This concern about our health money is touching.  The HMO's
pay their CEO's e.g. 50 million per year, doesnt that
cause any concern?
wcm>
> > No compulsory health insurance program has found a
> > means to discourage racketeers or petty complainers
> > who make useless trips to the doctor and monopolize
> > professional time that should be spent on people
> > really needing care.
>
> Whether they are sick folks, government employees, or assholes who shill
> for the folks makin' money off the whole project (such as drug companies,
> HMO's, etc., etc...)
> DDeBar
> [log in to unmask]
>
> ----------
> > From: Mumpsimus <[log in to unmask]>
> > To: [log in to unmask]
> > Subject: Re: [CHOMSKY] Whose health care system is superior?
> > Date: Monday, May 15, 2000 8:46 PM
> >
> > Socialized Medicine: The Canadian Experience
> > by Pierre Lemieux
> >
> > The Canadian public health system is often put
> > forward as an ideal for Americans to emulate. It
> > provides all Canadians with free basic health
> > care: free doctors visits, free hospital ward
> > care, free surgery, free drugs and medicine while
> > in the hospital -- plus some free dental care for
> > children as well as free prescription drugs and
> > other services for the over-65 and welfare
> > recipients. You just show your plastic medicare
> > card and you never see a medical bill.
> >
> > This extensive national health system was begun
> > in the late 1950s with a system of publicly funded
> > hospital insurance, and completed in the late
> > 1960s and early 1970s when comprehensive health
> > insurance was put into place. The federal
> > government finances about 40 percent of the
> > costs, provided the provinces set up a system
> > satisfying federal norms. All provincial systems
> > thus are very similar, and the Quebec case which
> > we will examine is fairly typical.
> >
> > One immediate problem with public health care
> > is with the funding. Those usually attracted to
> > such a 'free' system are the poor and the
> > sick -- those least able to pay. A political
> > solution is to force everybody to enroll in the
> > system, which amounts to redistributing income
> > toward participants with higher health risks or
> > lower income. This is why the Canadian system
> > is universal and compulsory.
> >
> > Even if participation is compulsory in the sense
> > that everyone has to pay a health insurance
> > premium (through general or specific taxes),
> > some individuals are willing to pay a second
> > time to purchase private insurance and obtain
> > private care. If you want to avoid this double
> > system, you do as in Canada: You legislate a
> > monopoly for the public health insurance
> > system.
> >
> > This means that although complementary insurance
> > (providing private or semi-private hospital rooms,
> > ambulance services, etc.) is available on the
> > market, sale of private insurance covering the
> > basic insured services is forbidden by law. Even
> > if a Canadian wants to purchase basic private
> > insurance besides the public coverage, he cannot
> > find a private company legally allowed to satisfy
> > his demand.
> >
> > In this respect, the Canadian system is more
> > socialized than in many other countries. In the
> > United Kingdom, for instance, one can buy private
> > health insurance even if government insurance
> > is compulsory.
> >
> > In Canada, then, health care is basically a
> > socialized industry. In the Province of Quebec,
> > 79 percent of health expenditures are public.
> > Private health expenditures go mainly for medicines,
> > private or semiprivate hospital rooms, and dental
> > services. The question is: How does such a system
> > perform?
> >
> >
> > The Costs of Free Care
> >
> > The first thing to realize is that free public
> > medicine isn't really free. What the consumer
> > doesn't pay, the taxpayer does, and with a
> > vengeance. Public health expenditures in Quebec
> > amount to 29 percent of the provincial government
> > budget. One-fifth of the revenues comes from a
> > wage tax of 3.22 percent charged to employers
> > and the rest comes from general taxes at the
> > provincial and federal levels. It costs $1,200
> > per year in taxes for each Quebec citizen to
> > have access to the public health system. This
> > means that the average two-child family pays
> > close to $5,000 per year for public health
> > insurance. This is much more expensive than the
> > most comprehensive private health insurance
> > plan.
> >
> > Although participating doctors may not charge
> > more than the rates reimbursed directly to
> > them by the government, theoretically they may
> > opt out of the system. But because private
> > insurance for basic medical needs isn't
> > available, there are few customers, and less
> > than one percent of Quebec doctors work outside
> > the public health system. The drafting of
> > virtually all doctors into the public system
> > is the first major consequence of legally
> > forbidding private insurers from competing
> > with public health insurance.
> >
> > The second consequence is that a real private
> > hospital industry cannot develop. Without
> > insurance coverage, hospital care costs too
> > much for most people. In Quebec, there is
> > only one private for-profit hospital (an old
> > survivor from the time when the government
> > would issue a permit to that kind of
> > institution), but it has to work within the
> > public health insurance system and with
> > government-allocated budgets.
> >
> > The monopoly of basic health insurance has led
> > to a single, homogeneous public system of
> > health care delivery. In such a public
> > monopoly, bureaucratic uniformity and lack
> > of entrepreneurship add to the costs. The
> > system is slow to adjust to changing demands
> > and new technologies. FOr instance, day clinics
> > and home care are underdeveloped as there exist
> > basically only two types of general hospitals:
> > the nonprofit local hospital and the university
> > hospital.
> >
> >
> > When Prices Are Zero
> >
> > Aside from the problems inherent in all monopolies,
> > the fact that health services are free leads to
> > familiar economic consequences. Basic economics
> > tells us that if a commodity is offered at zero
> > price, demand will increase, supply will drop,
> > and a shortage will develop.
> >
> > During the first four years of hospitalization
> > insurance in Quebec, government expenditures on
> > this program doubled. Since the introduction of
> > comprehensive public health insurance in 1970,
> > public expenditures for medical services per
> > capita have grown at an annual rate of 9.4 percent.
> > According to one study, 60 percent of this increase
> > represented a real increase in consumption. [1]
> >
> > There has been much talk of people abusing the
> > system, such as using hospitals as nursing homes.
> > But then, on what basis can we talk of abusing
> > something that carries no price?
> >
> > As demand rises and expensive technology is
> > introduced, health costs soar. But with taxes
> > already at a breaking point, government has
> > little recourse but to try to hold down costs.
> > In Quebec, hospitals have been facing budget cuts
> > both in operating expenses and in capital
> > expenditures. Hospital equipment is often outdated,
> > and the number of general hospital beds dropped by
> > 21 percent from 1972 to 1980.
> >
> > Since labor is the main component of health costs,
> > incomes of health workers and professionals have
> > been brought under tight government controls. In
> > Quebec, professional fees and target incomes are
> > negotiated between doctors' associations and the
> > Department of Health and Social Services. Although
> > in theory most doctors still are independent
> > professionals, the government has put a ceiling
> > on certain categories of income: for instance,
> > any fees earned by a general practitioner in excess
> > of $164,108 (Canadian) a year are reimbursed at
> > a rate of only 25 percent.
> >
> > Not surprisingly, income controls have had a
> > negative impact on work incentives. From 1972 to
> > 1978, for instance, general practitioners reduced
> > by 11 percent the average time they spent with
> > their patients. In 1977, the first year of the
> > income ceiling, they reduced their average work
> > year by two-and-half weeks. [2]
> >
> > Government controls also have caused misallocations
> > of resources. While doctors are in short supply in
> > remote regions, hospital beds are scarce mainly in
> > urban centers. The gOVernment has reacted with
> > more controls: Young doctors are penalized if they
> > start their practice in an urban center. And the
> > president of the Professional Corporation of
> > Physicians has proposed drafting young medical
> > school graduates to work in remote regions for a
> > period of time.
> >
> > Nationalization of the health industry also has
> > led to increased centralization and politicization.
> > Work stoppages by nurses and hospital workers have
> > occurred half a dozen times over the last 20 years,
> > and this does not include a few one-day strikes by
> > doctors. Ambulance services and dispatching have
> > been centralized under government control. As this
> > article was being written, ambulance drivers and
> > paramedics were working in jeans, they had covered
> > their vehicles with protest stickers, and they were
> > dangerously disrupting operations. The reason: They
> > want the government to finish nationalizing what
> > remains under private control in their industry.
> >
> > When possible, doctors and nurses have voted with
> > their feet. A personal anecdote will illustrate
> > this. When my youngest son was bom in California
> > in 1978, the obstetrician was from Ontario and
> > the nurse came from Saskatchewan. The only
> > American-born in the delivery room was the
> > baby.
> >
> > When prices are zero, demand exceeds supply,
> > and queues form. For many Canadians, hospital
> > emergency rooms have become their primary
> > doctor -- as is the case with Medicaid patients
> > in the United States. Patients lie in temporary
> > beds in emergency rooms, sometimes for days. At
> > Sainté-Justine Hospital, a major Montreal
> > pediatric hospital, children often wait many
> > hours before they can see a doctor. Surgery
> > candidates face long waiting lists -- it can
> > take six months to have a cataract removed.
> > Heart surgeons report patients dying while on
> > their waiting lists. But then, it's free.
> >
> > Or is it? The busy executive, housewife, or
> > laborer has more productive things to do besides
> > waiting in a hospital queue. For these people,
> > waiting time carries a much higher cost than
> > it does to the unemployed single person. So,
> > if public health insurance reduces the costs of
> > health services for some of the poor, it increases
> > the costs for many other people. It discriminates
> > against the productive.
> >
> > The most visible consequence of socialized
> > medicine in Canada is in the poor quality of
> > services. Health care has become more and more
> > impersonal. Patients often feel they are on an
> > assembly line. Doctors and hospitals already have
> > more patients than they can handle and no
> > financial incentive to provide good service.
> > Their customers are not the ones who write the
> > checks anyway.
> >
> > No wonder, then, that medicine in Quebec
> > consumes only 9 percent of gross domestic
> > product (7 percent if we consider only public
> > expenditures) compared to some 11 percent in
> > the United States. This does not indicate that
> > health services are delivered efficiently at
> > low cost. It reflects the fact that prices and
> > remunerations in this industry are arbitrarily
> > fixed, that services are rationed, and that
> > individuals are forbidden to spend their
> > medical-care dollars as they wish.
> >
> >
> > Is It Just?
> >
> > Supporters of public health insurance reply that
> > for all its inefficiencies, their system at least
> > is more just. But even this isn't true.
> >
> > Their conception of justice is based on the
> > idea that certain goods like health (and
> > education? and food? where do you stop?)
> > should be made available to all through coercive
> > redistribution by the state. If, on the contrary,
> > we define justice in terms of liberty, then
> > justice forbids coercing some (taxpayers,
> > doctors, and nurses) into providing health
> > services to others. Providing voluntarily for
> > your neighbor in need may be morally good. Forcing
> > your neighbor to help you is morally wrong.
> >
> > Even if access to health services is a desirable
> > objective, it is by no means clear that a
> > socialized system is the answer. Without market
> > rationing, queues form. There are ways to jump
> > the queue, but they are not equally available
> > to everyone.
> >
> > In Quebec, you can be relatively sure not to
> > wait six hours with your sick child in an
> > emergency room if you know how to talk to the
> > hospital director, or if one of your old
> > classmates is a doctor, or if your children
> > attend the same exclusive private school as
> > your pediatrician's children. You may get good
> > services if you deal with a medical clinic in
> > the business district. And, of course, you
> > will get excellent services if you fly to
> > the Mayo Clinic in Minnesota or to some
> > private hospital in Europe. The point is
> > that these ways to jump the queue are pretty
> > expensive for the typical lower-middle-class
> > housewife, not to talk of the poor.
> >
> > An Enquiry Commission on Health and Social
> > Services submitted a thick report in December
> > 1987, after having met for 30 months and spent
> > many millions of dollars. It complains that
> > "important gaps persist in matters of health
> > and welfare among different groups." [3] Now,
> > isn't this statement quite incredible after
> > two decades of monopolistic socialized health
> > care? Doesn't it show that equalizing conditions
> > is an impossible task, at least when there is
> > some individual liberty left?
> >
> > One clear effect of a socialized health system
> > is to increase the cost of getting above-average
> > care (while the average is dropping). Some poor
> > people, in fact, may obtain better care under
> > socialized medicine. But many in the middle class
> > will lose. It isn't clear where justice is to be
> > found in such a redistribution.
> >
> > There are two ways to answer the question: "What
> > is the proper amount of medical care in different
> > cases?" We may let private initiative and voluntary
> > relations provide solutions. Or we may let politics
> > decide. Health care has to be rationed either by
> > the market or by political and bureaucratic
> > processes. The latter are no more just than the
> > former. We often forget that people who have
> > difficulty making money in the market are not
> > necessarily better at jumping queues in a socialized
> > system.
> >
> > There is no way to supply all medical services to
> > everybody, for the cost would be astronomical. What
> > do you do for a six-year-old Montreal gift with a
> > rare form of leukemia who can be cured only in a
> > Wisconsin hospital at a cost of $350,000  -- a real
> > case? Paradoxically for a socialized health system,
> > the family had to appeal to public charity, a more
> > and more common occurrence. In the first two months,
> > the family received more than $100,000 including a
> > single anonymous donation of $40,000.
> >
> > This is only one instance of health services that
> > could have been covered by private health insurance
> > but are being denied by hardpressed public insurance.
> > And the trend is getting worse. Imagine what will
> > happen as the population ages.
> >
> > There are private solutions to health costs. Insurance
> > is one. Even in 1964, when insurance mechanisms were
> > much less developed than today, 43 percent of the
> > Quebec population carried private health insurance,
> > and half of them had complete coverage. Today, most
> > Americans not covered by Medicare or Medicaid carry
> > some form of private health insurance. Private charity
> > is another solution, so efficient that it has not been
> > entirely replaced by the Canadian socialized system.
> >
> >
> > Can Trends Be Changed?
> >
> > People in Quebec have grown so accustomed to socialized
> > medicine that talks of privatization usually are limited
> > to subcontracting hospital laundry or cafeteria
> > services. The idea of subcontracting hospital
> > management as a whole is deemed radical (although
> > it is done on a limited scale elsewhere in Canada).
> > There have been suggestions of allowing health
> > maintenance organizations (HMOs) in Quebec, but the
> > model would be that of Ontario, where HMOs are totally
> > financed and controlled by the public health insurance
> > system. The government of Quebec has repeatedly come
> > out against for-profit HMOs.
> >
> > Socialized medicine has had a telling effect on the
> > public mind. In Quebec, 62 percent of the population
> > now think that people should pay nothing to see a
> > doctor; 82 percent want hospital care to remain free.
> > People have come to believe that it is normal for the
> > state to take care of their health.
> >
> > Opponents of private health care do not necessarily
> > quarrel with the efficiency of competition and private
> > enterprise. They morally oppose the idea that some
> > individuals may use money to purchase better health
> > care. They prefer that everybody has less, provided
> > it is equal. The Gazette, one of Montreal's English
> > newspapers, ran an editorial arguing that gearing
> > the quality of health care to the ability to pay
> > "is morally and socially unacceptable." [4]
> >
> > The idea that health care should be equally distributed
> > is part of a wider egalitarian culture. Health is seen
> > as one of the goods of life that need to be socialized.
> > The Quebec Enquiry Commission on Health and Social
> > Services was quite clear on this:
> >
> >     The Commission believes that the reduction of
> >     these inequalities and more generally the
> >     achievement of fairness in the fields of health
> >     and welfare must be one of the first goals of
> >     the system and direct all its interventions.
> >     It is clear that the health and social services
> >     system is  not the only one concerned. This concern
> >     applies as strongly to labor, the environment,
> >     education and income security. [5]
> >
> >
> > A Few Lessons
> >
> > Several lessons can be drawn from the Canadian
> > experience with socialized medicine.
> >
> > First of all, socialized medicine, although of poor
> > quality, is very expensive. Public health
> > expenditures consume close to 7 percent of the
> > Canadian gross domestic product, and account for
> > much of the difference between the levels of public
> > expenditure in Canada (47 percent of gross domestic
> > product) and in the U.S. (37 percent of gross
> > domestic product). So if you do not want a large
> > public sector, do not nationalize health.
> >
> > A second lesson is the danger of political compromise.
> > One social policy tends to lead to another. Take, for
> > example, the introduction of publicly funded hospital
> > insurance in Canada. It encouraged doctors to send
> > their patients to hospitals because it was cheaper
> > to be treated there. The political solution was to
> > nationalize the rest of the industry. Distortions
> > from one government intervention often lead to more
> > intervention.
> >
> > A third lesson deals with the impact of egalitarianism.
> > Socialized medicine is both a consequence and a great
> > contributor to the idea that economic conditions should
> > be equalized by coercion. If proponents of public health
> > insurance are not challenged on this ground, they will
> > win this war and many others. Showing that human
> > inequality is both unavoidable and, within the context
> > of equal formal rights, desirable, is a long-run project.
> > But then, as Saint-Exupery wrote, "Il est vain, si
> > l'on plante un chine, d'espérer s'abriter bientôt sous
> > Son feuillage." [6]
> >
> >    1. Report of the Enquiry Commission on Health
> >       and Social Services, Government of Quebec,
> >       1988, pp. 148, 339.
> >    2. Gerard Belanger, "Les depenses de sante par
> >       rapport a l'economie du Quebec," Le Medecin
> >       du Quebec, December 1981, p. 37.
> >    3. Report of the Enquiry Commission on Health
> >       and Social Services, p. 446 (our translation).
> >    4. "No Second Class Patients," editorial of The
> >        Gazette, May 21, 1988.
> >    5. Report of the Enquiry Commission on Health
> >       and Social Services, p. 446 (our translation).
> >    6. 'It is a vain hope, when planting an oak tree,
> >       to hope to soon take shelter under it."
> >
> >
> > Socialized Medicine
> > by Dan Smoot
> >
> > In 1884, Prince Otto von Bismarck, Chancellor
> > of Germany, instituted the first modern program
> > of socialized medicine. It was called compulsory
> > national health insurance.
> >
> > Bismarck hated Communism. His motive in
> > introducing socialized medicine in Germany was
> > to buy the loyalty of the German masses as a
> > means of keeping them from becoming Communists.
> > Bismarck adopted "nationalistic socialism to
> > end international socialism"--to use his own
> > words. To use other words: Bismarck was the
> > first leader of a great nation to fight
> > Communism by adopting Communism.
> >
> > The German citizens paid more for their national
> > compulsory health insurance than they had paid
> > for private insurance before Bismarck came
> > along -- and they got less in return.
> >
> > Bismarck's scheme failed miserably to provide better
> > medical care for the people of Germany; but it did
> > become an important feature of the German militaristic
> > state; it helped pave the way for Hitler a generation
> > later; and it furnished a pattern with which practically
> > every other nation in the West - -including
> > America -- has experienced.
> >
> >
> > British Experience
> >
> > England first started experimenting with socialized
> > medicine in 1911. The experiments were a failure, as
> > they always have been everywhere.
> >
> > But government never retrenches. When government seizes
> > power and money from the people in order to promote
> > their welfare and then makes matters worse for them,
> > government always argues that it didn't have enough
> > power and money to do enough promoting.
> >
> > In England, for example, when Lloyd George's rather
> > moderate experiment in the Bismarckian type of national
> > health insurance was abandoned, the nation went all
> > the way into communized medicine.
> >
> > The National Health Program which became the law of
> > England in July 1948 is modeled on the Soviet system
> > created by Lenin.
> >
> > In less than two years, there were more than half a
> > million people on the waiting lists for hospitalization,
> > while some 40,000 hospital beds were out of service
> > because of a nurse shortage. The hospital shortage
> > in Britain has become so acute that many mentally
> > deficient and helpless, aged people are unable to
> > secure institutional care, The only effective means
> > of easing the shortage is to deny hospital admission
> > to the old and chronically ill who cannot be
> > discharged once they are admitted.
> >
> > In industrial centers, some British doctors have as
> > many as 4,000 registered patients each. Such doctors
> > can give each patient only three minutes per
> > call -- three minutes overall, for consultation,
> > diagnosis, prescription, filling out official forms,
> > and maintaining proper records for governmental
> > inspectors.
> >
> > Twelve percent of all British taxes go into the
> > national health program. Thus the wretchedly inadequate
> > 'free' medical services in Britain actually cost the
> > average Englishman considerably more than an American
> > pays for the most expensive private health insurance
> > and hospitalization plan.
> >
> > Over and above what the British themselves have put
> > into socialized medicine, one must consider also the
> > billions of dollars which America has pumped into the
> > British economy as loans and outright gifts. And
> > still the thing is a failure. Why?
> >
> > Whenever government enters a field of private activity,
> > that field becomes a political battleground. Whenever
> > you mix politics with medicine, doctoring becomes a
> > political instead of a medical activity.
> >
> >
> > "Something for Nothing"
> >
> > But the primary reasons for the inevitable failure of
> > socialized medicine can be found in the patients
> > themselves. When people are forced to pay for something,
> > whether they want it or not, they are inclined to use
> > as much of it as they can in an effort to get their
> > money's worth.
> >
> > There are endless stories about Englishmen who trade
> > their government-issued eyeglasses, wigs, and even
> > false teeth, for beer. There are housewives who trade
> > government-issued medicine for perfume and cigarettes.
> > And there are some who pick up extra money by selling
> > the gold fillings out of their teeth -- getting them
> > replaced by government dentists and then selling them
> > again.
> >
> > Malingerers are people who pretend to be sick in order
> > to get sick-pay, Social Security benefits, free
> > hospitalization, or a rest at government expense.
> > Hypochondriacs are people who think they are sick,
> > but aren't. There are countless thousands of such
> > people. No system has even been devised for definitely
> > identifying them, for weeding out the unnecessary or
> > unreasonable or dishonest demands made upon the medical
> > care services -- no system, that is, except the one
> > existing in a free society where a person must pay his
> > own doctor bill or is controlled by provisions of an
> > insurance policy which he himself has bought.
> >
> > No compulsory health insurance program has found a
> > means to discourage racketeers or petty complainers
> > who make useless trips to the doctor and monopolize
> > professional time that should be spent on people
> > really needing care.
> >
> > _____________________________________________
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