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[Deltas Awarded]CMV: The US couldn't successfully implement a single-payer health care system (self.changemyview)

steelerfaninperu3∆ が 投稿

EDIT: Good points have been made regarding all three of these points. While I'm still unsure of how a successful implementation would go and I question how private and public could co-exist (I think they can't), I'll say that I accept that such a system could be implemented and survive.

A lot of people suggest the US adopt a single-payer health care system, often mentioning Canada, Australia, Europe, etc...

My take on this has always been that it'd be impossible mainly for 3 reasons. Disproving these would be delta-worthy for me.

  1. Our population is just too big to micro-manage this way.

  2. Due to our diversity, a single-payer system would be more complex. So many languages to navigate for one. A huge variety of genotypes means more complexity when dealing with genetic disorders and complicates tissue donation. Geographical differences make providing coverage in specific places challenging, as well as presenting budget issues. Regional political variations limit certain possibilities (like more abortion clinics).

  3. The government is not very efficient in general when it comes to managing large business-like operations. The Post Office and Amtrak come to mind as services which could still be industry leaders but have been surpassed by private businesses.

I'd really like to know if it's feasible to install a single-payer system in the states because I think it would be good for people but I don't see it as viable. I'd like to come around, CMV

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[–]EctMills1∆ [スコア非表示]  (14子コメント)

The post office was successful until the Postal Accountability and Enhancement Act was passed requiring them to prefund employee pensions on a massive scale not seen in any private business. Last I heard it was still up in the air how bad the problem is and if the law is being implemented correctly but the post office has been seeking a more reasonable regulation. I suppose the situation could be spun either way but the bottom line is a successful large business model is possible, it just might be a good idea to keep Congress away from it.

[–]Xing_the_Rubicon [スコア非表示]  (1子コメント)

The PAEA was designed by Republicans to ruin the postal system so it could be sold away to private interests. The law requires postal employees' pensions be fully funded 90 years in advance - meaning that the retirements must be full funded for employees that will not be born for decades.

[–]EctMills1∆ [スコア非表示]  (0子コメント)

Apparently defenders are claiming that the law is being misread and doesn't actually require that much. I can't say I fully buy that argument though since the post office is still being held to some very insane requirements.

[–]steelerfaninperu3∆[S] [スコア非表示]  (11子コメント)

Which is precisely why I doubt the US's ability to run our health care.

[–]EctMills1∆ [スコア非表示]  (5子コメント)

Congressional meddling is a problem, but the fact that the post office was very successful beforehand proves it is possible.

[–]steelerfaninperu3∆[S] [スコア非表示]  (4子コメント)

Agreed, but if health care gets put in the hands of the government I don't think there's any going back unless the system fails. I mean, USPS can die because private companies have supplanted it, same with Amtrak. But would the government still allow for private healthcare competition?

[–]EctMills1∆ [スコア非表示]  (3子コメント)

I don't see why not, most single payer countries have both public and private run healthcare facilities. It's not even unusual for a country to still have private insurance available, that's the case in Canada, Spain and the U.K.

[–]steelerfaninperu3∆[S] [スコア非表示]  (2子コメント)

It's not even unusual for a country to still have private insurance available, that's the case in Canada, Spain and the U.K

Do these provide equivalent coverage or are they more of a supplemental variety? Because I fail to see how you could keep a public system stable if doctors gravitate towards private practice due to better pay.

[–]lonelyfriend16∆ [スコア非表示]  (0子コメント)

Most insurance is for supplementary care. If you want some quicker in the UK, private insurance can help you travel to different hospitals in Europe for CT, MRI, maybe even certain types of non-essential surgeries.

In Canada, private insurance covers homecare, Long term care, pharmacare, dental, massage therapy, etc.

Generally speaking, a public system requires everyone to participate. There have been a few pilots, like in the UK introducing private system - also known as two tier - as well as Australia. They are seen as failures, according to most Canadian policy makers.

[–]EctMills1∆ [スコア非表示]  (0子コメント)

Most of what I've read is that they are a small portion of the market but nothing says whether they are supplemental coverage or full. I'm afraid you'd need to talk to someone in one of those countries who uses the service for better info.

[–]GrumpyGuss1∆ [スコア非表示]  (4子コメント)

So instead of the reasons you listed, you think it'll fail because we'll actively sabotage it?

[–]steelerfaninperu3∆[S] [スコア非表示]  (3子コメント)

I meant inefficient in the long term sense. Inefficiency takes many forms, one of them is congressional. How could a public health system be protected from government foolishness?

[–]GrumpyGuss1∆ [スコア非表示]  (2子コメント)

By making it too important to fuck with. Republicans have repeatedly attacked SS and Medicare, but they get smacked down each time by the voting public.

If we were to successfully implement single payer, I think enough people would see just how much better it is that it would become sacred within a few years.

[–]steelerfaninperu3∆[S] [スコア非表示]  (1子コメント)

∆

While SS is a broken system and should be replaced, that's a good example of how you could secure the system put in place and keep it free from fucktardery.

[–]Bodoblock17∆ [スコア非表示]  (3子コメント)

  1. The EU has 503 million people and every member nation has universal healthcare. Could we not set up a system on a state by state basis if a federal basis were not possible?

  2. Again, a state by state basis solves this. Besides, there aren't that many languages we have to navigate. Most immigrants speak English. Many nations in Europe navigate multi-ethnic, multilingual parts of their society into their healthcare system. Canada is also a very multiracial country that executes universal healthcare well.

  3. Just because public service is not profitable does not mean it isn't a needed good. The US military is top of the line - unrivaled around the world. American public education like the University of California are unparalleled in their academic excellence among public peers. The list goes on.

[–]steelerfaninperu3∆[S] [スコア非表示]  (2子コメント)

The EU has 503 million people and every member nation has universal healthcare. Could we not set up a system on a state by state basis if a federal basis were not possible?

Hmm, I want to say honestly that I don't think the EU is identical to the US. But how is the quality of the care across countries?

[–]Bodoblock17∆ [スコア非表示]  (1子コメント)

Better than America's, according to the World Health Organization:

America ranks 37.

Of the 36 nations that beat out the US, 17 were EU member states.

There are 28 member states in total. The 11 states that weren't ranked higher than the US have a population of roughly 103MM.

That means roughly 80% of the EU lives in a place where healthcare is better nationally than in the US.

And of course the EU and US aren't identical. But why can't state-level healthcare be possible than federal?

[–]steelerfaninperu3∆[S] [スコア非表示]  (0子コメント)

I had understood single-payer as being different from state-level care. I interpreted multiple states as multiple payers, because effectively that's the role they'd take.

The issue with that becomes compliance with federal standards, which are obstructed by political views. I don't think a fair single-payer system has lower standards in different places.

[–]kobyashimarooned1∆ [スコア非表示]  (12子コメント)

Our population is just too big to micro-manage this way.

How do single-payer systems micro-manage? Getting ill works the same way as before, but the government pays instead of insurance (essentially the government supplies universal insurance for most illness types). Many places still have private insurance if you want various benefits in relation to your care, as well as coverage for items which may not be covered by the single payer system [change depending on place - but things like dental, or alternative medicines].

Due to our diversity, a single-payer system would be more complex. So many languages to navigate for one. A huge variety of genotypes means more complexity when dealing with genetic disorders and complicates tissue donation.

The US isnt any more diverse than a typical first world nation (particularly the other "immigrant nations" - CAN, NZ, AU. Also some parts of europe with long traditions of migration).

Geographical differences make providing coverage in specific places challenging, as well as presenting budget issues.

Central Australia (far more remote than any part of the contiguous US) uses the not-for-profit Royal Flying Doctor Service to provide emergency medical assistance in remote areas beyond the reach of government services.

Regional political variations limit certain possibilities (like more abortion clinics).

Australia has differing abortion laws in each state, just means that different requirements are in place depending on where you are.

The government is not very efficient in general when it comes to managing large business-like operations.

The US government spends more on healthcare (per capita) than pretty much any other nation, and you still need to get private insurance.

[–]steelerfaninperu3∆[S] [スコア非表示]  (11子コメント)

The US government spends more on healthcare (per capita) than pretty much any other nation, and you still need to get private insurance.

And that doesn't reassure me.

As far as the other country examples, I don't deny that there are solutions to some of those individual problems, but I'm still not sure how you would create a system that puts all of those together.

[–]kobyashimarooned1∆ [スコア非表示]  (9子コメント)

As far as the other country examples, I don't deny that there are solutions to some of those individual problems, but I'm still not sure how you would create a system that puts all of those together.

Every system fixes multiple problems, every country has its own unique challenges. You can choose to claim its too hard, and thats fine. But its not really the right attitude to have as a CMV OP

FWIW, I used Australia for every example I listed.

[–]steelerfaninperu3∆[S] [スコア非表示]  (8子コメント)

Sorry, read Canada on the first example.

I just question how well those solutions scale up to a much larger population. Australia also has a lot more doctors per people (3.3 vs 2.5) so I foresee a talent deficit and resources stretched too thin. Australia's urban population is also significantly higher than in the US, meaning we'd have to invest even more in complicated logistics.

[–]kobyashimarooned1∆ [スコア非表示]  (7子コメント)

I just question how well those solutions scale up to a much larger population.

Plenty of high population countries have universal healthcare.

Australia also has a lot more doctors per people (3.3 vs 2.5) so I foresee a talent deficit and resources stretched too thin.

The number of doctors in a country isnt set in stone. Im sure there are comparable countries in terms of doctors.

Australia's urban population is also significantly higher than in the US, meaning we'd have to invest even more in complicated logistics.

So look at a country that more closely matches the US in terms of urbanisation - the US is more urbanised than Canada and most of Europe. I'd also argue being more urbanised (like Australia) actually makes logistics and provisioning harder because you have large remote areas with small populations that still require adequate healthcare.

TL;DR - stop thinking the US is special and therefore unable to have universal healthcare, it isnt. Every country is unique, every country has its own challenges, every country has their own way of tackling these challenges. The US isnt going to exactly match any one existing country, but all the same problems will have been encountered elsewhere.

[–]steelerfaninperu3∆[S] [スコア非表示]  (6子コメント)

stop thinking the US is special, it isnt

Honestly I want to agree with you but I just have a hard time reconciling the massive population, massive size, and record immigrant population (along with lots of unregistered ones). Those issues affect and amplify one another.

[–]kobyashimarooned1∆ [スコア非表示]  (5子コメント)

massive population

See previous post

massive size

Is smaller than Canada. Lower 48 is the same size as Australia. Less remote areas than either of those.

and record immigrant population

Almost 30% of Australians are immigrants. Almost 50% are the son/daughter of an immigrant. FWIW immigrants make up just under 20% of the US population. Canada has immigrant levels approaching Australia's IIRC.

(along with lots of unregistered ones)

Why would you give free healthcare to non-citizens?

Even if we decide that everything you said were true. Just get the US states to implement it individually. Problem solved.

[–]steelerfaninperu3∆[S] [スコア非表示]  (4子コメント)

Yeah, it's smaller than Canada, I took 7th grade Geography. But 75% of Canada's population is near the US border. It's not that spread out compared to the US.

Why would you give free healthcare to non-citizens?

In a single payer system what other kind is out there? And besides, they already can get some in emergencies.

[–]kobyashimarooned1∆ [スコア非表示]  (3子コメント)

Yeah, it's smaller than Canada, I took 7th grade Geography. But 75% of Canada's population is near the US border. It's not that spread out compared to the US.

And the last 25% percent is spead out across massive expanses. Its the same case with Australia where 85% of the population lives within 50km of the coast (and ~50% in Sydney and Melbourne alone). Its good that the US is spread out because there is always a large population centre not too far way.

In a single payer system what other kind is out there? And besides, they already can get some in emergencies.

Non-citizens still pay in a single-payer healthcare system. If I travel overseas to another universal healthcare country (that doesn't have agreements with mine in place - or Im not covered by them for whatever reason) I'll almost definitely have to pay (Not that I'd travel anywhere without some kind of insurance).

As i said before:

Even if we decide that everything you said were true. Just get the US states to implement it individually. Problem solved.

[–]steelerfaninperu3∆[S] [スコア非表示]  (2子コメント)

∆

This was the last point to me. The US being so spread out means that they have the infrastructure to take care of people.

[–]GrumpyGuss1∆ [スコア非表示]  (0子コメント)

We pay that much because we have a for-profit, debt driven system which has no limitations on inflation & no reason to keep the prices low. A single payer system allows the government to negotiate prices for the entire nation, which is far more leverage than individual insurance companies, hospitals & patients can manage.

[–]UniverseBomb1∆ [スコア非表示]  (2子コメント)

OP, there's a large chunk of the nation that already has single-payer, the military. One giant medical network, set hospitals for free care and zero problems dealing with a growing population. The US has already proven it could do this, on a federal level. I agree that states and states rights would put a giant wrench in it, so I won't argue geographic issues with you. And I'm not here to talk about the VA, it's separate and a bureaucratic nightmare from what I've been told.

[–]steelerfaninperu3∆[S] [スコア非表示]  (1子コメント)

∆

That's an interesting angle that I hadn't considered.

I suppose if they scaled up the military system and expanded it to everyone else it could be effective. They could even employ military doctors in public health service.

[–]lonelyfriend16∆ [スコア非表示]  (3子コメント)

Good question! I hope we can avoid the obvious political reasons that make it difficult to implement this system.

First, let use remember that Canada, UK, Australia - the Anglo-sphere have more in common with the US than other countries. This is important. Let us also remember that Canada, was a late adopter of universal health care - and it started with a single province and then was modified for the whole country.

Second, let us also remember, that Taiwan has a single payer healthcare system. It was actually model (and against lol) the US system - it is based on the US Medicare system except expanded for coverage of all citizens. I think it includes dental.

I just want to give a quick "global" background for a preliminary understanding that other countries had barriers and managed to create systems through a one payer system.

1) Your population isn't too big. For a one payer system, there would still be ways to manage heathcare delivery. Canada is a huge country - as you know - and it manages to provide efficient healthcare delivery by using several mechanisms. a) Canada as a country doesn't do shit except ensure drugs are safe, First Nations has access, army has access to health, etc. They give money (Social-Health transfers) to the provinces and they provide health. If anything, by removing delivery by provinces - you can probably make Canada even better - but that requires a PhD dissertation on Federalism and quality healthcare.

Easily, the US can implement a model similar to this - by creating organizations through medicare that directly deal with healthcare delivery services in regions. Speaking of regions, in order to mobilize inefficiencies in the system, you can create Regional Health Authorities to help "micro-manage" and integrate services. They would probably be intra-state.

Also - remember that healthcare delivery is still private often!

2) Language, etc, is not really an issue. It just means that the government can ensure that private agencies have language/multicultural services before getting contracts. There are many ways to roll it out.

Also, the US is not really that complex genetically. I mean, England is Caribbean, African, Indian, East Asian, etc. Canada actually has two official languages, and First Nations are a priority for healthcare delivery. I don't mean to minimize your concern, but I feel it is a non-issue and one that is work-able!

3) Although many people hate medicare - it actually is efficient. It may be much more efficient than the private sector. For one, it is most likely the leading source of quality improvement. In order to receive medicare, you have to roll out inter-operable health informatic systems, you have to ensure you practice evidence based medicine. Remember, healthcare is a system - that is homecare, LTC, hospital, physio, nurses, physicians, etc - the government is just inherently in a better position to coordinate them.

This is why the US is over-paying for medical care - healthcare is just different than the post office or trains. It requires regulation and government oversight.

[–]steelerfaninperu3∆[S] [スコア非表示]  (2子コメント)

Easily, the US can implement a model similar to this - by creating organizations through medicare that directly deal with healthcare delivery services in regions. Speaking of regions, in order to mobilize inefficiencies in the system, you can create Regional Health Authorities to help "micro-manage" and integrate services. They would probably be intra-state.

Doesn't this just add to the bureaucracy and potential for inefficiency? Right now you deal with an insurer, but if that insurer becomes a regional authority governed by the federal system, now I've got to deal with two groups (albeit one indirectly).

Then there's the contact between the public system and private providers. That could easily be a nightmare.

[–]Drendude [スコア非表示]  (0子コメント)

Right now, you deal with an insurer. That insurer deals extensively with the government. There isn't that much of a difference, other than the objective of profit vs. public health.

[–]lonelyfriend16∆ [スコア非表示]  (0子コメント)

What is nice about the Regional Health Authorities, is that they don't "report" to politicians and the tend to deliver on their agendas according to civil servants.

At present, insurance(s) speak to different organization(s). In the regional authority via one payer system - all organizations work in sync and all are paid through the 1 Regional Health Authority. Redundant communication has been severed - that is an efficiency.

Further, the Regional Health Authority also reduce inefficiencies in other ways. Say, you have two hospitals in one city with two amazing cardiac programs. In a private system, both of them keep it as it is a 'money maker'. In a one payer system, and the Regional Health Authority system, they do have power to eliminate redundancies like that.

Finally - when you say now "I've got to deal with two groups" - patients don't have to deal with ANYONE. This is ALL back-end. Patients do not speak to the regional health authorities, ever. They will talk to front line management and clinicians 99.99 percent of the time. I'm sure many Canadians don't even know what a regional health authority is, let alone that it is a useful mechanism to ensure healthcare is sustainable and increasing in quality and integration lol.

Do you have any other questions on that point, or others? Keep in mind that I just put one type healthcare delivery system! There are others that are tested too - I just picked a Canadian one that I can see working in the US.

[–]freshthrowaway11381∆ [スコア非表示]  (8子コメント)

I agree with your statement but not with your evidence.

1) The size of the program actually enables a much more efficient use of resources, which you can see with many of the European nations.

2) Diversity? I would recommend looking into the variety of people's in Europe. They have immigrants from all over the place, usually because of the open immigration from former colonies.

3) Government operations, such as Medicare, have been shown to be just as efficient with a dollars to care basis as a private service.

Personally, I think that the single payer system couldn't be instituted in this country simply because we have too many people who do not want to be a part of something that provides an equal care for all citizens. We express ourselves through our inequality and symbols of status. This is then extended through a portion of our voting public to a desire to destroy the idea of a government that helps people. I would point to Grover Norquist who has been quoted as saying, "I don't want to abolish government. I simply want to reduce it to the size where I can drag it into the bathroom and drown it in the bathtub."

Basically, our politicians ,that represent a large portion of our populous, would rather make things privatized (and punishing to the most vulnerable) than admitting that a government program might be helpful.

[–]steelerfaninperu3∆[S] [スコア非表示]  (7子コメント)

Got a source for #3?

And diversity means more than just ethnic diversity, it also refers to geographical factors and economic elements.

[–]freshthrowaway11381∆ [スコア非表示]  (6子コメント)

I'll start you with this for #3, but if you look deeper into the issue you'll find that there is more evidence for government programs than there is for using federal contractors/privatization.

I'm not sure if you read my diversity statement. France, for instance, gets all manner of immigrants from it's previous colonies- from the caribbean to africa to south asia. And of all economic classes. I recommend a quick trip across the Atlantic and see for yourself that it isn't some white wonderland over there like so many Americans presume.

[–]steelerfaninperu3∆[S] [スコア非表示]  (5子コメント)

∆

Those are good data points. And I suppose I hadn't considered Europe's level of diversity, although I still think it's hard to compare to the US. My experience in South America has been that the populations are much more homogeneous than in the US. I mean, in the US you have entire districts with populations larger than many of Europe's towns and those reside within cities of very different populations ethnically speaking.

[–]DeltaBot∞∆[M] [スコア非表示]  (0子コメント)

Confirmed: 1 delta awarded to /u/freshthrowaway1138. [History]

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[–]freshthrowaway11381∆ [スコア非表示]  (2子コメント)

I think the problem with looking at South America, is that it isn't a place that brings a lot of immigrants into in recent times. The only place that I've been with recent influxes of immigrants would be in the Argentina in the post WW2 era. Otherwise you get the most variety in rich nations, like Europe or America. Heck, even Canada has a pretty high rate even considering their smaller population.

[–]steelerfaninperu3∆[S] [スコア非表示]  (1子コメント)

True.

I think to me the thing that stands out is that in the US you just look at these very large immigrant communities with different needs. I lived in and around Detroit and you look at Dearborn, that's a massive Arabic community the size of a decent town. Now you have to satisfy that demand next to the demands of an almost all black urban environment. And that's just the start.

I feel like those are hard situations for the government to manage effectively. You'll need to attract better doctors and better hospitals to those areas or you don't really solve anything. One of the best medical centers is at University of Michigan, located faaar away in yuppie Ann Arbor.

So my concern is mainly with that.

[–]lasagnaman1∆ [スコア非表示]  (0子コメント)

look at Dearborn, that's a massive Arabic community the size of a decent town. Now you have to satisfy that demand next to the demands of an almost all black urban environment.

How are the health care needs of an Arabic man different than those of a black man?

[–]lasagnaman1∆ [スコア非表示]  (0子コメント)

I mean, in the US you have entire districts with populations larger than many of Europe's towns and those reside within cities of very different populations ethnically speaking.

You're comparing the best of one country with the worst of another. I could just as easily say "in London you have entire neighborhoods with population larger than many US towns and with much more diversity."

[–]nightjar123 [スコア非表示]  (2子コメント)

We've already done it successfully. Medicare and the VA age basically the largest government run Healthcare programs in the world.

[–]steelerfaninperu3∆[S] [スコア非表示]  (1子コメント)

But those don't serve the whole population and particularly have less diversity seeing as they're focused on the lower-class and retirees

[–]Freckled_daywalker [スコア非表示]  (0子コメント)

I see you've already awarded deltas but just wanted to mention that even though Medicare is for seniors, the Center for Medicare and Medicaid services is the body that defines all of the codes (CPT and ICD10) that we use for billing and almost all private insurers use Medicare rates as the starting part for determining reimbursent. Private company reimbursements are always a multipler of (e.g. 3x or 1.5x) the medicare rate, meaning, from the billing system perspective, we could switch tomorrow to billing Medicare for everyone and aside from the scaled up workload on the gov't side, not mich would change. Actually, that's not true, it would actually be vastly easier and cheaper for the hospitals and private practices.

[–]molecularpoet [スコア非表示]  (0子コメント)

Our population is just too big to micro-manage this way

Healthcare in Canada is managed by the provinces. Only 4 states in the US (CA, TX, FL, NY) have populations larger than Canada's largest province, Ontario, which has over 13 million people and is roughly tied with Illinois. That means that in Canada there is a successful example of single payer health insurance for a population larger than or equal to 54 of the states (and DC).