Sullivan's crackpot, looney Libertarian theories on economic policy should be ignored. He's a Ron Paul advocate and sees medicare and social security as part of an "entitlement culture" - off the wall mentalist.

I'm sure I read a great piece by Jonathan Cohn on the absurd "choice" argument of the looney Right on healthcare. It would be a great time to post it.

Not only that, it's not true that the government decides stuff at the doctor-patient level.  Larger strategic decisions are of course governmental policy, but I've noticed that people from every advanced country with a good public health-care system are always bemused by conversations with Americans about "the state telling doctors and patients what to do" because that's simply not their experience.

Not only is American healthcare not 3x better, basic UK outcomes, at 1/3 the cost, are better.

Sadly, healthcare is not quite as simple as say retirement security (where there's only one product, and people still screw that up), it's a segmented market, so that unfortunately leaves a lot of room for 'teh stupid' to crowd the discussion.

Jonathan Chait writes:

A Health Care Post from the Wrong Jonathan C.

Ezra Klein points out that health care in the United Kingdom is really cheap:

In 2006, adjusted for purchasing power, the United Kingdom spent $2,760 per person on health care. America spent $6,714. It's a difference of almost $4,000 per person, spread across the population.

Andrew Sullivan, in response, waxes libertarian:

One reason I'm a conservative is the British National Health Service. Until you have lived under socialism, it sounds like a great idea. It isn't misery - although watching my parents go through the system lately has been nerve-wracking - but there is a basic assumption. The government collective decides everything. You, the individual patient, and you, the individual doctor, are the least of their concerns.

Andrew is completely missing the point. Nobody is proposing to import the British health system to America. But the conservative habit of pointing out that getting health treatment in the U.S. is better than getting it in the U.K. (as long as you have health insurance, that is) tells us nothing. Is American health care nearly three times better? Suppose you offered every Brit a chance to pay almost three times the cost of what they're currently paying for health care so they have an American-style system. Oh, and part of the bargain is that they have to accept a one-in-seven chance of having no insurance at all. How many of them would take it? Not very many, I'd say.

George responds:

This is what happens when a True Believer [especially one of the conservative persuasion] grabs something like health care by the balls and twists it into a political tract.

It is always either/or with them.

In particular those who, with respect to their own health, have all the money they need to get all the health care they want. And then some.

Yet what is the health care that US governmental officials and military veterans recieve if not "socialistic"? I'm an Army vet and these programs make a big difference in my life.

Rep. Steve Kagan from a June 27th opinion piece in the Huffington Post:

"As a Congressman, I have learned that Band-Aids are what politicians are using to "fix" our nation's broken health care delivery system. But you don't have to be a doctor or a Congressman to understand that Band-Aids can't fix a fracture

"That's why I declined to accept the health care insurance offer from Congress. Plainly put, I will not accept health insurance coverage until everyone I represent in Wisconsin and across America is given the same opportunity. After all, I did not run for this office to get health care benefits.

"I ran to change Washington and to guarantee access to affordable care for every citizen, everywhere in these United States."

George:

What this really comes down to is how the relationship between a government and its citizens is perceived. I remember reading a political science text some years ago. The author made an important distinction between what he called "positive law" and "negative law".

Governments that practice the "negative law" model [and the USA wrote the book here] construe citizens as being basically rugged individualists who want [and need] only a minimum of social, political and economic legislation impinging on their freedom to do...well...pretty much whatever they can afford.

Unless of course they want to be free to smoke pot, or get an abortion, or marry a member of their own sex. Then the relationship between a [conservative] government and its citizens comes in the form of a very short leash.

On the other hand, governments that tend more toward the "positive law" model [in short, all the rest of the world's democratic republics] see the relationship between government and citizenship very differently. Citizens and government in, say, Canada and in most of the European nations are construed to be part a social compact whereby in being citizens [voting, paying taxes, participating in the nation's economy, sharing a common language and culture] it is understood and accepted that basic human rights include a strong social safety net----health care, education, child care for working parents, retirement funding, programs to lessen or minimize poverty etc.

Which is not to say that some liberals don't advocate doing pretty same thing going in the other direction.  

But think about citizenship. It is not something we choose. It's not like we pop out of the womb and then for years study all the countries around the globe so we can pick the one we want to live in. No, it is purely fortuitious right from the start.

So, as far as I am concerned, if being a citizen [especially a child] does not qualify you to receive decent health care from the cradle to the grave, then it sure as hell ought to.

And it doesn't have to be EITHER all government OR all private corporations. It can always be a combination of both. But no citizen should be forced to shoulder the burden...the fear and the anxiety...of living from day to day, knowing they are just one pink slip or one health crisis away from destitution.

And as far as Andrew Sullivan's complaint about "the government collective" doing everything, has he ever had to endure the health care political economy that is an American HMO?

george walton

Right Irony,

However, as anyone who has ever attempted to navigate the American HMO system, it very often is the case that decisions about what tests are approved, what drugs  are authorized, what course of treatment can be taken, and even what doctor(s) you can/can't see, are determined by some anonymous bureaucrat--not the doctor or the patient.  They may not work for the government, but it doesn't make the system any less bureaucratic, wasteful or impersonal.

Or course, if you are independently wealthy, you can go outside the system and get whatever care you want, but for the other 99.9% of us, that isn't the case.

I don't get the title. In any case, the health care reformists had better steer clear of the UK. At a third of the cost of our system, and with 100% coverage, it's still overpriced (especially now since they've neglected the system on the cheap for decades, and only in the past few have upped spending levels to anything like sustainability).

Now the French and East Asian systems are a different story. The key to the French system, or one at least, is something that should make your average right wing ideologue's head explode: competition. Setting up competition amongst government agencies, and giving them more freedom in how they are managed, has tremendous potential to eliminate much of the increased waste fraud and abuse that can be expected with government run institutions. Swedish pension funds follow a similar model, although there you're managing money and skill and efficiency don't enter into the equation, see: crisis, financial...

I sure as hell haven't felt like the assorted American insurance companies from which I've sought coverage over the years have liberated me and my doctors into some utopia of whimsy and choice.

When Oxford slashed rates so low that it required my son's pediatrician to increase volume to a degree she found unconscionable, she, like a growing number of private practitioners, told Oxford to go to hell and went "boutique." We had to find a new pediatrician, one that could flip patients as if they were burgers.

Then comes the filing of claims. I not long ago found myself immobilized for a week by a disk so acutely herniated that it warranted emergency surgery. The trail of referrals was a kind of wilderness of paperwork, and when at last I was on the gurney, about to go under, my wife asked the anesthesiologist whether he was covered by Oxford. He told us, smugly, he did not know, but that the surgeon was covered by no means implied that he was too. Then he added, apropos of nothing, that he could really use a drink. Then lights out for me. Kafka-esque.

Having once been employed as an English teacher by the government of France, I'd take their system over ours any day.

I Majorajam: The title is a play on the fact that the resident health care expert at TNR is Jonathan Cohn.

Thanks liberal reformer, and good luck to you.

Nippers, I had an Irish anesthesiologist offer me all manner of pills in private conversation, likewise apropos of nothing. Their proximity to the funion juice can be corruptive, apropos of McCaffrey, the Bush administration, the last 8 years, etc.

How about comparing our system to Japan, a nation with uhc, better outcomes, older population, and less costs? Oh right, the conservatives won't do that because A. They are racist, believing Japanese people are somehow not as human as the rest of us. B. Ignorant in that they know nothing about the health care system of the worlds second largest economy. or C. Disingenous in that they know comparing America to England (and be honest, when is anything economic compared with Britain?) is their only hope.

I say compare US healthcare with Britain the same time we compare Automakers with them. Oh right, Britian doesn't have any. Interesting how Japan does and how much cheaper they can produce their cars since health care is subsidized by the entire citizenry, unlike the US where desperately poor or uninsured use emergency rooms for basic services thereby putting a strain on the system, and megacorps like Walmart offer nearly useless policies foisting true costs onto those companies, like our automakers, that do offer good ones.

Democrats so own this issue.

Another thing about our system that makes no sense is for it to be employer based at the same time that we are constantly being told that the age of long term employment by one company is over.  It doesn't make sense for peoples' job and career choices to be distorted by their insurance needs.  There are too many gaps and it is too difficult for even knowledgeable people to get the information they need to avoid them.  Try helping a recent graduate with a new chronic condition get insurance before he has a job.  No, you can't COBRA his student policy, it's not a group policy.  He can't afford the guaranteed issue policies, he doesn't have a job yet.  When he does get a job, the company policy is only available after being employed for several months.  Getting the information to help you make those vaunted "choices" doesn't happen unless you happen to ask the right question, and it's not presented in a standard format that makes comparisons possible.  Not to mention that companies don't tell you what they will pay for services & procedures until they are actually billed.  What other service do we buy without knowing what we are getting?  Somebody tell me what advantage these "choices' give us.  

Exactly, strabka -- the real nightmare about choices occurs under our present way of doing things, while Republicans try to tell us that if we had a UHC system the government (which is always bad, apparently, except when it's protecting our borders or bailing out the banks) would be messing up our lives by denying us treatment.  A lot of Americans seem to have a weird idea of what health care systems are really like abroad that sounds similar to Soviet Russia in 1937 -- which just suits the conservatives, of course.

I moved to England 8 years ago. Sullivan is right. No choice. Every time I've gone to the NHS, I have been 'coerced' by my socialist body and its refusal to maintain perfect health at all times. And every time I've gone, those socialist doctors have told me what I had to do to get better.

We have a friend with American and British passports. He's got a chronic illness and is unable to get health insurance because of the pre-existing condition. Our local public hospital has relatively good care for uninsured people - it's nothing you'd choose if you had insurance, but it strives mightily, with taxpayer funding and charity contributions, to provide decent care. It's not great by any means, he's probably better off here than he would be in numerous places in the US.

But, after trying to navigate the system, enduring the inevitable waits and the frustration of telling various medical professionals and para-professionals the same thing over and over again, he decided that it would be easier and cheaper to get his care in England. So, he scours the internet for cheap airfares to the UK and hops on a plane every three months or so. In the UK, he deals with the same medical staff every time. He gets enough medicine to last him for three or four months. He has one worry and one hassle - traveling to and from the UK. Of course he worries about his health, but he never has to worry about his healthcare. The peace of mind has got to be a little life-extending in itself, and it's a feeling unknown even to many Americans who have health insurance.

Echoing Bungler - those damn socialists are keeping him alive, despite the fact that he was foolhardy enough to get sick in the first place, and then compounded the error by not getting a job with a company that provided good health insurance before he decided to get sick. What a rotten system!  

Blackton, Walmart's health policies are so bad that their workers are sometimes forced to sign up for Medicaid or S-CHIP anyway.  There has been a movement afoot in some states to have Walmart reimburse these programs.

I agree with strabkha as well. How many man hours are lost by hr people negotiating with this or that insurance company? In Japan everyone is enrolled so that companies like Toyota can focus on making cars and not worrying about anything else.

satyendra, I absolutely support that. Walmart cares only about the owners and top executives. Employees, suppliers, customers are all things to use.

I have bored a couple of health sites with my story, but here goes:

Whem my US father was sent to hospital in Dearborn, MI for and MIR

I casually asked the receptionist what such a procedure would cost him.

After explaining that I lived abroad with universal health care, she said

well, one MIR costs $ 1,500,--.  I later saw the insurance company bill

(and my father hated insurance) there was a 5% discount.  Here in Europe

as an American citizen after having part of my wages "confiscated"  for

"socialistic" health insurance, I paid nothing, nill, zilch for each of the

three MIRs I have had after mini-strokes. Of a matter of course, the week

in the stroke clinic was free.  I will gladly pay for others, for they have

also paid for me!

Gee, blackie, I don't believe A, B, or C.  Democrats own the issue?  Be careful what you wish for, old friend.

A big issue will be how much state involvement there will be, and how much market.  Mass. offers some guideposts with their experiment, as does Indiana.  there should be others.  A federal solution is probably a bad idea.  We have 50 states - let's see how various systems play out.

Eventually someone must say no.  Should that be government?  Maybe, but if you think people hate insurance companies.....

there are somethings the free market does extremely well, and there are somethings it cannot do well by its nature of having to make a profit. There are somethings government does well, and there somethings it cannot do well by its nature of bureaucracy. Health care is one of those things - like rural electrification - that only government can do well. The notion that insurance companies can only make money BY NOT TREATING the sick and kicking them off their roles if their illness is too expensive is absurd. They are making doing the opposite of what they are supposed to be doing.

Government on the other hand, doesn't care about profit and therefore can treat everyone, regardless of age or illness or kind of employer worked for. Medicare is a better run entity than any private insurance company. No there shouldn't be 50 different sets of systems and no there shouldn't be multiple private companies forced to cover everybody - that makes it much more expensive and cumbersome than one simply system, everyone has it easy to administer, a hell of a lot cheaper.

If a free market really functioned in health care, insurance and treatment would have to be consumable goods that a consumer could choose to purchase or not to purchase.  But because everyone is going to need medical treatment in some form, at some stage in life, the consumer is in fact not one, but is rather reduced by the system to a kind of petitioner at the palace gates seeking a favor that can be withheld.

At least UHC transforms the relationship from a morbid consumer-business dynamic to a more realistic citizen/client-service.

The comparison with, say, auto insurance, is not a valid one, as it's quite possible to drive all your life and never have an accident (and the companies reward that).  However, it's not possible to live one's life and never get sick (and if children are insured too, that destroys the last vestige of justification for the present system, as there are certain illnesses that children always get as part of growing up).

The trouble, mcgumbleton, is that government, at root run by politicians who want to get re-elected, won't say no.  And there is much more health care out there than this or any other polity can possibly afford.

Obama ran on increasing access.  Great idea.  But without some sort of cost control mechanism, that sort of UHC will bankrupt us all (if we're not there already).  And Obama has been woefully short on details about any sort of cost control.  We will have to ratyion health explicitly, unlike today where we do it by price.

Irony, I agree that the health care market is NOT like other markets.  But insurance can still be sold, and government can still set the rules, without having to run the show.

ironyroad,

I see nothing wrong with viewing health insurance like auto insurance or within the context of a firm/household relationship. Ultimately that is what it is, and as I see it, framing the issue in such terms makes reform more appealing to the American People, not less. In fact, the auto analogy provides useful parallel in that people are required to purchase auto insurance, precisely due to negative externalities borne by the public if they do not do so. The same holds true for medical insurance in that the uninsured is a significant negative externality, whose cost is already borne by public and private expenditure, and of course by neglect of health care to the uninsured (returns to preventative medicine are massive, and over/misuse of emergency rooms is extremely costly). Incorporating back in those costs crystal clearly demonstrates how remarkably inefficient our system is relative to the rest of the developed world. That fact is the most important and, frankly, persuasive argument for those promoting health care reform.

There is another irony here. Health care costs are highly asymmetric and dominated by chronic illness to such an extent that the arbiter of success amongst insurance companies is their relative ability to screen out the sick, and otherwise drop them from coverage once they become sick, ('preexisting conditions', not covered procedures, etc.), before they become responsible for their large medical liabilities. The insurance companies have gotten so good at doing so that, for example, no one I know is without anecdote of someone they know getting screwed to the wall by such fine print, and in such horrible ways. I personally know a few. In this, they are victims of their own short-sighted 'success' at screwing people over in pursuit of profit. Because the reform that is going to evicerate their old ways of doing business will pass in large part because of the backlash such shenanegins have inspired.

Here again, a private entity ignored the fact that their long-term success was largely predicated on the function or dysfunction of a system in which they were steward, or at least critical participant, and hence they shirked their duty to safeguard it. This was the same story with Enron amongst many others of recent memory. Take the people for all they're worth while the getting's good. Damn the risk that the public will come to understand that the very system on which those long-term profits depend- in Enron's case, deregulated power markets, in health care, private insurance- is being manipulated against their interests.

I can hear Art Laffer now. Private companies with a myopic, short-term focus on profits at debilitating expense to shareholder value? But, but, but... that's impossible.

The big difference is that in America if you can't afford a treatment you have to declare bankruptsy but you get the treatment anyways; in Britain, if the government can't afford the treatment, well sorry then, your just gonna have to die.

The fact is that good health care costs a lot of money and it will always cost a lot of money because it represents the <i> state of the art </i> in medicine. Generally any state of the art product is more expensive then the obsolete version. You can certainly reduce health care costs, but only by using inferior products and services.

I think you're missing the fact that a significant aspect of health care in a system like the UK's (or almost anywhere else in the advanced world) is catching symptoms early.  The whole point of a health care SYSTEM as opposed to just dealing with a crisis is that you want to reduce the number of cases that need hyper-costly state-of-the-art treatment.  Indeed, not only can you only reduce costs by using inferior products and services, but you can reduce the costs by using services that are superior (e.g. more accessible, more integrated IT-wise, more targeted to prevention etc) than the norm here.  The embarrassing disparity between health care spending in the U.S. and the general health of the population -- again, the general health, not just the effectiveness of high-cost hi-tech treatments -- suggests that something is seriously wrong.

Also, we obviously need to fix one very damaging aspect of the U.S. approach, and that's the employer-based provision.  Even if we can't agree on the public-private balance, non-portable HC just makes no sense anymore.

that should read:

Indeed, although you can reduce costs by using inferior etc etc, but you can also reduce costs by using services that are superior . .

Andrew Sullivan is an ignorant fellow. I suggest to him to check the -pretty socialist- medical system of France. I lived there for three years. I live now in the US, so I can compare directly. Well, the US health system doesn't measure up to the French one, not by a long shot.

Not surprisingly, French people also LIVE LONGER than Americans. The same is true of other countries with quasi-socialist health care - Germany, netherlands, the Scandinavian countries. So before belittling those systems, why don't you look at the data? Of course, asking a blogger like Sullivan to look at data is about as effective as asking a pig to fly.