What is “socialized medicine” anyway?
A comment on an earlier post made me think about the ways in which the meaning of the term “socialized medicine” has changed over the years.
Decades ago, the term tended to be used to describe a system in which the public sector directly provided health care services, as is the case in the United Kingdom. To some extent, this usage makes sense as such a system literally “socializes” the practice of medicine.
During the 1950s, the term also got applied—in a pejorative way—to physician group practices such as those affiliated with Kaiser Permanente here in California (disclosure: KP is my employer). Kaiser Permanente physicians were refused admission to the California Medical Association and often refused admitting privileges at hospitals because they were practicing “socialized medicine.” The charge was ironic because Henry Kaiser was as capitalist as they come and operated huge construction and manufacturing businesses. Kasier tried to apply the same techniques of vertical integration that he used in his other industries to health care.
More recently, the term now seems to be applied, willy-nilly, to a wide range of national health insurance systems with fundamentally different features. In Canada, for example, the practice of medicine, per se, is not socialized. Physicians and hospitals (other than public hospitals) remain private entities. A more correct term for the Canadian system would be socialized insurance.
In other countries, though, the term has even less meaning because there is often a mix of public and private entities involved in both care delivery and insurance. In Germany, for example, union-sponsored “sick funds” play a major role in the health insurance market. The only thing really “socialized” about these systems is that there is an ultimate guarantee that if you fall through the cracks of the insurance market, there is some kind of public provision for your care.
When I look at the major health care reform bills moving through Congress, it looks to me like they envision this kind of mixed system rather than fully socializing the practice of medicine (UK) or insurance (Canada). For good or for ill, the vast majority of individuals will still obtain insurance through their employer, although purchasing coverage as an individual will be considerably easier and—for low and moderate income families—more affordable. Guaranteed issue and a moderate standardization of benefit packages will prevent the ‘race to the bottom’ that has recently characterized benefit design in the health insurance market. We can certainly raise a lot of questions about the financing and how much the federal government, employers and individuals should be asked to contribute. But that is haggling over the details.
My sense, though, is that the health care reform debate has moved far beyond these pragmatic considerations and has become an epic clash of ideological worldviews. Conservatives—when their criticisms are not completely detached from reality—seem fear that such a significant expansion of the federal government’s role in health care threatens to undermine the progress they have made in lowering the burden of federal taxation, retrieving the ideas of federalism, and reducing the dependence of individuals on the state. Many liberals, for their part, are hoping for just the opposite, i.e. that the success of health care reform will restore public trust in the capacity of the federal government to act effectively on behalf of the common good. A few, though, seem to be clinging to the idea of a “public option” out of an ideological antipathy to the private provision of health insurance and a a hope that a gradual migration of people into the public plan would lead to the de facto adoption of a “single payer” system.
These are concepts worth arguing about, but I wish the partisans had picked another issue. The reality is that our health care system is a patchwork partnership between the federal government, states, and the private sector and under any conceivable reform scenario it will—and should—remain so.
Peter, what an excellent and balanced thread and such a reasonable call for getting rid of the “socialism” mantra – one of many hindering insight into wher ewe’re gfoing and how to get there.
I expect that you can now be attacked on all sides , given the unreasonableness of town hall talking points debate – but thanks, anyway!
Ditto to Bob’s comments.
I’m starting to think that the health care reformers and commentators being “attacked on all sides” are the people we should be listening to the most carefully.
If the conservatives want to lower the burden of federal taxation, they will eliminate the tax deductibility of employer healthcare benefits costs. After all, if those aren’t taxable, the revenues must come from elsewhere.
Peter:
Great article. Good and succinct articulation of the realities of financing medicine.
I wonder whether the backlash against health care is not so much reform as it is a basic ideological clash of private/public and individualism/collective.
“The reality is that our health care system is a patchwork partnership between the federal government, states, and the private sector and under any conceivable reform scenario it will—and should—remain so.”
Precisely!! That is why I wonder why the town halls in the first place, Why is it so difficult to enact reform when you have a Democratic president and congress. It seems to me that there are other, invisible interests at play here.
As a total aside, I do think all the hand wringing about the town hall behaviour is historically naive. Town hall meetings and democracy have never (and shouldn’t be) been sanguine affairs. If someone is disruptive, have them removed. But booing, taunting….hey check out the House of Commons in Canada and the UK.
I read an article some time ago (which I will never be able to find now) that talked about the “Marcus Welby Factor” in medicine: Americans still have, as an ideal or image, the friendly, independent family practicioner who makes house calls with his black bag. The reality of medicine – institutional provision of medical care, hospital stays that run up astronomical bills, a bewildering array of specialists and tests, invoices from hospital stays from an unbelievable number of providers and services – are seen as regrettable deviations from the Marcus Welby “norm”. And now, with significantly greater government involvement in medical care quite likely, it seems that the things that Americans detest about medical care – the faceless bureaucracy, the emphasis on cost containment above all else – seems to loom larger and larger, and Dr. Welby recedes farther and farther away. People may be delusional, but that doesn’t mean that they have to like the new reality.
Peter, I think that you misunderstand the Canadian system. It is not an insurance plan. Everyone gets the same access to the same system. Nobody pays any premiums, there are no limits on the care provided. Or, at least there are no limits placed that result from your ability to pay. The doctors determine the appropriate treatment. There are certainly shortages, such as in hip and knee replacements. This is a result of changes to medical technology that has allowed these treatments for a far larger number of patients, but there are not enough trained orthopaedic surgeons. As we train more, the waiting list gets shorter.
In a few provinces there is an annual “health care premium”. This is not like an insurance premium. It is really a tax. It is the same for every person or family. You still get treatment if you cannot pay. And the hospitals, doctors, etc… do not even know if you have paid. The provincial government collects the tax and puts it into general revenue.
For some forms of treatment, there is no coverage under the public health system. For example, cosmetic surgery that doesn’t result from a disfiguring injury. For this, we can buy extended health insurance from a private company (Blue Cross, etc…) Most Canadians get this through their employer. Typically it is about $150 per month per adult. It normally includes dental care, pharmaceuticals, and eye exams as well.
I don’t like the use of the term “socialized medicine”, because it is intended to scare people into thinking it is some sort of socialist plot. I prefer “public medicine” or maybe “social medicine”. I think that a lot of people’s fears about health reform is that it will lead to some sort of central health authority making decisions about your care. This is not the case in Canada. The doctors are the ones who make the decisions. The health system is a provincial responsibility although it governed under the federal Canada Health Act (which establishes national standards). Each province divides their system into regional health authorities or boards. These are normally clusters of hospitals across a city. They have a board of directors appointed by the government, and in some unsuccessful trials elected directly by the people. The health district receives its budget allocation from the government and determines where to spend it (a new MRI here, a trauma ward there…). However, the health district does not deal with individual patient care. This remains the responsibility of the health professionals. The administrators, accountants, and politicians do not have any input into these decisions.
I don’t know much about the US system, but it seems to me that one of the biggest problems of private health insurance is that decisions about treatment are made by the HMOs, rather than by the health professionals and primary care physicians. That would lead to a public scandal in Canada.
Jim says: “People may be delusional, but that doesn’t mean they have to like the new reality.” What’s supposed to follow from this? Shall we all cater to these delusions?
For those of you who saw Dick Armey, one of the architects of the right-wing scare tactics, on the Jim Leher show tonight, it’s celar that he doesn’t give a tinker’s dam about what happens to our uninsured and underinsured fellow citizens. Try squaring that with anything that’s even remotely Christian. I wish that I thought that he was sufficiently dimwitted that he believed what he said. He dispelled such doubts. He knows damn well what he’s up to. Shame on whoever plays footsie with him and his ilk.
It seems to me that one reason some people get hysterical over the thought of socialized medicine, especially some over 60, is because they equate socialism with Communism, a dreadful system that didn’t work.
I do not so much worry about socialized medicine per se. Instead I would be concerned about who is running it; what ethics they employ.
Recently the government in North Carolina has made noises about Belmont Abbet College choosing an insurance package for its employees that does not cover abortion or contraceptives:
http://www.lifesitenews.com/ldn/2009/aug/09081005.html
Now, Belmont Abbet is a Catholic college, and they correctly are trying to follow Church teaching on contraceptives.
If the local state government has its way, they will be forced to offer their employees and insurance plan that covers contraceptives.
That then, is what worries me about any national or socialized medical plan.
Excuse me – Typographical Error. I should have said “that sort of thing is what worries me about any national or socialized medical plan.”
One more remark and then I’ll shut up. For years, I’ve enjoyed fine medical coverage. For years, millions of people, through no fault of their own, have had little or no medical coverage. For years, physicians and any number of other people have lived lives of abundance. For years, millions of people have lived in destitution.Leave all the hokum about bureaucrats, socialism, etc. aside. If our society can’t afford to cover more people without trimming some of the benefits of us well off, then what do you think that distributive justice calls for? Sure, there’s lots to figure out to try to make things work. But the principle is clear. We fatties have to give the skinnies a decent place at the table. As Matthey Boudway says elsewhere, we ought to do it not just any time when we find it convenient. We ought to do it now!
Bernard Daunhauer on the Newshour this evening and Dick Armey’s comments: Armey said at least three times that people at 65 must take Medicare, and if they don’t they lose their social security. This is untrue (I know, I’m over 65 and have Empire/Blue Cross from Fordham). What was shocking is that neither Judy Woodruff or the other guest pointed out the falsehood. This is journalistic negligance; how often will Armey’s comment be quoted and requoted. And while we’re at it, why don’t true conservative rise up in complaint that the Newhour allows Armey to speak for them on this issue.
By the way, thank you Peter; a very helpful post. Sane!
Nicholas:
I live in the province of Ontario and the scenario is hardly rosy. I do not have a doctor, cannot access one. For any kind of health needs I require (and I don’t need much), I go to a walk in clinic (and wait hours and hours and hours….). It is true that if something happened I do not worry about coverage and that is a benefit and I am happy to support others through my taxes even though I do not need the service. But health care is still contested in Canada and the provinces. As you mention, provinces administer health and portability is an issue. For example if someone lives on the eastern part of Ontario (Ottawa) they cannot just go to Quebec and have their cost covered and on the west they cannot go to Manitoba at least easily.
The big reform in Ontario is Local Health Integrated Networks whose mandate is to consolidate health care. A major issues continues to be emergency room visits and overcrowding.
It is an interesting issue and I am all for socialized medicine (call it what you will). But the original founder of Medicare Tommy Douglas envisioned as the next evolution of care, a distribution of community health clinics and less hospitals. But hospitals are an entrenched part of the health system and a huge problem in terms of cost. It is an issue of cost containment and I think, with all due respect, to say that decisions about health care are made by an HMO in the US but physicians in Canada is misleading. The medicare system will prescribe certain interventions for certain procedures not unlike HMO’s. The only difference is that the insurance is public and distributed across the province as opposed to private in the case of insurance.
A publicly funded system has many benefits but cost is an issue and health care is always a big issue in elections and lets face it lots of professional interests (doctors, nurses) lobby for their interests which may be at variance with a cost effective care system (i.e. investment in preventive care, more nurse practiononers, not every single pregnant women needs the services of an ob-gyn for the course of their pregnancy, children do not need a pediatrician, etc.).
Peter, thanks so much for this and other posts on insurance.
It would be good if there was a way to collect them n one place for easy access.
Peggy, Empire Blue Cross is paid by Medicare. At 65 it is automatic. Empire pays what Medicare does not but not all.
“Why is it so difficult to enact reform when you have a Democratic president and congress. It seems to me that there are other, invisible interests at play here.”
Not quite the interests are very visible. Thousands of health industry lobbyists have descended on Washington. That is six lobbyists for every congresswo/man. A lot of money is made in health care. That is the rub.
Another thought. How about getting the very rich drug companies to kick in. But they are part of the lobbying against.
I am not sure what set me thinking in this direction, maybe it was Kaiser’s capitalism, but how about if we propose non-socialist medicine?
We could have a system where capitalist employers provide healthcare, if it benefits them. People might be concerned that losing their jobs would mean losing their health insurance, so that would ensure that they remain employed, productive members of society.
Small businesses would be at a disadvantage, since they probably could not provide coverage comparable to larger businesses. Self employment would be prohibitively expensive. Again, these things would ensure that most would work for those with capital.
I suspect that huge companies would spring up to take advantage of this kind of a system, creating huge bureaucracies to obscure services and keep people from over-utilizing their insurance.
Try selling that as an alternative!
Not so Bill; I have employer provided health insurance and am issued a letter every year that says what’s on offer is as good as or better than Medicare. Apparently this is a Medicare requirement (the letter), but it essentially means Blue Cross is my insurer not Medicare.
I will be happy to join Medicare when I retire. My point: Armey has it wrong and no one corrected or clarified. This is how Death Panel and other lies (or rumors) get going and keep going.
Bill, Peggy is right. If you are employed by someone who issues health coverage, that employer may not refuse to enroll you on account of the fact that you are Medicare eligible. If you do enroll in Medicare, so long as you continue to be actively employed, Medicare will pay secondary to the employer provided insurance.
You would automatically be enrolled in Part A, but not Part B, once you turn 65. Normally, there would be a penalty for late enrollment into Medicare Part B (or D) but that penalty isn’t triggered for people like Peggy until she actually loses her employer provided insurance.
You are never “automatically” enrolled in Medicare HMO. For one thing, there are usually at least two or three of them, and they often have subvariations. You have to elect whether you want ffs or private plan coverage, and which plan you want.
When you turn 65 you are automatically enrolled in Medicare Part A. When it comes to B and D, that is optional. There is a financial penalty if you don’t enroll in those when eligible UNLESS you are covered by a bona fide group health plan. You may continue in the group plan until you lose it/opt out and you DO NOT suffer the late enrollment penalty.
So, that means that enrollment in Med A is mandatory, but Med B & D are optional.
I know this to be true because it is my situation. I will be 69 and have yet to take Med B & D as I have group coverage for Medical, Dental and Rx because my partner’s employer offers (they had to; this is California) Domestic Partner benefits. We do have to pay an income tax on the imputed income attributed to the employer’s contribution to the cost of my benefits.
“We could have a system where capitalist employers provide healthcare, if it benefits them. … Small businesses would be at a disadvantage … Self employment would be prohibitively expensive. … I suspect that huge companies would spring up to take advantage of this kind of a system … Try selling that as an alternative!”
No thanks, I’d rather stick with the status quo :-). But, at least your plan wouldn’t bend the curve upward by hundreds of billions of dollars we don’t have!
“There are certainly shortages, such as in hip and knee replacements. This is a result of changes to medical technology that has allowed these treatments for a far larger number of patients, but there are not enough trained orthopaedic surgeons. As we train more, the waiting list gets shorter.”
In other words … there is a shortage, and a waiting list. What voter with insurance wouldn’t want that?
FWIW – I’m told one reason there is a shortage of surgeons is that doctors work many more hours for much less money in Canada, and so doctors have an uncooperative propensity to set up shop elsewhere.
I wrote, “People may be delusional, but that doesn’t mean they have to like the new reality.” … to which Bernard replied, “What’s supposed to follow from this? ”
Nothing in particular – just commenting on the current scene. I suppose, if anything is to follow, it is that there is still a lot of convincing and persuading to do, as large sectors of the electorate don’t seem to have embraced the vision yet.
Let me get this straight: we don’t want to spend hundreds of billions of dollars for the health of our people, but we are perfectly OK with spending hundreds of billions of dollars on unnecessary wars, fought by an “all volunteer force” in places in which we will most likely get our butts kicked big-time (Afghanistan will be Obama’s Vietnam.)
That makes good Christian sense. I’m so glad for the enlightenment.
Jimmy Mac: “we” (meaning, “we the people”, not “we as represented by our federal government”) already spend many, many hundreds of billions on health care – most of it outside the auspices of the government, though.
Defending our country is part of the federal government’s job – nearly everyone agrees on that. That spending on health care should be funneled through the federal government’s tax-and-spend processes seems to be a huge bone of contention.
George D. — You are right that Canadians cannot normally seek health care outside their province. To be precise, they cannot seek elective treatments, but they can receive emergency care. The costs are billed back to their provincial health system. While I agree that portability would be nice, I can see why it might create stresses on a system.
You disagreed with my description of the Canadian system as one in which decisions are made by the doctors instead of the HMOs. You responded that the “medicare system” determines which treatments are covered. Yes, you are right that the provincial health department determines whether a particular kind of treatment will be covered, but it is made as a general policy. They do not approve individual cases. In the US, HMOs examine individual cases and determine whether to provide coverage. In Canada the provincial health departments take advice from their provincial College of Physicians and Surgeons which is responsible for determining whether certain treatments are the normal course of treatment. This is a self-regulating system for the doctors, in which their peers determine general policy and investigate ethical and professional breeches. So even the provincial health departments’ decisions about whether to include coverage of certain treatments are largely influenced by physicians, although the accountants and lawyers probably have significant input as well.
Jim Pauwels — shortages and waiting lists are not acceptable, the Canadian system needs vast improvements. However, it has the goal of universality. Every resident of Canada (including 1,000s of foreign nationals) gets full coverage. Any voter who opts for a system that does not have universal coverage is contemptible. I cannot comprehend why anyone in the US can accept a system that leaves 40+ million people without health care.
Also Jim, you are probably right that doctors in the US are paid more. This is certainly true of specialists. However, I don’t know how many actually leave the country for higher salaries elsewhere. I have heard of studies that support this theory, and others that discount it. As for hours of work, doctors everywhere work long hours. They are notorious for overworking. I have not seen any studies comparing Canadian doctors to others in the developed world.
“That spending on health care should be funneled through the federal government’s tax-and-spend processes seems to be a huge bone of contention.”
Yes, the insurance companies, pharmaceutical cartels, for-profit hospital corporations, etc. certainly don’t like the idea, do they?