WhiteCoat

Socialized Medicine Debate

This morning I read two competing views about whether our system should become “socialized.”

One view was from Op-Ed columnist Richard Cohen in a piece titled “Socialized Medicine? Bring It On” in the Washington Post.
He takes his experiences accompanying a “friend” to the emergency department and tries to generalize them to the medical system as a whole. There were “interminable” waits, there were not enough beds, and his friend had to wait “in agony” sitting in a wheelchair in a hallway for six hours. He then demonizes insurance companies who denied his friend’s claim for a return to the emergency department, saying that private enterprise makes “lots of money” on health insurance. He concludes that our privatized system has failed to the point that “everyone gets miserable treatment” and advocates for government-run health care because he doesn’t think that the government “could possibly do a worse job.”

Unfortunately, Mr. Cohen’s view relies on many false assumptions.

While Mr. Cohen is correct that our current medical system is “privatized” to some degree, our system is far from completely “privatized.” The government still has a significant impact on the care patients receive. Federal EMTALA laws require that every patient be evaluated – regardless of ability to pay. The threat of government fines and sanctions is hardly a “privatized” system. Through Medicare and Medicaid, state and federal governments control payments to physicians for a significant amount of the care that they provide. Hospitals have to meet their budgets or they will go bankrupt. When reimbursement from the governments declines, hospitals either need to cut staffing and services — which means longer waits and delays in care — or go out of business  — which means longer waits and delays in care. The number of hospitals emergency departments decreases each year.  As our administration struggles with a trillion dollar deficit, does Mr. Cohen or anyone else expect payments to hospitals to increase with socialized medicine?
Money is a great incentive. People spend days searching online for the best deal on a new LCD TV. People drive across town to get a gallon of milk twenty cents cheaper from a grocery store. Most people would not think twice about switching jobs if they were able to earn a few dollars more per hour for doing the same work. When insurance stops paying for one doctor’s care, most patients abandon ship and find a doctor that the insurance company will pay for rather than paying out of pocket. Doctors and hospitals are no different. When people are provided with an incentive, they will work harder. When deincentivized, they will work less. At some point, they will leave the system.
Look at the state of primary care in this country now. Doctors are leaving because the good aspects of helping patients are outweighed by administrative hassles, paperwork, and decreased reimbursement. Does Mr. Cohen think that there will be less administrative hassles and increased payments in a socialized system?

One quote just keeps resonating in my mind: “The government that has the power to give everything to you has the power to take everything away from you.”

The competing view I read was from a forwarded e-mail about an economics professor:
An economics professor at a local college made a statement that he had never failed a single student before but had once failed an entire class.
That class had insisted that Obama’s socialism worked and that no one would be poor and no one would be rich, a great equalizer.
The professor then said, “OK, we will have an experiment in this class on Obama’s plan”. All grades would be averaged and everyone would receive the same grade so no one would fail and no one would receive an A.
After the first test, the grades were averaged and everyone got a B.
The students who studied hard were upset and the students who studied little were happy.
As the second test rolled around, the students who studied little had studied even less and the ones who studied hard decided they wanted a free ride too so they studied little.
The second test average was a D. No one was happy.
When the 3rd test rolled around, the average was an F.
The scores never increased as bickering, blame and name-calling all resulted in hard feelings and no one would study for the benefit of anyone else.
All failed, to their great surprise, and the professor told them that socialism would also ultimately fail because when the reward is great, the effort to succeed is great but when government takes all the reward away, no one will try or want to succeed.

With tens of millions of uninsured patients, I worry about the health of our country’s citizens.

I worry more about the health of our country’s citizens if we implement a purely socialized system.

31 Responses to “Socialized Medicine Debate”

  1. Penny says:

    Correct me, please, if I am wrong, but I believe I heard Obama state that the plan he wants to implement is a plan that the people have to still pay in to. Granted, at a much lower cost than what private insurers charge monthly but a plan we would have to pay for. Then there’s teh issue of private doctors/companies not taking the insurance if reimbursements are too low (see: Walgreens in Delaware)

    There is also an upside to the “threat” of his plan. Many private insurance companies have returned to a $0 copay on generic medications. The more noise in the media about this plan, the faster the private insurers are to drop their prices. I have no problems with that.

  2. DaveyNC says:

    You must be a right-wing hater. You’re not supposed to speak the truth, you’re supposed to take whatever the government gives you and be happy they don’t take more from you. You already have enough, it’s time to spread the wealth. Those years of med school? They belong to us now. All that experience? You were paid as you gained that, time to share now. We get to set the prices, not you. Don’t hold out, give it all up. Emergency physician? No, we have enough of those. We need you to be an ob-gyn in the middle of nowhere. So go do that. We know what your patients need better than you do. We’re the government, and we’re here to help. You’re welcome.

  3. Matt says:

    Problem for docs is they’ve been on the govt teat for 30 years so it will be hard for them to wean now.

  4. MM says:

    while I agree with the professor’s sentiment, the story is an urban legend.

    http://www.snopes.com/college/exam/socialism.asp

  5. Mass says:

    I’ve seen that lame urban folktale about the econ professor and his “socialized” class floating around for some time now. It has absolutely no relevance to medicine. Rather than give spurious nonsensical theoretical fables, why don’t we look at “socialized” medicine in places like England, Canada and France where they pay much less, they have far higher (objective) standards of health and people are much happier with their systems of health care than we are here. Now, unless one posits that these various foreigners are alien beings, it is hard to understand why we too wouldn’t benefit from some government intervention in the healthcare field.

    I really think doctors care mainly about money. With pure socialized medicine where you don’t have to deal with insurance companies and where everyone is covered, you would have much less paperwork and uncertainty about what is covered. I urge less fearmongering about some kind of Orwellian medico-police state and more appreciation that we cannot sustain this level of spending on medicine. Either join in the debate on how to change our system or get out the way. Change is coming.

    • MikeMD says:

      I’d suggest actually reading up on how those systems work. I’ve lived in England and France and studied their health systems pretty thoroughly. There are good and bad things about each. The problem with adopting either system (and I think we can learn good things from them) is simply that Americans are not Europeans. Most Americans want everything but don’t want to pay for it.
      To say ‘they get more for less’ is pretty misleading. England takes 18% of your pay check each month to pay for the NHS. And it’s still running out of money. There are numerous BBC articles on it. Do you think that Americans are willing to pay that kind of taxes? I don’t even though I think the care provided is generally excellent. Moreover there are wait lines. If you’re sick the system is pretty good at bumping you but the average wait for a hip replacement is almost 2 years. Again, Americans won’t tolerate that well. The English are also much more honest about end of life care and don’t spend millions on futile cases like we do. Our politicians don’t have the balls to let docs make those hard decisions. Think of Terry Schaivo. Again, I like the NHS and would live in England (average gp salary exceeds 200,000 dollars/year
      btw), but I doubt Americans would deal well with it.
      France is a different ballgame but to sum it up they try to pay for everything and just jeep raising taxes to pay for it. Moreover they limit physician salaries severely. I couldn’t pay off my debt at their rates but both France and England make med school either free or much cheaper. I left with close to 200k in debt and that’s pretty average depending on where you go. If I were merely concerned with money I’d have gone into business. It’s much easier and people are less likely to insult you. But by all means believe what you want.

      • Mass says:

        I am not entirely clear on how Americans being unwilling to take necessary action should make you or me any less willing to support the need for that action. So if Americans want great care but not the pricetag associated with it, we should encourage, enable and promote their delusions? And as for great care, what about 47 million uninsured — are they getting great care?

      • MikeMD says:

        I never said things shouldn’t change; I was responding to your comment about France and England as you seemed to believe they got so much more for so much less.
        Have you bothered to research any of this stuff? Regardinging the 45 million uninsured, most do in fact receive great heathcare. As WC has posted, they can get evaluated in any ER no matter what. And I have never seen anyone with a catestrophic diagnosis denied care but they will get billed for it.. The issue is about billing, not just insurance. Were you aware that over 80% of medical bankruptcies come from people who actually have insurance? It’s the denial of payment by beaurocrats and companies that gets people into trouble. Reincentivise the insurance industry to actually insure people and you’ll have gone a long way. Insuring everyone may end up insured but that hasn’t worked for the state of Mass. Not to mention that a large part of that 45 million you mentioned is made up of illegals (should they be insured under a public plan? Who should pay for it?) and people who could have insurance (Medicaid or private) but don’t want it or haven’t bothered to apply for it.
        You should really read up on this stuff if you want to have a say in changing the system. And I agree that things must change. But to oversimplify matters, as politicians do on both sides, is dangerous to patients and providers.

      • Mass says:

        Oops, left out the best article:

        http://www.boston.com/bostonglobe/ideas/articles/2009/07/05/healthy_examples_plenty_of_countries_get_healthcare_right/?page=1

        Excerpt:
        But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

    • Mass says:

      As you think I don’t read about the issues, how about starting with some reading material for you to peruse?

      http://www.nchc.org/facts/coverage.shtml
      http://www.kff.org/uninsured/
      http://familiesusa.org/assets/pdfs/wrong-direction.pdf
      http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared
      http://www.npr.org/news/specials/healthcare/healthcare_profiles.html

      You might like to learn that only about 20% of uninsured are illegal immigrants, which I wouldn’t term a “large number.” And how exactly do the uninsured receive, according to you, “great healthcare”? Are you privy to a secret clinic or hospital where after one leaves the ER you can get an appointment or a procedure done without cash or insurance? And what exactly does this phrase mean: “Reincentivise the insurance industry to actually insure people and you’ll have gone a long way.” Huh???? Insurance companies are there to make money, perhaps the greatest incentive ever invented — they thrive on denying payments and on cherry picking healthy customers and excluding the sicker ones.

      I will leave you with this:

      http://content.healthaffairs.org/cgi/content/full/23/3/89

      “While the United States often performs relatively well for this set of indicators, it is difficult to conclude that it is getting good value for its medical care dollar from these data. The huge difference in the amount the United States spends on health care compared with the other countries could very well be justified if the extra money provided extra benefits. Population surveys have shown that the extra spending is probably not buying better experiences with the health care system, with the exception of shorter waits for nonurgent surgery. Earlier studies have shown the United States to be in the bottom quartile of population health indicators such as life expectancy and infant mortality.”

      I would advise following the data, not following an ideological opposition to government intervention in the healthcare system that doesn’t hold up in light of facts.

      • PMH_Doc says:

        “You might like to learn that only about 20% of uninsured are illegal immigrants, which I wouldn’t term a “large number.”

        You dolt….Only 15% of Americans are uninsured (47 million divided by 300 million total population), so by your logic we don’t have a health coverage problem.

        I just want to know where the public thinks they are gonna find doctors to work in this new system. There’s always talk of making it more European, but then you also need to pay for my medical education like they do in Europe. I have $300,000 of med school debt and cannot start paying it back until I actually start practicing at age 35….you bet I care about money.

        Mass, how many hours per week do you work for free?

    • Kim says:

      Yeah, the econ professor urban legend is pretty bogus. It also has no relevancy to anything but the right wing strawman version of current events (strangely often parroted by the D students who’d have been buoyed by the likes of me).

  6. John says:

    So the Government run Insurance will cost less than the Private insurance?? How do they plan to do this? Reimburse the Doctor’s less? If I have to mow a one acre lawn and one guy was paying me $100 and another guy was paying me $50 who’s lawn would i do a better job on? Why would I care if I lose that $50 account if I could pick up another $100 account? They both take the same amount of time to do and I can make twice as much.

    On the flip side by offering the Government run plan it would allow the private insurance carriers to dump the 3% of the population that is responsible for the 97% of medical claims. But let’s face the fact that either way, people will be crying…it’s a lose, lose situation.

  7. Famous last words: Let’s try something different, anything, because things couldn’t be any worse.

    It just shows a lack of imagination.

    How many people have had a glorious vacation after responding to an ad: “6 nights and 5 days at a wonderful Carribean resort, all food, transportation, and tips included, for $59/day pp double occupancy”.

    If you don’t know the details, you should’t buy the trip.

  8. Sabra says:

    I remember a conversation with a fellow as he was in the midst of leaving his federal government job for one with a local politician. He said the only thing it takes to succeed in government is longevity. You don’t actually have to be better than anyone, just outlast them, and eventually you’ll be promoted up the ladder.

    Even while making this complaint, he talked about his support of government-controlled medicine (I refuse to call it “socialized,” as socialism infers the workers taking over the government, not the government taking over the workers). There was an amazing cognitive dissonance there.

    I will say here what I’ve said elsewhere. I have years of personal experience with government provided healthcare, from the care the state of Texas has always provided to the uninsured on up to Tricare (the military’s HMO). In all cases, it is far inferior to the civilian, privately-owned system. I’ve no personal experience with the VA system–more government-run healthcare–but my mother has, and even though things have gotten markedly better for her in the past six months or so, she’s been in the system for years trying to get the same issues treated, and they’ve been put off again and again.

    Expecting me to believe that the government would take over all healthcare in this country and then magically do a much better job than it is now requires a suspension of disbelief greater than the vampire novel I’m currently reading.

  9. DaveyNC says:

    “With pure socialized medicine where you don’t have to deal with insurance companies and where everyone is covered, you would have much less paperwork and uncertainty about what is covered.”

    You’re kidding, right? You actually think that a government entity will have less paperwork? That we will know to a certainty what is and is not covered? Have you ever filed taxes? I mean, anything other than a 1040EZ? The regs and paperwork that can come into play on your taxes will be dwarfed by the paperwork from “pure socialized medicine”. And let’s not even talk about potential fraud.

    Here’s the change I want, since you challenge us to join the debate: HSA’s for all, major medical with a high deductible for all. Let the market work for things like routine check ups, colds, flu and the like. Use the insurance for true emergency situations. There, I just cut the cost of medical care by about 30%, based on my own personal experience. That wasn’t so hard, was it?

    • You are right about the bogus “less administrative costs” claimed for government healthcare. Medicaid is the example claimed to be more efficient than private insurers.


      Medicare Myth – Low Administrative Cost

      () Medicare serves a population that is elderly and receives much more medical care, making administrative costs smaller as a percentage of total costs.

      () Private insurers have a number of “administrative costs” that Medicare does not have, like state taxes of 2-4% on health insurance premiums. These can’t be reduced by better administration.

      () On a per-person basis between 2001-2005, Medicare’s administrative costs were 24.8% higher than private insurers.

      • Mass says:

        I’d rather trust a Nobel Prize-winning economist from Princeton who disputes the Right Wing talking points above:

        http://krugman.blogs.nytimes.com/2009/07/06/a-bit-more-on-administrative-costs/

        “This seems like fairly overwhelming evidence that single-payer systems do, in fact, have low administrative costs compared with private insurers. To argue that this doesn’t clinch the case, you have to resort to pretty desperate expedients; for example, one of my commenters says that the CBO study of administrative costs can’t be trusted, because Democrats control Congress. (The CBO bends over backwards to be nonpartisan — and anyway, the study was done in 2006, when Republicans were still in control.)

        I know that some people find that answer unacceptable: they know that the private sector is always more efficient than the government, and no amount of evidence will shake their faith. But that’s what the evidence shows.”

      • DaveyNC says:

        I will see your Nobel Prize winning economist and raise you one more acclaimed economist. Operative quote comes from Gary Becker:

        “The President wants to establish government-run health insurance companies to compete with private companies. This is a bad idea because experience from government-owned enterprises in other sectors conclusively shows that that they are run inefficiently, in good part because of political interference. Moreover, government enterprises do not compete fairly since they generally are subsidized, often generously and in hidden ways. Private health insurance companies in the US compete very strongly, although they are hampered by mandates and other regulations that frequently have nothing to do with effective and honest coverage of health needs.”

        Full post here: http://www.becker-posner-blog.com/archives/2009/06/health_care-bec.html

        Don’t be coming in here with Nobel prize winners. They’re all over the place, I can find one in a minute.

  10. RSDS says:

    There ALREADY is a socialized government run hospital system in the US. Currently its use is limited to veterans who meet certain criteria.

    I am a non-co-pay veteran whose only medical care is through a Veteran’s Affairs Medical Center. I have no other health coverage.

  11. Sarah says:

    We in NZ have a form of socalised medicine (I think?), that tends to work well. I wouldn’t say great, and we do have problems with people leaving NZ for higher pay, but the same is true of other occupations. Everybody that wants to go to a GP for a discounted rate must be a member of that primary health organisation of the GP or pay a higher rate per consultation (i.e. at my GP the co pay is $30 for an adult as a member or $75 for a nonmember). The PHO’s are given x amount of money for their population based on certain sociodemographic deatils, and the shortfall that the practices need to keep running are made up of the co pays. If you go to a PHO in a poor sociodemographic area, you pay $5 etc. We also have ACC, which provides no-fault insurance in the case of accidents and you don’t have to pay a cent – so in my case, I’ve had multiple surgeries in private hospitals that haven’t cost me anything because that is where my surgeon was based from. The money for ACC comes from us, as part of our yearly car registration because most of the ACC claims come from serious car crashes (I think it’s like 40% of the registration, about $150NZ per year) and is topped up my contributions that employers make as part of their responsibilites (I”m not sure about the % but I think that it’s about 25%). We also have private insurance companies, but it’s not needed since you will get to see the specialist within 3 months unless indicated as urgent – the govt pays for this as DHB’s.

    I’m not saying that this is perfect (and there are many changes that need to be made) but do you think that something like this might work at the state level (since NZ’s population is only 4.4 Million)? Or would that further split things for healthcare in the States?

  12. BlackSails says:

    Hey white coat, thought you might be interested in this:
    http://www.randi.org/site/index.php/swift-blog/594-25-billion-spent-on-cam-testing-result-it-doesnt-work.html

    Basically, after wasting 2.5 billion dollars the NCCAM found that everything they tested was pure woo. Shocking, I know.

    How many people without insurance could that have gotten insurance for?

  13. Max Kennerly says:

    Good idea. Next, let’s privatize the emergency services and the military, too.

    Money makes everything better, right?

  14. Matt says:

    Mass, Krugman’s Nobel, while nice, doesn’t mean much in this debate unless it was in this particular area. It certainly adds nothing to the merits of the debate. Here is a well reasoned counterpoint to his, frankly, under-reasoned position:

    http://meganmcardle.theatlantic.com/archives/2009/07/medicares_mythical_administrat.php

    Here’s just a short take:

    “Rather, private insurers have costs that Medicare doesn’t have within the agency. Private insurers bill. Medicare does too, but the IRS has its own budget–hell, its own courts–which don’t show up on Medicare’s balance sheet. Private insurers negotiate with suppliers. Medicare does too, but most of the negotiation takes place between lobbyists and Congressmen who again, do not show up on Medicare’s balance sheet. The Federal government has all sorts of these little items which relieve government agencies of reporting certain costs. But the costs remain.”

    Now, I’m not saying that there aren’t problems with the Heritage Foundation’s report, which Krugman attacks, because they’re a lobbying organization and like the AMA or ATLA they’re going to put out stats that favor them, but you can’t just buy one side’s argument wholeheartedly.

  15. Bookwyrm says:

    I’m on limited time today so I’ve only scanned the debate so far & I hope this comment isn’t too far off track….. My Dad gets gov’t health care through VA. He had chest pain. He had to wait 3 months for an appointment, then another 6 weeks wait for a stress test after which they scheduled a scan another 3 months out, which got rescheduled 3 or 4 times, thus extending the wait. In the meantime he had to go to the ER, when he had his heart heart attack (that could have been prevented with timely care). Fortunately he survived & got the referral for the immediate bypass surgery from the ER Doc. THAT is the best we can expect from Obama’s plan. We’d be better off addressing WHY health care is so expensive that insurance coverage is a necessity (unfunded mandated maybe?)

    Personally, I’d rather have affordable routine care that I can plan for & pay out of pocket with a medical savings account. Then I only need have a catastrophic care policy for the major unexpected stuff like broken arms & pancreatic cancer. It may be an extremist statement, but I think the health care industry might actually be better off if both doctors and patients could avoid dealing with insurance companies…

  16. MT says:

    I am familiar with the English, French and Canadian universal healthcare systems, having used each one of them. There are large differences between them and yes, they are not perfect, but then, neither is our system.

    One misconception here is that universal healthcare is free. It is not. Instead of paying premiums to a private insurance company, you pay your premiums to the government in the form of taxes. It is only a matter or terminology, but you still pay. And there are co-pays involved.

    However, the difference between those systems and the American one is that in those countries, everyone has access to health care: the employed, the temporarily unemployed, the wealthy, the poor. No one is in that grey area of too much income to qualify for help but not enough to afford care.
    I have yet to see anyone in those countries having to lose home and file for bankruptcy because of overwhelming medical bills, having to beg family and friends for financial help.

    • WhiteCoat says:

      Good point about the taxes.
      Still, the tax rate in Great Britain is 40%, including all medical care, correct? Makes you wonder where all the money in the US is going.
      I’m interested to know – because I have read conflicting reports.
      With high-expense items such as cancer treatment or treatment for liver failure, are all treatment expenses still covered? I’ve heard stories about people having to mortgage their homes to pay for cancer care. How about dialysis? How about end of life care?
      You’re a valuable resource and I’d like to tap your knowledge.
      Thanks for contributing!

    • steve says:

      I have lived in australia, worked as a MD in their system,a nd have trained and worked with lots of UK docs. if you think that universal healthcare a’la england or australia is the way to go, then you are sadly delusional.

      First off, there are horrendous wait times. GP’s (PCP’) get paid 20 bucks per visit if they take the universal option, so most try to see 10 to 15 patients per hour to try and make a decent hourly wage. One I know works 7am to 10p every day except sunday.

      the other alternartive is to have ‘private’ insurance, which charges an arm and a leg, gets you seen faster, but also charges a huge amount in copays for anything. my mother in law had a hip replacement. she could barely walk. cost over 10000 private insurance, or she could have waited, almost bedbound for 2 years to have one on the public system

      the other problem with this system is physician pay. I dont want to come off a a money hungry doc, but I invested years into my training, specialization. I incurred huge debt. if my pay gets slashed, what happens to those things. do I foreclose my house, just give up my car. take my daughter out of private school. and on top of that, we still have the possibility of being sued by some crackpot lottery malpractice attorney. I guarantee you this is something that would not happen in australia or england, but about which not one work has been mentioned in our current debate

    • DaveyNC says:

      One reason that each of the countries you named can afford the health care systems that they have is that in every case, the US either provides military protection outright, or subsidizes it for them. Canada essentially has no real military. Britain and France do, but we provide heavy support through NATO and other, more direct involvement such as military bases in Europe. We still have a large military presence in Germany and always will have, so long as Russia remains a potential belligerent. This fact gets lost in this debate. There is more to this than just the medical/insurance part of it. We have obligations around the world that we cannot simply ignore; Canada, France and Britain couldn’t afford their medical systems, either, if they had to protect their own asses.

      As much as I would like to think that we could withdraw militarily from Europe, our experience in the Balkans back in the ’90′s makes plain that Europe either cannot or will not police their own neighborhood.

      Yeah, yeah, I know–this is a medical blog, not a military or political blog. This issue is inseparable, though, from our ability to pay for such niceties as single-payer coverage for all.

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