In my experience, there are a number of go-to arguments that conservatives employ for their reasons why we can’t or shouldn’t have a universal health care system. The underlying principles can vary, but their resolve is steadfast. It’s almost as if there is this knee-jerk reaction to resist any hint towards the idea that foreign countries may do something—anything—better than these UNITED STATES OF AMERICA (cue Star-Spangled Banner and an F-22 flyover). Some of them are the very arguments I would reach for before I started to support universal health care. The more common arguments typically sound something like the following which I’ll address individually:
- More taxes
- I don’t want socialism
- Those countries have worse care
- I don’t want government to ration care or control my doctor
- Those countries are smaller / different demographics
- We’re less healthy / fatter / drink more / smoke more
- Malpractice insurance
- Government can't even do X right, why should we trust them with health care?
By far one of the most common arguments is that those countries pay more taxes. But if you look at the chart of health care expenditures per capita in the last post, this argument does not have any validity. No matter the structure of how those countries fund their health care system, it means more money in the pockets of individuals and/or businesses.
Let’s use the Dutch model which costs about $5,400 per capita and compare it to the US (we’ll round down to $10,000). For simplicity, we’ll use an example of a group insurance plan offered by a private sector employer with the only cost being an annual premium at the United States' per capita rate. Maybe the employer pays $8000 and the employee pays $2000. The government doesn’t subsidize any of it—there are zero taxes for it. The total is simply $10,000 paid directly to the insurance company in the form of a premium.
Now in the Dutch model, by law their premiums are the same for every adult—about $120 per month ($1,440 per year). Again for simplicity, we’ll say the remaining amount is subsidized by the government ($3,960). Now that amount needs to be taxed. Let’s say this tax is entirely paid by the employer. In this scenario, the employer is paying the government $3,960 rather than paying an insurance company $8,000 and the Dutch employee is paying $1,440 rather than the US employee's $2,000 premium.
I don’t know about you, but I’d much rather have $560 more in my pocket and I’m sure my employer would love having over $4,000 more per employee in their pocket! Obviously these exact figures are hypothetical, but the underlying principle is there. No matter how you slice it, from a fiscal perspective the Dutch model is without a doubt a better deal. The tax argument is a moot point because, as it is, we will always be paying more in the US. That might come directly out of our pockets, the bottom line of a business, or via various methods of taxation. The end result is simply that we pay more.
I Don't Want Socialism
As for the “socialism” argument, I think it’s just a ridiculous fear tactic used to illicit some type of negative emotion that’s usually coupled with references to countries like Venezuela or Cuba. Hold on sparky—let’s stick with developed countries. First, the closest any of the mentioned systems come to “socialism” is the NHS of the UK, but even then government doesn’t have a complete ownership of the health care industry. Most of the other countries have systems where most of their providers are private and many have private health insurers and hospitals.
Second, so what? Health care is such a core necessity to a civilized society. We don’t complain about the “socialism” we employ via firefighters, law enforcement, the military, space exploration or a whole host of other services. And quite frankly—and maybe it’s just my generation—but I look around to other developed nations and the picture doesn’t look too bad.
More so, something like health insurance doesn't even really fit the definition of socialism, which is the public ownership of the means of production. What are the means of production? The factories, tools, machinery, or other facilities used to create goods and services. Financial and human capital are not considered the means of production. And what is insurance? It's simply a funding mechanism to distribute financial risk throughout a population. For-profit insurance companies do nothing to provide additional economic value. They are what's called rent-seeking entities—they extract wealth from individuals without creating net positive wealth. When you think about it, insurance companies add additional layers of complexity and inefficiencies when ultimately their only purpose is to pool financial resources from many individuals to pay for health care expenditures.
Besides, let's be honest. A good portion of Republicans, conservatives and others who oppose a universal health care system love themselves "government run health care". Start talking about cutting Medicare and pitchforks come out. Additionally, public payers of health care expenditures are ranked the highest when Americans are polled on their satisfaction of their health insurance. The VA and Medicare top the list, then Medicaid, then Union provided insurance, employer-sponsored insurance, individual insurance, and then lastly (duh), no insurance.
The typically retort to this is that beneficiaries of Medicare have paid in to the system and therefore it's not "socialism". Except, the amount of benefits that Medicare patients receive can be up to three times more than what they've paid in to the system throughout their lives. This isn't surprising, since the demographic of Medicare recipients are the most likely to need expensive care given their age. Hate to break it to you, but it's quintessential redistribution of wealth.
Worse Care In Other Countries
Another argument is that the other countries provide worse care: their wait times are worse, their quality of care is worse, they come here for care, etc. Before we get into any specifics, let’s say this were true. Since most of the countries spend less than half the amount we do on their systems and they cover everyone, it would be reasonable to extend the argument to say that they should be twice as bad as the US. Who pays twice as much for something without the expectation that it provides double the value?
The reality is that this isn’t close to being true. Let’s start with wait times. I absolutely concede that there are countries that have worse wait times than the US for elective care. Atrocious wait times, even. Canada is one example of this. Keep in mind, though, that this does not typically apply to primary care, but to specialized, elective care. If you need essential care, you are going to get it.
However, there are some countries like Germany, the Netherlands, and Switzerland that have similar or better wait times for such care than the United States. Let's dig into some data that addresses multiple facets of wait times and barriers to care. We're going to take a look at responses to the Commonwealth Fund's 2016 International Health Policy Survey.
Here is how long people waited to get an appointment to see a doctor or nurse when they needed medical attention:
|Country||Did not need to make an appointment to see doctor or nurse (%)||On the same day (%)||The next day (%)||In 2 to 5 days (%)||In 6 to 7 days (%)||In 8 to 14 days (%)||After more than 2 weeks (%)||Never able to get an appointment (%)|
As you can see, when it comes to no appointment required or the same day, Australia, Netherlands, New Zealand, Sweden and the UK all perform better. When you include the next day, Switzerland, Norway and France also perform similarly or better. Basically, the US is in the middle of the pack. We pay double the rest of these countries to achieve median wait time for seeing a doctor.
Now, let's look at the ease of getting medical care in the evenings, on weekends or holidays.
|Country||Very easy (%)||Somewhat easy (%)||Somewhat difficult (%)||Very difficult (%)||Never needed care in the evenings, on weekends or on holidays (%)||Not sure (%)|
Once again, we see that the US is in the middle of the pack of those who say it's somewhat or very easy to get medicare care on evenings, weekends or holidays.
Next, let's look at how long people waited in the emergency room:
|Country||Never treated/left without being treated (%)||<1 hour (%)||1 hour to <4 hours (%)||4 or more hours (%)||Not sure/decline to answer (%)|
Once again, we're the median. I'm really starting to sense a pattern here.
Now, let's look at how long—after being advised that surgery was needed—people waited for non-emergency or elective surgery:
|Country||<1 month (%)||1 to <4 months (%)||4 or more months (%)||Not sure/decline to answer (%)|
The US leads the pack for waiting less than a month, although Switzerland and Australia are right on our heels. When looking at four months or less, France and Germany edge out the US with Switzerland, Netherlands and Australia following closely.
Next, we're going to look at how long it takes to get an appointment with a specialist:
|Country||<4 weeks (%)||At least 4 weeks (%)||Don’t know/decline to answer (%)|
Switzerland performs the best, with Germany coming in 2nd and the US in third. Netherlands and France aren't too far behind, either.
So, as we can see, it's not true that the US has the best results when it comes to wait times. Additionally, we can't just look at wait times to measure how readily care is available. We also have to look at accessibility in terms of cost barriers and how that affects people's decisions to seek care. Here's how people answered when asked if in the last 12 months, they needed to seek medical care but didn't because of the cost:
|Country||Yes (%)||No (%)||Not applicable (%)||Not sure (%)||Decline to answer/blank (%)|
Holy crap. Over 21% of Americans who had a medical problem in the past 12 months did not visit a doctor because of the cost. This is over THREE TIMES the median. We don't even have the best wait times, but who the hell cares about wait times when you don't even bother to get care because it'll cost too much? This is absolutely damning. But it's not just visiting a doctor. Here's the results for people who didn't get a medical test, treatment or follow-up that was recommended by a doctor because of the cost:
|Country||Yes (%)||No (%)||Not applicable (%)||Not sure (%)||Decline to answer/blank (%)|
Once again, we are the worst performing country and this time we're almost four times worse than the median. It doesn't stop there. Of those who didn't fill a prescription or had to skip doses of their medicine due to cost, the US is the worst at 17.7% compared to a median of 5.7%. Of those who skipped dental care or checkups because of the cost, the US is the worst at 32.5% compared to the median of 20.9%. The only other country where more people said they had serious problems paying their medical bills was France, coming in at 23% compared to the US's 19.5% (of the people who could actually get care in the first place) and the median of 6.4%. Only 1.4% of people in the UK said they had serious problems paying their bills.
When it comes to quality of care, we have one of the highest infant mortality rates, lowest life expectancies at age 60, and highest mortality rates amenable to health care. We literally have the worst maternal mortality rate in the developed world. While the maternal mortality rate is decreasing in all other developed nations, we are unique in that ours is on the rise. Our mothers are dying at a rate almost five times greater than the median of other developed nations. Our system is failing them.
One area I knew we'd be better is one that hits pretty close to home—cancer. One of my brothers first battled non-Hodgkins lymphoma when he was 19 and then again when he was 21. My dad was diagnosed with prostate cancer at the end of 2010. It seems that everyone—whether personally or with someone close in their life—has experienced the indiscriminate, cold touch of cancer. It has no mercy and it gives zero f***s. I [redacted] hate cancer. But, I have to be honest. Going in to this, my biases started to seep through. At first I didn't want to talk about this subject as if pointing out a positive in our system would somehow hurt my argument. The more I thought about it, the more I was convinced I had to point out how my dad and my brother benefited greatly.
Living in Houston, TX, I can proudly say we are home to the number one ranked cancer hospital in the United States—MD Anderson. MD Anderson has been ranked as one of the top two cancer hospitals since the U.S. News & World Report started taking the survey in 1990. Both my brother and my dad received treatment at MD Anderson. I will always be thankful that they were able to have access and receive their treatment at a world class facility. I know many others who have been blessed by the care they've received there and they'd feel the same way.
The cold hard truth is that not every hospital is a top rated cancer center. Despite my initial instincts, the United States does not lead the pack in terms of cancer survival rates. As I dug into the data, I came to realize that even in this area we lag behind other nations. The gold standard when it comes to research on cancer survival rates is the CONCORD Programme. It is endorsed by over 40 national and international agencies and its studies have spanned multiple decades. The latest study is the CONCORD-3 that covered 5-year survival rates over 18 cancer and cancer groups (what they call "index cancers") that represent over 75% of all worldwide cancer cases from 2000-2014. This study covers almost 40 million patients across 71 countries. I did a deep dive into the data from this study and the findings were not what I expected.
Before I delved into the CONCORD-3 data, I thought it was going to just reinforce my preconceived notions—the United States was indisputably the best when it came to cancer survival outcomes. However, when looking at the outcomes, this was sadly not the truth despite us paying over twice as much per capita as other developed nations. I narrowed my analysis to OECD countries and when looking at the rankings for all 18 index cancers, we average 9th place. The only two cancers where we rank #1 are breast cancer and prostate cancer. Even then, at 90.2%, our net 5-year survival rate for breast cancer is only 0.7 percentage points above Australia's 89.5%. Our prostate cancer survival rate of 97.4% is only 1.8 percentage points above Israel's 95.6%. The next 10 countries after the US average a 5-year survival rate for prostate cancer of 93.5%.
Furthermore, we are only ranked in the top 5 for 6 of the 18 index cancers. Out of all childhood cancers, we rank 13th. When weighted by the prevalence of the index cancers, we have an overall net 5-year survival rate of 61.2%. This puts us in fourth place behind Japan, Israel and Australia. Canada—a country that conservatives love to use as a whipping boy when it comes to cherry-picked wait time stats—is less than 1 percentage point behind us. These other four countries achieve these results with a per capita spending of $4,717, $2,833, $4,543, and $4,826 respectively. Again, we spend over $10,500 per capita. According to so many outcome metrics, we are not even close to being the best. This is disgraceful. How is this acceptable?
Don't get me wrong, I am thankful that we are #1 when it comes to prostate cancer survivorship. That has had a very real impact in my life with my dad being cancer free for 7 years now. But what good is top-tier, world-class cancer treatment to the many Americans who do not have access? How proud can we be of a system that benefits the privileged among us but leaves the marginalized behind? According to the American Cancer Society, cancer death rates among the poorest counties were 40-100% higher compared with the richest counties. A few of the key factors in this disparity are "lower rates of routine cancer screening, later stage at diagnosis, and a lower likelihood of getting the best treatment."
Following up on that disparity, perhaps the biggest counter-argument to other countries providing worse care is the fact that about 8.8% of our population doesn’t have health care coverage. This simply can't be ignored. You can't get much worse in terms of quality of care than having no care. That plays a significant role in affecting health care outcomes because when someone doesn’t have health care coverage, they are less inclined to seek out preventative measures or treatment when symptoms aren’t as severe. This results in seeking emergency care once symptoms are much worse which in turn develops into higher mortality and higher costs. Depending on the study, the number of people that are uninsured results in an increase of between 20,000 and 40,000 extra deaths each year. Ultimately, we’re paying more than twice, and sometimes three times, as much as other developed nations and our outcomes simply don’t justify that cost.
Government Will Ration Care
The argument that the government will ration care or control doctors is just another one of those scare tactics along the same lines as the “socialism” argument. First, the cold hard truth is that resources are finite. There are not an unlimited numbers of doctors, hospital beds, nurses, etc. Resources have to be allocated in some type of manner and that means we don’t all get the #1 doctor in the field or a procedure we elect for the instant we want it.
Ideally, I would prefer that the health care professionals make those decisions. I think this is more likely in the systems of other countries than in our system where much of the time the ultimate decision maker is some business person in a suit at an insurance company whose top priority is their fiduciary duty to their shareholders (i.e. making butt loads of profit for their investors). It is arguably in the best interest of an insurance company to deny as many claims as they can because that has one of the most direct effects on their net income. Of all the reasons why health care could be denied, I’d rather profit from rent-seeking insurance companies not be one of those. In the end, given the aggregate outcomes described previously, the idea that we’d have worse results due to government rationing simply doesn’t play out.
So, if we want to talk about death panels, let's actually look at the bigger threats that result in people not getting the care that they need. The risk of an American not getting the care they need is so much more likely to be due to cost than it is because some governmental agency decides they don't get care. Every day, people in our country decide to forego health care treatment either because they decide the cost is too high or because a health insurance company denies their claim. Whether it's a situation where a person chooses to skip an insulin injection or they are one of the tens of thousands who prematurely die each year because they don't have access to care, these people are facing the "death panel" that is the "free market." It's one thing to read some statistics about how costs negatively affect people's health care needs, but let's take a look at some personal examples to really bring it home:
There are countless stories like these. Everyone needs to take the gut punch and spend 10 minutes reading through some of those replies. If the data I've been providing doesn't speak to your head, let those responses speak to your heart.
Can't Compare US To Smaller Countries
Another argument that I tend to hear a lot is that all of those other countries are so small! Sure, Norway with its 5 million citizens or Netherlands with its 17 million doesn’t compare to our 325 million. There’s just no way those systems would scale to our size! My immediate question is simply—why not? Assuming the premise is true, at what population size do health care expenditures start to rise? Do they rise linearly? Would we see a trend of increasing health care costs if we look at nations with larger and larger populations? Let’s test this premise:
|Country||Population (in millions)||$/capita|
So, we can go from Norway to Netherlands to Canada to UK to Japan and what do we see? It’s actually the opposite of the conservative argument. As the size of the country increases, the cost of their health care decreases. In fact, out of all of the countries listed, the UK with the system that has the most government control is actually the cheapest. It’s not until we get to the United States that the trend completely goes out the window.
If an increase in population doesn’t result in higher costs, perhaps it’s some type of demographic difference. Generally speaking, we are definitely a more diverse population than most or all European countries. But again, I ask why that would result in higher costs? Are there a significant number of increased medical needs that come about from a more diverse population? I’ve never really heard a good argument for this assertion and I’m going to resist assuming malice in the potential undertones that come with such a claim.
The US Is Unhealthier
Maybe our system is much more expensive because we’re simply an unhealthier population. Perhaps we drink more, we’re more obese, and we smoke more. Let’s look at alcohol consumption by country:
Ok, so almost 2/3 of the countries in that list drink more than the United States, so that can’t be it.
Let’s look at smoking rates by country:
|Country||Rate of Tobacco Use|
|United Kingdom of Great Britain and Northern Ireland||19.15|
Almost 3/4 of the countries in that list smoke more than the United States. That can’t be it.
|United Kingdom of Great Britain and Northern Ireland||27.8|
Ah, so now we might be on to something. The United States is the most obese developed nation in the world with the median country being 38% less obese than us. We could estimate how much this factors in to our inflated health care costs by finding out what we pay on obesity related health care costs and then subtracting out that 38% difference. The CDC estimates this cost to be $147 billion in 2008 dollars. The highest estimate I could find was from a Cornell University study that put it at $342 billion. By contrast, if we reduced this by the difference in the median obesity rate, it would be a total cost of $212 billion. That’s a per capita reduction of about $400 which would bring our total per capita health care expenditures to about $10,180. I think it’s safe to conclude that our increased obesity rates, while contributing a significant cost, is not a primary factor when determining why other countries are able to spend so much less than us.
Malpractice Lawsuits Are Costly
A common reason that some raise for our higher costs is medical liability and malpractice suits. A Harvard study in 2010 showed the total medical liability costs, which included both malpractice costs and the cost of defensive medicine, to be about $55.6 billion. Let’s say we were able to eliminate all of that (we can't). That would reduce our per capita spending by about $170. Combined with our reduction in obesity related spending, we’re now at $10,010. We could be a bunch of non-litigious vegans and we would still be paying more than twice as much as most other developed nations.
Government Can't Do Anything Right
Last, but certainly not least, my personal pet peeve argument: government can't do anything right. You've heard it before: "Look at how the VA is run! You really want the government running the entire health care system?" Or "The government can't even run the Post Office well, why would we put them in charge of health care?" Let's examine these types of assertions, starting with the VA.
Let's look at the scope of the wait-list scandal that came out in 2014. First, while the faking of wait-list data was unacceptable, it did not lead to widespread deaths. It was particularly an issue with the Phoenix VA and possibly the Los Angeles VA. The IG report into the Phoenix VA found that 6 patients died due to "clinically significant delays in care associated with access to care or patient scheduling." The report into the LA VA found that two patients who experienced delayed consults died. The first patient was a 70-year old man with history of heart disease and "a timely consultation by a CT surgeon would not likely have prevented his death because he was receiving appropriate care from the cardiologist." The report concluded that the second patient in his late 60's had "severe multi-organ disease" and "a history of poor attendance at his cardiology appointments, including a 'no show' to a heart failure consultation in month 9."
So, we have 8 verified deaths due to the malfeasance of VA personnel. Our veterans deserve the best care of the world and this is unacceptable. However, we shouldn't blow it out of proportion. The VA serves over 9 million veterans and is rated the highest among all insurance types. A report from Rand Corp says that the "VA health care system performs similar to or better than non-VA systems on most measures of inpatient and outpatient care quality". Additionally, a study from January 2019 concludes that "VA wait times have improved between FY2014 and FY2017 and that VA facilities have shorter wait times than the [private sector] across a range of specialties." Finally, a 2018 Dartmouth study found that “Veterans Health Administration hospitals outperform non–Veterans Health Administration hospitals in most health care markets.”
If you are so outraged by these incidents at the VA, surely you're even more incensed about the worse results in the private insurance market. After all, due to our numbers of uninsured, tens of thousands of people die prematurely a year due to lack of care. Due to our costs, thousands do not seek care, do not take their medication or have to ration it. Hundreds of thousands of people go bankrupt a year due to medical bills. If you are outraged by the VA scandal but defend our private system, then I think it's time you re-assess your motives and base assumptions.
Now to address the broader assertion that government can't do anything right. As Reagan succinctly put it, "the government is not the solution to the problem. The government is the problem." It's all the rage to point to scandals like the VA or rag on the Post Office and then take very narrow criticisms and paint all of government with a broad brush as a failure. Take the Post Office for example. You can send a standard letter to anywhere in the United States for $0.55. Can UPS do that? Can FedEx? No. They don't even deliver to every single address in the US. In fact, the USPS delivers about a third of UPS and FedEx's final destination packages. At 6.2 billion packages, the USPS delivers more packages annually than either UPS's 5.1 billion or FedEx's 5.2 billion. This isn't even counting the USPS's 146 billion individual mail pieces. And it does all of this without using any tax dollars. All of its operations are paid for by postage fees. But the government can't do anything right.
Then there's NASA and all of the amazing accomplishments it has achieved. An entire series of posts could be dedicated just to illustrate that. We went to the freaking moon with computing power a fraction of what's on my wrist right now. We could point to efforts like the Manhattan Project, or programs that led to the invention of computers or the internet. What about the transcontinental railroad or the Federal Highway System and the economic boon those created thanks to the Federal government making it possible. There's the insane success of Social Security keeping tens of millions of people out of poverty. But the government can't do anything right.
I could go on and on about how government does a lot of amazing things that makes our lives better. Much of the time, it's very mundane, behind-the-scenes that we're not expressly aware of. Do I think it's the solution to every problem? No. But it's definitely the solution to some very big problems. It's the solution when markets can't or won't be the answer. It isn't without its warts, but what isn't? Being imperfect isn't a valid reason to conclude that it's incapable. When evaluating many of the facts I present regarding our for-profit, rent-seeking insurance system, it's a little tone deaf to prop up the Post Office as an argument that the government shouldn't run health care when people are needlessly dying because of aspects of our private healthcare model. Let's cast off this Big Lie that government can't do anything right and work to produce the best government we can.
This list of arguments against universal health care is by no means exhaustive. I’m sure there are many other arguments people use to defend why we shouldn’t or are unable to move to a universal health care system. If I missed any reasons that any of you personally object to a UHC system, please let me know. I’d love to hear you out. At the same time, I implore you to take in to consideration what other nations spend on their health care. It doesn’t even come close to what we spend and they cover everyone. After that, ask yourself, do our aggregate outcomes come anywhere near being twice as good as those nations? Even 25% better? No. In some cases, we have even worse outcomes—certainly when it comes to lack of coverage and medical bankruptcies. So, can we do better? I believe we can and I’ll try to make that case in the final post of this series. But, before that, I want to talk about the free market. In my next post, I'll talk about why properties of medicare care don't make it conducive to typical free market principles.