Medicare for All

Sorry, Bernie Sanders: Taiwan's Single Payer System Isn't an Argument for Medicare for All

Taiwan’s system is less generous than the Sanders plan—yet it still struggles with cost control and access to care.

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One of the most frequent arguments that Sen. Bernie Sanders (I–Vt.) makes in favor of single-payer health care is that other countries have universal, government-financed health care systems, so the United States should be able to have them as well. This is often declared with a sort of grumpy indignation, as if the existence of other systems is the final word in any debate on the issue. It is not really an argument so much as a declaration that single-payer is easy, and there is no real argument to be had. 

So it wasn't exactly a surprise to see the following Sanders tweet show up in my timeline this morning: 

What's notable about this tweet, however, is that Sanders links to a feature-length report by Vox's Dylan Scott on how Taiwan converted to a single-payer system in the 1990s. Scott's piece is smart, thorough, and sharply observed, and I'd encourage everyone to read it—because, if anything, it shows just how difficult implementing and sustaining a single-payer system would probably be, even under relatively favorable conditions. 

As a newly formed democracy, Taiwan worked with well-known health policy scholar and single-payer advocate Uwe Reinhardt (who died in 2017) to build its system, which relies on a government-run insurance system to finance the majority—though not all—of the country's health care. Some private insurance is available to cover additional benefits. 

As is often the case with government-run health care systems, the country determined that cost-control measures would be necessary, so it set up a system of relatively modest premiums and copayments. Eventually, at Reinhardt's recommendation, the system converted to "global budgets" in which the government negotiates payments for providers based on a capped amount of total spending. 

Already, the differences between Taiwan's system and the Sanders plan are apparent: Sanders' Medicare for All bill calls for no copays and no premiums and effectively outlaws private insurance as we know it. It is substantially more generous than Taiwan's system, which means it would be substantially more expensive. 

Yet one of the big themes of Scott's piece is that Taiwan's health care providers believe their system is too generous to patients. Even with copayments and premiums in place, Taiwan's patients heavily utilize the system. This, Scott writes, has "predictable downsides: Hospitals get crowded in Taiwan. The capacity of health care providers to attend to everyone in need can be stretched pretty thin." As a result, some patients face long lines, and limited access to expensive treatments.  

Doctors and other health care providers are frequently exhausted and have a much less favorable view of the system than the rest of the public. "I believe we are too kind to our patient[s]," a health economics professor at National Taiwan University told Scott, "which is not a good thing, actually." Health officials believe that the copayments and premiums are, if anything, too low; one top health official said he planned to propose increasing them following an election. 

Taiwan's system, in other words, is less generous and less radical than the system Sanders has campaigned on. And unlike the United States, which has a vast and complex network of health care providers and public and private financing, Taiwan started from something like a blank slate—without the embedded complexities and pathologies of the American system. 

Yet in the quarter-century it has existed, Taiwan's health care system has nonetheless struggled with sustainable financing and utilization issues. And it has pitted doctors against patients, resulting in overworked caregivers and pressure to raise costs on individual users. 

Although Scott notes that in Taiwan, these difficulties "aren't treated as an indictment of national health insurance," they should certainly serve as a caution tale for anyone thinking of trying out a similar system here in the United States, where aggressive cost-control measures often fail, and where health care providers have considerable political power—in part because they have the trust and backing of the public.  

Indeed, before he died, none other than Uwe Reinhardt, the health policy expert who helped design Taiwan's system, warned that single-payer probably wouldn't work in the United States. "I have not advocated the single-payer model here," he told Ezra Klein, then of The Washington Post, "because our government is too corrupt." Doctors and providers, he argued, have too much political power.

There are inherent limits to the ability of one country to adopt another country's system; Taiwan's system probably tells us more about how a similar system in the United States would struggle than it does about how it would "surely" succeed. As Klein observed "Reinhardt's argument is a reminder that the simple fact that a policy worked in another country does not mean it will work in this country." It's a useful reminder—and one that Bernie Sanders could stand to hear. 

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  1. Despite any other problems we Koch / Reason libertarians have with his economic agenda, Sanders would certainly be better than Drumpf on immigration.

    #OpenBorders
    #ImmigrationAboveAll

  2. Once again, Sanders continues to unwittingly prove my point. America CAN afford a national health plan, but it wouldn’t work the way Sanders thinks it would work.

    1. America CAN afford a national health plan, but it wouldn’t work the way Sanders thinks it would work.

      ^ This.

      It’s the same way that he ‘wants’ Denmark-style ‘socialism’ without the low corporate tax rates, without the deregulation, without the lax labor laws, and without sky-high middle-class income taxes and consumption taxes.

    2. America CAN afford a national health plan because it would be free market.

      You pay cash for minor medical stuff and have cheap catastrophic health insurance for major stuff.

      Imagine credit cards that give you perks (points/cash back/etc) for charging your minor medical procedures.

      1. All the taxes you would save with Medicare and Medicaid ending as a government program go toward those medical expenses.

        Plus, a financial incentive to eat well, exercise, and lower risk since YOU have to pay for you own medical care. Goes without saying that YOU paying for medical and reviewing a medical bill will also lower medical padding since people will want to know what a procedure costs before paying.

      2. That’s not really my point. I’m not defending a national health plan, I’m merely saying that America Can’t Afford an NHS style health system is wrong. And arguing that we can’t just gives the proponents ammunition.

        We can afford a single-payer system, we’d just need to close 2/3ds of the healthcare facilities around the country, nationalize the system and the workers. Doctors now make $75,000 a year, and every position on down gets a major salary reduction as well. You want an MRI, drive to Chicago, Boston, Seattle, New York, LA, San Francisco. We’ll see you in 18 months for your appointment.

        There, NHS system paid for.

        1. The US has fewer hospitals and fewer general practitioners than most countries. We have a comparable number of specialists – but yeah you are right the difference is income for those specialists – 400k+ here, 250k+ in other places.
          The area where we have more capital invested is the MRI’s and stuff but in fact that doesn’t drive costs down because the machines are very underutilized here in the US (which is why they cost a lot more – fixed cost spread over fewer images). Here in the US, we have about 36 MRI’s/million peeps. In the stricter ‘single-payer’ systems they have about 13-15 MRI’s/million peeps. Most of those in the US would disappear from ‘pill hill’ areas. A spread out place like Wyoming might not lose any cuz I’d bet most of the existing ones are county-owned at the county-owned hospital. MRI coverage there is far better than cell phone coverage.

          Which does point to the real solution. In most places, medical is local infrastructure. The federal role should solely be as a financial backstop/reinsurer (not a fucking claims payer) for states/localities and a 14th amendment guarantor of equal protection – in the form of an interstate compact not a federal ‘program’. If it means money gets distributed to states for some minimum general health coverage – so fucking what. Distribution of govts money is a govt function and there is nothing in the Constitution that requires that to go thru primary dealers in NYC Fed. But no ‘customer facing’ anything at the fed level – no ‘Medicare’ plans – no ERISA or other corporate loopholes.

          If some people here want google as their doctor and don’t want a muni hospital nearby cuz they think they can find a better deal for a heart bypass in South Bullshit, then all they have to do is convince their muni/county. Otherwise move or STFU.

          1. The doctor shortage for GP’s is a result of Medicare, the AMA, and the Clinton administration. To sell Medicare to the hospitals, LBJ had Medicare pay for internships and then the AMA lobbied the Clinton administration to limit the internships to 100,000 per year because it was afraid of an over supply of doctors. This allowed medical schools to raise costs to a high level. Thus encouraging doctors to go into specialties to pay for student loans and support a high life style. So now we have a doctor shortage which is worse in countries with single payer systems.

            1. The doctor shortage for GP’s is a result of Medicare, the AMA, and the Clinton administration.

              Actually it is the direct consequence of Rockefeller and Carnegie. They commissioned the Flexner Report in 1910. That report in essence created a system that served the interest/mindset of the donors. They didn’t need a lot of GP’s. They just needed one each. They did however want a ton of specialists – trained in the latest science and competing to practice on the peasants/rats so that the billionaires could choose ‘the best’ when it came time for them to need specialist care. Cost didn’t matter one whit to them. They funded the hospitals too and that was all just a fixed overhead cost – in preparation for maxing their own survival rate if/when they needed specialists at which time they would move to the front of the line. The result was that half the med schools – some of which were pure quackery, most of which trained GP’s – closed and med training became highly centralized under the AMA.

              The lag in the effect of that was because doctors have long careers and it was only after WW2 that the combo of older family doctors (the sort who carried a black bag and made ‘house calls’) retiring and tech that made true ‘specialists’ possible created a serious disconnect. And yes – med schools lobbied for Medicare precisely because older peeps are the ‘demand base’ for specialists. Everything govt has done is just building on that 1910 ‘plan’.

              So now we have a doctor shortage which is worse in countries with single payer systems.

              Yes we do have a shortage. No it isn’t worse in countries with social/single-payer systems. It’s far better there. Because those countries all make regular efforts to anticipate future demographics, anticipate the actuarial stuff, etc. We don’t do ANYTHING more than one year out – which is also why preventive care doesn’t work here. They don’t rely on the assumptions of 100-year old reports.

              That doesn’t mean we would do anything right if we go that route. That Uwe guy is right. We are totally corrupt and view govt solely as a trough for private cronyism. Medicare has had 50 years of being virtually 100% responsible for elderly care. In that time, they did literally nothing to anticipate boomers getting old – and hence a future need for geriatricians (who are really more like GP’s for the elderly than normal ‘specialists’). Which is why we have fewer geriatricians than Denmark (6 million peeps) – and the number is going down not up.

      3. You pay cash for minor medical stuff and have cheap catastrophic health insurance for major stuff.

        You clowns who think actual catastrophic spending is ‘small’ and would be ‘cheap’ if only there wasn’t all that routine medical stuff being paid by insurance. FACT:

        1% of the peeps incur an average of $110,000/year. That same group also likely spends an average of $12,000/year out-of-pocket in addition to insurance. Is that ‘catastrophic’? Cuz if that’s the limit, then spreading that over the entire peeps = 22% of the current cost

        5% of the peeps incur an average of $50,000/year. This is almost certainly also the level where ‘insurance’ ceases to be relevant because these people are basically disabled and can’t work to pay insurance premiums. It’s also an easy fix – all you have to do is publicly say – ‘Medicare will cap spending at $50k and then you die’. Easy as pie. Is that catastrophic? Cuz if that’s the limit, then spreading that over the entire peeps = 50% of the current cost

        10% of the peeps incur an average of $33,000/year. Is that catastrophic? Cuz if that’s the limit, then spreading that over entire peeps = 67% of current cost

        30% of the peeps incur an average of $15,000/year. Now we’re in the range of your ‘fix’. Just require a $15,000 deductible (which also roughly matches the out-of-pocket for the 1% which is also a pretty good measure for rapidly spending down towards bankruptcy for most people) – and ‘catastrophic insurance’ will actually become relatively cheap. If you can’t stomach a $15k deductible (and I’d bet that gets about 1% support in the population), then including this as catastrophic insurance = 90% of current cost.

      4. Here in Taiwan, pharmacists can prescribe common medicines without a permission slip from an MD. A minor eye infection? That’s solved by walking into a pharmacy and spending two or three dollars.

        1. Let’s not get ahead of ourselves. If people were allowed to buy anything, they’d be vaping in open on the street and America can’t have that.

  3. I wish Bernie (and others) would stop calling it Medicare for All. It conjures up positive images among most people, especially those who don’t have actual Medicare or don’t understand it. It glosses over the fact that Medicare recipients actually pay premiums (although usually deducted from Social Security payments) and covers only 80% of hospital expenses. It also doesn’t cover a lot of other things and is already heavily subsidized by payroll taxes.

    The system he proposes is more like Medicaid for All, except if he said that many people wouldn’t think nearly so positively about it.

    And what’s with outlawing private health insurance? The UK’s system allows private insurance although only a relatively few people opt for it. Foreclosing that option for anyone is simply punitive. If the public system is so good it will simply die on it’s own.

    1. The system he proposes is more like Medicaid for All, except if he said that many people wouldn’t think nearly so positively about it.

      Yes, exactly.

    2. So he’s either profoundly ignorant about one of his signature issues or he’s brazenly lying about it. Seems pretty obvious one of those things is happening. How do so many people fail to notice? DO they really believe that government is a wish-granting machine?

      1. Because they imagine they’re not paying for it.

    3. So far we can’t figure out how to keep Medicare solvent.

      Here’s my challenge to those politicians who want universal health care. First start by making the current Medicare cover 100% with no copay, co-insurance, or deductibles. And it must cover preventive medicine which is currently does not. If you can’t do that for people 65 and over, you can’t scale it to the rest of the population.

      1. They use “MediCare For All” because it polls well. Not because the proposal has much to do with how MediCare actually functions, or that MediCare itself functions all that well.

    4. Who knew a system exclusively for old people and funded by working people can’t be extended to everyone?

    5. Medicare is also subsidized by private insurance. Costs are higher so Medicare costs can be lower. Health care providers have to make it up somehow.

    6. Indeed — I’ve been posting everywhere I can pointing this out. But I never thought to relabel MFA to Medicaid For All – that’s an excellent description.

      And don’t forget the (convoluted) lifetime caps on hospital and skilled nursing days under Medicare!

      My understanding is that about 10% of those in the UK do have private health insurance of some form.

      I assume the primary motivation for banning private health insurance is to effectively “force” doctors and medical facilities to accept Medicaid For All levels of reimbursement.

      Some doctors and portions of facilities will of course offer higher quality (at least in terms of “personal touch”) care to the wealthy who can just pay out of pocket.

      I also expect that if private health insurance is banned, many facilities and doctors will switch to a concierge or membership model (probably joining networks created by Cigna et al) where people (or their employers) pay an annual fee (maybe $5K/person in higher cost areas) and only “dues paying” members will be able to access the facilities or doctors. The actual procedures will still (as Sanders’ MFA bills require) only be paid at MFA rates. Networks may ban overutilizers from renewing and/or charge them more.

  4. “Government is the great fiction through which everybody endeavors to live at the expense of everybody else.”

    -Bastiat

    1. That is why Libertarian Volunteerism is so great.

      We all volunteer to provide for a common defense and other minor and limited government roles that benefit us Americans (roads).

  5. Don’t tell me the United States cannot implement a Medicare for All system ….

    OK Boomer.

    1. Hey “if we can put a man on the moon” [or just insert your favorite trope]

      1. We should be able to put metal in a microwave?

      2. , we can put a Democrat woman in the White House.

        1. We can; but we are too wise – – – – – –

  6. No system actually guarantees a person will get any particular health care service. They are all subject to rationing. Either there is limit on what services will be paid, there are waiting lists or something similar. Sanders rhetoric is dishonest. What it does create are a large group of voters who can be easily panicked by perceived threats to their benefits, which unscrupulous pols can control.

    1. It’s what Marx called “Bourgeois Socialism.” It’s the self-delusional belief of the Bourgeois that the Proletariat is deprived of a Bourgeois lifestyle by policy, and that if we just fiddle the levers of policy correctly, the Proletariat can all be raised up into the Bourgeois, and we can all have tea together.

  7. “This is often declared with a sort of grumpy indignation, as if the existence of other systems is the final word in any debate on the issue.”

    Not unlike gun control.

  8. So Suderman points out that part of TV he problem with Taiwan’s system is that medical professionals are overworked and underpaid. Reinhardt says th as t Taiwan’s system ed m cannot work in the US because the medical profession corrupts the politics. In other words, suppressing medical professional’s economic rights is a feature, not a bug, of the system Reinhardt developed for Taiwan.

    1. Once we enslave our doctors, universal healthcare can become reality!

      1. +1 hobbled blacksmith.

      2. The US health care “system” is an extortion racket built on a foundation of an intentional market failure. The AMA/Insurer/Pharma cartel has monopoly power and should be regulated as a public utility.

  9. “Doctors and providers have too much political power.”

    Gosh, I wonder why. Could it be because health care has been made into a political process?

    The only way to cure this is get the government out of health care. The simplest way is either allow individuals the same tax deduction that employers have, or take that deduction away from employers; either way puts individuals back in the game.

  10. Medicare for All violates the NAP and is therefore immoral.

    1. Try telling that to the hordes who don’t care about the NAP and just want what they can get.

  11. It’s been 100 years since the publication of Economic Calculation in the Socialist Commonwealth–is that not enough time to read it and realize that central planning can never work?

    1. Central planning works fine. It just doesn’t scale that well.

  12. One problem I see rarely discussed is this: the US is responsible for a very large portion of medical research and discoveries. While the destruction of incentives for innovation in Sweden or someplace has little impact on the rest of the world (indeed, maybe even in Sweden, since they still use treatments from abroad), doing so in the hotbed of innovation will not only damage healthcare here, but also around the entire world.

  13. Its worth noting that not only is the Taiwan model more limited than Sander is proposing its also serving 300million LESS people! States wth smaller populations than Taiwan have tried this already and it didnt go well for them (VT,CO,MA). How about we not fail with orders of magnitude more risk and potential damage.

  14. Once again, Medicare, for the record:
    First you pay premiums for all of your working career with NO benefits at all
    Then you get to have Medicare pay for SOME healthcare; you are responsible for 20% of all expenses after deductibles
    There are NO annual out of pocket spending caps
    There are NO lifetime out of pocket spending caps
    There are NO dental benefits
    There are NO vision benefits
    There are NO drug benefits
    There ARE deductibles and co-pays
    AND YOU STILL HAVE KEEP PAYING PREMIUMS!!!

    So yeah, I would follow any politician who thinks this is a good idea.
    I would follow him to be sure after they put him in the loony bin they threw away the key.

    1. Premiums are also indexed to income.

  15. Bernie won’t need an argument when elected Dictator (oops, I meant President), you IMPOSE at that point.

    1. What’s the point of gaining power if you have still have to present arguments?

  16. The problem with socialized medicine is not that it is difficult to implement, and that it might not work the same in the U.S. as it does in Taiwan. The “problem” is human nature. When you give people something they have not earned, you destroy the incentive to work for what you get, destroying self esteem in the process. When people get something for free, they do not value it and over-consume it. When you take by force from people who earn, and give to people who are freeloaders, you destroy freedom and social justice. You undermine good will in society. And you wind up with a nasty, brutish government deciding who gets what, and who is left to die. And you wind up with nasty people running the government and suppressing freedom. That’s why socialized – anything – does not work.

  17. It’s almost like the economics of medicine don’t change just because it’s your health.

    I really would love to know why we all throw our brains out the window the moment the subject shifts to healthcare. There are already lots of health-related necessities (food, water, work safety, etc.) that we primarily deal with through free market solutions. Why should health insurance and medical treatment be any different?

  18. It also sounds like Bernie’s taking a stance on Taiwan self-determination by referring to it as a “major country.” War with China, anyone?

  19. Medicare for all is not going to reduce the cost of medicine or provide quality medicine. Escalating medical costs began in the mid-1960s when insurance companies and BigGovernment started controlling costs, billing codes, etc. BigPharma has been able to run Medicine by controlling the Government and the lawyers running Congress. FMTVDM is the first step to controlling medical costs and it does so by removing the power from the Government and BigPharma – out of the hands of the lawyer politicians. FMTVDM restores the power back to the doctors and patients – reducing costs while saving time, money and lives. Medicare for all is more control over medicine – not better medicine.

  20. The problem here is not obtaining coverage for everyone as much as it is that there is ZERO price discovery in medicine in the USA. In Italy 2 years ago I found a place where I could get an MRI for about $175 US (135 Euros) – “socialized medicine!” – I can hear the screams already. Except this was a private-pay facility completely outside the Italian national healthcare system. So apparently they can make money on $175 MRIs in Italy, where here it is over $2,000.

    The reason medical services are so damned expensive in the USA is that the corporations who have taken over the system WANT it that way, and pay our corrupt legislators to keep it that way.

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