Egalitarian Healthcare versus multiple tier healthcare systems

[NGinpa]

Egalitarianism is the moral doctrine that equality ought to prevail among some group along some dimension. When we on the political left talk about single payer healthcare, we really need to define what that means because there are many people who are very fearful of what kind of a system single payer implies. Many in America want privileges that power and money can bring and are not willing to be denied or to wait in long queues for care they can afford to pay for themselves. Even countries that have a single payer option vary on what that means and almost all are having problems dealing with the resultant consequences. I wonder what the majority of folks on this site actually mean when they think about single payer healthcare system.

Is the single payer system that we envision a one tier care system where everyone is allowed only the same processes and must wait for that care on some fair queue basis? Is it a multiple tier system where people can get care outside the single payer system or move into and out of it for covered items that they do not wish to wait to get? For items not covered by the single payer system, can folks go outside the system for those processes?

We can learn quite a lot by looking at different countries on this kind of issue. Britain has a multiple tier system, but they are having problems deciding if people can go in and out of the public system during the same care episode. Look at this story in the NY Times today.

LONDON — Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.

Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirst’s. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist’s support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment.

By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Mrs. Hirst heard the news from her doctor.

“He looked at me and said: ‘I’m so sorry, Debbie. I’ve had my wrists slapped from the people upstairs, and I can no longer offer you that service,’ ” Mrs. Hirst said in an interview.

“I said, ‘Where does that leave me?’ He said, ‘If you pay for Avastin, you’ll have to pay for everything’ ” — in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients “cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs,” the health secretary, Alan Johnson, told Parliament.

“That way lies the end of the founding principles of the N.H.S.,” Mr. Johnson said.

In Canada, there is only a single payer, and at least in the past if the procedure is covered by the system, you cannot go outside the system for quicker care if you self pay. That is why many Canadians of means come to the US for faster care. Now for care that is not covered by the system. you can self pay, such as for dental care. Even here, however, there is great stress on the system to afford what care is covered and let people have decent access to that care. In British Columbia, sustainability of the healthcare system is getting new attention.

From the Throne speech this year

All the money raised from sales tax, Medicare premiums, tobacco tax, health-care fees, federal health transfer payments and corporate income tax combined does not cover the costs of our health services.

Health expenditures have grown at more than twice the rate of growth in GDP over the last 20 years and at nearly quadruple inflation rates in this decade.

If we fail to come to grips with that trend, it will be our children and their families who will pay the highest price.

This obliges us to adopt new effective strategies that at once improve the health of our citizens, improve health delivery and protect our public health system for the long term.

In the American medical system of the future, should critical but not universally available to all care be distributed according to who can pay the most or by other more socially determined criteria. For example, if there is only one organ available for a life saving transplant, should it go to the one who can pay the most for it?? If life saving vaccination or antibiotics or anti-viral meds is available in short quantities during an epidemic, should the doses go to those families that can pay the most?? If all people even with insurance in need for heart operations cannot get them right away, should those that can pay the most get them first even if they are not as severely ill or may not benefit the most from the operation? etc., etc, etc!

I personally want a single payer system where queuing and/or triage would make the calls over who can pay the most to live, but I see that may be very unpopular with many. Who and how would the system rules be made?? Then there are the special situations like if a family member is willing to donate an organ to another family member, does that allow the family recipient quicker access to the procedure?? What if a person A solicits an organ donor from a relative but this organ doesn't match A, should he be moved forward in the generic queue for his efforts? How about if one family member would donate an organ to a non-related richer person in exchange for something else, like family financial assistance to the donors family, would that be okay??

Well I think you get the idea now. I would like to hear as many comments as possible about how people here envision the rules of our future to be single payer system for both system covered processes and non-covered processes? Is there a multiple private pay or private insurance option that allows quicker access to covered procedures or not? Is that fair? Should non-covered processes be allowed to be done period which may use up needed resources by competing somewhat with the public pay system?

[Celebration]

1. since you don't have any comments here

I will just say that Hillary's plan in the 90s left me cold, because I think it would have made it illegal to pay a doctor for services outside the system, or something egregious like that. I consider than an infringement on my personal freedom, as well as the doctor's.

I sure don't have the answers to a "perfect" system, or even a good one. I also worry that what with all the waste on the war, we may not even be able to afford a decent health care system. We have frittered away our solvency.

For what it's worth, then, I would not be in favor of restricting a person's right to pay for a different unapproved drug or treatment. Honestly, that seems almost totalitarian to me.

Whatever the outcome, I intend on using an acupuncturist for 80-90% of my health care needs, at least. Whatever system is developed I hope would allow me to do that, at least if I pay for it.

[kristopher]

2. In Japan, they have UHC w/ no individual mandate

This is cross posted from another thread - I wrote it just before reading your post. I think it on point, and I added a fit to better address your questions:

In Japan, they have UHC w/ no individual mandate.

However they do mandate that all employers above X size (I believe it's about 5,000+- employees) provide insurance to all employees. Those not ensured by their employer are eligible to enroll in the government's single payer program; and although there is medical care available outside the system, there is very little that the system doesn't provide.

Costs are brutally managed - hand cranked beds, lots of small wards and few private/semiprivate rooms, lots of old equipment, but all the modern stuff also, needed care is there now and they aggressively treat even terminal cases with up to date care. And it is not expensive. Statistically they spend about 1/3 as much as we do, per capita; and of course their health care deliverable stats (infant mortality, lifespan etc) are better than most - including the US. For most people, they pay into the system about $100 - 175 a month depending on family size, and about a $5 deductible for physician visits, prescriptions, and common special procedures. Dental is, of course, included.

I've had a lot of experience as a user of their health care system and ours. I'll take theirs any day. They really want you to be healthy. I have a friend who is a plumber. I gave him a hand once clearing a backed up toilet. After I observed that it must be unpleasant to do his job sometimes, he corrected me by replying wih a big grin "It smells like money to me!"

Here, I get the creepy feeling that a lot of health care providers have the same view of me. They barely see ME, I'm mostly just something they can run through their newest shiny and very, very expensive machine in order to churn a payment out of the insurance company.

I note that a couple of people posting here say they are doctors. I mean no insult, nor disrespect. It is just, I'm sorry, but I'll never believe the profit motive improves medical care. It works well to push the margins of technology, but the 2/3s we spend more than Japan result in an extremely lopsided benefit for us.

It should be clear to even the most obtuse that the profit motive produces, along with that amazing technology and medical opulence, perverse incentives that measure system success by increased used of medical care and increased dosing with the most expensive medications that can be slipped by the almost completely pro forma watchdogs.

Our system is fundamentally and fatally flawed.

At least, that's the way I view it.

[NGinpa]

4. Excellent analysis, IMO

I really believe the conservatives in this country that say without this profit push innovation is stifled fail to see all the waste it also incites!! That waste is dangerous in both resulting in expenses that deny good care to many, and in the fact that the system we have allows lies and corners to be cut (especially in drug research) which puts folks at risk from dangerous processes and drugs that are barely researched but are allowed on the market! That risk is huge and growing.

The Insitute of Medicien study from 1999 that showed medical mistakes were conservatively the 8th leader cause of death in America or lower, again shows that our jumping the gun on pushing false treatements may well be for the financial well being of companies and providers and not for patients. I sometimes think this entire problem comes from lack of a mission statement in healthcare which gives the system a target. In fact I would go so far as to say that with a proper mission statement in healthcare, a non-profit system would be the only solution that MIGHT work to fill that misison!

[kristopher]

5. You may have a point.

* I solemnly pledge to consecrate my life to the service of humanity;
* I will give to my teachers the respect and gratitude that is their due;
* I will practice my profession with conscience and dignity;
* The health of my patient will be my first consideration;
* I will respect the secrets that are confided in me, even after the patient has died;
* I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
* My colleagues will be my sisters and brothers;
* I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
* I will maintain the utmost respect for human life;
* I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
* I make these promises solemnly, freely and upon my honour.


This is the modern version of the Hippocratic Oath, now known as The Declaration of Geneva. While it is a perfect mission statement for the physician personally, it doesn't seem to serve as very good guidance for shaping national policy. Once you institute a structure of rewards such as we have, the good intentions of even the most dedicated physicians have almost no chance of reshaping economic demands and realities.

Tell me more about the details of what you are thinking. The "who, what, where..." of the matter, if you know what I mean.

[NGinpa]

7. Good intentions are not enough

That physician oath sounds good, but it has no connection with proven accountability, effectiveness or efficiency for the system. It basically says that if the physician can justify what he/she is doing to himself, then it is fine. However maybe 50% of what is now being done is unproven, maybe useless, maybe dangerous. Without clearer standards for diagnostic processes and treatment processes and less variability nationally on how the same conditions are treated, we will never get a handle on accountabilty for quality and costs. It is no wonder the system continues to spiral out of control on all front as if everyday was medical russian roulette day.

I believe in a single payer, non-profit system covering all, but the system and its providers must be held accountable to standards of care. Also because of this, the methods of making such standards of care better be truthful and effective! Therefore, if no standards, no hail mary treatments at pooled group expense. Also the problem of timely access must be addressed with adequate infrastructure, which means the narrow scope of practice laws in most states (controlled by the providers in reality) must be loosened. More and varied providers must be available to minimize waits. However, when waits are involved, the queues must be set up on fair basis. No earlier and better treatment for those that can pay the most. In brief, that is what I would like to see!

[Warpy]

6. Your view is an accurate one

A single tier, single payer system in this country is the only one that can possibly be counted upon to be fully funded. There should be no opt outs for the wealthy unless they leave the country for elective procedures and cosmetic work that national insurance won't pay for. They should have to face the same system the rest of us do in times of emergency, probably 90% of what they'd use it for. It's only in that way the rest of us will be assured that Congressmen in their back pockets won't underfund the system to try to prove that national health insurance doesn't work, the game they're playing in the UK.

The rich will always be able to circumvent rules by traveling out of country for heroics a sensible system won't offer because they just don't work often enough to make it worthwhile. I can think of no worse curse on them than to condemn them to ruining the end of their lives with the best technology money can buy.

However, care here should be to a set standard for everyone, not a computer model to limit costs but a standard of care to be provided at the very minimum to all who seek help. The wealthy loathe having to rub elbows with the proles, but tough shit. If they'd ever played fairly in their lives, they wouldn't have had to face the prospect.

[Jim__]

3. In 2000 the French Health Care system was rated the best in the world by the WHO.

I'm not sure if it is still rated the best.

My understanding is that the French can opt to pay for their own care above what the system offers and many of the French have supplemental insurance. (Some details on the French system - from the French government)

I've always favored people having the right to buy medical services that are not available under the universal medical insurance; but I haven't really thought this through and you raise some interesting questions. I have to think some more about these issues.

[FLDCVADem]

8. Single payer plus options

I'm not opposed to a single-payer system, however, I would oppose such a plan if there was a prohibition on people seeking care outside of the system, at their own expense.

First, we all know that a single-payer plan won't be "free" - it will be taxpayer funded, and that funding should occur in such a way that people can't "opt out" of paying into the system, i.e., through taxation. Now, that taxation could be via a separate, dedicated "health tax", such as the way Medicare is funded (my personal preference) or via the general fund through income taxes.

Second, once everyone is paying into the system, it shouldn't matter whether or not they choose to use the system or pay out of their pockets for care outside of the system. Everyone would still be paying for it, whether they choose to use it or not, just as my family currently pays property tax to support public schools, even though our children attend a Catholic school that we pay for separately.

My problem with a single-payer system that would prohibit going outside the system at personal expense is that single-payer, like any health care system, will need to impose limits on level of care for any number of conditions, otherwise, the system will not remain financially viable. If someone is able to pay for additional care that isn't offered under the single-payer system, I don't see why they shouldn't be able to do so. And I don't believe that this is an option that is only available to the very wealthy, nor do I believe that if any person that could afford paying for the care inside the U.S. could also afford to have to leave the country to seek that care.

Boiled down to the bare bones, my opinion of a single-payer is this - no one should be able to opt out of paying for it, but anyone that chooses should be able to opt out of using it, if it would be to their medical advantage to do so.