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.