> (They really hated it. Senator Cornyn of Texas said it was "a step down the road to a single-payer, government-run health care system"). President Bush promised a veto.
I don't understand why Republicans have such a raging hard-on against universal healthcare. Pretty much every country that has implemented such a program agrees it is a Good Thing and worth funding through new taxes.
I'm a Democrat and generally in favor of state-sponsored universal health care, but unlike other commenters on this subthread, I don't have a hard time seeing the issue Republicans have with single-payer healthcare.
Single-payer essentially nationalizes more than fifteen percent of the US economy (by dollars). It would more or less make every doctor, nurse, and technician an employee of the US government. But much more importantly than that, it would remove broad market price discovery from allocation of medical services. Instead of prices rising or falling to match demand from actual consumers, things would cost what a system of bureaucracies would say they cost.
Republicans aren't simply concerned about single-payer because they oppose entitlements (although they do). They also have a valid concern that single-payer would distort and degrade the health care system.
(For what it's worth, I like the balance Obamacare tries to strike, and support anything that puts us further along down the road to the Swiss system of health care).
> It would more or less make every doctor, nurse, and technician an employee of the US government.
Medicare paid out $583bn[0] in benefits in 2013. Total annual healthcare spending in the US $3.8tn[1]. Does that mean each healthcare professional is 15% employed by the government?
Not in the least.
Northrop Grumman has ~25bn in revenue as of 2012. A majority of its revenue comes from government spending. Does that mean Northrop Grumman employees are employed by the government?
You spend $12 on a movie ticket. Is the projectionist employed by you? The box office personnel? The on-set supplier of craft services?
> it would remove broad market price discovery from allocation of medical services.
Like we have broad market price discovery now?
For perfect price discovery, the purchaser of a product must have access to the same information as the provider of a product. Given the average citizen, can they make an informed decision about what the cost of an appendectomy should be? The outrage over the $82,000 hepatitis c cure informs us that no, they don't. And even if they did: is the average healthcare consumer going to refuse to purchase a life-saving drug or procedure because it's too expensive? The purchaser in this situation _has no bargaining power_. They cannot determine whether or not to purchase a life-saving service due to cost! It's buy it or _perish_.
For-profit healthcare is a hostage situation. In a hostage situation, market forces are moot.
The fallacy in this comment is that the choices are between the (totally broken) system we had in the US in 2007 and single-payer. There are countries where health care works that occupy neither of those extremes.
Is there something you particularly like about the Swiss system, or do you like the Bismarck model [1] in general, which they use (as does Germany, France, Belgium, the Netherlands, Japan, and much of Latin America), and are simply using them as a good example of that model?
Frontline did an interesting comparison of the UK, Japan, Germany, Taiwan, and Switzerland [2].
"In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge."
That's plain wrong - there is still private health care here in the UK and, as far as I know, they charge what the market will bear.
Of course, most people use the NHS - but in the smallish city I am in (Edinburgh - 450K people) there are a number of private hospitals.
Private healthcare is generally seen as a way of keeping senior medical staff happy as they get to work at the NHS and do private healthcare work on the side.
It's a combination of Frontline and the fact that my wife used to live there. My impression before you asked was that the German system was more centralized, involved more coordination with employers, and was tax-based. 5 minutes of research suggests that I might be wrong about that and equally happy with the German system.
Basically: I like private health insurance with guaranteed issue, community rating, and a coverage mandate.
> Single-payer essentially nationalizes more than fifteen percent of the US economy (by dollars). It would more or less make every doctor, nurse, and technician an employee of the US government. But much more importantly than that, it would remove broad market price discovery from allocation of medical services. Instead of prices rising or falling to match demand from actual consumers, things would cost what a system of bureaucracies would say they cost
Eh? Universal healthcare doesn't mean price regulation. The price signals are still there but you now have a very large public buyer able to negotiate prices with very big private suppliers. How is that not better than the current system where large numbers of citizens cannot afford adequate healthcare and big companies can extort whatever price they want out of those seeking access to life-saving drugs?
> They also have a valid concern that single-payer would distort and degrade the health care system.
Degrade how? Universal healthcare can still work with e.g. privately-run hospitals and clinics. You don't need the government to hire all the medical practitioners; just pay for the cost of treatment.
If there's a single federal buyer paying for 90+% of the market (look how much of the market for seniors Medicare covers), it's hard to see how the price signals continue to work the same way. The (slow, error-prone) political process is engaged in every buying decision.
Already you can see that changes in the way Medicare reimburses and measures outcomes have impacts on the way services are delivered today, and Medicare is just a fraction of the overall market for health care in the US.
The federal government doesn't hire all the practitioners. They just fix all the prices.
At any rate, there's a difference between disagreeing with an argument and pretending that it doesn't exist, as other comments on this thread did.
(I am in part assuming the mantel of the GOP argument against single-payer here; I prefer the Swiss system to the NHS, but unlike most Republicans I strongly believed that a national solution was needed for health insurance and financing.)
Public and private spending in most single-payer countries is far, far lower than what it is in the United States. The bloat is a product of market inefficiencies:
What you are suggesting is essentially that market failures have made private health care "too big to fail." Not a reasonable argument when public health is at stake.
First, be careful with the word "you". As I've been at pains to point out in both comments on this thread: this isn't my position.
Second, "lack of single-payer insurance" isn't why Americans overpay for health insurance. We have collusion between cartels of buyers and sellers (hospital chains and insurance companies) with secret price lists, funded by HR managers several hops away from the actual demand for services. It is probably enough to decouple insurance from employment. The Swiss, for instance, don't have a single-payer system, and they also pay far less than the US on health care.
(That latter argument, unlike the ones I've written about previously on this thread, actually does represent some of what I believe).
> If there's a single federal buyer paying for 90+% of the market (look how much of the market for seniors Medicare covers), it's hard to see how the price signals continue to work the same way.
I'm not sure I follow. Price signals are based on demand. The same demand is still there in the sense that customers still interact with private health providers. The only thing that changes is payment is now handled by a single government system. Uncle Sam guarantees you access and his guys sort out the payment with the private provider, later.
> The (slow, error-prone) political process is engaged in every buying decision.
I'm not sure I agree with your premise for a start (i.e. publicly ran organisations are necessarily slow and error prone) but setting that aside, why is bulk billing between government financiers and the private health providers not an option? The government knows how much demand they have for XYZ product or service so they can negotiate based on volume. Have I missed something?
> Price signals are based on demand. The same demand is still there in the sense that customers still interact with private health providers.
Price signals require both a supply side and a demand side. Government funded healthcare likely increases demand, since it reduces cost on an elastic good. However, it also reduces supply, since it reduces payment.
To put it another way... if we passed a law saying that all programmers could charge at most $30/hr [edit: which is a good wage compared to other non-degree requiring jobs] we would have increased programmer demand (since now more businesses can afford programmers) and would also have less total programmers since many would switch careers to meet their financial needs. Something similar would happen in the medical industry with a single large federal buyer.
> The government knows how much demand they have for XYZ product or service so they can negotiate based on volume. Have I missed something?
This is also missing the supply side. When you take money from one group and give it to another it is very very important to look at what happens to the group you've taken from in addition to the group you've given to.
The real value in healthcare hasn't been created yet. It's in the drugs of the future. Changing the incentive structure for health startups changes how many people found healthcare startups.
A system with basically a single buyer is a reverse monopoly (ie http://en.wikipedia.org/wiki/Monopsony). If you find you're building a product for essentially a single customer... you should probably found a different company. They're not going to voluntarily pay you anywhere near what you'd make in a real market.
> Price signals require both a supply side and a demand side. Government funded healthcare likely increases demand, since it reduces cost on an elastic good. However, it also reduces supply, since it reduces payment.
I'm not arguing for the government to fix the cost of drugs or health services. I'm arguing for the government to guarantee access to a minimum set of healthcare products and services and then negotiate price with the providers based on uptake. From a consumer perspective, this is much better. Far better than buying said products and services directly from a monolithic private entity.
From a supplier perspective, this is less good and there may be some incentive to artificially limit supply. But that's why we have governments in the first place: to take over in cases where the market is unable or unwilling to function in a way that is beneficial to society as a whole. If private hospitals decide to limit the number of e.g. heart procedures per year then government needs to step in and either regulate or take other measures to ensure the delivery of essential services.
> If the government is guaranteeing it'll pay, why give them a price break?
Because you want to stay in business and there are other healthcare providers the government could use instead? Including those providers that are publicly funded?
In the case of expensive drugs, there are a myriad things the government could do including taxpayer subsidies, government health loans and placing limits on the length of the period a private company can exercise monopoly control over substances deemed necessary for universal health.
> Because you want to stay in business and there are other healthcare providers the government could use instead?
Okay, now suppose that you have a patent on a particular drug or device or procedure and as a result are the monopoly provider of it. Where does the government go to get the lower cost alternative? Where is the downward pressure on your prices?
Please refer to my points re subsides, loans and limits. These are not insurmountable problems. Many other countries have figured how to make universal health achievable. IMO it is time America did the same.
>>>> If the government is guaranteeing it'll pay, why give them a price break?
>>> Because you want to stay in business and there are other healthcare providers the government could use instead?
>> Okay, now suppose that you have a patent on a particular drug or device or procedure and as a result are the monopoly provider of it. Where does the government go to get the lower cost alternative? Where is the downward pressure on your prices?
> Please refer to my points re subsides, loans and limits. These are not insurmountable problems.
So first you say that market forces will still be in play because the government could always go elsewhere. Then when provided with an example of a situation where market forces cannot come into play, you suggest that legislation can fix it. That is EXACTLY what tptacek was the problem, the loss of MARKET incentives and information.
> I'm not sure I follow. Price signals are based on demand.
Normally demand goes down as price goes up because more and more entities get priced out of the market. With the government as the sole (or very nearly sole) buyer demand is constant because the government quite literally has a mandate to supply healthcare to the citizens. That means that suppliers have no incentive (short of avoiding legislative action aimed at them which they can cheaply and easily dodge through lobbying) to bring prices down. It's in their interests (read profit motive) to supply as much as they can at as high of a price as they can. This is the problem that people are talking about.
> 1. If the government is guaranteeing it'll pay, why give them a price break?
Why indeed? The threat of legislative action? See my comments above re: lobbying. Got a way around that? Most of the population of the US would be VERY interested to hear how you circumvent it. So far the only halfway viable strategy is what Lawrence Lessig is doing with mayday.us and that's a long way from making it a solved problem.
2. If the reason is passing laws saying you have to give them a price break (as you imply in paragraph 2), how is that not price fixing?
Again, see comments re: lobbying. Unless there is no possible way to circumvent the lobbying problem you're simply proposing that we replace one broken system which you dislike -- and rightly so, it's not that great -- with another broken system which you like. Sure you like it better but others do not. We're at the point of arguing about opinions.
"But other countries do it just fine!" you say. Okay sure, but which other countries with single payer systems have the kind of demographics that we do here in the US? Answer: none. They're all relatively small countries (relative to 310mm people) with rather homogeneous demographics (again at least compared to the US).
It MIGHT work OK and it MIGHT not be more broken than the system we have now but those aren't guarantees.
Way to miss my point. Well done guy. Fight that good fight for unfettered capitalism. Americans don't need no stinking commie health system, amirite?
Once again: universal health doesn't mean price regulation. Like any private insurer the government can negotiate for lower prices when multiple providers exist and subsidise the cost when they do not. I also see no problem with limiting monopoly control over life saving substances. That's why we have governments. To act in the best collective interest.
That's a bit unfair. I wasn't making a personal attack; just posting a sardonic rebuttal to a poster who seems to me more interested in pushing a specific ideology than posting a considered response to what I have been saying.
> Way to miss my point. Well done guy. Fight that good fight for unfettered capitalism. Americans don't need no stinking commie health system, amirite?
This is what bugs me. You're arguing against what you THINK I'm arguing, not against what I'm ACTUALLY arguing.
I'm not saying that American healthcare is a paragon of efficiency and low cost. Nor am I arguing against "commie health system" but instead that the idea that having a SINGLE purchaser of medical care will quite likely result in less good information about prices and as a result less efficiency.
Right now in the US we have a problem where not enough price information is known: almost no doctors list prices anywhere that a person can find PRIOR to going to a doctor. How could that be remotely efficient?
Wanna buy some Microsoft stock? OK just call up a million people who may or may not tell you how much they want for their shares. Depressed yet? That's how terrible the price information is in the medical world. It's no wonder everything is so damn expensive.
Yes you can trot out the tired old trope about "but medical care isn't something you can't shop around for!" which is true really only in trauma cases where minutes are the difference between life and death. Got a cold? You've got time. The flu? You can check around. Broken bone? Uncomfortable yes but realistically you could spend 15 minutes on doctor-yelp so long as it's not a blood-gushing compound fracture. Mess up a joint like say an ACL? They're not going to operate on you the same day anyhow so might as well spend an hour reading reviews. Having a kid? Guess what, there's a roughly 9 month lead time on that one. You could spend a week shopping around.
> Once again: universal health doesn't mean price regulation.
If the government is the only buyer of medical care and they "negotiate" for discounts and don't do business with people who "charge too much" then that's EFFECTIVELY regulation. It might not be in the technical sense; there might be no law saying "an ACL surgery costs $4200" but if the sole purchaser of ACL surgeries says it's not willing to pay more than $4200 that kinda-sorta sets the price.
You can argue 'til you're blue in the face on technicalities and whatnot but if it walks like a duck and quacks like a duck most people will agree that its a duck.
> I'm not saying that American healthcare is a paragon of efficiency and low cost.
Good. Because it isn't. American healthcare is a laughing stock in the developed world. Per capita, Americans spend more of their income on healthcare than countries with universal health. Ironically, health outcomes for Americans are actually worse.
You can shop around for elective procedures. If you are sick however, shopping around is a terrible and exploitative burden. You're sick. Your primary concern should be to get help and get better, not whether or not you can afford it.
> If the government is the only buyer of medical care and they "negotiate" for discounts and don't do business with people who "charge too much" then that's EFFECTIVELY regulation. It might not be in the technical sense; there might be no law saying "an ACL surgery costs $4200" but if the sole purchaser of ACL surgeries says it's not willing to pay more than $4200 that kinda-sorta sets the price.
This isn't what I'm saying at all.
Firstly, I'm not saying the government is the sole buyer of healthcare services because experiences the world over (UK, Australia etc) have shown there's plenty of room for private insurers.
Secondly, I'm not saying that prices are kinda-sorta fixed. What I am saying is that if the government decides apriori that ACL surgeries (whatever that is) are something that's important to universal health, and something everyone should have access to, they subsidise the cost. Period. Whatever it is.
If multiple providers exist, they opt for the cheaper option. If they're getting stiffed by all the private providers then the government has two options: (i) they can decide to offer ACL surgeries in public hospitals for a lower price; (ii) (in the case ACL surgeries depend on some very expensive bit of licensed kit controlled by a single supplier) they can set limits on the amount of time that supplier can wield exclusive control over this technology. Break the monopoly, lower the price. Recall that they've decided beforehand ACL surgery is something everyone should access to.
Well, right there you have a problem. The U.S. has a larger % of the economy tied up in healthcare, and arguably worse services than any other civilized country:
the countries with the very best healthcare spend 10% of their GDP, the U.S. spends 7% MORE (17% according to the World Bank). And we're talking about very inefficient bureaucracies in most cases.
Every time I read about it, I'm amazed at how they can be so screwed up.
I have better healthcare than 99.9 of the U.S. population and I live in Uruguay - it is literally unbelievable for many that I can pay U$ 40 and get unlimited ER services with an ambulance at my door, doctor house visits for something like a fever, and amazing healthcare for U$ 150/month (plus small co-pay costs).
Second Edit: in any case, the solution is going to be very hard and will require a very strong leader - I'm sorry for the U.S. that Obama didn't turn out to be the solution. There are no easy answers, I can understand what tptacek says about the Republicans not wanting such a massive nationalization of 17% of the GDP, and I can understand the Democrats looking at the mess and wanting to get it under their control.
I don't know if the U.S. has a strong surgeon's union, but there are several healthcare unions here in Uruguay that can raise their salaries at will by threatening (and actually going on) strikes.
Can you explain how you have better healthcare than 99.9% of the US population?
You realize the wealth of the top 10% of Americans, right? That inherently means you're wrong, and you were exaggerating to a hyper extreme.
I don't think you are likely to have better healthcare than the top 50% of Americans in fact. The top 50% of Americans have healthcare coming out their ears, in terms of spending, check-ups, early diagnosis, and in fact too much medical care - which is part of the cost problems, Americans are the most over-tested and over-doctored people in the world.
You realize very few Americans with a full time, decent paying job are not covered by proper health insurance, right? That gives them access to some of the best medical treatment options, doctors, and technology on the planet.
The US has many of the best health facilities and doctors in the world. In fact the US healthcare system is first world, it's the cost structure that is the problem, not the quality of the facilities and doctors.
You're right, I did add an extra nine (it was a bit hyperbolic), but I would still stand by saying that I get better healthcare in Uruguay than 95% or so of Americans.
The net worth for a one percenter in the United States is about 8 million dollars, or a salary of about 160.000 a year. To be a five percenter, you just need to earn about 80.000 a year, so yes, I definitely have better healthcare than someone making 80.000 in the U.S.
How do I believe I have better healthcare? Exactly in the opposite situations to check-ups - in situations where I need urgent medical services, or when there's an expensive or complicated condition requiring specialist services.
In the U.S., ambulance service is EXTREMELY limited and expensive (how the hell can it cost 20.000 dollars for a visit?), and you basically cannot have home visits by a doctor. I pay U$ 25 for ambulance services, and for an extra U$ 5 I get house visits by a doctor (as long as it's reasonable and I don't overuse the service).
"The US has many of the best health facilities and doctors in the world. In fact the US healthcare system is first world"
Absolutely true. If I had a strange disease, or I wanted to be operated on by the absolute best doctors, I'd go to the United States.
It's the treatment for the "common man" which fails miserably.
I can get an appointment for any specialist within a week, and if it's a serious condition and I'm not picky, next-day or same-day (this is not true of most Uruguayans, I pay extra for that). Every Uruguayan can, and usually does, get at least once a year, same-day house doctor visits.
If I got one of these expensive conditions (say, the discussed cure for Hepatitis C), government will pay for my treatment (ok, there's lobbying, delays, sometimes bribes and other problems, but they will end up paying).
If I need a transplant, there's a national transplant service, same for prothesis, burns, cancer, etc.
Not a single Uruguayan has to file bankrupcy due to medical conditions (he can get destitute due to not working, which is a different problem).
So, Americans might be over-doctored in early health care, but they don't have access to some services which seem basic and essential, and are believed to be every man's right in my country.
Primarily, because universal healthcare involves greater government expenditure and complexity, and Republicans consider both the extra cost and regulation an assault on capitalism and states' rights. This is the party which is politically beholden to a man who famously said he wanted to shrink government down to the size that it can be drowned in a bathtub[1], after all.
Also, because it smacks of socialism, and socialism is considered a moral evil that creates an underclass of lazy underachievers who don't understand the dignity of a hard day's work and only want to feed at the government trough. And of course by implication vote for the other party.
It's probably also worth pointing out that it being the way things are done in Europe and elsewhere only makes it even more offensive, because Republicans believe in American exceptionalism - which implies at its core that our way is Just Better, and everyone else is Just Worse.
The health care industry contributes substantially to both parties, even though the Democratic party supports single-payer. They contributed more to the GOP in the 2000s, but the GOP controlled the government for most of that time and held the presidency. Starting in 2008, health care resumed contributing more to the Democrats, as they did at the start of the Clinton administration.
The idea that politicians assume public policy positions because they're captured by donors is sometimes true, but it's incorrect as often as not.
They only need to contribute to a few key people to influence lawmaking.
A significant number of politicians (of both parties) will oppose single-payer on principle. A significant number will oppose it based on what they think their electorate wants. Some will vote for single-payer on principle. And some are on the fence or just don't care.
Lobbyists are paid big money to ferret out these few and influence them.
Don't try too hard to analyze the Republican platform, as it's mostly just an assortment of special interests without any real coherent underlying ideology, and don't fool yourself into thinking a single Senator or Congressman is capable of independent thought.
I don't understand why Republicans have such a raging hard-on against universal healthcare. Pretty much every country that has implemented such a program agrees it is a Good Thing and worth funding through new taxes.