Wait, Wait…Don't Treat Me

My former colleague Johnny Munkhammar, author of European Dawn—After the Social Model and fellow at the Swedish think tank Timbro, cautions Americans not to get too excited about the single-payer health care model. Europeans, Munkhammer writes in the Examiner, "have already been down that road. So a word of caution is in order":

In my home of Sweden, for instance, patients in need of heart surgery often wait as long as 25 weeks, and the average wait for hip replacement is more than a year. Some patients have even been sent to veterinarians for treatment, and many Swedes now go to neighboring countries for dental care, despite having paid taxes for "free" dental coverage.

This shouldn't be a surprise. Only with an infinite supply of health care funding can government dole out an infinite supply of health care services, so waiting lists are a natural consequence of state-sponsored coverage.

The same is true, he writes, of Britain's NHS:

In Britain, more than 1 million citizens who need medical care are currently waiting for hospital admission, and every year, the National Health Service cancels as many as 100,000 operations because of shortages.

Only about half of all British adults are registered with public dentists, as dental work is notoriously inadequate and roughshod. The reason? The U.K.'s dentists are paid on a per-patient basis, so their incentive is not to offer the best treatment but to treat as many patients as possible. Surgeries, complicated procedures and other time-consuming treatments are a waste of precious billing time, from the economic viewpoint of the dentist.

Whole article here.

Comments

[Kwix]

Listen to much NPR?

[joe\'s spokesperson]

joe stopped reading after the weak-assed insult to Johnny Munkhammer's patriotism.

[Art]

But its free damnit.

[Kwix]

The U.K.'s dentists are paid on a per-patient basis, so their incentive is not to offer the best treatment but to treat as many patients as possible. Surgeries, complicated procedures and other time-consuming treatments are a waste of precious billing time, from the economic viewpoint of the dentist.

Well, the "proper" answer would be to remove the economic incentive of the dentist all together. Clearly Cuba and North Korea lead in this model so we should look to them for guidance. I mean, every North Korean is a model of perfect health, yes?

[highnumber]

Whadyaknow?

[bmp]

Mark Kleiman has a challenging and rewarding piece on rationing healthcare here.

[Art]

Kwix:
I would say that every North Korean and Cuban is a model for the low calorie, locally grown and totally organic lifestyle being advocated to us by some of the smartest people in the world.

[MP]

The problem with this article is that defenders of socialized medicine are unconcerned with rationed care. They simply want to guarantee a level (even a barely mediocre level) of care for everyone, regardless of income. And you can't fight the defenders argument with numbers, because they aren't concerned about net consequences.

Frankly, I don't know how to fight the argument of the defenders of socialized medicine. Since they're willing to accept a low level of care, regardless of costs, as long as it covers everyone, there's no defeating that stance.

[JasonL]

Kleiman strikes me as more than a bit diningenuous. He claims skepticism that cost containment of medical services matters much in the long run compared to spreading costs out to ensure greater access. Okay, but don't you think that absolute availability, supply and demand, otherwise reflected as a price, might have something to do with rationing? Can having fewer MRI machines REALLY not be relevant?

[David]

Only about half of all British adults are registered with public dentists, as dental work is notoriously inadequate and roughshod.

There's a shock!

[Pro Libertate]

Hmmm. We better start getting more veterinarians on the street in a hurry, then!

[Bill Pope]

No health care system on earth can provide high quality care to everyone who needs it right when they need it. So whatever the system, care will be rationed by price or by waiting. The single payer systems yields better results in terms of life expectancy and infant mortality than in the US, at a lower cost per person. Furthermore, they don't have administrators who are paid bonuses for denying care, and they don't dump the uninsured into the streets.

[Alan Vanneman]

"Only with an infinite supply of health care funding can government dole out an infinite supply of health care services, so waiting lists are a natural consequence of state-sponsored coverage."

Is Johnny arguing that private sector health care services providers do have an infinite supply of health care services, and thus could supply such services without any waiting lists? Or does he mean that in the U.S. only people who "need" heart surgery receive it? The following dialogue suggests itself.

"What do you mean he didn't need heart surgery? He died!"

"If he needed it he would have paid for it. Death, after all, is always an option in these matters."

[grumpy realist]

I had quite a lot of dental work done via an outside provider, and had no problems with waiting.

Why would a two-tier system be so bad? Socialized medicine, paid out of your taxes, free if you're willing to wait, and private medicine, where you pay to get treatment?

We are moving towards a socialized system because the present system has shown itself incapable of providing the services needed. End of story. Libertarians can bitch about this as much as they want, but they'd have a better shot derailing the movement if they went after the insurance companies and got them to fix the problems.

Do Libertarians honestly want to live in a world where if you're poor or have bad genetics you get dumped on the mercy of whatever Jesus-thumping "charity" exists in the neighborhood?

[JasonL]

"Frankly, I don't know how to fight the argument of the defenders of socialized medicine. Since they're willing to accept a low level of care, regardless of costs, as long as it covers everyone, there's no defeating that stance."

Sigh. I agree. All you can do is point out over and over again that they ARE choosing a low level of care and that the cost savings they see in the offing are illusory. There will be no incentive to innovate and other systems seem cost effective because ours isn't. When costs spread out, a chunk of the efficiency argument of single payor systems goes away. Canada will be hurting when we do this.

[josephdietrich]

You know, if I wanted to make a case against European health care systems I too would enjoy the ability to look at the thirty-something different implementations and choose the worst examples I could find to bolster my argument.

[JasonL]

grumpy:

The problem is that the two tier system is difficult to maintain as two tiers. The incentives line up for everyone to swamp "free" care.

[joe]

Only with an infinite supply of health care funding can government dole out an infinite supply of health care services, so waiting lists are a natural consequence of state-sponsored coverage.

Anyway, it's a good thing our privately-funded health care system has an infinite amount of money. That must be why it provides an infinite amount of medical care.

crymethink,

I didn't notice anyone's patriotism being questioned.

[joe]

And you can't fight the defenders argument with numbers, because they aren't concerned about net consequences.

Well, you could provide quantitative data that demonstrates that our system produces superior medical outcomes than countries with similar levels of wealth and universal systems.

Except, of course, you can't. All your health care data are belong to us.

[Rattlesnake Jake]

"No health care system on earth can provide high quality care to everyone who needs it right when they need it. So whatever the system, care will be rationed by price or by waiting."
But we don't have to wait as long as they do in countries with socialized medicine. Some people are rationed out of the system in those countries. Some die while waiting for operations and diagnostic tests.
"The single payer systems yields better results in terms of life expectancy and infant mortality than in the US, at a lower cost per person."
Genetics and diet have alot to do with life expectancy. Our high ratio of minorities has a lot to do with a higher infant mortality rate. Our health care system has nothing to do with those factors as if there are better health care systems in those other countries, which is not the case.
"Furthermore, they don't have administrators who are paid bonuses for denying care, and they don't dump the uninsured into the streets."
These factors are the result of government intervention in our health care system. It is the fault of the 1973 HMO Act for the purpose of controlling costs. Actually, HMO's by paying for routine care when our insurance used to be more for catastrophic care has led to overuse and have actually raised costs which has resulted in our "uninsured being dumped into the streets" because they can't afford the expensive health care made expensive by our government meddling. A single payer system is nothing but a giant HMO which will utilize rationing to lower costs and will result in more people not getting the care they need. We don't need more government, we need less government and more competition in the health care market to make it more affordable for more people.

[creech]

Several of the commentors are right - for those who want medical coverage provided through first having armed federal agents go out and take the money from the citizens, then there is no argument except trying to show there is a better, more moral, way. If the majority doesn't buy it, then America will get socialism.

[carrick]

All Hail the increasing health care costs. I definitely for them.

[JasonL]

A short list of the concerns with the direction we are heading would look something like this:

1) Nobody on the planet except for US healthcare consumers pay for innovation or development to any extent whatsoever. If we remove the profit incentive from the US market, I struggle to see where innovation will come from. I firmly believe that this alone will cost more lives than ultimate toll of Iraq will be. You can't remove the profit incentive and get remotely similar development.

2) The lower cost per head of nationalized systems is often thrown around, but without regard to the massive US market subsidy. When our costs do down, everyone else's go up.

3) The US market serves as an opt out for top shelf care for people in other nations. This is another subsidy that all these efficient systems will have to pick up or do without.

4) As if it isn't bad enough already, the advent of single payor means that public health regulation will explode. In an effort to maintain cost controls, your neighbor will have their nose in your refrigerator.

I can't see any possible configuration of positive outcomes from a nationalized system that will offset even one of these.

[GImme Back My Dog]

joe and AV,

I think johnny's point is that when you put a price of zero on health care, there is an infinite demand. A privately funded system puts a price on health care and moves demand down to an attainable level.

[Art]

Bill:
Haven't seen you in awhile but I see you are still being selectively supportive of socialism.

Your statements are patently false. The hospital administrators in single payer Canada and England are either getting bonuses or keeping their jobs by faking their wait time and health care statistics. Thats their job and they are damn good at it. You've been waiting 6 months for a surgery, get a call at 6 to be in surgery the next morning, can't make it, no problem, back to end of the line.

In New york we have both for and not for profit health plans and the amazing thing is that the not for profit plans have significantly higher administrative costs with out profits than the for profit plans with profits (20% vs 15%). But it sounds good when you say there should be no profits.

The reality is that profits show you finished the job and had some money left over, not for profit means there will never be enough money to get the job done.

[Reformed Republican]

It was only later that I discovered why the insurance company was stalling; I had an option, which I didn't know I had, to avoid all the approvals by going to "Tier II," which would have meant higher co-payments. The process is designed to get very sick or prosperous patients to pay to jump the queue.

So he had an option to get things done faster, but did not take it, and he thinks a system without that option would be better?

Libertarians can bitch about this as much as they want, but they'd have a better shot derailing the movement if they went after the insurance companies and got them to fix the problems.

Many libertarians do have problem with the current insurance system, especially in the way the payroll tax system encourages employers to provide insurance, distorting the market. Problems caused by state interference are generally only made worse by more interference.

[Rattlesnake Jake]

"Anyway, it's a good thing our privately-funded health care system has an infinite amount of money. That must be why it provides an infinite amount of medical care."

It provides a hell of a lot more that the socialized medicine countries.

[Art]

The true test of a health care system is how well they treat sick people and what those outcomes are.

Clearly if we use this as a measure the US is superior to all other systems, even accounting for the fact that 15% of the population does not have health insurance.

[joe]

JasonL,

Where do you get this idea that the incentive to innovate will decline if everybody is guaranteed health insurance?

As Ron Bailey pointed out yesterday, innovation saves money by replacing more-expensive and less-effective treatments with better ones, which saves both on medical costs and by making citizens more economically productive. Why would doctors not prescribe, and the single payer not cover, the use of money-treatments, thereby sending the same money to, for example, drug companies? Not to mention, a single payer (the government) would also have a stronger incentive to maximize the "making citizens more economically productive" piece of the equation than a private insurance company that gains nothing if its customers are more productive.

I don't see where you get the idea that universal coverage means less money going to drug companies. That certainly isn't the way Medicare Part D worked out.

[TrickyVic]

"""The problem is that the two tier system is difficult to maintain as two tiers. The incentives line up for everyone to swamp "free" care.""""

Only if insurance companies drop clients. I'm currently covered from my job. If I have the option between free socialized health care or use my insurance, I would use my insurance, that's a no brainer. I'm sure how longer lines and less quality of care is more of an incentive just because it's free. Anyone who could afford better, would.

"""All your health care data are belong to us."""

Maybe, maybe not. But when all health care is recorded in EMRs (electronic medical records) it is most likely they will be held in a clearing house which the government will probably have access to. I'm pretty sure current HIPAA laws allow law enforcement to access your records when authorized by law. Who knows, some of those laws could be top secret. So your statement will probably become true social medicine or not.

[Chuck]

grumpy realist said:
Why would a two-tier system be so bad? Socialized medicine, paid out of your taxes, free if you're willing to wait, and private medicine, where you pay to get treatment?

Why, it would be just like public and private schools! Who could be against that?

Seriously, though, I have some distant relatives who are British, and they all think that the NHS is wonderful. Of course, they don't actually *use* the NHS, because they are wealthy, and get private treatment when they are sick.

[joe]

Art,

The true test of a health care system is how well they treat sick people and what those outcomes are.

Actually, much of health care revolves around keeping people from getting sick, and keeping slightly sick people from becoming very sick.

The 15% of the country who can get treated by a doctor just as soon as their chest infection gets bad enough for them to go to th ER, or who don't get that little lump checked out until it hurts to pee, would probably disagree that the treatment of late-stage diseases is the only relevant criteria for measuring the quality of a health care system.

[TrickyVic]

I gotta stop hitting submit so soon. The above should have said

I'm not sure how longer lines and less quality of care is more of an incentive just because it's free. Anyone who could afford better, would.

[Rattlesnake Jake]

"I don't see where you get the idea that universal coverage means less money going to drug companies. That certainly isn't the way Medicare Part D worked out."

When taxes go up, people start complaining and the government has to cut down on expenses to control taxes. That means less money available for R & D. Why is it that most new drugs and medical technology comes from America?

[JasonL]

joe:

A single payor can set his own price down to the margin and has every reason to do so. What I know is that the US market pays for nearly all research and development because profits come overwhelmingly from we fools who 'pay too much'.

Pharma research is an absurd undertaking. Your homerun has to carry your 20 nightmare debacles, each of which cost a fortune. That kind of risk has to be balanced by the ability to profit.

At least a large portion of the argument about the cost of healthcare is framed by the idea that medicine is currently too profitiable. It isn't.

[JasonL]

joe:

To be clear, if there is a way to nationalize while maintaining market incentives for innovation, we would have a system that would make me unhappy but without the tragedy.

If the system is redesigned such that the profit motive is removed from development, I think will will have, no exaggeration, horrific misery and widespred deaths that could have been prevented.

[Paul]

Actually, much of health care revolves around keeping people from getting sick, and keeping slightly sick people from becoming very sick.

Right, like an Health Maintenance Organization.

Raise of hands for anyone who worked in healthcare during the 80's and 90's and remembers "capitation". I can tell you from a systems standpoint, that's about eight years of my life I'll never get back.

[Rattlesnake Jake]

"The 15% of the country who can get treated by a doctor just as soon as their chest infection gets bad enough for them to go to th ER, or who don't get that little lump checked out until it hurts to pee, would probably disagree that the treatment of late-stage diseases is the only relevant criteria for measuring the quality of a health care system."

Why would they need insurance for routine exams? Most people can afford the cost of routine exams without having to have insurance to pay for it.

[gtspm]

You don't need more government and you don't necessarily need less government- you need better government. Pooling insurees into statewide risk pools would be a good compromise at this point between dog eat dog Libertarianism and socialized Kommie care. The wall coming down should be proof enough that centralized planning doesn't work and the current sorry state of affairs should be proof enough that the current situation is untenable from both an economic and political standpoint.

[neilpaul]

We don't really need inovation, people live long enough as it is. bigger gains could be made for society if more people got the care we have already and if people didn't smoke or overeat. Sorry cancer people, you lose. Luckily we will be shutting down new drug development after the scourge of ED has been largly addressed. I only wish we had solved the second biggest outstanding disease, baldness.

Why shoudn't the rationing be a matter of gov't waiting lists instead of ability to pay? Does anyone not on this site really think healthcare is a "want" not a "need?" As a guy who can pay, I suppose I should feel more upset about this, but I'm pretty comfortable with my mortality. Please Jesus, take me now.

The only problem with sociaized medicine is that many upper middle class proponents are going to freak out when they realize that under such a system they will pay more for less than now while the poor come rushing in and improve their lot the most. Actually that is not a problem, that's the funny part.

[joe]

JasonL,

That makes some sense to me. I see the overhead and advertising budgets of drug companies and HMOs as appropriate targets for efficiencies, not drug research. What you've mentioned is a reasonable concern.

I think the key here would be to socialize health insurance, while keeping providers of health services and products on a free-market footing.

[Mr. Nice Guy]

"In Britain, more than 1 million citizens who need medical care are currently waiting for hospital admission, and every year, the National Health Service cancels as many as 100,000 operations because of shortages."
That must suck, especially having no other option if you could use it. However, aren't there like, multiple millions of folks in the US who not only need medical care, but are not even on waiting lists because they have no insurance at all and can't afford the treatment? A better way to look at this might be not to assume that proponents of socialized medecine have to prove their system has no faults, but do their faults outweigh our systems faults?

[Andy]

The problem is that we DON'T have a true free market system. The HMO legislation in 73' helped create these organizations
http://www.lewrockwell.com/paul/paul339.html

[joe]

Paul,

Right, like an Health Maintenance Organization.

See my point above - with a single payer, who also has to pick up the costs of a less-productive society if sufficient treatment isn't provided, there is a closer aligning of interests than there is under the existing HMO system.

Rattelsnake Jake,

Most people can afford the cost of routine exams without having to have insurance to pay for it.

Figures, please? For example, what's "most people?" How must is a mamogram out of pocket?

[Mr. Nice Guy]

I'm not suggesting I know the answer to that question I posed though. I suspect we do better on certain criteria (like providing specialized care or developing innovative techniques and/or drugs/equipment) while sucking on others (providing equality of care and covering/treating those who can't afford coverage/treatment). But I'm just supposing on these as well, I don't have any access to numbers on these criteria.

[neilpaul]

Joe,

do you really see a single payer caring about the costs of a less productive society? What penalty will the beurocrats who work for this payer incurr that will incentivise them to give a damn?

Right now we have employer based insurance. Who should care more about declining work productivity than employers? Still we don't see lavishing of preventitive care on those with these employer based plans.

I think there is a disconnect there.

[JasonL]

"I think the key here would be to socialize health insurance, while keeping providers of health services and products on a free-market footing."

I agree in the abstract, but that starts to look odd up close. You start getting this feeling that insurance isn't insurance any more at the single payor level. If you are trying to guarantee that everyone is fully funded for whatever they need, don't all the competing risk models go out the window? What risk? You will pay and that is that.

Once you are there, in a place where your actuarial analysis and selection of your market can't give you cost advantages, how do you contain costs?

That is the problem. If you are going to buy it no matter what, you can't contain costs. Your recourse will be to regulate prices, and down we go.

[Rattlesnake Jake]

"The only problem with sociaized medicine is that many upper middle class proponents are going to freak out when they realize that under such a system they will pay more for less than now while the poor come rushing in and improve their lot the most."

You don't think the poor in our system aren't getting medical care now? It's called Medicaid. It's the middle class who don't have insurance who have to pay the high prices caused by overuse of the system caused by Medicare, Medicaid, and private insurance that covers routine care. I've been there, so I know what I'm talking about. Medicare and Medicaid don't pay doctors and hospitals enough to cover their costs, so they have to make it up by charging more to private insurance and non-insured. We need more competition in the market place to bring down costs such as voucher systems for Medicare and Medicaid users with the users paying for routine care with them, getting to keep the money they don't spend on routine care by shopping around for the best prices. We need to go back to catasrophic policies and have patients pay for their routine care. We need to have means tests for Medicare recipients. All these things would help bring about lower more affordable health care. We also need to have tort reform which would bring down medical costs.

[Art]

Joe:
Your absolutely right. Let's spend all of our money and give all of our resources to keeping people healthly. And if you get sick then screw you, it's your own fault.

The reality is that if every person in this country got every recomended preventative test and treatment the entire, current health care budget of $1.7 Trillion would be spent on this. With no money left over to treat any illness.

This is one of the many reasons I hate Health Care Nannys and socialized health care. They both like "Preventative Care" and give you plenty of primary care and cheap health care, but when your sick, screw you.

[Rattlesnake Jake]

"I think the key here would be to socialize health insurance, while keeping providers of health services and products on a free-market footing."

The problem with that is that the government in all it's profound wisdom would dictate how much can be charged for pharmaceuticals and leave the pharmaceuticals without enough money for R & D. This is a concept that Hillary doesn't seem to be able to grasp either. If you regulate the prices pharmaceuticals can charge, it's not a free market.

[Mike Laursen]

Frankly, I don't know how to fight the argument of the defenders of socialized medicine.

The weakest point in their argument is their insistence that the system has to be universal. Ask why it wouldn't be sufficient to simply provide health care or insurance assistance to those below a certain income through a means-tested program.

The only answer I've ever seen to that question is that everyone must participate in order to create the economy of scale to make the system more economical than a private system. The flaw in their thinking is that they don't realize you need two conditions to make economy of scale work. The first one, scale, is obvious. The second condition, however, is competition or some other motivation to economize.

[Art]

Joe:
And another fact is that most socialized medicine coutries have a disability rate of about 10% of the workforce.

You can add that 10% to the unemployment rate or to medical expenses but it is a glaring example of a system that is glorified without any basis.

[Rattlesnake Jake]

"However, aren't there like, multiple millions of folks in the US who not only need medical care, but are not even on waiting lists because they have no insurance at all and can't afford the treatment?"

They could always go to a charity hospital.

[joe]

neilpaul,

We don't have "employer-based insurance." We have "employer-paid insurance."

The employer pays exactly the same for the insurance plan, regardless of the health outcomes. The insurance company does not save or earn any additional money by making its customers more productive for their employer. So, no, we do not have a system where those paying for the costs reap a benefit for keeping people healthier.

[joe]

Not to mention, neilpaul, insurance companies can drop customers whose little illnesses turn into big, expensive illnesses because of inadequate preventive care, while a single payer could not.

As for bureacrats, what incentivizes HMO bureacrats, who don't personally make more money based on the quality of the medical care they provide? Promotions for meeting company goals, that's what. So maybe changing the "company's" goals would make some sense.

[joe]

Art,

The current system over-provides tests for healthy people with good insurance, and underprovides them for people with lousy insurance. So, no, socialized insurance would not only increase testing, but would decrease it as well.

Rattlesnake Jake,

I can see your side, but there is a rather obvious problem with overcharging for medications as well - it leaves fewer resources available for other stuff. You need to think it terms of a balancing act, because falling off both sides is a problem.

They could always go to a charity hospital.

When they get sick enough to go to the ER. Which costs a lot of money, and produces bad outcomes. And is eventually reimbursed by the government. All hail efficiency.

[TrickyVic]

First we have to realize that few can actually afford the price of health care. That's why we have insurance companies. Those companies actually obstruct the free market forces. If everyone had to pay out of pocket for the full cost of health care, few would be able to get it. Therefore the demand would drop and prices would come down.

So if you really want market rate medical care, abolish the insurance companies.

[Bill Pope]

Rattlsnake Jake:
You are being ridiculous.

"But we don't have to wait as long as they do in countries with socialized medicine. Some people are rationed out of the system in those countries. Some die while waiting for operations and diagnostic tests"

No system is free of wait times. People have died after waiting for hours in US emergency rooms. Not to mention the uninsured (about 18,000 per year) for lack of care.

"Genetics and diet have alot to do with life expectancy. Our high ratio of minorities has a lot to do with a higher infant mortality rate. Our health care system has nothing to do with those factors as if there are better health care systems in those other countries, which is not the case"

Really? Cuba's population is almost entirely Latino and black and they have a lower infant mortality rate. And to say the health care system has nothing to do with these rates is silly.

"These factors are the result of government intervention in our health care system. It is the fault of the 1973 HMO Act for the purpose of controlling costs. Actually, HMO's by paying for routine care when our insurance used to be more for catastrophic care has led to overuse and have actually raised costs which has resulted in our "uninsured being dumped into the streets" because they can't afford the expensive health care made expensive by our government meddling. A single payer system is nothing but a giant HMO which will utilize rationing to lower costs and will result in more people not getting the care they need. We don't need more government, we need less government and more competition in the health care market to make it more affordable for more people"

Health care will always be expensive because it is so highly-skilled labor-intensive. Actually the cost inflation has been less for Medicare than private insurers. Also, what is "overuse"? There may be some people who are hypochondriacs, but I seriously doubt they have a significant impact on overall costs. And finally, no one is in competition to cover sick people simply because it's unprofitable to do so.

[creech]

Guys, we are losing this battle because we are faced with opposing Santa Claus when it comes to health care. Libertarians had better come up with some damn good reasons to oppose socialized medicine or that's what we will get. And two generations from now, that's all they will have known and will never be able to visualize how their grandparents lived with a semi-free, semi-private health care industry.
Just like our kids were taught the Robber Barons operated under laissez-faire, our great grandkids will hear about how only the rich got to see doctors under laissez faire medicine in 2007 America.

[Cesar]

I said it before on another health care thread, I'll say it again--

If single-payer health care is a great idea, try it out on the state level and show everyone how wonderful (or terrible) it is before dragging the entire nation into it.

[neilpaul]

Joe,

employers pay and they would benefit from healthier employees by getting HEALTHIER EMPLOYEES.

Thus we do have a system where the payer gets a benefit for conferring more health on their insureds. Employers, especially large ones should be able to insist on a plan that maximizes its workforce's productivity, yet they don't. This leads me to believe that the productivity losses of illness among the work force are less dramatic than presented.

[Cesar]

Really? Cuba's population is almost entirely Latino and black and they have a lower infant mortality rate.

Infant mortality rates are measured differently from country to country.

[joe]

neilpaul,

employers pay and they would benefit from healthier employees by getting HEALTHIER EMPLOYEES.

Thus we do have a system where the payer gets a benefit for conferring more health on their insureds. Employers, especially large ones should be able to insist on a plan that maximizes its workforce's productivity, yet they don't.

In practice, companies are offered a few pre-packaged options from insurance companies, and the rate of denial of claims is not an option they can express a preference for.

[Max]

First we have to realize that few can actually afford the price of health care. That's why we have insurance companies.

Huh? You make it sound like insurance magically makes health care cheaper. Insurance is an added cost.

One of the problems is that people don't have freedom of choice in insurance. The government regulates that insurance policies must cover X, Y, and Z. Effectively you have the choice of buying a gold-plated policy or nothing. Cheap insurance isn't just unavailable, it's illegal.

[Lord Duppy]

It is simply ridiculous to assert that externalizing the costs of health care will cause demand for heart surguries and hip replacements -- the two examples given above -- to rise. The demand for heart surgury and hip replacement are INELASTIC. That we do not have people going without hip replacements in the United States does not indicate that demand is any lower, it means that, for reasons you may debate, we are doing better on the supply side.

[joe]

I think, Max, what he meant is that few people can afford to be the guy who gets the big injury or disease and has to pay for it out of pocket my himself.

[Mr. Nice Guy]

Cesar-Could you provide some more info on that claim that infant mortality rates (IFR) are measured differently in different nations? I thought IFR was the rate babies from live births die before they reach the age of one, and I'm not sure how that would vary due to measurement differences (do some countries count live babies as dead and vice versa, or do they use a lunar year?). According to the CIA, however they define IFR, Cuba has us beat.
https://www.cia.gov/library/publications/the-world-factbook/geos/cu.html#People
https://www.cia.gov/library/publications/the-world-factbook/geos/us.html#People

[Cesar]

Sure nice guy, look here

From the article:

The exclusion of any high-risk infants from the denominator or numerator in reported IMRs can be problematic for comparisons. The United States counts many infant births as live which other countries do not and therefore usually appears to have a much higher rate of infant mortality than similar countries.The US counts an infant exhibiting any sign of life as alive, no matter the month of gestation or the size, but other countries differ in these practices. For example, in Germany and Austria, fetal weight must reach one pound to be counted as a live birth, while in some other countries, including Switzerland, the baby must be at least 12 inches long. Both Belgium and France report babies as born lifeless if they are less than 26 weeks' gestation.[2]

[Mr. Nice Guy]

"You don't think the poor in our system aren't getting medical care now? It's called Medicaid." Jake, do you think Medicaid is a good program? Without such a program would not many people not be able to afford care? If it is a good idea for the government to give care for these folks, why not give care to the ones who actually pay for programs like Medicaid, the middle and upper class taxpayer.
"We need more competition in the market place to bring down costs such as voucher systems for Medicare and Medicaid users with the users paying for routine care with them, getting to keep the money they don't spend on routine care by shopping around for the best prices."
That is a really interesting idea. I wonder if people would "shop" for health care, of if people just go the nearest doc when they are sick (being sick has a way of making prices inelastic I would think). But, again, I think this is a neat idea with high potential. Ditto for the means testing.
"We need to go back to catasrophic policies and have patients pay for their routine care." But isn't it a big problem now that many, many people cannot afford "routine" care so they put it off creating a "catastrophic" situation? If it were covered to a lesser extent people would get less of it (I realize that is partly your point, in theory that decrease in demand drives down the price, but to get there you get a lot of people passing up that cholesterol screening that used to be covered).
"We also need to have tort reform which would bring down medical costs." I think there are some flaws in tort law, but I really think this is a canard put out by folks like the AMA. I mean, we are tough, rightly so, on companies that sell defective products that cut off your fingers or burn down your house, we are tough on people who run a red light and cripple you, and we should be tough on doctors who amputate the wrong leg or leave a scapel in you...I can't believe the way people who normally espouse a healthy view of individualism and personal responsibility now attack tort law. Tort law is all about individual personal responsibility, making sure that people follow a duty of reasonable care so they don't hurt people (and thus kill of that injured persons opportunity in life).

[Mr. Nice Guy]

Thanks Cesar. Wow, it's like my old research methods prof used to drill into us: the main question is not what results were found, but how the variables were defined. I was naive enough to think that "babies born alive that do not make it to age one" had too little wiggle room for much to be done, but that's what I get for assuming! For the record, do you know what Cuba's operationaliztion for "born alive" is by chance?

[TrickyVic]

"""Huh? You make it sound like insurance magically makes health care cheaper. Insurance is an added cost."""

Few people without insurance can afford the cost of health care. If insurance went away, most people could not afford health care. If you broke your leg, you would have to take out a loan. I do believe that outstanding medical bills are a leading cause of bankruptcy.

[Cesar]

For the record, do you know what Cuba's operationaliztion for "born alive" is by chance?

You're welcome. I just know western Europe has a much looser definition of "born alive" than the rest of the world, and the US has a very strict one. I'd wager that our strict definition has to do with religious influence in politics, "life begins at conception" and all.

I can't get anything on Cuba's definition, but then again its a dictatorship so go figure.

[MP]

If insurance went away, most people could not afford health care. If you broke your leg, you would have to take out a loan. I do believe that outstanding medical bills are a leading cause of bankruptcy.Few people (under 65) require expensive corrective action health care. Insurance is a natural free market response to this limited risk. Abolishing insurance companies is definitely an anti-market approach.

[Mike Laursen]

If you broke your leg, you would have to take out a loan.

I'm going to assume you just didn't choose your example carefully. I think most middle-class folks could pay for having a broken leg treated out of pocket.

[Pig Mannix]

A single payor can set his own price down to the margin and has every reason to do so. What I know is that the US market pays for nearly all research and development because profits come overwhelmingly from we fools who 'pay too much'.

I'd be interested in seeing some support for that statement. I've heard that said frequently, but I've never been able to find any support for it. If anyone can produce any studies to that effect, I'd like to see them.

[bill]

Maybe someone has the numbers, but isn't true that some huge percentage of health care costs goes to treating people in their last 5-10 years of life.

[mnuez]

It's actually funny how much I hate you Mikey. In the interest of ensuring that you get the absolute best medical care possible, you're willing to condemn tens of millions to the worst sort of medical care and absolutely zero dentistry.

You're a monster.

Every system has a limited supply of product. It isn't only geniuses such as yourself that have figured that great secret out. In Europe as in the United states there's only that much medical care (and lung tissue) to go around. In Europe they ensure that everyone receives at least the minimum and then (in most cases) allow the wealthier, more privileged, members of society to pay more for better insurance and better healthcare. In America by contrast all of the resources go to the highest bidder and let everyone else be damned.

What you advocate allows for tens of thousands of needless DEATHS a year, not to mention countless millions of hours of suffering.

You're a monster.

mnuez
http://www.mnuez.blogspot.com

[sage]

joe:

we have "employer-paid" health insurance"

Meh. For myself, my wife, and two kids I'm paying about $540/month. Granted, that's pre-tax. But dental and eye care are separate. So to call it "employee-paid" is more than misleading.

[Russ R]

Ultimately, it doesn't matter whether your health care is paid for by the government, private insurers, or out of your own pocket.

In every case, the care you receive will be either good, fast or cheap (pick two).

[Mike Laursen]

So to call it "employee-paid" is more than misleading.

Good point. For a lot of people, employer and employee both contribute to the insurance payments. And, its arguable where one should draw lines between the employer's money and the employee's money when doing the accounting.

What it always is, though, is "employer-negotiated" health insurance. Your health insurance options are different from those available to someone who doesn't have a job or who works somewhere else.

[Mike Laursen]

In every case, the care you receive will be either good, fast or cheap (pick two).

A clever adage, but I don't think it applies to the health industry. The tendency is for the treatments for a particular disorder to become more effective, more routine, and cheaper as that disorder is better understood and as patents expire.

[John]

I am very sorry I missed out on this thread. First, the measure of a healthcare system is not infant mortality and life expectancy alone anymore than test scores are a measure of education. European countries have very homogeneous populations. They do not have the large latin American immigrant populations that we have or the large African American popluations. African Americans geneticlly are more susecptable for things like diabetes and heart disease, giving them a lower life expectancy regardless of how good the healthcare is. Our immigrant populations tend to have a bad habbit of shooting each other, which lowers life span. This of course happens in African American communities as well. The fact that African American males under the age of 25 have a higher violent death rate than men under 25 had during world war II is not a product of our health system.

As far as infant mortality goes, Europe does not have anywhere near the prenatal care the the US does. Babies that would aborted in europe because of problem pregnancies are miracle premies here. Of course a lot of those miracle premies don't make it and drive up our infant mortality rates. The implications of pointing to infant mortality rates is that babies who would have made it under other systems are dying under the US one and that is just a lie. But hey that is what socialists do, lie.

Has anyone ever noticed that every person who advocates socialized medicine is healthy? My mother died of cancer a few years ago. She was middle class but got first class care from the getgo and managed to make it a year. Had we been in Europe, no way would a 67 year old woman suffering from cancer for the second time ever gotten care. She would have been dead in a month. We got an extra 11 months and hope thanks the US system. Had there been a Canadian system, we would have had a month and always wondered if she would have made if only the government had treated her. No thank you.

[joe]

Cesar, I don't doubt that there really are differences, and that they may influence the figures to some degree, but I read someone using terms like "many" and "much higher" in a wikipedia article about a topic that is relevant to poltical debate, without any actual numbers being provided, my b.s. detector goes off.

Born at less than one pound, less than 26 weeks, or less than 12 inches? That is a vanishingly small number of the live births counted in the U.S.

[joe]

sage,

I assume you meant "employer-paid."

I was only discussing the employer cost in the context that employers would, allegedly, be able to influence the insurers to provide care that maximized their employees' productivity.

[joe]

John provides a classic example of explaining away inconvenient data. He tells us that infant mortality and lifespan aren't good ways of measuring the quality of health care (oh, heavans no!), but does not offer any better measurements, just some anecdotes and name-calling.

Come to thin of it, I don't ever see any critics of the rather overwhelming medical-outcome evidence that so badly implicates the American health care system offering up any counter-evidence. It's rather like the global warming and evolution debates in that way - one side offers all the evidence, while the other's only contribution is criticisms of that evidence, without providing plausible evidence to the contrary.

[Robert]

The weakest point in their argument is their insistence that the system has to be universal. Ask why it wouldn't be sufficient to simply provide health care or insurance assistance to those below a certain income through a means-tested program.

The only answer I've ever seen to that question is that everyone must participate in order to create the economy of scale to make the system more economical than a private system.

No, they have another, and it's the same given against having private alternatives to gov't-delivered schooling, postal service, or dispute resolution: That providing for the poor only is politically unstable. Everyone must have to use the single server or not enough people have a stake in the quality of the service. So the service to the poor will be cut to the point that it's not worthy. Or perhaps it will simply be cut out entirely. Meanwhile if everyone's forced into the same system it becomes very difficult to cut much or indeed to restructure at all -- too many short term losers.

We do see trends running counter to that pattern, or privatiz'n & private options would never be instituted. But they are at least partly correct, and that's part of the argument against what they want as well as in favor.

Also there's the economic argument of moral hazard. Unless the subsidized service is awfully shitty, it becomes worthwhile for some at the margin to voluntarily impoverish themselves to qualify. Happens plenty with Medicaid. Some people will even think it's less risky to put themselves in line now for Medicaid (there are look-back provisions for income & assets) than to take the chance that their income won't be able to keep up with their insurance premiums or other health costs; some of those people will turn out to be wrong, and forego income that would have been sufficient, but they reduced their risk.

[Cesar]

joe-

If socialized, single-payer health care is so great according to you and many liberals, why can't such a system be tried on a state wide basis for, say, 10-15 years?

If infant mortality et al, drops dramatically in Massachusetts, then you will have a stronger argument.

If such a system leads to nothing but high taxes, waiting lists, and government meddling in your private lives, then at least the rest of the country would be spared.

[Russ R]

"If socialized, single-payer health care is so great according to you and many liberals, why can't such a system be tried on a state wide basis for, say, 10-15 years?"

It's been tested for just over 4 decades in Canada, where I live. Why not look at how it's been going up here?

"If such a system leads to nothing but high taxes, waiting lists, and government meddling in your private lives, then at least the rest of the country would be spared."

Haw are the taxes? My marginal tax rate is 46.4%. And that rate applies to all income over ~$100k. Yup, the taxes up here are high.

Waiting lists? It took me 10 days to get an X-ray and a cast for a broken hand last year. More recently, my father had to wait nearly 5 months for surgery to repair a torn shoulder ligament. (And he was at the front of the line due to it being a workplace-related injury which qualifies for priority treatement. If it wasn't work-related, he'd have be waiting well over a year.) So, it seems that the wait lists are long.

Fortunately, the government doesn't meddle too much in my private life, but that's only because I don't drive without a seat-belt, ride wihtout a helmet, eat unhealthy foods, smoke, use drugs, have unsafe sex, drink excessively, or gamble, so I'm not the target of any current crusades in the name of public health.

What else do you need to know?

[Cesar]

It's been tested for just over 4 decades in Canada, where I live. Why not look at how it's been going up here?

I would, Russ, but those who support socialized medicine in this country believe you have the best healthcare system in the world. They also believe that in Canada, there is no crime, no poverty, no racism, and that everyone leaves their doors unlocked at night. I'm not kidding.

Haw are the taxes? My marginal tax rate is 46.4%. And that rate applies to all income over ~$100k. Yup, the taxes up here are high.

Woah, if thats just federal income tax alone thats really, really high.

[Russ R]

It's combined federal and provincial (Ontario).

The top federal rate is 29%. Provincial tax rates vary by province, from a flat rate of 10% in Alberta to a top rate of over 20% in some of the eastern provinces.

There's also a 6% federal sales tax and a provincial sales taxes of 8% (again Ontario).

[John]

I leave the forum for a day and Joe gets away with saying something completely stupid without being challenged. The point is that the stats are not a good measure. If you adjsut life expectancy and infant mortality rates for factors like premature babies and violent deaths that are no reflection on the quality of the healthcare recieved. None of the statistic given by people like Joe ever do that. They just site the raw numbers and say "look how terrible America is". Comparing non adjusted raw numbers in healthcare is just like comparing nonadjusted raw numbers in anything else; completely misleading. I can't believe Joe is so stupid he doesn't get that. What should we measur it with Joe? Numbers that reflect reality. It is not my job to give you the justification to impliment your primitive ideas. The burden is on you as the person arguing for change to produce meaningful numbers and raw infant mortality and life expectancy numbers are simply not meaningful. Too bad he probably won't be read this.

[Cesar]

Another thing I'd like to ask people who peddle socialized medicene, how do we pay for it? And please, please for the love of God don't you say "by rolling back the Bush tax cuts for the 'wealthy'. Thats B.S., that won't begin to pay for it. You will either have to A) Raise taxes by a lot, or B) borrow.

In case you haven't noticed, we have a massive deficit and federal debt. And you want to pile on to it?

[John]

The more I read that crap Joe, the angrier I get. You don't have any fucking evidence Joe. That is the point. The evidence you do give is misleading and meaningless. The only meaningful evidence on this thread I see is the anicdotal evidence of Russ R about how horrible things are in Canada. I would also point to the French booing Micheal Moore for lying about how wonderful their systems are. Everyone else in the world is leaving or trying to leave socialized medicine. Wonder why? "One side has all the evidence". Only if you beleive lies. God. Joe you are dumbest person on earth sometimes. You mean well but you are just fucking stupid and so stupid in fact, you don't even realize it.

[John]

Ceaser,

You will just get Canada like tax rates, a bigger deficit and much worse healthcare.

[joe]

I have a ton of evidence, John. Every comparative study shows better health outcomes among countries with universal systems. Whether that evidence is completely reliable or needs to be taken with a grain of salt, it stands in marked contrast to the absolute goose egg the opposition can come up with.

One health care measure could skew against the United States because of local factors. Two, and that would be some bad luck. But when, time after time after time, the measures just keep lining up the same way, putting the United States at about 20-25th, nitpicking at this or that measure doesn't get you very far. It just defies the law of averages that the data would all skew so dramatically against the US without it indicating a real trend.

Also, you need to swear less.

[joe]

Cesar,

If the money withheld from my paycheck and labelled "employee health care contribution" gets relabelled as "employee health care tax," and the money I never see because my employer sends it to an insurance company gets sent instead to a government office, I'm not going to notice any difference.

You take the money currently being spent on health care plans, you take the larger risk pools created by a universal system, you take the "free care pool" money being spent on really sick poor people who walk into Emergency Rooms without insurance of a means to pay, you take Medicare and Medicaid, and you take the appalling overhead of your typical HMO, and you will be well on your way towards paying for a universal system.

[Russ R]

joe,

would you be willing to allow people to voluntarily opt out of the state run health system and pay for private-sector insurance instead?

[Cesar]

Russ R. posed one of the questions I wanted to ask, the other is this: what guarantee is there that the feds won't raid the "health care" fund to pay for everything from the Iraq War to sheep research in Montana and replace the fund with a bunch of I.O.U.s, a la Social Security?

[Peggy]

It seems that everyone who cites the stupid " the US was ranked 37th internationally in healthcare" survey fails to mention that criteria totally irrelevant to healthcare, such as the number of women representatives in the national governments.
Furthermore, if socialized healthcare is so great, why are countries such as France and Canada trying so desperately to move away from it.

P.S. Joe, you have proven in past threads that you have absolutely no knowledge of the United States heathcare system. Please quit trying to pass yourself off as an expert.

[Mark]

I would like to ask one question of the fans of these surveys that claim the United States is only 18 or 37th (depending on the survey) in the world in healthcare? Do you honestly believe Colombia and Saudi Arabia provide better healthcare than the United States?

I think the answer to that question is pretty self-evident to any reasonable and intelligent person. The notion that Colombia has a better health care system than the U.S. is so laughable, it reveals those surveys to be the irrelevant nonsense they are.

[Max]

Few people without insurance can afford the cost of health care. If insurance went away, most people could not afford health care.

That's a nonsensical statement, because the cost of insurance includes the cost of health care.

Insurance is simply a risk management tool. And like any product it has a (positive!) cost.

[Mr. Nice Guy]

I understand why many people would be so adamantly opposed to nationalized health care. I have great insurance for me and my family, in part because I have a good job that I worked hard for (years and years of education). Nationalized health care would force me and my family to adopt the government plan (I think, I hear that people are free to get suplemental insurance in some places that have it), and it could be worse than what I have. So that's the health of my family you're talking about.
On the other hand, I think the pile on Joe tack is a little much. Joe is just right that a slew of studies, many by fairly independent and objective researchers, support his view. Of course one could sit back and critique this operationalization and that conceptualization, this indicator, etc. As my research methods prof used to say no study is going to be perfect, you have to choose something and measure it in some way. Most of the studies Joe et al can point to have reasonable though admiteddly flawed indicators. The WHO study oft cited can be read in full here: http://www.who.int/inf-pr-2000/en/pr2000-44.html. I won't say I read this monstrosity entirely, but I glanced at it and the methods seemed reasonable. Does anyone think a Cato study would have indicators that aren't worthy of critique?
Many people on this thread have commented on the rationing that goes on in nationalized health systems. Well, duh. Certainly there is rationing that goes on in ours too. In fact Sicko is all about that, how people (and more importantly their doctors) ask for procedure or treatment x and the insurance company says "heck no we ain't approving that." BTW-while people wait for that approval or denial, that's a wait, so we have those in our system too. And one thing we have that the others do not is a slew of folks who, since they have no insurance ration their own care to the point of serious harm.
Where I certainly break with Moore is that he seems to think insurance companies are evil for denying procedures that if they approved would put them out of business in about five minutes. Any system of health care will have cases where they say, look, there is such a chance this treatment won't help much and it is so burdensome that we just can't do it. We're sorry.
The American people themselves are fed up with their health care system (yes, other nations are upset too, but no serious Canadian or French politician would dare suggest scrapping the premise of nationalized universal care, they argue for 'reform' of the current concept). I don't think that is due to demagogues and such, if anything the majority of spending to convince folks on this issue comes from the status quo. It's just the reality is for most that their private insurance companies seem incompetent, inefficient and conniving.

[Mr. Nice Guy]

Here is another study that supports the WHO one. Again, it seems to be pretty reasonable, and if you click on its board of directors its hardly a bunch Marxist radicals (it looks more like a country club executive board).
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

[DogBreath]

"Insurance is simply a risk management tool."

Insurance should be a risk management tool, but in this country it is not. Health insurance is considered by waaaay too many to be a blank check on the healthcare system. Have hang-nail, access the healthcare system. Have a bad hair day, access the healthcare system.

If car insurance was like health insurance, we would expect the policy to install wiper blades and put gas in the car.

[joe]

Russ R,

Personally, I see no reason why a universal system can't exist alongside private options. I pay for my city's public schools, then I pay out of my own pocket to send the little one to a private school down the street. If I had my druthers, the health care system would work the same way.

Cesar,

There is no guarantee, and why should there be? It would be a federal program, subject to yearly appropriation, just like the Pentagon and FBI.

Peggy,

Furthermore, if socialized healthcare is so great, why are countries such as France and Canada trying so desperately to move away from it. They're not. They're reforming them, or their methods of paying for them. You might as well point to the Reagan/Greenspan Social Security reforms in the 80s as proof that Americans have turned their back on Social Security. No, they're proof that Americans love them some Social Security, and are willing to go to the mat to keep it solvent.

As for your helpful advice, I'll treat it with all the respect it deserves, given your demonstrate expertise about public health care systems in other countries.

Mark,

The United States provides different levels of health care. The people who get good health care get better care than people in those other countries, while the people who get lousy or no health care here get worse care, and throw off the curve.

[Isaac Bartram]

joe

Personally, I see no reason why a universal system can't exist alongside private options.

Since I am resigned to the fact that we will eventually get a National Health scheme I hope our overlords decide against a single-payer system a la Canada. And also against a Physician-as-civil-servant British model (but at least the Brits do have a private sector to act as something of a safety valve).

Two tiered systems such as exist in Australia, Germany and France do seem to deliver somewhat satisfactory results. And to some extent have not stifled innovation. Australia, for example, is a world leader in developing Orthopedic devices like hip replacements (probably because they are a bunch of sports nuts).

France's system does seem to be buckling under a certain bureaucratic overload, but that tends to be true of just about everything there.

Another thing to consider about Welfare states in general is that they are most nearly successful in small homogeneous countries.

After all Sweden has only nine million people, and they're all Lutherans (or at least they were when the system started). Now that they've raised a couple of generations who don't hold the Protestant Work Ethic in such high regard and admitted a bunch of immigrants whose cultures never had it in the first place it's not working quite as well.

I'm not to sure a country with over three hundred million people can really sustain a National Plan. It seems to me to be something to leave up to the States.

[joe]

Isaac B.,

I see the Canadian "No Private Doctors, Period!" policy as representing a degree of egalitarianism that is mainstream in Canadian society, but not in America.

As for Britain, the Labor government that nationalized the means of prostate exams was practically a Marxist party, and did so during a period when Western political thought was much further to the left than it is today, or is likely to be in the near future.

[Isaac Bartram]

joe,

While in Canada the payer (and the controller of access to treatment) is the Government physicians and surgeons in Canada are still considered private practitioners. As a patient you are free to select any one you choose and he or she is free to refuse to accept you as a patient (and they frequently do since many doctors now have terribly high patient loads).

Beautiful second paragraph there ("nationalized the means of prostate exams" - love it). Yes, indeed, they nationalized steel and coal too, real socialists, those guys. Not like these wimpy welfare state "socialists" people complain about here.

[Isaac Bartram]

I meant to add that in Canada doctors are compensated on a fee for services basis while under the NHS in the UK the compensation tends to be on a formula that has to do with the number of patients one has.

The UK is also the model people seem to be referring to when they complain about "picking your own doctor". As far as I know it is one of the few systems that is tha restrictive*.

Also, joe, physicians and surgeons in Canada are still among the highest paid professionals although they lag significantly behind dentists whose profession has yet to have a government payment plan applied to it. Not much egalitarianism there.

But then I suppose the "egalitarianism" lies in the everyone gets the same lousy service.

*Even to the point of women not being able to geto a birth control prescription because their doctor did not approve of contraception.

[Mike Laursen]

No, they have another, and it's the same given against having private alternatives to gov't-delivered schooling, postal service, or dispute resolution: That providing for the poor only is politically unstable.

Missed your reply to my comment before. This argument is harder to counter. I would argue that, historically, giant government programs that are supposed to treat poor, middle class, and rich folks equally have always ended up providing shitty service to the poor.

Only problem is that my argument isn't going to win anybody over unless they're as pessimistic as I am about giant government programs. The optimists just reply that, "This time it's going to be different!"

[Mike Laursen]

The other thing I always wonder is why Democrats aren't more concerned about the likelihood that any national healthcare system they set up will be run by a Republican administration about half the time. What happens when our wonderful single-payer system refuses to pay for abortions?