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Kevin Drum leaves out the words "single payer"
Read him here. Canada, North Korea, and Cuba have single-payer governmental systems. If you know of others (I believe there are some), please leave them in the comments. The successes, or supposed successes, of most West European systems do not constitute evidence that a single payer system is a good idea. This is one of the most commonly overlooked points in the debate over health care.
Posted by Tyler Cowen on November 10, 2005 at 01:03 PM in Medicine | Permalink
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Though there is some confusion over what the term "single-payer" really means, Tyler's statements make very little sense with any of them. In fact, the only way I really understand Tyler's response is as the familiar libertarian cheapshot of lumping ... [Read More]
Tracked on Nov 11, 2005 9:37:35 AM
Comments
OK, I'll start it off. What are you saying? I read your post, but I don't understand it. I'm all cool with having problems about other countries' single-payer health care. But I **still** don't know what your problems are. Would you be so kind as to explain how you define the word, "viable"?
Posted by: ralph at Nov 10, 2005 1:10:06 PM
OK, I'll start it off. What are you saying? I read your post, but I don't understand it. I'm all cool with having problems about other countries' single-payer health care. But I **still** don't know what your problems are. Would you be so kind as to explain how you define the word, "viable"?
Posted by: ralph at Nov 10, 2005 1:10:26 PM
Tyler, did you alter the post to remove the word "viable" from it? I wrote the comment using that word for a reason. Am I mistaken?
Posted by: ralph at Nov 10, 2005 1:15:00 PM
Yes right after I posted it I thought "good idea" made more sense. I wasn't trying to make your comment obsolete. Tyler
Posted by: Tyler Cowen at Nov 10, 2005 1:18:51 PM
No, that sounds fine -- so long as you let us know. :-)
I had assumed that you were using the word "viable" figuratively -- obviously the Soviet Union was viable within some limited time frame. Back to the issue: Can you outline quickly why it's not a "good idea" when laid against what we have now? I'm fine with your objections, but I want to have a clearer idea what they are. Yes, the free market is in general the best way to go: but health care isn't a free market. Stipulate that there is a moral value at work that we cannot ignore. In this environment, what major objections do you have to a single-payer plan a la Canada or some other variation? I, in return, stipulate that there ARE benefits that we enjoy in our health-care system here that the single-payer systems don't seem to.
Posted by: ralph at Nov 10, 2005 1:25:49 PM
I do not know which other countries besides those you listed
have single payer systems. However, this is a rather odd
bunch to lump together. An important difference between them
is that while Canada has single payer, medical personnel are
not directly employed by the state, as they are in the UK, as
well as Cuba and the DPRK, of course.
Posted by: Barkley Rosser at Nov 10, 2005 1:26:12 PM
Ah, but you left out the phrase "developed country" from my post, Tyler! I really don't think Cuba or North Korea prove anything. We should be comparing ourselves to other roughly similar countries, shouldn't we?
As for Canada, their system isn't so bad. It's not the one I'd choose, and it's certainly true that every country's system has its own upsides and downsides, but overall, single-payer works well in an awful lot of places. Given that, it seem perverse to suggest that it defies the laws of economics.
Posted by: Kevin Drum at Nov 10, 2005 1:41:22 PM
I am confused when you write "single-payer works well in an awful lot of places," when we find it only in a single developed country that I am aware of. Germany and France, for instance are not single-payer systems. Plus I think the Canadian system is a mess.
Tyler
Posted by: Tyler Cowen at Nov 10, 2005 1:50:13 PM
In what way is the UK system not single-payer?
Posted by: Peter Clay at Nov 10, 2005 2:04:35 PM
British citizens can buy top-up insurance. I guess that disqualifies it from being single-payer.
Regardless, it is a better system than we have, by far.
Posted by: John Y. at Nov 10, 2005 2:12:57 PM
North Korea has a public health system? I thought all the Communist
countries had people pay for their own health care, and that's why
medical care is so bad in those countries for poor people.
Posted by: wkwillis at Nov 10, 2005 2:16:45 PM
How is France not single-payer? It is not single-provider, but, every citizen gets some kind of government card that pays most of the costs.
With the phrase "single-payer" are you making a distinction between systems that outlaw private supplemental spending and national systems that don't outlaw supplements?
IMHO I would choose a system like France's any day over the British single-provider system.
Posted by: DK at Nov 10, 2005 2:29:59 PM
I would also question how "single payer" Canada is as a practical matter when the US is a feasible alternative for those with many non-emergency conditions.
Posted by: Dylan at Nov 10, 2005 2:33:36 PM
Could you (& Kevin) maybe disentangle the following for the less-informed reader:
(1) What makes a health care system "single payer", and why isn't, e.g., the UK's system a single-payer system?
(2) In your earlier post, you state:
He does nail market-oriented views on the issue of risk; we don't have a good explanation of why private insurance markets do not function better. But since single-payer national health insurance violates every economic law known to mankind, I am again unsure how I could leap on the Democratic bandwagon.
This tends to imply that there are two possibilities: private insurance markets, and single-payer systems. It also definitely implies that the Democrats specifically endorse a single-payer system. But much of the subsequent discussion seems to be talking about the existence of "universal" health care systems that aren't single-payer. Is it true that the Democrats endorse specifically single-payer health care, or do they in fact endorse national health care systems in general, which may not necessarily be single-payer and therefore don't violate the (still unspecified) laws of economics?
Posted by: derPlau at Nov 10, 2005 2:37:28 PM
Western European governments, like Germany, would mostly like to move toward a single payer system. This is because single payer represents the best way to keep costs down.
As with the US and Canada, European health care costs are rising at the same time the number of people who are going to want access to that health care is growing. Cost containment is an enormous problem.
That Europe's governments are finding this shift difficult to manage is no surprise. The same interests which oppose single payer health care in the US exist in Europe.
In Canada single-payer health care destroyed the Canadian health insurance market as the government now provides the service from tax revenue.
Posted by: wsam at Nov 10, 2005 2:37:58 PM
Yes, I also request more information on which systems are "single payer" and which are not, and what the difference is.
Is Sweden's system single payer? (See http://www.sweden.se/templates/cs/BasicFactsheet____6856.aspx)
Posted by: Joe S at Nov 10, 2005 2:40:19 PM
I a am wondering as well what you mean by single-payer. In Sweden, the country I know best, the state(actually subdivisions of the state) pay the overwhelming part of your cost for medical treatment. The small fees that exist are mainly to discourage overconsumption of healthcare more than anything else. The state will pay for your treatment either at a private clinic or a state-owned one.
Buying private medical treatment is perfectly legal though but rare. I am not interpreting Krugman et al. as suggesting outlawing private medical insurance.
As for quality, the opinion you often hear ín Sweden is that the treatment is good once you get it but there are long quees for operations and similar stuff.
Posted by: Johan Richter at Nov 10, 2005 2:45:16 PM
"The successes, or supposed successes, of most West European systems do not constitute evidence that a single payer system is a good idea"
This is known as "moving the goalposts". This is what you originally wrote:
"single-payer national health insurance violates every economic law known to mankind"
The successes of single-payer insurance systems may not constitute evidence that single-payer is "a good idea", but they clearly constitute evidence that they do not "violate every economic law known to mankind."
Posted by: Ivan at Nov 10, 2005 2:45:36 PM
Norway has a singer-payer system, and I would think all of the Scandinavian countries were the same.
Posted by: Stian Haklev at Nov 10, 2005 2:46:55 PM
Single-payer is typically used to refer to an arrangement in which the government exercises a monopoly in market for primary health insurance and is therefore NOT involved in health care delivery. Europeans sometimes refer to this a "quasi-market" model, since it is not really socialized medicine, but actually just socialized insurance. In any case, it is somewhat misleading to lump Canada together with Cuba and North Korea in this regard.
Note that in Canada "primary health care" does not cover dentistry, prescription drugs, private rooms, vanity MRIs, etc., so Canadians typically get supplementary private insurance for those things. As a result, the system is mixed like any other, it's just that the mix is somewhat unique.
The single-payer arrangement has certain advantages over the "socialized medicine" model that one finds in Europe. Apart the fact that it eliminates adverse selection problems in one fell swoop and in many cases allows for more effective control of moral hazard, it also means that the state is able to leave health-care delivery entirely to the private sector. This has certain advantages over the arrangement of, say, the NHS in Britain. For my wife, who is a surgeon in Toronto, the salaries of her office staff are essentially an out-of-pocket expense. As a result, she has the most advanced IT setup that money can buy, including a 100 per cent paperless billing operation, fully integrated with her patient records. The kind of massive underinvestment in IT that one finds in the NHS is not a problem in Canada, precisely because of the incentive effects of the purchaser-provider split that single-payer provides.
Naturally, the Canadian system has problems, just as every health care system has problems. Are they worse than what one finds in Britain? or in the United States? That's a complex debate. One thing I'm pretty sure of, however, is that mere red-baiting is not a useful contribution. Comparing the incentive structure generated within the NHS, within a giant HMO, and within the Canadian single-payer system, I don't think any are more obviously "viable" than any other.
If there are problems for the Canadian model, they are legal, not economic. There was a recent, very important Supreme Court ruling in Canada, decreeing that (roughly) in cases where the public health care system was unable to provide care in a timely manner, individuals have a right to purchase private treatment. This is obviously going to have significant consequences down the line.
Posted by: Joseph Heath at Nov 10, 2005 2:56:15 PM
Ivan,
I believe that what Tyler was saying was that since most Western European countries do not in fact employ single-payer systems, the success or not of those systems is irrelevant to a discussion of the merits or lack thereof of a single-payer system. This isn't moving the goalposts.
David
Posted by: sirromdivad at Nov 10, 2005 2:58:59 PM
WSAM writes >>Western European governments, like Germany, would mostly like to move toward a single payer system. This is because single payer represents the best way to keep costs down.<<
Next to the U.S., Canada has the most expensive system of any developed country (as measured against GDP). So why would Germany save money, when the evidence seems to indicate the opposite?
Posted by: Mcwop at Nov 10, 2005 3:15:29 PM
I think it may be time that we stop talking about healthcare as a market in the normal sense of the word. It brings with it an enormous sense of morality and fair play from society that really make its allocation something that just does not fit the usual market mold.
For example, if someone is looking for a car, he may decide he wants a Lexis. But his budget may not allow this. So he will have to consider a new Ford. If he cannot afford this then he can look in the used car market. If he still cannot afford a car then he can use public transport. In short, the budget constraint faced by individuals forces them to substitute certain modes of transportation for another. No one has a real problem with this because it is not a life and death issue and usually does not substantially reduce a person's material well being. The same could be said for many of our purchases.
But there are no substitutes for a mammogram, cancer surgery, chemotherapy, emergency room services, etc. You either get them and survive, or you do not and you either suffer or die. Now society has to decide whether to ration healthcare resources via price (i.e. let the market sort it out) or by some other means. I believe that society has already made the decision that price rationing should not be the rule. That is why we do not auction off hearts and other organs despite the fact that there are fewer of them than patients who need them. As a result, the classic price-quantity equilibria does not come to be and people are put on waiting lists and often die while waiting for an organ.
So, given that society has already put us in this place where free market economics are not going to differentiate who gets healthcare and who does not (for a fact, even poor people get some healthcare but in the most expensive manner conceivable - the emergency room), what is thee best way to manage this. Interestingly, people point to Canada and Europe for a model when one exists right here at home - the military. I work for a Navy think tank and have looked at the mil healthcare system. I do see some abuse in it (the amount of prescriptions is higher for the average sailor than for the general population because they are free so the docs write prescriptions for everything under the sun including tylenol) but overall it is not bad and the admin costs are very low. A few tweaks here and there and the system would be much better. And it is universal and it is a single payer. If it is good enough for the military then it probably is good enough for the general population as well.
Posted by: DON B at Nov 10, 2005 3:30:43 PM
I'm not sure what one labels it, but a few years ago the World Health Organization rated the French medical care system as the "best overall," whatever that means, in the world (they do not have the greatest life expectancy of lowest infant mortality or the lowest costs, although they look a lot better than the US on all of those measures).
Posted by: Barkley Rosser at Nov 10, 2005 3:31:03 PM
Let's all agree that health care is a hard problem. The free market makes good health care unaffordable to a lot of people, but a government controlled system forces costs down which stifle innovation. This is no different from any other market, except for the moral dimension. We don't mind some people buying more expensive computers than others, but we do mind (or at least care) that everyone gets decent health care in some form.
There is no doubt in my mind, however, that a giant, federal single-payer system would be just as full of warts and pimples as the current private insurance market is. You'd get cheaper health care which everyone could afford, but I don't believe for a second it would you'd get better care. Long term I'd say you get worse, since there would be less innovation.
I'm no expert but I'm willing to predict that a disproportionate share of the technological and pharmaceutical innovation in health care is fostered in the US market precisely because of its system of private system (although not necessarily by US firms).
Posted by: Eric Mortensen at Nov 10, 2005 4:01:18 PM
