Like other government-centric healthcare proposals, this plan rests on the fatal conceit that the government can manage the health care needs and choices of all of its citizens.
The cost reduction piece would primarily come from government price controls on the healthcare treatments and services that we all consume. In spite of the very serious flaws of all single-payer proposals, the popularity of the idea appears to be increasing.
Medicare Choice would be optional, yes, but unlike Medicare Advantage, there would be no choice in plan. The plan also promises to allow employers to opt into Medicare Extra or continue to sponsor different coverage. Again, the language — and idea — of greater choice and competition is bastardized here: With subsidies and other favorable treatment, a public option would unfairly out-compete private options. When private options fold in the face of this, the public option becomes the only option i.
And now even Canadian governments are looking to the private sector to shrink the waiting lists. This privatizing trend is reaching Europe, too. Britain's Labour Party — which originally created the National Health Service — now openly favors privatization. Since the fall of communism, Slovakia has looked to liberalize its state-run system, introducing co-payments and privatizations.
And modest market reforms have begun in Germany. Yet even as Stockholm and Saskatoon are percolating with the ideas of Adam Smith, a growing number of prominent Americans are arguing that socialized health care still provides better results for less money.
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. But such outcomes reflect a mosaic of factors, such as diet, lifestyle, drug use and cultural values. It pains me as a doctor to say this, but health care is just one factor in health. Americans live Health care influences life expectancy, of course.
But a life can end because of a murder, a fall or a car accident. Such factors aren't academic — homicide rates in the U. In The Business of Health, Robert Ohsfeldt and John Schneider factor out intentional and unintentional injuries from life-expectancy statistics and find that Americans who don't die in car crashes or homicides outlive people in any other Western country.
And if we measure a health care system by how well it serves its sick citizens, American medicine excels. Five-year cancer survival rates bear this out. The survival rate for prostate cancer is Like many critics of American health care, though, Krugman argues that the costs are just too high: health care spending in Canada and Britain, he notes, is a small fraction of what Americans pay. Again, the picture isn't quite as clear as he suggests. Because the U. Take America's high spending on research and development.
Anderson in Texas, a prominent cancer center, spends more on research than Canada does. That said, American health care is expensive. And Americans aren't always getting a good deal. In the coming years, with health expenses spiraling up, it will be easy for some to give in to the temptation of socialized medicine. In Washington, there are plenty of old pieces of legislation that like-minded politicians could take off the shelf, dust off and promote: expanding Medicare to Americans 55 and older, say, or covering all children in Medicaid.
But such initiatives would push the U. True, government bureaucrats would be able to cut costs — but only by shrinking access to health care, as in Canada, and engendering a Canadian-style nightmare of overflowing emergency rooms and yearlong waits for treatment. America is right to seek a model for delivering good health care at good prices, but we should be looking not to Canada, but close to home — in the other four-fifths or so of our economy.
From telecommunications to retail, deregulation and market competition have driven prices down and quality and productivity up.
Public patients in public facilities face longer wait times. The Netherlands, meanwhile, has handed over the responsibility for providing coverage to private health insurers, and that has come with costs too. The Dutch have had to impose strict regulations on health insurance, including harsh penalties for people who fail to sign up for insurance on their own. Doctors in the Netherlands are more likely than those in more socialized systems to say their patients struggle to afford medical care.
They are also more likely to say the administrative work they have to do is a drain on their time. Health care spending in the Netherlands has also been rising at a faster clip since the move to the mandatory private insurance system.
So the question becomes what kind of trade-off is more palatable. There is no way to avoid it: If you want universal coverage, the government is going to play a huge role. In Taiwan and Australia, that means the government runs a universal insurance program that covers everybody for most medical services. But even in the Netherlands, which relies on private health insurers, the government oversees everything. It sets rules about what benefits have to be covered, what prices can be charged, and what cost sharing is required.
It collects contributions from employers to pay the cost of covering everybody and spreads it among the insurers based on the health status of their customers. All told, about 75 percent of the funding for health insurance in the Netherlands is still running through the national government, even if the actual insurance benefits are being administered by private companies. Under all of these insurance schemes, the governments use much more force to keep health care prices down compared to the US.
In Taiwan, that means global budgets — an annual amount set aside every year for various sectors of the health industry hospitals, drugs, traditional Chinese medicine, etc.
In the Netherlands, even with private insurers, the government sets limits on how much health spending can accrue in a given year and has the authority to impose budget cuts if spending exceeds that limit. Prices are also set for particular services, like after-hours primary care.
Insurers do have some limited flexibility in which providers they contract with, but the government sets their health care budget for them.
We have experimented with that kind of system in the US, as Tara Golshan covered in this series in her story on Maryland. She documented how the state has tried to use a model like this, global budgets, to improve care for patients by encouraging hospitals to focus on the health of their patients instead of whether they have enough people in their beds. But Maryland remains an exception.
And as the research shows, the US spends dramatically more for many common medical services compared to other developed countries:.
For most developed economies, their aging populations will present a serious challenge of both cost and care delivery. The chart below shows what countries were already paying notice the US lags significantly both overall and in public investment and then projects what they will be paying in Yi Li Jie, a spinal atrophy patient I met, has to pay out of pocket for her caregivers; she also has to pay a substantial share of her transportation costs to get to medical appointments.
On the other end of the spectrum, the Netherlands has a universal public program to cover long-term care, even though it has private medical insurance. Of course, the needs for these populations extend beyond the basic provision of medical care.
No matter the health system, the most complex patients are going to have the most challenging needs to meet. Nobody has figured out a silver bullet for fixing that yet.
It would be the most equitable and the most efficient. But other countries, like Australia and the Netherlands, have found a significant role for private insurance even as they strive toward the same goal.
Frankly, however, private insurance seems to be more of a political compromise and, by extension, to reflect some differences in societal values than a preferred policy solution. Australia had had private insurance for decades before its universal public insurance plan was introduced in the s; both of its major political parties have come to accept the existence of that program. Private insurance in Australia has given the better-off more options in their health care; that comes at the expense of some equity, but it is a compromise the country has been willing to make as it tries to balance access and choice.
Because a center-right government was in charge, they wanted to pursue a market-driven, managed-competition model to try to fix it. Universal coverage was still a shared goal for all the political parties, but they pursued private insurance to do it because it aligned more with the ideology of the ruling government.
Now critics say that was a mistake, that it has made health care more expensive in the Netherlands. But it was the pragmatic path available to the country at that moment. He had approval ratings for the single-payer plan on big whiteboards, and he had just been showing us the enormous spike in approval among the public for the national insurance plan and its steadiness over the years. As recently as , 39 percent of physicians said they were either dissatisfied or very dissatisfied with national health insurance.
Another 31 percent said they were neutral. Just 30 percent said they were satisfied or very satisfied a paltry 2.
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