What is the Health Care Debate Really About?

Hint: It’s not about health care.

Ask yourself this question: What is the one health system characteristic every developed country has, except the United States?

If you answered: Every other country has made health care a right, you’re wrong. Citizens of Canada have no right to any particular health care service. They have no right to a CT scan or open heart surgery. They don’t even have a right to a place in line. The 100th Canadian waiting for heart surgery isn’t entitled to the 100th surgery.

If you answered: Every other country guarantees essential care to all its citizens, you’re wrong. Citizens of Canada and Britain are routinely denied prompt access to basic health care.

If you answered: Every other country guarantees access to care, regardless of ability to pay, you’re wrong again. In Britain people routinely go to the private sector and pay out-of-pocket for care they cannot get from the state. Canadians come to this country. In both cases, lack of ability to pay is a barrier to care.

If you answered: Other countries make primary care more accessible because there is no barrier of money, you’re wrong once more. Americans get more primary care than Europeans. Even uninsured Americans get as much or more primary care as Canadians get.

So what really is the difference?

What’s It All About Alfie


Answer: Other countries have nationalized, or collectivized, their health care systems. So far we have not.

In the United States, whether you have insurance at all, what kind of insurance you have, where you get it, what price you pay — these decisions are primarily made by individuals and employers in the private sector. In other countries, they are made by government.

In terms of democratic theory, in other countries people get to vote on what kind of insurance you have and you get to vote on theirs. In the United States the health insurance of most working-age families is based on individual choice, not public choice.

As for day-to-day operations, the U.S. health care system is actually far more similar to the systems of other countries than most people realize. Critics tend to exaggerate the role of out-of-pocket payment in the United States and minimize its role in other countries. In fact, U.S. citizens pay about 13¢ out of pocket every time they spend $1 on health care and this is well below the OECD average (20¢) and even and below that of Canada (15¢)!

Despite all the claims about how different the U.S. system is from the Canadian system, the two systems are far more similar than they are different. Both countries pay doctors the same way; both rely heavily on third-party payment; and both ration by waiting. In Canada, when people see a doctor, the visit is free. In the U.S., it’s almost free. In fact, it’s probably fair to say that there are fewer differences between U.S. and Canadian health care on average than there are among the various types of health plans within the U.S.

The real issue, then, is not about health care at all. It’s about collectivism. It’s about whether we are going to make decisions in one-sixth of our economy privately or publicly. It’s about private sector institutions versus government and ultimately the ballot box.

If I’m right about this, two follow-up questions spring to mind:

  1. Why would any rational person want other people to vote on his health insurance and why would he want to vote on theirs?
  2. If the real issue is individualism versus collectivism, why don’t those who want to collectivize the system admit that?

The answer to the second question is: It’s bad salesmanship. In Europe the collectivists often do admit what they’re all about. Granted, they use code words like “solidarity,” but they frankly admit they are fundamentally opposed to having individuals make their own decisions about their own care. In the United States, the very word “collectivism” sounds unAmerican. So the proponents often resort to intellectual dishonesty — making intentionally inaccurate comparisons between our system and the systems of other countries, finding fault with private health insurance while ignoring the even great faults in Medicare and Medicaid, and making ridiculous claims about how problems are going to be solved once the government takes over.

I don’t recall a recent example of an American being intellectually honest enough to admit that the real reason for national health insurance is that in matters of health, private decision-making is socially intolerable. If you know of an exception, post it in the comment section

The answer to the first question I’ll reserve for a future Health Alert.

Comments (22)

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  1. Joe S. says:

    Very good post. How true!

  2. Larry C. says:

    Agree totally. This is not about health care. This is about government controlling your life.

  3. Linda Gorman says:

    Another difference: in the U.S. the private system is large enough that what constitutes good care has, until very recently, been benchmarked by the private system.

    The various commissions and panels in the ObamnaCare bills were set up to change that. It would make the definition of good health care much NICEr.

  4. Tom H. says:

    Linda: very clever pun! I don’t remember seeing this side of you before.

  5. Gertkvist says:

    In principle I agree, but I have to point out that

    a) In Switzerland you are free to chose your own health insurance. Yes, it is obligatory to have an insurance, but what it includes is up to you.

    b) In a way the US already votes on other peoples inurances. Both by the federal laws that obliges hospitals to treat people without insurances and by state laws regulating what health insurances must contain (drug reahb, advices from priests and so on).

    c) Comparing the US to other countries is difficult. A better comparison would be between the US and the EU, or between countries and US states.

    d) If the US had the Swedish tax system (where everyone is registered, all the time) I doubt that the US healthcare system would survive for long. The possibilities to create special “healthcare taxes” is irresistable. So it is not only healthcare that determine the system.

  6. Don Levit says:

    Do we make decisions publicly or privately?
    Well, as long as a third party is involved, be it insurance companies or the government, the dichotomy is not that clear cut.
    I believe the real issue, the bottom line here is one of contrasting values.
    Are they “situational values,” or “sustainable values”?
    Situational values allow the parties to do whatever the situation will allow.
    Thus, we have the patient trying to maximize care, and the insuter trying to minimize care.
    Sustainable values provide guidance to behave in ways that sustains future generations.
    That, we don’t have presently in our health care system.
    Whether public or private, the system is not sustainable.
    And, it won’t be sustainable until we can think ahead, long past our physical survival.
    Don Levit

  7. William G. Shipman says:

    Because of your efforts, and those of others, we may have avoided this monster. As one of my political friends recently said, “Massachusetts gets
    it right about every 300 years.” Social Security may be next.

  8. Mike says:

    You seem to forget that the main reason for universal health care is the fact that the employer will no longer have control on YOU. Would you start a company or job of your own if you KNEW that you and your family would have health care? The answer is yes.
    Does your employer control your health care and use this control to keep you working at a job you may not like? The answer is YES. Be honest, you are tied to a job you don’t like because you need the health care and so does your family. Your employer gives you a very narrow choice of health care options.
    You can’t just leave your job and go to another job if you have pre-existing conditions (and who doesn’t) so you stay at a job you don’t like.
    Trying to make this out to be a simple choice is the right wing way, it’s complicated. But we need to have some type of choice in health care so we don’t have to be chained to a job we don’t like.
    More is better than less and health care for all is more.

  9. Bruce says:

    Of course it’s not about health care. It’s about control, and making people dependent on government. Which means, dependent on politicians.

  10. Matt says:

    I continue to enjoy the posts. What dollar value do you equate to “almost free”? Particularly in regards to this statement:

    In Canada, when people see a doctor, the visit is free. In the U.S., it’s almost free.

  11. John Goodman says:

    Matt: We pay 10 cents out of pocket every time we spend a dollar at a doctor’s office. “Almost free” means we get physicians’ care for ten cents on the dollar.

  12. Jennifer Siefert says:

    Unfortunately, most consumers of health care do not know how much the care actually costs. Any model where people are disconnected from the true cost of care cannot be sustained. Certainly, an attitude of “let the rich pay for it” or “let the people with rich plans pay a high tax on them – except for union members” is not going to improve things. You are not going to bring down the cost of care without changing behavior. I would rather have my employer offer me a lower insurance premium for exercising regularly or not smoking than have the federal government ban smoking or send me to jail if I don’t purchase the “right” level of coverage for my family.

  13. Joseph Chiarelli says:

    In my opinion, healthcare is very personal and each individual is unique – physically, emotionally, and economically. Private enterprises or government agencies that make healthcare decisions for individuals based on groupings, statistical samples extrapolated to broad populations, or glittering generalities will, by definition, create issues, errors, and mistakes for some individuals. This process creates resentment, resistance, and attempts at retribution on those who made the decisions/created the rules. As these issues, errors, and mistakes become known, the effort to compensate and either correct or avoid these issues, errors, and mistakes in the future increases the cost of providing care. However, the underlying issue – personal choice – is never addressed so the cycle continues. It appears that if a system of options is provided to individuals to make their own choices – with guidance and help to avoid choices that are deleterious either to them or to the population/ country as a whole – the underlying root cause can be addressed.

  14. Bobby Morris says:

    Mr. Goodman, well put! You are correct about the misleading rhetoric that confuses so many. The problems with our system of health care are indeed numerous. I could not agree more with you and Mr. Chiarelli’s comment about the needs of each individual being different strikes a resounding chord. I am fairly new to your site so I may be beating a dead horse here, but one of the huge problems with the cost factor of health care in our country stems directly from the pharmaceutical manufacturers. Why oh why do we have to foot the bill for advertising of prescription drugs which are obviously only availableby prescription. Why, because these mega corporations need justification for their budgets and write offs on their taxes! It is preposterous to think that advertising these drugs to the general public is a public service. The very notion that because a commercial telling you that a particular prescription drug is what you need and then suggesting that you ask your doctor for it is reprehensible. Health care as we know it need not be this way.

  15. hoads says:

    “I don’t recall a recent example of an American being intellectually honest enough to admit that the real reason for national health insurance is that in matters of health, private decision-making is socially intolerable. If you know of an exception, post it in the comment section.”

    While I haven’t dug up exact sources, I have read either in Congressional testimony or from some liberal think tank statements that individuals should not be allowed to determine individual insurance benefits because of the concept of “everybody in, nobody out” which is prominent within the literature of healthcare reform. Proponents of nationalizing healthcare believe the government should determine the actuarial value of an insurance policy because they believe everyone should be paying for a baseline of healthcare benefits determined by government. And that basket of benefits include maternity and infant child care, drug and alcohol rehab, mental health therapies, preventive screenings on top of treatment and hospitalization for acute and chronic medical care.

    And, there is also the concept of “healthcare equity” that is rampant within liberal circles and promotes the idea that “overutilization” of healthcare needs to be regulated by government in order to spread healthcare resources to all.

    So while there are probably no headlines in mainstream media that read private healthcare decisions are socially intolerable, scratching below the surface reveals an ideology that relies on collectivizing all healthcare decisions.

  16. John R. Graham says:

    “Mike” (above) states that employers control our access to medical services in the U.S. But his “universal health care” seems to be run by government. If we had (for historical reasons) employer-based housing, so that every employed American lived in a house chosen by his (or his spouse’s employer), would the appropriate reform be to put government in charge of the housing? No, it would be for the government to let families control their own housing dollars, by reforming the tax code.

    Nevertheless, he is right that the employer-based system is idiosyncratic to the U.S. and harmful. In other countries, health insurance is portable (although the Dutch seem to be experiencing a rise in group health benefits: http://tinyurl.com/n9lcrz).

    As to the more philosophical question, I think the drive by the political class to take over Americans’ access to medical services is driven by international class envy. Think about it: If you are the Secretary of Defense, or State, or Treasury, you are the Big Cheese at an international meeting of your peers. If you are the U.S. Secretary of Health & Human Services, you look like kind of a loser when you meet your Canadian or British peers. The same goes for the various bureaucrats at lower levels of the system.

  17. OldSailor says:

    In Obama’s State of The Union address, there was a momentary slip in the so-called Health Care Reform. The President actually said that the administration is pursuing “Health Insurance Reform”. From what I have read, the pending legislation is really about bringing the insurance industry to heel just as the administration has done to the banking/financial sector and the automobile manufacturers. Most people would agree that health care delivery is a patchwork that does not consistently deliver high quality care across the population or even across the country. Throwing billions (Trillions?) of dollars at the problem will never work as long as the politicians are in charge of doling out the money. When the current, pending bills from House and Senate are each 2,000 pages, we all know that each bill is riddled with massive problems and special interest provisions. “War and Peace” is less than 1,500 pages for Pete’s sake! The Obama/Pelosi/Reid troika seems to be blinded by what they see as their legacy being “Universal Health Care” for everyone. What they do not see is the total dissatisfaction with how the bills are going to be punitive to the entire population, with the exception of the unions’ (government unions) of course. This whole process is reminiscent of a line in “Animal Farm” by George Orwell in which the ruling class (pigs) state that: “All animals are equal, but some animals are more equal than others”

  18. [...] a previous Health Alert I argued that the real issue in health reform is not health care. It is collectivism. The natural [...]

  19. Concerned College Student says:

    It is human nature not to show concern or empathy, watching humans die, while knowing that your intervention can save them. The “9/11” incident would say that statement is far from reality. In a moment of crisis, local municipal workers (firefighters, police, and paramedics) and civilians came together to aid those in need. Their thinking wasn’t centered on the financial burden of increased taxes. In that scenario, over five-thousand people lost their lives. How is it immoral, unreasonable, or unethical then, to defray a few dollars of income for your taxes to save millions of lives? Who doesn’t have a heart that goes out to the poor and sick children of third world countries? Even if a person never paid a penny to non-profit organizations, their heart may wish that they had the finances to do so. The answers to these questions, relies upon ones’ ethical morality, or plainly, parsimonious view. Views, such as these, are generally evoked when a person might feel as though there’s no reciprocation. Dr. W. responded to the Nationalized Health Care issue on the website “www.healthcare.procon.org.” His words illuminated his true sense of clinging on to his possessions, that he didn’t want to lose another dollar to the government in which he felt was, “truly unsustainable.” Dr. W.s’ contrived would strike a chord of disharmony among Americans. Often, events of change are defensively charged off by those who would possess these less than subtle attributes. For those who seek truth, it becomes easy to discern the true nature of the intentions of remarks like those of Dr. W.
    When taking a closer look at this argument, let’s first separate this complex issue to gain more of an understanding of how it works. One such factor is the problem of integrating a system that offers an insanely expensive service for low or no cost when every resource to this system thrives upon profit. To paint a picture where it is easier to identify problems with this issue, imagine the equivalent being a “Mc Donald’s’” which serves food for free to homeless and unemployed individuals and families. How would (or could) you keep donations coming in to sustain the organization? Donations would have to consistently flow in at an extremely high volume to keep up with the demand. The donations (actual food, equipment, the building, money) would have to also be scrutinized so that it is certain consumable items are free of bacteria, that workers have acquired the proper licenses/certifications to work with food and to operate the machinery, and finally, that the people receiving the services aren’t subjected to harsh chemicals and building environments (asbestos, broken glass, wet floors, sharp edges, etc.). Workers would have to be hired or volunteer their services to operate the organization and, somehow, the overhead (maintenance, upkeep. electricity, gas, waste disposal, water and sewage, rent, and taxes) would have to be routinely taken care of. When computing that not only does the organization have to purchase product from other companies to manufacture its product, it also has to purchase other goods and services to get its product out and to conduct business. In the medical field, the suppliers of medical equipment, pharmaceuticals, prosthesis, and chemicals create a huge problem; they all want to get paid. All of the products and services are extremely expensive and to hire the medical professional staff to service and implement these products belies yet another incredibly huge expense. Add to this to the mixture; Medicare takes care of Americas’ citizens over 65. It is widely known that medical expenses exponentially increase as the age of 65 is reached and surpassed. This means that more medical care has to be provided for the elderly than someone in their 30’s. Overhead for the cost of operating such an organization easily runs into the tens of millions per quarter. In Americas Commercialist society, it creates a sense that the one with the most money is the strongest, even though, it may not be true. However, having a lot more money ensures the capability of being healthier by being able to afford any kind of necessary preventative care versus not having as much money to manage. If the government picked up the cost of Medicare (as it has), of course, working citizens would have to pay for it in their taxes. Here lays another problematic situation. The issue isn’t that Americans would have to pay more, its’ that while most citizens pay their fair share into the taxes, the most prosperous of them don’t do so and the less fortunate are forced to bear the huge financial weight. Having large sums of money allows one to ascertain certain privileges such as hiring tax attorneys to find loopholes in tax laws so that they can preserve more of their earnings. This undermines the skeletal structure of the Americas’ tax system. The money that would be used from these well to do citizens would offset the tax structure and alleviate the pressure of heavy taxes imposed on the middle and lower class citizens. The poor and middle class are taxed into submission because the money has to come from somewhere. If the rich aren’t willing to part with their money, then Americas financial weight shifts to the next class lower class; middle class America. Why, if more than 70 percent of Americans want health care, has the NHC issue being so hotly debated? Aren’t American citizens’ desires, ideas, and wishes supposed to be represented by those they elected? Then if 70 percent of Americans want health care, why are their government almost equally divided on the issue? According to Yes! Online magazine, “It could be the fact that the health care industry, the top spender on Capitol Hill, spent $183.3 million on lobbying just in the second half of 2005, according to PoliticalMoneyLine.com. And in the 2003–2004 election cycle, they spent $123.7 million on election campaigns, according to the Center for Responsive Politics” (Yes!). Social health insurance: contributions for health care are collected from workers, self-employed people, enterprises and the government. These monies are pooled into a social health insurance fund or funds. Universal coverage can be achieved with this type of financing scheme only if contributions are made on behalf of each member of the population and contributions are individualized based on people’s ability to pay. For this reason most social health insurance schemes combine different sources of funds, and the government contributes on behalf of people who cannot afford to pay themselves.
    Before I delve into this topic, let me be perfectly clear: I understand both sides to this argument and am involved personally in both sides. My family is split republican/democrat. We have something to lose on both sides and I have discussed with all of them what NHC means to both sides. It becomes painfully obvious the main concerns of both parties once the topic is on the table. I began to do my own research on the topic, finding truths on both sides and even writing papers in college on the debate.
    It’s understandable that people work hard to get what they have. It’s perfectly arguable that someone that works hard doesn’t want to part with what they worked so hard to get. Believe me. I understand hard work. I was an automatic upset operator for a tier one automotive supplier. For those of you who don’t know what that is, I hot forged axles for trucks and cars. My job was one step above working in a foundry. It was back-breaking work. The pay was substantial ($55,000-$100,000+ per year) and the work dangerous. I had excellent health care until the company reduced it to HMOs’ with limited coverage. Mind you, at this business, workers lost eyes, digits, limbs and life regularly. I could afford most of what I wanted but money was slim if I really wanted to go into business for myself or go on vacation. So do I understand losing something I worked so hard for? YES.

    One thing is for sure; people scare easy. It’s no surprise that politicians use scare tactics to their advantage to vie for political positioning or accomplishing whatever agenda they have before them.
    It’s interesting, however, how people are quick to discount the ideology behind NHC (nationalized Health Care). I see no one on here, in my class debates, on the news, or in congress offering a real solid solution to the present NHC law, only negative conjecture and abstract words. It’s tiresome to listen to people using doomsday scare tactics and assuming the worst out of what hasn’t even taken hold yet. According to many, because of NHC, America will plunge into some kind of indescribable, unspeakable torment. I’ve heard everything from death panels to financial destruction to socialism and as of yet, America hasn’t folded up shop. What is the real truth? Perhaps one should make themselves well informed and read the law for themselves instead of quoting others and being cliché. My favorite policy is: READ EVERYTHING ENTIRELY AND THEN GET SEVERAL DIFFERENT SOURCES TO FORMULATE AN OPINION FOR YOURSELF. I will ply a few simple questions and perhaps we might clear some things up.
    1) How truly disastrous is NHC? Will we have earthquakes? Will America immediately become socialist or even worse? Will we somehow enter the last days of earth? Will the Financial sector bottom out? Will the sky turn to flames and spew brimstone down upon us? Will America turn into a “Mad Max” scenario?

    2) Why isn’t Frances’ or Canada’s’ financial structure falling apart from their NHC seams? A minority (outweighed by the number of cases in existence), of Canada’s’ citizens come to America to receive treatment… less than what this blog would have people believe. Indeed, Americans are even leaving here to live in France! How outrageous!?! Did anyone watch the movie “Sicko” by Michael Moore? Outside of his being overly pro health care, he does provide some interesting facts to his position. It’s something that should be watched by anyone debating this issue.
    3) Who takes the biggest loss from NHC? The Lower class? Middle class? Upper class?
    According to Yes! magazine, it’s the Upper class and Corporate America. “It could be the fact that the health care industry, the top spender on Capitol Hill, spent $183.3 million on lobbying just in the second half of 2005, according to PoliticalMoneyLine.com. And in the 2003–2004 election cycle, they spent $123.7 million on election campaigns, according to the Center for Responsive Politics.” That’s a lot of money to “Have it your way.” With bought lobbyists and politicians, big business has made a loud statement: We don’t care about individuals. When over 70% of America’s citizens wanting NHC, it explains why the house and senate were so “divided” on the topic.
    Would America stand the test of time and brave criticism to be more like France- where everyone is taxed a percentage of their income, regardless of how much they make, and companies aren’t allowed to shuffle or hide their income in loopholes, America just might end up with a torrential supply of income. I fear that America has become an Ebenezer Scrooge; a greedy mad man, unconcerned with his family or his neighbors unless it suits his greed.

    Unfortunately, America has never been completely fair to its citizens as far as this is concerned. America is supposed to be the most advanced industrialized country on Earth; yet, it’s just too clouded by individualistic oh-well-it-wasn’t-me personalities. We spend hundreds of billions on wars that have no merit, yet there’s more debate over helping our own citizens, than killing people in foreign countries for no reason. I’m beginning to see a pattern…
    Is it possible that Americans put themselves on witch-hunts? Going after huge so-called problematic issues to cover up the true nature of what’s going on? It seems to be not a debate over health care, but healthy pocketbooks.
    According to the W.H.O. (World Health Organization), “Social health insurance: contributions for health care are collected from workers, self-employed people, enterprises and the government. These monies are pooled into a social health insurance fund or funds. Universal coverage can be achieved with this type of financing scheme only if contributions are made on behalf of each member of the population and contributions are individualized based on people’s ability to pay. For this reason most social health insurance schemes combine different sources of funds, and the government contributes on behalf of people who cannot afford to pay themselves.” This is not talking about changing America from a representative democracy to a socialist government. It is explaining how the system should work. So, “POOF!” goes the theory of America becoming socialistic.
    While it’s true that Canadians may wait longer to receive their health care, their average life expectancy and infant mortality rates still out-rank Americas’. While researching Canada’s’ Health system, I found nothing that states Canadians can’t get proper health care and are forced to come to America to receive these services.

    Has anyone thought about the fact that Americas’ NHC system won’t be fully implemented until 2018? It does, however, provide that the “high risk pool” still be allowed until 2014 and then will become illegal. This means that insurance companies will still have time to deliberate the care of more serious patients. The whole system as of yet is a work in progress; a progress that we are all supposed to have a say in.
    In the laymen’s terms, a country will progress quickly if it’s healthier. By increasing healthier lifestyles, you will increase productivity, profit, the mortality rates, citizen spending, and so on. What’s so bad about that? So what if you spend a few dollars out of your pocket to save MILLIONS of lives. How incredibly selfish we are! You’d spend that much wasting money on things you don’t need than something worthwhile.
    Before people begin to issue out death certificates on the new NHC, lets see what happens first. Lord knows, we have enough negativity in America as it is.

    Wikipedia Comparison of Health Care (Canada/America)

    World Health Organization

    Yes! Magazine

    Wikipedia Forms of Government

    The French Health Care System

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