Health Reform: What Liberals Want

Kevin Drum seconds Alex Massie that a British-style nationalized health system is not a politically feasible option in the United States.  Indeed, even Democrats don’t want that:

[W]ith the exception of a few outliers, the liberal community really, truly doesn’t want a fully government owned and operated healthcare system like the NHS.  We want a government-funded healthcare system like Medicare or most of the world outside of Britain.  And unless I’m mistaken, this isn’t a ruse in any way.  That’s really what most of us want: basic care funded by taxes, with additional care available to anyone who wants to pay for more.  France and Holland, not Britain or Canada.

I do think that’s what most want.  HillaryCare was a single-payer system.  That’s what ObamaCare would be, too, if it were politically viable.  Since it’s not, he’s willing to settle for a “public option,” essentially a government-run insurance program that would “compete” against privately run insurance companies.  And he might have to settle for less than that — a system that expands Medicaid and/or Medicare and patches some holes in the existing system.

For a variety of reasons, the public simply doesn’t seem to understand these distinctions.  First, Canada and the UK are the logical comparison points in that they’re fellow Anglosphere countries and the ones with which we’re most familiar.  Second, those who oppose the reform for various reasons have a strong incentive to elide the differences and capitalize on fears people reasonably have about an NHS-style system.  (To say nothing of the silly fears of the “They’d let Stephen Hawking die!” variety.)

Many of the leaders of the pro-reform side are rather dishonest in their presentation, however. They insist that what’s written in the bill should be the limit of legitimate debate when, as Kevin admits and Obama once did, single-payer is the ultimate goal.   The current “as much as we can get” measure is not only a step in that direction but one that will make it inevitable over time as it kills off the existing system of employer-financed insurance.   So, while it’s dishonest to argue against the proposed legislation as if it were NHS-style “socialized medicine,” it’s perfectly legitimate to treat it as HillaryCare Returns.

An honest debate on this is vital. The current system is on a collision course with collapse because the rate of growth in health costs is unsustainable, especially with so many about to hit the retirement rolls.  And there really are significant problems with our hodgepodge public-private system where those of us not on the government dole are reliant on the vagaries of care by whatever provider our current employer offers.

I’m naturally more skeptical than Kevin of government-run anything.  But I’m prepared to be convinced that a French- or Dutch-style system would be an improvement over the status quo.  But pretending that we can simultaneously cover everyone, cut costs, not ration, and retain the current private system for those who want it isn’t a very effective method of persuasion.

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James Joyner
About James Joyner
James Joyner is Professor and Department Head of Security Studies at Marine Corps University's Command and Staff College and a nonresident senior fellow at the Scowcroft Center for Strategy and Security at the Atlantic Council. He's a former Army officer and Desert Storm vet. Views expressed here are his own. Follow James on Twitter @DrJJoyner.

Comments

  1. Tlaloc says:

    The sad thing is that the NHS even with its many issues would still be a huge improvement on what we currently have. And the Canadian system would be much better still. But pointing that out usually just inflames the arguments of the asses determined to derail reform. So the argument goes something like this:

    Progressive: We should have a system like X.

    Demagogue: You want Y! Y is terrible. We hate Y!

    Progressive: Actually X is really nothing like Y at all, but that said Y is vastly superior to our current system Z.

    Demagogue: I knew it! You like Y, you want us to be Y! And by the way here are all the horrible things that happen in Y…

    Progressive: None of those things actually happen in system Y.

    Demagogue: Why would you defend the system so much if you didn’t secretly want to force it on us! No Y! No Y!

    and so on…

    It’s not coincidentally very similar to the various lying done by certain other big industry groups to avoid public regulation (cigarettes, banks, energy companies). Make up lies faster than they can be debunked and shout them as loud as possible so the gullible start to believe.

  2. Steve Plunk says:

    The first step in creating an honest discussion is to stop mixing health insurance talk with health care talk. Two different issues.

    We also need to quit acting like better insurance benefits means cost control. We are not actively doing anything about costs, only coverage.

  3. Steve Hynd says:

    The bottom line is that the UK system provides consistently better healthcare at a lower cost:

    Defenders of Britain’s system point out that the UK spends less per head on healthcare but has a higher life expectancy than the US. The World Health Organisation ranks Britain’s healthcare as 18th in the world, while the US is in 37th place. The British Medical Association said a majority of Britain’s doctors have consistently supported public provision of healthcare. A spokeswoman said the association’s 140,000 members were sceptical about the US approach to medicine: “Doctors and the public here are appalled that there are so many people in the US who don’t have proper access to healthcare. It’s something we would find very, very shocking.”

    Imagine a day when you don’t have to wonder “can I afford it, what’s the coverage, what’s the co-payment?” and just think “I’m ill, I should see a doctor.” The difference really is shocking.

    But then again, I’m not a US Democrat, I’m an ex-pat Scottish socialist. Not that that changes the facts any.

    Regards, Steve

  4. Dave Schuler says:

    I agree with that, Steve. I think we need both healthcare insurance reform and healthcare reform. Unfortunately, the administration has been proposing insurance reform and using healthcare reform as a justification for its preferred approach.

    Fair or unfair that leads people to fear that their intent is to achieve healthcare cost controls via a fiat system. They can’t head that off by denying it. The only ways are to abandon the discussion of cost control (as Mickey Kaus has advocated) or propose a credible system for serious cost control, something that has been politically poisonous.

    Every other industrialized nation has lower administrative costs than we do and it’s not unreasonable to believe that, even if they’re stacking the deck, we could achieve savings in administrative costs. I’ve favored doing that for 30 years either by going to a French-style system or other measures but only as a component of broader reforms in the system. The reason is simple: we can only achieve marginal savings via reducing administrative costs.

    John Mackey, CEO of Whole Foods, proposed some commonsense healthcare reforms in an op-ed in the WSJ this morning. I’ve commented on his and added my own.

  5. JKB says:

    Problem is the President doesn’t have a plan. They were all rushed to pass something before the end of July, yet here we are in mid-August and they can’t lay out their plan. Just last night on The Daily Show, Austan Goolsbee, speaking for the Administration, stated the centerpiece of the President’s plan is we have to find a way to limit the growth of costs. It is critical we rush to pass something and that is the plan in all its defined glory? He also took up the evil insurance company mantra stating the public option was necessary to keep the single insurance company we now have in check.

    Let’s have a reasoned discourse on the issue but how about at least laying out the outline of the plan. Step 1 – limit growth of healthcare costs, cover everybody. Step – 2 …. Step – 3 Save money, be hero.

    Shouldn’t we at least be talking about step 2 by now? Yet here we are several weeks after legislation was hoped to be passed and the Dems can’t even discuss step 2 in terms that are logically aligned.

    They offer no rational counter to the logical conclusion that if we must limit costs, we must either ration or triage healthcare, which will naturally adversely impact granny who is in the most need and likely to exceed her ration or be sorted into a lower priority in a triage since she has a lower future productivity potential. Or as Jon Stewart quips, do we depend on leprechauns.

    Until we flesh out Step 2 with more than hope for change, this whole healthcare debate is premature.

  6. Dave Schuler says:

    Steve Hynd:

    Whatever its virtues our base costs are simply too high to go to a British-style system. To make it financially feasible we’d need to reduce the salaries of non-GP physicians sharply (to remind people: under the British system GP’s are independent operators, reimbursed by the government, most specialists are government employees).

  7. kth says:

    So, while it’s dishonest to argue against the proposed legislation as if it were NHS-style “socialized medicine,” it’s perfectly legitimate to treat it as HillaryCare Returns.

    I’d find this more persuasive if some kind of path dependence could be reasonably be inferred from the plan Obama favors to single-payer.

    And that path dependence would have to be more direct or limiting or over-determined than merely observing that people might like the current plan, so it will be politically easy to expand it. After all, the latter reasoning would apply to any expansion of a government role in health care, including regulation without a public option.

  8. floyd says:

    THEORETICALLY, when an insurance company commits fraud while providing heath care coverage, the injured party can turn to government to enforce their contract.
    Who does the injured party turn to when the perpetrator is that very government?

  9. Steve Verdon says:

    The sad thing is that the NHS even with its many issues would still be a huge improvement on what we currently have. And the Canadian system would be much better still.

    They are both fiscal nightmares…just not as bad as ours. Is that better, I guess, but shooting yourself in the head with a .38 vs. a .44 isn’t really my ideal of improvement, but YMMV.

    And we can’t have NHS. NHS has mandatory waiting times of up to 16 weeks. Obama just said no lines….oh wait, I guess if you are sitting at home waiting while in pain or discomfort or limited mobility (all costs that don’t have a dollar sign attached to them…geez are they really better now) you aren’t waiting in line. Great lets go with NHS!!!

    Steve Hynd:

    Defenders of Britain’s system point out that the UK spends less per head on healthcare but has a higher life expectancy than the US.

    First, people who are waiting for treatment are a cost, just not one that is represented in monetary terms. Second, life expectancy has more to do than with just the health care system. In other words, your argument is not valid.

    These things being said, health care reform is desperately needed. As is health insurance reform. The U.S. system is seriously broken.

  10. sam says:

    Can we have a discussion of “rationing”? McMegan talked about this the other day, Rationing By Any Other Name, but I think John Holbo at Crooked Timber pretty much showed her to be confused, Rationing By Any Other Name?, however, as we say, vis-a-vis the arguments, YMMV. But what do you folks understand by the term ‘rationing healthcare’?

  11. An Interested Party says:

    The first step in creating an honest discussion is to stop mixing health insurance talk with health care talk. Two different issues.

    I wonder if that is a distinction most people make…perhaps that is part of the problem…

  12. Stan says:

    “NHS has mandatory waiting times of up to 16 weeks.”

    Steve Verson, mandatory waiting times for what? And what is the source for this truly astounding fact?

  13. Crust says:

    a “public option,” essentially a government-run insurance program that would “compete” against privately run insurance companies

    James can you elaborate on why you put “compete” in scare quotes?

    I imagine you mean one of two things, and I’m curious which. Do you mean you doubt it would a true level playing field and the public option would be subsidized in some way compared to private plans? (I say “compared to” because of course private plans are subsidized, principally through the tax deductibility of premiums.) Or do you mean the public option would over time come to dominate even without a differential in subsidy?

    In other words are you saying it’s not a fair fight or are you saying a public option would win a fair fight to the exclusion of private plans?

  14. Crust says:

    For extra credit, how would you characterize Medicare vs. Medicare Advantage? That’s a current example of a public option vs. private plans at some level. Medicare Advantage has a modest but non-zero market share. As I understand it, Medicare Advantage was in the past subsidized compared to Medicare, so that may change as the extra subsidy is eliminated.

  15. James Joyner says:

    In other words are you saying it’s not a fair fight or are you saying a public option would win a fair fight to the exclusion of private plans?

    Both, really. First, the government plan would have a huge advantage in dictating pricing and forcing acceptance by providers. Second, a goodly number of employers would naturally stop insuring people in a government “option” system, which would cut off the major customer for private companies.

  16. Crust says:

    Steve Vernon:

    They are both fiscal nightmares…just not as bad as ours. Is that better, I guess, but shooting yourself in the head with a .38 vs. a .44 isn’t really my ideal of improvement, but YMMV.

    The NHS costs around 40% per capita of what the US system does. That’s right, we’re spending 2.5X as much per person than the Brits. Independent of what you think of the quality (a big debate obviously), that’s a huge fiscal difference.

  17. TangoMan says:

    Steve Verson, mandatory waiting times for what? And what is the source for this truly astounding fact?

    News from Canada:

    A long wait for hip replacement surgery was what prompted the Quebec case that wound up before the Supreme Court.

    George Zeliotis argued his yearlong wait for surgery was unreasonable, endangered his life, and infringed on the charter’s guarantee of the right to life, liberty and security. The second plaintiff, Dr. Jacques Chaoulli, wanted the court to overturn a Quebec provision preventing doctors who don’t operate within the medicare plan from charging for services in public hospitals.

    Once upon a time, there were few complaints about lengthy waits for treatment. It was a time when the federal government provided about a third of the money the provinces spent on health care.

    But as government belts tightened to deal with record budget deficits in the early 1990s, complaints about access to health care increased. The federal government drastically cut the amount of money it transferred to the provinces to cover health-care costs.

    Most Canadian provinces have, due to angry public demand, a centralized database detailing wait times. Here is one from Montreal, one of Canada’s largest cities. Patient wait times are measured in months. Depending on the hospital, within six months of a patient’s final specialist consultation anywhere from 62% to 100% have had their surgery. Keep in mind that one of the gimmicks that are used to manipulate the statistics is to book the patient for another specialist consultation thus resetting the timer on the waitlist. I’d hate to see the statistics absent the statistical gaming effect.

  18. Steve Verdon says:

    The NHS costs around 40% per capita of what the US system does. That’s right, we’re spending 2.5X as much per person than the Brits. Independent of what you think of the quality (a big debate obviously), that’s a huge fiscal difference.

    Okay, one more time.

    If you are waiting in pain for treatment for weeks even months that is a cost.

    It is a cost that does not have a dollar value. Thus it is easy to ignore.

    Waiting times for the UK, search the archives here and you’ll find this. Google gives you this, this, this, this, this from the BBC. This from the Times Online. Now it isn’t all bad, in some stories wait times are dropping, but the point is that there have been periods in the UK where wait times have been substantial, and while they don’t show up on an accounting ledger are still a social cost.

  19. sam says:

    Wait time in Canada hasn’t changed much from the 2006 story you cite, see Medical wait times improving only slightly: Report

    I wonder, though, if the wait times aren’t function of scarcity of resources (e.g., doctors)? And that can happen here, too.

    I have a really, really funky ankle (if you saw an X-ray of it, your hair would stand on end). I get around OK. I wear orthotics, and when I play golf, I wear a space-age looking brace and fortify myself with Naproxen, walk nine holes, and then ride nine. So my condition is not life-threatening, but there is not a little discomfort involved. Last time I saw my foot doctor (three weeks ago), he told me that two orthopaedists in town were now doing ankle replacement surgery. They do the surgery as a team. Now, I live in a medium-sized city, and although we didn’t talk about wait times, I’d bet I’d have wait 3-4, maybe more, months for the surgery if I elected it. And this just because there are only two guys in town doing it.

  20. Crust says:

    TangoMan:

    Depending on the hospital, within six months of a patient’s final specialist consultation anywhere from 62% to 100% have had their surgery.

    Huh? Following your link (here’s the summary page), the worst category of surgeries in any region of Quebec (so including Montreal) are knee surgeries in Estrie of which only 23% had to wait over 6 months (in Quebec as a whole 6% had to wait that long). The conventional wisdom that wait times in Quebec and the rest of Canada are typically worse than in the United States is probably correct. But exaggerating doesn’t help your case.

  21. TangoMan says:

    I wonder, though, if the wait times aren’t function of scarcity of resources (e.g., doctors)? And that can happen here, too.

    The US has 2.4 physicians per 1,000 population compared to Canada’s 2.2 physicians per 1,000 population. Yes, Canada has fewer physicians but the question is why? Perhaps this might shed some light on the issue:

    Under the imposed contract, Quebec’s 8000 medical specialists receive a 2% wage increase in each of 4 years, leaving them on the bottom rung of the Canadian specialists’ salary scale. The average gross annual income for a specialist in Quebec is $233 000 — $100 000 less than the national average.

    I couldn’t find a reliable source for income comparisons between US and Canadian physicians, but I did find plenty of stories of Canadian physicians moving to the US to practice in order to benefit from the higher rates of remuneration in the US. With Canada having one funding source for physician salaries, the government, this gives the government the ability to use its market power to depress wages.

    The ability to depress physician income is certainly an effective tool in cost containment efforts but once we move from a static model to a dynamic model we have to account for the effects that such wage depression will have on the physician training pipeline, in that some aspiring physicians will opt for other careers that a.) pay better and b.) allow for a competitive labor marketplace.

    Huh? Following your link

    My link went directly to the page that categorized HIP ARTHROPLASTY in Region 06 Montréal. The fourth column in summarizes the percentage of operations performed within 6 months at the various Montreal hospitals. There is no exaggeration.

  22. Dave Schuler says:

    Here’s a paper that may be helpful. It’s a comparison of policies on non-emergency, non-urgent surgeries in 12 OECD countries.

  23. Crust says:

    TangoMan:

    My link went directly to the page that categorized HIP ARTHROPLASTY in Region 06 Montréal. The fourth column in summarizes the percentage of operations performed within 6 months at the various Montreal hospitals.

    Either you didn’t post the link you meant to. Or your French is really bad. Or something. In any event, the site you linked to on “Montreal” shows 3% of patients waiting 6 months or more for hip surgery in Montreal, not 38% as you’re apparently claiming.

  24. TangoMan says:

    I found this report very interesting:

    The specialists’ federation says the monetary package is disappointing, but it’s what the federation calls the “extraordinary and punishing” nature of the decree that has pushed it to challenge the law’s constitutionality.

    “It is an abuse of power and a breach of doctors’ rights to freedom of association and freedom of expression,” says Dr. Yves Dugré, the federation’s president.

    Bill 37 penalizes Quebec specialists for failing to accept a $593-million global offer in early June. The imposed contract cut $125 million from that offer and docked a further $50 million from the deal in fines and penalties. There is also a threat of further penalties should specialists balk or do anything to protest against their working conditions or wages. These penalties include not renumerating specialists for the time during which they contravened the act, plus a fine of double what they would have been paid, up to 20% of their total pay.

    “We are handcuffed,” says Dugré. The law imposes heavy fines for any kind of “concerted action,” which the federation’s legal expert, Sylvain Bellevance, interprets as anything from modifying work practices to quitting or accepting a position in another province.

    “You’re not allowed to resign,” Bellevance says. “It’s absurd. A doctor and his wife decide to go practise in Ontario — they can’t. There is no limit to this law.” . . .

    “We want to prevent any mass desertion from our hospitals.” Couillard says. “But there’s nothing in the law that prevents people from discussing it.” He called the legal challenge “unfortunate,” suggesting it could stand in the way of productive talks between the government and Quebec doctors.

    Dugré contends Bill 37 has deepened a climate of resentment among Quebec doctors, who are considering pulling up stakes in ever greater numbers.

    A survey conducted by Leger Marketing for the Quebec Medical Association in August shows that 23% of physician respondents are considering leaving the province in the next 5 years. That figure climbed to 29% among medical specialists, and 39% among young doctors (those who have been practising 10 years or less).

    Almost all (94%) of the doctors say Bill 37 is fully or partly responsible for hurting morale and motivating them to look elsewhere for work.

    Even among family doctors — who accepted a final offer from the government in June and thus are exempt from the special law — frustration is growing. In the same survey, 88% expressed dissatisfaction with their salary level. Like Quebec specialists, their wages are the lowest among their peers across Canada.

    Ah, the joys of a single payer system, especially when the monopsonistic buyer can also wield the power of government to enforce their position.

  25. TangoMan says:

    Either you didn’t post the link you meant to.

    I posted the link correctly, but after your comment I tested it and found that it redirects back to the site’s main page.

  26. Steve Hynd says:

    Steve Verdon,

    “NHS has mandatory waiting times of up to 16 weeks.”

    Mandatory? I call bulls**t. Prove it or admit you’re making stuff up. The NHS median inpatient waiting time in June 2009 was 4 weeks, for outpatients it was 2.3 weeks. (Source)

    “First, people who are waiting for treatment are a cost, just not one that is represented in monetary terms.” So are people who can’t even wait because they have no coverage and no money. The NHS avoids that far larger problem. And in the UK if you don’t want to wait you can still go private if you can afford it using one of the many not-for-profit providers.

    “Second, life expectancy has more to do than with just the health care system.” Like diet, environment, poverty level? According to the Right, all these are worse in the UK too, so explain the discrepancy if you can. What is about Britain that gives its inhabitants longer life? Arthur’s Holy Grail? I’d suggest free and easy access to healthcare is the major factor.

    “In other words, your argument is not valid.” Sorry, but that’s illogical. It’s your argument that is out of gas.

    Regards, Steve

  27. TangoMan says:

    TangoMan: Depending on the hospital, within six months of a patient’s final specialist consultation anywhere from 62% to 100% have had their surgery.”

    Crust: not 38% as you’re apparently claiming.

    Channeling the spirit of Governor Palin, quit making stuff up.

  28. Crust says:

    TangoMan:

    Channeling the spirit of Governor Palin, quit making stuff up.

    Einstein, you may notice that 100%-62% = 38%.

    If I were you I wouldn’t invoke Palin on the subject of making things up

  29. TangoMan says:

    What is about Britain that gives its inhabitants longer life?

    1.) Motor vehicle fatalities: UK = 5.6/100,000; US = 14.5/100,000

    2.) Deaths by homocide: UK 1.4/100,000; US = 6.4/100,000.

    3.) Demographics: UK = 90% White, 1.8% Black; US = 74% White, 13.4% Black. Disease interacts with race in a non-uniform fashion.

    4.) Longer life measured from which starting point? Birth or age of retirement?

  30. Brett says:

    I posted it over at Drum’s blog, but I don’t like how he lumps Canada and the UK systems together, as if they’re the same. They’re incredibly different – Canada’s is basically federalized Medicare (the provinces actually operate the plans and use federal funding to pay for them), whereas the British system is a mix of publicly-owned hospitals and contracted GPs.

    As for Quebec, well, as mentioned Quebec has unusually low physician salaries even for Canada.

  31. Crust says:

    Oops, right, I see your “depending on the hospital” bit. Sorry. Still, that’s a pretty silly metric given the overall average is 97% waiting less than 6 months.

    If we’re allowed to cherry pick both the hospital and the operation, I imagine with enough work one could find a hospital somewhere in the US and some operation where everyone had to wait at least 6 months.

  32. TangoMan says:

    Einstein, you may notice that 100%-62% = 38%.

    No kidding there, Federline. What seems to have escaped your keen analytic insight is that there is a huge substantive difference between my stating a range of values and your conclusion that I stated that 38% of patients are waiting 6 months or more for surgery. “In any event, the site you linked to on “Montreal” shows 3% of patients waiting 6 months or more for hip surgery in Montreal, not 38% as you’re apparently claiming.”

    In other words, quit making stuff up.

  33. TangoMan says:

    If we’re allowed to cherry pick both the hospital and the operation, I imagine with enough work one could find a hospital somewhere in the US and some operation where everyone had to wait at least 6 months.

    It’s not a matter of finding a hospital somewhere in the US, this is the largest city in the province. Look, here’s data from another province, Nova Scotia – after waiting 540 days, between 86% – 91% of the patients have received their hip operation. At the 180 days mark only 45% of patients have had their hips replaced.

  34. TangoMan says:

    If I were you I wouldn’t invoke Palin on the subject of making things up…

    Not to derail this thread, but I sure didn’t see any X-wing and Tie fighters in Earth orbit nor did I see different star systems engaging in deadly conflict when Reagan’s Ballistic Missile Defense System was being tagged as “Star Wars.”

  35. Zelsdorf Ragshaft III says:

    Death panels Palin discussed as being nuts by critics. Yet what is “end of life” if not death? Are death counselings not going to have guidelines? Are theses guideline going to be drawn up by a group of people? Could you call a group of people drawn together for such a meeting a panel? Don’t let the professional bullshitter bullshit you.

  36. sam says:

    Zels:

    Here’s the bill. See pages 425-429 for what is involved in the consultation.

  37. TangoMan says:

    Death panels Palin discussed as being nuts by critics.

    Palin is a certified genius compared to Obama. She looks at the process of government simultaneously taking over 1/6th of the economy, unfairly competing against insurers, setting up cost control panels to limit treatment choices, and incentivizing physicians to start making patients aware of the limitations on treatments that they should expect and how to prepare themselves for the end of their lives, and she coins the phrase “Death Panels.”

    Obama counters her argument by telling people that when government inserts itself more fully into the health care sector that they can expect their health care will be delivered with the same efficiency that they encounter with their dealings with the US Postal Service.

    Someone knows how to encapsulate a complex subject into vivid verbal imagery and that someone sure isn’t Obama, rather it’s some Great Communicator up in Alaska.

  38. Steve Verdon says:

    Steve Hynd,

    Mandatory? I call bulls**t.

    Depends on what you are going in for and where. Read the first link, wait times can vary from 10 weeks, to 20 weeks.

    So are people who can’t even wait because they have no coverage and no money.

    Please don’t spew ingorant pablum. In the U.S. nobody is denied treatment. This is just a complete canard. Now, the way we handle people without insurance is probably a contributing factor to why our costs are out of control, but please don’t try to peddle this nonsense that people without coverage get no care.

    Like diet, environment, poverty level? According to the Right, all these are worse in the UK too, so explain the discrepancy if you can.

    I’ve never made these claims. But see TangoMan’s posts on homicide rates, vehicle fatality rates, and racial compostion of the overall population, just to name a few different issues that could contribute to life expectancy aside from the one’s you noted.

  39. dutchmarbel says:

    To make it financially feasible we’d need to reduce the salaries of non-GP physicians sharply

    Here is a recent (dec. 2008) comparison of income in various OECD countries, both for GP’s and for specialist.

    About waitinglists for hospitals: they don’t work like the waitinglist in a shop. How long you have to wait also has to do with how urgent your operation is. For example: the waitinglist in our hospital for eye specialists is 4 weeks, the waitinglist for the eye specialists from the University Hospital 20 km from here is longer. Yet when my spouse had a detached retina he went from our GP to the local hospital to the University Hospital (he needed a special operation) within one afternoon.

  40. Tlaloc says:

    Palin is a certified genius compared to Obama.

    Hrrrm. One of these people has had huge popularity and managed to get elected to the highest office in the country. His popularity has declined but is still rather good (+18.9).

    The other one went from quite popular to unpopular (-7.2), was on the losing presidential ticket, and has quit being governor.

    Palin’s masterplan is subtle indeed.

  41. Tlaloc says:

    In the U.S. nobody is denied treatment.

    So you’re a blatant liar, huh? Alright then, that tells me everything I need to know about your value in this (or any) conversation.

  42. An Interested Party says:

    re: TangoMan | August 12, 2009 | 06:01 pm

    That has to be the lamest attempt I’ve seen to try to excuse Palin’s comments…but I guess we should expect as much from Palin’s number one fanboy on this blog…

    Someone knows how to encapsulate a complex subject into vivid verbal imagery tell bald-faced lies…

    There, fixed that for ya…you’re welcome…

  43. Dave Schuler says:

    Thank you, dutchmarbel. Very useful and it demonstrates my point nicely. To bring costs down to UK levels (which was the point under discussion), we’d need to cut specialists’ salaries roughly in half. Perhaps more, since we have a larger proportion of specialists than the UK does.

  44. dutchmarbel says:

    @Dave Schuler: it is one of the factors, but making it the deciding factor is too simplistic imho.

    Our specialist salaries are quit high too. But we have the GP as a gatekeeper to cut the costs. We also have a lot less administration since we have fixed prices for treatments and it is very clear what will be paid for. I’ve never ever talked to my health insurer in the almost 30 years I have individual health insurance (apart from the standard forms for payment of bills). I doubt that our health providers have many conversations with health insurance companies.

    Culture will have an impact; we bike a lot more than you do, but we smoke more sigarettes too. Annual checkups are not really in our system, outside the basic screening programs – and most Dutch people have a strong dislike for pills. Calvinistic tendencies I guess: you have to suffer whatever ails your body and letting Nature run it’s course is always preferrable.

  45. TangoMan says:

    Someone knows how to tell bald-faced lies…,

    You mean like a group of people who advocate failed and regressive policies marketing themselves as progressives?

    To bring costs down to UK levels (which was the point under discussion), we’d need to cut specialists’ salaries roughly in half. Perhaps more, since we have a larger proportion of specialists than the UK does.

    The statement sounds downright scary to me. Philosopher Kings deciding that they’re going to interfere in free market transactions with the goal of purposely sabotaging the interests of one group and imposing income limits. What could go wrong?

    And yet a substantial percentage of grads from almost every medical school leave the province. McGill’s numbers are the highest, but all Canadian medical schools are “bleeding” graduates to other provinces or countries. Look at Memorial: almost all of its students come from Atlantic Canada, yet a third of those who exited its post-MD training in 2006 are practicing elsewhere.

    See, the problem with Philosopher Kings imposing their wisdom on a population of free agents is that free agents have a habit of acting in their own self-interest. When Wall Street was offering boffo salaries and bonuses, the proportion of MBA grads that went into investment banking shot through the roof. When Wall Street started shedding personnel MBA students started looking elsewhere to plant their career stakes. When Computer Science work started getting off-shored the number of Computer Science majors shrank.

    Why would intelligent students who are starting out in their journey of specialization choose medicine and a challenging sub-specialty when their incomes are going to be administratively capped by leftist Philosopher Kings who know what’s best for everyone? Like in the quotation I referenced, bureaucrats devise plans to further their goals but when they rely on free agents to march to the beat of the bureaucratic drummer, then all hell breaks loose and the plans, despite the mental firepower directed at crafting them, don’t seem to play out as they are supposed to.

  46. anjin-san says:

    Most Canadian provinces have, due to angry public demand

    Yeah? And how many Americans friggin’ die every year because they have zero health care?

  47. Stan says:

    Nobody in the US goes without medical care because they can’t afford it? Then why do we see scenes like this?

    http://tinyurl.com/mnatzn

  48. DL says:

    Hasn’t anyone yet figured out that these evil doctors that Obama says will do anything to people just to make money (cut off our feet or take out kid’s good tonsils) are the very same people that Obama, in his “money-saving” Obamacare, expects us to trust with our most vital end-of-life decisions?

    It’s like telling a Roman era Christian that the hungry lions are just there to help them figure out what’s for lunch!

    A man that would coldly slaughter innocence babies outside the womb wouldn’t be so immoral as to lie — would he?

  49. sam says:

    @Tangoman

    See, the problem with Philosopher Kings imposing their wisdom on a population of free agents is that free agents have a habit of acting in their own self-interest.

    There’s a lot of truth in that, but the examples you offer following don’t have much to do with Philosopher Kings imposing their will, etc. Those were the results of business decisions made by private corporations (run by, you might say, Philosopher Princes). But I take your point. But, really, the brain drain problem is global. One of the very difficult issues facing Third-world countries is that young folks go abroad to get trained, and then never return home, where that training is sorely needed. And here in the US, it’s damned difficult to get medical professionals to practice in rural communities: How you going to get them back on the farm, after they’ve seen Chicago? Professionals, under any kind of regime, leaving for greener pastures is, I’m afraid, the emerging norm.

  50. rodney dill says:

    Hrrrm. One of these people has had huge popularity and managed to get elected to the highest office in the country. His popularity has declined but is still rather good (+18.9).

    The other one went from quite popular to unpopular (-7.2), was on the losing presidential ticket, and has quit being governor.

    …and Mariah Carrey is more popular than Stephen Hawking, …. and therefore more of a ‘genius’ due to the established direct link for popularity to genius.

  51. Tlaloc says:

    …and Mariah Carrey is more popular than Stephen Hawking, …. and therefore more of a ‘genius’ due to the established direct link for popularity to genius.

    I forgot that Carey was a physicist… or Hawking a singer. I rather thought they were in totally different fields making a direct comparison hard, unlike say comparing a politician to another politician.

    Thanks for playing.

  52. Our Paul says:

    Strange, as a nation we suffer acute attack of angst whenever we are unable to wave our index finger in the air and shout “We are number one, we are number one!!!”, yet in this blog I have yet to stumble across the term excellence in medical care. With the stage set, let me say this:

    I join Dave Schuler (August 12, 2009 | 08:37 pm) in thanking dutchmarbel (August 12, 2009 | 08:05 pm) for her link to specialist salaries. My printer is humming away as we speak… In gratitude I offer dutchmarbel Russel Shorto’s fun article titled “Going Dutch” in the NY Times Magazine. It is a fun read, as Mr. Short examines the quirky Dutch social network and health care through the eyes of an expat steeped in the tradition of American exceptionalism. I was fond of this from dutchmarbel:

    About waitinglists for hospitals: they don’t work like the waitinglist in a shop. How long you have to wait also has to do with how urgent your operation is.

    And as most physicians would point out, to use knee or hip replacements as an index of waiting time is fraught with a singular hazard. Commonly the operation is scheduled months in advance to allow a patient to lose weight.

    However, we in the USA (please do not chant) have an added problem which I suspect is not operative in the Netherlands, that of the salary of Medical Insurance, HMO’s, Preferred Provider Organizations, and the multiplicity of medical provider corporations grant their higher administrative echelons.

    Now I know some correspondents to this blog will cry out that this a function of the free market system, yet it is a corrosive element in health care reform. Consider Blue Cross and Blue Shield of Western New York. The CEO of this organization in 2008, as the financial system was unraveling, bumped his salary up to 2.7 million. Recently in a memo he urged all employees to actively resist health care reform. I wonder why?

    I wonder whether Tangoman is a physician, or whether he sits in higher echelons of a financial health provider. He sure is an ace at selectively quoting health information and twisting it to his point of view. Despite his rants, he is unable to focus on two major problems. Significant number of Americans are not receiving excellence in medical care, and we are growing broke in providing medical care.

    And yes, as I have stated before, I am a retired physician.

    R. Paul Miller, MD

  53. anjin-san says:

    Please don’t spew ingorant pablum. In the U.S. nobody is denied treatment.

    Could you elaborate a bit? All have access to ER care. Suppose a visit to the ER by an uninsured person reveals that they have cancer. Will they also have access to an oncologist? Necessary surgery? Chemo and/or radiation? Perscriptions?

  54. rodney dill says:

    I rather thought they were in totally different fields making a direct comparison hard, unlike say comparing a politician to another politician.

    Well if you didn’t WANT comparison of disimiliar things — like genius and popularity, then you shouldn’t have started it.

    point-game-set-match

  55. Steve Verdon says:

    Could you elaborate a bit? All have access to ER care. Suppose a visit to the ER by an uninsured person reveals that they have cancer. Will they also have access to an oncologist? Necessary surgery? Chemo and/or radiation? Perscriptions?

    If it is life saving treatment then they cannot be denied treatment. Its the law.

    Really, you should become more familiar with the basic facts of this debate before wading in and trying to call others on what, in your ignorance, you think is “bullshit”. Same goes for you Tlaloc, if you are an ignorant jackass it is nobody’s fault but your own.

  56. hln says:

    This is quite simply the best, most concise, clearest article I’ve seen on this yet. Anywhere.

    Thanks.

  57. TangoMan says:

    I wonder whether Tangoman is a physician, or whether he sits in higher echelons of a financial health provider. He sure is an ace at selectively quoting health information and twisting it to his point of view. Despite his rants, he is unable to focus on two major problems. Significant number of Americans are not receiving excellence in medical care, and we are growing broke in providing medical care.

    1.) Who I am and what I do are irrelevant; what counts are the arguments that I advance.

    2.) If I’m selectively quoting material or twisting its meaning, then rebut and clarify. Simply asserting that I’m doing this is cheap character assassination, which by the way, I’m very used to.

    3.) No reform yet publicized is designed to insure Excellence in Medical Care, so your complaint that I’m not offering a plan that provides such excellence is a meaningless complaint.

    4.) We’re not actually going broke in providing medical care, rather it’s taking up a larger share of our national income. Medical care is, in terms of economic principles, a superior good. You might as well claim that we are going broke as a nation by consuming better quality food than our ancestors did 100 years ago or that we’re going broke as a nation because we’re spending more on housing that is larger and has more amenities that was the case with our grandparents who managed to raise larger families in smaller homes. Medical care, like food and housing, is a superior good, in that the wealthier we become as a nation the more we are inclined to spend on superior goods.

    The actual problem is not that we’re going broke, it’s that we’re not happy with having to pay the bill. When faced between measures to increase the quality of care, which increases costs, or reducing the quality of care, which decreases costs, we grumble but we invariably choose to bear the costs so that we can enjoy the quality of care.

    The real crisis is the injustice inherent in redistributing wealth in order to fund other people’s appetites for medical care. This being the case, the root problem is one that deals with redistribution, not with the state of medical provision.

  58. anjin-san says:

    How old are you Steve? 12? Because you sound like a kid.

    I asked a question, and you did not answer it. In asking, I am trying to become more informed. What law says “they cannot be denied treatment”? Are we talking just ER situations, or follow up treatment?

    Where did I refer to your comments as “bullshit”? Nowhere. I said “Could you elaborate a bit?” Which is perfectly polite, not even sarcastic Grow up. We don’t need another bithead.

  59. anjin-san says:

    Oh and Steve, about the “Jackass” thing. Are you that bold when you are talking to another guy to his face? I kind of doubt it…

  60. Our Paul says:

    It’s OK TangoMan, in this thread and in your past correspondence you began to define yourself by bolding salient aspects of the links you quote. You do not have to present your credentials in health care, a simple web search of TangoMan and Health Care will bring up this ode to Sarah Palin, with your trademark bolding at Volok Conspiracy. You sure have a “thing” about Sarah, as you do about Obama’s birth certificate.

    I think we would both agree that if you are going to be quoting genetic markers in breast cancer as it relates to black women that the discussion would enhanced by a mutual presentation of credentials. Similarly, if you are going to pass yourself off as a knowledgeable in Canadian Health Care, simply quoting an article will not make you an expert. Some critical thought is necessary.

    But you are indeed an eclectic expert, for unless you have an evil twin, your avatar is scattered through out the blogsphere. This one I particularly liked. But I will let you speak for yourself:

    The real crisis is the injustice inherent in redistributing wealth in order to fund other people’s appetites for medical care. This being the case, the root problem is one that deals with redistribution, not with the state of medical provision.

    My advise is do not go to a Hospital Emergency Room. Folks with aberrant thinking and a poor grasp of reality may get admitted for observation.

  61. TangoMan says:

    You sure have a “thing” about Sarah, as you do about Obama’s birth certificate.

    I’ve invested time to investigate her record at the primary source level. I disagree with the media constructed narrative which is predominately sourced on rumor and on other media sources. Is there anything wrong with my arguing her case with data and analysis?

    As for the birth certificate issue, your characterization is without substance. I’ve stated I don’t really care about his birth certificate, I care about the secrecy involved with all of his other endeavors and records. I want to see his university transcripts so that I can more fully understand the man who is my President.

    I think we would both agree that if you are going to be quoting genetic markers in breast cancer as it relates to black women that the discussion would enhanced by a mutual presentation of credentials.

    This is the internet bub. My telling you what my credentials are means absolutely nothing. All you have to go on is the quality of what I write.

    Similarly, if you are going to pass yourself off as a knowledgeable in Canadian Health Care, simply quoting an article will not make you an expert. Some critical thought is necessary.

    You see, you claim credentials but you sure don’t display any rigor in your writing. I sense an incongruity here. You’ve made an assertion and you haven’t provided any evidence in support of your case. Perhaps we’re just at loggerheads over subjective issues such as you classifying as “critical thought” only points that you can agree with.

    The endgame here is really quite simple – if you don’t agree with what I’ve written, that’s no skin off my nose. Your requests for a credential exchange don’t really add any substance to the points under discussion. Over a few posts I’ve presented my case that confounding factors need to be controlled when looking at international comparative data, that population variance has an influence on medical outcomes, that life expectancy is affected by more than just how the medical system is financed, etc. I’m happy to think that I’ve displayed critical thinking skills in advancing these argument. I’m not upset in the least that you may disagree. Take me to school and show me where I err. However, save your energy by refraining from appeals to your own authority and instead put some energy into critical thinking and persuasive writing.

  62. dutchmarbel says:

    Maybe folks here are interested in John Prescotts reply to the anti-NHS statements in the USA. It’s a 5 minute talk on youtube.

  63. crumja says:

    Time to take up the pen.

    Of all the arguments mentioned here, the most egregious is probably the citation of average waiting time as a determinant of health care quality. Being a part of the health care industry, I can say that many patients simply do not opt for a hip replacement surgery. Another possibility is that many physicians would not recommend a radical surgery such as hip replacement given individual circumstances.

    What I say applies to situation in the US and Canada. I am 12 years removed from the UK and do not have firsthand knowledge of mandatory wait times there.

  64. crumja says:

    A Parthian shot:

    What saddens me most about the health care debate is that a majority of the people involved in the debate are not aware of the actual situation. This applies to forums and Congress. It’s easy to legislate from your own computer citing horror stories from Canada and the NHS without knowing the whole story.

    Let’s wait for the proposed legislation to be finalized before we all poke holes in it.