For the last couple of days I’ve been watching the latest series of Foyle’s War. While previous series concerned crime on the British homefront during World War II, this newest series concerns itself with Foyle’s activities after the war. The war with which Foyle’s activities are juxtaposed is the Cold War.
One of the great developments in British life in the aftermath of World War II was the establishment of British National Health, that’s touched upon a bit in the series, and, in the context of our own feeble healthcare reform, that’s made me think about the factors that underpinned the creation of British National Health and why we haven’t followed the lead of the rest of the developed world.
This is a pretty fair paper on the subject. I think that I would characterize the reasons that underpinned the adoption of British National Health as
- World War II
- Technological
- Sociological
- Economic
- Political
It’s obvious that World War II was an enormous impetus towards the adoption of a national health service in Britain. The massive bombings created both a feeling of national solidarity and the need. British killed or wounded during the war were numerically higher than ours and three times as high as a percentage of their population. I wasn’t there but I suspect that nearly every Briton knew someone who’d been killed or injured in the war and many of the injured needed ongoing care. The historian Charles Webster noted “The Luftwaffe achieved in months what had defeated politicians and planners for at least two decades.”
Additionally, the war upset entrenched bureaucracies and power structures that had worked against a universal healthcare system.
I think that technological developments, some spurred by the war, also played a major role. The first sulfa antibiotic was developed in 1935, penicillin was productized in 1942, and streptomycin developed in 1943. These antibiotics had two implications. The first was that for almost the first time medicine was actually able to do something to make people healthier. The second was that it raised the expectation of future developments. People were eager to share in the benefits of these developments.
Britain was a very different country in 1948, when the BNH was established, and today. About 3% of its population were immigrants and most of those were Irish who had a sort of grudging status as honorary Britons due to the many-century relationship between the Irish and the Brits. Would Britain have adopted a system of universal care if its immigrant population had been many multiples of what it was (as it is now) and most of the new immigrants were non-Europeans? Frankly, I doubt it.
One of the considerations not frequently mentioned is that during the period just before the war and certainly by the war and its aftermath, a generation of young doctors had arisen in the United Kingdom that were not only convinced that they could practice medicine more effectively under a system of universal care but that they would benefit economically from such a system. In the United States by contrast the most ardent and organized opponents of universal care, at least in the 1960s and 1990s, were physicians. The tide on that may be turning very, very slowly.
In 1945 Labour won a historic electoral victory, gaining nearly 300 seats in Commons. One of the planks of the manifesto they ran on was universal care. By comparison no major political party in the United States has ever run on such a platform.
There’s a final factor which might be deemed “historical”. Germany adopted a system of universal care nearly 150 years ago. France and the United Kingdom adopted their plans in the aftermath of World War II as did most other European countries. Japan adopted its system in the 1960s. The tide of history is moving in somewhat the opposite direction now with most developed economies retrenching, including Sweden whose healthcare system is nearly 400 years old.
I’m not sure what my point in this post is. It may be that universal care in the United States is likely to continue to prove a hard sell.
One thing about the German experience is that though it dates back to the beginnings of the German Empire, the initial program only covered the “lower-paid segments of the labor force, or 10 percent of the population.” Backgrounder on German Development of the Health Care System It was by incremental increase in the occupations covered and increase in the income cap that moved it towards a system of universal care. So, possibly the question for the U.S. might be, why didn’t Medicaid continue to expand?
I’ve given my answer to the question any number of times: lack of social cohesion. I don’t think that most Americans see themselves as ever being eligible for Medicaid.
With the changes to Medicaid that are part of the PPACA that could change over time. Or it could backfire because people who don’t see themselves as Medicaid beneficiaries suddenly are. I just don’t know.
As I’ve written repeatedly, I’m concerned that the addition of so many people to the Medicaid rolls who were already eligible will prove a burden that the states aren’t prepared to bear.
I imagine Obamacare will be sold pretty effectively given that the insurers are apparently preparing to spend half a billion dollars doing just that. http://dish.andrewsullivan.com/2013/12/17/the-campaign-to-sell-obamacare-2/
Retrenchment in some European systems is not abandonment of that system, any more than when we cut our military expenses we’re planning on declaring neutrality. Governments will remain the insurer of a nation’s health.
We are now finally joining the rest of the world in placing the ultimate responsibility for healthcare on the government, and as I predicted long ago, it is now extremely unlikely to be reversed. The insurance companies will be the not-so-secret weapon.
Michael, you continue to conflate insurance with care.
I don’t honestly know what’s going to happen with the PPACA. We’ll know in the fullness of time. However, I’m not convinced by the writer at Andrew’s site’s logic.
First, spending money is no guarantee of success. I seem to recall that we spent about a trillion dollars invading Iraq. Saddam is gone but otherwise I don’t think the effort can reasonably be called “a success”.
Second, according to Kaiser the amount paid in premiums in the individual market annually is about $40 billion. The insurance companies have just received an offer they can’t refuse from the Administration. A half billion is probably not a bad bet just to provide plausible deniability.
Finally, how would one measure the success of the PPACA? There doesn’t seem to be an accepted definition. For its supporters survival appears to be equivalent to success. I’ve offered my own definition: if more people are insured on April 1, 2014 than were insured when the law was enacted, it wouldn’t be unreasonable to consider it a success. As of today the number of those insured is actually lower than it was then and I have some difficulty in believing that will correct itself by the end of the year. Will it happen by the end of March? Time will tell.
If they were really confident in the success of the PPACA, they wouldn’t spend a dime. Why would they? The mere perception of a need for an advertising campaign suggests some level of doubt.
Though I loath Bismarck, who gave us the intrusive Nanny State, I have to say that health insurance is not universal, compulsory or single-payer.
In the German system, one can choose his Krankenkasse; healthcare is not gummint-run, as in Britain. It is not universal, because it is not compulsory.
As an employee of Siemens, I was able to declare myself “freiwillig versichert,” which meant that I was able to refuse to join a Krankenkasse, meaning that I was a self-pay health care consumer. Unfortunately, while I kept my half of the usual healthcare-premium normally deducted from my salary, I lost the half that Siemens paid on my behalf.
Of course, I quit Siemens and continued to work independently (i.e., on a contract basis) doing the same type of engineering work. In that status, I was able to avoid paying healthcare insurance premiums altogether. And there was no Obamacare fee (tax) assessed, meaning that the Germans are more free than are Amerikans who have to suck up to Obamacare, EVEN if they leave the country!
Over the years I have read many horrendous stories related to patient care under the NHS guidelines. However, most of these critiques come from the overseas press, not really covered here in the U.S. Last July, though, Forbes published a comprehensive analysis of Britain’s health care, written by a physician contributor to the news service.
Dr. Atlas cuts to the chase in exposing the flaws he sees in this 65 year old UK socialized medicine program. In his commentary he writes about long waiting period, difficulties in accessing medicare care, and most notably, what is described as ‘unacceptable’ care in medical journals.
A line from July’s 2013 Scotland’s Herald, puts the application of big government in even a more cogent perspective:
We are already experiencing this in how our own PPACA has been processed — being held back during the 2012 election period (cover-up), and then rolled out haphazardly in 2013 (incompetence), with mostly ill results and negative twists and turns for the people. What follows, once these so-called computer glitches have been solved, will be the nuts and bolts of how the PPACA will effect people, along with it’s ‘real’ costs. From the vantage point of witnessing the current incompetence, cover-ups, to the cavalier disregard for people losing their HC coverage or having huge out-of pocket increases because of higher premiums and deductibles, it reflects poorly on what is to be expected for the next step — that of dealing with appointment waiting periods, access, and finally quality of care rendered under shrinking choices in medical exchanges. Just think of all the government excuses, or worse yet, ‘menu options’ the government will give people to remedy their complaints about HC services!
Basically, IMO, many of our HC assets and privileges are in jeopardy of suffering huge, perhaps irreversible, reversals in the delivery of healthcare services that many have come to consider as the ‘Standard of care’ norm in this country.
We are now finally joining the rest of the world in placing the ultimate responsibility for healthcare on the government…
Never treat government like God.
When people bring up the NHS, they should keep several things in context.
1) They spend about half of what we do, as a percentage of GDP, on health care. They have chosen to save money rather than have every expensive treatment available. In spite of that, their outcomes are still pretty good, but not up to what we are used to or what you see in France or Germany. Of note, the Brits like their system better than we like ours.
2) The US probably has more horror stories. Lots of stories about how people could not afford care. How they were shunted away by ERs that didnt want to see them. People dying on wait lists to get into high risk pools. Our wait times, by international standards are not very good, except for when you want to see a specialist. Then we are in the top 3 IIRC. Of course, wait times can be infinite if you cannot afford care.
3) No one is advocating that we take up an NHS type system. If you want to cite the NHS, then I should get to cite Somalia as what happens when you have smaller government. Both are kind of stupid. I choose to not cite Somalia. I invite you to stop citing the NHS, unless you want to talk specifics, and always in the context that their system costs half of ours.
Steve
Why Did Britain Adopt a System of Universal Care?
So they could have the weirdest possible Opening Ceremony in Olympic Games history? Seriously, WTF Britain, WTeffingF?
My point is neither to advocate nor critique the British National Health Service. I’m only musing about their path to universal care.
Culturally, we’re more similar to Canada or Britain than we are to Germany or France but, honestly, I think we’re sui generis. We have the largest immigrant population of any developed country and a higher proportion of immigrants than any developed country. The closest competitor is France. We’re ethnically, racially, and religiously more diverse than any other developed economy.
We’re geographically large and diverse, too. Although state identities have weakened over the years we continue to have state loyalties. Just check the attitude that Californians have towards the Golden State.
We’re the only developed country that shares a long land border with a country where the per capita income is a quarter what it is here.
I think that the U. S. is best thought of as a European-type developed country and a Third World country sharing the same space.
I don’t think that most Americans see themselves as ever being eligible for Medicaid.
That used to be true, but I’m not sure it is any more. Even the people that I know who are employed now are usually worried about losing their jobs. That’s reinforced periodically when someone we know DOES lose their job unexpectedly. That’s happened to two friends in the last month. Both unexpectedly, of course, both from companies that are posting nice profit margins.
First, spending money is no guarantee of success.
Not even in advertizing. Remember New Coke? Or every summer blockbuster flop ever made? Lots of money gets spent advertizing products that fail every year.
I don’t think that the British model is the way to go but I don’t see any reason why insurance companies should be involved. They contribute nothing to health care but still take 20% + of the health care budget. Compare that with 3% overhead at Medicare.
No doubt the diversity really matters, but I don’t get that mindset. What I do get, and identify with, is the feeling that government must show that it is ethical and competent enough before it can be entrusted with healthcare. Also, that the system chosen for healthcare delivery should make sense and be run at the scale at which it could be workable (state instead of national, perhaps.)
I think one of the implications here goes beyond “social cohesion.”
Example One: Germany enacted the first national healthcare program, following the Franco-Prussian War. This was the time of Bismarck’s “blood and iron” militaristic nationalism.
Examples Two and Three: Great Britain and France immediately following WWII. Particularly the UK had embraced “war socialism” to fend off the German onslaught, placing unprecedented control of all aspects of life under centralized control.
These examples (I’m skipping Japan) point to time periods in which these countries probably had more social cohesion than normal; these were periods of strong nationalism, not untouched by nationalism and/or militaristic interventions in the economy. Outside the Civil War, the U.S. did not experience anything comparable (and that didn’t leave all parts of the country feeling unified).
I agree with the general historical consensus that, absent authoritarian rule, big change only happens with a crisis. While the Depression and WWII were crises for the US, they were not to the same scale or depth as France and the UK. Still, the US did change and the federal role in many aspects of American life increased considerably. We had a cultural shift from isolation to that of the necessary nation with global interests. We accepted the idea of a large, professional standing military. Our cohesion was more external than other nations.
I’ve maintained the premise for a long time that big changes in the US won’t happen absent a crisis – I still think that’s true. Coming to grips with the imbalances in terms of what people expect from government vs. what people believe they own government won’t go away without a crisis or generational change.
steve
Are you not making the same error you criticize with NHS or Somalian comparisons? Correct me if I am wrong, but your arguments seems to be that “yes, ObamaCare is a mess right now, but just you wait, we will fix it”……..and “the old US system has problems too, but ObamaCare will be better”……….and “well, we had to take the best shot we could now, even if it stinks.” I’m not trying to pick a fight, but if a senior exec at one of our companies came in trotting out those lines about a major corporate initiative they would get thrown out of the board meeting and we’d call a headhunter.
Those seem like completely blind shots in the dark, with no evidence to support them. And the only empirical evidence, so far, is a complete mess.
I want to be clear. If I thought government funded and administered health care would work I’d be all for it. This isn’t some Obama-centric criticism; its a guy in his mid-50’s who has observed and guided organizational behavior for a living and sees, empirically, that government can’t do much right, because of basic and irrevocable structural issues. I’m just a pragmatist.
I don’t want to see people uninsured, and harmed therefore. But I can think of better ways of dealing with it than Obamacare.
I hear all kinds of stories about suboptimal care in the US. I have quite a history personally. I know of no such problem. And why is it that people seem to come here from all over the world for care? (And I know their can be cases of great care elsewhere) Could there be a reporting and statistics problem? eg When a Mexican woman drops a premature baby in the desert, its not reported. “Price” is narrowly defined, and doesn’t include reliability, quality, availability etc. A Ponderosa Steakhouse serves “steak” at an “affordable price,” but would you not rather go to Peter Luger’s??
I recently posted a youtube link to a debate between Bill Buckley and Milton Friedman about the negative income tax. At its heart, the argument by Friedman was that, yes, we must provide income sort to some people, but let’s just do it – provide income support and avoid the huge administrative costs with organizations created to control the handout. (So why not do the same for health care??) Buckley, arguendo, noted that people might not be trusted to use the money as they should, so does it not need to be administered?
This, effectively, is where I am. Someone wants to tell me we need to turn the entire health care system over to the government because we need to address a minority of people, who we – implicitly – don’t trust to use the dollars we give them to actually purchase health care or health care insurance?
That is insanity.
Last thoughts –
Is the Pentagon administered cost effectively and is it cost effective?
Is Medicare?
Social Security?
The Agriculture Department?
Education?
DMV?
I could go on…..what on earth makes anyone think the government will administer health care better?
I hear all kinds of stories about suboptimal care in the US. I have quite a history personally. I know of no such problem.
I know several such examples of people getting sub-optimal care.
My father got lazy treatment from a cancer specialist who decided the small mote on the x-ray was just dust from my father’s work in construction. This while my father was being treated for laryngeal cancer (or whatever it’s called). When my father’s condition worsened and they checked his lungs a month later, they were eaten up with cancer. Perhaps that would have happened anyway, but shrugging the shoulders and saying, “eh” didn’t seem optimal to me, even by 1988 standards. That was through private insurance.
In the late 1990s and early 2000s my father-in-law had a problem with misdiagnoses that ultimately ended up with the docs not figuring out he had prostate cancer until it had spread to his spine. Not sure how the FUCK they missed that with the state of the testing at that time, but they did. That was through the VA.
I’m not going to go into details, but both my mother and brother in recent years had to jump through so many hoops (caused by stubbornness of doctors and bureaucratic red-tape, respectively) that by the time they got their cancer diagnoses there really wasn’t anything to be done. Mom’s care was a combined Medicare/private insurance which was funny – nobody except maybe the President was more covered than she was for expenses but the doc still wouldn’t order the tests that would have shown Mom had thymic carcinoma BEFORE it had grown into all the arteries and veins in the area. He was convinced she was just really old and complaining of general aches and pains. My explaining how tough the old biddy was fell on deaf ears and he just wouldn’t test, and Mom refused to switch doctors like I wanted. My brother had union insurance, and they simply would not approve a goddamned thing without a fight, my brother having fallen out of favor with the union. (No, local union leadership should not have been able to throw up roadblocks for healthcare coverage, and yet they did. Lots of things happen on the bottom end of society that the rich and powerful insist can’t and don’t happen. Imagine that.)
I had my own issues back in 2003 with a neck problem that did not get properly diagnosed because the insurance I was under at the time insisted I go through one long process after another before they would allow for the scan (I can’t remember now if it was an MRI or CT scan that was needed) to determine that I didn’t have a sore neck because I had slept funny, but had two degenerating disks. Taking a couple of aspirin wasn’t going to fix the problem. Eventually got it diagnosed when I got new insurance and new doctors and got tired of living with unexplained pain.
My wife had a fun experience with the birth of our child, but I still get too goddamned mad thinking about that to write about it. She had too many doctors, and what the course of action set by one group was counteracting completely what the other set of doctors were doing. Neither set bothered to talk to the other and apparently could read the damned charts. It wasn’t until a year later when talking with a very experienced nurse that we found out the two things the docs were doing were counteracting each other. (One set was trying to induce labor. The other set was ordering procedures that made it impossible to induce labor! Big fucking win, as both sets of doctors worked for the same fucking practice.) End result was that my wife and child didn’t die, but it was real dodgy at times, with my wife’s blood pressure going somewhere north of 250/125 (at rest) and my daughter being born with an Apgar of 1. ONE. Perhaps some or all of that would have happened anyway, but they could have spared her several days of torture in the meantime.
Oh, and I forgot the time my wife’s gall bladder was acting up and the doctor kept insisting it couldn’t POSSIBLY be her gall bladder causing problems because HE was the doctor and he knew these kinds of things. (He was wrong, of course, and didn’t go see that turkey again.)
Care is not always optimal in this country, not by a long shot. I won’t bother recounting what a friend with Crohn’s disease has gone through, but that hasn’t always been pretty either.
Doctor’s are a crap shoot. I’ve had a couple of great ones through the years (the guy that put me back together back in 1988 was a brilliant carpenter, and that’s no snark) and a bunch of doctors in the middle. But I have certainly seen some real screw-ups. And most of the screw-ups have had the same root cause: two many doctors and agents involved in a case so that none of them really knew what was going on. But really, you just roll the dice and hope to don’t roll snake eyes to start.
ice
I’m sorry to hear of these events, and they are definitely at odds with my experience.
But ObamaCare will fix this how?
How did I suggest ObamaCare was going to fix any of this? Or that any other system will?
Drew- Look at the trend of the old system. Fewer people with insurance while costs were rising. Suppose one of your execs came in and said we are selling fewer widgets and the costs of making widgets is increasing, but we should just ignore it all. Does that guy get thrown out of the board meeting? I bet he does.
So, we got a suboptimal solution. This being politics and not business, you got a political solution that didnt please many people, but it does test out a few principles and could, I hope, answer a few questions.
First, do people w/o insurance really want it? If you make it affordable, will they still not buy it? Most of us think so, but we dont really know.
Next, if we sell insurance on markets with some transparency, will people buy it? We buy our insurance through a broker. I suspect you guys did too. We don’t have the time to sort through every possible plan. They are too difficult to compare, and we are doctors. At least on an exchange, an idea central to many if not most right wing reform plans, you can compare apples to apples.
Next, will skin in the game help lower costs? That is also a central theme in most right of center plans. While the right has chosen to decry the high deductibles in some Obamacare plans (good politics on their part if they can get away with it), it is what they have pushed for all along.
Does it have to be govt dominated reform? I dont know. It certainly seems to work pretty well for other countries, but maybe we really are different. We certainly dont see the strong Protestant influence that gives us the prosperity gospel, and its parallel idea that the poor deserve to be poor, in the rest of the world like we do here. Maybe an Asian country have very cost effective govt dominated health care, but we cannot.
Last thoughts
How does the free market provide health care to the working poor when family plans cost $15k?
Since Medicare admin costs are less than those of private insurers, should we expand Medicare? (Assume that I have read the different comparisons on Medicare expenses, and while I think CATO/AEI have made a good effort trying to claim Medicare costs are higher, I think they have failed. YMMV. Of course I am biased as it costs me much more to deal with private insurance companies.)
Since we have the best education system in the world, people from all over the world send their kids here (unlike the tiny, tiny percentage who come here for health care), is education a good model for quality? Maybe the costs are high, but they are perceived as worth it? (If you have visited any upper level college recently you can easily verify the presence of all those kids.)
Steve
I don’t think that’s a particularly good comparison. Healthcare is a private good while an education at Harvard, Princeton, Stanford, or MIT is a club good.
Relatively few people people come here from other countries to attend San Francisco City College.
Changing subjects, one of the characteristics of a good plan is that it lays the groundwork for future developments. The strategy for this in the PPACA is apparently via administrative discretion. While the advocates of the PPACA believe it will naturally evolve and expand, I think that the opposite is just as likely. Administrative discretion can work in both directions.
Said another way, I don’t think the PPACA is nearly as good a plan as you seem to.
It’s certainly noteworthy that it required specific circumstances in Britain to get the NHS through. And I agree with the overall theme of the post (that our unwieldiness and diversity make it harder for the US to get things through), but the place to really look for an analog to the US here would be Canada. When did their system come to fruition? They weren’t devestated by WW2 like Britain was. So that would open up a sliver of hope for a national plan or some sort. On the other hand, they’re less unwieldy, less diverse, and less ornery.
My guess is that it will only happen in the event of a systemwide collapse. I don’t think it’s what happens if PPACA fails… but I think it may be what happens if PPACA fails spectacularly and everything else goes horribly wrong.
Our frontguard against such a national plan is that most people are at least somewhat satisfied with what they have and are afraid of losing it (which is why Obama lied about that) even if the dissatisfied are very dissatisfied.
The history of how Canada’s present healthcare system came to be is a bit complicated. Essentially, it came from the provinces up and the impetus was physician shortage.
Saskatchewan passed a provincial system for universal coverage in 1946 modeled on the municipal systems that had sprung up there. Alberta followed suit in 1950.
It wasn’t until 1961 that all ten provinces had enacted what they call “HIDS laws” (healthcare insurance and diagnostic services).
One of the interesting things about Canada’s experience is that in one way it has been quite similar to ours: major reforms take place about once every twenty years. 1946, 1961, 1984, 1996. Canada’s most recent reforms have been in the direction of private insurance.
Healthcare is a private good while an education at Harvard, Princeton, Stanford, or MIT is a club good.
One also wonders how much of the ‘education’ people get at such schools is about the education as opposed to the connections made. Seriously, did Chelsea Clinton’s degrees in history and international relations truly prepare her for a career in hedge funds, purchasing and evaluating CDOs and distressed equities? Not to mention broadcast journalism? (Well, okay. Given what one sees on the news, apparently huffing diesel fumes is considered sufficient prep for a career in broadcast journalism. So she’s got me there.)
First, do people w/o insurance really want it? If you make it affordable, will they still not buy it? Most of us think so, but we dont really know.
Steve,
You sound like the government should have the leeway of a grade school science class, placing in it’s petri dish the social experiment of government mandated health care, for everyone — whether they want it or not. With something so vitally important you just don’t make such abrupt changes in a whole system without having some good indications on what will happen. Do you?
Also, how the PPACA was repeatedly marketed to the public was that it would lower HC costs and give insurance coverage to those not having any. The fact that it repeatedly assured people the vast majority of those satisfied with their existing coverage would not be effected, was a huge qualifier in making this law seem relatively benign. That proved to be entirely bogus. It’s like having tickets to see one play, and when the curtain opens there’s an entirely different production on stage.
Regarding variation of plans and transparency — the PPACA has created too broad a spectrum of criteria that everyone must conform to, no matter age, gender, health issues. The main difference in the plans are the amount of co-pays and deductibles. Often times you don’t even get a better choice of doctors and hospitals to chose from, even in the top-tier plans.
Basically had this bill been honestly laid out, showing how it was going to alter so much for so many, it never would have passed.
jan: With something so vitally important you just don’t make such abrupt changes in a whole system without having some good indications on what will happen.
Any change to a complex system is going to have unintended consequences. The problem with your stated position is that it leads to paralysis: You can never update complex systems, no matter how decrepit and out-of-date.
Steve / Dave
I’m willing to be schooled or persuaded. I really am. But just saying the jury is still out, or that things will get better (just because) seems a weak reed to lean on. And bad things are happening in the interim.
steve –
“Drew- Look at the trend of the old system. Fewer people with insurance while costs were rising.”
Yes, but still fewer today than 6 months ago, and the cost problem is hardly being addressed by Obamacare.
“Suppose one of your execs came in and said we are selling fewer widgets and the costs of making widgets is increasing, but we should just ignore it all. Does that guy get thrown out of the board meeting? I bet he does.”
No, and this is part of my problem with your argument – its a complete straw man. I have never said “do nothing.” I have said the opposite: portability, the bridge to covering those with pre-existing conditions; the very difficult free rider problem. All legitimate problems. (steve – I have a diagnosis of congestive heart failure. Out of naked self interest of the Reynolds variety don’t you think I would be an advocate for pre-existing condition coverage? But I’m not. This is just bad public policy.) What I have said is that ObamaCare is like taking a rusty axe into the OR for brain surgery.
“So, we got a suboptimal solution. This being politics and not business, you got a political solution that didnt please many people, but it does test out a few principles and could, I hope, answer a few questions.”
I hope you are correct, but this would be a political result with which I am not familiar.
“First, do people w/o insurance really want it? If you make it affordable, will they still not buy it? Most of us think so, but we dont really know.”
I think we do know. The so-called “invincables” won’t buy into a plan that simply subsidizes the old. Nor should they. But they should buy a plan that is responsive to their current needs and long term actuarial realities.
“Next, if we sell insurance on markets with some transparency, will people buy it? We buy our insurance through a broker. I suspect you guys did too. We don’t have the time to sort through every possible plan. They are too difficult to compare, and we are doctors. At least on an exchange, an idea central to many if not most right wing reform plans, you can compare apples to apples.”
C’mon, steve. You are not a fireman, automobile designer or lawyer either, yet you somehow manage to buy home, car and (hopefully) umbrella liability insurance. Risks come in categories and tiers of exposure. Its not rocket science. And Obamacare solves the issue how?
“Next, will skin in the game help lower costs? That is also a central theme in most right of center plans. While the right has chosen to decry the high deductibles in some Obamacare plans (good politics on their part if they can get away with it), it is what they have pushed for all along.”
Here, we agree, as I noted in a comment several weeks ago, and have advocated for years: exposure to price. Don’t confuse “the right” with me. I’m just a free agent with views. The problem is that the high premiums and deductibles under ObamaCare are really subsidies for those who improperly insured for years. Kind of like the wealth transfers of SS. You on “the left” (sorry, couldn’t resist) need to reconcile the stated goal of providing a safety net insurance scheme to those of sub-par incomes with bofoing young people.
“Does it have to be govt dominated reform? I dont know. It certainly seems to work pretty well for other countries, but maybe we really are different.”
I don’t read papers on foreign country health systems. But I dispute that it “works pretty well.” Its anecdotal, for sure, but I’m not impressed that Canadians or the English really like the sytem, other than its all they know.
“We certainly dont see the strong Protestant influence that gives us the prosperity gospel, and its parallel idea that the poor deserve to be poor, in the rest of the world like we do here. Maybe an Asian country have very cost effective govt dominated health care, but we cannot.”
You are wandering off into la-la land now. No one “deserves” to be poor, except a certain fraction who are just no damned good. Liberals hate this, but I know first hand. My sister’s former husband had one goal in life: get on disability and drink beer and watch Jerry Springer. Eff’m. And if we really cared about the poor government spends so much money we could set them all up with an annuity (I once did the math) for life. Government spends on crap and administration, not the poor.
“How does the free market provide health care to the working poor when family plans cost $15k?”
Reform the system so $15K isn’t the number, and go watch the video of Friedman and the negative income tax I cited. ObamaCare is costing $14K per enrollee right now. You pick.
“Since Medicare admin costs are less than those of private insurers, should we expand Medicare? (Assume that I have read the different comparisons on Medicare expenses, and while I think CATO/AEI have made a good effort trying to claim Medicare costs are higher, I think they have failed. YMMV. Of course I am biased as it costs me much more to deal with private insurance companies.) ”
I hold no brief for any institution with regulatory capture capability, but IMHO you need to ask how ObamaCare will reduce this. They currently are partners in crime.
Lastly, to riff off of one of Jan’s observations. If ObamaCare is so obviously desirable, why did they ram it through so dishonestly? And is that the model for governance?
Lastly, to riff off of one of Jan’s observations. If ObamaCare is so obviously desirable, why did they ram it through so dishonestly? And is that the model for governance?
This is my issue too. Progressives who are frustrated by the difficulty in getting buy-in from the US population could have focused on gaining trust first- trust in their abilities to manage complex systems, and trust that the goal was expanding healthcare availability and not enriching themselves and their benefactors.
Instead, this bunch has gone nuclear, blowing up any chance of earning that trust.
First, do people w/o insurance really want it? If you make it affordable, will they still not buy it? Most of us think so, but we don’t really know.
For many people, a $15,000 per year policy with a high deductible and no co-pay is not much different than having no policy. You are paying out of pocket until you reach the deductible, and many people do not have an extra $4,000 (much less $8,000) to reach the deductible.
For $15,000, you get no health care. You do get the peace of mind knowing that nobody will be able to take everything you have, bit if you have nothing, that is little comfort.
I also agree with Drew about the three big problems that needed to be addressed: portability, coverage for those with preexisting conditions, and free riders.
The portability issue could be solved by phasing out the current system of tax incentives. Decide at what level to subsidize and put caps (I think they’ve done that with PPACA anyway.) Make the subsidy available for individuals and phase out the business model, over a period of 5 or 8 years, to allow time for adjustment of employment contracts.
Problems two and three could have been simultaneously addressed by modeling term life insurance- push for HD /HSA for all (through a mandate if necessary, but potentially it could have been done with more tweaks to the incentives and subsidies for low earners.) As it is, it seems that the price controls and coverage mandates for the insurance exchanges have led to policies which have the worst features of HD but without the benefits of HSA.
The problem with your stated position is that it leads to paralysis: You can never update complex systems, no matter how decrepit and out-of-date.
Zachriel,
Big changes in national policy are best orchestrated when done gradually, with at least some bi-partisan agreement. In this way implementation, finessed in stages, can exclusively focus on getting one piece right first, before rolling something else out. You might even find that making some initial fundamental and less disruptive adjustments to health care, such as tort reform, creating real, free market competition between insurance companies, having a voucher or high-risk pool for the uninsured, greater incentives for HSAs, may render “fixes’ to the HC problem without the necessity of changing and/or jeopardizing everyone’s HC insurance and services. Of course, this kind of problem-solving is more apolitical, in that it studies and encourages beneficial HC reform through the eyes of making HC better for everyone, without the need to arbitrarily take away or redistribute monies or services at the discretion of some bureaucratic government entity.
As to CStanley and Drew coalescing around the issue of the dishonesty inherent in the inception of Obamacare: To me dishonesty is poisonous to any agreement, whether it’s between two people in a marriage, a business and its employees, or a government and it’s citizens.
Although, the Obama Administration may have had good intentions, their HC reform package was carried out in an insidious fashion. They exploited the issues surrounding HC, connived with insurance companies so they would come on board, misrepresented the wide-spread ramifications of the PPACA, bribed various Congress people to get the votes, passed a 2700 page bill without reading it on a narrow partisan vote, and then proceeded to change vital parts of the bill though 15,000 pages of complex, convoluted rules and regulations. They then layered more audacity onto their PPACA contrivance, by the unilateral WH dismissal of mandate deadlines for some, and party-favored waivers and subsidies for others.
Even the Constitutional ruling of this law was not without controversy, in how the Court suddenly looked at the punitive fiscal parts of the PPACA as a “tax” rather than how it was pedaled by Obama, throughout this law’s gestation period, as a low-key “penalty.” Basically most of the harsh and cold reality parts of the PPACA were either hidden, lied about, or left in a latent state until it had safely passed the gauntlet of passage, Constitutional mustard and finally the 2012 election cycle — where if the other guy had won there were greater chances of repealing this awful law.
Maybe not, but a fair number come over here to go to schools like the University of Texas at Arlington and Georgia State University.
An interesting post and commentary. One thing worth considering when discussing the national health systems of countries like France, Germany, Canada etc. is that they were established when health care consumed only a very small piece of national GDP. As such it represented a small bone which could be tossed to the electorate with minimal budgetary implications. Were they faced with providing such a benefit in today’s environment I think it problematic they would have reached the same policy decision.
The failure of ACA is an attachment to the concept of universal care which may well be an idea whose time is long past. Had we proceeded with incremental, imaginative, experimental solutions to the obvious problems of health care in the US, we might now have an easier sale as well as solutions appropriate to 21st century medicine.