose which UHC to compare it with… “AHA! US has more MRI’s than Canada!” (But Japan has more than the US.) “AHA! Japanese tend to live longer, including Japanese-Americans!” (But the same cannot be said for Canadians, who also tend to live longer than Americans.) Back and forth, ad infinitum. It’s not sound, productive, and in the end, even honest, reasoning.

  7. 307
    Dianne says:

    4) A high coronary heart disease rate, which has dropped in recent years but remains high;

    This sounds to me like another argument against the US’s healthcare system. Coronary artery disease (CAD) is both more preventable and more treatable than the vast majority of cancers. So if the rates of death due to CAD are higher in the US, that strongly suggests a problem with the way CAD is being treated in the US. (Though, admittedly, the USian habit of driving everywhere and therefore getting little exercise may have something to do with it as well.) The higher HIV rates in the US may be something of a historical accident, but then again they might not be. Does anyone know what sort of HIV prevention is being implimented in Europe? It’s not abstinence til marriage and absolute fidelity, I can tell you immediately. Anyway, HIV transmission to others, particularly maternal-fetal transmission, can be decreased significantly with the use of HAART. Again, expensive meds that may not be obtainable by people without health insurance. So not much of an “excuse”, if one is seeking excuses for the poor survival rates in the US.

  8. 308
    Jamila Akil says:

    sylphhead Writes:

    Also, before we go any further, I’d like a straight answer to my proposal in post 299. Yay or nay?

    Nay. I oppose any system that says people have to have insurance if they don’t want it–whether that system is like Switzerland where everyone has 3 months to get private insurance or like Canada where everybody has to opt into the basic health care system.

    In the book “Lives at Risk” by John C. Goodman, he outlines a policy proposal which basically says that people who privately insure get a deduction on their taxes and those who choose to go without insurance pay a set amount as a tax penalty; the funds from the tax penalty are then used to reimburse hospitals that have provided care to the uninsured. I prefer his plan because it keeps government from intruding further into the provision of health care and it retains consumer choice to either get insurance or go without it while reimbursing hospitals for free care.

    “So who are you going to believe, the commonwealth fund or the WHO?”

    Jamila, you are saying one of two possible things here, both of which are misunderstandings of the scientific process.

    I’m saying that when two different ( and both valid) methodologies are used to measure the same thing, but the results of the studies are diametrically opposed, then you have to accept the results of one of the studies as being a better measure of what you are actually trying to measure.

    I believe that the WHO ranking on responsiveness which uses more objective measures is a better indicator of health care quality than the one study by the Commonwealth Fund which uses the same indicators. No ad hominem intent on my part.

    I already addressed the problem I have with using such measures as “equity of financing” in regards to the quality of a health care system when I talked about the problems with the WHO ranking the US health care system as #37.

    “Once again, I have no idea how you managed to come up with that conclusion from a study that only compares metropolitan areas in Canada and the US.”

    If the Toronto-Honolulu study bothers you, then the cancer link I provided on top of this post expands the net to Detroit, not to mention that cancer is included in the table from a study I referenced earlier: http://www.openmedicine.ca/images/8/table3.png

    Adding one–or two or three–more cities to the mix when there are dozens (hundreds?) of metropolitan cities both in the US and in Canada–and millions of people that don’t live in metropolitan cities–means next to nothing. What about Chicago, IL and Toronto? Or Dallas, TX and Toronto?

    I know there are several posts on this thread where various cancer survival rates are discussed.

  9. 309
    Jamila Akil says:

    Dianne Writes:

    4) A high coronary heart disease rate, which has dropped in recent years but remains high;

    This sounds to me like another argument against the US’s healthcare system. Coronary artery disease (CAD) is both more preventable and more treatable than the vast majority of cancers.

    Hopefully the drop in recent years means that people are either beginning to change their eating habits or that preventative measures in the health system may be beginning to be implemented so that something can be done to bring the rate down.

    The higher HIV rates in the US may be something of a historical accident, but then again they might not be. Does anyone know what sort of HIV prevention is being implimented in Europe? It’s not abstinence til marriage and absolute fidelity, I can tell you immediately.

    I think everyone will agree that the US does a shitty job with sexual education in the schools and the outcome of this is bad, bad, bad. We also have ridiculously high rates of std infection and teen pregnancy compared to the rest of the Western world and the health care system can only do so much about it. Our rates of violence, particularly violence due to guns, looks astounding when compared to Canada that sees very little of this problem. There are many ways in which the larger culture in America is failing at preventing many problems that end up causing a burden on the health care system, problems that could be easily prevented before they turned into even larger issues.

    Immigration policy needs to be fixed, which has a large impact on the number of illegal immigrants going without care and using emergency rooms in place of routine care in a doctors office. Sex education in the schools is in shambles, which is partly why we have so much teen pregnancy and unnecessary disability related to stds, and the number of young healthy people dying due to homicide related to drugs and gangs etc.,

    Oh, you won’t find any disagreement from me when someone points out that America has serious problems that need to be dealt with which impact the ability of our system to provide excellent care and lower the costs of treatment.

  10. 310
    Jamila Akil says:

    sylphhead Writes:

    Back and forth, ad infinitum. It’s not sound, productive, and in the end, even honest, reasoning.

    I agree. I think we have reached the point where we both just repeating ourselves. I’ll thank you for the stimulating discussion and bid you adieu until next time.

  11. 311
    nobody.really says:

    I don’t have much to contribute to the current system vs. UHC system debate, sorry.

    I wasn’t comparing insurance with gambling – did I inadvertently signal a cliche or something?

    Kinda. Not a cliche, perhaps, but a point of distinction in the theory of insurance.

    Your point was that insurance tends to have the effect of transferring wealth from insured people who take fewer risks and to insured people to take more risks. I wasn’t disputing the point – indeed, I had made the same point – but rather was disputing the characterization of this dynamic as the “basic philosophy behind insurance.” See the discussion debunking the “Gambling analogy” to insurance here. In particular, it says that Gamblers, by creating new risk transfer without regard to existing risk, are risk seekers. Insurance buyers are risk avoiders, creating risk transfer in terms of their need to reduce exposure to large losses.

    All in all, [the agency administering the British Columbian heath insurance system is] a fairly stingy, by-the-book government bureau, and most British Columbians don’t like them….

    That’s a useful insight. What do most British Columbians object to?

    Are these bureaus depriving people of government-offered services without cause? Why is the BC government so ineffectual at clamping down on these bureaus? What does this tell us about national health care systems?

    Or are you saying that the BC legislature (or the national legislature) does not have unlimited resources and therefore puts limits on the health care for which the government will pay, that somebody has to have the thankless task of enforcing those limits, and that citizens of BC are blaming bureaucrats for a dynamic that arises in any health insurance system?

    Since occasional masturbation is linked to better prostate health in males, should some board of bureaucrats decide to impose what amounts to a tax on those who choose never to masturbate? Since some alcohol is linked to healthier circulation (though this one screams urban legend….)

    Wait a minute. We have stories that identify positive health outcomes with both masturbation and drinking, and you thing the DRINKING one sounds like an urban legend? Just one more difference between the US and Canada, I guess…. :-)

  12. 312
    nobody.really says:

    Some of you here say that you don’t want something like government intruding into our personal lives through health care, and I want to believe you, but really, I can’t imagine a more pervasive way than this convoluted sin tax method for allowing higher institutions to make personal decisions for us….

    Again, the purpose of the system is to reduce the extent to which government makes decisions for you – specifically, the extent to which government decides how much you will subsidize my lifestyle decisions. And my neighbor’s. And her neighbor’s. And roughly 300 million other people’s. I have yet to hear of any other UHC system that accomplishes this.

    If at all possible, put aside the whole “sin” aspect and simply look at the issue of choice: Right now, if I am willing to accept a generic drug to fill my prescription, my insurer will cover it (ok, with a co-payment). If I choose the name-brand equivalent instead, that’s ok too, but I have to pay the difference between the cost of the name brand and the generic equivalent. The same policy applies to everyone else in my health plan. So my insurance premiums don’t subsidize anyone else’s choice to buy a name-brand drug, and their premiums don’t subsidize mine. Does this policy intrude upon my autonomy or vindicate it?

    Similarly, imagine that there are insufficient medical merits to conducting routine circumcisions, tonsillectomies or chin-lifts. I wouldn’t expect a UHC system to prohibit me from having these discretionary procedures done; I just wouldn’t expect a UHC system to compel you to pay for them. If I choose them, then I should pay for them. Again, would such a policy intrude upon my autonomy or vindicate it?

    So how different are these choices and the choice to smoke? To me, “sin” is not the relevant feature. It is only people who choose to burden their neighbor that are acting sinfully. By providing a means for people to pay for their own choices, on the other hand, I offer forgiveness, absolution and fullness of grace!

    That said, the devil’s in the details. Yes, such a system could get complex.

    In industrial organization law, we have the Essential Facilities doctrine. Your railroad company cannot refuse to let a competing rail road use your tracks, but you may charge the competitor for the cost the competitor imposes on your system. It’s a good doctrine, although calculating those costs can get extremely involved.

    Telephone Company A cannot refuse to let Telephone Company B complete a call on A’s lines, or otherwise use A’s “network elements,” but A may charge B for its costs. Again, fights about costs can get quite detailed.

    Electric Utility A cannot refuse to let Electric Utility B transmit electricity across A’s lines, although A may charge for its costs. Today regional transmission organizations calculate these costs; the calculations are mind-numbing.

    Similarly, Electric Utility A cannot refuse to permit people in its service area to generate their own electricity, and even to sell this electricity back to the utility at the utility’s avoided costs. Calculating those costs, as well establishing the interconnection requirements, is not simple.

    Conceptually, I like school vouchers – a “single payer system” for primary education. But before government should implement such a system, government would need to identify with particularity what it was buying, and how to measure that it was getting it. Again, a lot of complexity, both in establishing the standards and in verifying the performance.

    I should probably include examples involving the tax code or Net Neutrality, but they provoke more controversy.

    Clearly, indisputably, undeniably, the simplest system is one-size-fits-all. One railway. One phone company. One electric utility. One school. One level of web access. One level of taxation. Whatever. We’ve been moving away from these one-size-fits-all systems for a while now. The extent to which we can achieve the same thing with a national health care system remains to be seen.

  13. 313
    Dianne says:

    Hopefully the drop in recent years means that people are either beginning to change their eating habits or that preventative measures in the health system may be beginning to be implemented so that something can be done to bring the rate down.

    The reduction in heart disease seems to be due to both decreasing risk factors and better treatment. This is true in both the US and other countries studied, including Holland, New Zealand, and Finland. If that helps.

  14. 314
    Dianne says:

    Again, sorry, but the link above is to an abstract rather than the full article. ^#%*@ journals that don’t provide free web based full text (wanders off muttering crankily to self.)

  15. 315
    sylphhead says:

    “That’s a useful insight. What do most British Columbians object to?

    Are these bureaus depriving people of government-offered services without cause? Why is the BC government so ineffectual at clamping down on these bureaus? What does this tell us about national health care systems?”

    You’re reading more into this than there is. As a general rule, people don’t like faceless bureaucracies, and they don’t like being turned down for anything, for whatever reason. They especially don’t like being turned down for anything BY a faceless bureaucracy. Perhaps some of it is due to the BC system facing some massive spending cuts almost a decade ago, owing to the election of the Liberal party (an idiosyncracy of BC politics is while the federal Liberal party is a left-ish centrist caucus slightly left of the Dems in the US, the provincial Liberals are hard right wing and can be best described as “Liberals” in the European sense of the word) that wanted to create, for political reasons, an artificial spending crisis a la Bush with Social Security. Yes, Virginia, that kind of thing happens all the time in Canada too, it’s not an unshifting lefttopia. But I’d expect most of it comes from people being people.

    There’s a similar situation occurring right now with higher education, which in Canada is almost always public. (The best Canadian schools, such as McGill’s and Queen’s, are all public.) UBC still accepts as many students as it can, but now it’s finding perfunctory reasons to drop students and decrease its enrollment, simply because there’s a set limit on how many students it can take without decreasing quality significantly for all. Thanks to immigration and more competitive students from all across Canada, more and more qualified students are applying there at a rate much faster than it can possibly hope to expand. The BC government responded by creating two more universities (one of the few things the Liberals did right): Thompson Rivers University and UBC Okanagan – but people have been slow to embrace these new schools because of the intractable issue of prestige, instead continuing to complain about the unfairness and tyranny of UBC. As I myself chose to go to a school with considerable prestige, I don’t mean to fault the parents who think this way; I’m just pointing out that sometimes, even if a bureaucracy is partly at fault, human nature just guarantees that there’s going to be problems. No manmade system gleams with a spitless shine.

    “… citizens of BC are blaming bureaucrats for a dynamic that arises in any health insurance system?”

    Perhaps. But citizens of America – and to a lesser extent Canada – blame bureaucrats for a dynamic that arises in basic large scale organization. That’s why commensensical measures of fairness and decency can be scarequoted as the work of “bureacrats” and “politicians” and so many are baited, at least for a while.

    “Again, the purpose of the system is to reduce the extent to which government makes decisions for you – specifically, the extent to which government decides how much you will subsidize my lifestyle decisions.”

    With the method you propose, someone else is making my decisions for me. By making me pay more to live a certain way, what they are doing is no different than saying, “you like to close your eyes in the bathtub – that’s a tax”, “your hair’s long, it occasionally obstructs your vision – that’s a tax”. If a random policeman on the street started barking out fines for things such as this, we’d rightly consider it tyrannical. What makes it okay if it’s done with a stamped signature on a monthly bill?* I don’t give a tosh if my life is being directed and controlled by a government health bureau, a government accounting office, or a private corporation. It demeans the very idea of freedom if the immorality of its curtailment is contingent on who is doing the curtailing, and those who believe so must truly not value freedom.

    It’s interesting, because so much of anti-government sentiment rests on not what power is intended for, but it could potentially be used for. What’s next – the company starts streamlining their processes by designating a ‘most watched’ list for those who take out too many books about skydiving at a library? Watch too many movies starring extreme sports stars? Wow. I cannot in good conscience support anything of the sort.

    I do agree with your circumcision example – that is already policy in many UHC systems. Elective procedures are often not covered under government plans, and are considered extremely low priority (hence the waiting lists associated with them).

    “Conceptually, I like school vouchers – a “single payer system” for primary education.”

    I am open to the idea of introducing competition to our schools. I’d want significant government regulation, however, to prevent segregation from occurring by class, race, or gender. School isn’t just where we learn our ABC’s, it’s also where kids first learn to relate socially to the outside world. Also, I’d still insist on a standard curriculum – the freedom for cultist parents to send their children to the L. Ron Hubbard Academy is one, being the freedom-hating commie that I am, that I can do without.

    That being said…

    I’d like to highlight a problem common in straight “anti-government” bombast. A single payer education system ensures choice, whereas single payer health care is One Size Fits All? Essential control of the food industry by large, private companies, but with myriad government safeguards for quality, is unspeakable big government intrusion? The same situation for utility companies is Liberty with a capital ‘l’ (given that the alternative in many other countries is state owned enterprise). And so forth.

    Now, I understand the “One Size Fits All” claims for health care, for instance, are meant in a directional sense, but still, the difference between single payer health care and ‘socialized medicine’ is identical to the difference between school vouchers and current public education. And I’m not saying the level of regulation should be identical for each and every industry – that’s as laughably simplistic as saying there should no regulation for each and every industry. So many are just unwilling to admit out loud that natural monopolies exist, though, as if admitting so presents drastic complications for the rest of their ideology.

    It’s the same with my Medicare-for-all proposal. Jamila’s response to this was unexpected, because as I made clear, NO ONE is forced to sign on to this program, anymore so than they for existing government health plans in America such as Medicaid (and, reading through the thread, she has no problems with existing programs such as these, insofar as she incorporates them in a defense of the American system). If someone, god forbid, wants to go without either public or private insurance, let’s just let them – I think it’s fair to say, though, that the vast majority of the currently uninsured would prefer to be insured, and for them an expanded Medicare option should exist, without limitations on age or disability. Perhaps she was talking about my caveat with children, but I really don’t get this – do libertarian parents let their children drive motorcycles when they say they want to?

    The response I was actually expecting, and the one I’ve gotten before, amidst much sidestepping and nervous evasion, was that I was being too optimistic on how it will impact tax rates – expanded Medicare would actually increase taxes by quite a bit. Let’s just suppose for the sake of argument that this is true, though I vehemently protest. America already pays more taxes than any other industrialized nation, and this isn’t an arrangement most of them explicitly object to – most, like Jamila, accept Medicare and Medicaid and use them to defend the American system, since understandably they don’t pine for having to defend an American system where the number of uninsured may possibly be tripled the number it is now. Can you imagine if America paid more taxes for *unemployment insurance* than any other industrialized nation? Or *public transportation*? Look, either taxes are theft, carried out by Men With Guns wielding a Monopoly On Force, or they aren’t. A position along the lines of “being ROBBED by state coercion to pay for health care more than any other industrialized nation is acceptable, but paying just a little more ISN’T” to oppose Medicare for All, isn’t strictly disprovable in the standard sense, but it does strike as remarkably inconsistent, shallow, opportunistic, and dishonest. I think you’d agree.

    Yes, this was the answer I was expecting Jamila to give, and yes, the latter was a prepared, if disjointed, response.

    * Don’t bother pointing out that this mirrors standard anti-tax arguments. It’s meant to, it’s tongue-in-cheek, and not 110% serious.

  16. 316
    Jamila Akil says:

    Sylphhead writes:

    America already pays more taxes than any other industrialized nation, and this isn’t an arrangement most of them explicitly object to – most, like Jamila, accept Medicare and Medicaid and use them to defend the American system, since understandably they don’t pine for having to defend an American system where the number of uninsured may possibly be tripled the number it is now.

    Ideally I would like for America to get rid of Medicaid and Medicare by adopting the plan I spoke of in #308 or some similar plan.

  17. 317
    sylphhead says:

    (Post 310 is duly noted. I won’t go over anything that has already been gone over.)

    Even if I were to accept the premise that government intervention in health care is bad, it is not true that Goodman’s plan, as you describe it, would decrease government involvement, for the simple reason that taxation is a form of government involvement. You say that those who choose not to buy private insurance will be taxed extra to pay for care for the uninsured, while those who do buy it will be given tax breaks.

    If Medicare and Medicaid were to be done away with, many, many more Americans will be left uninsured. This greatly increases the tax strain that will have to be put on those who opt to go without insurance – and without slogging a debate on just how many otherwise able Americans regularly choose to go without insurance, wouldn’t be safe to say that those who WOULD choose insurance would greatly outnumber the former? Taking into account the tax break that’s assigned to each and every individual or family who buys insurance (which by itself would probably override the extra funding obtained by tax penalties), I don’t see much relief being given to the uninsured. At best, all I see is a means for the government to substantially punish those who choose to go without insurance when they otherwise could – perhaps justifiably, but aren’t taxes, according to libertarians, a form of coercion? If so, how is this any different from those systems you mention where people are ‘forced to get insurance’? No similar mechanism exists in my Medicare for All* proposal; your primary complaint about it was actually groundless.

    But that’s not the biggest conceptual problem with the plan. The weak point, as I see it, hinges on the word ‘choose’. Who decides who has ‘chosen’ to go without health insurance, and who has been merely hit hard by circumstance? The government, obviously; and THIS is what I consider to be unacceptable government instrusion into people’s private health. An income or wealth cutoff would be the simplest, most humane method; above a certain income floor, being without insurance, regardless of cause, means that the tax penalty applies. This would largely recreate Medicaid, in which case I don’t see the point in axeing the former in the first place, but at least the plan is still somewhat sensible.

    If we choose to go beyond a crude income cutoff and start parsing which middle-class families ‘chose’ uninsurance and which had it thrust upon them, we run into more problems. We have to remember that many who are otherwise reasonably well off have perfectly valid reasons for not having health insurance. For most Americans with private coverage, it is their employers who have direct control over their insurance plan; if their employer decides to drop it, what recourse do they have? Or say, they recently switched jobs, which is another major cause. At this point, they’d have to purchase private insurance for themselves to avoid the tax penalty, but how will this be enforced? Who decides the point at which they are uninsured no longer out of circumstances beyond their control, but from their ‘choice’? They could conceivably be given a grace period, but that would make this identical to the Swiss method that you denounced earlier.

    Not to mention the added strain this will give to the self-employed and to small businesses. Are we to count everyone who works for a small business as having ‘chosen’ to go without health insurance**? Is that the new right libertarian credo? Tax small businesses to pay for care for the uninsured?

    The government could decide who has ‘chosen’ to go without health insurance and who has not by other means, of course. It could be entirely arbitrary, but I doubt that would be an arrangement that would have anyone’s support. It could tautologically define anyone who’s uninsured, at any level, to have ‘chosen’ their predicament. Given that most of the presently uninsured are too poor to be taxed, this would not be much different from the income cutoff method. Essentially, then, the uninsured are on their own as a group – but since they’re all paying for each other’s health care by state fiat (taxes), isn’t this now basically a mandatory insurance plan of sorts? A very limited, and honestly quite crappy one, but some of the same principles apply. It seems to me that the end result of this is that the poor do get some sort of ‘insurance’, but by state command it is of the flimsiest, most worthless variety. There’s no upside to this, from any ideological angle.

    This plan seems thoroughly flawed from every angle, but if in some inconceivable way all these problems could be rectified, I wouldn’t be averse to an entirely private, non-state solution to health care, provided it solve the problems of equity and access in the current system. But do libertarians themselves sincerely believe this can be done? There is inhumanity in Goodman’s plan, to be sure, but for the most part I’d say that is unintentional (though by no means unsubstantial). So are health care libertarians up front about plans like these, laying them down on the table at the start of a debate? Do they contact their representatives, the RNC, and the Wall Street Journal, with point-by-point abstracts of plans such as the one above? In my experience, they do not; they first and foremost support the current American system, which is by no stretch of the imagination a stateless system.*** If prodded for consistency, they conjure up some anarcho-capitalist plan, but they never bother with the details and for the most part don’t seem particularly attached to them.

    * Medicare for All isn’t *my* idea, but I specifically use the first person possessive to distinguish the one describe in this thread between the many other proposals called Medicare for All put forth by many other advocates, politicians, and interest groups. Some of them may contain provisos that I don’t agree with, such as mandatory enrollment or prohibition of private care.

    ** I realize that small businesses aren’t literally being taxed for the sake of the uninsured, and if the small business is incorporated, there’d be no corresponding corporate tax penalty necessary to say that the business *itself* is being taxed. But small business owners and employees disproportionately fill the ranks of the middle class uninsured, and any attempt to tax the latter group necessarily taxes the former. For all intents and purposes, small businesses are being taxed for the sake of the uninsured, and I’m sure many conservatives sincere in their concern for small businesses would agree with me.

    *** In fact by the most important measure, government involvement in American health care is ‘worse’, if we are to accept that taxation is theft. Non-universal does not mean the same thing as less government involvement, and in fact the simplicity of removing age restrictions to Medicare could decrease government involvement elsewhere.

    (BTW the infant mortality link w/r/t Canada adopting UHC was mentioned in an article I linked to on post 209.)

  18. 318
    mythago says:

    specifically, the extent to which government decides how much you will subsidize my lifestyle decisions.

    And back we are again to health care as a cookie for Right Livelihood.

  19. 319
    Jamila Akil says:

    Even if I were to accept the premise that government intervention in health care is bad, it is not true that Goodman’s plan, as you describe it, would decrease government involvement, for the simple reason that taxation is a form of government involvement.

    Government involvement necessitates more and more government involvement to correct for the problems created by the initial government involvement. What I mean by that is this: In America, hospitals are legally forced to treat patients needing emergency care regardless of ability to pay–the law forcing hospitals to treat all comers is the initial government involvement; because people know that they can get treatment at the hospital if something tragic and unforeseeen happens to them, even if they don’t have insurance, this provides an incentive for them to save their money and not pay for insurance. Voila! You now have a free-rider problem because there will people who won’t pay for insurance, yet they will still get treatment, and the hospital is left to foot the bills. The only way to remedy this problem is to revoke the law requiring private hospitals to treat all patients. But, because it is not palatable to most people to allow a hospital to refuse to treat a patient who can’t pay ( thereby forcing the person to go without treatment or go to a public hospital) the only way to remedy the problem of private hospitals being burdened with unpaid medical bills–bills that will eventually get passed onto paying customers in the form in increased prices for treatment–you now have to have more government involvement to remedy the situation so that there won’t be an avalanche of hospitals going out of business due to unpaid bills.
    You can remedy this situation by revoking the initial law that intruded on how private hospitals operate or you can attempt to solve it by some form of taxation. Goodman knows that trying to get rid of that law requiring treatment is probably futile so he–and I–advocate minimizing the damage while still keeping the government away from attempting to institute a UHC scheme. The plan would also eventually get rid of Medicare and Medicaid.

    You say that those who choose not to buy private insurance will be taxed extra to pay for care for the uninsured, while those who do buy it will be given tax breaks

    Those who don’t buy insurance will still be using hospitals for emergency treatment and they should be charged a tax that is used to fund and pay for those public hospitals ( and reimburse private hospitals for care given to the uninsured). Even those who choose to go without insurance can still have a sudden unforseen illness and end up needing treatment somewhere–these people should be forced to fund the public hospitals and clinics that they are using as a back-up plan.

    If Medicare and Medicaid were to be done away with, many, many more Americans will be left uninsured. This greatly increases the tax strain that will have to be put on those who opt to go without insurance – and without slogging a debate on just how many otherwise able Americans regularly choose to go without insurance, wouldn’t be safe to say that those who WOULD choose insurance would greatly outnumber the former?

    Yes.

    Taking into account the tax break that’s assigned to each and every individual or family who buys insurance (which by itself would probably override the extra funding obtained by tax penalties), I don’t see much relief being given to the uninsured.

    Many of the uninsured in America are only temporarily without insurance. ( I think that something like 85% of the uninsured are without insurance for a year or less, primarily due to job changes or job loss. )
    And there are many people who really do perform a cost-benefit analysis and opt to go without health insurance.
    What exactly to do you mean by “relief”?

    At best, all I see is a means for the government to substantially punish those who choose to go without insurance when they otherwise could – perhaps justifiably, but aren’t taxes, according to libertarians, a form of coercion?

    I believe that anarchists are the only ones who oppose all taxes. For instance, the military and a small federal government must be funded and those funds would have to come from some form of taxation. Of course, I believe that most libertarians would get rid of the vast majority of government programs and departments that currently exist so the tax burden would be substantially lower than it is now.
    The intent is not for the government to punish those who go without insurance but the public hospitals that the uninsured use as a form of back-up in case of catastrophic injury must be funded somehow.

    If so, how is this any different from those systems you mention where people are ‘forced to get insurance’? No similar mechanism exists in my Medicare for All* proposal; your primary complaint about it was actually groundless.

    Because under this system no one is forced to get insurance. If you want private insurance than you get your own private insurance. If you choose to go without insurance, no problem, but there is still the possibility that you might get sick and since the hospitals won’t throw you out on the streets for not paying someone has to fund your care.
    The plan is designed so that the government will be neutral on the choice of citizens to get insurance or not; the government won’t be trying to take in more taxes than necessary to fund the public safety net.

    But that’s not the biggest conceptual problem with the plan. The weak point, as I see it, hinges on the word ‘choose’. Who decides who has ‘chosen’ to go without health insurance, and who has been merely hit hard by circumstance?The government, obviously; and THIS is what I consider to be unacceptable government instrusion into people’s private health.

    Those who don’t “choose,” in the usual sense of the word, to go without insurance, but instead end up the victim of circumstance, will be using the public hospitals and clinics.
    Government will not be choosing anything for you or making decisions about who can or can’t afford health care. The public safety net will still be there, funded by the people who are using it.

    An income or wealth cutoff would be the simplest, most humane method; above a certain income floor, being without insurance, regardless of cause, means that the tax penalty applies. This would largely recreate Medicaid, in which case I don’t see the point in axeing the former in the first place, but at least the plan is still somewhat sensible.

    The way that I see things now there are 3 choices: 1) private insurance, either through an employer or purchased on your own; 2) public insurance, such as Medicaid or Medicare and 3) no insurance, you use public hospitals and clinics if need be but for the most part you get by however you can. The plan I am proposing gets rid of options number 2 and 3 by combining them into one option. In essence, there would be the private option and the public option with the government remaining neutral on which option you choose.

    If we choose to go beyond a crude income cutoff and start parsing which middle-class families ‘chose’ uninsurance and which had it thrust upon them, we run into more problems.

    The system I’m proposing won’t be concerned with whether people chose to go without insurance or had it thrust upon them; their only option would be to use the public system if they can’t afford the private one.

    For most Americans with private coverage, it is their employers who have direct control over their insurance plan; if their employer decides to drop it, what recourse do they have?

    They can purchase private insurance or use the public system.

    Or say, they recently switched jobs, which is another major cause. At this point, they’d have to purchase private insurance for themselves to avoid the tax penalty, but how will this be enforced?

    If you had insurance for 9 months or more of the previous fiscal year then you don’t have to pay the penalty. I just pulled the figure of 9 months out of my head, but I think 9 or 10 months sounds like a reasonable amount of time.
    It would be enforced the same way taxes are currently enforced: people figure their own taxes and pay accordingly. Just like the government currently goes after people for tax evasion, it can go after people for avoiding this tax too.

    Not to mention the added strain this will give to the self-employed and to small businesses. Are we to count everyone who works for a small business as having ‘chosen’ to go without health insurance**? Is that the new right libertarian credo? Tax small businesses to pay for care for the uninsured?

    1) Most small businesses don’t offer insurance to their employees now and they wouldn’t be forced to do so under this plan.
    2) Self-employed people will continue to do what they have been doing: pay for their own insurance or go without it.
    There is no extra burden on small businesses or the self-employed.

    Essentially, then, the uninsured are on their own as a group – but since they’re all paying for each other’s health care by state fiat (taxes), isn’t this now basically a mandatory insurance plan of sorts? A very limited, and honestly quite crappy one, but some of the same principles apply.

    In a way, yes. However I prefer the term “safety net” to “mandatory insurance plan”. The other alternative is to completely eliminate government involvement in health care–no clinics or hospitals funded by the federal government–and make the entire system private. There would still be public hospitals funded by schools to teach health care professionals and public facilities funded by philanthropists and public facilities that are paid for at the state level.

    It seems to me that the end result of this is that the poor do get some sort of ‘insurance’, but by state command it is of the flimsiest, most worthless variety. There’s no upside to this, from any ideological angle.

    You get what you pay for. The public system is meant to be a safety net in case of a severe sudden illnesss or, in the case of clinics, to take care of cheap routine needs like a yearly pap smear or flu shots.

    This plan seems thoroughly flawed from every angle, but if in some inconceivable way all these problems could be rectified, I wouldn’t be averse to an entirely private, non-state solution to health care, provided it solve the problems of equity and access in the current system. But do libertarians themselves sincerely believe this can be done?

    I don’t believe that a non-state solution could completely solve the problem of equity or ensure that everyone received care. I think it could come close but I’m not enough of an expert on health care to tell you exactly what that system would look like or how it would work.
    I think many libertarians believe that an excellent private health care system could be accomplished in this country, but I am not the best person to explain such as system in detail.

    So are health care libertarians up front about plans like these, laying them down on the table at the start of a debate?

    I don’t know if they do so at the beginning of a debate but I know that whenever I’ve asked one what his/her plan was they were able to lay it out for me.

    Do they contact their representatives, the RNC, and the Wall Street Journal, with point-by-point abstracts of plans such as the one above?

    I think they do. Goodman has been publishing books about health care since the 80′s and he has a blog. Goodman lays out is plan pretty well in his book. There are plenty of libertarian and classical liberals with websites who have been writing books and talking about their health care ideas but since they are in the minority few are listening.

    In my experience, they do not; they first and foremost support the current American system, which is by no stretch of the imagination a stateless system.*** If prodded for consistency, they conjure up some anarcho-capitalist plan, but they never bother with the details and for the most part don’t seem particularly attached to them.

    I’ve read papers and books explaining how health care would operate in the absence of government interverntion so I know that such plans do exist for those that want to read them.

    The problem is this: once you start giving people something from the government, it is very hard to get people to accept that the government should stop giving it. It’s much easier to modify the currenty system than to throw it out and start a new one. Which is partly why once countries start moving toward a UHC they don’t turn back; people get accustomed to government ensuring care, then they expect the government to ensure care and any suggestion that the government should stop ensuring care is going to be automatically met with intense hostility. (See the comment by Mandolin about how I’m “on the side of suffering” and I supposedly want people in the streets dying.)

    Most people also know very little about the various UHC systems around the world (I read tons of books and I still feel like it’s a drop in the bucket) and how those systems work compared to our own system. It is much easier to get people to understand that the government will provide everyone with health care than to explain in detail the intricacy of a complete free-market health care system. I think free market ideas stir up far more skepticism from the starting gate than does the simple explanation of ” government will take care it.”

  20. 320
    mythago says:

    The point of a free-market system being to make money, rather than to provide health care.

  21. 321
    Mandolin says:

    Jamila and nobody.really,

    You’ve had enough time on this thread. I appreciate your willingness to express and argue for your opinions — and I hope you’ll be willing to write on other threads of mine — but I think these particular lines of debate have now been about played out.

    I’m leaving the thread open for people to discuss differences of philosophy within an acceptance of universal health care as a good. Anyone interested in arguing within those terms is welcome.

  22. 322
    Marty Gister says:

    I am an RN who works in a Pediatric ICU, so I see first hand the internal workings of our healthcare system. I work as what is known as a traveling nurse. I work in a location for 13 weeks and then move on to a new location, so I also have experience in more than one area of the country as well as different types of hospitals. I have worked at Duke University and also at the county hospital in Phoenix, AZ. Currently, I work at a hospital just outside Washington, DC. Throughout all these experiences, I have gained pretty strong opinions about what is wrong with the system and what it will take to fix it.

    First, what I believe to be wrong with the system. In a nutshell: insurance companies, including government programs. Actually, the medicare/medicaid system is probably the biggest offender here. Every hospital I’ve ever worked at has had to have a number of people on staff whose full-time job it was to “deal with” insurance issues. I am not referring to the accounting and billing people, these are clinical people (nurses, social workers, etc), who spend their entire day talking to insurance companies about why a patient is still in the hospital, why they’re still in ICU, etc. We have insurance adjusters picking apart the patients medical condition and attempting to micro-manage their medical care. On a daily basis, the nurses and physicians involved in the patients care are asked to explain and justify why we’re doing what we’re doing. I understand the need for accountability, however, when physicians are spending a couple of hours everyday justifying their actions to an insurance adjuster, how are they compensated for this time? Further, how can a nurse provide appropriate care when they know that every action is going to be torn apart for billing purposes? People often wonder why a visit to the doctor costs hundreds of dollars yet they only see the doctor for 5-10 minutes. Because that 5-10 minute visit results in 1-2 hours of additional work for the doctor, the nurses and the office staff. Some of this time is due to legal paperwork having to do with licensing requirements in the sense of “we may need to defend a complaint over this visit to keep my license”. Even greater is making sure paperwork is in order enough to withstand being torn apart by an attorney in a malpractice suit, justified or not. I have experienced this same problem in my own family. When I made the decision to step down from a staff position as a nurse and begin to travel, it resulted in a change in employer, hence a change in insurance. My 3 year old son is on a couple of different medications for severe allergies. We were unable to keep him on his established medicines because the insurance would not pay for one until another, cheaper, alternative had been tried. Of course, we had already done this previously, but this documentation wasn’t good enough. He had to spend 3 months in agony ‘trying’ this other medication because the insurance would not pay for the one that we had already established worked for him. In speaking with the insurance company myself, I asked the adjuster I was speaking to (who had the power to approve the correct medication) what type of college degree she held. I was shocked to learn that she had no degree at all. I have since asked this question anytime I have had to deal with an insurance company professionally and found that commonly, the people at insurance companies deciding whether to approve or deny coverage either have no degree at all or have a degree in business or accounting. In my opinion, these people are making medical decisions with no medical training whatsoever. My question regarding insurance companies is this: Why should someone with no medical training or background at all decide what medical care someone should receive? We have people with no more than a high school education second guessing medical specialists in their care of their patients. Does this make any sense at all? I have witnessed this and can tell many more stories in great detail if you would be interested in listening.

    I work in an ICU where split-second life or death decisions are made. i.e. the patient is dying and we must save them…do something in the next 15 seconds or they are dead. If you have ever watched an episode of ER when they are scrambling to save someone and doing many things very quickly, remember that all those actions must be documented to defend against an insurance company’s examination days later, calmly sitting at a desk somewhere with all the time in the world to sit and think. Worse yet, to defend against a lawsuit up to 10 years later being microscopically examined by attorneys with all the time in the world. I am sure you have seen episodes of different attorney shows where the attorneys are dissecting a physician’s action on the witness stand. Keep in mind the statute of limitations for malpractice suits is 10 years, longer if the patient is a child. They have until they turn 28 to file a suit. We as healthcare professionals always must keep in mind as we do our “charting” that we must write enough information so we can confidently defend our actions 10 or 20 years and hundreds to thousands of patients later. I make a point of remembering my patient’s names while I am caring for them, but I am just not good enough to remember them all by name forever. Even a few months later, I am sorry to say I remember them better by their medical course than by name. Therefore, in addition to changes in how insurance operates, the court system as relates to malpractice must be changed. You do realize that malpractice insurance costs more for physicians than a lot of people make in a year? For physicians that I work with, their malpractice insurance costs up to $100,000/year. This money must come out of their billing rates. Hence another reason why your 5-10 minute visit costs hundreds of dollars. People tend to think of doctors as rich. Nothing could be further from the truth. Yes, they make a good living, but they literally make life and death decisions on a daily basis. Remember, I work in a Pediatric ICU, so if your child were critically ill or injured, how much is it worth to you for the doctors and nurses who save your child’s life? Thinking about it from that perspective, how much should they make? And keep in mind, the doctors to make quite a bit more than us nurses. Add to this equation that most of the doctor’s decisions are made based upon information they receive from the nurses and we get into a whole other argument regarding nursing salaries.

    I could ramble on more and more about the problems, but it does not fix anything. Solutions are needed and I have a few thoughts in that area as well. You may think I would be in favor of nationalized healthcare. Actually, I think nationalized healthcare would be even worse than what we already have. As I stated earlier, the government programs are the worst offenders when it comes to what I call insurance meddling in medical care. They say no the most often and have no avenue to make a more detailed argument to attempt to prove the necessity of a needed treatment. Talk to anyone, especially someone in the medical field, who has emigrated from Canada and they will tell you how poor the healthcare is in Canada. Sure, everyone is covered and all healthcare is essentially free, but what level of healthcare do they have. I have worked with many nurses from Canada who have stated without reservation that the medical care provided in Canada is vastly inferior to that of the care here. The principle of free enterprise and competition improving the quality of a product applies in healthcare as much as it does anywhere else.

    I sincerely feel and believe with all my being that the insurance industry as it exists is the very foundation of the problems in the healthcare system. How to fix that? Somehow create a system whereby decisions on coverage are made based on sound medical grounds, not financial considerations. Perhaps a law requiring physicians in the appropriate specialty making decisions regarding coverage and authorizations without regard to costs. Insurance companies always complain about the high cost of healthcare, yet they are the primary reason for it. Perhaps a standard form whereby the physician can state “this is the patients condition, this is what we need to do”, and then get a yes or no without multiple requests for more information. This would result in the physician performing much more efficiently, thus enabling the billing rate to be more reasonable. There are other ways to address this as well.

    In combination with this must be some kind of reform of the malpractice laws. There are much too many frivolous lawsuits being filed and making it all the way to trial. There has to be a way to hold attorneys accountable for clogging the system with cases that should not even see the light of day. I have encountered respected attorneys who have medical personnel on their staff who research cases for merit before deciding to even take a case. The burden in medical malpractice is “acceptable medical practice”. This perhaps needs a more specific definition. Also, not to put a value on a life, but is “uncle john”, who dies at 85 due to complications after surgery really worth $100 million? This seems outrageous to me. The constitution states “a jury of peers” in criminal cases. Should a doctor or nurse in a malpractice case not be afforded the same protection? Perhaps a jury composed of doctors or nurses who actually have the training and experience to judge the actions taken in the case?

    I do not claim to have all the answers to this problem, but I do feel I am extremely qualified to pinpoint the causes of the problem. I would be happy to answer any questions and/or discuss further with anyone who is interested in discussing this issue with an open mind. Bottom line is this: show me a government run program in ANY AREA that works, and I may rethink my position somewhat.

    Marty G., RN

  23. 323
    Mandolin says:

    Marty,

    I’m leaving this comment up because it seems to reflect a lot of labor. However, you’re not welcome to post more here. If you’ll look above, this thread has been closed to people who [don't] accept universal health care as a good.

  24. 324
    mythago says:

    There are much too many frivolous lawsuits being filed and making it all the way to trial.

    You may understand how the medical profession works, but you really have no idea how the legal profession works. Lawyers who take malpractice cases essentially do so on commission. Which means that if a frivolous malpractice case “makes it all the way to trial”, and the plaintiff loses, the lawyer eats 100% of the costs of bringing that case to trial.

    You’ll be glad to know that if you or one of your colleagues hurt Uncle Marty, you probably won’t have to worry about being sued at all. Because Uncle Marty is 85 and doesn’t have an income, the economic damages are very low, and the doctors’ lawyer is going to argue that he was old and would have died soon anyway. Meaning that Aunt Martina is going to be told by a lawyer “Sorry, I can’t take your case. Even if we win, you won’t make enough money to pay for the costs, and I won’t make any money either.”

    You may also be gratified to learn that both sides get to pick a jury. So if your lawyer would like to pack a jury with doctors and nurses who think patients are all greedy, lying sacks of shit squeezing money out of those poor dedicated medical professionals, that’s something your lawyer has some ability to do.

    If you really care about malpractice reform, I suggest you take a hard look at your insurers. You might notice that your premiums don’t actually drop when lawsuits or legal awards do. They are, however, a convenient excuse for insurers to cover up the fact that they took a hit in bad investments–not on jackpot lawsuits.

  25. 325
    joe says:

    The high cost of the malpractice insurance isn’t driven by semi-large regular awards. It’s driven by the smaller chance at a HUGE award. Also, for obvious reasons, it’s going to be much more common to have people on the jury that are completely ignorant of medical science.

  26. 326
    Jake Squid says:

    Joe, you are wrong and Mythago is right about what drives up the cost of malpractice insurance.

  27. 327
    mythago says:

    The high cost of the malpractice insurance isn’t driven by semi-large regular awards. It’s driven by the smaller chance at a HUGE award.

    As Jake already said, joe: wrong.

    Imagine if lawyers insisted that, in any trial involving a malpractice suit or other claim for wrongdoing against a lawyer, the jury ought to be composed of lawyers and paralegals. Or if a CEO brought up on a stock scandal said that a real ‘jury of my peers’ meant everybody in the jury ought to have an MBA. You’d go apeshit, because you’d realize that the intent was not to make sure the jury got it but to try and get a biased group that would close ranks.

    99% of what’s going on here is that doctors and lawyers just plain can’t stand each other. The rest of it is that doctors are clueless about the business aspects of medical practice, meaning they’re stick-and-stone stupid about how badly they’re getting screwed by their malpractice insurers. But, like a dog obediently chasing a tennis ball, they go haring off after lawyers while their insurers count their profits.

  28. 328
    Marty Gister says:

    I was told I am banned from posting here, but I would like to respond to those who responded to me re: malpractice litigation reform. No disrespect to the owner is intended….

    [Rest of post cut by Amp.

    Whether or not any disrespect to Mandolin and to this site was intended isn't the point. You demonstrated disrespect when you chose to disregard the rule Mandolin had very politely and reasonably explained to you.

    Don't post on this thread again. Period. If you have something more you must say, find an open thread or a different thread about universal health care and insurance to say it on, or say it on your own blog. If you have any actual respect for the folks here, demonstrate it by respecting our rules. --Amp]

  29. 329
    Marty Gister says:

    [Comment deleted by Amp. You were banned from this thread. If you need to respond, please do it on another thread, or on your own blog. --Amp]

  30. 330
    sylphhead says:

    I’ve been unable to post for a while, so both as a measure to make sure this post will reach at least one reader, and to respect Mandolin’s ban on Jamila replying again on this thread – it would make little sense for me to make a post mainly directed at someone who cannot answer back – I will crosspost this on Jamila’s blog. There are many threads there on health care, I’ve arbitrarily chosen the “Why do so many seemingly intelligent Americans want…” one, as it appears to be the broadest in scope. For the sake of any readers here who’ve followed this exchange (but who understandably do not read all the contributors’ individual blogs), I’ll post a final edition here, just to get a last word in for *our side*. Yes, this means the Left gets the final shot in here – boo hoo, go to Freeper.com if you want it the other way.

    To avoid excessive quote frisking and repetition, I’ll lay out a few general thematic problems with Goodman’s proposal, which by itself is a good stand-in for all anarco-capitalist plans for health care.

    First, the way he talks about the uninsured and their access to the emergency wards, he seems to think that the predominant medical concern in the country is re-attaching severed hands from lawn mower accidents. This is by no means unique to fringe libertarians – mainstream Right wingers from Bush to apparently every single Republican 2008 hopeful (though I’ll admit to having only watched the recapped version of the debates) believes that the uninsured can get medical care ‘if they really need it’ – by which they mean access to the emergency ward. (Note that this would also necessarily mean that any time anyone procures care in a manner not available to the uninsured, they must not ‘really need it’.) Well, as far as the big picture and valid international comparisons are concerned, emergency care only makes up a part, and a comparatively unimportant one at that, of overall health care. Genuinely effective health care requires regular checkups, a regular doctor with whom the patient is comfortable, regular screenings, regular appointments; by the time most people realize they need health care, it’s already too late in many cases. Good health care also requires that this regularity be built up into someone’s year in year out routine, which is why alternating periods of being insured and uninsured is often not much better than being uninsured all the time. The uninsured do not get this with the current American system and they’d only fare worse under a system like Goodman’s.

    Second, like all libertarians, he doesn’t seem to realize that there’s such a thing in the world as an economic dependent, and that this group actually outnumbers the working population by quite a bit. It’s easy enough to say that a working age man gets a time limit to buy the private insurance that he can’t afford before BOOM! the state Initiates Force on him, levies a tax penalty (further hindering his ability to obtain private insurance), and relegates unto him a vastly inferior standard of care. What of his children, who in any world close to this one could only hope to be bundled in with whatever plan he can get? While we’re in Republican Heaven, what of his wife who doesn’t work? What of his elder relatives who’ve been newly ‘liberated’ from Medicare? Even if the guy’s inability to afford private insurance is entirely his fault, it’ll still be his children and his parents who won’t get regular appointments, treatment, checkups, and care. His children and his parents, who actually need them a lot more.

    This isn’t just about health care. Any politically pleasing and nice sounding move toward ‘economic independence’ (read:lower taxes on the rich) so often has this effect on those whose only crime is being of an economically dependent demographic. Look at the poor in America, and what do you see? By far, mostly minors, elderly, single mothers, those with medically and/or mentally debilitating conditions, etc. To Right wingers, of course, the poor consist of nothing but middle aged white male vagabonds with scruffy beards and an empty bottle of hooch, or whatever group is politically most convenient to villify*.

    Third, both he and Jamila nervously sidestep the obvious fact that the ‘safety net’ you generously provide for will be just plain worse than anything else in a civilized country today – it will be horrendously underfunded, will fund nothing but most ‘needed’, or otherwise cheapest, procedures, and won’t even be available at all hospitals. Given that Jamila already acknowledged that there’s such a thing as victims of circumstance, I think even libertarians realize that plans like these are non-starters; they are thrown out there when it is required of them in a debate, that is all. As I’ve alluded to before, most Right wingers do not seriously, sincerely want an overhaul of the American health care system, and their interest in the topic is purely in reaction to the Left, which is the only reliable and consistent voice for true reform – in the past couple of decades before 2006 when Republicans virtually had ideological reign, their complete inaction on health care made Managed Care look downright revolutionary.

    “Those who don’t buy insurance will still be using hospitals for emergency treatment and they should be charged a tax that is used to fund and pay for those public hospitals ( and reimburse private hospitals for care given to the uninsured). Even those who choose to go without insurance can still have a sudden unforseen illness and end up needing treatment somewhere–these people should be forced to fund the public hospitals and clinics that they are using as a back-up plan.”

    The second statement slipped in a phrase that wasn’t supported. Can you spot it? There’s a difference between those who “don’t buy insurance” (first statement) and those who “choose to go without insurance” (second statement); the former encompasses the latter, but the latter is a subset of the former. To whom does the tax penalty apply, specifically?

    “Many of the uninsured in America are only temporarily without insurance. ( I think that something like 85% of the uninsured are without insurance for a year or less, primarily due to job changes or job loss. )”

    If you got that 85% from the Manhatten Institute or something, I’ll save you the trouble and just tell you it’s wrong. According to the CBO, between 50% to 75% are uninsured at least for the entire year. (Strictly speaking, the longest duration of time they measured was a year. But unless between two-thirds to four-fifths of those who remained uninsured at the end of that year magically obtained insurance within, say, a week or two after they stopped measuring, when they hadn’t been able to all year, my ‘at least’ is mathematically warranted.)

    By the same token, many of the currently insured in America are not far from dropping out themselves – many live on a cycle of insured/uninsured. If you count those along with the uninsured, the number goes substantially up; recurrent periods lacking coverage present their own problems to regular, consistent care.

    “What exactly to do you mean by “relief”?”

    For your sake, I’ll continue to stay here in the wealthy white bubble of Right-Libertopia where it’s not a moral calamity to not provide for the care for the uinsured. By the somewhat alarmist libertarian reasoning employed earlier, there’d be an ‘avalanche’ of private hospital bankruptcies if the uninsured were provided care that wasn’t paid for. And since Goodman’s plan doesn’t do away with the law that everyone who’s hurt or sick must be cared for at a hospital – mind you, merely because it’s *politically* infeasible for some impossible, inscrutable reason – this care for the uninsured must be paid for. The only fund that’s paying for them are the tax penalties of those who choose to go without insurance, correct? These same tax penalties must also pay for the tax breaks for everyone who actually did obtain private insurance. Just how much remuneration, then, are private hospitals receiving, when we know perfectly well they need it to prevent an ‘avalanche’ of failure?

    “I believe that anarchists are the only ones who oppose all taxes.”

    It is not necessary to believe all taxation should be abolished for my earlier point to hold. If you believe that taxation is a necessary evil, a form of coercion, something that’s only above base robbery – whatever you consider its practical merits to be – then it follows that *selective* taxation is a form of punishment. Your tax penalty is an example of selective taxation.

    Adding that to the tax *break* that the privately insured get, which would be state favouritism even if you didn’t believe the above, it’s not at all true that your system is ‘neutral’ and that the government does not care what option you pick. But hold onto this notion if you wish; by the same standard, the rich aren’t forced to pay taxes, because if they don’t all that happens is a surtax penalty – which apparently is not a mark of state disapproval.

    Under my Medicare for All, by contrast, the government has no preference whether you sign up for Medicare, private insurance, or neither.

    “The intent is not for the government to punish those who go without insurance but the public hospitals that the uninsured use as a form of back-up in case of catastrophic injury must be funded somehow.”

    We’ve entered a very curious land if intent, not outcome, solely determines the rightness or wrongness of any action, by the state or by anyone. Didn’t we leave deontological ethics back in the 19th century?

    Then again, given how so many libertarians and wingnuts want us to return to the 19th century, perhaps that’s not such a pejorative when applied to them.

    “The way that I see things now there are 3 choices: 1) private insurance, either through an employer or purchased on your own; 2) public insurance, such as Medicaid or Medicare and 3) no insurance, you use public hospitals and clinics if need be but for the most part you get by however you can. The plan I am proposing gets rid of options number 2 and 3 by combining them into one option. In essence, there would be the private option and the public option with the government remaining neutral on which option you choose.”

    Actually, I think all it does is take (2) off the block and subject all those who are dependent on it currently, which includes nearly the entire senior population, to the horrors of (3) as it is currently.

    “If you had insurance for 9 months or more of the previous fiscal year then you don’t have to pay the penalty. I just pulled the figure of 9 months out of my head, but I think 9 or 10 months sounds like a reasonable amount of time.”

    So, in other words, you get a grace period of 2-3 months to get private insurance and *keep it*, or else the state sends Men With Guns in to rob you of more of your hard-earned money that you earned all by yourself – which is all taxation amounts to, isn’t it?

    “1) Most small businesses don’t offer insurance to their employees now and they wouldn’t be forced to do so under this plan.”

    Small businesses are made up of small business owners and employees. If the latter suffer, the former does as well. Also, many small businesses aren’t even incorporated, so you can’t always differentiate between small businesses and their owners.

    “2) Self-employed people will continue to do what they have been doing: pay for their own insurance or go without it.”

    Except you’re taking away Medicaid and any other form of state health care plan from them.

    “There is no extra burden on small businesses or the self-employed.”

    On the contrary, they are burdened with the following:

    1. The removal of Medicaid or similar government programs, with their only option being the basest of safety nets that is sure to provide insufficient care.

    2. The tax penalty that’s being applied to those who ‘choose’ to go without insurance.

    “The problem is this: once you start giving people something from the government, it is very hard to get people to accept that the government should stop giving it.”

    Jamila, this is a problem when people get used to anything above the most basic Stone Age necessities. For instance, if you give people junk food and reality TV, it’s very hard to get people to accept that you should stop giving it. And if you give some people certain luxuries such as same day care to remove little Suzie’s tonsils (at the expense of same year care for some uninsured guy with lymphoma), it’s very hard to get them to accept them that you should stop giving it; and if you try and stop giving it, they cry foul, pay off a few political reps, and fund crackpot think tanks like CATO and Heritage Foundation to churn out whatever their rich donors want them to.

    *To a more aged, conservative audience, this group in question becomes younger, female, blacker.

  31. 331
    sylphhead says:

    Well, I don’t see a problem then with capping awards to limit the hugeness of some of those awards. That’s not as important to me as smaller amounts rewarded on a more consistent basis, and I doubt that’s what’s bothering tort reformers, either.