03 Apr

Why I Hope California Goes Ahead With Medicare For All

As part of my attempts to reduce anxiety-loops related to media consumption, when the argument broke out about Obamacare eight years ago I purchased a number of books about healthcare around the world to better understand the global context and options.

I find Americans tend to argue that there’s ‘market’ driven healthcare and ‘socialist’ healthcare. Europe has ‘socialist’ healthcare and that’s expensive, they use a high amount of taxes to support it. America has less taxes, and spends more on defense, so it uses ‘market’ healthcare that its citizens pay for.

Often, the argument between left and right Americans is between arguing for higher taxes and better healthcare, or using the ‘market.’ Many Americans who have healthcare via their jobs are also somewhat uninformed about what American healthcare looks like and how it works. The number of people I’ve talked to who have day jobs and healthcare through employers and who are upset about Obamacare market exchanges being forced on them when they’re not using it, is somewhat astounding to me.

Talking to Europeans and other folk around the world, I also noticed that people took it for granted and saw it as invisible, or talked about the downsides. It wasn’t until I would outline how it worked in the US that they got horrified faces (I knew it was bad, but fuck me, was one friend’s response via email).

As far as I can tell, the America system is an amalgamation of a number of different healthcare approaches all followed somewhat haphazardly. It actually uses elements of ‘socialized’ healthcare and ‘market’ healthcare. But those two dualities are not altogether right, as far as I can tell.

The book that laid it all out the best is The Healing of America, which I really recommend anyone who opens their mouth about healthcare options read.

Different Types of Healthcare Models

There are basically 4 approaches to offering healthcare in the world that humanity tries. Wikipedia summarizes them here:

The Bismarck Model

This is the model followed in Germany and in its rudimentary form was laid out by Otto von Bismarck. The system uses private initiatives to provide the medical services. The insurance coverage is also mainly provided through private companies. However, the insurance companies operate as non-profits and are required to sign up all citizens without any conditions. At the same time all citizens (barring a rich minority in the case of Germany) are required to sign up for one or the other health insurance. The government plays a central role in determining payments for various health services, thus keeping a decent control on cost.

The Beveridge Model

This model adopted by Britain is closest to socialized medicine, according to the author. Here almost all health care providers work as government employees and the government acts as the single-payer for all health services. The patients incur no out-of-pocket costs, but the system is under pressure due to rising costs.

The National Health Insurance Model

The Canadian model has a single-payer system like Britain; however, the health care providers work mostly as private entities. The system has done a good job of keeping costs low and providing health care to all. The major drawback of this system comes from the ridiculously long waiting times for several procedures. The author, T.R. Reid, would have had to wait 18 months for his shoulder treatment in Canada.

The Out of Pocket Model

This is the kind of model followed in most poor countries. There is no wide public or private system of health insurance. People mostly pay for the services they receive ‘out of pocket’. However, this leaves many underprivileged people without essential health care. Almost all countries with such a system have a much lower life expectancy and high infant mortality rates. The author gives his experience with the system in India, and a brief description of the ancient medical system of Ayurveda.

So by the writer’s estimation, the USA mixes in from all four of those models above in bits and pieces.

Healthcare Models the US uses all simultaneously:

  • The Bismark Model for people under 65 and in the workforce. Although not non-profit, as in cheaper and more successful Bismark models, for profit companies work with employers to get health insurance set up in US. 64% of the US population, according to the US Census, is covered by the for-profit Bismark model. Kaiser Family Foundation claims it’s 49%.
  • The Beveridge Model for Veterans, Active Military Personnel, and Native Americans. This is where the government directly hires the doctors, and builds the hospital. This is how the UK creates national health care (and is actually sort of what Americans think socialized healthcare is). .5% of the population is active military, 5.2% are veterans, and about .5% of the US population are Native American eligible for that coverage. Up to 6% of the US population is covered by this centralized government healthcare model.
  • The National Health Insurance Model in the US is used for anyone 65 or older. This is called Medicare and Medicaid. The government acts as the insurer, collected payments (either through taxes or straight payments) and negotiates with private hospitals and doctors. According to Kaiser, 14% of the US population is on Medicare. 20% of the US population is on Medicaid. 2% is on other public assistance (like CHiPs for children to get access to healthcare if their parents have none). Canada uses the NIH model, it’s even called ‘Medicare’ and it’s basically Medicare for all, even though it’s decried as socialism by the American right wing.
  • The Out of Pocket model is used in the US for poor folk who have slipped between all those other systems and is often advocated for by right wing folk.

So, 36% of the US uses some form of a system from the NIH model, 50-60% of it uses some form of Bismarck mode, but using for-profit systems that are lightly regulated, whereas every other place that uses the Bismarck model (some of Germany, France, Belgium, Netherlands, Japan, and Switzerland) don’t actually do socialized medicine, they just highly regulate the companies that provide and demand they cover all citizens and offer minimum benefits.

Canada and the UK, which offer what some might imagine as socialized medicine, do it through two radically different mechanisms (Canada creates a national health insurance company via the government, Medicare, while UK government directly hires doctors and makes hospitals).

Few of the above, even in Europe, are actually truly socialized medicine, by the way. The UK comes the closest. Socialism is ‘seizing the means of production from private capital.’

What is ‘Single Payer?’

Okay, a number of debates are about ‘single payer’ and socialized healthcare vs ‘market’ healthcare.

Single payer means the government acts as an insurer and collects all the payments, whether via a tax, or via a set payment, and then pays private hospitals or doctors for your treatment. Having a single source means the government can negotiate down costs.

Medicare and Medicaid are single payer. The UK and Canada are single payer models. Canada is Medicare for all. A third of the US system is single payer. It is just that most Americans do not realize this, it’s a wonky term. Many people hear ‘single payer’ and they don’t think ‘Medicare’ they think ‘Canada’ or ‘Europe’ even though Europe has a mix of systems.

Who likes their healthcare the most?

Funnily enough, UK patients tend to self-report as liking their healthcare the best:


But that doesn’t mean the more socialized the healthcare the happier people are. Switzerland has a fairly lean Bismarck model that the US would recognize and is second on that chart up there. The difference is that they regulate the ever-loving hell out of it and require (mandate) that everyone buy some, something the US keeps shying away from.

Who lives the longest?

People in Japan live the longest. Switzerland is next, followed by Singapore, then Australia, Spain, Iceland, Italy, Israel, Sweden, France and then Republic of Korea for your top 10.

Now whenever I post that someone links me to a look at how much more they have public transportation, or a better diet. Sure, it’s not healthcare alone. But it’s the single largest impact on life expectancy of a civilization. The fact the USA is #31 on the life expectancy list  and dropping (one of the few or only developed nations to be reversing a trend in life expectancy growing in areas of the US) demonstrates the power of healthcare and quality and longevity of life.

But can America afford healthcare?

Often I hear an argument that goes “well, the US spends so much on defense we’d have to give up other things to have the government create socialized medicine, socialized medicine is too expensive.”

Well, arguments against the complicated amalgam of systems the US currently has isn’t an argument for socialized healthcare and also no other system is more expensive than the US system.

Here’s what countries spend, both in taxes via the public government, and via private systems, visualized on a graph:

You can see that just in government spending, the US spends as much as Switzerland, Netherlands, Sweden, Ireland, Austria, Denmark, Belgium and more than the UK. So we don’t have to spend any more than we’re already spending, we just need to change what we’re doing.

Also, all of those systems get dramatically better results for longevity and patient-reported happiness.

Woah, why is American healthcare so expensive?

There are a lot of reasons. A big one is that America is one of the few countries that assumes health insurance companies should be big, profitable businesses. Most countries look at it as a service. Fire, police and teachers aren’t big, for-profit business, but are services for the community. They make assumptions moving back from there. America’s education system also puts a huge burden on medical professionals who take on a lot of debt, who then charge more. The US also has a legal system that allows big lawsuits, that means doctors take out expensive operating insurance.

There are many other pain points as well, but another huge one is this:

The entire US system is actually socialized, and it was socialized by President Ronald Reagan in the 1980s with something called EMTALA. I have a long post about that here.

Short version: the US used to require payment or proof of insurance before you went into the ER. Reagan changed that to legally force ERs to take care of anyone who came in. Thus, the moral contract America legalized was that all people should be taken care of.

What Reagan never did was to decide how we paid for it. We’ve been arguing ever since. But hospitals are still admitting people. And since many Americans don’t have insurance for preventative care, they use the ER as their doctor. ERs pass this cost onto any American who has insurance by randomly fiddling with billing to make sure the hospital as a whole makes a profit.

I sometimes thus make the argument that American health insurance is a ‘socialist’ (using some right wing arguments about healthcare) unfunded mandate.

So what do I think we should do?

Funny you should ask.

This is of interest to me:

One of my friends who is a nurse retweeted this and it caught my attention because of the history of how Canada came to adopt the NIH model. In 1947 in Saskatchewan, a Canadian province rolled out an act that guaranteed free care, thanks to one Tommy Douglas. They couldn’t quite do universal health care, the original vision, due to funds at the time. Alberta came next with medical coverage for 90% of the population. In 1957 Canada’s Federal government created a 50% cost payment plan, and by 1961 all the provinces were using that plan to create universal programs. In 1966 it was expanded further.

That hints to me that all we need is one big state to do something similar in the US. Vermont had looked into it after Obamacare was passed, as that law has a provision allowing a state to take federal funds for health and pool them all into one giant pot if it’s creating a universal healthcare situation. That’s basically the Canada path.

I also think using Medicare as the vehicle is smart.

Medicare has a great brand. In the US, 75% of its users report satisfaction, making it one of the more well-liked American institutions.

Further, using existing Medicare program for growing would bring down older users costs in the program by healthifying the Medicare user base.

Lastly, Medicare, even though it’s for older folks and higher risk by default, is pretty damn cheap in comparison to workforce insurance and self employment health insurance. Part A is free (basic emergency stuff and hospitalizations) and Part B (doctors and preventative stuff) is $150/month and part D for drugs is $50. I’d jump on that.

And none of this means employers have to stop offering great healthcare plans to sugar employment deals. In the UK, and all throughout Europe, people who make extra money bolt on private health insurance plans on top of the public options so that they can the care they want in the style they want. Medicare has a part C, which is where you can get a more Cadillac private insurance set up added on.

But having the option so you can get out of a shitty employer healthcare plan, or move around, be portable? That sounds great.

One Canadian province setting it up got other provinces to look over there and say ‘hmmm’ and spread the idea. If California got rolling, it wouldn’t be too long before Washington and Oregon joined up, and the entire west coast was set up. They’d draw a lot of small business over there.

I’ll be rooting for California.

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