Medicare for All (the Perplexed)

Yves here. Michael Olenick is correct to point out how one of the many bad features of US exceptionalism is that we refuse to learn from the experience of other countries, particularly with health care. And that’s before you get to the fact that big swathes of the public have been propagandized to view foreign “socialized” medicine programs as failures and thus regard like Medicare for All and other single-payer initiatives with suspicion.

Having said that, there would be transition issues with the adoption of any Medicare for All type program in the US. However, what isn’t sufficiently well recognized is that US doctors are already being “transitioned” to corporatized medicine, where they are employees of large health care organizations and have little autonomy.

By Michael Olenick, a research fellow at INSEAD who writes regularly at Olen on Economics

Sitting here in France and watching the Medicare for All debate. Good idea? Bad idea? How would it work? How would costs be controlled? I think everybody, for and against and in the middle, miss an enormous point: there are lots and lots of national healthcare systems to copy. There’s no need for the US to create a new one from scratch. Nothing happens in the US — besides the current cesspool called healthcare — that’s any different than the UK, France, Spain, Germany, or countless other developed countries that have healthcare systems.

My wife was just saying this morning “I should probably see the doctor but don’t want to waste the €35.” “All but €1.50 is put back into our account within a few days,” I answered. She’s used to the US system. Even the idea that seeing the doctor is a waste is foreign here; people are encouraged to go for the most minor things, which can turn out to be nothing, because they can also turn out to be something that’s much easier to treat earlier than later. Even chronic hypochondriacs have something wrong with them — a mental issue — that needs to be treated. The French run off to the doctor for virtually anything, and that’s the way the system is supposed to work, and it costs much, much less.

As for the socialized thing that’s not even true. Like everybody else here legally for more than three months we’re enrolled in the government system. That pays 2/3rds of less serious things, an amount that increases with seriousness. Regular doctor visits are reimbursed 2/3rds of the government rate of €25. Our mutuelle, private supplemental insurance provided by employers or that the self-employed buy at a reasonable price (or that’s free for poor people) pays most of the rest. But, you might have noted, you said your doctor charges €35 – is that a typo? No, it isn’t. Our doctor speaks fluent English and is close-by. Like all doctors, he sets his own rate schedule; he doesn’t have to charge the government price. In our case, our supplemental insurance pays all but €1.50 of the difference. If we had a doctor that charged €25 — and there are many, many that do (and most speak English – we just like ours) — it’d be reimbursed at 100%.

So there is still a private system, doctors in private practices — which most doctors are — set their own rates. And the public/private insurance companies reimburse at those rates. Pharmacies outside hospitals are all privately run and seem to have lots of customers but the prescriptions are paid for by insurance; the ones we’ve had are reimbursed at 100%. Hospitals are typically run by the government (I’ve been told all are, but the American Hospital in Paris is private, so that can’t be accurate). Clinics, that often look a lot like hospitals, are all private. In any event, they’re all affordable.

This public/private combination is common. Government healthcare systems do not eliminate the private market. In many ways, the system here has more elements of a genuine marketplace than the US, where insurance companies often dictate more terms than governments do. I can’t think of any US insurers that allow people to choose more expensive than baseline doctors then cover the vast majority of the cost. Usually, they pay a set fee and if people want something above it the patient pays the difference. There is no gaming prescriptions like we see in the US; pharmacies fill what a doctor prescribes and insurance (the public/private combination) pays. I don’t know the numbers but overhead has to be much, much less than in the US.

Americans tend to be creative, which is usually a fine attribute, but not in this case. Stop overthinking – take a system and copy it. And maybe come to the realization the complexity is not in the implementation, it’s in the political will to stop bickering and break away from a broken system that literally kills people for profit.

* * *

As Lambert added:

“Stop overthinking – take a system and copy it.”

Canada. Same continent, continental scale, multicultural/multilingual population, Federal structure, “mixed economy,” common law, Anglosphere, etc. They are absolutely the political economy closest to our own (and so there’s no need to look for some locale that’s wildly exotic by US standards, like the UK or France).

All the jerks at Vox yammering on about Germany or whatever are just trying to muddy the waters. It’s exactly what the same crowd did in 2009-2010; muddy the waters to keep the health insurance industry alive for another couple election cycles. Like Iraq, where the people who caused the debacle 15 years ago (rounding) are still in charge and still authorities, the people who caused the ACA debacle 10 years go are still in charge and still authorities. They’re not overthinking. They’re obfuscating.

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  1. John Zelnicker

    I’m beginning to think that a system like the one described here should be seriously debated. If the the public can receive health care for zero cost at the point of service perhaps a supplemental insurance that covers high-priced physicians and other amenities is an idea that could blunt the resistance of the insurance companies. As proposed, the best of the Medicare-for-All proposals would eliminate the private health insurance industry. For a multitude of obvious reasons the industry is fighting this tooth and nail. If the ultimate result of the push for universal health care gives these companies some kind of insurance to sell that might help the cause.

    1. Artanis Lossletter

      If the the public can receive health care for zero cost at the point of service perhaps a supplemental insurance that covers high-priced physicians and other amenities is an idea that could blunt the resistance of the insurance companies.

      No. American insurance companies, if given the opportunity to insert themselves into a process, will find a way to exploit their position to maximize their profits. There must be no room for such schemes until the American insurance industry is properly neutered through regulation, as they are in most civilized countries.

      1. Yves Smith Post author

        If they maximize price gouge on supplemental insurance, that very few will buy it. On a product no one needs to buy, they have to offer a not-abusive price to have decent volumes.

        I have a New York state regulated policy, and New York offers external appeal on claims and keeps them on a short leash. So the idea that this isn’t being done now in the US is inaccurate. It’s just not being done in the overwhelming majority of states.

        1. Donna

          It seems that if you leave the insurance companies to operate with the kind of power they now have we are setting ourselves up for disaster once again. They will always be in there trying to game the system. Look at how they wedged themselves further into the Medicare system with the insidious Advantage plans.

          My husband and I are retiring this year with residual income from the commissions on the employee health insurance plans he has helped employers manage from almost 40 years. We will loose that income of course eventually through attrition. With Medicare4All we will loose it over night. Still watching the insurance companies at work these last 40 years, we both fear leaving them in place to gradually erode the good system we replace them with.

          Of course regulation is the key. There was a time when we could go to an employer at renewal and quote rates and benefits from 10 different insurance companies. With competition, they had to perform for their insureds and compete on price. That was not a panacea. There were still health questionnaires for small groups and of course individual policies we almost impossible to find for people with pre-existing conditions.

      2. jrs

        People need to stop using the term “Medicare For All” if the idea is not to involve insurance companies.

        Of new enrollees in Medicare (people hitting 65) OVER 50% (yes the *MAJORITY*) are enrolling in Medicare advantage plans. That *IS* Medicare at present and in the future. It’s not an infestation at this point, it is Medicare.

        Using the term MFA while talking about eliminating insurance companies makes one sound either profoundly ignorant of the healthcare system in the U.S., or hopelessly confusing (including to those on Mecicare now!). Improved and expanded Medicare at least qualifies it. Single payer probably works.

        Or fine whatever, keep using the term MFA and don’t be surprised when the next Dem president delivers Medicare Advantage for all. Which granted *might* (maybe depending, but maybe not) still be an improvement … But sheesh at least negotiate for more.

        1. JohnnySacks

          Agreed to a certain extent – ‘Medicare for All’ is the soundbite. Lest we forget, the guy in the white house got there via ‘Lock Her Up’, ‘Repeal and Replace’, ‘Build the Wall’, etc.
          Same as with that guy’s soundbites, the implementation is always the key once the soundbite wins the day. that’s where the hard work begins, hard work that a lot of people are afraid, petrified even, of being forced to undertake. Perpetual outrage is a hell of a lot easier.

    2. GM

      The insurance companies are the obvious villain in the story, but the problem in the US goes much deeper than that, because everybody in the system is for-profit. So if the focus is solely on the insurance companies, the problem will not be fully solved. Right now you have:

      1. Insurance companies extracting a rent from the population. Those have to go. But you also have:

      2. Pharma and biotech companies selling drugs and therapies at much inflated prices

      3. Device manufactures doing the same

      4. Private hospitals operating as for-profit enterprises

      5. Doctors being paid more than anywhere else in the world.

      6. Medical schools putting those doctors hundreds of thousands of dollars in debt at the beginning of their careers.

      All of that has to change if the system is to be properly reformed.

      But it is politically unpalatable to talk about how doctors have to be paid less, how hospitals have to be non-profits, and how medical schools have to be free. Especially given how strongly the universities and the people working in them are leaning towards the direction of the political spectrum that is calling for Medicare-for-all.

      Also, on a fundamental level and from a long-term perspective I don’t see how any socialized healthcare system can survive with private for-profit actors in it. It can survive for some decades, but long-term it is doomed, because what happens is that if there are private options, the rich go there and separate themselves from the rest of society. Then, because they don’t need the services that the national system provides, they lobby hard for its defunding and dismantlement. You see that process in action with the NHS in England. You have to nationalize everything and ban the existence of private options so that the rich and powerful have no choice but to be personally interested in the system functioning well.

      By the way, the same applies to education too.

      1. Acacia

        These are excellent points. Scary, though, because they imply the issue is deeper and more ideological than simply the medico-insurance-complex.

      2. Ptb

        Absolutely right.

        Unfortunately, correcting the deadly and ruinously expensive dysfunction in our health system is going to inconvenience a lot of wealthy people and businesses.

        However, despite being locked in the system, most docs (nurses too) understand better than anyone how messed up it is. Probably getting them on board en masse, and flipping the AMA would be a political imperative.

        As for the insurers and especially pharma, they will fight it to the last dollar they have, which is a lot. sabotage every step of the way too. It’s not going to be pretty.

      3. JEHR

        The for-profit model of doing business fits in nicely with individual belief system that each person is responsible for his/her own welfare no matter where the individual starts his life journey. On the one hand, some people believe that anyone who cannot pay his/her own way is not pulling his weight and deserves to suffer the (bad) consequences. On the other hand, many individuals born within a wealthy family begin to believe that they have actually worked for or earned their much higher status in life. How does one learn to believe that less well off individuals deserve to have help when they cannot help themselves? How does one become concerned for the welfare of all when they only dwell on increasing their own welfare? There are many billionaires who think they absolutely deserve their place in life because money is equated with success and hard work even when neither may be true.

        How does a nation develop a feeling of community responsibility when many individuals in it do not?

      4. Jerry B

        Good points in your comment GM.

        =But it is politically unpalatable to talk about how doctors have to be paid less, how hospitals have to be non-profits, and how medical schools have to be free==

        That idea is one I have been “beating the drum” on for a long time. That we need to bend the cost of living curve back to some semblance of modesty. In the case of healthcare, if we want to reduce costs then everyone in the chain is going to have to take a pay cut. No more hospital systems where the hospitals look like five star hotels. No more doctors/surgeons, hospital administrators, Big Pharma CEO’s, etc. living in gated communities. They live in the same neighborhood as everyone else but with a slightly nicer house and car, and not a McMansion and a Mercedes.

        The same thing applies to any “industrial complex” industry (cars, higher education, etc.) To make things affordable for everyone will require everyone who has been living off of the “system” to take a cut. Yves has mentioned many times in regards to climate change that we are going to need to exhibit radical conservatism in the way we live. So a reset in how we live is coming whether people like it or not.

        All the people that have been living large off of the system will not take a cut quietly. It is going to take a long time for people to learn to live modestly. Changing habits, paradigms, and ways of life is hard but we need to learn or it will be forced on us by climate change.

        1. Harold

          Doctors maybe will accept being paid less pay if they also understand they themselves are not going to have to pay out of their own pockets for a) ongoing medical education debt; b) staff to handle negotiating with private insurance bureaucracies c) skyrocketing malpractice insurance from people who have no other way to finance long-term care. Hopefully, too, there will be a long-term non-financial benefit from not having to have an adversarial relationship with their patients, many of whom, absolutely detest their doctors and hospitals with a purple passion.

          In the end it is a win-win

          1. Jerry B

            Thanks Harold. Excellent comment. From your a, b, and c points it stands out that on so many levels our healthcare system is a dysfunctional mess. It is like being a child or an adult in a dysfunctional family. You come to see the dysfunction as normal and think this the way everyone lives and do not realize that there are better ways. Maybe 5-10 years from now with a saner and less dysfunctional healthcare system we will look back and say, “What were we thinking? How could we have been so blind?”

            To Michael’s point in the post, I think one reason we are overthinking this is that we are so used to being “dysfunctional” that we do not know anything else. It is like a child suffering a trauma and then as an adult the person keeps recreating the trauma hoping for a different result or trying to fix it with the same dysfunctional tools the person learned as a child, and it’s not working.

            BTW one dysfunction of the US healthcare and other industrial complexes compared to other countries are the extreme profit seeking, the legal extortion, legal criminal racketeering, revenue generation, ponzi schemes, and mafia type kickbacks that are part of the US Crony, Casino, Sociopathic, and Psychopathic Capitalism.

            So for us to “copy” another country’s healthcare model would require a “paradigm shift” in our culture. So maybe the reason we are overthinking this is because like all things in the US we want to have our cake (extreme corrupt profit seeking) and eat it too ( universal healthcare).

      5. Jerry B

        ===because what happens is that if there are private options, the rich go there and separate themselves from the rest of society===

        My sense is the “rich separating themselves from the rest of society” has been going on since the beginning of time. However, it has been taken to extreme measures the last 40 years in the US.
        From reading about healthcare and other industries around the world there are a lot of private-public partnerships. As mentioned in the post ,healthcare is one area. Many transit systems in Europe are private public partnerships.

        IMO the difference is the private sector in other countries does not engage in the sort of rent seeking, extraction, affluence seeking, and extreme lifestyles that the US exhibits. And this has to do with culture. The US of the last 40 years has taken the Milton Friedman model of capitalism to it’s extreme and it’s all about satisfying the wants of each individual no matter how obscenely expensive. I hope commenters who live in other countries will respond to my belief that the private sectors in other countries are not so extremely profit seeking and this is due to the each country’s culture.

        ===You have to nationalize everything and ban the existence of private options so that the rich and powerful have no choice but to be personally interested in the system functioning well.===

        That is a great statement. I am not sure I totally agree, but I do think it does apply to education.

      6. Jeffrey Fisher

        I think our current dysfunctional healthcare finance system makes it very hard make progress on those issues.

        As long as figuring out how to pin the bill on someone else (usual some sick person or their family), or just not providing care is an option it is chosen over actually figuring out how to reduce cost.

      7. Oh

        You’re quite right. There is no place for insurance companies when it comes to health care.

        Non Profit hospitals are just a tax classification. The profit that the make is called reserve and they’re allowed to carry over a certain portion of this for the next year. Instead of paying taxes they build grand atriums, add more equipment (to later make doctors force patients to use them, thus generating more profit reserve), pay thier management more $$$$ and thus get around creating a taxable level of reserve. Most people think non profit means that these hospitals are better because they charge less.

        Yes, the rich need to have the same system of health care as the rest of us.

      8. John k

        First, get the politicians to have the same system as their voters. Copper plan. Change would come fast.

  2. The Rev Kev

    I have a feeling that there will be a lot of people commentating on this article before the day is done but may I add that the most cited study for uninsured fatalities was published by the American Journal of Public Health in 2009 and found that nearly 45,000 Americans die each year as a direct result of being uninsured. That is working its way up to the number of total Americans killed in Vietnam – but annually. I am willing to bet that the cost of all those fatalities is never worked into the cost of having the present system kept in place. That study, by the way, is here-

    1. JBird4049

      They’re not overthinking. They’re obfuscating.

      It’s not obfuscation. It is paid propaganda.

    2. JBird4049

      This a bitter subject to me as I am a widower likely because of the lack of insurance. I rather have no acceptance of any objections to a system like those in country in Western Europe.

      I think much of the resistance comes from feeling only those with money should be counted in the cost/benefit analysis of our current “healthcare” system. It is never stated explicitly. It might often only be unconscious, but it is there. A person’s wealth however gotten determines just how worthy they are to be treated as a human being.

  3. Acacia

    I lived in France and concur with the author’s experience. Coming from the completely broken rip-off system in the US, it was truly eye opening.

    Sadly, I think the American health insurance lobby will resist any serious change (it’s far too profitable for them), using disinformation campaigns in the media, fear of “socialism”, bought-off politicians, etc., and the Democrats will be more than happy to help them do so.

    1. Geo

      I was in Cuba for a week and had a better experience in their hospital system (emergency procedure) than almost any in my adult life in the U.S as a relatively poor person with no coverage.

      That said, there are enough in power who are comfortable in our current system who are either afraid of change or just unable to see why change is needed (especially when not changing things pays so much better!) that I agree with you – they will do everything they can to protect the current system. No stats about annual deaths due to lack of coverage, better outcomes and costs in other countries will convince them.

      It’s the same mindset that believes black people are lying about police abuse or that women are lying about sexual abuse/harassment. It’s not happening to them so it’s not a real problem. That’s where America fails: an inability to empathize with others due to a cultural narcissistic myth of “the rugged individual” that has magical gravity defying bootstraps: “I got mine all by myself, get your own!”

      1. Acacia

        Yes, and that “I got mine… every crumb fer himself!” mindset is pretty much what I encountered when I tried to talk with my American coworkers about the French system. Of course it wasn’t expressed as such, but they started cycling through all kinds of excuses and rationalizations instead of admitting that a country in “Socialist Europe” might actually provide vastly superior health care. This nitwit exceptionalism is likely one of the angles the insurance lobby will play to resist real change in the US.

        I agree with Lambert, above, that for this reason Canada is probably a more effective point of reference than France, Germany, Japan, etc., however effective their systems may be, because they can always be dismissed as “well, it may work for them but… we are special … blah blah blah”.

        1. Carla

          Never forget: “I got mine… every crumb fer himself!” — is almost always a lie. People who “got mine” tend to conveniently forget that they grew up with all the advantages of a middle class life — a stable home, good public education, mom & dad paying for college or at least helping, and a decent public health system that has fallen by the wayside in this country. You didn’t used to be able to enroll in public school without proving that you’d had your vaccinations — that is no more, and now everyone is at greater risk.
          I’ve known a heckuva lot of people in my life, and only one could legitimately claim to be “self-made” although she never did make that obnoxious claim.

      2. notabanker

        First hand experience:
        UK system for years. Worked great for family care, never had to navigate a serious illness. 7 GBP for all prescriptions. Pharmacies co-located in Dr clinics. Fill the prescription in 5 minutes and leave with it in your hands.
        Singapore – Worked great for family care. Son had surgery, few hundred dollars out of pocket. My personal physician was trained in both Western and Chinese medicine and gave me the best advice I have ever had from a medical professional.
        Vietnam – Son had food poisoning. Immediate treatment, IV’s, antibiotics, english speaking care, overall excellent care and service. $300 out of pocket on a credit card that was fully reimbursed.
        Indonesia – Multiple bouts of food poisoning. Cheap drugs available over the counter within walking distance of any populated area. 8-24 hours recovery time.

        I laugh at Americans that tell me we have the best healthcare in the world. For the average person, it’s not even close.

    2. rd

      The corporate healthcare entities will fight anything like this tooth and nail because it is existential for them. The long-term goal is to move US healthcare spending from 17% of GDP to say 12% and most of that cut would come out of corporate revenue and profit.

      I know that the people talking about these ideas are not really serious or are uninformed as they are always talking about European models which allow everything to be branded as “socialist” while never mentioning Canada, which does not have the “socialist” branding in the US while looking and sounding a lot like America (at least northern US).

      So have hearings that go through the details of the French, German, Swedish, and Canadian healthcare systems so that people understand the real and functioning alternatives to the disaster that is the US healthcare system.

      1. Eclair

        Yes, “the corporate healthcare entities will fight anything like this tooth and nail ….”

        Helped out by supposedly ‘liberal’ columnists like The Seattle Times’ Danny Westneat (10 March 2019) who devotes an entire column, saying that Medicare for All is a great idea but comparing Congresswoman Jayapal to Trump because of her ‘tone-deaf’ tweet on replying to the news that health insurance stocks had tanked: “Sorry Not Sorry.” With shrugging emoji.

        He accuses her of being insensitive to the 850,000 workers employed by the health insurance industry. Thus insidiously turning Medicare for All into that un-American beast, “job-killer.”

        No mention of how so many of those paper-pushing administrative overhead jobs contribute to the US’s high per-capita health care costs. No mention of how jobs that actually produce needed stuff (like shoes, shirts, kitchen appliances, tools, pots and pans) have been suctioned off and sent to low-cost countries, leaving unemployed people with no options other than to take paper-pushing jobs. Not even a nod to the proposed Green New Deal, which mandates a job guarantee, because when you remake an entire economy there are going to be lots of workers whose jobs disappear.

        Yeah, maybe Jayapal could have been a bit more diplomatic in her tweet. But, an entire column identifying her completely with the odious Trump, is a nasty piece of work.

        (Apologies, I can’t link to the Seattle Times piece because I have reached my on-line limit for the month. I read my husband’s daily paper subscription!)

  4. Luke

    One concept I never hear mentioned in discussions about health care funding:
    if a given concept (“Medicare for All”, say), why don’t people who think it’s a great idea just form voluntary associations, where would-be patients, hospitals, doctors, pharmaceutical companies, etc., can all join them if they have been convinced that those are a good idea? When someone says their idea only works if it involves using guns on innocent people who just want nothing to do with it (that’s what laws are), then IMO most of the time an idea that’s intellectually bankrupt has been identified.

    1. The Rev Kev

      It sounds like you are describing something like an extended version of the old Fraternal orders or Friendly societies of the 19th century where members would all kick in and hire a doctor to attend their needs as well as pay for any funerals as well. It worked – mostly – well enough then if you could afford it but sorry, won’t work in the 21st century. Too much has changed with medicine since then.

      1. bmeisen

        Insurance is by definition a friendly society. Risk can be public or private. Reason dictates that in functioning, democratic states the hedging (if you will) of large-scale public risks be defined as state responsibilities. A standing military is insurance against the public risk of being threatened by a violent aggressor. The definition of public risk has been manipulated. Insurance companies have emerged and grown also because the complexity of risk exposure has overwhelmed the traditional friendly society model. Calculating rates and administering claims is challenging and unpleasant and those who do it need a degree of competency and deserve rewards. Not surprisingly, insurance companies have produced efficient solutions for individuals who want to hedge private risks, e.g. the damage to or loss of valuable possessions, death (premature or otherwise), liability, etc. As the definition of public risk has decayed in the neoliberal culture of the USA uncertainty and fear have grown. The treatment of health care as a private risk is a case in point.

        1. The Rev Kev

          I would actually agree with everything that you say except the last sentence. Health care is, in the long run, a public risk and not a private one. If a population is denied health care because it is unaffordable, then you have an increasingly larger segment of the population that become more vulnerable to epidemic diseases. Having a healthy population is a stabilizer for a robust society. If you want proof of this, then consider the fact that Los Angeles has a goddamn Typhus epidemic at the moment that is growing steadily worse. And last time I looked at my calendar, it said that we lived in the 21st century and not the 19th century.

          1. bmeisen

            I agree – my last sentence was unclear.

            I wonder if ranchers in the US get more support for caring for health of their livestock than families in the US get for caring for the health of their children. Are health care costs for families tax deductible? Can ranchers deduct veterinarian costs from tax exposure? I assume so. Can a freelancing specialist deduct her health insurance bill?

            Maybe Yves knows.

    2. a different chris

      Yeah that would be fine in a time where most people never ventured more than 20 miles from their birthplace.

      My company makes me fly to, say, Utah. I get sick or trip and break my arm, how does the voluntary association work across 1500 miles? Now there is a real bill that somebody has to pay, and now we get right back into contracts and laws.

  5. Tom Bradford

    Some months ago my wife suffered a detatched retina at 4.30 in the afternoon. By 6.30 she and a friend (I stayed to look after the stock) were on a plane to a larger city with a hospital having the necessary facilities and at 9.30 she was on the operating table having it repaired. She overnighted in a hospital bed while friend went to a motel – arranged by the hospital. Discharged the following day she and friend returned overland, as wife couldn’t fly. Total cost of travel for wife and friend, surgeon, anaesthetist, theatre, overnight stay in hospital and motel, plus meals? NZ$0.

    She’s now three days away from a procedure to remove a cataract resulting from the original surgery. Cost? NZ$0

    Two weeks ago my prostate closed off my urethra. GP diagnosed it at 11.30 am (cost NZ$47) by 12.30 I was having a catheter installed in hospital. (cost NZ$0). I’ve since had two visits at home from a district nurse and will get them weekly at least – they are on call – to ‘assist’ with the catheter and etc supplies (cost NZ$0). I’ve been been promised an operation within two months in the public service but have elected to go private in two weeks at a cost for surgeon, anaesthetist, theatre and two nights in a private hospital of around US$6,500.

    So both medical emergencies cost us next-to-nothing – or could have had I not elected (and could afford) to go private – tho’ they weren’t free. The cost is met from the nation’s wealth equally for all citizens, and we have our share of politicians or businessmen who think that cost should instead be spent on NZ’s military, or on building motorways from Auckland’s CBD to close to their holiday homes in the Coromandel, or on more pay and better perks for politicians. Fortunately they don’t get a lot of traction!

    1. Eclair

      Tom, thank you for your description of the NZ health care system.

      A few year’s ago, I was traveling on Amtrak overnight from Chicago to Denver. I struck up a conversation in the lounge car with a man who turned out to be from NZ. Over glasses of wine we got to talking about comparative health care systems. Turns out he was business consultant to the head of a (the?) NZ medical school, so knew the fine points. We continued our conversation over dinner in the dining car (where we gleefully picked apart the arguments of a fellow diner who was spouting the “America has the best health care system in the world” line. Haven’t had that much fun in years!

      He did mention that prescription drug care costs were contained by having an approved list that the NZ government negotiated for with the pharmaceutical companies. If you wanted a drug that was not on the list, for example, an new or experimental drug, you could petition the system to pay for it. They might or might not accept it.

      1. Tom Bradford

        Yup. “The Pharmaceutical Management Agency, better known as Pharmac, is a New Zealand Crown entity that decides, on behalf of District Health Boards, which medicines and pharmaceutical products are subsidised for use in the community and public hospitals.” It’s able to negotiate drug prices in bulk from manufacturers and has a good handle on generics.

        Whatever the prescription and its original cost there’s just a standard cost charged by the pharmacist – NZ$5. And yes, courses of drugs that cost tens if not hundreds of thousands can be subsidised.

    2. RW Force

      Traveling in NZ a decade ago I met a US woman whose physician son had emigrated to NZ for the lifestyle. Each year he took a one month vacation in the US to work as an emergency room physician. He doubled his annual income.

  6. PlutoniumKun

    A very good example of this is Taiwan. In the mid 1990’s they were searching around for models for a new healthcare system and found… Medicare. They liked the way it worked, they just adapted it wholesale, with one difference – they made it universal. Current spending is only something like 6-7% of GNP, much less than half what the US spends.

    An example not to follow is Ireland, which has a needlessly convoluted system which mixes private insurance companies with direct provision. A few years ago they wasted a lot of time trying to copy the Dutch system, for no other reason than it was rated the best in the world. Unfortunately, the Dutch system – based on employer contributions – is for historical reasons very complicated and only really works in the specifics of the Dutch government system, its almost impossible to replicate. Likewise, the French system, although it provides excellent healthcare, is also relatively expensive (as with the German system). While they work, healthcare systems which have at their base employer based insurance tend to end up significantly more expensive than direct provision or single-payers systems.

  7. Cripes

    Luke, that is about the most ignorant thing I’ve read in a long time.

    And I suppose you think we should all join voluntary associations for Fire and Police and transportation and customs and Food and Drug safety Services? How do you think that would work out?

    I’ve got a gun to my head right now every time I want Medical Care I’m gambling on bankruptcy homelessness or death, in order to keep your precious Healthcare profiteers rolling in ill-gotten money. I mean that. Literally.

    Not to mention, your supercilious idea of rugged individuals searching for his personal brand of healthcare is completely idiotic, because that’s the lie of consumer choice we’ve been sold for decades which is really no choice at all. Universal medicare-for-all IS every citizen has Healthcare from Cradle to grave.

    By the way, no one ever asked me if I wanted to participate in this screwed-up system. So get your collectivist hands out of my pockets.
    Why can’t we have nice things? Because of Kool-Aid drinkers like you.

    1. carl

      You beat me to it. Those kind of objections are why we can’t have universal health care in the US.

    2. JEHR

      Cripes, you said to Luke, “So get your collectivist hands out of my pockets.” Why do you associate working for a common goal (healthcare) with collectivism (i.e., communism, socialism?) The words you use denigrate the idea that Luke was making. Maybe, that is why your country does not have collective (working as a group) healthcare. In order to have healthcare for all, you have to work together.

      1. Cripes

        JEHR: that was sarcasm. By using the ridiculous language those people employ, I’m saying that he’s forcing us to use the exploitive so-called free market Healthcare model against my will.

        Of course I prefer a universal Public Health System based on common welfare instead of private profit.

  8. Jen

    My brother in law was just diagnosed with a serious heart condition. He’s going to need an implantable defibrillator. He’s self employed – installs flooring. Can’t do that now. His wife, my step sister, is working for a company that is consolidating its operations out of state, and will be out of a job before too long. Of course, they have health insurance through her job. When that ends, she can continue that insurance through COBRA, but it’s going to be way more expensive.

    They have, right now, a very solid middle class life. They aren’t rich, but they’ve been careful with their money. They own their home free and clear. They were able to send their kids to college and save for retirement. Now they are facing the prospect of huge medical bills, much more expensive insurance, which they can’t afford to go without, and on much smaller (or even non-existent) income.

    They are still better off than most. After all, they still have assets they can deplete (house, retirement savings).

    This is our health care system: your money, or your life.

  9. Peter

    Why look to Europe – Canada is right next door with a functioning system.
    Before we left we paid about 120$ a month, families with children pay a bit more. Persons earning less than a threshold income can have their monthly fees reduced or waived.
    Exclude from the provincial plan are usually dental and optical. Private plans for those are usually supplied by the employer.
    Treatments needing hospital stay or day surgery are 100% covered as are visits to the privately owned clinics or practices.
    Post surgery care is also free like changing bandages, physio etc.

    At present we live in portugal, not a country of affluence. Participation by employees is mandatory and will be paid by the employer, freelancers (trabalhadores independente) pay a fee depending on the income per month. low income freelancers below a threshold pay about 20€ care plan participation. Pensioners join the system for free, even non citizens have the right to join.

    The coverage for all treatments needing hospital stay are free (with a proviso further down), as well is day surgery. The centros de saúde are the clinics that supply post surgery care, day surgery and where the medical doctors operate out of. One gets assigned a family doctor who then directs patients to the specialists.
    Private clinics are available, at a first time fee of 75€ with 35€ for following visits.

    Visits to the hospitals and to the doctors at the centros will set you back 2€ – 5€ each time, which
    includes all lab services, and of course all surgeries needed. It has to be paid before the visit to the doctors assigned for the surgery with entry for surgery then free.
    Post operative care includes home visits by nurses if needed from the centros, physiotherapy clinics are either at the hospital for 5€ a visit or privately owned.
    As in Canada, dental and optical re excluded.

  10. Shonde

    I must have a blind spot since I never hear this mentioned as a way to sell Medicare for All to the general population.

    There may be some people this does not apply to but most people have older relatives on Medicare. I don’t know a single person on Medicare who does not love it. So why do we have to look to other countries for examples to sell Medicare for All? Why don’t politicians honestly just ask voters to talk to all their senior citizen relatives and ask them to compare what they go through every year with employer based insurance compared to what a senior citizen is required to do with Medicare. Also ask about the care received under Medicare. I have never heard any complaints from Medicare recipients. They love it.

    As to cost, a nephew who is self employed pays $24,000 a year for health insurance for his healthy family of 4 (wife and two children). What would his cost be under Medicare for All? How much would his taxes increase to provide the same coverage under Medicare? The Dems better get some cost estimates out soon.

    1. Anonymous

      Actually, I do know someone on Medicare who does not love it. My mother has, over the past two years, had numerous problems both with access and payment. On Medicare with a highly rated supplemental insurance plan. She ended up post-surgery in a physical rehab place that was highly rated but just didn’t get around to doing her PT. Maybe because they were too busy trying to pressure me into moving both parents into their nursing home affiliate? And because she wasn’t getting care, she wasn’t getting better, so Medicare and the plan refused to pay for PT — in *any* facility. We finally got her out of there to a decent assisted living place, but she is still getting bills for things like a wheelchair that she bought because they refused to get her one that fit or was suitable (meaning double payment for the wheelchair), not to mention the PT that they never provided.

      1. a different chris

        >On Medicare with a highly rated supplemental insurance plan.

        That’s the thing. We not only have a “universal” health care system, it allows private supplementation. So where’s the problem? I’m always one for “looking elsewhere” for problem solutions, but not in cases we don’t actually need to.

        1. jrs

          it requires private supplementation not allows, buying Medicare supplemental plans are necessary or part of your medical bills isn’t covered is my understanding.

          People that can’t afford supplemental plans tend to go with Medicare Advantage plans as it’s a cost advantage, and that’s why they are popular in terms of enrollment, because they don’t leave a coverage gap at no additional cost. Basically it’s the way the system is set up.

        2. marym

          Medicare pays 80% of the cost for the range of services that it covers. People buy supplements for the other 20%, and separate plans for prescription drug coverage. As jrs notes, Medicare Advantage plans may offer all of that and sometimes additional coverage like vision. So there’s a tiered system based on what people can afford.

          Medicare for All (the original HR 676, the Sanders version, and the current Jayapal plan) expands the range of services covered, and pays 100%. Supplements for the currently typical reasons would then not be required. They would be for whatever isn’t covered: often cosmetic surgery and private hospital rooms are given as examples, but basically it would depend on what’s eventually excluded from what is now a pretty broad proposal for the range of M4A coverage.

    2. Jeffrey Fisher

      I have a relative on medicare who will bad mouth it at the drop of a hat.

      But gosh she got a bunch of expensive medical care the year she was allowed to join and raves about the treatment she received and will accuse you of socialism for approximately anything.

  11. David

    I think the reality is that there are plenty of good systems out there for the US to copy. It scarcely matters which. The French system has many advantages, but like many others it grew up rather than being deliberately structured, so it’s full of inefficiencies and contradictions. For example, the profusion of Mutuelles (the insurance organisations) and the profusion of so-called “Caisses”, which between them pay the government’s part, means that few people actually understand how much they pay, and who pays the rest and how. So when I went for some dental treatment a couple of years ago, the secretary of the practice took all my details, consulted a lot of data and said yes, this would be OK, but it would take about a week before she could tell me how much I would have to pay myself, and before I received the official agreement of the Mutuelle to part-finance the treatment.
    Likewise, doctors in France are not salaried employees of the state, but “profession liberale”, ie independent businessmen. They are paid by the state for visits, but otherwise charge fees for other things, and generally have a large administrative workload for taxes etc. since few of them can afford a secretary. Increasingly they cluster together in “Cabinets” (“practices” in the UK) to share the administration around. Because of their status, which is jealously preserved, they have a lot of independence, and most go to practice in comfortable areas where patients are less demanding. Few want to install themselves in remote country areas or in rough suburbs. This leads to so-called “deserts” in parts of France where it can be difficult to find a doctor. A corollary of setting up shop in a prosperous area is that you can charge more. A doctor who does not have an contract with the state can charge whatever they like, and you’ll only be reimbursed for part of it: in posh areas you can pay €100 for a visit.
    None of this is to say that the French system is not good (though it’s presented here as being eternally in crisis). Rather, even if you adopt a foreign model you would not want to incorporate every last wrinkle and particularity of it.

    1. vlade

      The problem with adopting any system that has been run somewhere for a time is that there’s culture and cultural acceptance (or at least knowledge and ability to deal with) of its idiosyncracies.

      When you try to bring the system over, you either:
      – drop those, running the risk that you’re dropping somethign that actually matters (in complex systems, you never know)
      – keep those, but without both the users and providers being in-cultured, again, with dubious results.

      That doesn’t mean you’d not adopt systems, but you need to be aware of the risks.

      From that perspective I believe that the easiest way forward for the US (and I know very little about the US healthcare details) is to make Medicare universal, as a first step. Then you can tackle other things that this will throw up (too expensive drugs etc..). At least people are sort of familiar with Medicare.

      But trying to implant a foreign system w/o the culture (=accumulated history) that goes with it is asking for trouble and will eat up a LOT of political capital. And if it fails, the failure will be felt for decades.

  12. Carla

    @Michael Olenick — are the insurance companies that offer supplemental policies in France for-profit, or non-profit?

    1. Michael Olenick

      Good question – I don’t know the answer. I do know that there are lots of them and there are strict requirements about what they cover and don’t (dental, optical, and a certain amount over the government base for those who want pricier doctors or clinics). Mine is provided through my employer so I’ve never had to shop for one but if you Google them you’ll see that there are lots (install the Google Translate plugin if you don’t speak French).

      Since there are so many they compete on price and service. I know there are rules preventing discrimination based on pre-existing condition and that pricing can only be adjusted by service level and age, and even that is flattened out.

      My mutelle is listed on the NYSE and operating in the US, though not as a health insurer. I’m sure they’d be pleased to sell Medicare mutuelle insurance (I think there is already a thriving market for Medicare supplemental insurance).

      1. David

        Both. There are purely non-profit companies usually linked to a profession (such as the public service) as well as companies which are subsidiaries of large insurance companies .

    2. Olivier

      I don’t know about the exact mix but there are definitely private ones. See, e.g., this complémentaire offering by AXA. Most insurance companies offer such policies.

      And like David I would caution that the french system is actually a little byzantine and probably not suitable for wholesale adoption by another country.

  13. Rodger Malcolm Mitchell

    The U.S. has an easier time than France providing Medicare for All, for one simple reason. The U.S. is Monetarily Sovereign (so cannot run short of money), while France is monetarily non-sovereign and can run short of money.

    See here.

  14. JustAskin

    I find it stunning that nobody is questioning the oft-heard “fact” that 70%+ of people like their current insurance. How was that question asked? And of whom? Honestly, I don’t know how I would respond to that question as it asks me to choose between my current crappy insurance and the unknown — unknown in terms of quality, coverage and price. I believe there is a real hunger for change out there, but nothing is going to happen until specific proposals are put on the table. “Medicare for All” is a nice rallying cry, but what does it mean?

      1. Carla

        It’s not that complicated. Let me give you a simple example. We were traveling in Italy and my companion developed an infection in his finger. Not life-threatening by any means, but very annoying. After inquiring at our B&B (this was in a town called Lucca), we were directed to walk around the corner to a hospital and enter the ER. There were two other people waiting in a large waiting room. After a few minutes, a nurse came in a took my companion into an examining room. A doctor examined his finger, lanced the infection, put some antibiotic ointment on it, and wrote out a prescription — in Italian, of course. With sign language, we were directed to a pharmacy close by to fill the prescription. Before leaving the ER, my companion took out his wallet, but it was waived away. Human beings in pain received treatment at no charge.

        Expanded, improved Medicare for All would work like that. For everyone in the United States.

  15. Adam1

    I don’t think Americans are overthinking it because we haven’t noticed that there are already good choices to copy. The conversation is designed to force overthinking to the point that we throw up our hands and either do nothing or “tweak” the existing system to fatten up somebody else in the healthcare industry. Rinse and repeat in 2028.

    1. JEHR

      There are a lot of “ifs” that have to be considered before the US gains healthcare for all. First, if you have the support all those democratic socialists in the Democratic party, you can run a progressive democratic group that promotes healthcare. Then, if you elect a lot more of those democratic socialists to the House and to the Senate you will have a majority in each. Next, if the voters support any healthcare legislation that is put forward for universal healthcare, you move on to the next phase. In the meantime, all those billionaires will be spending big, BIG, bucks defeating the legislators and their legislation. If every voter in the USA were visited by a person explaining universal healthcare, then you could have universal healthcare. That could be done but, Good Luck!

  16. Paul Harvey 0swald

    A couple of points I want to add…

    I was a freelancer for a couple decades with an Individual policy, and the price tag that goes with it. What burns me is that I didn’t belong to a “group”. WTF? I have an age, a gender, residency in a state, county and municipality, a degree (or not), a race, a spouse (or not), children (or not), an income (or not, on occasion-ha!) et cetera. Faceblog and Gugle don’t have the slightest problem placing me in groups. But health insurance can’t figure that one out?

    One angle that is rarely mentioned: The health insurance industry on the whole enjoys a massive subsidy in *not* insuring essentially everyone over age 65. And what is it? 80 or 90 percent of an individual’s health care costs rack up in the last year of life? So health insurance is already getting the pick of the litter. Sure, it would cost the rest of us more if that group was included in the general pool. It sure would. But I don’t hear the argument to add them in – I mean “let the market decide”, no? Textbook “privatizing the profits” and “socializing the risk”.

    1. adam eran

      FYI, the nurses promoting single payer in California note that government bears 70% of health care costs anyway. With 100% at least they’d have some bargaining power…

  17. Susan the Other

    Just thinking about all the tricks of the trade for the last 30+ years. The equivalent of offshoring for the med profession was subcontracting – to independent or affiliated labs; GPs referring to specialists if a patient was taking up too much time; ignoring input from patients if it required any time-consuming services (like thinking); etc. I remember when I had surgery in the late 80s I had to go all over the hospital to different departments within the hospital to pay my bills – I did an autologous blood donation knowing that I bleed a lot and the AIDS epidemic had contaminated blood supplies; I requested a spinal instead of gas because I was still experiencing temporal lobe epilepsy – basically things that cannot be handled by assembly-line healthcare. The hospital sent me separate bills for everything. This was the beginning of their attempt to keep prices under control. A scam, of course. Just another technique for externalizing costs. Soon after that my regular lab tests trippled in cost from 30 to 90 dollars for a simple thyroid screening. The clinic sent out separate bills. The medical industry hadn’t controlled its costs at all (that was the pretext) – it had increased them. All this in an effort to streamline their own bookkeeping. Of course insurance premiums doubled. Services were denied. Pharma did their own version – actually offshoring. We all know the history. If you did not have healthy teeth you were SOL. I started flossing compulsively. My point is that the capitalist medical “health care” industry did not know how to contain costs. It could not do it. And our government did nothing. “Just let the market do it.” So this is the end of the road. Everything has been streamlined for profit and there is none left to be had. They’ll soon be eating their seed corn if they try to extract any more profit from “providers” or pile any more paper pushing costs on doctors. Healthcare corporations are monopolies at the end of the game because they have priced their services out of reach. They are killing people to make a profit. And externalizing costs is no longer an option. That is why we are finally getting a humane medical industry. What I am describing is the perversion of capitalism by trying to force it to accomplish something that is impossible. It is not suited for purpose unless a profit can be achieved and this does not happen when it comes to social services. For our government to ignore this fact has been a complete dereliction of duty. Medicare for All is not “socialism” – it is a human right. It is time to stop pretending otherwise.

  18. marym

    The propagandist/neolib/centrist/incrementalists had their chance with the ACA. There was some attempt even then to paint it as being somewhat like European Bismarck model plans (multiple insurance companies, some standardization of coverage). They knew its flaws at the time, and have never even made suggestions toward “incremental” improvements other than to revive the public option scam.

    What do we have as a result? People who still can’t afford insurance or health care; medical bankruptcies; the administration, Congress, courts, and state governments chipping away at the ACA, Medicare, Medicaid, and CHIP; narrow networks; flawed exchanges; rising costs.

    We’re a sprawling, diverse country. That doesn’t mean we need a sprawling, diverse approach to universal healthcare with a thousand potential points of failure. It means we need a simple, universal, comprehensive approach and we already have the basic and largely successful national Medicare infrastructure with which to accomplish it.

  19. Jim A.

    Indeed the very label “medicare for all” shows that we don’t have to look to foreign countries to see different ways that socialized medicine could be run. From the Indian Health Service and the VA system, and their National Health-esque system where the doctors are government employees to a Medicare single-payer system to the medicaid system where the government sets the reimbursement rates.

  20. Jerry B

    ===However, what isn’t sufficiently well recognized is that US doctors are already being “transitioned” to corporatized medicine, where they are employees of large health care organizations and have little autonomy.===

    To support Yves statement above I highly recommend reading The Social Transformation of Medicine by Paul Starr. Here is an excerpt from the beginning of the book:

    I tend to be a root cause or peel the layers of the onion back to the core person. And The Social Transformation of Medicine is really good at showing how medicine/healthcare has progressed from the traditional healer/medicine man/woman centuries ago to the “Professional Sovereignty” of doctors and now to the corporatization of medicine. The book discusses the transition from the household to the market as the dominant institution in the care of the sick —that is the conversion of healthcare into a commodity.

    Starr also discuses that this transformation of medicine has taken away a person’s “personal judgement” in their healthcare which is not a good thing. I commented in today’s Iran post about the way people in the US and the rest of the world are socialized to defer to authority figures and not think for themselves.

    ===people are encouraged to go for the most minor things, which can turn out to be nothing, because they can also turn out to be something that’s much easier to treat earlier than later. Even chronic hypochondriacs have something wrong with them — a mental issue — that needs to be treated. The French run off to the doctor for virtually anything, and that’s the way the system is supposed to work, and it costs much, much less.===

    As Michael mentions above, I think in a counterintuitive sense universal healthcare/Medicare for All would give people more autonomy in their healthcare lives ( they can be proactive), and not less.

  21. Pat

    While the better idea is that education should be available for free regardless of the subject. It isn’t just Medical School that would need to be free, think of the degrees needed for nursing, physical therapy, pharmacy, medical testing, and all forms of medical research which would also need to be free.

    One of the things that has been happening in our profit concerned health care of the United States, is that getting the education needed for the certification in any of those areas has become increasing expensive while most of those professions have been hit with wage stagnation or even wage cuts to fund the profits of those who don’t provide any form of health care.

    We shouldn’t forget that it is not just the patients who have been increasingly screwed in our utterly obscene system.

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