Direct primary care is a good thing, and I greatly appreciate you contributing your experience to this discussion.
On the other hand, having grown up with a public health system (in Ireland, whose model is almost identical with the UK's NHS), I'm strongly of the opinion that the necessarily higher rates of income tax are well worth it. Why? Because when you get sick you just go the doctor, and if the doctor's clinical opinion is that you need additional care, you go to the hospital. There is no financial decision-making involved, there's no additional paperwork to be filled out (not by you anyway), and you don't have to have conversations about who's in or out of your provider network in the normal course of events. The only focus is on your clinical care and recovery needs. Is it perfect, of course not - but when you develop a medical problem, you get to focus on that rather than having to split your attention between medical, financial, and administrative worries. My experience of the American healthcare system is that while there are many sincere and selfless people working in it, the system itself is badly corrupted and wildly inefficient.
One objection I've heard from opponents of single payer healthcare is that if going to the doctor is free or almost so, doctor's offices will be filled with hypochondriacs and genuinely needy patients will be crowded out. I have never seen any evidence for this claim, and it doesn't match my experience. Most people don't like going to the doctor because it makes them nervous, it's icky, and they dislike being around other sick people in the waiting room - same as everywhere. Of course there are some hypochondriacs out there, and doctors quickly become skilled at spotting them and running them off. It may be a bit harder in these days of WebMd, but I am disinclined to believe that a tiny number of hypochondriacs are the major obstacle to restructuring and industry comprising 10-15% of our economy.
I'd gladly pay the increased tax rate if I didn't have to deal with all the BS that surrounds using health insurance; in/out of network, deductibles, companies trying to get out of paying, etc.
I think the main opposition to single payer in the USA is that it's counter to some of the bedrock principles the country was founded on, such as freedom, independence, limited government and personal responsibility.
America (disclaimer: I'm a US citizen, born and raised) has this delusion of rugged individualism, that everyone should pull them up by their bootstraps. In reality, everyone who is successful is simply taking advantage of those who came before them, and shared infrastructure (both the physical an economic types).
I don't see Americans adverse to Medicare, which is essentially single-payer for anyone over 65. Why does being under 65 mean you should die in the street without healthcare?
Single payer is cheaper/more efficient than our current system. We just need to find the political will to implement it, and cut the legs out from anyone attempting to stymie that change who is currently profiting from the status quo.
There's also some degree of moral judgment involved. It would be much easier to sell single-payer to Americans if coverage was denied to lifestyle illnesses. It's easier for the American ethos to swallow charity for the poor sap who got brain cancer from an errant cosmic ray than for the obese chain-smoker with type II diabetes and lung cancer.
There is a long history of Puritanical thought running in American culture, in which personal virtue is reflected in outcomes.
It goes way further than that. How about people who have children (again a choice) as that also increases health expenses. Living in areas with more sun (let's call that a choice too) means more likelihood of skin cancer. Those people using private cars rather than public transport are also more likely to be more severely hurt in more accidents. Someone engaging in "bad behaviour" like smoking may have higher health costs at the end of their life, but their lifetime total costs may be lower because their life ends quicker than healthy people having a longer end of life period. (And the smokers paid more tax, collected less social security etc.)
Realistically all legal choices and activities have to be covered, or you would be arbitrarily victimising certain groups.
The personal responsibility riff gets really problematic when you are faced with things like alcoholism or venereal diseases. People certainly have a choice to keep alcohol consumption down practice safe sex &c. But it's a reality that some people catch STDs or drink too much even though they should not, and these things have a way of affecting more than the afflicted individual.
And food deserts are a very real thing. If you live in one of those you haven't even much of a choice regarding obesity.
"Personal responsibility" is not a founding American principle. There's no Federalist Paper dedicated to "personal responsibility." Indeed, "independence" and "personal responsibility" along with "individualism" were retconned into American history during the settlement of the West.
Moreover, "limited government" in the context of American founding principles refers to the allocation of responsibilities between states and the federal government, not the overall scope of government.
There is, in fact, a principled originalist argument for universal healthcare. First, it has always been assumed that the states have the power to provide for the welfare of their citizens, as well as to police their behavior and morals. The states are, in that regard, decidedly not "limited governments" of "enumerated powers." State-level universal healthcare is contrary to no founding principle.
Second, the Commerce Clause was incorporated into the Constitution to allow the federal government to solve what we today would recognize as economic collective action or free-rider problems. At the time it was aimed to address the collective action problem of free trade. It's good for the United States as a whole, but individual states have a short-term incentive to erect trade barriers. The purpose of the Commerce Clause was to allow the federal government to counter-act those short term incentives. Precisely the same problem exists with state-level universal healthcare. Even if most people in a state want it, they can't enact it because it's too easy for people from neighboring states to free-ride on those services. The Commerce Clause is thus properly invoked for resolving that problem at the federal level.
Vermont looked into single-payer insurance within the state borders, but AFAIK they abandoned the idea after seeing the estimated price tag. I think it would be great if some state tried implementing this, some state tried implementing a Singapore-style free-market solution, etc., and we got to see what worked.
> Precisely the same problem exists with state-level universal healthcare. Even if most people in a state want it, they can't enact it because it's too easy for people from neighboring states to free-ride on those services.
How so? If you are a resident, you get "free" care. If not, you get a bill. Is this not how Canada works WRT Americans who need to use the Canadian health system?
Say Arizona doesn't have universal healthcare, and California does. Someone gets cancer, so they move to California. Under the privileges and immunities clause, California generally cannot say "hey, you just moved here, so here is a bill." Consider also a company that doesn't like the extra taxes used to support universal healthcare. So they hop across the border to Arizona, and continue selling to California customers. California cannot, without violating the Commerce Clause, say "hey, you get the benefit of selling to healthy Californian consumers but you moved just to evade the tax that pays for it, so here is a tariff on your products."
The Constitution imposes an open market on commerce and movement within the United States. The Commerce Clause exists to give the federal government the power to address the economic issues that arise as a consequence of that.
At least 1/3 of the US population, probably closer to half, is pretty serious about not wanting much government involvement in personal affairs. I'm left of center but that sentiment doesn't seem crazy or crazy to associate with freedom.
It's amusing they don't want government involvement with personal affairs, but they have to deal with endless private companies meddling in their lives, taking tons of money, denying their claims, denying them coverage, etc. etc.
Why does that argument get applied to healthcare, and not to education? Those bright yellow government provided schoolbuses painted National School Bus Glossy Yellow aren't paid for out of educational transport insurance copays, you know...
Vouchers are a mechanism for diverting government funds to individually chosen (government accredited) education providers. They aren't comparable to employer funded private 'insurance' programs. In healthcare terms they more resemble Medicaid. They're hardly an example of rugged individualism.
It's good to hear from someone that's experienced another system. I would rather have that system than one that caters to the big corporations and corrupt officials. ObamaCare just shifted the burden of the uninsured directly onto the tax payers, through subsidies, from the insurance companies and hospitals that billed higher for it. It's a BS system that allows the Obama administration to look at statistics and say, "Wow, look at how many people are insured now!"
I've been unemployed for 9 months and now have to pay the individual mandate for 6 of those months. I think the Supreme Court was bought or blackmailed on that one. We need a system, but not this one and it can't be opt-in or get fined! Maybe a sales tax would work.
Author here: My father and ex husband were both career military. I was married long enough to still be entitled to medical coverage through the military system. We briefly dealt with insurance and copays and all that when he was a recruiter stationed someplace without a military base. Other than that, I have had an experience of medical care closer to what many Europeans experience. I would be all for the US finding some means to institute government paid universal coverage. But I think that health insurance is too entrenched in the system for such hopes to be realistic any time soon. I think that is why the ACA chose the unfortunate path it chose: the transition directly from what we had before Obamacare to a European style solution is too harsh to be politically viable.
Maybe someday the US will get on board with providing a better solution. In the mean time, direct primary care is a legal loophole in the ACA that cuts out the middleman. Perhaps if it grows enough, we can eventually move towards something more civilized.
I fully agree - I'd like to see single-payer tomorrow, but that's as much of a cultural as an economic change and as you point out there are large entrenched interests in place already; the ACA is a flawed by still necessary beachhead onto that economic territory. If I thought it could all just be improved by fiat I'd be urging people to vote for Bernie Sanders, but I'm not - having a beautiful ideal is mind does not automatically provide the tools and resources required to attain that vision, a problem which seems lost on many of his supporters.
> My understanding is that health insurance originated in this country as a means to plump up employee compensation in a situation where paying more wages was not desirable. You could not entice good employees by offering them a pay raise because it bumped them up into another tax bracket and it just wasn't worth it to them.
Really hard to take the article seriously when it crams so much misinformation into one paragraph. There is no such thing as "bumping you up into the next tax bracket." The marginal extra dollar might be taxed at a higher rate, but the dollars below that will be taxed the same as before.
Moreover, the fact that health insurance isn't taxed now can't explain the origin of the industry. Initially, health insurance was taxed just like any other non-cash benefit. A tax break on health insurance was implemented as a way to offer some relief from the wage controls of WWII: http://www.npr.org/sections/health-shots/2012/12/04/16643424.... But such a tax break wouldn't have come about if the industry didn't already exist.
Employee health benefits been tax free since at least 1954, and the top marginal rates were much higher then. So WWII controls were an early factor, but marginal tax impacts were significant too.
Sorry, could you explain what you mean by marginal tax impacts?
I assume this is something along the lines of:
Employer: "We can offer you an additional $3k/year in income but it will be taxed at 40%. Or we can offer you 3k in health benefits tax free. Which do you prefer?"
Sure. Employer observes that they can spend $10,000 on wages to increase the employee's take-home pay by $1,000; or they can spend spend $5,000 on insurance premiums and buy the employee an excellent health plan. The employee and employer both have incentive to take the tax break.
I'm taking about the 1950 here, when the top marginal rate was around 90%.
The top marginal rate was 91%, yes, but that rate was for income over $200,000 in 1950 dollars, which is (adjusted for inflation) nearly $2m in today's dollars:
So although there were very high marginal rates at the top, they applied only to people making over 40 times the median income. And just to pay a higher marginal rate than 2015's maximum of 39.6%, one needed to be making around three times the median income in 1950.
So you'll need another explanation, because it's unlikely that the risk of being bumped to an ultra-high marginal rate was an issue widespread enough to spur the offer of untaxed health care. And as others have pointed out, it's well-documented that the actual reason was a reaction to wartime wage controls -- given the choice, companies would have simply offered more cash.
My dentist's office offers this. My work didn't offer dental coverage but the clinic itself offered "coverage" in the form of paying a flat fee and getting your cleanings and exams taken care of for the year (with discounts for other care). I was on that like white on rice: my money went directly to the dentist, no middleman taking their cut out of my paycheck, and my basic dental care was paid for.
If you don't mind me asking, how much did you pay for the "coverage"?
Did it offer any kind of discount for minor or major dental work (e.g., cavity removal, wisdom tooth removal)? Or was this covered by your health insurance?
Employer dental care is one of the best deals you can get. Find a dentist who optimizes for insurance and you will get back way more than what you put in. This works because few do it.
The problem you face with DPC is in the US you'd have to subscribe to 2-3 different healthcare providers, your GP, a hospital and perhaps another specialist (endocrinologist, cardiologist, etc.) Unless you have a DPC membership with a provider that supplies all of that. My GP has DPC, but I still have insurance from my employer that would cover any hospital visits.
This post is confused. Employer-sponsored healthcare is excluded from both payroll and income taxation which makes it very attractive for employers to offer. The author doesn't understand how marginal tax rates work. Only incremental dollars are taxed at the higher rate so it's not like you hit some taxation cliff. If health "insurance" really was "insurance" it really would be a "bet". Instead, it's become more of a payment plan with an insurance component. "Real" insurance is now called "catastrophic insurance" and is dying in the US (I think Obamacare basically outlaws it).
Deductibles are part of it but coverage is the bigger element. What is typically referred to as "catastrophic insurance" is only available to people under 30 or with a "hardship exemption". Higher deductibles and higher coverage (i.e., higher premiums) are basically the worst of the worst situation.
What I don't get: why does the private sector have to be involved in insurance?
In my opinion, as the right to health care is a basic human right, the state should be responsible for providing its citizens with health care - and as all citizens are equal, so should the health care be.
Unfortunately, Germany isn't perfect either - privately insured patients get faster access to specialized MDs, they enjoy better quality of service (esp. dentals and glasses/eyewear) and the basic insurance (Gesetzliche Krankenkasse) is in fact a staggering number of distinct insurances, each of course carrying its own administrative bloat and its own deals with pharma companies. This may result in a doctor giving two identical receipts for medication - and because the two patients are insured at different companies, they get different generics with all the problems this causes (e.g. different colors of the pills, leading to lower stick-through rate because patients mistrust changes, or different composition leading to different absorption rate even though the medical compound is identical).
There's a shitload of money wasted in healthcare, not only in the US, and the poorest people (as always) have to suffer.
Well, privately insured patients pay for their privilege when they're getting old, when the insurances hike up their fees to no end. Everyone knows that, but people that earn enough to qualify are in denial because it provides them with a bit more disposable income in the short run.
The situation of having that many insurances is certainly bloat, but interestingly enough, it led to the situation where some of them operate with a deficit, while others operate quite efficiently. With the current legal situation, and literally hundreds of companies still being around, I'm not sure this is something that can be streamlined in the next few decades. People would lose jobs, after all.
if public healthcare was wonderful, there'd be no private insurance business in germany. it baffles me that people think the same government that pisses away billions on big digs, pointless fighter jets, and whatever else would magically save us billions on health care.
>if public healthcare was wonderful, there'd be no private insurance business in Germany
Private insurance companies exist in Germany, Australia, Canada, etc. because it's about choice. If everyone was given a perfectly functional Toyota Camry, people would still buy Porsches and Ferraris simply because they want the ultimate. Healthcare is no different.
>it baffles me that people think the same government that pisses away billions on big digs, pointless fighter jets, and whatever else would magically save us billions on health care
And yet Healthcare costs more in America than any other developed country. So the evidence is clear that when the government does it, it is cheaper.
> And yet Healthcare costs more in America than any other developed country. So the evidence is clear that when the government does it, it is cheaper.
When the American government does damn near anything it costs more than when any other government in the world does something. Showing that other governments can do something cheaper does not demonstrate that the American government can as well. I have much more faith in the ability of a European government to set up a social program than I do my own.
Calling healthcare a human right is implying that we have the right to take from others what we need, even if indirectly via the police-power of the state (i.e., threat of violence or actual violence if necessary). To take this further, it means we have the right to a portion of another citizens labor.
Now, don't get me wrong. Talking about what governments should provide their citizens as part of their benefits package is important, but calling healthcare a right is a stretch. None of the rights on the UN or US Bill of Rights involve coercion towards other citizens to provide said rights.
Whenever someone says that some rivalrous resource is a 'basic human right', I have a hard time taking them seriously.
As I get older, I have mellowed a great deal, and I understand how smart people can reasonably disagree about a large number of things...but I honestly can't fathom how intelligent people can fail to grasp that you can't possibly have a 'right' to a finite, tangible resource which you yourself don't produce.
Healthcare is not a finite or tangible resource, it is a service provided by medical professionals. It isn't possible to run out of healthcare. It is possible to have a healthcare shortage, but as long as there is money to pay for running hospitals and training doctors, that won't happen. You might think that the amount of money it would take is impossibly large, but other nations provide free healthcare to 100% of their population for less money per person than we spend in the US already. If you disagree with the fundamental idea of taking money (taxes) from some people to pay for services used by others, than you may actually disagree with the entire concept of government.
> Healthcare is not a finite or tangible resource, it is a service provided by medical professionals.
Medical professionals and equipment are finite, tangible resources. No matter how capitalist or socialist your health care system, you are subject to limits on how much time, energy, and money you devote to health care.
Medical professionals and hospital rooms are absolutely finite resources. You can certainly build more, either by incentivizing their construction (capitalism) or have the state build them as part of some 5 year plan. Medical professionals are somewhat harder...we get them now by paying them handsomely...you could continue to do that, or conscript people into service. I'm not sure I'd want my heart surgeon to be a draftee..but ok.
How about donor organs? is there some infinite source of hearts and livers out there I'm unaware of?
Once you accept the fact that a given resource is rivalrous, you have to come up with some way to distribute it. Currently, that mechanism is money. If you get rid of that, then you have to replace it with _something_..whether it be algorithms, favor-economies, or central planning.
Now if you want to argue that insurance companies distort the market, then I probably agree with you (though I think there is room for interesting discussion here...). Certainly I think a single-payer solution is preferable to the current status quo, which mandates that individuals purchase insurance from private companies.
> Medical professionals are somewhat harder...we get them now by paying them handsomely...you could continue to do that, or conscript people into service. I'm not sure I'd want my heart surgeon to be a draftee..but ok.
You can also increase the supply by opening up medical schools and giving more students the chance to attempt to become doctors without needing 10s of thousands of dollars.
On the other hand, having grown up with a public health system (in Ireland, whose model is almost identical with the UK's NHS), I'm strongly of the opinion that the necessarily higher rates of income tax are well worth it. Why? Because when you get sick you just go the doctor, and if the doctor's clinical opinion is that you need additional care, you go to the hospital. There is no financial decision-making involved, there's no additional paperwork to be filled out (not by you anyway), and you don't have to have conversations about who's in or out of your provider network in the normal course of events. The only focus is on your clinical care and recovery needs. Is it perfect, of course not - but when you develop a medical problem, you get to focus on that rather than having to split your attention between medical, financial, and administrative worries. My experience of the American healthcare system is that while there are many sincere and selfless people working in it, the system itself is badly corrupted and wildly inefficient.
One objection I've heard from opponents of single payer healthcare is that if going to the doctor is free or almost so, doctor's offices will be filled with hypochondriacs and genuinely needy patients will be crowded out. I have never seen any evidence for this claim, and it doesn't match my experience. Most people don't like going to the doctor because it makes them nervous, it's icky, and they dislike being around other sick people in the waiting room - same as everywhere. Of course there are some hypochondriacs out there, and doctors quickly become skilled at spotting them and running them off. It may be a bit harder in these days of WebMd, but I am disinclined to believe that a tiny number of hypochondriacs are the major obstacle to restructuring and industry comprising 10-15% of our economy.
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