Health Care, Post 3: Why the free market doesn't work here.

[Silverhair]

In the previous two posts I talked about what was wrong with the insurance system and why it was the system itself, and not bad companies that was causing the problem.

In this one, I will state why capitalism fails in delivering health care.

After this post I will sift the focus of my series of health care posts. I will go from why what we have doesn't work, to what we need to do. I have been preaching to the choir in these three posts, because I wanted to establish WHY the current system fails.

I am NOT a socialist. In most areas of life the free enterprise system simply can't be beat. It does a better job of providing goods and services than any other. But the free enterprise requires at least four conditions be met for it to do so well. They are:

1. There must be genuine competition among the sellers.

2. The person making the buying decision must be spending his
own money or have other reason to economize.

3. Most consumers must be reasonable well informed about the product
or service to be able to may comparitive decisions.

4. Most consumers must not be under duress.

Obviously, these conditions are not met in today's healthcare delivery system if there is insurance, so costs go up dramatically. If you don't have insurance, you can't afford a serious illness.

When I see a doctor, I don't have the specialized knowledge to be able to negotiate prices. And I am definately under duress if I have had to go to an emergency room and am in pain.

When I take my car to the shop, I may not have the knowledge, but at least I can ask for an estimate, and consider buying a new car, or going to a different garage.

So the idea pushed by some of the right, that people should simply pay for their own medical bills themselves just doesn't work.

[sybylla]

1. I would add one other thing

Health care for all will never occur under a for-profit system.

I say this because no for-profit business is looking to service everyone. They only want to service the customers who cost them the least and maximize profit.

For example, the hardware store down the street doesn't want all the contractors in the area to shop in their store. They only want all the contractors who pay on time and pick up their special orders in a timely manner. The rest just eat up profits.

Just like health insurance companies only want to insure the healthy customers because the sick customers eat up all their profits.

It doesn't matter how much competition there is. Three pharmacies, all run for profit, all have the same motivations and are all only likely to compete in a few areas. None of those areas will include servicing the more "expensive" customer.

In addition, I would suggest that non-profit alone is a cure either. I have a large not-for-profit clinic and hospital in my nearby community that operates no differently as a for-profit. They watch their bottom dollar, they harass people who owe them money and they charge top dollar for their services just like for-profit clinics and hospitals. They even ran all their competition out of the area so that their higher prices would become "reasonable and customary." The only difference: this clinic/hospital complex pays no tax whatsoever to their supporting community.

To my mind, regulated non-profit is what we need. Whether you regulate prices that can be charged or you regulate how much cash-flow these organizations have, there has to be controls.

[Silverhair]

2. Correct. I like a free enterprise hardware store. But free enterprise

in health care, just doesn't work. The whole system needs to be redone. The free enterprise system in pharmacies doesn't allow them to carry "orphan drugs."

[ewagner]

3. I know exactly what you're talking about

Here is the way it is starting to shake out (both locally and nationally):

Those who can pay will get health insurance. Those who cannot will get government subsidized health care, which may or may not be quality care. Health Insurance companies are supposedly prohibited from "cherry picking" the best risks but, in practice, it is done by costs. The end result will be a two-tiered system where government will get stuck with financing the unhealthiest population and the health insurance companies will take the healthiest population for profit.

I tried an exercise some time ago using the "deep Throat" analogy: follow the money and found that there is this unholy trilogy in the system:

Insurance Companies: making almost obscene profits.
Doctors: making equally obscene salaries/profits
Lawyers: making equally obscene settlements

It's an endless loop with each of the elements feeding off of each other.

[Silverhair]

5. Actually, many health insurance companies are in financial crisis.

Health insurance isn't that profitable, and many companies lose money on health insurance.

I have no quarrel with doctors making lots of money. Why do we want only the best people to do a particualar job, and then want to pay them a ditch-diggers pay? If we want top minds studying medicine, then they need to get top pay.

Lawyers - Yep, this is a huge part of the problem. I have a recommendation for that. It will be in a future post in the series where I will talk about malpractice.

[sendero]

8. Hmmm.....

.... I've seen nothing that shows that lawyers are a "huge part of the problem". Certainly, doctors are more careful about running certain tests, etc - to protect themselves from negligence claims. But I'm not so sure this is a bad thing.

As for doctors and their pay, I think some specialists are vastly overpaid. But the family doctor is anything but. The insurance/government axis has out the major squeeze on basic doctoring. My own doctor claims that he is down to barely into 6 figures, hardly overpaid. Any good doctor should be able to make 150-200K, they work their butts off and have a lot on their plates.

But a lot of them are not because they have to sell an office visit, with all its overhead, for $20 under a PPO contract.

[Lydia Leftcoast]

11. My brother started private practice this year

and he has lost $15,000 despite being fully booked with patients.

The problem is the insurance companies, which refuse to reimburse him within any reasonable time frame and like to turn down claims. He's learned that the decisions to accept or reject claims are made not by medically trained people but by clerical workers who are trained to blindly follow bureaucratic procedures.

He gets good results in treating people with job-related injuries and disabilities, but since he refers people to surgery and prescribes drugs only as a last resort and insists on spending time with each patient, he gets penalized for deviating from standard procedures.

In the meantime, he has office rent, equipment to pay for, and a bookkeeper-receptionist to pay.

[WhereIsMyFreedom]

39. Then where is the money going?

There is a whole lot of money circulating in health care, whose pocket is it ending up in?

[sybylla]

10. Exactly.

I came up with the trilogy a few years ago too. And our neighborhood clinic with its own insurance company helped me figure it out. Though I would put less blame on doctors and more on the clinics/hospitals who hire them and force them to work in conditions that maximize profits - e.g. 5 minutes with each patient.

[ewagner]

12. In the case you are referring to

It's a "group practice" where there is a "distribution" of funds which would normally be considered profits. Therefore, the system which requires them to maximize revenues eventually financially rewards the docs for doing so.

[NewGuy]

4. Free Enterprise day-to-day?

I have always thought that a combination of catastrophic health insurance (either govt or private) and a savngs account for day-to-day care is what is really needed. It puts the competition back in on a day-to-day basis. If I need a physical or have a cold or other minor illness, I can see anyone I want and can shop price before I go.

In the day-to-day business of health care my needs are much like a new car buyer or a person shopping in a hardware store. When I am seriously injured or if I become seriously ill, the catastrophic plan kicks in after a thousand of my own money. I need my savings account but I do not have to pay hundreds of dollars a month for health insurance. Putting a couple of thousand in a savings account only requires a few months of not paying for the health care insurrance. Of course during that time you would still want to have the catastrophic and you may end up going into debt if you become ill before you save the requires amount to offset the high deductible.

[IrateCitizen]

6. Except it STILL has one big hole...

That being that the vast majority of those currently WITHOUT healthcare cannot afford to generate a "savings account" for regular visits -- even when "catastrophic" illness after the $1,000 deductible is still covered. Your plan also says nothing about the exponentially increasing costs of prescription drugs.

In fact, one of the primary ways in which our for-profit system fails is that it encourages conditions to develop to the point at which it costs a lot more money to treat them, rather than being preventative in nature.

Still trotting out the "new car salesman" analogy? I thought that one had been debunked already by one of our more knowledgable real economists....

[NewGuy]

13. If we start from today's situation...

we have to consider today's cost. For those with insurance, the option to pay less for catastrophic only and to put the rest in an account is a good one. Even if you include the cost of drugs. The company I work for provides this option and most people take it. Regardless of who pays for it, it costs the same or less to have. It is very similar to car insurance. In most years you won't have an accident (or a serious health problem) so carrying a low deductible doesn't pay for itself.

If we agree we need to cover everyone then what we should look for is the cheapest method that would do so, then work to determine where the money would come from to cover those who cannot cover themselves. What I hesetate to do is develop another program that will cover everyone to make it "FAIR". If, instead we work from an assumption that the current cost is too high and must be brought down. An entire diferent set of assumptions is required.

[IrateCitizen]

16. You'd still have to supply a "full coverage" threshold

below which, no deductibles (or a greatly discounted one) would be paid.

There are some pretty big groups of people in our country who can't afford unforseen expenses of as little as $25 per week. They are the true working poor -- the same people detailed in Barbara Ehrenreich's book Nickel and Dimed as well as the A&E Documentary, "Not Getting by in America". These people are EVERYWHERE, although you wouldn't know it by watching the television. They can't afford a deductible. Do you think they should then just be left out of the system?

[NewGuy]

22. Not left out, just a diferent system

I don't believe they would have a problem now if they looked into all of the options available to them. However, if a plan is needed just to cover the routine health care costs of the chronmically poor, I would support that.

[Lydia Leftcoast]

42. I'm currently uninsured and "looking into all the options"

Believe me, if you have "too much" money to qualify for Medicaid (and it's a VERY low threshold), there aren't many good options.

You can either pay an utterly unaffordable amount for low-deductible/low copay insurance or a somewhat less unaffordable amount for high-deductible insurance. Either option would really strain the budget of someone earning $25,000 a year.

Blithely saying that all the uninsured people should just get health savings accounts is like saying that homeless people should just sign up for those mortgage programs for first-time buyers.

I'm probably going to settle on a health savings account as the least of all the evils, but it's still going to be tight.

I was with an HMO in Portland, and last year they raised both the monthly premium 15% AND jacked up all the copays, so that instead of paying $25 for a standard gynecological exam with the usual lab work, as I had for the past ten years, I suddenly had to pay $75.

Those types of price increases can discourage low-income women from getting Pap smears and mammograms, which in the end is penny-wise and pound-foolish. It's easier to treat some iffy-looking cervical cells than to treat full-blown cancer.

[ret5hd]

29. well, using your assumptions...

everything i have read states that all western europes and canadas per capita healthcare costs are substantially below ours.

also, why is it that this country has chosen to base the availability of healthcare on employment? if you're not employed (or rich enough to afford self-insuring), we would just as soon you die? that is what it seems like.

it seems like employers would be clamoring for nationalized HC.

[Silverhair]

7. That leaves lot of people falling throught the gaps, and

eventually everyone (Unless they die first) will fall into a gap.

What do you do when no insurance company will cover you?

Use the search function and look up my two previous posts on the subject. I used to own a small insurance agency, specializing in health insurance. Free enterprise health insurance doesn't work.

[NewGuy]

15. The current system does not work

However, where is the large gap you are talking about? If people convert to major medical or begin taking major medical coverage, that should reduce the gap. Additionally, millions of people actively shopping for health care on a day-to-day basis should bring down,or at least slow the increase, of health care costs.

If you are driving down the "we need universal health care" road. The thing to discuss is the cost. Otherwise you are advocating cold beer and warm women all around without being able to provide either. I am a huge advocate of universal health care if someone can show me where to get the money, while keeping in mind that our current system of government is (more or less) a representative democracy.

[IrateCitizen]

19. Because it actually costs LESS

The US currently spends the most money per capita on health care than any other nation in the world -- and yet we STILL have some 14% of our population without health insurance and probably at least as many with substandard insurance. That's close to 30% of the population with inadequate access to medical care.

The costs of this are high themselves -- in missed work, decreased production, and so on.

Why is it that other countries that DO have single-payer plans spend less money than we do while insuring all their citizens? One factor is the elimination of profit as an expense in the administration. Another is the simplification of the overall healthcare system by having only ONE system rather than countless labyrinths for doctors to navigate. Another is the fact that, under the current system, those with existing illness and/or injury will put off going to the doctor until they can no longer function -- quite often resulting in preventible illnesses becoming much more serious and therefore having significantly higher treatment costs. And yet another is the streamlining of bureaucracy that would result from having just one provider rather than countless ones. Contrary to popular belief, placing things in private business does not streamline them -- in some cases it makes them MORE complicated. I can attest to this as someone who has worked his entire life in the private sector.

I've read figures that the administration costs of health care go from 14% to 9% of the total cost when you move from for-profit to single-payer. Those savings in themselves should come close to providing enough funds for adequate preventative healthcare for all.

[NewGuy]

24. If the entire health care problem...

could be fixed with the 1/3 savings in administrative cost I would whole heartedly endorse such a plan.

However, the devil is always in the details. A few years ago the Canadian system instituted a fix that prevented Canadians from vacationing here and getting their health care here. The reasons sited by the Canbadian patients who came here included long waiting times for care, poor quality of care, and administrative dificulties (apparently single payers are no more anxious to pay than are insurance companies) in getting care. What they changed was to limit what the Canadian system would pay for care outside the system to the amount they would pay in the system. In other words, the entire administrative burden came back.

[IrateCitizen]

25. And there it is (finally)!

The reasons sited by the Canbadian patients who came here included long waiting times for care, poor quality of care, and administrative dificulties (apparently single payers are no more anxious to pay than are insurance companies) in getting care.

Y'know, I love it how this line is always trotted out in times of trouble by those advocating AGAINST single-payer. But I used to work with a guy from Canada who had lived his entire life in the Great White North before moving to NY for a job (he's since returned) who had nothing but good things to say about his system -- and would consistently bash ours.

I'm certain that there are some Canadians who are dissatisfied with their system. By the same token, if you'd talk to the 30% or so in the US with either no coverage or inadequate coverage, they'd probably express deep disillusionment as well. No system will be perfect -- the key lies in finding the system that best meets the needs of society as a whole. In that regard, the US system is a complete failure -- based on the two facts of the 30% w/o adequate care AND the highest expenditure on health care per capita of the entire WORLD. We're spending MORE and getting LESS in return!

[NewGuy]

27. Canada changed the law because

this was happening. This is not one of those 'a friend of a friend told me it was a bad deal' story. I heard this talked about in great detail on the local news from Canada radio talk show. I live in Florida in snowbird country and the local radio has a bit called Canada Calling they were warning people when the change occured because of the potential downside for those who had been receiving care and weren't aware of the change.

I try to avoid posting opinion unless I tag it as such.

Are you or anyone else planning to answer the question of how single payer gets around these issues. That is one I have not seen here or elsewhere. Apparently it is easier to ignore part of a post and challenge the rest than it is to post an actual answer.

[IrateCitizen]

28. Hello pot, meet kettle...

Are you or anyone else planning to answer the question of how single payer gets around these issues. That is one I have not seen here or elsewhere. Apparently it is easier to ignore part of a post and challenge the rest than it is to post an actual answer.

I guess the same could be said for you refusing to touch the fact that we pay the highest per capita for healthcare in the world with 30% receiving substandard coverage or no coverage at all....

What they changed was to limit what the Canadian system would pay for care outside the system to the amount they would pay in the system. In other words, the entire administrative burden came back.

You're talking about apples and oranges here. What it appears to me is that people seeking to live in both the US and Canada were unhappy that their Canadian medical coverage would not fully cover US doctors. This has absolutely nothing to do with "the entire administrative burden (coming) back."

If I were injured while travelling to another country without supplemental insurance, I would not be guaranteed reimbursement. It seems that these Canadians spending significant time in the US are running into the same problem. And it also seems that they are not suffering for lack of coverage under the Canadian system, so long as they remain in Canada.

I would be interested to learn more about how the EU members' systems are integrated to prevent such problems from occurring -- as all of mainland Europe has socialized medicine and they have people going between countries so much. Perhaps there would be a lesson there?

I fail to see how this is a major issue. Now, if you're talking about long waits and inadequate care, we have plenty of that to go around on our side of the border as well, with more people falling through the cracks.

[NavajoRug]

33. I'd love to do some research on health care costs . . .

. . . for different countries, but only take into account those health care costs related to things that would be deemed "medically necessary" to your average citizen.

While 14% of the U.S. economy is related to health care, I suspect that a lot of the money we (not ME, but WE in general) spend on health care is for things like plastic surgery and other things that may not be "needed" in a health care sense. I'm certain the U.S. spends more on that kind of stuff than anyone else in the world.

[Silverhair]

38. How about the amount used in the final year of life?

It has been years since I have seen the stat, and I will try to research it some for my next post on next Monday. I do remember that it is something like the average person using one third of their costs in the final year of life. That would mean that a lot of our health care costs are spent stretching out the act of dying instead of healing.

[IrateCitizen]

45. I'd bet that plastic surgery is a small contributor

Probably the biggest contributor is that our current system discourages many people from going to the doctor (because it will cost them money they can't afford) until an illness reaches crisis level.

Our system is completely penny-wise but dollar-foolish. It actually discourages people from PREVENTATIVE measures that would cost some money in the short term but save in the long run -- because if someone doesn't have regular checkups that might spot a disease in its early stages (such as cancer), it inevitably costs exponentially more to treat it after it has really taken hold.

I'd bet that this is a much more common phenomenon than plastic surgery. Plus, people in other countries that have socialize medicine can still get nose and boob jobs -- it just isn't covered, same as here.

[Silverhair]

51. No insurance covers cosmetic surgery - except reconstructive.

If you want a nose job, you have to pay for it yourself. If your nose was injured in an accident and disfigured, most insurances will pay for getting it fixed.

So cosmetic surgery doesn't really enter into the equation.

[IrateCitizen]

53. Do you agree with my preventative vs. catastrophic argument?

Just curious.

Thanks for the clarification on cosmetic surgery, too. When I visited Europe this summer for my honeymoon, it is clear that there are a fair share of Europeans who engage in cosmetic surgery. Not as many as in the US, but it still happens.

[Silverhair]

55. Absolutely. Prevention is far cheaper than treatment.

And it produces a healthier more producive population. Lots of benifits to prevention.

[Snow]

56. This is another example of a denominator problem....

the Canadians who come to the US for care are a lot different from the Canadians who don't. There's an implicit assumption in NewGuy's statement that those border-crossers are like other Canadians, that most or all Canadians have those same complaints. That may or may not be true, but it's not a question that can be addressed by asking questions of a group who chooses to come south for health care.

[Silverhair]

20. What do you do about the people that insurance will not touch?

I am an insulin dependent diabetic. No health insurance company will touch me, except that I get coverage from my wife's plan at her work. I am self employed so if it weren't for her, I would have to find a job with benefits, and probably make less than I do working for myself.

There are loads of people that insurance companies will not insure, and as we each get older, we usually begin to develop health problems. Health insurance for individuals becomes more difficult, and finally - impossible.

Yes, the problem of costs does need to be addressed. And that will mean some political biting of the bullet. But I think that the public is ahead of the politicians and will be willing to get rid of certains things that are very wastefull. I will start talking about reducing waste in my next post in this series.

[NewGuy]

23. Again, I would have no problem with

a change to our current system that would help those with unique problems. My concern is with those who want to change the system thatcreated the long living healthy people who live here.

[tkmorris]

31. But that isn't really true

It's amazing how people seem to assume that the life expectancy in the US is high compared to other countries. It seems to be taken as a given, due to our "superior health care" system that we have now.

It isn't true though. In truth the life expectancy in the United States ranks 42nd in the world. 42nd. That is shameful. We have BY FAR the mightiest military machine the world has ever seen but health care is apparently not worthy of attention.

Source: http://www.nationmaster.com/graph-T/hea_lif_exp_at_bir_tot_pop

[Lydia Leftcoast]

44. Truth time, New Guy

Do you work in the insurance industry?

[IrateCitizen]

46. Nah, he's just one of those "free market zealot" types...

I think he said in an earlier post that he was an engineer -- which is interesting, considering that engineering is one of the biggest publicly-subsidized occupations on the face of the earth.

I should know, because I am one -- and even though I work in private industry, ALL of my projects are with big public works agencies.

[Silverhair]

49. You can't find one solution for all situations.

I am a free market zealot too, but even I recognize that the free market doesn't work with health care.

[IrateCitizen]

50. If you recognize it doesn't solve everything, you're not a zealot

That is the very essence of the term "zealot" -- someone who shuts out all evidence that would go against his/her thesis, because they believe in it so fervently that they are perfectly willing to defy reason in support of it.

By recognizing that the free market does NOT work with health care, you have shown that you are willing to consider reason above ideology. Therefore, you are not a zealot. ;-)

[Silverhair]

52. OK, I'll go with that. Thanks. n/t

[rman]

47. the system created only a few long living healthy people;

for many it doesn't work.

[Lydia Leftcoast]

43. I know a couple in Portland

The husband owns a store, and the wife has been free-lancing in her profession. Until now, they have gone without medical insurance.

However, their young daughter has been diagnosed with Type I diabetes and requires regular medical care.

No insurance company will touch a self-employed person with a diabetic child, at least not for any rate that this couple can afford.

At the time I left Portland, the wife was regretfully giving up her profession and looking for any old job that provided health insurance.

[sendero]

9. I agree...

... I tried to find such a policy a few years ago. I wanted to "self-insure", but be protected against anything larger than say $20K in a year.

I could find no such product. And I talked to many an agent.

[NewGuy]

17. Blue Cross/Blue Shield offers this coverage

They have it with varying levels of deductible and max out of pocket.

[ewagner]

18. Two I sell

are coming up with high deduct plans........AND

they are gearing up for individual Medical Savings Accounts......

[DinahMoeHum]

14. Old but still timely article - from The Washington Monthly. . .

Link:

http://www.washingtonmonthly.com/features/2001/0105.glasser.html

(snip)
"...a $1.2 trillion-a-year industry does not go away easily. Recently, Dr. George Lundberg, the former editor of the Journal of the American Medical Association, discussing managed care, put the whole issue in more prosaic terms. 'Managed care is basically over, he said. But like an unembalmed corpse decomposing, dismantling managed care is going to be very messy and very smelly'..."
(snip)


:bounce:

[Sir_Shrek]

21. How does universal health care address these problems?

.....

[Cleita]

26. I missed your post number 2 and a search failed to bring it

up. Do you have the link?

[Silverhair]

30. I posted it on last Monday, Dec 29.

I tried to search for it, but the search function won't let me go back more than 24 hours.

[Kanary]

36. URL for Health Care Posts #s 1 and 2

Health Care Post # 1
http://www.democraticunderground.com/discuss/duboard.php?az=show_topic&forum=104&topic_id=950721

Health Care Post #2
http://www.democraticunderground.com/discuss/duboard.php?az=show_topic&forum=104&topic_id=967210

Hope this helps...

Thanks again, Silverhair... this is a great series!

Kanary

[Silverhair]

41. Thanks for the assist, and the compliment.

I am saving the URLs for my posts now. Should have done that from the first.

[Kanary]

54. No problem. I exist to serve. ^_^

You're the one doing the hard work.

Thanks again.

Kanary

[Cleita]

58. Thanks Kanary.

Downloaded to my hard disk and URL's bookmarked.

[NavajoRug]

32. This is a very good article . . .

It reinforces something I've said for a long time.

ANY insurance-related system is fundamentally flawed because it involves distorted transactions in the marketplace. Under normal circumstances, a buyer agrees to buy what a seller charges, and prices fluctuate with supply and demand.

The problem with an insurance-based system is that there are two "buyers," and they don't have the same goals in mind when they approach a transaction. Buyer #1 is the person who is insured, and he does not care about the price of the service because he is not paying the cost. Buyer #2 is the insurance company, and it does not care about the quality of the service because it does not have to live with the results.

This does not just apply to health care, mind you. If you look at any state with serious problems with auto insurance costs, you'll find that the source of the problems is remarkably similar to what we're facing with health care.

[Silverhair]

34. Excellent observation. n/t

[DrBB]

35. Did you already cover "Competition drives costs UP"?

That left wing loony, C Everett Koop did a great documentary on this. He used the example of Kalamazoo MI. Two hospitals in the city, and they start competing. Both have to provide state of the art services, but even though there were enough patients to justify two hospitals there weren't enough patients to justify two emergency helicopter services, two heart catheterization clinics, etc. These systems were exceedingly costly, but competition meant each hospital had to have its own--if your life's at stake you want the best--so overall prices went up to cover these redundant services.

The answer ended up being cooperation rather than competition. They worked out some arrangement so that one hospital ran the emergency helicopter and the other got the heart catherterization facility.

[Silverhair]

37. Interesting. The dynamics of the free market just don't apply.

Health care is in a class by itself.

[KoKo]

40. Kick......I missed your posts 1 and 2 which you linked here. Good read.

:kick:

[Wapsie B]

48. Any discussion of healthcare in the US

has got to deal with the inefficiencies in the system; one being the administrative payroll in your average sized hospital.
On the one hand we have doctors, technologists, nurses, and therapists busily seeing and treating patients on a daily basis 24/7. These people
need leaders. The hospital corporation needs leaders. But exactly how many MBA's or MSN's does the system need before it starts to implode? A number of hospital depts. are top-heavy. One of the dirty little secrets of healthcare is the fact that there are vast legions of workers in a hospital that don't come within miles of an actual patient. This all impacts the costs on an already overburdened system.


"A hospital is just an office building with beds"

bushwentawol

[Z-axis]

57. z-axis solution? But few will like it.

I’m going to jump in with both feet (possibly stuck in my mouth).

For all the reasons given in all the thoughtful posts, and excellent original article, Capitalism is inadequate and in conflict with its own profit-self-expansion missions to address the need for an effective, accessible health care system. Overburdened at best, Darwinian at worst – it either mitigates in favor of profit or doles out life, liberty and relief from pain as a class privilege. These are not acceptable conditions for the modern conscience. Equally, Socialism cannot offer much better. Its successes (as in Euro-socialism) are undeniable but modest. Healthcare provision and delivery stretch Socialistic practice to the breaking point. The Canadian system is beginning to show the strains, and what is left unreported would raise serious doubts that it succeeds any better than we do with our hodgepodge of insured, uninsured, Medicared, wealth-up-front, emergency room drop-in, patch&forget system.

Indeed, these failures also appear in the minimum provision of other ‘essential support’ goods and services – food, shelter, clothing – and to which I’d add ‘information’ and ‘energy’. Much of the failure is buried or hidden. The recent welfare reforms were little more than masquerades by Capitalism to further inflate the labor pool with low-cost workers, but did not move anyone further up the income/class ladder. It just added competitive stress to the lowest end of the working poor. But I digress.

Both-feet-in-mouth proposes that the entire list of basic human needs (well, perhaps ‘clothing’ can be dropped) be shifted from welfare/class-war objects to entitlement-objects. What I suggest is that they be shifted (including healthcare) not as entitlements because they are essential (though they are), but entitlements because they are earned, by each and every citizen of this country. How does that get done?

The ‘entitlements’ thing isn’t new, of course. Social Security (for all its faults) makes that experience clear. You get social security because you earned it/paid for it by your own labor. The faults of the system have nothing to do with principle in that definition, which clearly sets it apart from say, welfare (you get because you need). That is why it is not okay to humiliate or disparage people for taking social security (not even the wealthy who are entitled to dip in), but it is okay to humiliate and punish welfare recipients. They didn’t earn it, let them pay in shame then. No one talks about how this serves Capitalism which is completely at easy with exploiting the misfortune of others, but that’s another story.

What lacks in our concept of entitlements (and to some extent makes it vulnerable in coming years) is that:

1. The entitlement does not generate wealth for the system it is meant to support. The surplus of your labor still goes into the business you happen to be in at the time. It could be wealth for the porn industry, it could be wealth for bagel production. The earmarked taxes for social security are over and above the wealth you generate (usually they are “surplus” from your own pocket which was nearly empty to begin with).

2. The entitlement is delinked from the specific lacks that may befall a citizen in later life (though it generally answers the question, What do you do for money if you’re too old or disabled to work?)


Moving the list of things we need (which only wealth or welfare now supply) from the ‘gift’ category to the ‘entitlement’ category suggests that we earn them in a way that deposits surplus directly into the systems we wish to deliver as entitlements. To do this we must revisit that almost unspeakable phantom – the Social Contract. Life, liberty and other goodies simply cannot be delivered to every citizen throughout their lives. It costs too much. We see it in healthcare because the cost begins to eat into features of the product which are not simply bells and whistles. Some of those features can mean lifetimes of tremendous pain. Some just kill you.

When we come into this world (or more germanely, into our majority) we discover doing without certain items may be extremely hazardous. There just isn’t any option to run off and find a patch of land and scratch a living, or die, Thoreau fashion. The essential tools to do that are no longer free. We must have wealth to even escape. Most of what might be useful is already used up – as somebody else’s right-of-way. So that’s not an option. Work is a lottery – let’s face it. Merit plays its part. But the hundred at the door are not unmerited because only one gets the job. Needing to eat doesn’t wait. Sickness may cost the very source of wealth that was supposed to pay for the medicine. And the actual distributions of work pretty clearly show that more than a little Confucianism is still operating no matter how much we like to pretend in ‘equal opportunity’.

But imagine, if the social contract were to put the citizen (consumer of critical goods) back in the picture. Suppose it says, You can go in the military if you want. Or, you can choose to work from 2-4 years in two of the six essential services (food, shelter, health,…) to produce the surplus that will entitle you to have those goods and services (from all six categories) for the remainder of your life. Yes, I know it sounds like ‘fighting words’. But if you think about it, consider what it does –

1. It shifts things like healthcare from welfare to entitlement in the true sense (you earned it through the surpluses you created).

2. It links the product of your labor for a brief part of your life directly to the services you may need. You become the insurer and the insured.

3. It places an essential part of the social contract beyond the pale of either socialism (government) or capitalism (industry).

4. It partitions those parts of production which are found to be essential to survive and function into a non-competitive compartment while leaving the other parts free to be exploited by capitalism. Viagras & viagras yet to be discovered can remain the grails of Capitalist pursuits. That doesn’t effect your ability to survive or recover from illness.

5. It encourages the participation of the consumer as the ‘owner’ of essential entitlements to participate in their description and delivery. Consumers Unions for healthcare would likely have already appeared.

6. It solves the problem of a perpetual state of war between left and right (liberal/conservative) approaches and exposes the fact that Socialism and Capitalism are more alike in their failures to deal with these matters than they are different in their approaches.

Then, after a couple of years in the Entitlement Service – producing for say, healthcare and first-time affordable homes – you get to decide, do I want to live with just minimums, or do I want some of those luxuries (dvd players, trips to the mineral baths, etc.)? Voila! the Capitalist labor force is still intact (except they cannot be forced to work through fear of deprivation; they have to be coaxed with good salaries and nice perks). Ah, can you hear Capitalism sharpening its swords?


Ok – that’s how z-axis thinks about the problem. Rough and shoddy, but certainly not a well-beaten trail.

z-axis

[Silverhair]

59. Interesting. A few years of national service required to

pay for the services you recieve. How about those that want to pay higher taxes to go straight into their careers?

[Z-axis]

60. Interesting question

It is one of those questions, important as it is, that I relegate to what I would term 'administrative details'. That is, first the principle must be hammered out. Equally interesting, and loosely related is the question of whether participation in such a National Entitlement Service would be voluntary or mandatory. The analysis and debate that renders the principle in final form should reveal the answers (if one believes in sticking to the principle - which I do.)

My own short answer is: National Service would be mandatory (i.e. it is, as such, fundamental to the revised social contract); and No, you cannot simply pay higher taxes and skip the actual contribution; again because the idea is to remove the national commitment to provide for the common welfare from a paid-for, to a 'created and manifest' actuality. Something which is inseperably linked to the personhood of the citizen - i.e. the social contract - individual and not to the apparatus of government as a representation. It becomes an entitlement because it is ours, a priori any mediating government body.


In the principle I have outline, you don't so much 'pay' for future services in the 'essentials' category as you create the actual surpluses from which those needs will be payed for if you should want them. It also stands to reason that opting out subverts the size of the contributing pool and therefore weakens its ability to fulfill the promised entitlements.

In that sense, your question needs to be examined in light of whether the principle of redefining the nature of 'entitlement' originates within the social contract itself (which I hold is the invisible platform upon which the U.S. Constitution is derived). Fiddling with the Constitution (as most would agree) is tricky business. Even more so is to contemplate re-examining the contract, itself, which brings us all together and makes its promises without ever stating them.

That is why I say, your question is part of the administrative detailing. Once the principle is resolved, there are generally people very good at figuring out how to implement it. I'm not one of them.

thanx for reading. Z-axis

[Kanary]

61. I don't know where this question belongs....

Not knowing the future topics you are planning, I don't know where to insert this question. However, it is something that is on my mind, so I'm putting it in here. If it belongs later, in another topic in your series, please let me know, or please save it. (Not sure I'll know where to store it for later...._

While engaged in a discussion about Socialized Medicine in another forum, a person brought up this issue. since I was not familiar with the incident reported, I had no answer for it. I'd appreciate your input. So, here is what was said..

"Many years ago (I know that many of you do not like historical references but, sometimes a historical prospective clarifies a point), General Motors instituted health insurance whereby every employee was covered for every medical visit or procedure. Do you know what happened? The number of visits to doctors multiplied dramatically as did the number of tests per person and the number of invasive medical operations. Why? If it's free with no strings attached, the majority of people have no compunction about using the service/money freely; they have nothing to lose and no interest in saving money. The doctors, being financially motivated, realize that they can make a greater profit by ordering more tests, surgical procedures, return visits, etc.; they have nothing to lose by this either. Hence, the managed care system can into vogue.

My first point, we (the USA) cannot give carte blanche health care coverage to every single person. Yes, money is a factor. But, everyone must realize that health care is not endless and there must be some personal feedback to people that abuse and over use of the medical system has a direct negative consequence to themselves. Health care cannot be free and endless."

I, personally, cannot imagine people who would keep going to drs for fun and games, since I try to stay away from drs, but since this was brought up, I'd like some input about it.

Thanks for whatever you can add to this, and again... this is great work you're doing with this! I'm learning a lot!

Kanary

[Lydia Leftcoast]

62. I'm sure people went to the doctor more often, but

does this mean that the hypochondriacs went in for every sniffle, or does it mean that people finally got all the cancer screenings they needed?

Did anyone audit the individual doctors to find out whether they were actually gouging or whether they now had patients who could afford to have procedures that they actually NEEDED?

[suigeneris]

63. Great Thread. Some Thoughts

I'll read the other prior threads but why not bravely drop in a few thoughts anyway.

It seems to me a big part of the health care insurance problem is that we do not use insurance in this realm like we would in virtually every other: for protection against relatively large unexpected losses - instead we use it for what amounts to maintenance: colds and flu, etc.

This is so because of the disconnect between the cost of care and the insurance premium. With our cars, we think twice about using the insurance even to replace a broken windshield because we worry that our premiums will go up. We would never think our insurance should buy the new battery we need. Not so with health care insurance, but accessing the system for every health care need, many merely perceived and entirely unnecessary, does drive costs up and hence raises premiums for everyone.

I would do the following:
1. Set up single-payer insurance for everyone that kicks in at a financially catastrophic level tied to income or assets but with reasonable caps at both ends regardless of income. So, perhaps the lowest threshold would be $2,000 for the poor but the highest would be $25,000 for the wealthy.

2. In order not to provide a disincentive for needed care and early intervention, require mandatory examinations on a scientifically sensible schedule both as to frequency and comprehensiveness. Excepting babies and children, a special case, these exams might be as often as every six months for a cancer survivor to every three years for a previously healthy 22 year-old. Mostly, they would probably be every year or two.

3. If people want more care than that they can buy all the private insurance they want.