> 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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