single-payer system ... singled out

[Architect]

I am very much against the whole "from each according to his abilities, to each according to his needs" philosophy.

Can I just check what you mean here? Are you suggesting that those who cannot afford to pay more are entitled to a lesser standard of care?

 

[ARubberChickenWithAPulley]

Can I just check what you mean here? Are you suggesting that those who cannot afford to pay more are entitled to a lesser standard of care?

It seems like it would depend on what we mean by "standard of care." At some point, things become luxuries.

E.g. there are a lot of extras you could get if you have more money that seem to be pretty much expected here in the U.S., but aren't really related to your medical care: a private room with a television and DVD player and a private bath and nice artwork on the walls and furniture for guests and internet access, and your own phone, and gardens outside, and so on and so forth, and access to all of the most cutting-edge procedures and technology.

When I was in Korea, I visited a few friends in the hospital. They had some more American-style hospitals there, but a lot were fairly bare-bones: larger rooms with more people in them, communal televisions and toilet facilities, etc. The hospitals were sanitary and the actual medical care was just fine, but it wasn't fancy.

Similarly, at some point, even some procedures become "luxuries" in a sense. The U.S. system is notorious for choosing more expensive, "cutting edge," but not necessarily proven treatments over older, cheaper, ones.

Hopefully, we would strive to ensure everyone had access to some standard of care. But if we tried to do it at that level, it's going to be expensive. Somewhere in the system, there is going to be some form of inequality based on ability to pay.

 

[Ziggurat]

Can I just check what you mean here? Are you suggesting that those who cannot afford to pay more are entitled to a lesser standard of care?

That is necessarily the case unless you prohibit people from buying their own health care services. Which I am opposed to doing. I do not think you are advocating that, and if not, then you too think those who cannot afford to pay more are entitled to a lesser standard of care.

 

[Architect]

Let me be quite clear.

There is a baseline level of effective medical treatment, i.e. consistent with an acceptable clinical outcome. Everyone should, in my view, be entitled to this without any consideration as to ability to pay. There are, however, clearly luxuries such as - for example - private rooms and having a tv at your bedside which are not, in fact, in any way relevant to clinical outcome. If people wish these and want to pay for them, then fine.

Do you disagree with that position? Are you advocating varying standards of clinical treatment and care depending upon ability to pay?


ETA: "Clinical outcome" does not merely refer to keeping them alive, but to an entire course of treatment for the relevant condition, i.e. not just stabilising the patient then chucking them out.

 

[NoZed Avenger]

nm

 

[Ziggurat]

No, I have not conflated two different problems. I have introduced the other side of the same problem.

No. These are NOT the same problems.

In many respects, insurance works best if neither the insurer nor the insuree has any information about how their risk differs from the general pool. Everyone thus has equal incentive to buy insurance, and insurers have no reason to price anyone's insurance any differently. But that's not the case in healthcare, since pre-existing conditions mean some people will be known to be high risk. This is an information problem. It exists regardless of income disparities.

Conversely, even if we had no information problem, the ability to pay even a common insurance premium would differ from person to person. This is the equality problem.

These are two different problems. You did indeed conflate them.

You have not answered my question. You have rejected the concept of people paying in in proportion to their abiity to pay. You have mentioned paying according to the level of benefit you would like to receive. Sounds good, but what does it mean?

It means keep the system primarily market-based.

If you have very limited means, you decide you don't want to be covered for cancer treatment, or a heart bypass? Then what happens if you need such treatment?

I would like insurance to be priced such that people of limited means can still get coverage for serious conditions, even if it means some government assistance. I do not want a system where you don't have to pay anything and still get full coverage.

Assisting the "poor" is all very well, but first that gets you into a lot of expensive means testing, and the clear temptation to fraud.

It doesn't have to be very complex. Hell, the IRS already does means testing on basically every taxpayer, no reason you couldn't use that existing infrastructure.

And second, it leaves those just above that poverty line in a very bad position if they happen to need something expensive.

That presumes some abrupt cutoff. One need not do anything of the sort. There are plenty of ways to phase out benefits over an income range. Again, the IRS already does this.

How are you going to determine what each citizen contributes

I don't intend to. Which is part of the point: I don't want a system where someone determines how much everyone pays. Centralized planning doesn't work very well for large, complex systems. I want individual choice about how much someone wants to pay: if they want more coverage and more services, they can pay more, and if they are willing to accept less coverage and fewer services, they can save money by doing so.

in a system designed so that everyone will receive the healthcare they need, when they need it?

Don't kid yourself: there is no such system. Healthcare, just like almost everything else with a finite supply, will always be rationed. Some people will always be going without healthcare they need.

 

[elbe]

And no, I don't want people to pay in proportion to their ability to pay. I want what people pay to have some connection to what they get in terms of service and coverage (and that includes paying for good coverage even if you end up not using it). This does not preclude the possibility of assistance to the poor (which already exists in the US system), but I am very much against the whole "from each according to his abilities, to each according to his needs" philosophy.

Then wouldn't you be against insurance? There is no guarantee that the money I pay into my medical insurance will be returned to me in medical care. I'd be willing to bet that I'll pay more in insurance than actual care because the insurer wants to make a profit. If someone who has insurance but has only been paying into it briefly (just entered the workforce or some such) not be entitled to as much medical care as promised by the insurer as an older person with the same insurance plan?

And personally, I think that Marx quote is overused and, in my opinion, unrelated to the topic.

 

[Ziggurat]

Then wouldn't you be against insurance?

No.

There is no guarantee that the money I pay into my medical insurance will be returned to me in medical care.

When you buy insurance, you are NOT buying medical services themselves. You are buying coverage for those services. That coverage has value (which you paid for) whether or not the services end up being used. Your argument seems to amount to saying that insurance is inconsistent with free markets, but that's simply not the case.

 

[Architect]

I don't intend to. Which is part of the point: I don't want a system where someone determines how much everyone pays. Centralized planning doesn't work very well for large, complex systems. I want individual choice about how much someone wants to pay: if they want more coverage and more services, they can pay more, and if they are willing to accept less coverage and fewer services, they can save money by doing so.

So why does the NHS cost less for at least equal results? How do you square the effectiveness of the comparable socialised healthcare systems?

Don't kid yourself: there is no such system. Healthcare, just like almost everything else with a finite supply, will always be rationed. Some people will always be going without healthcare they need.

Correct. The difference is that you've got a private, profit-driven system rationing it and we've got a government funded system with no profit incentive. The outcome is similar either way - few, if any systems, pay for a treatment with only a (say) 1% chance of success.

 

[Architect]

Let me be quite clear.

There is a baseline level of effective medical treatment, i.e. consistent with an acceptable clinical outcome. Everyone should, in my view, be entitled to this without any consideration as to ability to pay. There are, however, clearly luxuries such as - for example - private rooms and having a tv at your bedside which are not, in fact, in any way relevant to clinical outcome. If people wish these and want to pay for them, then fine.

Do you disagree with that position? Are you advocating varying standards of clinical treatment and care depending upon ability to pay?


ETA: "Clinical outcome" does not merely refer to keeping them alive, but to an entire course of treatment for the relevant condition, i.e. not just stabilising the patient then chucking them out.

(cough)

 

[ARubberChickenWithAPulley]

Correct. The difference is that you've got a private, profit-driven system rationing it and we've got a government funded system with no profit incentive. The outcome is similar either way - few, if any systems, pay for a treatment with only a (say) 1% chance of success.

So what's the difference aside from a few percentage points? The government has to remain fiscally solvent and break even. How is the motivation for rationing any different?

 

[elbe]

When you buy insurance, you are NOT buying medical services themselves. You are buying coverage for those services. That coverage has value (which you paid for) whether or not the services end up being used. Your argument seems to amount to saying that insurance is inconsistent with free markets, but that's simply not the case.

It isn't inconsistent with free market, but it is hardly the free market solution. Insurance, any sort of insurance, is a safety net system. The government also operates safety net systems - medicare, medicaid, social security, etc. You want free market, then you should be willing to pay for all your medical services as needed, and if you can't afford a life saving operation than you're SOL.

 

[ARubberChickenWithAPulley]

There is a baseline level of effective medical treatment, i.e. consistent with an acceptable clinical outcome. Everyone should, in my view, be entitled to this without any consideration as to ability to pay. There are, however, clearly luxuries such as - for example - private rooms and having a tv at your bedside which are not, in fact, in any way relevant to clinical outcome. If people wish these and want to pay for them, then fine.

Do you disagree with that position? Are you advocating varying standards of clinical treatment and care depending upon ability to pay?

Not exactly -- I don't actually disagree with you that there should be a minimum standard of care for everyone, I'm just pointing out that even defining what affects "clinical outcomes" isn't easy, and the U.S. has cultural issues with what we expect from care and our attitude toward cost.

If, for example, I want a $10,000 procedure that has a short recovery time, instead of a $1,000 procedure that has a longer recovery but is equally effective in solving an illness, is the former a "luxury"? I would guess, based on experience, that most doctors would recommend the more expensive treatment, unless they knew the patient absolutely couldn't afford it. Or, for example, if a new drug had a slightly higher effectiveness than an older drug, but was, say, 10X the cost: luxury or clinical outcome issue?

A specific example would be imaging: the U.S. uses MRIs and CTs at ten times the rate of other countries. Doctors in other countries tend to use X-Rays and cheaper procedures more, with better outcomes. If my doctor orders an MRI instead of an X-Ray, that could be considered a luxury. My doctor would probably disagree, but the evidence doesn't seem to. Yet, few patients would be happy if a doctor thought they needed an MRI and the doctor was overruled because of cost.

 

[Ziggurat]

It isn't inconsistent with free market, but it is hardly the free market solution.

Nonsense. It's subject to the same laws of supply, demand, and profit motive that any other product is. Although often regulated by government, it's completely compatible with free markets.

 

[Ziggurat]

There is a baseline level of effective medical treatment, i.e. consistent with an acceptable clinical outcome. Everyone should, in my view, be entitled to this without any consideration as to ability to pay. There are, however, clearly luxuries such as - for example - private rooms and having a tv at your bedside which are not, in fact, in any way relevant to clinical outcome. If people wish these and want to pay for them, then fine.

Do you disagree with that position?

I would like there to be a baseline level that everyone has access to. What that baseline should be is not something we will all agree on, and I would likely set it lower than you, not because I want poor people to get worse coverage but because there are costs (including opportunity costs) to raising that baseline level. And in fact, we already have a baseline. It's well below what you want, but it's there.

So I want a baseline, I'd probably set it lower than you would, but I'd also like it to be possible for almost everyone to purchase care above that baseline. I'm not actually a heartless bastard, I'm just a regular bastard.

Are you advocating varying standards of clinical treatment and care depending upon ability to pay?

Well, yes. And that doesn't even conflict with your position as stated above. If someone wants to pay for an MRI to investigate their gas pains, that's fine by me. That's an extreme example, but it's clearly possible to get better care with more money, and always will be unless it's prohibited.

(cough)

Patience, grasshopper.

 

[Ziggurat]

So why does the NHS cost less for at least equal results? How do you square the effectiveness of the comparable socialised healthcare systems?

Because a badly but heavily regulated market system is not a good way to achieve efficiency either. I'm not arguing that what we've got is even close to ideal. Furthermore, many of the higher costs would persist even with a government system.

For example, much has been made about the inordinate amount spent on end-of-life treatment. This isn't simply a matter of our insurance system (because face it, insurance companies would be happy if that treatment wasn't so costly), it's also a result of American's expectations. Those expectations won't magically change with a socialized system: the public will continue to demand expensive end-of-life care, and would therefore still rack up higher costs than Canadians even with a nominally equivalent system. And don't kid yourself that our politicians would be brave enough to make hard decisions to keep costs in line. Ain't gonna happen.

 

[Architect]

So what's the difference aside from a few percentage points? The government has to remain fiscally solvent and break even. How is the motivation for rationing any different?

"A few"? You pay roughly DOUBLE what we pay.

 

[Architect]

A specific example would be imaging: the U.S. uses MRIs and CTs at ten times the rate of other countries. Doctors in other countries tend to use X-Rays and cheaper procedures more, with better outcomes. If my doctor orders an MRI instead of an X-Ray, that could be considered a luxury. My doctor would probably disagree, but the evidence doesn't seem to. Yet, few patients would be happy if a doctor thought they needed an MRI and the doctor was overruled because of cost.

I'm sorry, but in the absence of evidence supporting the wider user of MRI scanning I'd have to say that the Doctros were just wasting your insurer's money.

 

[martu]

Nonsense. It's subject to the same laws of supply, demand, and profit motive that any other product is. Although often regulated by government, it's completely compatible with free markets.

How does the incentive of a profit motive for the insurance companies result in better health care for the population?

 

[volatile]

I wonder what you mean by "doesn't work", especially with the odd qualifier of "by any metric you care to pick."

Here's a metric: Nationalization of health care will lead to slower development of medical technolog, leading to more deaths and protracted suffering, due to cures and treatments coming later and later than they otherwise would have in an "evil, greedy" system like the US's.

Evidence?

Architect and Rolfe have just posted links that blow this claim right out of the water.

You're clutching at ideological straws.

Also - what on earth does "development of medical technology" have to do with the provision of primary care free at the point of use anyway? The two are entirely separate issues...