1) Coverage extensions will lead to a second-class group of insured poor
This bill extends coverage to the remaining block of fifty million uninsured Americans. However, it only mandates coverage for these individuals in public or non-profit inpatient settings. There is no guarantee of coverage in outpatient services or private practice offices. As such, these coverage extensions will function much like “universal” coverage in Massachusetts, where individuals with insurance can not find doctors who will offer them treatment. Thus, we will have a fully insured country of people who can not receive services. In fact, this coverage extension will likely lower coverage for existing patients under Medicaid as crowding-out occurs.

2) Coverage extensions are occurring without any mandates to increase provisions of physicians
America already faces a 10-17% gap between physician supply and demand of care. Without changes to AMA rules around medical school graduation rates or major efforts to increase supplies of patient care, this bill will lead to rationing and limitations of care, but not in a centrally-organized way, as could be designed under a non-socialized but, rather, single-payer comparative health delivery system.

3) The bill claims to “provide funding for every penny of coverage increases”, which will end up being a doubtful provision given past precedent of cost overruns. Even if this is true, it does not resolve the gap in the Medicare/Medicaid trust funds, which are scheduled to bankrupt America
Through 2030, America is underfunded in the tens of trillions of dollars on its Medicare obligations. This bill claims to yield a cost-neutral solution to care expansions, but it does not address the 17% gap in current physician/service provision, the double-digit percentage increases in existing health care services or the burdens of existing services within the Medicare trust fund. You can thank the AARP for not allowing any reduction in senior services.

4) The bill does not address comparative effectiveness
Under federal law, comparative effectiveness is illegal in America, unless applied through direct trials by the FDA. There is no effective agent in America, under this bill, to regulate and ration therapy, drug and device availability to patients against metrics of efficacy. Obama’s $1.1B CER program has completed its course, and there is no plan for follow-up CER or implementation of a new program.

5) The bill does not address implementation or effectiveness of electronic medical records, but rather just “throws money at the problem”
There is some money for EMR in this bill, but on a per-capita, per clinician basis, funding is not even 1/3rd of EMR provision in Western Europe or Scandinavia. Furthermore, centers of care are being encouraged to have an “EMR arms race”, which does not encourage building systems that can talk to each other and enable information sharing, or correct underlying problems of analog operational problems that will merely be translated into digital format.

6) The bill will waste all the political capital generated over a century of frustration and efforts at health reform. The failure of this reform will further entrench resistance against single-payer, universal coverage reform for another century
People will feel wonder if this is finally the reform that we wanted after a century of failed reforms going back to Woodrow Wilson. The willingness and patience for further, incremental reform will be gone after this legislation, especially after it fails. From Rahm Emanuel on down, politicians and economics rebuff experts in policy for being “idealistic”, but this is the other extreme, the most watered-down, do-nothing piece of legislation imaginable.

7) The bill lets insurers, drug companies and device companies off the hook with a perceived sense of sacrifice
Drug companies have somehow used successful PR and lobbying to convince the public that the concessions they offered to Congress and the President were noble and major sacrifices. In fact, independent studies show that they will receive positive NPV outcomes from this bill, given the increases in product delivery and margins that Congress will lay in their arms by minimizing the public option and not offering any meaningful price controls or comparative effectiveness.

8) No funding for changes in public health standards in America
30-40% of health outcomes in a country, maximum, are attributable to medical care. There is no emphasis on increased funding for public health and individual health standards in America. This is a major failure of this legislation.

9) The failure of this legislation will push political power back to conservatives in subsequent elections
People are going to be really, really upset when they see how big of a disaster this really is, and the right will regain power. Ugh.

10) No malpractice reform
Top journal studies, both in America and Europe, besides flaw studies completed by econometrists, show that the real costs of defensive medicine are 2-3% of total healthcare costs, not the 0.5% that is often alleged. More importantly, however, the indirect costs and burdens of physician liability are drawing doctors out of high-risk services, creating further shortages in medical care in vital areas, as well as encouraging billions in unneeded tests, diagnostics and procedures due to doctor worry. This is a failure encouraged by the ABA-dominated democratic Congress.

This bill will be a disaster. You’ll see.

Amir,

I was wondering what your thoughts were on a "safeway" type system where people who meet basic health metrics such as BMI, BP, cholesterol, fasting glucose and don't smoke receive a discount on on health care. The only thing that worries me about a single payer system is that there won't be any incentives to keep health care costs down through wellness incentives.  What are your thoughts?

Thanks for the informative site.  Your thoughts reinforce my reasons for not liking the current health care bill.

Jen

Jen,

Thanks for the feedback on the site and for visiting.

I am totally supportive of Safeway-like systems that encourage individual accountability and reimburse or financially burden those who do not take care of themselves at the expense of the health system. Single-payer systems, in fact, do take such responsibility into account, but only in countries such as Norway or Sweden.

We have to keep in mind that Americans have no desire for personal accountability in any sense, and thus, as much as it might be desired from a health or financial perspective, taxing people for smoking or being overweight would probably get even less traction than general, systematic payment or other more basic reforms.

You have me aboard and other countries have certainly done it. It works great to control perverse incentives and over-utilization of care. It's just near-impossible to institute in America, although it has worked well in some smaller private settings, although in many of those cases it has been maliciously used to raise people's premiums or force them off the rolls, rather than just taking corrective action.

Best,

Amir

Hi Amir!

Great website- I got here through your comments on the article in the WSJ (Lifting the Veil).  I pay $525/month for myself ONLY for healthcare with a high deductible.  My pre-existing condition is depression- I sought counseling and took anti-depressants after my divorce, and I suppose I'll never live it down!  I have Anthem and I live in Virginia.  My children have healthcare through their father's military job.  I think he pays $40-ish/month for all five of my children to have healthcare, and for his wife and their two children to have it.   Taking my kids to the doctor or hospital is never a problem, and I usually have a shorter wait at the military clinic than at my own civilian doctor.

I'm quite perplexed as to the direction we should go in this country with regards to healthcare, and appreciate your compiled information.  I currently have health insurance purely for a catastrophe.  I am a healthy, non-smoking, non-drinking 40 year old woman.  It seems my insurance should be significantly lower than it is.

This is just to thank you, not ask a question, and to let you know I'll be a regular visitor to your site!

My Response: Thanks for your kind words Jessica. Keep reading and please do tell your friends :)

Wendy T. writes:

Amir,

ln your article ''Common Arguments...'' you say ''the average cost of insuring an individual''. Are you talking about only the premium? Or the cost of the premium plus medical out of pocket costs (deductibles,co-pays)?
l and my friends and family have needed medical services in France, Guadaloupe, Holland, and Australia. All these countries have various clinics and some doctors offices that are open after 5 PM, before 8 AM, and weekends and holidays. ln the U.S. only ERs are open during these times. l've had to go to an ER when an ''urgent care'' clinic or internist would have sufficed. l've never seen this fact addressed in any of these universal healthcare discussions.
l've read that 5% of doctors are responsible for 50% of malpractice claims payouts. These are bad doctors that lose their MD license in one state, get a license in another state and continue to do harm. Physicians should be federally licensed as are pilots. lt's impossible (unless you're a lawyer) to even find out if a doctor has lost his license in another state once his license has expired in that state. A family member ended up in lCU  for 4 days because of a drunken surgeon who had already lost his license in 2 other states. lf doctors were federally licensed, once they lost their license they would no longer practice-l think this would go a long way towards reducing malpractice premiums and protect patients from further harm. l've never heard this discussed either even though it would be fairly simple to do. lt's hard to believe that medical ''facts'' that a doctor must know to pass MD licensing exams vary from state to state!

My response:

Wendy, the average cost of insuring an individual is not only the premium. These expenses reflect true, total system costs, which most people can't "see" within our system. These are true treatment costs, whereas the costs you mention are financing breakdowns of the costs into payers. Treatments costs need to be viewed as provider-billed expenses. In fact, this "moral hazard" of cost invisibility both leads to people not understanding the true nature of disaster in our health system and to commit excess utilization of services. Most people think premiums represent the true cost of health care, where, in fact, this is often a very small percentage of total expenses. For employed individuals, premiums can be as small as 5% of total health expenditures.

I agree with you about emergency room problems. This falls under problems relating to a lack of outpatient clinics and primary care physicians. I address these issues both in my op-eds about primary care doctors and in my discussions about a lack of front-end care access in America. There is no random correlation in the fact that (a) America's doctors-per-capita is 30% below the average of industrialized countries and (b) that we have an inverse relationship between primary care / specialist physicians in America and other industrialized countries and the fact that we have terrible comparable outcomes for preventative care, front-line care and emergency room utilization.

5% of doctors are not responsible for 50% of claims. This is completely wrong. Costs are spread and primary blame lies with lawyers who generate 15% of malpractice costs towards direct waste and who deliver a quarter of the other 85% of claims to clients who have no medical claim over lawsuits in indirect waste. There are bad doctors just as there are bad professionals in any other field. Anecdotal discussions of failed efforts to maintain license removal from problem physicians do not represent any statistically significant trend or problem on a state or national level in America. This is a red herring for other real problems.

Thanks for the questions. I encourage you to read my featured research post on malpractice and its true costs to America, its citizens and its health providers.

Wendy T. writes:

Amir,

Thank you for responding so quickly. You say it is ''completely wrong'' that 5% of doctors are responsible for 50% of malpractice payouts - but this info is on the internet.  l don't have your email address or l would forward the articles to you. Check out stats for Kentucky and Maryland. Check out stats on National Practitioner Data Bank- ''5% of U.S. doctors are responsible for 54% of malpractice''. l will research the % of doctors who lose their licenses and go on to practice in another state.

My response:

Wendy, first I would hold a health skepticism that something is true just because it is on the internet. That being said, I will credit to you that the following is true: 5% of doctors are responsible for 54% of settled claims in health care. This is not equivalent to payouts, but, rather only payments that do not go to jury trial and judge decision. Since roughly half of malpractice payments are decided on settled claims, this means that 5% of doctors are only responsible for 27% of malpractice payouts. People have misinterpreted these terms for years.

As far as license losses and resumed practicing in other states, I encourage you to send me what data you can find, as I don't have time to research this just at this moment, but I have heard presentations on the number of doctors losing licenses who are not "shut down" from practicing, and this number, if I recall correctly, was very high.

Thanks again!

Nathan P. Says to the Site about my comment:

"I just can’t buy this and sit comfortable with it. Switzerland and Netherlands examples do not bear fruit with me because there are smaller countries with concentrated wealth that can bear private, incremental coverage for a small number of citizens. We have already seen that even in Massachusetts, private-based expansion to attempted universality can’t work without single-payer and that, if it does work, radically balloons costs."

Amir, I think you're wrong here. The Swiss and the Dutch are different than MA. Those two countries don't have an employer provided insurance system that makes consumers blind to costs. In the Swiss and Dutch system, you get a voucher of fixed value and shop around for insurance of your choice. In MA, people still mostly get insurance from their employers, they don't see that it comes out of their wages, and they overconsume care. Insurers respond by hiking premiums, and employers don't care, they just take it out of worker's pay. This vicious cycle drives up costs. That's why MA is doomed to failure, and the Netherlands and Switzerland are not.

My Response:

Nathan, perhaps I just expressed myself poorly because I don't disagree with you. Switzerland and the Netherlands are definitely different from Massachusetts. You are right. Now, your voucher point is a good call-out on me. However, I promise you that was not an oversight but my effort to slightly oversimplify the situation. Now, we could debate whether the vouchers get you there or not compared to non-vouchers. I will admit research on that is not sufficient or clear enough for either of us to say that's definitely the only cause, but I'll grant you vouchers are better than non-vouchers. I am totally for anything that makes consumers "see the costs" of their care more. It reduces moral hazard.

I guess my real point is even if I grant you the voucher issue is a contributor to cost management, I think the bigger contributor is that our countries are different and Americans don't self-manage over-utilization. Vouchers affect that a little, but we know that rationing and single-payer government oversight on care manage overuse very well while either leaving health outcomes the same or improving them.

In conclusion, I will grant you vouchers explain some of the differences, but most European countries, because of cultural differences, inherently manage overuse better than Americans. This is why I think single-payer and some government oversight of care, including formulary systems and other treatment and diagnosis guidelines, give you more opportunities for a success in a place with a higher propensity for overuse like America. I would suspect these would reduce care much more reliably than vouchers. I wouldn't mind doing both, frankly.

Amir,

Is there any way to accurately gauge the margin that is added to healthcare costs by insurance companies?  I am so cynical that I assume any reports/statistics presented by the companies themselves would be unintelligible to most people, myself included, because profits/wages can be hidden as "investments" or some other type of shell game.

I remain surprised that with all of the loud debate going on nobody has shown a pie chart of where the money in healthcare goes.  A graphic representation of the money trail should be good for somebody's cause: if there's a large slice of pie in the "health insurance executive salary" wedge compared to the "healthcare provider" wedge it would be easy for me to say "get rid of insurance companies."

It makes me think of a bunch of questions:

1.  What percentage of healthcare dollars come via insurance companies and what percentage comes directly ot of payers pockets (either as copays, uninsured, etc)?

2.  What percentage of healthcare dollars go to "administrators" (i.e. hospital/physician office employees not directly involved in patient care)?  It would be especially telling to see this borken down by yearly salary (i.e. what percentage goes to clerks making less than 75K a year, what percentage to those making 75-125 K a year, and what percentage goes to those making over 125K a year).

3.  Same question, but instead of healthcare administrators, I would want to see the breakdown for insurance companies.

If you remember, the last time I asked you a question I hadn't decided on whether a government option would be a good thing or not.  I am more and more in favor of a LIMITED government option.  I like the idea of the British system, where a "basic" health plan is held by all, but those with the means can pay for a higher standard of care.  I find this morally appealing (rewards hard work, expresses a degree of compassion and caring for all) but understand that implementing it may be more difficult.

I am encouraged that the President seems to be willing to negotiate on tort reform.  I think that any plan he passes without both tort reform AND a government option will make the situation worse, not better.

Again, thanks for providing EVIDENCE and INFORMATION to support your opinions as this debate has degenerated into people shouting anecdotes and personal opinions with no factual basis.

Very respectfully,
Dave F., MD

My response:

Dave,

Thanks for becoming a regular contributor to the site. You deserve as fulsom answers to your questions as I can provide. Let me try...

Question 1: Is there any way to accurately gauge the margin that is added to healthcare costs by insurance companies?

Answer 1: There sure is. A good proxy is to compare Medicare to Private HMOs. Medicare operates at a flat cost basis of about 3%. This data is readily available from CMS. However, there are other loaded costs in Medicare as well. To be fair, these costs bring total operating fees for Medicare up to about 8%, all-in, for administrative costs.

If you compare this to insurance companies, they operate at 3% profit (mind you this is generously favorable of an estimate on my part to the insurers), along with 15% in administrative costs. This is 18%. Thus, insurance companies, per dollar put through the insurance system, add a 10% administrative cost load to every funneled dollar, which is all waste from a consumer perspective but serves as unneeded salaries and bonuses to insurance employees. This is a proper read of financial statements for insurers.

This is the SWEET part of being an academic who also is getting an MBA and working for Goldman Sachs in Healthcare Investment Banking, predominantly covering insurance and hospitals. I can give you almost exact estimates of where the costs are hidden because I was processing this data for them for several years. I didn't like doing those things, but it was essential so I could get a real, behind-the-scenes look at how private corporations operated.

Question 2: What percentage of healthcare dollars come via insurance companies and what percentage comes directly ot of payers pockets (either as copays, uninsured, etc)?

Answer 2: This will amaze you. According to a recent study by Kaiser, only 8% of health expenses come out of the pockets of 1st party payers (patients) directly. We channel almost everything through 3rd party payers. 3rd party payers pick up roughly 80-85% of the health payments in our country. Mind you, they are a funneling agent. You and I pay for every single dollar in the health system. However, costs are concealed. This is different from socialized countries where payments and individual's contributions to their health care are fairly obvious.

Ask a person to tell you how much her healthcare really costs. You have to add together out-of-pocket, employer contributions, government contributions...it is almost an impossible calculation to make. This is a major reason why Americans have high overutilization of health services compared to other countries. They do not feel or see the costs nearly as much as they should. Out-of-pocket premiums and payments have gone up in America, so people get sticker-shock, but this is nothing compared to true increases in employer contributions to health care or government expenses. People are paying a far smaller share of their health expenses 1st-party then they have in the past ten years.

Question 3: What percentage of healthcare dollars go to "administrators" (i.e. hospital/physician office employees not directly involved in patient care)?  It would be especially telling to see this borken down by yearly salary (i.e. what percentage goes to clerks making less than 75K a year, what percentage to those making 75-125 K a year, and what percentage goes to those making over 125K a year). How about for insurance companies?

Answer 3: Insurance companies have ALR of 15%. Hospitals get by with roughly 10%. The concentration of pay for upper management is not that bad in hospitals. The top five usually are 10% or less of total hospital administration costs. In insurance companies, however, you have to consider that huge parts of executive pay, within private companies, tie to options and stock, which are backed by net income, which non-profits and government clearly don't have. In this context, the top five executives in a private insurance company can represent 25% or more of total administrative labor costs.

I am pleased you are coming around a bit on government plans. You know my view on the contrasts and obvious benefits.

Thanks for your contributions and, as always, keep the questions coming.

Best,

Amir

Let me share with you my live-blog of the President’s speech on Health Care to Congress tonight.

7:57 PM – Interesting to hear that Obama plans on meeting with ten centrist Democratic senators tomorrow at the White House to talk about health reform. However, already, it is known that the senators he is meeting with are all adamantly against public option. I think this signals a breakdown of the plan that the president is going for and open ground for compromising to nothing even further. I am uneasy because I think this triggers a move towards signing something, but it will be watered down. We will have to see what’s discussed tonight.

8:11 PM – “Madam Speaker, the President of the United States” (soon to be followed by 6 hours of clapping)

8:16 PM – Pelosi reintroduces the President…we may actually get a speech eventually J

8:17 PM – Obama makes the point that since the start of his presidency, financial and monetary policy have started to initiate an economic recovery. Fair enough to some measures that have worked, but we know, on an objective basis, that the stimulus package, legislative and fiscal initiatives have been slow acting in getting where they need to go. Monetary policy, managed by Bernanke, has been top notch, however, no question. Some still question whether the economy is truly stabilized, and I am one of those, but it is an open question.

8:19 PM – “We didn’t come here just to clean up crises but to build a future”…”I am not the first President to take up [health care] but I am determined to be the last”. Obama makes the point that it has been 100 years since Teddy Roosevelt tried to fix health care. He also cites that the Dingell bill was introduced long ago and, regularly reintroduced, still goes nowhere.

8:21 PM – Obama points out that most of those in insurance risk are employed…not stereotypical welfare cases. This is objectively true. He also cites that we are the only late-stage industrialized country that does not have universal coverage. This is also true. He points out the risk of losing care as well as not getting it in the first place. He gives a few examples of how pre-existing conditions and co-morbidities have caused people problems with keeping or maintaining insurance.

8:24 PM – He well cites the $1,000 a year people pay in an “invisible tax” to cover emergency room expenses. He also points out that Medicare and Medicaid are going broke. Both good points. But what are your solutions Mr. President? I am eager to hear. He does also cite that the Medicare and Medicaid problems are the biggest problems. This is true too. Now he is transitioning to solution proposals.

8:26 PM – Obama doesn’t bind to either single-payer or employee-based system removal. He punts and says we “shouldn’t rebuild the system from scratch”. I am reading this a euphemism against single-payer and socialized care. Boo.

8:28 PM – Obama says it’s time to act and that people on both sides have been left confused…but he has to address that people are confused for a reason…they are lacking details on what is going on. Hopefully he will go further into specifics…lacking specifics…

8:29 PM – Details – he says if you already have coverage, Medicare, Medicaid, VA, nothing will change for you. I am REALLY skeptical about the long-term sustainability of such a claim… He says no care elimination for pre-existing conditions but all of this can’t possibly happen without much higher taxes or cost-controls. We will see where he goes with this… He also says he will make it illegal for insurance companies to drop coverage or water it down or caps on benefits or really high out-of-pocket expenses…Again…show me the money…Not sure how you will pay for this without fundamental system adjustment

8:32 PM – Details – he says if you don’t have coverage… insurance exchange…sounds like the Clinton cooperative of 1994, but in a private format. Customers will compete for benefits, but again, they will just guarantee SOME plan…the devil is in the details…you can’t possibly offer every person a ridiculously quality plan with no caps without more money or eliminating private insurance, drug company or device margins…

8:33 PM – Insurance exchange won’t happen for 4 years. Until then, there will be low-cost coverage. However, this could facilitate hospital closures…it will become pseudo-bad underfunded medicaid. Many doctors will also potentially refuse to receive these claims. Very dangerous…

8:35 PM – He would require every individual to carry basic health insurance. This I think is a fantastic idea. Businesses will also be required to pay or play…I agree with this too. He says 95% of small businesses will be exempt…I have heard similar numbers in studies…objectively true.

8:37 PM – He will address key controversies…such as…panel of bureaucrats will be set up to kill senior citizens. I get his point but you will need $/QALY cost management of late-stage of chronic diseases. In a sense, although less coarse, such things could be true.

8:39 PM - He says the plan will not allow illegal immigrants coverage…someone yells out this is a lie. Kind of true kind of not… complicated explanation… He says it will not fund abortions…this is true too in the sense he means it.

8:40 PM – He says this will not be a complete government takeover. He says competition is good for the market and there should be cross-state private insurance competition. This is certainly better than the current system but complete private insurance elimination, we know, would be even better.

8:41 PM – Obama admits that Insurance companies are encouraged to disenfranchise others but he says he doesn’t want to put insurance companies out of business, just to hold them accountable. I disagree with him on this… Just getting rid of pre-existing things won’t do much.

8:42 PM – He does at least say a not-for-profit insurance option should be made available in the insurance exchange as an option for those without insurance…the problem is it would not be utilized…it would be low-cost and providers would exclude those insurers. He says that the non-profit option would have to run on its own.

8:42 PM – He acknowledges that non-profit could be cheaper because of lower overhead and waste, but then why not just eliminate for-profit. So confused!

8:43 PM – He emphasizes that the public option in insurance should not be emphasized…it is just one factor. I think single-payer is much bigger than he thinks…as is nationalization.

8:45 PM – He says more than anything he is focused on providing those without insurance a choice or other options. He makes the point of bureaucrats not getting in the way of care delivery. Ok, fine.

8:46 PM – He says he will not sign a plan that adds a dollar to the deficit. Fine, but with what money? We need major tax increases or expense cuts… He says there will be a stop-gap to cut spending if savings don’t materialize…but this is easier said than done…consider Medicaid…cutting back like that is impossible and crippling.

8:47 PM – He jabs Bush for all his wasteful spending.

8:48 PM – He says we can pay for future plans with just savings from current systems. This is not entirely true. At the end of the day, any plan would need more taxes or single-payer conversion.

8:49 PM – He says that the Medicare trust fund will not pay for health reform. He says he will get savings from waste and fraud…this will not happen without tort and single-payer reform…also more taxes are needed. He says there will be a doctor panel to find and eliminate waste.
 
8:50 PM – He says he wants to do more to cover senior prescription drugs…but again…out of what pool of funds? STILL NO DISCUSSION OF TORT REFORM…

8:51 PM – He makes a big push for large care centers like Geisinger… those systems can work in some areas…but like Mayo…are almost impossible to expand on scale nationally.

8:52 PM – He finally mentions the idea of tort reform, saying Republicans have mentioned it before. He says he is open to tort reform. However, just looking at safety of patients is soft. The commitment to this did not sound very convincing…it’s something though.

8:54 PM – He again says spending will come out of waste…but I want to hear where more money will come from… No mentions of tax increase…

8:55 PM – He says he will call out people distorting the plan and won’t let special interests and others kill a plan.

8:57 PM – He mentions Kennedy and his commitment to make sure health care passed this year. Kennedy characterized health reform as a moral issue and social justice and the character of our country. I agree with this.

9:00 PM – He puts down socialism and says it is not what we want to become.

The Case For Single Payer, Universal Health Care For The United States

Outline of Talk Given To The Association of State Green Parties, Moodus, Connecticut on June 4, 1999

By John R. Battista, M.D. and Justine McCabe, Ph.D.

Why doesn’t the United States have universal health care as a right of citizenship? The United States is the only industrialized nation that does not guarantee access to health care as a right of citizenship. 28 industrialized nations have single payer universal health care systems, while 1 (Germany) has a multipayer universal health care system like President Clinton proposed for the United States.

Myth One: The United States has the best health care system in the world.

Fact One: The United States ranks 23rd in infant mortality, down from 12th in 1960 and 21st in 1990

Fact Two: The United States ranks 20th in life expectancy for women down from 1st in 1945 and 13th in 1960

Fact Three: The United States ranks 21st in life expectancy for men down from 1st in 1945 and 17th in 1960.

Fact Four: The United States ranks between 50th and 100th in immunizations depending on the immunization. Overall US is 67th, right behind Botswana

Fact Five: Outcome studies on a variety of diseases, such as coronary artery disease, and renal failure show the United States to rank below Canada and a wide variety of industrialized nations.

Conclusion: The United States ranks poorly relative to other industrialized nations in health care despite having the best trained health care providers and the best medical infrastructure of any industrialized nation

 
Myth Two: Universal Health Care Would Be Too Expensive

Fact One: The United States spends at least 40% more per capita on health care than any other industrialized country with universal health care

Fact Two: Federal studies by the Congressional Budget Office and the General Accounting office show that single payer universal health care would save 100 to 200 Billion dollars per year despite covering all the uninsured and increasing health care benefits.

Fact Three: State studies by Massachusetts and Connecticut have shown that single payer universal health care would save 1 to 2 Billion dollars per year from the total medical expenses in those states despite covering all the uninsured and increasing health care benefits

Fact Four: The costs of health care in Canada as a % of GNP, which were identical to the United States when Canada changed to a single payer, universal health care system in 1971, have increased at a rate much lower than the United States, despite the US economy being much stronger than Canada’s.

Conclusion: Single payer universal health care costs would be lower than the current US system due to lower administrative costs. The United States spends 50 to 100% more on administration than single payer systems. By lowering these administrative costs the United States would have the ability to provide universal health care, without managed care, increase benefits and still save money

 
Myth Three: Universal Health Care Would Deprive Citizens of Needed Services

Fact One: Studies reveal that citizens in universal health care systems have more doctor visits and more hospital days than in the US

Fact Two: Around 30% of Americans have problem accessing health care due to payment problems or access to care, far more than any other industrialized country. About 17% of our population is without health insurance. About 75% of ill uninsured people have trouble accessing/paying for health care.

Fact Three: Comparisons of Difficulties Accessing Care Are Shown To Be Greater In The US Than Canada (see graph)

Fact Four: Access to health care is directly related to income and race in the United States. As a result the poor and minorities have poorer health than the wealthy and the whites.

Fact Five: There would be no lines under a universal health care system in the United States because we have about a 30% oversupply of medical equipment and surgeons, whereas demand would increase about 15%

Conclusion: The US denies access to health care based on the ability to pay. Under a universal health care system all would access care. There would be no lines as in other industrialized countries due to the oversupply in our providers and infrastructure, and the willingness/ability of the United States to spend more on health care than other industrialized nations.

 
Myth Four: Universal Health Care Would Result In Government Control And Intrusion Into Health Care Resulting In Loss Of Freedom Of Choice

Fact One: There would be free choice of health care providers under a single payer universal health care system, unlike our current managed care system in which people are forced to see providers on the insurer’s panel to obtain medical benefits

Fact Two: There would be no management of care under a single payer, universal health care system unlike the current managed care system which mandates insurer preapproval for services thus undercutting patient confidentiality and taking health care decisions away from the health care provider and consumer

Fact Three: Although health care providers fees would be set as they are currently in 90% of cases, providers would have a means of negotiating fees unlike the current managed care system in which they are set in corporate board rooms with profits, not patient care, in mind

Fact Four: Taxes, fees and benefits would be decided by the insurer which would be under the control of a diverse board representing consumers, providers, business and government. It would not be a government controlled system, although the government would have to approve the taxes. The system would be run by a public trust, not the government.

Conclusion: Single payer, universal health care administered by a state public health system would be much more democratic and much less intrusive than our current system. Consumers and providers would have a voice in determining benefits, rates and taxes. Problems with free choice, confidentiality and medical decision making would be resolved
 

Myth Five: Universal Health Care Is Socialized Medicine And Would Be Unacceptable To The Public

Fact One: Single payer universal health care is not socialized medicine. It is health care payment system, not a health care delivery system. Health care providers would be in fee for service practice, and would not be employees of the government, which would be socialized medicine. Single payer health care is not socialized medicine, any more than the public funding of education is socialized education, or the public funding of the defense industry is socialized defense.

Fact Two: Repeated national and state polls have shown that between 60 and 75% of Americans would like a universal health care system (see The Harris Poll #78, October 20, 2005)

Conclusion: Single payer, universal health care is not socialized medicine and would be preferred by the majority of the citizens of this country


Myth Six: The Problems With The US Health Care System Are Being Solved and Are Best Solved By Private Corporate Managed Care Medicine because they are the most efficient

Fact One: Private for profit corporation are the lease efficient deliverer of health care. They spend between 20 and 30% of premiums on administration and profits. The public sector is the most efficient. Medicare spends 3% on administration.

Fact Two: The same procedure in the same hospital the year after conversion from not-for profit to for-profit costs in between 20 to 35% more

Fact Three: Health care costs in the United States grew more in the United States under managed care in 1990 to 1996 than any other industrialized nation with single payer universal health care

Fact Four: The quality of health care in the US has deteriorated under managed care. Access problems have increased. The number of uninsured has dramatically increased (increase of 10 million to 43.4 million from 1989 to 1996, increase of 2.4% from 1989 to 1996- 16% in 1996 and increasing each year).

Fact Five: The level of satisfaction with the US health care system is the lowest of any industrialized nation.

Fact Six: 80% of citizens and 71% of doctors believe that managed care has caused quality of care to be compromised

Conclusion: For profit, managed care can not solve the US health care problems because health care is not a commodity that people shop for, and quality of care must always be compromised when the motivating factor for corporations is to save money through denial of care and decreasing provider costs. In addition managed care has introduced problems of patient confidentiality and disrupted the continuity of care through having limited provider networks.


Overall Answer to the questions Why doesn’t the US have single payer universal health care when single payer universal health care is the most efficient, most democratic and most equitable means to deliver health care? Why does the United States remain wedded to an inefficient, autocratic and immoral system that makes health care accessible to the wealthy and not the poor when a vast majority of citizens want it to be a right of citizenship?

Conclusion: Corporations are able to buy politicians through our campaign finance system and control the media to convince people that corporate health care is democratic, represents freedom, and is the most efficient system for delivering health care

Two gentlemen, Brad and David, raised the following questions the other day on Facebook:

Brad: Amir, Insurance is not perfect, but it sure beats the government sticking their nose in my business! You know all the arguments. I don't understand how anyone for the Constitution can be for this. Especially when Obama has self admitted communists for Czars which wrote the healthcare bill. (And that is true, check the facts) Congress did not write this bill or they would have read it! If a communist wrote this how could it be good for America? We want to be free and they want to control us. It's messed up! I understand the arguments for healthcare for everyone but not with government control.... Looking forward to your response.

David: I agree w/ the above comment (Brad). Plus, I've rarely had good experiences dealing w/ the government. They seem to lose everything over budget everything and are extremely wasteful. Look at all their projects... every year they ask for more and do very little w/ it. Just look at the school issue in CA and don't blame it on prop. 13. Socialized health care in Europe is about bust according to my cousin. The wait for operations are horrendous... she tells me they wait anywhere from 12 - 18 months. Part of the waste is that there doesn't seem to be a clear definition as to what health care is, and who can get it. She claims that everyone entering their country is privy to their health care also anyone who has a little depression goes in for a belly tuck or a tatoo removal. How would the government legislate all of this waste out of the system? Don't get me wrong either, I'm all for getting everyone health care, I just don't think the government is the way to go.

Amir's Response:

1 - A general point - Vague arguments ("don't you think the government in our faces sucks"), emotional arguments ("I hate all these high taxes") or anecdotal arguments ("a friend said"..."my cousin said"..."Uncle Joe said"... "In my experience"...) hold absolutely zero value with me. I think a shit in a bucket is of more value to me than such arguments.

2 - Good arguments are those grounded with facts and statistically meaningful data from any of the following sources: independent and respected academic journals, academic medical center studies, audited government reports and budgetary findings and audited financial reports. Unless you can back up any argument you make with journal-published research or statistics that are not from a partisan source, you have no argument with me and I will not acknowledge the start of a debate.

3 - Socialized countries have less waste than we do as a percentage of GDP. This has been proven in several comparative U.S. Budget Office and Journal of Public Health publications.

4 - Socialized countries have rationing of services, but it has been econometrically proven to not worsen health outcomes in the Journal of Public Health. We are 37th in health care and all the countries above us are socialized. The ones that are the most socialized like France and Scandinavia are in the top 10. People may complain, but on the aggregate, based on statistics, their complaints are simply not backed up by facts. In any country, anecdotally, if there are 100,000,000 people, I could easily find you even 50,000 people who complain and that could be statistically irrelevant to the larger population and health performance in that country.

5 - Schools are failing in California, first and foremost, because they are underfunded. Education in America has waste, but it is significantly underfunded.

6 - Education in Europe is completely socialized, in many cases even through college, and they get much better outcomes than we do at lower cost.

7 - If you are talking about waste, private insurance is the biggest example of health waste I can think of. The companies have a much higher administrative cost load than the government, because there are so many of them duplicating the same function with individual executives and management who all draw separate salaries. Also, they have 5-7% net income. Net income does not exist for public incomes. They put all the money in services. Thus, 5-7% of all health spending + ALR spending (which has been estimated in JAPH at 3-5%) means that JUST from direct insurance, let alone public insurance's effect on drug and device spending, up to 8-12% of total aggregate US insurance spending is waste

9 - Numerous WHO and UN studies show that the percentage of people in the socialized countries who are happy with their health care versus America is 20-30% higher (comparative population), depending on which year you take the data since 1997. So...for all the supposed "complaining" and dissolution of citizen happiness with socialized care in Europe, our people hate their system much more. Every system is imperfect. It is about finding the system that is least imperfect.

10 - Socialized care is actually growing at a lower percentage rate than health expenditures in America. It is "busting", to your incorrect claim, at a lower and slower rate than in our country. Remember, policy is about the best relative solution and they are all doing better than us.

Anonymous MD

Amir,

Tomorrow i'm going to a town hall meeting hosted by 9-12ers who have called it a Tea Party Town Hall meeting with Congressman John Carter attending. The liberterian or extremely conservative thoughts are very intriguing to me. What do yo think would happen with no health insurance (ie no government of private system), a system wherein all medications were over the counter (ie anyone could practice medicine in today's internet society ), no FDA (private consumer agencies and industry led studies would still exist) with credentialed physician's in a free market with no restrictions on numbers graduated? I don't necessarily endorse these views but this is the extreme libertarian model? Are these models ever discussed in your studies or are they in the "twilight zone" in terms of Wharton or Harvard academia?

Thank You

My Response:

Thank you for your question. These are definitely not "twilight zone" assertions. I am regularly amused by libertarian ideas and strongly disagree with them.  I will deal with all your points one-by-bone.

With no health insurance, we would have what we had in the 60s when there was fee-for-service and indemnity plans like Blue Cross and Blue Shield, but no Medicare, Medicaid or SCHIP. Basically, those who are old without means, 300% or more below the poverty line or poor children would have no care.

No medications over the counter would be a disaster because, as it is, patient compliance with medication and devices is extremely low. However, I wouldn't mind SOME deregulation of medical license granting for doctors because we are due for a huge physician shortage in America.

These laissez-faire ideas of how to organize a society are fun to discuss as a pedagogical exercise, but libertarians are on another planet in terms of holding a realistic view of how we could use policy to organize a society. Libertarians policies would basically place 20% of the population, at least, in a state where they would have no social services of public safety net. If one only believes about taking care of one's self, maybe that is not a concern. This is not how I was raised, however.