A very good article on health care economics
August 18, 2009 6:40 AM Subscribe

How American Health Care Killed My Father After the needless death of his father, the author, a business executive, began a personal exploration of a health-care industry that for years has delivered poor service and irregular quality at astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form. And the health-care reform now being contemplated will not fix it. Here’s a radical solution to an agonizing problem. (via mr)

BONUS
-Health Care Spending and PCE
-Consumer Driven Health Care Plans
-4 Points on Health Care
-A Public Option Isn't a Curse, or a Cure [also btw Thaler vs. Posner]
-'A Plan to Swissify America' (P.Krugman)
-Why We Need Health Care Reform (B.Obama)
-Health 2.0 could shock the system (E.Dyson)
-Mont. Clinic Aims to Deliver Top-quality Care for Less
-Cleveland Clinic Chief: Lower Care Costs Must Be Focus in Reform Efforts
-Healthcare lessons
-The world's worst healthcare reforms

posted by kliuless (142 comments total) 42 users marked this as a favorite

Is it a bad thing or a good thing that I've already read these articles? I recommend heartily Thaler's argument with Posner and the general criticism of hand-wringing on the public plan v. the real meat of health care reform, which now looks to be consumer protection and insurance regulation, combined with subsidies and incentives to cover the remaining uninsured.

Here's Krugman:

So where does Obamacare fit into all this? Basically, it’s a plan to Swissify America, using regulation and subsidies to ensure universal coverage.

If we were starting from scratch we probably wouldn’t have chosen this route. True “socialized medicine” would undoubtedly cost less, and a straightforward extension of Medicare-type coverage to all Americans would probably be cheaper than a Swiss-style system. That’s why I and others believe that a true public option competing with private insurers is extremely important: otherwise, rising costs could all too easily undermine the whole effort.

But a Swiss-style system of universal coverage would be a vast improvement on what we have now. And we already know that such systems work.

posted by anotherpanacea at 6:49 AM on August 18, 2009

I really don't see what this hubbub is all about, since most Americans love their health care system the way it is.

"Almost two years ago, my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City."

Well, there's your problem!
posted by Stonewall Jackson at 6:53 AM on August 18, 2009

Also good:

10 Steps to Better Health Care
The Veterans Health Administration: An American Success Story?
Obama took wrong turn on health
posted by anotherpanacea at 6:59 AM on August 18, 2009

This is a really good roundup. Thanks.
posted by lysdexic at 7:02 AM on August 18, 2009

Inventor Dean Kamen Says Healthcare Debate "Backward Looking" from Popular Mechanics (via).
posted by JoeXIII007 at 7:24 AM on August 18, 2009 [2 favorites]

The problems he talks about - doctor arrogance, emphasis on treatment over prevention and caring, generally horrible decoration of hospitals despite the fact that people end up living in them for months or even years - are not related to the private-public debate. They are more general problems in western health care.

The private health care problem is that had his dad been 20 years younger and faced those problems, the family would have been bankrupted to pay for them.
posted by jb at 7:27 AM on August 18, 2009 [14 favorites]

Agree with jb. Hospitals often kill people - they are highly stressful places, rife with deadly bacteria and prone to systemic organizational problems that don't have much to do with funding, more with embedded assumptions and tradition. An emphasis on prevention and pre-hospitalized and non-hospitalized care except for extremities and surgery would ameliorate this problem quite a bit.

I do feel like I've seen most of these articles all over the place. A for-profit system is the problem, at the heart of it. It is not possible to make the same kind of money delivering good, minimal, and preventive care as it is to deliver high-input, highly specialized, highly drug- and hospital-dependent care. If the free market were going to be able to use the profit motive solve the problem of rising costs and consumer suffering, it would have done so already. It's not efficient at that sort of thing. It's efficient at extracting money from other businesses and from individuals and shifting it upward.
posted by Miko at 7:33 AM on August 18, 2009 [10 favorites]

I really don't see what this hubbub is all about, since most Americans love their health care system the way it is.

Healthcare costs are the leading cause of bankruptcy in this country. Only one quarter of those people are uninsured. For the rest, their insurance was capped (which rather defeats the point), or it did not cover their pre-existing condition, or they were brutally rescinded when they got sick. The American system gives them quality healthcare in exchange for bankruptcy.

How often do medical costs lead to bankruptcy in the rest of the developed world? Never. It doesn't happen.

If Americans love their system it is because they haven't gone bankrupt yet. Why is this not a larger part of the debate?
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 7:35 AM on August 18, 2009 [21 favorites]

This says 71% of Americans want healthcare reform, 41% this year
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 7:36 AM on August 18, 2009 [2 favorites]

Ezra Klein on why Wyden-Bennet is the best bill, and why we won't get it, anyway.
posted by anotherpanacea at 7:36 AM on August 18, 2009

Americans filed for bankruptcy at a rate of 6,020 per day in May 2009
Medical problems contributed to nearly two-thirds (62.1 percent) of all bankruptcies in 2007 ... between 2001 and 2007, the proportion of all bankruptcies attributable to medical problems rose by 49.6 percent
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 7:44 AM on August 18, 2009

How often do medical costs lead to bankruptcy in the rest of the developed world? Never. It doesn't happen.

Former nurse is forced to sell her home after forking out £100,000 on treatment abroad because of NHS shortfalls

Nicola Mackintosh, the lawyer involved in the original Coughlan case, says it is further proof many of the people who have been assessed by the NHS and denied free care on the basis of the NHS criteria, have lost their homes unlawfully.

A Kent man with lung cancer is paying £70 a day for tablets which are not available on the NHS.
posted by anotherpanacea at 7:47 AM on August 18, 2009 [2 favorites]

JoeXIII007: "Inventor Dean Kamen Says Healthcare Debate "Backward Looking" from Popular Mechanics (via)."

I had to go read the article in more depth to understand how he was using the term "backward looking," and I gotta say:

I fucking hate it when people say things like "you guys are looking at [x policy debate] all wrong. the RIGHT way to look at it is to give companies like mine a whole fuckton of government money."

you know what, dude? you do some really great things for some very unfortunate people, so go you. because of that, I won't tell you to go fuck yourself.
posted by shmegegge at 7:51 AM on August 18, 2009 [2 favorites]

That first link is a bit misleading. She spent 100 000 pounds getting a pacemaker and treatment done in Monaco and Germany to avoid the NHS 7 month waiting list. She last had a heart attack in 2001 but felt that waiting 7 months would be fatal.
posted by PenDevil at 7:51 AM on August 18, 2009 [5 favorites]

It's not a question of incidents of the problem - it's a question of incidence, as in 'frequency of'.
posted by Miko at 7:53 AM on August 18, 2009

And as for the 70 pound a day tablet (Tarceva):

A Roche spokesman said: "Unlike Herceptin, Tarceva has already been licensed in the UK, but has not been given Nice guidance.

"Tarceva is expected to be given Nice guidance in 12 to 18 months time."

He said: "Tarceva can slow the progression of cancer, but cannot stop it. It can increase life expectancy by two months or longer."

posted by PenDevil at 7:54 AM on August 18, 2009

Don't look to Canada for the answers -- our Health Care system (or lack thereof) kills people, too. Building up hospitals, but closing beds and emergency rooms isn't exactly the formula for saving lives, either...

Oh please. Our health care system isn't perfect by any means, but it's a hell of a lot better than the media and right-wing-let's-privatize-the-works crowd would have you believe.

And you're also confounding two lines of argument here. All health care systems can and have killed people. The question becomes one of whether it's a problem with the system itself, or whether there are issues of personal responsibility involved, or both. All of which requires are far more detailed analysis than "Yeah, well, I've heard ours sucks."
posted by Zinger at 7:56 AM on August 18, 2009 [13 favorites]

If Americans love their system it is because they haven't gone bankrupt yet. Why is this not a larger part of the debate?

Exactly. I would like to see "I've Got Mine" grow into some sort of catchphrase, because the only thing that's going to fix the selfishness on the other side of the fence is either education (which generally doesn't work with that crowd) or shaming. It just blows my mind that some of my fellow citizens want to sabotage the safety nets of millions just to preserve their own access to medical care. It's not like those people are simply too lazy or too fat to get insurance.
posted by crapmatic at 7:59 AM on August 18, 2009 [1 favorite]

Please amend my "never" to say "almost never".
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 7:59 AM on August 18, 2009

I'm a little tired of the comparisons only being to the Canadian or British systems. While I think they are both superior to the U.S. system, they probably aren't the best health care systems available, just the ones most familiar to Americans. What about the French system? I hear great things.
posted by grouse at 8:01 AM on August 18, 2009

Don't look to Canada for the answers -- our Health Care system (or lack thereof) kills people, too. Building up hospitals, but closing beds and emergency rooms isn't exactly the formula for saving lives, either...

From where I'm sitting, the Canadian health system is roughly comparable to our own, except that you don't go bankrupt and you aren't flat-out denied coverage for the sin of "pre-existing conditions." That alone makes it vastly superior to our own "system."
posted by Tomorrowful at 8:06 AM on August 18, 2009 [8 favorites]

Look, East Manitoba, I'm sympathetic, even very sympathetic, to your concerns. I think a great plan has to start with medical bankruptcy and supply catastrophic coverage to everyone. I just think we should avoid hyperbolic statements and stay fact-based. It's easy to get lost in resentment and passion in these debates, because people die.

So, it's simply true that, like in the US, UK residents with dementia are often forced to sell their homes in exchange for the right to nursing home care. This has happened even if a spouse is not currently in need of care, because he or she is a liable relative. Though the NHS has been moderating this policy due to lawsuits, it's still the case that folks are "going bankrupt" i.e. being stripped of all assets, as a result of their medical needs.

The UK is better in this regard than the US, where children also find themselves paying for their parents long term care, but it's still not perfect. There aren't any medical utopias in the world: we're all trying to figure this out together, and it's important to embrace our collective fallibility.

And PenDevil, dude: a 7 month waitlist for a pacemaker? An honest question: how many people die before they get their turn? Our system sucks, but that doesn't mean the grass is always greener of every other side.
posted by anotherpanacea at 8:08 AM on August 18, 2009

A pacemaker is not a lifesaving device. My dad had one put in and 2 months later passed away. If your heart decides it's not going to beat anymore a pacemaker is not going to make it.
posted by PenDevil at 8:19 AM on August 18, 2009

This debate comes down to 1 spocklike question.

Does the good of the many outweigh the good of the few?

I think the answer is quite obvious. You simply cannot maintain a modern, democratic society without a common social good.

So, I'm sorry that the 7 month pacemaker wait was too long. The NHS deemed it as a reasonable wait. In exchange, millions of others received healthcare. Hundreds of thousands of lives were saved. It's a system that focuses on doing the most good while minimizing the bad.

You have a choice. Build your society around the bell-curve, or build it baround the extremes. We've tended to focus on the extremes. You might win the lottery. You might get rich and famous. You might have to face the choice of spending 100,000 dollars on a pacemaker. At the neglect of the majority cases. We focus on extremes. We declare that it's better for everyone to burn than one single dime go to someone we deem unworthy.

That's kinda fucked if you ask me. Absolutism at a stunning level. Cutting off your nose just to make sure someone you never fucking met doesn't get to keep theirs.
posted by Lord_Pall at 8:20 AM on August 18, 2009 [45 favorites]

I've experienced some of the absurd situations described in the linked article. About 15 years ago, when I had little money but did have dental insurance, I needed a crown. My insurance covered let's say 100% of "the usual and customary rate." I called them to ask how much they actually covered, so I could find a dentist under that number. My insurance company told me that they would not tell me what "the usual and customary rate" was for the procedure unless I first went to the dentist and got a quote.

I understand why they are opaque about the number - presumably they don't want dentists to know and raise their prices - but surely a dentist who does a reasonable amount of business a month already knows what the going reimbursement rates are. So the only person kept in the dark is the patient

So yes, as the article says, the system is broken. My story is one minor example, but shows a big part of the problem. It's impossible to make an informed decision when the two other players (doctors and insurance companies) have no reason to keep you informed.
posted by zippy at 8:25 AM on August 18, 2009 [3 favorites]

Seriously, Lord_Pall, that's an interesting perspective. But let me ask you, what is it about the US system that strikes you as libertarian? Medicaid, Medicare, charity hospitals, free clinics... hell, we even have a right to health care! Have had since Reagan.

This is about fixing a gap between Medicaid and affordable health insurance and reducing the costs. It's not about good versus evil.
posted by anotherpanacea at 8:27 AM on August 18, 2009 [2 favorites]

From where I'm sitting, the Canadian health system is roughly comparable to our own...

From where I'm sitting, the Canadian healthcare system smokes whatever the fuck American's call a healthcare system. I don't think the two are comparable at all. I don't know anyone who has to think about whether to go see a doctor or not. My wife's dad has had 3 major heart surgeries, two of which were performed in Canada. He's still alive (a miracle in and of itself) and isn't broke. Reading about America's "healthcare" makes me love the fuck out of Canada's all the more. I think people here don't really appreciate what we have.
posted by chunking express at 8:27 AM on August 18, 2009 [1 favorite]

Birthers, Town Hall Hecklers and the Return of Right-Wing Rage. I like this quote at the end: Good thing our leaders weren't so cowardly in 1964, or we would never have passed a civil rights bill -- because of complaints over the provisions in it that would enslave whites. I have no idea why the democrats aren't acting like they have a mandate from the American people to act like fucking democrats.
posted by chunking express at 8:30 AM on August 18, 2009 [13 favorites]

Is the pro-life lobby in the US weighing in for healthcare reform, given how much higher infant mortality is in the US than in those industrial economies with socialised healthcare?
posted by Abiezer at 8:33 AM on August 18, 2009 [8 favorites]

I’ll say this for George Bush: you’d never have caught him frantically negotiating against himself to take the meat out of a signature legislative initiative just because his approval ratings had a bad summer. Can you imagine Bush and Karl Rove allowing themselves to be paraded through Washington on a leash by some dimwit Republican Senator of a state with six people in it the way the Obama White House this summer is allowing Max Baucus (favorite son of the mighty state of Montana) to frog-march them to a one-term presidency? -- Matt Taibbi
posted by chunking express at 8:33 AM on August 18, 2009 [9 favorites]

It just blows my mind that some of my fellow citizens want to sabotage the safety nets of millions just to preserve their own access to medical care. It's not like those people are simply too lazy or too fat to get insurance.
posted by crapmatic at 10:59 AM on August 18

It blows my mind that some of my fellow citizens want to steal the private property of other citizens and launder it through the federal government just to pay for their own access to medical care, when millions of other citizens are starving and homeless.

It's astoundingly selfish if you think about it. How many times in these threads do people offer their own stories of how the system screwed them and how they need this reform to pass? That's fine and that's their right, and it is certainly a legitimate grievance, but please don't insult everyone's intelligence by presenting the issue as one of altruism.

What about all the people you don't know who are homeless or starving, here and elsewhere in the world? As long as you're taking other people's money to pay for stuff, would it make more sense, wouldn't it be more moral, to take that money and give it to the absolute poorest and most destitute? Oh, right, we aren't talking about them. Yet. First you get yours, and then we'll take whatever Peter has left to pay homeless Paul, is that it?

And selfish? How dare you. It's "selfish" to suggest that I don't want to simultaneously pay more in taxes AND continue to pay the same price for insurance? I'm not using my after-tax income on hookers and blow you know. Is it selfish to want to live in a horribly overpriced area so my children can attend the best public schools? Is it selfish to spare no expense to send them to the best private schools or colleges in the country?
posted by Pastabagel at 8:39 AM on August 18, 2009 [5 favorites]

I've spent my adult career as a teacher of medical students and other health care professionals. I've mostly sat out the health care debate because those debating don't really get to the point of how broken the system really is. This article is a good starting point, however, let me put forward, three radical propositions.

1. For many diseases it is better to avoid treatment by health care professionals.
2. HMOs with their algorithms of what sort of care to give out actually improve health care.
3. It is reasonable to make decisions based on cost.

All three of these are coming from someone who considers himself a liberal.

#1, avoid treatment. For many basic illnesses the treatment that is promulgated by modern medicine does not improve the problem. This is not to say there is no treatment at all. For obesity, sensible diet works, maybe you can even get a doctor to direct you that way. On rare occasions, medical treatments (stomach stapling, pills) are justified. But if you go to a physician you will likely have the heavy handed approach prescribed.
The statin, cholesterol lowering agents, are promoted as miracle drugs. They do have uses, especially for those who have elevated cholesterol due to genetic conditions, for diabetics and for some other circumstances. They are pushed on people with moderate cholesterol. If you look at the original studies for those with moderate cholesterol you will find they lower heart disease deaths and increase overall deaths - along with other side effects that make quality of life worse. A general theme with these treatments is that they have been proven to affect a disease marker - not improve quality of life.
Alzheimer's drugs have minimal benefit and a lot of side effects. Irritable bowel syndrome has drugs that are pushed on TV commercials. Some benefits, lots of side effects. There are many, many drugs and treatments that fit this description. Sleep medicines, antianxiety medicines. Quite often, they are not worth it. The treatment is the cause of further sickness.

This is even if the doctor makes the right diagnosis and treatment choice. The knowledge base required to be a good doctor is huge and always expanding. In my dozen or so personal experiences visiting a physician for a health problem, I would say ten times the doctor tried to treat me (or my family member) with the wrong medicine. I would not have known it was the wrong medicine if I didn't have a PhD in pharmacology.

#2. HMO algorithms improve medicine. This proposition would make good doctors scream. This is primarily because HMO algorithms tie the hands of good doctors. The good doctor is taking into account the nuances of the patient and tailoring the treatment correctly for that patient. The good doctor may be choosing the more expensive drug for a good reason. However, there are a lot more bad doctors out there than good doctors. These algorithms limit the bad doctors from foisting expensive and unnecessary drugs on their patients. So, this is a statistical argument. The algorithms make medical decisions that are on the average better - making the bad decisions better and the good decisions worse.

#3. It is reasonable to make decisions based on cost. Before I was a professor of pharmacology, I was a social worker. I saw time and again when expensive undertakings were performed that would help a single person when cheap decisions that would help a lot of people were overruled. Health care does this all the time. We save a single person for $500,000 and ignore a hundred persons for a thousand dollars each. Until that is turned on its head, I won't have sympathy for that very expensive operation.

Teaching medical school, the problem starts here. We don't train physicians for the reality where drugs (used correctly) cause 100,000 deaths per year (US). Or, for reducing medical errors or nosocomial infections or post-operative clots (summing these together and you have several hundred thousand deaths.)

We teach them the science underlying illnesses they may never see during their careers. And while it might be wonderful to have them diagnose pheochromocytoma if they run into a case, they probably won't remember how to do even that because of everything that is being crammed into their heads.

How do you rip apart and start over with a system where good health care is not the entitlement, but the deity of the physician is? I'm pessimistic as to whether it can be done. The health care system monster is too big. When lobbying and "persuading" Congressional representatives can be done for millions, the players in this game have hundreds of billions at stake. And for the anti-reform lobby to succeed all they have to do is obstruct.

Clinton bit off more than he could chew by going after this. The money funneled into the anti-reform is what helped put the Congress in the control of the Republicans in 1994. I think Obama is falling into the same trap. A land war against Russia is easier.
posted by dances_with_sneetches at 8:48 AM on August 18, 2009 [29 favorites]

I have no idea why the democrats aren't acting like they have a mandate from the American people to act like fucking democrats.

Maybe their true intentions are now showing? They never intended on executing the change they campaigned on in the first place. The status quo is more profitable than upheaval and reform for those who already have money and power.
posted by nowoutside at 8:53 AM on August 18, 2009 [2 favorites]

The first article in the OP was fascinating. It's the first time I've really considered the possibility of health care without health insurance, to be honest, and the author raises lots of good points.

I think those of you who dismissed the point about his father's death (jb, miko) probably didn't finish reading the article. A major argument the author makes is that lots of the accidental deaths that occur in hospitals are a side effect of the fact that patients are not actually the customers the hospital worries about -- as a result, the hospital can make a lot more money from a patient who catches a secondary infection during his hospital stay than from a patient who is successfully treated and gets to go home the next day. So while individual doctors and nurses may be interested in a patient's health, the hospital as a business is set up to resist some simple changes that could reduce such infections, because they will increase operating costs.

At any rate, that's not the most important point in the article. I highly recommend reading it all the way through. I'm not ultimately convinced by the alternative system the author proposes near the end, but he gives some good explanations for how many of our healthcare system's problems can be traced back to the fact that we use health insurance for all healthcare, even in routine and predictable situations. The result is that patients aren't any longer the customers of the healthcare industry, our insurers are. And that gives "customer satisfaction" in this situation an entirely different meaning than one might hope.
posted by voltairemodern at 8:53 AM on August 18, 2009 [3 favorites]

(I mean, "...because they will increase operating costs without increasing profits.")
posted by voltairemodern at 8:55 AM on August 18, 2009

This has happened even if a spouse is not currently in need of care, because he or she is a liable relative. Though the NHS has been moderating this policy due to lawsuits, it's still the case that folks are "going bankrupt" i.e. being stripped of all assets, as a result of their medical needs.

Nursing homes aren't part of the NHS. If the best criticism of the NHS you can come up with is not providing something they have no mandate to provide then you've pretty much lost the argument.
posted by cillit bang at 8:59 AM on August 18, 2009

the hospital can make a lot more money from a patient who catches a secondary infection during his hospital stay

Medicare has attempted to address this issue. The current rule is imperfect, but represents a move toward performance-based reimbursement by Medicare.
posted by Mister_A at 8:59 AM on August 18, 2009

>when millions of other citizens are starving and homeless

I honestly believe we would have less homeless in this country if we provided better health care (including substance abuse and mental illness support) to everyone. But that's a false conflict, did you fight as much against the war? against the bailout? or it is just heathcare that makes you upset?

>It's "selfish" to suggest that I don't want to simultaneously pay more in taxes AND continue to pay the same price for insurance?

You should support single payer health care then.

I do think it's selfish to leave the system the way it is. You have yours now, who is to say that your kids won't be screwed by the current system when it's their turn.

In the 90s I (for some stupid reason) was against the change in the health care system. In the next decade I saw friend and family members bankrupted (even with 'good" insurance) due to cancer and other health problems. This doesn't happen in other western countries. It's time to fix the system.

Nobody in Iraq did anything to my family or country, but we're willing to spend 2 trillion+ dollars there.

Shame on us if we don't fix this problem this generation.
posted by bottlebrushtree at 9:01 AM on August 18, 2009 [4 favorites]

Gee, Dean, I've been on a high deductible plan and you know what I put off over a weekend late last year because a) Treating it would've taken too much out of my wallet immediately, b) I wasn't sure I'd be reimbursed for incredibly expensive ER care, and c) The nearest ERs were already overcrowded due to people using it as a general clinic--to to mention overcrowded for post-Katrina/Baton Rouge incompetence-related reasons in NOLA, which is an entirely separate story, but ...? Anyway, what I delayed was treatment for what turned out to be a broken arm, one that took six weeks to heal, could still feel the effects of six months later. The arm was not turning purple or anything, but I could to move it much, I knew I needed treatment soon, but delayed it for two days. I look back on that and think, That was crazy. In a well-working system, I would have had every incentive to go to the ER, pronto, even if I weren't screaming in pain. Instead, I was steered away from the ER.

What was used to treat my injury, meanwhile, was a sling with a wrap-around stabilizing thingie, hardly cutting-edge technology, unless you count the Velcro. Later, I had physical therapy with the use of such high-tech devices as weights and big rubber bands. What worked better than the crazy expensive physical therapy, however, was this exotic thing called lap swimming, combined with massage. Insurance paid for neither of the latter treatments, which I suppose weren't quite medical-ey and all wondrous Bright New Future-ish enough.
posted by raysmj at 9:04 AM on August 18, 2009 [2 favorites]

I don't necessarily want to defend this theory very far, but how likely is it the recent statements about the public option being "unessential" were a deliberate tactic to anger the Left? Get them good and riled up so you can point to them during negotiations "we can't remove it, because look at these guys" and also point them at the Progressive Caucus to make sure they really won't sign a public-optionless bill.

Also, remember the story of the last two weeks has been "little (insane) guys against Those Liberal Democrat Fat Cats at townhalls". Suddenly the story is "grassroots left against Those Conservatives/Blue Dogs In Washington".

Now Sibelius is out there saying "no no no, the public option is great! We love it!"

Crazy like a fox?
posted by DU at 9:06 AM on August 18, 2009 [1 favorite]

And selfish? How dare you. It's "selfish" to suggest that I don't want to simultaneously pay more in taxes AND continue to pay the same price for insurance? I'm not using my after-tax income on hookers and blow you know. Is it selfish to want to live in a horribly overpriced area so my children can attend the best public schools? Is it selfish to spare no expense to send them to the best private schools or colleges in the country?

Not selfish so much as deluded as only an intelligent, informed, hardworking, decidedly libertarian position can be. By which I mean, in some small way, I used to be you. I operated from the perspective that if everyone just had integrity and took care of their own ends and concerns, things would somehow work out.

I was wrong, I believe. The world just ain't that simple. It doesn't matter how pure my actions and intentions are. If too many people are left in the margins, then everything eventually gets worse FOR EVERYBODY. Call it socialism/communism etc if you must, but there is a certain wisdom in some redistribution of wealth some of the time. I'm not talking Soviet Russia here. But I am talking about friendly Canada.

Try it this way.

Is it deluded to think that my nation's deeply messed up health care system can somehow be fixed by me NOT paying a few more bucks in tax even though, as someone with a good health care plan, my coverage won't actually improve? Yes ... and so on.
posted by philip-random at 9:07 AM on August 18, 2009 [10 favorites]

when millions of other citizens are starving and homeless

Millions of citizens are not homeless (yet) in this country. Millions are uninsured, though.
posted by enn at 9:08 AM on August 18, 2009

It's "selfish" to suggest that I don't want to simultaneously pay more in taxes AND continue to pay the same price for insurance?

At least one version of the public option is self-funded. Another, IIRC, only raises taxes on the top income bracket (something like from 33% to 39%, big deal). Are you in the top income bracket?

And of course you could just discontinue paying for over-priced private insurance.
posted by DU at 9:09 AM on August 18, 2009 [1 favorite]

I was thinking something like that myself, DU. This is a long game and we're nowhere near done.
posted by Mister_A at 9:10 AM on August 18, 2009

My family was nearly bankrupted by long-term medical care when I was a kid.

We most likely had excellent insurance, but when you have to pay even a small fraction of cost for over a year of home health care and hospitalization, even when you've saved up for years and lived well within your means, even when you have two incomes, it's often not enough.
posted by zippy at 9:10 AM on August 18, 2009 [1 favorite]

My last comment was a reference to this comment from DU.
posted by Mister_A at 9:12 AM on August 18, 2009

In the US, people w/out insurance end up in the emergency room once they've gone through whatever other options exist. The public hospitals are required to treat them. The hospital then bills the folks at a higher total cost than would be reimbursed by an insurance plan. Now, that's only fair? And if they cannot pay the bill?

If the hospital gets stuck with the bill, anyone who has insurance or pays taxes is paying for the indigent person's care. You can have the more expensive bill caused by lack of access to prevention, lack of capped fees, loss of potential spending by those who are bankrupt by medical bills - or, you can provide a public insurance option.
posted by mightshould at 9:12 AM on August 18, 2009 [1 favorite]

And big pharmaceutical giants and big medical products companies have stopped working on stuff that could be extraordinary because they know they won't be reimbursed, according to the common standards. We're not only rationing today; we're rationing our future.

Then he brings up the polio vaccine as an example of technology that did so much for the world, at a fairly inexpensive cost. Who brought you that? A predecessor to one of today's big pharmaceutical giants, acting heroically and alone? No, try: American state research universities like Pitt and Michigan, non-profit hospitals, etc.
posted by raysmj at 9:16 AM on August 18, 2009

Another personal health care anecdote, this one involving long-term care for Alzheimer's. In the US, finding a facility for some one with an incurable illness is terrible.

It goes like this.You call around to different facilities and they want to know how much money the patient has before they will accept them. I think they want to know how many years the patient will be paying their own way before Medicaid kicks in (at a lower rate of payment to the facility).

So in this one conversation, you are: a) talking about how profitable grandpa will be, and b) seeing their life savings go just for basic care.
posted by zippy at 9:17 AM on August 18, 2009 [3 favorites]

Taxation is not theft. Whenever someone says that, I know I can ignore anything else they say.
posted by vibrotronica at 9:21 AM on August 18, 2009 [18 favorites]

We're talking about a system where everyone currently makes or spends amount X.

'Health Care Reform,' by definition, is about changing X as it relates to Health Care spending.

It's been my experience that when deciding who gets to keep less money (or resources, or what have you), the decision is most strongly influenced by those who have the most money (or resources, or what have you). This is a self-perpetuating cycle (though not a stable one).

Is there any reason whatsoever to believe this will not be the case this time? I mean, you can get angry about it if you like, you can rail about the injustice of it, but do you really expect any different?
posted by Pragmatica at 9:28 AM on August 18, 2009 [1 favorite]

The annual premium for an employer health plan covering a family of four averaged nearly $12,700. The annual premium for single coverage averaged over $4,700.

I got this from XQUZYPHYR's link above and all I can say is

!!!!

The cost here for additional coverage on things not covered by OHIP is $3600/employee. That's medical, dental, and a counselling hotline, and chiropractic. And we're peeved that OHIP doesn't cover it.

Why on earth isn't big business in the US on board the socialized medicine bandwagon?? Even leaving aside the question of better health = better worker productivity, that's got to be slaying the bottom line.
posted by Zinger at 9:28 AM on August 18, 2009 [1 favorite]

Why on earth isn't big business in the US on board the socialized medicine bandwagon??

Big Business, especially in the US, is far from the rational actor proponents of Free Market Theology would have you believe.
posted by DU at 9:32 AM on August 18, 2009 [1 favorite]

would it make more sense, wouldn't it be more moral, to take that money and give it to the absolute poorest and most destitute? Oh, right, we aren't talking about them.

There are already public health and assistance options set up that they qualify for (if they apply) - including Medicaid, public housing/shelter, Section 8, and Food Stamps. If they are elderly, then there's Medicare, housing programs, Social Security, and more.

Unfortunately for anyone who is employed and making over about $10k a year, they don't qualify for any of those programs. But the very poorest, starving people you mention are theoretically covered already, so it's a piss-poor argument on your part.

And sufficient insurance is out of reach for millions starting from those min-wage workers to those going bankrupt over medical conditions and red tape. That's an extremely large group of people, way more than merely the 45million+ uninsured.

What would happen if you came down with cancer tomorrow and faced long, expensive treatment? Would you lose your home? Would you be able to afford to keep your kids in such great schools? I'm asking based upon the idea that you aren't filthy rich and thus not on as unshakable ground as your smugness might convey.
posted by cmgonzalez at 9:39 AM on August 18, 2009 [1 favorite]

This is a UK Pay As You Earn tax calculator. In my experience, there is a rough dollar to pound correlation between the UK and the US, in that if you paid five bucks for something in the US, you'd pay £5 for it in the UK (with some notable exceptions like fuel, which is absurdly cheap in the US compared to most first world countries).

As an exercise, try punching your US salary in to this calculator. Of course, the US has a bigger tax base and bigger tax expenditures, deficits and so on, so it's not an apples to apples comparison.

But take a look at the take home numbers for pay, after all taxes, NI etc. Then, compare that to what you currently pay in taxes in the US plus what you pay for healthcare (if insured). Have a think about what your actual costs are. I've seen people quoting a third of their salary going to healthcare.

Now, imagine paying for healthcare out of general taxation, with the option to get affordable and worthwhile private insurance if you feel the need. Here's a pretty typical one. Most importantly, for those of you supremely concerned with your wallet over everything else, including the general wellbeing of the society that supports you and your lifestyle, do the numbers on how much actual take-home pay you'd have under a universal system.

Oh, and don't forget to account for the hundreds of hours shopping for a plan, then dealing with the administrative fallout of ever actually using it.

It's not a perfect exercise, I'll admit, but it's a good start if you have any existing assumptions about what the cost might actually be to you.
posted by Happy Dave at 9:40 AM on August 18, 2009 [1 favorite]

Exactly. I would like to see "I've Got Mine" grow into some sort of catchphrase, because the only thing that's going to fix the selfishness on the other side of the fence is either education (which generally doesn't work with that crowd) or shaming.

Interestingly, the phrase "I'm all right, Jack" is an existing historical catchphrase used to indicated selfishness.
posted by sevenyearlurk at 9:41 AM on August 18, 2009

Commentary: Frightening future if health reform fails
posted by KokuRyu at 9:42 AM on August 18, 2009

I have a decent insurance plan and a family. Before I started a business, I had the same plan with my employer. On my own, under COBRA, I pay (IIRC) 110% of the cost of the plan (the CFO at my old company says the 10% premium is because people who choose plans under COBRA are more likely to use them).

The cost is a bit more than $13000/year. Tax deductable, but still. That's the price of a pretty solid used car every year, just to make sure we can go to the doctor without worrying too much about bankruptcy.

Recently, I went to a specialist doctor for a minor condition. The doctor ordered two MRIs initially to diagnose. then then wanted two more followup MRIs. The initial MRIs were necessary, the fourth that he wanted was not.

I observed, from this and other experiences^* with the same doctor, that he was not being paid to think and be deliberate, but instead to perform procedures quickly.

When I asked why the fourth MRI was necessary, given the other tests and symptoms, he thought and said that it wasn't given the lab work and symptoms. In other words, he hadn't thought through the necessity of the the procedure, and it was only when I asked him to stop and think that he figured it out.

* - for one, he refuses with all patients to disclose test results except in person, necessitating an office visit for every test, even basic lab work where the results are "you're fine."^**

** - very much considering DTMF and having my GP do the remaining diagnostic work.
posted by zippy at 10:00 AM on August 18, 2009

And selfish? How dare you. It's "selfish" to suggest that I don't want to simultaneously pay more in taxes AND continue to pay the same price for insurance?

Uh, yes.

Is it selfish to want to live in a horribly overpriced area so my children can attend the best public schools? Is it selfish to spare no expense to send them to the best private schools or colleges in the country?

Yeah, in general I would say wanting to see poor people get sick and die in order to save money to send your kids to fancy schools is pretty selfish.
posted by delmoi at 10:04 AM on August 18, 2009 [15 favorites]

I don't necessarily want to defend this theory very far, but how likely is it the recent statements about the public option being "unessential" were a deliberate tactic to anger the Left? Get them good and riled up so you can point to them during negotiations "we can't remove it, because look at these guys" and also point them at the Progressive Caucus to make sure they really won't sign a public-optionless bill.

Oh come on, they're clearly just idiots. They look ridiculous flip flopping like this. Thank god the Progressive Caucus has some balls here.
posted by delmoi at 10:09 AM on August 18, 2009

Nate Silver: Not All Socialist Countries are Alike
posted by anotherpanacea at 10:13 AM on August 18, 2009

Is it deluded to think that my nation's deeply messed up health care system can somehow be fixed by me NOT paying a few more bucks in tax even though, as someone with a good health care plan, my coverage won't actually improve? Yes ... and so on.

Of course it's possible. The difference between what the private insurance companies pay in "not healthcare" (that is, administration, advertising, executive compensation, and returns to investors) compared to what Medicare pays for is enough to cover every uninsured person today. So if they money were being distributed more efficiently, everyone could be covered.

Why on earth isn't big business in the US on board the socialized medicine bandwagon??

Because it would mean higher taxes for the executives, as well as most people in the direct shareholder class. If company A has to spend %10 of it's would-be profits on health insurance, but the companies directors save more in taxes then they would get back on their shares then it's a win for them, and of course, they are the ones who control the lobbyists.
posted by delmoi at 10:19 AM on August 18, 2009 [1 favorite]

I've said it before and I'll say it again. Americans just love shouting "We're Number 1! We're Number 1!" with absolutely nothing to back it up (except perhaps defense spending, not that that's anything to be especially proud of).

If we truly are what we proclaim to be - the best and the brightest and vastly superior to every other nation on the planet - then I see absolutely no reason why we can't look at the existing systems in every other industrialized nation in the world and do it better.

We're Number 1? PROVE IT!
posted by ValkoSipuliSuola at 10:22 AM on August 18, 2009

^ CT, not MRI, in my previous comment. Carry on.
posted by zippy at 10:43 AM on August 18, 2009

A case for co-ops from the perspective of civic engagement:

1. People deeply distrust government, so it may be smart politics to build a more progressive infrastructure that includes mechanisms for enhancing trust, such as local ownership.
2. In numerous cases around the world, public participation has been found to reduce corruption and waste. When people have decided what to spend money on, they watch to see if it is spent as promised. When the money vanishes, they rebel.
3. Participation in co-ops would increase people's civic skills and their expectations that other major institutions will treat them respectfully.
4. Health decisions involve complex scientific and technical issues--but also irreducible value judgments that cannot be made "scientifically." Co-ops can include deliberative bodies that make value judgments and tradeoffs, accountably and transparently. Moreover, those decisions can be made differently in different parts of the country, thus reducing the intensity of our cultural battles. (Yet co-ops would also be regulated by the federal government to protect rights that Congress deemed essential.)
5. Co-ops could contribute to political pluralism by lobbying in the interests of their members.

posted by anotherpanacea at 10:44 AM on August 18, 2009

The main article here is great. I think its critical to really chew on his point that we need to change the customer from the insurance company to the individual. This is basic economics; if the market can't dictate the price of a good or service because there is some intermediary distorting prices through controls naturally prices will be higher than necessary. Bureaucracy doesn't pay for itself!
posted by zennoshinjou at 10:48 AM on August 18, 2009

Pastabagel, the government "steals" money from taxpayers to pay for highways and sidewalks and stealth bombers and bike lanes and public schools and so on, and you know what really sucks? The poor people have just as much right to the highways and things as the rich! It's ridiculous! Education, maybe not so much.
posted by Mister_A at 11:50 AM on August 18

First, everyone is being taxed for schools and highways that everyone uses. Second, the option is not private insurance or taxes, the option is exactly the same premiums for exactly the same insurance + taxes for something I am not using. See the difference?

Yeah, in general I would say wanting to see poor people get sick and die in order to save money to send your kids to fancy schools is pretty selfish.
posted by delmoi at 1:04 PM on August 18

Do you own an ipod or an iphone? You could feed someone for a month merely with the premium you paid for those products over competing brands. So, did you starve someone because you wanted to buy apple?

Here's the fallacy in the arguments being presented here. I'm not depriving someone of healthcare by refusing to pay more in taxes any more than you are depriving starving people of food by using your money how you like. The two are not related.

But the argument is trying to create the illusion of a connection. Why doesn't the government reshuffle a few dozen billions in the over $1 trillion budget to pay for this if it's so important? Why is the government spending on foreign aid, for example, if Americans are dying as a result of this crisis?

Hell, the government technically doesn't even have the trillion it is spending now - it's borrowing that from other people (hint: that includes me). So why not borrow another $x billion?

Why is this the only program that must be paid for by raising taxes on some people for the benefit of an entirely separate and mutually exclusive group? If it's so important, cut the space program. Cut defense. End the war right now, and I literally mean before 5:00 pm today. This is surely more important than those things, right?
posted by Pastabagel at 10:56 AM on August 18, 2009 [1 favorite]

Americans are so used to dominating the world's economy, dominating the world militarily, dominating the world culturally, having such an outsized influenced technologically and scientifically, that it seems genuinely absurd that there really might be something we that we do horribly, that almost every other nation on the planet handles better. I hear a lot of "yeah, but those socialist systems aren't perfect either!" without recognizing that those "imperfect" systems are better than ours by just about any objective standard you can think of, except of course for "Is it SOCIALIST!?!?!?"
posted by Tomorrowful at 11:08 AM on August 18, 2009 [6 favorites]

Pastabagel, I think you've confused collective responsibilities with individual responsibilities. I may not have an obligation to give all my wealth to the global poor, but this is a question independent of my advocacy for just institutional arrangements that assist the global poor. And obviously, you can advocate against higher taxes, but you're obliged to pay them if and when the IRS comes calling: that's an individual and a collective duty.

The real question is: what ought we to advocate? And here, I think it's clear there are institutional arrangements that would be more just than the present set. We can dispute which of many possible solutions is best, but let's at least acknowledge that there's work to be done!

Must fix:

1. rescission
2. differential pricing that leads to adverse selection (for instance, for pre-existing conditions)
3. universal catastrophic insurance (like car insurance)

After that it's a simple matter of tweaking the system to make it more efficient and effective. This might include tort reform, changing the tax treatment of employer-based health insurance, and finding an alternative funding mechanism for indigent patients who currently flood emergency rooms. All the plans on the table try to do both, and I don't see why you'd object to that goal except for a principled objection to taxation-as-illegitimate-coercion, which is silly, and frankly, beneath you, or because it's fun to rile up delmoi.
posted by anotherpanacea at 11:16 AM on August 18, 2009 [3 favorites]

I would love to see the government end the war. Many wealthy people don't use the public schools and in fact bitch and moan about their property taxes being used to subsidize the education of other people's children. Not everyone uses the highway system directly, but we all benefit from it. Not everyone uses the healthcare system the same way, but the vast majority of us are being punished by it. This country will benefit from healthcare reform that includes price controls. Don't you know that your healthcare costs are increasing at a rate that outstrips inflation? Are you really sure you're going to be better off keeping a few dollars from your salary out of Uncle Sam's hands, even though those dollars are going to end up in the hands of insurance and HMO execs?

I don't think that the people who are paying the taxes are an "entirely separate and exclusive group" to the people that will benefit from healthcare reform. This is very much a classist argument, but downward social mobility is the new black here in America. If I lost my job tomorrow, I am not sure how long I'd be able to pay COBRA at $1000+ per month. I would like to know that if I lose my job, I am not going to lose my house, too if I get sick or injured.

Healthcare is a giant black hole sucking wealth out of this country and discouraging innovation and entrepreneurship. I am not sure what your objection is here, but I assume it is directed at the public plan. I think it's worth considering whether a public plan makes sense in light of the huge federal deficit, but we should remember that the healthcare costs of the uninsured are already being paid, right now, in the form of ever-higher premiums and co-pays, by everyone in this country who has healthcare coverage. It makes a good deal of sense to systematize this ad hoc healthcare system for the uninsured; it should reduce total expenditure for healthcare, and that's a good thing.
posted by Mister_A at 11:20 AM on August 18, 2009 [3 favorites]

First, everyone is being taxed for schools and highways that everyone uses.

I don't drive. I don't use the highways.

Second, the option is not private insurance or taxes, the option is exactly the same premiums for exactly the same insurance + taxes for something I am not using.

Should I get a tax break for not driving then?

Or can you see the collective benefit to providing such services? Because things I like and use are also being paid for through those tax dollars. It's not a la carte.
posted by cmgonzalez at 11:23 AM on August 18, 2009 [2 favorites]

Arguing with Libertarians will make you stupid. For reals.
posted by chunking express at 11:25 AM on August 18, 2009 [5 favorites]

Don't you know that your healthcare costs are increasing at a rate that outstrips inflation? Are you really sure you're going to be better off keeping a few dollars from your salary out of Uncle Sam's hands, even though those dollars are going to end up in the hands of insurance and HMO execs?

On the first point, yes I am aware of that. I believe part of the problem has to do with the fact that the supply of medical professionals, i.e. doctors, is kept artificially low by the med school and residency admissions process (med students know what I'm talking about). Compared to other industrialized countries, we have a much higher patient to doctor ratio. Simple economics tells us that lower supply for a given demand raises the price.

Another part of the problem is that medicine relies to a great extent on technological innovation, and being a market innovator (i.e. being the purchaser of new innovative products) is extremely expensive (compared with say ordinary computer technology which is more a commodity).

The second factor is unavoidable in any system. Research is insanely expensive, medical research even more so. But the first factor reflects a malfunction of the economics of medicine. If doctors are the primary caregiver - they control access to medicines, treatments, hospital beds, etc - they are a choke point in the whole system. My belief is that increasing the number of qualified doctors (a lot of bright students with good grades and score don't make it all the way through) will have a dramatic effect on the cost of care.
posted by Pastabagel at 11:32 AM on August 18, 2009

I don't drive. I don't use the highways...

Should I get a tax break for not driving then?
Or can you see the collective benefit to providing such services? Because things I like and use are also being paid for through those tax dollars. It's not a la carte.
posted by cmgonzalez at 2:23 PM on August 18

Nope. You get nothing, because you live in New York. And according to your mayor, New York City is a "luxury product" that is worth the cost:

"If New York City is a business, it isn't Wal-Mart -- it isn't trying to be the lowest-priced product in the market,'' a draft of the speech reads. ''It's a high-end product, maybe even a luxury product. New York offers tremendous value, but only for those companies able to capitalize on it.''

You want luxury, you pay up for it. You pay for roads you personally don't use because your entire existence in that luxurious city depends on the flow of goods into that city by truck.
posted by Pastabagel at 11:40 AM on August 18, 2009

I believe part of the problem has to do with the fact that the supply of medical professionals, i.e. doctors, is kept artificially low by the med school and residency admissions process (med students know what I'm talking about).

Perhaps I'm mistaken but I recall that colleges do this at the behest of the AMA. The same AMA that has been fighting against any kind of socialised healthcare since hiring Ronnie Regan in the 50s.
posted by PenDevil at 11:45 AM on August 18, 2009 [1 favorite]

I don't drive. I don't use the highways.

cmgonzalez: Do you buy products shipped in trucks? Do you receive mail? Then guess what? You use the highways.

No tax break for you.
posted by HyperBlue at 11:47 AM on August 18, 2009

cmgonzalez: Do you buy products shipped in trucks? Do you receive mail? Then guess what? You use the highways.

For the record, Hyperblue,, I think cmgonzalez acknowledges that here:

...can you see the collective benefit to providing such services? Because things I like and use are also being paid for through those tax dollars. It's not a la carte.
posted by EmpressCallipygos at 12:05 PM on August 18, 2009

When I didn't have kids (and after I no longer do) I paid and will continue to pay taxes for public schools. Why am I more than happy to do this? Because I'm generous. But also because I'm self-interested: The kids being educated in public schools are the future adults who will be maintaining my car, designing and manufacturing my products, helping me make financial and health decisions, producing my entertainment and representing me in government.

I am better off when everyone else is educated.

Now, to return to the question at hand: Why should I pay for public healthcare? Because I'm generous. But also because I'm self-interested....
posted by DU at 12:05 PM on August 18, 2009 [11 favorites]

"Why on earth isn't big business in the US on board the socialized medicine bandwagon??"

CostCo CEO: pro-business, pro-consumer, pro-universal health care:

What's your stand on universal health coverage?

We should have it. I think that in the wealthiest nation in the world, it's a shame and disgrace that we don't. We try to provide a very comprehensive health-care plan for our employees. Costs keep escalating, but we think that's an obligation on our part.
posted by zippy at 12:08 PM on August 18, 2009

"Taxation is not theft. Whenever someone says that, I know I can ignore anything else they say."

No, because then you might actually have to question your assumptions rather than just keep believing them without truly thinking about them.

Taxation is not theft. But they are both the application of violence, and thus they are equivalent. See what happens when a citizen writes a letter refusing to pay said taxes. Through merely stating their refusal to pay, and no action causing harm to anyone else, watch as that citizen has their freedom and civil rights taken using violence. All in the name of the illustrious, ever-changing "greater good".

I ask: You may pay taxes to provide any service you believe the government should provide to everyone. Suppose I refuse, however, to pay those taxes for whatever reason. Should I be ultimately subjected to arrest, confinement, and asset forfeiture if I continue to refuse to pay for everyone else's services? Does a simple majority rule of 50.1% consenting for an additional government service justify imprisoning the remaining 49.9% if they refuse consent? Do the ends of health care for all justify the means of imprisoning those that do not agree?
posted by TheFlamingoKing at 12:56 PM on August 18, 2009

TheFlamingoKing: "Taxation is not theft. But they are both the application of violence, and thus they are equivalent. See what happens when a citizen writes a letter refusing to pay said taxes. Through merely stating their refusal to pay, and no action causing harm to anyone else, watch as that citizen has their freedom and civil rights taken using violence."

by this same logic, preventing murder is the application of violence. defending the president of the US from assassination is likewise the application of violence.

when your logic specifically equates two opposite things, it's time to re-evaluate your logic.
posted by shmegegge at 1:00 PM on August 18, 2009

Does a simple majority rule of 50.1% consenting for an additional government service justify imprisoning the remaining 49.9% if they refuse consent?

While that's a lovely thought experiment in Libertarian fantasyland, back in reality most laws and taxes passed have to reach a broad consensus.
posted by PenDevil at 1:08 PM on August 18, 2009

Who let that guy in here?
posted by Mister_A at 1:11 PM on August 18, 2009 [1 favorite]

Another link back to this old comment on how the Founding Fathers might have regarded socialized health care and how they felt about "spreading the wealth" might be instructive, TheFlamingoKing.
posted by saulgoodman at 1:17 PM on August 18, 2009

Taxation is not theft. But they are both the application of violence, and thus they are equivalent.
So's private property. Party round yours!
posted by Abiezer at 1:20 PM on August 18, 2009 [1 favorite]

I ask: You may pay taxes to provide any service you believe the government should provide to everyone. Suppose I refuse, however, to pay those taxes for whatever reason. Should I be ultimately subjected to arrest, confinement, and asset forfeiture if I continue to refuse to pay for everyone else's services?

Yes, you should be, as long as you keep calling 911 to report a crime, keep driving on roads, keep using money, etc etc etc. You get services back by paying taxes, whether you like them all nor not. Tax is the price you pay for keeping in a proper society, and out of a cave, spending all day hunting for food. The only reason you are posting here on this wonderful internet full of information and ideas, is because most everyone before you and after you did and continues to chip in to the big pot of money that may or may not go where you want it to go, but touches every aspect of your life.
posted by Mach5 at 1:25 PM on August 18, 2009 [1 favorite]

A universal health care policy is a benefit to the well-off because it provides a safety net in case of disaster.

Also it fuels economic growth because healthier workers have less down time and are more productive, reduces the incidence of medical crisis bankruptcies that have indirect costs on society in the form of legal costs and that cost creditors billions in lost returns on investment, and decreases the broader social costs of public health issues by managing them more proactively and effectively. Etc. Etc.

Everyone benefits (well, except Big Health scabs). That's why virtually every other successful nation on earth already has more robust public health care.
posted by saulgoodman at 1:25 PM on August 18, 2009

Taxation is not theft. But they are both the application of violence, and thus they are equivalent. See what happens when a citizen writes a letter refusing to pay said taxes. Through merely stating their refusal to pay, and no action causing harm to anyone else, watch as that citizen has their freedom and civil rights taken using violence.

People need law, military protection, roads, public health, fire service etc etc, otherwise life sucks (compare with: life, liberty, pursuit of happiness). None of those services can be effectively provided by free-market capitalism.

Those government services need a somewhat predictable revenue stream or they are worthless. Representative democracy provides the best method of determining that revenue stream and how it is spent, within the realm of the possible. If someone chooses to remain in the country and benefit from these services but not make a democratically determined contribution, they are doing harm against their neighbor. Their punishment is not just pragmatically required, it is just.

Alternatively, every American citizen has a God-given right to go found Ronpaulville in the Gobi desert and see how their society flourishes - you can watch the documentaries "Deadwood" or "Bioshock" for some clues.
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 1:29 PM on August 18, 2009 [3 favorites]

Should I be ultimately subjected to arrest, confinement, and asset forfeiture if I continue to refuse to pay for everyone else's services? Does a simple majority rule of 50.1% consenting for an additional government service justify imprisoning the remaining 49.9% if they refuse consent? Do the ends of health care for all justify the means of imprisoning those that do not agree?

Yes, yes, and yes.
posted by dirigibleman at 1:34 PM on August 18, 2009

I thought Bioshock was a dramedy?
posted by Mister_A at 1:43 PM on August 18, 2009

I have a decent insurance plan and a family. Before I started a business, I had the same plan with my employer. On my own, under COBRA, I pay (IIRC) 110% of the cost of the plan (the CFO at my old company says the 10% premium is because people who choose plans under COBRA are more likely to use them).
Perhaps the law has changed in recent years, but about five years ago when I worked in HR, we were only allowed to charge COBRA participants 1% above our cost for their insurance. The additional 1% was supposed to cover our time and trouble for the extra billing and bookkeeping.

The title of the article in the OP seems deliberately slanted against the U.S. health care system for whatever reason. It seems to me that his father's death was a result of conditions that could happen in any hospital, anywhere in the world. Even hospitals that have the most stringent quality control systems in place are still staffed by human doctors, human nurses, human aides, etc. Humans are not perfect, they're fallible and there will always be instances of someone shirking their duty (consciously or unconsciously)....we're short-handed today, so the wastebaskets won't get emptied as often as they should, the nurse was up all night with her newborn and is exhausted at work today and may take some potentially dangerous procedural shortcuts.... etc. Just like there are airline pilots who get behind the controls when they're overtired or they've been drinking, even though there are company rules in place prohibiting this. I'm not defending the folks who caused the author's father's demise; I'm just saying that I don't believe this is a problem unique to or caused by the American health care system. There are understaffed hospitals and irresponsible employees all around the world.
posted by Oriole Adams at 1:43 PM on August 18, 2009

Perhaps I'm mistaken but I recall that colleges do this at the behest of the AMA. The same AMA that has been fighting against any kind of socialised healthcare since hiring Ronnie Regan in the 50s.
posted by PenDevil at 2:45 PM on August 18

Okay, so there's a place to start that will actually create more jobs and lower prices of care. Is anyone talking about doing that? Of course not.

The kids being educated in public schools are the future adults who will be maintaining my car, designing and manufacturing my products, helping me make financial and health decisions, producing my entertainment and representing me in government.

I am better off when everyone else is educated.

posted by DU at 3:05 PM on August 18

It's nice that you are generous. I'm generous too. Collectively we spend more on education than any other country. Perhaps we should demand more from the beneficiaries of our generosity than that they produce students who rank 16th among 30 industrialized countries in math proficiency.

I don't believe for a second that the government can deliver this service efficiently. It loses money delivering the mail. It loses money on Medicare and Social Security. It wastes money in Defense and the space program. We spend more on education than any other country and our 8th graders are mathematically illiterate.

Paying taxes is a duty and a responsibility. It's my duty to pay them. It's their responsibility not to waste our money.

Taxation is not theft. Whenever someone says that, I know I can ignore anything else they say.
posted by vibrotronica at 12:21 PM on August 18

No, taxation is not theft. Asking the government to raise someone's taxes and then transfer the money to you is morally equivalent to theft. But if it makes you feel better, call it a "wealth transfer."

You know what is hilarious about all this? That the magical number that identifies "the rich" is $200,000. You know who makes over $200,000 a year? Doctors.
posted by Pastabagel at 1:47 PM on August 18, 2009

Collectively we spend more on education than any other country.

I'm pretty sure you also spend more on Healthcare.
posted by chunking express at 1:59 PM on August 18, 2009 [1 favorite]

Yes, some doctors may have to pay a few bucks more on their income over $200,000. Also some lawyers, ad execs, certain plumbers, etc. We have a progressive tax code in the US.
posted by Mister_A at 1:59 PM on August 18, 2009

I get your point, but the answer isn't to make public schools private, but to actually make a sincere effort to improve them.
posted by chunking express at 2:00 PM on August 18, 2009 [1 favorite]

»Healthcare costs are the leading cause of bankruptcy in this country. Only one quarter of those people are uninsured. ...

This really blows my mind. The Swedish national healthcare system is far from perfect, but citizens forced into bankruptcy because of it is unheard of. I can't even imagine the stress and worry that would create, on top of being sick!

I've had readily available, tax funded healthcare all my life. Huge medical bills for the individual isn't part of healthcare, ever. Granted, my income tax is around 30%, maybe a bit less after deductions. And healthcare in Sweden isn't completely free for the individual either, but close.

I haven't seen a doctor in years, but a visit to one costs $0-40 (depending on e.g. county, and social services help people who are completely broke). Staying at a hospital costs $0–10 a night—you pay for the food, never for the surgery/MRI/chemo/etc. And you never pay more than a total of 900 SEK ($125) over a 12 month period ("high cost protection" kicks in and you get a "free card"), prescription drugs are heavily subsidised for everyone (and "high cost protection"→"free card" of some kind too), and so on.

That it could be any other way didn't even occur to me for the longest time. It's part of the social fabric, our shared safetynet.

There're 9+ million Swedes, so reading about tens of millions of Americans who can't afford to get sick is absolutely terrifying. I really hope you create a better system, your current one has millions of family-sized holes in it. You created rock & roll for chrissakes, this is well within your abilities.
posted by Glee at 2:01 PM on August 18, 2009 [5 favorites]

Asking the government to raise someone's taxes and then transfer the money to you is morally equivalent to theft

Yeah, because asking the government to transfer money to me is equivalent to asking for healthcare to included in the many services we give to every citizen.

You sir, are a cad and a scoundrel.
posted by lumpenprole at 2:01 PM on August 18, 2009

Any plumber who has a personal income of over $200,000 has been spending a lot of time in the Mushroom Kingdom
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 2:02 PM on August 18, 2009 [3 favorites]

It's astoundingly selfish if you think about it. How many times in these threads do people offer their own stories of how the system screwed them and how they need this reform to pass? That's fine and that's their right, and it is certainly a legitimate grievance, but please don't insult everyone's intelligence by presenting the issue as one of altruism.

Hey, the system's never screwed me, not at all; I've always had terrific coverage, first through my parents and then through my jobs. I've always had a home, too; never lived on the street.

Funny, though; I want people who need health care to get it, and people who are homeless to have homes, even though it doesn't directly benefit me. But I'm also selfish, and I don't want to foot the entire bill for everyone's health coverage or open my home to everyone who needs one. So I think that all of us who have jobs (to pay for health care and houses) pooling our money to help those that aren't as fortunate as we are is a good idea -- it lets me be altruistic AND selfish.
posted by davejay at 2:05 PM on August 18, 2009 [4 favorites]

Perhaps we should demand more from the beneficiaries of our generosity than that they produce students who rank 16th among 30 industrialized countries in math proficiency.

And as we know, none of the countries that did better have public, taxpayer-funded educational systems.
posted by dirigibleman at 2:07 PM on August 18, 2009 [1 favorite]

This was the situation re: education spending in 2001. I will search for more recent data.

In 2001, the 29 countries covered in this report spent approximately $1.1 trillion dollars on education or roughly 4.1 percent of their collective gross domestic product. The United States spent the most on education in 2001 at roughly $500 billion, followed by Japan, Germany and France at $139 billion, $89 billion and $82 billion respectively. While the U.S. spent the most in absolute dollars, it ranked tenth in education spending as a percent of GDP at 4.8 percent.
posted by Mister_A at 2:08 PM on August 18, 2009 [2 favorites]

Asking the government to raise someone's taxes and then transfer the money to you is morally equivalent to theft.

What about asking the government to raise my taxes and then transfer the money to someone else, in return for which I can get some money if I need it someday? I think that's the moral equivalent to hedging my bets.
posted by davejay at 2:09 PM on August 18, 2009 [1 favorite]

Although we did rank second in per capita spending.

SOURCE
posted by Mister_A at 2:13 PM on August 18, 2009

No, taxation is not theft. Asking the government to raise someone's taxes and then transfer the money to you is morally equivalent to theft. But if it makes you feel better, call it a "wealth transfer."

Was Robin Hood immoral? A fictional character, I know, but his tale has held strong for centuries. Maybe because we, the so-called "common people" understand the great wisdom in "wealth transfer"; neither moral nor immoral, just pragmatically resolving the many negative issues inherent in there being too many people around who, for whatever reason (indolence, sloth, bad luck, ill health, shitty parents, bad investment advice, artistic temperament) find themselves too poor to survive with any degree of dignity.

No doubt, you believe that you, individually, can spend your hard earned dollars more effectively toward the resolution of this problem than any government. And maybe you can, individually. But collectively, the so-called rich have utterly blown it over the last three decades (since 1980 when Ronny Reagan set his trickle-down revolution in motion) and they have no one to blame for it but themselves ... and the poor, of course, sly and devious architects of their own misery, every darned one of them, particularly the children, and the infirm.

Kill them all.
posted by philip-random at 2:21 PM on August 18, 2009 [1 favorite]

I don't believe for a second that the government can deliver this service efficiently. It loses money delivering the mail.

I believe you are conflating efficiency and profitability.
posted by zippy at 2:24 PM on August 18, 2009

Perhaps the law has changed in recent years, but about five years ago when I worked in HR, we were only allowed to charge COBRA participants 1% above our cost for their insurance. The additional 1% was supposed to cover our time and trouble for the extra billing and bookkeeping.

I believe it's now 2% Federal, 10% for California's Cal-COBRA extension once COBRA runs out.
posted by zippy at 2:37 PM on August 18, 2009

No, because then you might actually have to question your assumptions rather than just keep believing them without truly thinking about them.

Sorry, I have thought them through and taxation is not theft. Taxation can be unfair, punitive, useless and arbitrary, but it's not theft. It's taxation. We have words, and words mean things. You can say "I'm against taxation, because it's not fair," and I'll listen to what you have to say and maybe agree with you and maybe disagree with you. But when you say "taxation is theft", there's no arguing, because you're not there to argue.
posted by vibrotronica at 2:38 PM on August 18, 2009 [9 favorites]

You know, I gotta say - having lived in a social-democratic country for ten years now, where 38% of my income goes to taxes, I'm OK with that. Because those taxes go, in part, into a health care system that is going to cost me little or nothing for any amount of treatment I or my child needs (the degree of free, hands-on post-natal care we received was, in a word, breathtaking). Sometimes making an appointment with the GP means I'll be waiting a couple weeks before I see him. That's fine by me, because that's really the worst thing I have to deal with. The quality of the care is good and it's fully and completely affordable.

I'm not saying it's a perfect system by any means - there's a bit of brain drain here, as some graduating medical students get recruited by private hospitals in the US - and I don't think the existence of some private health care institutions along side the government plan would be the end of the world. I realize this is anecdotal and all, but really, going from America to here, this "socialized medicine" thing really isn't all that bad. I think the drop in stress levels from the piece of mind alone has probably added a couple years to my life.
posted by Marisa Stole the Precious Thing at 2:39 PM on August 18, 2009 [2 favorites]

Sometimes making an appointment with the GP means I'll be waiting a couple weeks before I see him.

Crist, my doctor is booked a month out. I don't think these so-called 'wating times' are some feature of a public health care system that will suddenly show up here. They're already here for most of us.
posted by lumpenprole at 2:41 PM on August 18, 2009 [1 favorite]

Sorry for the double, but I forgot to finish what I wanted to say.

This article is exactly the kind of debate we (the evil lubruls) need to be having with the conservatives. The author has clearly done his homework and makes some excellent points. We have been too focused on the health insurance companies as the only bad actors in the health care problems, and because of my bad experiences with the health insurance industry, no one is more guilty of that than I. We need reform on all levels, and I think this article brings some excellent ideas to the table that need to be looked at. I do not share his faith in the market to solve the problem, and I think health savings accounts are a bad idea, but at least he's making the best, most reasoned argument he can and not screaming and waving his gun around. If we had more of this kind of thinking and rhetoric, we would stand a better chance of getting out of the mess we're in and making a better society.
posted by vibrotronica at 2:45 PM on August 18, 2009

A very bad confrontation about health care. This is the worst thing I've seen about health care debate; an Israeli immigrant confronts a hectoring bully who says literally the worst thing to say to an jewish person.

Opponents like this aren't going to offer any meaningful kind of dialog, it's almost like a game to get people riled up. There's no way to please them because they're not for anything, but always against whatever idea is being floated.
posted by boo_radley at 2:46 PM on August 18, 2009

If I had seen something like this, I would have ended up in jail. Jesus Fucking Christ what the fuck is wrong with these people?!?
posted by ValkoSipuliSuola at 3:00 PM on August 18, 2009 [1 favorite]

And as we know, none of the countries that did better have public, taxpayer-funded educational systems.
posted by dirigibleman at 5:07 PM on August 1

Yes, but the ones that do worse also have public, taxpayer funded ones. In other words, the solution you are proposing is completely unrelated to the problem.

I don't like living in a country where so many people can't access the healthcare system or do so at their financial peril. So I would like an actual solution to the problem that doesn't alternately blame me for the problem or demand that a small segment of the population bears the burden of solving it.

The problem with talking about this issue in isolation is that you are ignoring the fact that the next thing that everyone thinks is a public service is also going to require a very minor tax increase. Fix social security? Okay, raise the taxes a percent or two. Need to shell out more for unemployment? Another percent or two. And when we actually have to pay back the $10 trillion debt? Another percent or two.

And the result will not be that the rich pay 6-10% more. The result will be that the rich will pay 0% more, because they will spend money to find legal ways to avoid paying it. And then what? You aren't solving the problem. You are just moving problems around.
posted by Pastabagel at 3:01 PM on August 18, 2009 [1 favorite]

Sometimes making an appointment with the GP means I'll be waiting a couple weeks before I see him.

Crist, my doctor is booked a month out. I don't think these so-called 'waiting times' are some feature of a public health care system that will suddenly show up here. They're already here for most of us.

I can usually get an appointment with my family doctor the same week, unless there's some major 'flu bug going around or something. And that's in 'rural' Ontario where we have a doctor shortage. And when I say doctor shortage, I mean that some people don't have a doctor they can regularly call up - not that they never get to see one. Those without a family doctor can go to walk-in clinics. Sometimes the wait is longish - you can lose a day doing this, if the clinic is busy. But it's not like you don't have access. And you are still covered, whether you have a GP or not.

Another important point about the Canadian medical situation -- one that rarely gets raised in US vs Canadian health care discussions -- is the fact that the system suffers from a uniquely Canadian problem. We have a relatively small population (32 million) spread out across the second biggest country on the planet. Therefore providing *any* kind of infrastructure, like phone or Internet or highways, either privately or publicly, is an expensive proposition with very low to non-existent ROI.

And Canada, like everywhere else, is becoming increasingly urban, which makes the problem worse. As people move into cities, their hospitals back home become even less "efficient" in terms of dollars spent vs. consumers helped, and the hospitals in the cities become oversubscribed.

This will settle out eventually, I'm sure, and in the meantime we don't lack for innovations to help solve the problem - this is why Canada has typically been in the forefront of things like satellite communication and telemedicine.
posted by Zinger at 3:01 PM on August 18, 2009 [2 favorites]

The United States has two parties now—the Obama Party and the Fox Party. The Obama Party is larger, but it is unfocused and its troops are whiny. The Fox Party, which shows up en masse to harass politicians, is noisy and practiced in the art of simplistic obstruction. As the health-care debate rages, it's the Party of Sort-of-Maybe-Yes versus the Party of Hell No!

Newsweek has pretty much hit the nail on the head.
posted by ValkoSipuliSuola at 3:01 PM on August 18, 2009

ometimes making an appointment with the GP means I'll be waiting a couple weeks before I see him.

Crist, my doctor is booked a month out. I don't think these so-called 'waiting times' are some feature of a public health care system that will suddenly show up here. They're already here for most of us.

I can usually get an appointment with my family doctor the same week, unless there's some major 'flu bug going around or something

I live in London and I've always been able to get same-day appointments with my GP. There's anecdote for you, if anyone needs it.

They have also called me to remind me that its been a year and I should consider getting a new blood test to see if my thyroid medication dosage needs changing. That would be the medication that i go to the pharmacy and pick up for free because this drug, which I take every day, has been classified as essential.

I also wanted to chime in to agree with this: I think the drop in stress levels from the piece of mind alone has probably added a couple years to my life. Oh yes.

And I say this as someone paying the top tax rate (40%) here. I wish all government usage of my taxes were something I was this happy about.
posted by vacapinta at 3:35 PM on August 18, 2009

I say this as someone paying the top tax rate (40%) here.

Working as a part-time MeFi moderator pays a lot more than I thought!
posted by grouse at 3:40 PM on August 18, 2009 [3 favorites]

Sometimes making an appointment with the GP means I'll be waiting a couple weeks before I see him.

At least 1.5 months to see my GP unless something is dire. And I have one of those fancy gold plated American health insurance plans.
posted by ryoshu at 3:45 PM on August 18, 2009

Since others already got to the non-fact about education, I'll do the doctor shortage.

First, MD salary is not the major reason US health care is so expensive. MD take home is only 10% of health care expenses. Even people who think we pay MDs too much point out that the other waste components are larger. Fee-for-service waste: $147B. Administration: 98B. Profits: 75B Drugs: 66B. MDs: 58B. There are a couple of reasons for this, but the main one isn't that across the board salaries are higher. It's that we have (and use) more specialists. Specialists are costly for higher take-home, their real cost (longer training = more deferred earnings, more interest on med school loans), and their more expensive skillset (more procedures). It's not reasonable to look only at salary and not take home across countries because US physicians have higher administrative and legal costs as well as self-financing their education. I remember a few years ago seeing Canadian primary care physicians having a higher average take home than US peers, but their specialists doing much worse.

More problematic is that we pay per-service (and mostly per-procedure), which means that to make more money we have to do more whether or not it is in the patient's best interest. Since physicians are able to induce demand (create waste) and get paid off of it (you really need that 4th MRI), in the absence of a central payer they are able to keep themselves busy in the face of additions to the work force.

Second, we regulate the number of doctors more at the residency level than medical school. Comparisons which look at medical school aren't useful since we make up for it by bringing in foreign MDs for residency and sending our undergrads out (eg, Caribbean medical schools).

The number of residency slots is titrated to prevent MD unemployment because of supplier-induced demand mentioned above..

The fact that MDs are paid well in the states relative to other countries is not really an argument that the work force is too small. We have a different population of doctors and choose not to regulate their salaries or pay them in a sane way.

I'll also point out that "MD shortage - make more and pay them less" is completely at odds with the conservative position on health care. We're supposed to have great quality (we don't, but anyway) and paying your physicians less and incentivizing them to waste more isn't going to help that. Making more specialists won't drive down costs, it'll send them up.
posted by a robot made out of meat at 3:53 PM on August 18, 2009 [2 favorites]

Excellent post - please contact the White House, your Senator and Rep about the public option.
posted by hooptycritter at 4:03 PM on August 18, 2009

crapmatic: the only thing that's going to fix the selfishness on the other side of the fence is either education (which generally doesn't work with that crowd) or shaming.

Toastmasters gives members an opportunity to craft a "speech to persuade." I'll be forever grateful to them for providing this bedrock concept for communicating persuasively: Appeal to your audience's self-interest. As directly as possible, I would add, because indirect appeals (eg, uninsured people using emergency rooms for health care) are more easily derailed and rationalized away. I had some guy reply to me that if it wasn't for all those illegal immigrants overburdening emergency rooms for their health care, the system would be fine. Aaargh.

It's been mentioned in previous threads, but it's worth reiterating that the I've Got Mine crowd obviously doesn't realize that they or their kids often come into contact with, say, restaurant or daycare workers without insurance, who can't afford a doctor's visit, who don't realize they've got swine flu or CA-MRSA or whatever other communicable disease.

emeiji's comment from a previous thread: When SARS hit Toronto in 2003, 43 people died. How many would have died had it emerged in a big American city instead, where large swaths of the population have little to no access to health care?
posted by cybercoitus interruptus at 4:42 PM on August 18, 2009

This morning I was awoken by my alarm clock powered by electricity generated by the public power monopoly regulated by the U.S. Department of Energy.

I then took a shower in the clean water provided by a municipal water utility.

After that, I turned on the TV to one of the FCC-regulated channels to see what the National Weather Service of the National Oceanographic and Atmospheric Administration determined the weather was going to be like, using satellites designed, built, and launched by the National Aeronautics and Space Administration.

I watched this while eating my breakfast of U.S. Department of Agriculture-inspected food and taking the drugs which have been determined as safe by the U.S. Food and Drug Administration.

At the appropriate time, as regulated by the U.S. Congress and kept accurate by the National Institute of Standards and Technology and the U.S. Naval Observatory, I get into my National Highway Traffic Safety Administration-approved automobile and set out to work on the roads build by the local, state, and federal Departments of Transportation, possibly stopping to purchase additional fuel of a quality level determined by the Environmental Protection Agency, using legal tender issued by the Federal Reserve Bank.

On the way out the door I deposit any mail I have to be sent out via the U.S. Postal Service and drop the kids off at the public school.

After spending another day not being maimed or killed at work thanks to the workplace regulations imposed by the Department of Labor and the Occupational Safety and Health administration, enjoying another two meals which again do not kill me because of the USDA, I drive my NHTSA car back home on the DOT roads, to my house which has not burned down in my absence because of the state and local building codes and Fire Marshal's inspection, and which has not been plundered of all its valuables thanks to the local police department, and which has not been bombed to smithereens thanks to the various branches of the United States Armed Forces.

And then I log on to the internet -- which was developed by the Defense Advanced Research Projects Administration -- and post on Freerepublic.com and Fox News forums about how SOCIALISM in medicine is BAD because the government can't do anything right.
posted by five fresh fish at 5:03 PM on August 18, 2009 [24 favorites]

Fuck yes.
posted by chunking express at 5:09 PM on August 18, 2009

Nicely done, fff.
posted by Zinger at 5:12 PM on August 18, 2009

Nicely done, fff.

It's an email forward that's been going around that was also reproduced here a few days ago. It is a good one, though.
posted by stavrosthewonderchicken at 5:18 PM on August 18, 2009

In my Canuck experience, doctors appointments are booked a week or less in advance. If it's for a real health issue, ie. flu, usually one gets same-day/next-day service or advice to head down to the walk-in clinic.

My experience with emergency-room procedures is that they perform effective triage. The triage guidelines are posted. They are perfectly obvious and sensible. When I end up waiting in ER, I know it is for good reason: because when I've ended up not waiting in ER, it was for things that made my other ER visits seem embarrassingly not-real-emergency.

What I would like to see us Canucks?BCers? using are nurse practitioners. I experienced that service in the US, for a wracking¹ upper respiratory infection. She ran a couple swab quick-tests, which I presume eliminate cause for panic (ie. go to a doctor immediately) and did what I myself would have done: prescribed a big-ass antibiotic. The infection was clearly bacterial, it was clearly rampaging beyond my own body's ability to control it, and it clearly needed to be clobbered hard. She prescribed Biaxcin, I think. IIRC, her checkup cost about U$80/C$100 and the prescription ran U$100/C$125. The scrip here would have been $60. The doctor/nurse visit would have been free to me.

When I got home I immediately visited my doctor. He agreed with her diagnosis and prescription and sent me on my way. I don't know what he got in remuneration. Might as well free up his time to do real work, and have relatively inexpensive nurses do the easy stuff. There's a whole lot of healthcare that is so mundane any bright person could follow a flowchart and come to the correct conclusion and course of action.

(Actually, this is the tactic the BC Government uses: everyone in BC gets a health care manual. It's a good 1" or more thick, printed using telephone directory paper and process. Loaded with health information, all clearly explained, illustrated, and cross-referenced. Includes flowcharts for self-diagnosis.)

¹To my surprise, that is the lesser-used spelling.
posted by five fresh fish at 5:49 PM on August 18, 2009 [2 favorites]

Whoops, I neglected to attribute or block quote or whatever. I don't remember where I first saw that. Might well have been StWC's link. Maybe Reddit.
posted by five fresh fish at 5:50 PM on August 18, 2009

Barney Frank lays it all out.
posted by Lord_Pall at 6:46 PM on August 18, 2009 [1 favorite]

Bob Herbert: This Is Reform?
posted by homunculus at 7:50 PM on August 18, 2009

I don't like living in a country where so many people can't access the healthcare system or do so at their financial peril. So I would like an actual solution to the problem that doesn't alternately blame me for the problem or demand that a small segment of the population bears the burden of solving it.

Look, it's not about you.

Bush took the tax level down, but what's being proposed is bringing it up to Clinton-era levels. What the hell is so wrong with that? I'm about sick up to here with hearing about the poor rich people. Us poor people are carrying the burden.

You know, the last time we went through this, the rate for the top bracket went to 79%. Then when the war hit, it went up to the upper 80%. Notice how that tax rate remained high and held at 70% until Reagan, and since Reagan we've run up huge debts. Consider yourself lucky for the low tax rate you enjoy now. That's not the way we did it when we paid our way.
posted by krinklyfig at 10:46 PM on August 18, 2009 [2 favorites]

Do you own an ipod or an iphone? You could feed someone for a month merely with the premium you paid for those products over competing brands. So, did you starve someone because you wanted to buy apple? --Pastabagel

No, I don't own anything made by Apple, and I never have.

Anyway, It's not clear if you're following along here, you asked if you were being selfish for valuing luxury items (including living in 'the best' neighborhoods) for your family over poor sick people, and of course you are. I would be being selfish if I demanded expensive luxury electronics over a reasonable tax increase to pay for public healthcare, but the thing is I don't.

Besides, I don't have much money. I, as an individual can't do much, but it's very easy for me to support government policies that take money from the rich to do the things I can't.

But the argument is trying to create the illusion of a connection. Why doesn't the government reshuffle a few dozen billions in the over $1 trillion budget to pay for this if it's so important? Why is the government spending on foreign aid, for example, if Americans are dying as a result of this crisis? --Pastabagel

Most of that aide is military aide that gets funneled right back to U.S. defense contractors. Presumably, cutting the humanitarian aide (which is not much) would have pretty dire effects on people in the countries we give the money too, another example of you wanting to shaft poor people in order to keep your taxes low. Nice.

This is a flawed argument, because there is no separate and mutually exclusive group here. Everyone, no matter how healthy their lifestyle, is susceptible to serious illness, and everyone, no matter how prudent their savings and investments, is susceptible to being in poverty. -- homuncula

Not true, there are people in this country who are rich enough never to have to worry about being broken by healthcare costs, and they're the ones with the most power as well.

And the result will not be that the rich pay 6-10% more. The result will be that the rich will pay 0% more, because they will spend money to find legal ways to avoid paying it. --Pastabagel

LOL. You don't actually expect anyone to take that argument seriously, do you? Obviously, if it were possible to chose your tax rate, no one would pay anything. It isn't like rich people are just sitting on a bag of tax tricks they could use, but choose not to, but will if taxes go up for some reason.
posted by delmoi at 12:09 AM on August 19, 2009 [1 favorite]

So, I'm sorry that the 7 month pacemaker wait was too long. The NHS deemed it as a reasonable wait. In exchange, millions of others received healthcare. Hundreds of thousands of lives were saved. It's a system that focuses on doing the most good while minimizing the bad.

...and a system where the criterion for dispensing care is NEED, not the ability to pay. Money buys a lot of things, but it shouldn't buy you the right to butt in line ahead of people who need care more urgently than you do. This makes sense only if the aim of the system is to sell healthcare services. As a means of ensuring a healthy population, it completely sucks ass.
posted by emeiji at 10:47 AM on August 19, 2009 [2 favorites]

David Sedaris is answering to questions from New Yorker readers online as I type and paste this:
3:12
The New Yorker: From e-mail, Pat Donohue from Point Pleasant, New Jersey asks:

As a resident of France and an American citizen, your point of view on health care in the two nations is of interest to those of us who have never received medical treatment via a system such as France's, which, I understand is a hybrid between single-payer (the government of France) and some private insurers. We receive so much information to the negative on France's health care and I would like to hear your view point and/or comparison between the two. Thanks.
3:13
David Sedaris:

Allow me to answer with kidney stones. I had my first one at the age of 34. At the time I was living in New York, and had no health insurance. Never in my life had I experienced such pain, but I couldn’t afford to go to the hospital, and so I passed it at home, not knowing until the end what it actually was. (I thought I was delivering Satan’s baby through my penis.)

I had my second kidney stone seven years later, in Paris. It was ten o’clock in the morning, and after looking at my options in the phone book in the phone book, I took the metro to a hospital in the 15th. Two minutes after walking through the door, I was in a private room. Delicious, mind-numbing drugs were delivered to my blood stream by way of a tube and life was beautiful. I was in the hospital for four hours, and as I was leaving, I asked the receptionist how I was supposed to pay.

“Oh,” she said, “We’ll send you a statement.”

“But you never even asked me my name.”

“Really?”

A few weeks later I got a bill for the equivalent of seventy dollars, this because I’m not a French citizen, and am therefore not entitled to free care.

I got my third kidney stone a few months ago, while on a lecture tour of the United States. The hospital I went to was in Westchester county and the service was outstanding. Maybe I arrived at the slowest time, but, like in France, I was waited on immediately, and the doctor and nurses could not have been more pleasant. Again I was there for four hours, though this time the bill came to $5,800. Not including medicine.

I’m completely fascinated by the health care debate going on in the United States, especially by posters of Obama with a little mustache drawn on his upper lip. Is that what Hitler is really known for, his health care plan? To quote Bill Maher, “I haven’t seen this many pissed off old white people since they canceled, “Murder She Wrote.”

Now I live in England. I’ve just been granted Indefinite Leave To Remain, which allows me access to the NHS.
posted by lucia__is__dada at 12:27 PM on August 19, 2009 [2 favorites]

At one point, when I didn't have health insurance, I went to a clinic run by a small non-profit. You paid for your tests and examinations, but they gave you the prices up front so you could make decisions about what you really could pay for and what you really needed.

Contrast this with the time I did have insurance and went to the hospital. The bill goes to the insurance company and then whatever they don't pay to you. Let's just say it was an unpleasant surprise.

How is anyone supposed to make decent decisions about personal monetary investment in health with such a system? Whenever I hear people complain how health care is an example of the free market not working, it boggles me and I'm not even a rightest. It's not an example of much....except maybe an example of things that don't work very well.
posted by melissam at 6:20 PM on August 19, 2009

American healthcare works exactly like the "free market" would have it work.

Take a look at Ontario Hydro. They were a public utility at one time, mandated to deliver power to the most consumers at the lowest possible cost. Ontario had stupidly cheap electricity for the longest time.

Then a corrupt government privatized it. Being free market, prices are now higher than they have ever been, with lesser service. But hey, at least now the CEO is paid a small fortune every year, and stockholders who don't live in Ontario nor use Ontario electricity have the opportunity to make money. The only losers are the citizens of Ontario! What a deal!

The same applies for healthcare. As soon as a profit motive is introduced, the focus is not on maximum benefits for least cost, but for maximum profit regardless the consequences for the actual users of the product.
posted by five fresh fish at 7:15 PM on August 19, 2009

American healthcare works exactly like the "free market" would have it work....

The same applies for healthcare. As soon as a profit motive is introduced, the focus is not on maximum benefits for least cost, but for maximum profit regardless the consequences for the actual users of the product.

I don't see why this article implies we need a completely free market...don't think that exists for anything yet. I think he's making a valid point that the new plan isn't much of an improvement, if any at all.

The current system just seems like a protectorate for large hospitals. Many I'm biased because I've received such amazing care from small non-profit clinics and I work in a small non-profit myself, but I don't think that's right. I don't support a totally free-market system, but that doesn't mean I have to support the current proposal.

I would be very nice to see the gov fund lots of diversified competing non-profits and not restrict any of them from doing good.
posted by melissam at 7:42 PM on August 19, 2009

melissam: by your screen name, I assume you're female, but i can't tell from your profile so I apologize if your not, but have you ever had a baby? just an uncomplicated, routine birth (not emergency c-section) costs nearly $10,000 on average (and that varies widely from place to place; I think we were told it would be closer to $20,000 at our hospital). Never mind the costs if there are complications.

Who can afford to pay that out of pocket?

Catastrophic care is even worse. My uncle broke his neck earlier this year and has had to have extensive care and therapy. He's a former paper mill worker who watched his pension disappear when the mill closed. He's been working as a carpenter and roofer since then with no insurance of his own (he couldn't afford it). Since the accident, he hasn't been able to get a dime of disability and now he owes upwards of $50,000.00.

What possible free market or small, non-profit solution could there be in situations like these, where the care simply costs a lot whether you pay through a health insurance plan or pay out of pocket and have no choice but to pursue the treatment? In my uncle's situation, the only free market solution is to either to let my uncle die without treatment or lose all his personal wealth and property.

Isn't it the one fairly clear, constitutionally-mandated role of the federal government, as defined under the amendments that make up the bill of rights, to protect our rights to life and property?
posted by saulgoodman at 7:51 AM on August 20, 2009

(arggh. typos everywhere.)
posted by saulgoodman at 7:52 AM on August 20, 2009

Out in Alberta, Canada, there are always ongoing rumblings of discontent from the gov. peoples who compare the current system (and it's cost to the Government) to the free (ah ha) enterprise system our neighbours to the south... enjoy. The multple entities (two, or three really) that made up the health care system in Alberta have been coalesced into a 'Superboard' run by Dr. Stephen Duckett.

He's an australian fellow who was involved in running the hybridized system they have down there, and has been making more official rumblings of increasing the private nature of the system that currently exists to reduce wait time, and optimize facility use.

I guess I"m a little concerned that the rhetoric remains while the venue changes
posted by LD Feral at 1:41 PM on September 2, 2009

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A very good article on health care economics
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A very good article on health care economics
August 18, 2009 6:40 AM Subscribe