Krugman: Pride, Prejudice, Insurance

This is the one political issue of which Christians should be addressing immediately.  A single payer plan would be one of the greatest ways to establish justice and some semblance of equality in the country.  It would be hard work- but eventually one that would help everyone - from small businesses to the... sick.

General Motors is reducing retirees' medical benefits. Delphi has declared bankruptcy, and will probably reduce workers' benefits as well as their wages. An internal Wal-Mart memo describes plans to cut health costs by hiring temporary workers, who aren't entitled to health insurance, and screening out employees likely to have high medical bills.

The typical response to this is - why should we offer health insurance?  Noone has a right to health care.

These aren't isolated anecdotes. Employment-based health insurance is the only serious source of coverage for Americans too young to receive Medicare and insufficiently destitute to receive Medicaid, but it's an institution in decline. Between 2000 and 2004 the number of Americans under 65 rose by 10 million. Yet the number of nonelderly Americans covered by employment-based insurance fell by 4.9 million.

The funny thing is that the solution - national health insurance, available to everyone - is obvious. But to see the obvious we'll have to overcome pride - the unwarranted belief that America has nothing to learn from other countries - and prejudice - the equally unwarranted belief, driven by ideology, that private insurance is more efficient than public insurance.

Let's start with the fact that America's health care system spends more, for worse results, than that of any other advanced country.

In 2002 the United States spent $5,267 per person on health care. Canada spent $2,931; Germany spent $2,817; Britain spent only $2,160. Yet the United States has lower life expectancy and higher infant mortality than any of these countries.

...

Above all, Americans are far more likely than others to forgo treatment because they can't afford it. Forty percent of the Americans surveyed failed to fill a prescription because of cost. A third were deterred by cost from seeing a doctor when sick or from getting recommended tests or follow-up.

You see, Paul, medicine is generally quackery.  They should try vitamins. 

Why does American medicine cost so much yet achieve so little? Unlike other advanced countries, we treat access to health care as a privilege rather than a right. And this attitude turns out to be inefficient as well as cruel.

Isn't it possible to be cruel to be kind?  And besides, we don't want anyone to get anything for free.  offering health care to everyone would lead to fornication, bad hairstyles and dope peddling.  We might encourage a nation of hypchodriacs.  And that's much worse than having people who are really sick....

The U.S. system is much more bureaucratic, with much higher administrative costs, than those of other countries, because private insurers and other players work hard at trying not to pay for medical care. And our fragmented system is unable to bargain with drug companies and other suppliers for lower prices.

You mean that capitalism CREATES bureaucracies? 

Taiwan, which moved 10 years ago from a U.S.-style system to a Canadian-style single-payer system, offers an object lesson in the economic advantages of universal coverage. In 1995 less than 60 percent of Taiwan's residents had health insurance; by 2001 the number was 97 percent. Yet according to a careful study published in Health Affairs two years ago, this huge expansion in coverage came virtually free: it led to little if any increase in overall health care spending beyond normal growth due to rising population and incomes....

The economic and moral case for health care reform in America, reform that would make us less different from other advanced countries, is overwhelming. One of these days we'll realize that our semiprivatized system isn't just unfair, it's far less efficient than a straightforward system of guaranteed health insurance.

But who will care for the insurance companies?

Comments

[Erin]

Salty, I am of two minds about health care. On the one hand it seems to me that health care is rather like a fire department, in that both aim to prevent things that could be catching, and thus there is similarly compelling government interest in providing each. However, a friend of mine who is against socialized medicine worries that if some level of health care becomes a right, people will begin to treat "getting well at all costs" as a right and demand treatments that are expensive and unlikely to work. To some extent this happens even with relatively more minor things like education; I think her concern is that when a person's life is on the line, the higher stakes will lead to a lot more insanity and a lot more entitlement. Do you have a principled way in mind that the government might draw the line between "what we cover" and "you're on your own, pal"?

[Phil Snyder]

What level of care is the Government going to provide? Catostrophic care (i.e. Government covers anything over a high deductible?)? How about all care? How will we ration health care? Right now, it is rationed based on ability to pay. Those who are wealthy or have health insurance get good care. Those who are indigent get care (medicaid and county hospitals). The ones who fall through the cracks are the lower middle class.

Government run healthcare would have "all the efficiency of the Post Office with all the compassion of the IRS." As a matter of record, there is a strong coorelation between the involvment of government in health care payment (through Medicaid and Medicare and increased regulation) and the increase in cost of healthcare.

As for caring for the "insurance companies," I don't think that will be a problem. Someone has to process those claims and determine what is covered and what is not covered under different programs. Additionally, unless the government outlaws private insurance, many people will want medical supplement plans and will be willing to pay for them. Just as many insurance companies provide medicare supplement plans today. In time, employees will clamour for company provided supp plans as what is provided by the basic plan just won't be enough.

Government is very inefficient at what it does, so why don't we work on solutions to the problem that don't involve government?

YBIC,
Phil Snyder

[John]

Erin, I think that we already have such a system - where people demand to be treated better at all costs. But the nature of the rationing would probably change from rationing against the poor, to rationing against those less likely to recover. I don't know exactly how this would work.

Phil, the problem is that the idea that the government is always inefficient has to be held up to scrutiny. Fire departments, the police, and public school teachers are expected to be run by the public because the alternative - private services that serve only those who can afford it - is also unacceptable. We've chosen to have a society where the public is protected from fire, crime and is educated. What I don't understand is why we've decided in a system of arrangements that benefits only the ones who can afford it. What we have now is simply unacceptable. And the easy solution is right before us.

You also don't quite understand how the system would work. All the government would do is transfer money - without the administration that private corporations require [in fact, medicare is 1/10th the administrative costs of most insurance companies]. This it does efficiently [say, from your pocket into the military], if it is given the resources [alas, since the IRS has been strangled from finding cheats, it probably doesn't do this as well as it could]. You also seem to avoid the hard questions about the fact we're paying for something that we're not getting: a lot of money for a health care system that doesn't work excpet for the well-insured. Phil - the facts are in - single payer plan is a more efficient system [unless you think of what we're doing now as efficient - in which we have to argue about what constitutes efficiency] that will result in a healthier populace. Your anti-government bias is strictly ideology share by the people who would lose this battle: the insurance companies. As Krugman notes, Taiwan works.

[Phil Snyder]

John,

I work in the health care delivery field and I have extensive experience in government services. Right now, the insurance companies and provider organizations (hospital companies, IPAs, Group Practices, and other groups) do their best to keep each other in check. The insurance companies do their best to reduce the cost from providers and the providers do their best to increase their revenue.

Government has close to a monopoly on health care for seniors. They are reducing the payments for certain medicare procedures and DME (Durable medical Equipment). As a result, many doctors are getting out of geriatric care because they cannot make a living at it and other, not as regulated, fields provide better livings.

A single payor plan is more efficient. The most efficient form of government is a dictatorship. Efficient does not mean best. I ask you - who would determine who gets care? Would it be up to the doctors? The hosptitals? A government official? Who decides?

What we have now is not the most just system possible. We need to work on making it more just. But I fear that a system run by the government would be less just than the systems we have now.

YBIC,
Phil Snyder

[John wilkins]

Phil, I think we're avoiding those same questions. Canada has a single payer system, and it is not a dictatorship. The core problem is that it is hard to make medicine a profit-making enterprise unless you find ways to cut out the sick. Right now we have the best health care system in the world - for the healthy. The sick, alas, are unprofitable.

The reason the government has a monopoly is because private businesses realize that its impossible to creat revenue from such a population. This is why the corporations are getting out of it.

But the evidence is still pretty clear, although you might be right. The plain fact is that health care is cheaper in Europe, and people are healthier. You don't refute these things.

Maybe Americans simply aren't good at bureaucracy. In Europe, being part of the government is an honor - the top students are taught to care about their country and serve in government agencies. Its a culture very foreign to us. Maybe we just don't have the talent, as a country, to believe that people can serve other citizens as a career. Maybe all this country is about is making money. Then, of course, we get the sort of government we deserve. But that's a choice - it's not a philosophy.

[David Huff]

Fr. Salty said: Maybe all this country is about is making money.

And it is.

Then, of course, we get the sort of government we deserve.

And we do.

(As an aside, this is perfect example of why I am such a fan in general of Canada. The place is just generally so much, well... saner than we are here in Jesusla^H^H^H^H^H^H the U.S.).

[Erin]

Salty, I think there may be a big difference between how people react now when an insurance company won't pay for treatment, versus how they would react when the government might not pay for treatment. If an insurance company won't do it it's evil, but it's business; if the government won't do it then the government is denying you your civil right, and you're gonna spend the last N months of your life suing the bastards. I think that's the attitude a lot of people would have.

Put another way: Insurance companies are effectively allowed to decide someone's going to die because of the bottom line. I don't think the government can possibly get away with such a thing, not in this country, and thus I expect premiums for healthcare would skyrocket, possibly past our collective ability to pay. Not that current costs are all that manageable...

It's not that I want people to die for being poor. But I look at this situation and see two options: one world in which I get a terminal illness with a slim chance of cure, and my ability to acquire that cure is to some small extent under my control; and one in which I get the same illness with the same chance of cure, but whether or not I get that chance depends entirely on someone else's decision. I don't love that second option, I have to tell you.

Though I suppose in reality we'd still have the first world. Bribery is the true universal language. It would just cost more.

I don't know. I'm not firmly set against socialized healthcare. I don't like the fact that not just hard work, but one's *profession* determines one's ability to acquire health care; if you happen to be, e.g., a church organist, you're probably screwed. But I'm very skeptical about socialized medicine becoming a world that sucks less than this one, despite how low that standard seems at the moment.

Just rolling ideas around in my head...

[Erin]

Salty, I think there may be a big difference between how people react now when an insurance company won't pay for treatment, versus how they would react when the government might not pay for treatment. If an insurance company won't do it it's evil, but it's business; if the government won't do it then the government is denying you your civil right, and you're gonna spend the last N months of your life suing the bastards. I think that's the attitude a lot of people would have.

Put another way: Insurance companies are effectively allowed to decide someone's going to die because of the bottom line. I don't think the government can possibly get away with such a thing, not in this country, and thus I expect premiums for healthcare would skyrocket, possibly past our collective ability to pay. Not that current costs are all that manageable...

It's not that I want people to die for being poor. But I look at this situation and see two options: one world in which I get a terminal illness with a slim chance of cure, and my ability to acquire that cure is to some small extent under my control; and one in which I get the same illness with the same chance of cure, but whether or not I get that chance depends entirely on someone else's decision. I don't love that second option, I have to tell you.

Though I suppose in reality we'd still have the first world. Bribery is the true universal language. It would just cost more.

I don't know. I'm not firmly set against socialized healthcare. I don't like the fact that not just hard work, but one's *profession* determines one's ability to acquire health care; if you happen to be, e.g., a church organist, you're probably screwed. But I'm very skeptical about socialized medicine becoming a world that sucks less than this one, despite how low that standard seems at the moment.

Just rolling ideas around in my head...

[The Green Knight]

Much of this discussion is taking place on the "what if?" level, as if no other country in the world had ever tried this idea before. But most Western countries have universal health care, and have not encountered any of the nightmare problems that some comments on this thread suggest. Why speculate when you can look at real-world evidence?

[IT]

To me the well-known statistic that we pay a higher rate of GDP for health care than much of Europe and the West, and we STILL leave a massive number of people uncovered and sick, sums it up. Don't you guys get it? Big companies are going broke because they cannot afford health care insurance. The bottom line is, we can't continue like this. We can't afford it. We currently ration health care economically. There has to be a better way. How anyone can consider this "just"... have you ever talked to someone with kids and a job with no coverage??? That's "justice"???

The UK ain't it (I lived there; if you could afford it, you bought private insurance anyway) but Canada seems to be doing a more reasonable job in making the essentials available.

People MAY start to pay attention to this if GM goes bankrupt or if...hey, what about this? BIRD FLU strikes and the total absence of investment in public health in our "market driven" system shows us up while collapsing the economy. See, those poor people who have no health care? They may just have sneezed on that cart in the grocery store or that nozzle you just pumped gas with. Point is, the virus isn't just going to wipe out them pesky poor folks. And our selfish, me-first, I-can-afford-it-you're-on-your-own will come back and bite HARD.

[Erin]

Several people have mentioned the health care systems in other countries as evidence that it can work. The rumor I hear is that Canadians routinely pay for private care in the US rather than wait months for free care in Canada (which, if it were true, would mean the dollars-per-citizen measure of efficiency is actually fairly misleading). I don't know how one substantiates such a thing, however...

Also, while it's true that some of the nightmare scenarios I worry about with socialized medicine have not come to pass elsewhere, the particular one I mentioned may well be rather culturally-specific. We're not great at sharing, in the US, and I simply don't think we have the collective mindset that would enable people to accept being effectively sentenced to death because the money is better spent on their fellow citizens. I can't speak for other nations, but it may be that this is less of a problem elsewhere.

I would feel much better about socialized medicine if it were not, in fact, single-payer, but instead one could opt either for some adequate level of care provided by the government, or for more expensive private care. This way poor people would still get some coverage, but nobody would be forced to settle for "adequate" if they could afford better. The trick would be keeping the budget at the "adequate" mark or better when the affluent people would have no personal investment in the quality of care... but given a constant budget, one could even get a better level of adequacy by letting people opt out.

[Adrienne]

Hi there. I've been reading for a few weeks. I figured I'd delurk, since I have, perhaps, some perspective to offer as a Canadian now living in Florida.

To Erin's last comment: I've heard anectdotally, primarily from Americans, that there are scads of Canadians travelling to the US for healthcare. I've never met anyone who's done it.

Anecdotally again, I underwent diagnosis and treatment for thyroid cancer in Canada before I immigrated to the US to be with my American husband. A year later, in Florida, I underwent the followup care. I can tell you that if there was any way I could go back to Canada for all further cancer screening (and if necessary treatment), I would take it in a heartbeat.

As I said in June, when I was going out of my mind with frustration at the way things were transpiring: "I've never met doctors who talked so little to each other, or to the patient, and I do think a large part of that is systemic. There's an economic incentive for them to limit the amount of time they spend on overhead like patient education/consults with other professionals/consults with me, in that if they limit that overhead, they can see more patients and thus bill more to the insurance company.

I have photocopies of all the consultation that was done back and forth between the surgeon, endo, and nuc med doctor for my treatment in Canada. It's quite voluminous. They all CC'd each other on test results. By this point in the process last year, I'd had 2 phone consults with the nuc med doc. I found out this morning that there *was* a nuc med doc at the hospital, but I won't really be dealing with him at all.

Now, I will concede that I had the best family doctor in the city I lived in, who referred me to the best surgeon in the city, who only worked with the two best endos in the province. So I was getting top notch care.

It could be that the endo I'm seeing now is the problem. However, he's not directly responsible for the glitches that occured at the hospital (I shouldn't have been told to call scheduling when I was, and they shouldn't have told me to use the lab they did, and the technologist who rescheduled my appointment back in April should have told the unit secretary that he'd rescheduled me. I was, they did, and he didn't.)

The points of error have been occuring all along the process, and if I wasn't aware of my own diagnosis and preferred treatment plan (and why), I'd be lost in the shuffle."

As it is, I never actually had the opportunity to talk to anyone but the nurse about the results of my tests; so while I can guess that the cancer is not back, I don't really know.

It's not only an unjust system for those who don't have good insurance, it's a very infantalizing and difficult to navigate system for those who do.

[IT]

Adrienne, our thoughts are with you, and hopes that you remain cancer free.

Your email sums up what I've heard from many Canadian friends. THe US thinks Canadians swarm over the border. None of my Canadian friends knows anyone who has done that. Urban myth?

I also concur that if you aren't very very involved in managing your own care, the system will lose you, drop you, and maltreat you. US health care the best in the world? Sucks to that! Not in my experience. Too many people looking for cash and playing cover-their-aXX.

We will not get national health care here until the corporations and companies finally scream ENOUGH!

[John wilkins]

My own feeling is that Christian should focus on this issue, the way Republicans focus on tax cuts. What say you?

[Erin]

Adrienne, that's an interesting story - thanks for sharing it. My own and my family's experiences with US medicine and insurance have been quite different (tangible illnesses = no trouble (e.g. cancer), non-tangible illnesses = endless fights (e.g. depression)) but I'm certainly sorry yours has been so awful... and I hope that the rest of your treatment goes more smoothly! :|

[Phil Snyder]

I have a neighbor who is Canadian and has lived in the US for a while. He would much rather have care here than what he had in Canada. He said that the Canadian system is the best in the world if you don't have to use it *NOW*.

I agree that our system is unjust. A single payer system that allowed people to suppliment their care with private insurance would become the system we have now, except some care would be provided by the gov't for everyone. Companies would subsidise the supplimental insurance for their employees as a means of keeping or attracting the best employees.

I spent 12 weeks of last summer in Parkland Hospital - the County Hospital for Dallas County and the place where JFK was pronounced dead. I was doing CPE there (the only place a deacon should do CPE in my opinion). I saw the effects of rationing health care based on need and on government money and it was not pretty. If I am ever in a trauma situation, please take me to Parkland. If not, please take me anywhere else. The staff try real hard and are top notch, but they are overwhelmed by the system and by the lack of resources to do what they believe best for the patients.

There is a stat that runs something like over 50% of most people's lifetime health care cost is incurred in the last two weeks of life. To reduce this cost, we should all die two weeks earlier :).

To provide a more just system, we should gather a committee (btw, a committee is a life form with six or more legs and no brain) of all people engaged in the delivery and payment of health care - doctors, hospitals, skilled nursing facilities, insurance companies, HMOs, IPAs, malpractice attorneys (plaintif & defendant) as well as government people and ask them to come up with a better solution than the one we have now and a way to move from the current system to the new one. You would be surprised how much people working in a system know about how to improve it.

YBIC,
Phil Snyder

YBIC,
Phil Snyder

[John wilkins]

Alas, phil, the anecdote you use is... anecdotal. There are no numbers. Numbers would be nice. Parkland works only in our current system of arrangements, where people generally don't get care until its too late or catastrophic. It makes sense that Parkland sucks because, well, its based in the American system. Have you asked, perhaps, why they are overwhelmed? Because the system looks at patients, in the end, as commodities or liabilities. thats the nature of the profit making system. I just don't think this should have much to do with health.

Although I am sympathetic to sin taxes - of foods that are clearly bad for one's health.

[John Wilkins]

And tellingly, you don't list the sick as someone who would be on the committee. They should have at least half the seats.

[obadiahslope]

It is possible to provide health care to every citizen AND avoid the perils of having a monoploy provider. At least that is what we do in Australia. Every Australian has access to public hospitals (free) and local doctors (for a small co-payment). At thge same time we are encouraged through the tax system to have private health insurance (which gives access to choice of doctors, faster service for elective procedures, private rooms).
Some 60% of Australians have private insurance.
No-one gets asked if they are insured if they are involved in a serious crisis.
Our system is not perfect. Remote towns do not get as good a serivice as they should. We need more aboriginal doctors and nurses. And there are crises of funding from time to time.
I would say that our system reflects gospel values (in an imperfect way) in that the poor are alawys helped.

[John Wilkins]

Obadiah, I think you're correct - there are lots of better options available. We don't need to go the English route or Canadian one. We could go the Australian or French if we so chose. But something organized nationally is much better than the system of arrangements we have now. All the government is doing in the single payer plan is negotiating prices and transferring money. It's not doing the work of the HMO - doctors are allowed to do medicine, and not worry about insurance.

[California Health Insurance]

It is unfortunate to hear so many lack health insurance. Temporary health insurance is a great product which helps many students and others that are not covered. We really need to improve our health care system. Health insurance is a major aspect to many and we should help everyone get covered.

[Prior Aelred]

All of the statistics are irrefutable -- as a society we more moeny for less care than anyone else in the world -- "denial is more than a river in Egypt" -- confession -- I have a friend who is a doctor in Quebec who would never move to the US -- he didn't become a doctor because he wanted to make a lot of money -- also, I have a rather wealthy friend who was in Europe with his son -- his son broke his ankle -- he was immediately treated free of charge -- Do people pay? Of course! Are the poor discriminated against? Of course not! What part of the Gospel do you not understand?

[Toujoursdan]

I am a Canadian expat who has lived in both New Zealand and the US and recently moved back to Ottawa. I would agree that there are shortcomings in the Canadian system. The technology isn't as up-to-date as the US and if you have a non life threatening medical issue, you have to wait on the list.

At the same time, every year I lived in the US, I watched my medical premiums go up and my coverage being cut back and in essence, found myself putting off non life threatening treatments and doctor visits because of cost. So in both cases I was waiting. And navigating the private bureaucracy in the US is a nightmare.

Still, while some Canadians may go to the US to get a procedure done, there isn't much agitation in Canada to dump the single payers system in favour of the US version. Most of those who go don't want the entire system to be scrapped, they just want to get around a hurdle it presents.

I would agree that there are more options then a US or Canadian model. Odabiahslope talked about the Australian model which gets good reviews and I found the New Zealand system pretty easy to navigate.

The problem in the US is American's knee-jerk reaction against government. While I fully support government accountability, I don't buy the line that all government programmes are doomed to inefficiency and abuse (which is what you hear on the media in the US all the time.) while private companies or systems are necessarily more efficient (How can they be when each company is extracting a profit) or free from abuse (Enron anyone?)

Until Americans can think of goverment as a collaborative tool rather than just the advisary, I feel that healthcare delivery, infastructure, public education and other macro societal programmes will continue to suffer.

But a change in mindset is needed first. Currently, it is easier for a camel to go through the eye of a needle that to get an American to support a government initiative ;-)

[Toujoursdan]

I should mention that while I don't know any Canadians who have gone to the US for treatment, I remember a news story a few years back where the Province of Ontario sent a few dozen patients (out of a covered population of 12 million people) to the US for treatments because of a temporary bottleneck. So perhaps that is what people are remembering.

I Googled "wait times Canada" and come up with this summary from the American Medical Student Assoc.:

=============================================
Summary

What is clear from this analysis is that Canadian waiting lists are undoubtedly a problem for many Canadians on certain elective procedures. What is not clear, however, is the magnitude of the problem, or whether there is a Canadian "waiting list crisis."

• The lack of quality data on waiting lists from the Canadian government, coupled with the limitations of surveys (e.g. differing methodologies), makes it very difficult to conclude with any certainty the size of the true waiting list problem.

• The Canadian experience with waiting times will necessarily be uneven, as waiting times vary by specialty, procedure, province, and region. That is, any given individual Canadian will have different experiences with waiting times. This may partly explain the existence of anecdotal reports of intolerable waits from certain individual Canadians (such stories often are dramatized in the media), juxtaposed with the denial of the problem from other Canadians.

• The U.S. does not experience problems with waiting lists as much as Canada does, although the problem does exist for some Americans.

• There is a small minority of Canadians who receive care in the U.S., and even a smaller minority who specifically come to the U.S. to receive care. The idea that hordes of Canadians cross the border to avoid waiting lists is a myth.

============================================

I should also point out that while the money comes from the federal government, each province manages their healthcare programme independently and that the programmes each have their stengths/weaknesses. I think B.C. has the longest wait times and Nova Scotia has the shortest.

(If you are in the Ontario plan, you can find out your wait time on the Ministry of Health - Ontario's website http://www.health.gov.on.ca) I have heard that wait times are declining though the Supreme Court of Canada recently ruled that they are still too long.

Here in Ottawa-Gatineau, which stradles the Ontario-Québec border, people go from one province to the other for faster care depending on the procedure.

I should also mention that Canada is unique in banning private hospitals and private insurance.

[J. C. Fisher]

This topic is very personal for me right now.

I have something on my face: might be cancer, might not (my father has a history of having things like this removed from his bald head).

I don't have health insurance (lost it last year).

I'm unemployed.

I was able to see a clinic, one-time-only, for $10.

The diagnosis?

"You should have that checked by a dermatologist: here are the names of a couple near-by. Medicaid? I don't think you can get Medicaid now. Good luck."

?!?!?!

So I'm in exactly the same place I was: there's something on my face. It might be cancer. It might not.

God bless America?

:-*(