While the United States is an exception among high-income countries in lacking an universal healthcare system, the politics of healthcare should not be thought of as entirely uncontentious in countries which have adopted it. In the United States, neither of the main parties favors a socialized system that puts the government in charge of hospitals or doctors, but they do have different approaches to financing and access. Democrats tend to be favorably inclined towards reform that involves more government control over health care financing and citizens' right of access to health care. Republicans are broadly in favor of the status quo, or a reform of the financing system that gives more power to the citizen, often through tax credits. Supporters of government involvement in health care argue that government involvement ensures access, quality, and addresses
market failures specific to the health care markets. When the government covers the cost of health care, there is no need for individuals or their employers to pay for private insurance. Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research.
Cost of care Socialized medicine amongst industrialized countries tends to be more affordable than in systems where there is little government involvement. A 2003 study examined costs and outputs in the U.S. and other industrialized countries and broadly concluded that the U.S. spends so much because its health care system is more costly. It noted that "the United States spent considerably more on health care than any other country ... [yet] most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. The researchers examined possible reasons and concluded that input costs were high (salaries, cost of pharmaceutical), and that the complex payment system in the U.S. added higher administrative costs. Comparison countries in Canada and Europe were much more willing to exert
monopsony power to drive down prices, whilst the highly fragmented buy side of the U.S. health system was one factor that could explain the relatively high prices in the United States of America. The current
fee-for-service payment system also stimulates expensive care by promoting procedures over visits through financially rewarding the former ($1,500 – for doing a 10-minute procedure) vs. the latter ($50 – for a 30–45 minute visit). This causes the proliferation of specialists (more expensive care) and creating, what
Don Berwick refers to as, "the world's best healthcare system for rescue care". Other studies have found no consistent and systematic relationship between the type of financing of health care and cost containment; the efficiency of operation of the health care system itself appears to depend much more on how providers are paid and how the delivery of care is organized than on the method used to raise these funds. Some supporters argue that government involvement in health care would reduce costs not just because of the exercise of monopsony power, e.g. in drug purchasing, but also because it eliminates profit margins and administrative overhead associated with private insurance, and because it can make use of
economies of scale in administration. In certain circumstances, a volume purchaser may be able to guarantee sufficient volume to reduce overall prices while providing greater profitability to the seller, such as in so-called "
purchase commitment" programs. Economist
Arnold Kling attributes the present cost crisis mainly to the practice of what he calls
premium medicine, which overuses expensive forms of technology that is of marginal or no proven benefit.
Milton Friedman has argued that government has weak incentives to reduce costs because "nobody spends somebody else's money as wisely or as frugally as he spends his own". Others contend that health care consumption is not like other consumer consumption. Firstly there is a negative utility of consumption (consuming more health care does not make one better off) and secondly there is an
information asymmetry between consumer and supplier.
Paul Krugman and
Robin Wells argue that all of the evidence indicates that public insurance of the kind available in several European countries achieves equal or better results at much lower cost, a conclusion that also applies within the United States. In terms of actual administrative costs, Medicare spent less than 2% of its resources on administration, while private insurance companies spent more than 13%. The
Cato Institute argues that the 2% Medicare cost figure ignores all costs shifted to doctors and hospitals, and alleges that Medicare is not very efficient at all when those costs are incorporated. Some studies have found that the U.S. wastes more on bureaucracy (compared to the Canadian level), and that this excess administrative cost would be sufficient to provide health care to the uninsured population in the U.S. Notwithstanding the arguments about Medicare, there is overall less bureaucracy in socialized systems than in the present mixed U.S. system. Spending on administration in Finland is 2.1% of all health care costs, and in the UK the figure is 3.3% whereas the U.S. spends 7.3% of all expenditures on administration.
Quality of care Some in the U.S. claim that socialized medicine would reduce health care quality. The quantitative evidence for this claim is not clear. The WHO has used Disability Adjusted Life Expectancy (the number of years an average person can expect to live in good health) as a measure of a nation's health achievement, and has ranked its member nations by this measure. The U.S. ranking was 24th, worse than similar industrial countries with high public funding of health such as Canada (ranked 5th), the UK (12th), Sweden (4th), France (3rd) and Japan (1st). But the U.S. ranking was better than some other European countries such as Ireland, Denmark and Portugal, which came 27th, 28th and 29th respectively. Finland, with its relatively high death rate from guns and renowned high suicide rate came above the U.S. in 20th place. The British have a
Care Quality Commission that commissions independent surveys of the quality of care given in its health institutions and these are publicly accessible over the internet. These determine whether health organizations are meeting public standards for quality set by government and allows regional comparisons. Whether these results indicate a better or worse situation to that in other countries such as the U.S. is hard to tell because these countries tend to lack a similar set of standards.
Taxation Opponents claim that socialized medicine would require higher taxes but international comparisons do not support this; the ratio of public to private spending on health is lower in the U.S. than that of Canada, Australia, New Zealand, Japan, or any EU country, yet the per capita tax funding of health in those countries is already lower than that of the United States. Taxation is not necessarily an unpopular form of funding for health care. In England, a survey for the
British Medical Association of the general public showed overwhelming support for the tax funding of health care. Nine out of ten people agreed or strongly agreed with a statement that the NHS should be funded from taxation with care being free at the point of use. An
opinion piece in
The Wall Street Journal by two conservative Republicans argues that government sponsored health care will legitimatize support for government services generally, and make an activist government acceptable. "Once a large number of citizens get their health care from the state, it dramatically alters their attachment to government. Every time a
tax cut is proposed, the guardians of the new medical-welfare state will argue that tax cuts would come at the expense of health care -- an argument that would resonate with middle-class families entirely dependent on the government for access to doctors and hospitals."
Innovation Some in the U.S. argue that if government were to use its size to bargain down health care prices, this would undermine American leadership in medical innovation. It is argued that the high level of spending in the U.S. health care system and its tolerance of waste is actually beneficial because it underpins American leadership in medical innovation, which is crucial not just for Americans, but for the entire world. Others point out that the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it
Access One of the goals of socialized medicine systems is ensuring universal access to health care. Opponents of socialized medicine say that access for low-income individuals can be achieved by means other than socialized medicine, for example, income-related subsidies can function without public provision of either insurance or medical services. Economist
Milton Friedman said the role of the government in health care should be restricted to financing hard cases.
Rationing (access, coverage, price, and time) Part of the current debate about
health care in the United States revolves around whether the
Affordable Care Act as part of
health care reform will result in a more systematic and logical allocation of health care. Opponents tend to believe that the law will eventually result in a government takeover of health care and ultimately to socialized medicine and rationing based not on being able to afford the care you want but on whether a third party other than the patient and the doctor decides whether the procedure or the cost is justifiable. Supporters of reform point out that health care rationing already exists in the United States through insurance companies issuing denial for reimbursement on the grounds that the insurance company believes the procedure is
experimental or will not assist even though the doctor has recommended it. A public insurance plan was not included in the Affordable Care Act but some argue that it would have added to health care access choices, Opponents of reform invoke the term socialized medicine because they say it will lead to health care rationing by denial of coverage, denial of access, and use of waiting lists, but often do so without acknowledging coverage denial, lack of access and waiting lists exist in the U.S. health care system currently or that waiting lists in the U.S. are sometimes longer than the waiting lists in countries with socialized medicine. Proponents of the reform proposal point out a public insurer is not akin to a socialized medicine system because it will have to negotiate rates with the medical industry just as other insurers do and cover its cost with premiums charged to policyholders just as other insurers do without any form of subsidy. There is a frequent misunderstanding to think that waiting happens in places like the United Kingdom and Canada but does not happen in the United States. For instance it is not uncommon even for emergency cases in some U.S. hospitals to be boarded on beds in hallways for 48 hours or more due to lack of inpatient beds and people in the U.S. rationed out by being unable to afford their care are simply never counted and may never receive the care they need, a factor that is often overlooked. Statistics about waiting times in national systems are an honest approach to the issue of those waiting for access to care. Everyone waiting for care is reflected in the data, which, in the UK for example, are used to inform debate, decision-making and research within the government and the wider community. Some people in the U.S. are rationed out of care by unaffordable care or denial of access by
HMOs and insurers or simply because they cannot afford co-pays or deductibles even if they have insurance. These people wait an indefinitely long period and may never get care they need, but actual numbers are simply unknown because they are not recorded in official statistics. Opponents of the current reform care proposals fear that U.S. comparative effective research (a plan introduced in the stimulus bill) will be used to curtail spending and ration treatments, which is one function of the
National Institute for Health and Care Excellence (NICE), arguing that rationing by market pricing rather by government is the best way for care to be rationed. However, when defining any group scheme, the same rules must apply to everyone in the scheme so some coverage rules had to be established. Britain has a national budget for public funded health care, and recognizes there has to be a logical trade off between spending on expensive treatments for some against, for example, caring for sick children. NICE is therefore applying the same market pricing principles to make the hard job of deciding between funding some treatments and not funding others on behalf of everyone in the insured pool. This rationing does not preclude choice of obtaining insurance coverage for excluded treatment as insured persons do having the choice to take out supplemental health insurance for drugs and treatments that the NHS does not cover (at least one private insurer offers such a plan) or from meeting treatment costs out-of-pocket. The debate in the U.S. over rationing has enraged some in the UK and statements made by politicians such as
Sarah Palin and
Chuck Grassley resulted in a mass Internet protest on websites such as Twitter and Facebook under the banner title "welovetheNHS" with positive stories of NHS experiences to counter the negative ones being expressed by these politicians and others and by certain media outlets such as ''Investor's Business Daily'' and
Fox News. In the UK, it is private health insurers that ration care (in the sense of not covering the most common services such as access to a
primary care physician or excluding pre-existing conditions) rather than the NHS. Free access to a general practitioner is a core right in the NHS, but private insurers in the UK will not pay for payments to a private primary care physician. Insurers do not cover these because they feel they do not need to since the NHS already provides coverage and to provide the choice of a private provider would make the insurance prohibitively expensive. The UK Department of Health said that Grassley's claims were "just wrong" and reiterated health service in Britain provides health care on the basis of clinical need regardless of age or ability to pay. The chairman of the British Medical Association, Hamish Meldrum, said he was dismayed by the "jaw-droppingly untruthful attacks" made by American critics. The chief executive of the National Institute for Health and Clinical Excellence (NICE), told
The Guardian newspaper that "it is neither true, nor is it anything you could extrapolate from anything we've ever recommended" that Kennedy would be denied treatment by the NHS. The business journal ''Investor's Business Daily'' claimed mathematician and astrophysicist
Stephen Hawking, who had ALS and spoke with the aid of an American-accented voice synthesizer, would not have survived if he had been treated in the British National Health Service. Hawking was British and was treated throughout his life (67 years) by the NHS and issued a statement to the effect he owed his life to the quality of care he has received from the NHS. Some argue that countries with national health care may use waiting lists as a form of rationing compared to countries that ration by price, such as the United States, according to several commentators and healthcare experts. Britain's former age-based policy that once prevented the use of
kidney dialysis as treatment for older patients with renal problems, even to those who can privately afford the costs, has been cited as another example. A 1999 study in the
Journal of Public Economics analyzed the British National Health Service and found that its waiting times function as an effective market disincentive, with a low
elasticity of demand with respect to time. Supporters of private price rationing over waiting time rationing, such as
The Atlantic columnist
Megan McArdle, argue time rationing leaves patients worse off since their time (measured as an
opportunity cost) is worth much more than the price they would pay. Opponents also state categorizing patients based on factors such as social value to the community or age will not work in a heterogeneous society without a common ethical consensus such as the U.S. Neither argument recognizes the fact that in most countries with socialized medicine, a parallel system of private health care allows people to pay extra to reduce their waiting time. The exception is that some provinces in Canada disallow the right to bypass queuing unless the matter is one in which the rights of the person under the constitution. A 1999 article in the
British Medical Journal, stated "there is much merit in using waiting lists as a rationing mechanism for elective health care if the waiting lists are managed efficiently and fairly".
Arthur Kellermann, associate dean for health policy at
Emory University, stated rationing by ability to pay rather than by anticipated medical benefits in the U.S. makes its system more unproductive, with poor people avoiding preventive care and eventually using expensive emergency treatment.
Ethicist Daniel Callahan has written that U.S. culture overly emphasizes individual autonomy rather than
communitarian morals and that stops beneficial rationing by social value, which benefits everyone. Medical facilities in the U.S. do not report waiting times in national statistics as is done in other countries and it is a myth to believe there is no waiting for care in the U.S. Some argue that wait times in the U.S. could actually be as long as or longer than in other countries with universal health care. There is considerable argument about whether any of the health bills currently before congress will introduce rationing.
Howard Dean for example contested in an interview that they do not. However,
Politico has pointed out that all health systems contain elements of rationing (such as coverage rules) and the public health care plan will therefore implicitly involve some element of rationing.
Political interference and targeting In the UK, where government employees or government-employed sub-contractors deliver most health care, political interference is quite hard to discern. Most supply-side decisions are in practice under the control of medical practitioners and of boards comprising the medical profession. There is some antipathy towards the target-setting by politicians in the UK. Even the NICE criteria for public funding of medical treatments were never set by politicians. Nevertheless, politicians have set targets, for instance to reduce waiting times and to improve choice. Academics have pointed out that the claims of success of the targeting are statistically flawed. The veracity and significance of the claims of targeting interfering with clinical priorities are often hard to judge. For example, some UK ambulance crews have complained that hospitals would deliberately leave patients with ambulance crews to prevent an accident and emergency department (A&E, or emergency room) target-time for treatment from starting to run. The Department of Health vehemently denied the claim, because the A&E time begins when the ambulance arrives at the hospital and not after the handover. It defended the A&E target by pointing out that the percentage of people waiting four hours or more in A&E had dropped from just under 25% in 2004 to less than 2% in 2008. The original
Observer article reported that in London, 14,700 ambulance turnarounds were longer than an hour and 332 were more than two hours when the target turnaround time is 15 minutes. However, in the context of the total number of emergency ambulance attendances by the
London Ambulance Service each year (approximately 865,000), these represent just 1.6% and 0.03% of all ambulance calls. The proportion of these attributable to patients left with ambulance crews is not recorded. At least one junior doctor has complained that the four-hour A&E target is too high and leads to unwarranted actions that are not in the best interests of patients. Political targeting of waiting-times in Britain has had dramatic effects. The
National Health Service reports that the median admission wait-time for elective inpatient treatment (non-urgent hospital treatment) in England at the end of August 2007, was just under 6 weeks, and 87.5% of patients were admitted within 13 weeks. Reported waiting times in England also overstate the true waiting-time. This is because the clock starts ticking when the patient has been referred to a specialist by the GP and it only stops when the medical procedure is completed. The 18-week maximum waiting period target thus includes all the time taken for the patient to attend the first appointment with the specialist, time for any tests called for by the specialist to determine precisely the root of the patient's problem and the best way to treat it. It excludes time for any intervening steps deemed necessary prior to treatment, such as recovery from some other illness or the losing of excessive weight. ==See also==