Socialized Medicine: Utopia or Dystopia?

Rep. Utt (R-CA) said this about Medicare in 1965.

First, what is it?  That's right, do you know what socialized medicine is?

A better question, perhaps, is what people mean when they use the phrase.  The simplest definition is a system of health care for all paid for with public funds.  Providers (which means doctors, hospitals, and everyone else who renders health care to patients within the system) provide the care, and it is paid for with money that comes from taxes.  In its pure form, then, there is no health insurance, there are no bills, and there are no deductibles or copays.  You, as a human being in need of health care, consult me, a physician; I take care of you; no money changes hands; the government pays me, using public dollars (tax revenues) for what I do.

There is a lot more information on what people use, and have used, this term to mean, including complete control by the state (meaning the government) of the health care system.  Depending on how you view the government - is it competent, reliable, trustworthy? - the thought of a government-run health care system may hold more or less (maybe even zero) appeal for you.  But in its most basic sense, the essence of what I'm writing about here is public financing of health care, which can occur within but does not require a health care system that is operated by the government.  So, for example, the Medicare and Medicaid systems are financed with public dollars, and the Veterans Health Administration is operated by the government.  Right there you can see how a broad spectrum of opinion might be generated on the idea of the government doing things.  The VA has its admirers and critics - recently mostly critics, because of failings in looking after the health care needs of veterans, and Medicaid has more critics than there are crystals of salt in the ocean, it seems, while Medicare gets pretty high satisfaction ratings from seniors.

The USA is, in many ways, fundamentally opposed philosophically to the very idea of socialism, because it seems to require Big Government.  Most (but certainly not all) of our Founding Fathers were mistrustful of the idea of a powerful central government.  During the 19th Century there was vigorous public debate over whether the government should be involved in, and spend public dollars on, "internal improvements" such as roads and canals.  After the development of an Interstate Highway System in the 1950s it may seem odd to us that in the first half of the 19th Century many were opposed to giving this sort of power to the federal government, and foremost among the opponents, perhaps, was President Andrew Jackson.  Some of my readers may recall that Jackson was also the last president during whose administration the national debt was paid off, so support for or opposition to public spending has obvious potential implications.

Aside from basic mistrust of Big Government by some, there is concern about Big Waste by the feds.  After all, can we trust public financing of health care by the same government that paid $600 for a hammer?  (By the way, the $600 hammer is a myth.)  Well, Medicare is, by any measure, less wasteful than just about any private health insurance enterprise, in that it spends a higher proportion of every dollar on health care, with less going toward administration and zero going to profit.  The role, or lack thereof, of profit in the health care system and the way we finance it is an important part of the consideration of "socialized medicine."  That could be the subject of a very lengthy essay all by itself, but if you believe the profit motive is bad in this context, I submit that socialized medicine is the only way to eliminate it.

Physician satisfaction with Medicare is another matter altogether, and many doctors are opposed to socialized medicine largely because of their frustrations with Medicare.  Medicare, they believe, pays too little for their services and requires them to do a great deal of useless clerical work to collect what they do get.  Ironically, that should be part of the attraction - not the repulsion - of socialized medicine.  Medicare irritates me as much as it does any other doctor, mostly because I'm a pretty irritable fellow (also known as a crank).  But if we have a system in which all health care is financed with public dollars, the reasons for most of what Medicare does that annoys doctors could (and should) disappear.  In the system I envision, I could be paid for taking care of patients in a way that wouldn't require me to provide documentation of everything that was done or doing all sorts of clerical work (or paying others to do all that) to submit claims to an administrator.  I could go back to putting information about my caring for the patient in the medical record for its original purpose: communicating with other people who are also caring for that patient or who will in the future.

Now wait a minute, I can hear my physician readers saying.  The only way that could happen would be if I become a government employee.  That isn't necessarily so, but it does require a system in which money is allocated for the health care of the general public and is paid to the providers of that health care without being based explicitly on the exact services provided.  That doesn't require that doctors be government employees, although that is one approach. What it does require is a fundamentally different approach to financing health care from what we have now.

Doctors aren't necessarily the only ones leery of physicians being employed by the government.  Many of us like to quote, derisively, the imaginary expression, "I'm from the government and I'm here to help you," as if those two things couldn't possibly go together, and anyone who says such a thing should be viewed with a mixture of amusement and paranoia.

But we don't have a problem with firefighters being government employees.  Or the Coast Guard.  Or air traffic controllers.  Or any number of other people we trust with our lives.  So we certainly shouldn't assume that doctors who are government employees would be in any way inferior.  The patients in the VA system do not, as a rule, have a problem with the quality of the doctors but with the system that lacks the capacity to care for them.  As a nation we recognize that shortfall, and we are demanding it be remedied.  If we had a system for everyone that had inadequate capacity, how quickly do you think we would demand - and get - action to remedy that?

Many who deride socialized medicine look to the United Kingdom's National Health Service and say people wait weeks or months for elective surgery, and Americans won't tolerate that.  Three things you should know about that.  First, Americans with no health insurance don't wait weeks or months for elective surgery.  They wait forever.  And that is unacceptable in the wealthiest nation in the history of the world.

Second, the satisfaction of the Brits with the NHS is higher than our satisfaction with our non-system, regardless of any of the (exaggerated) claims about their waits for elective surgery.  Third, per capita spending on health care in the UK is half what it is in the US.  I am entirely unwilling to believe we couldn't create a system that covers everyone with what we're spending, with high quality and no long waits for anything.

[What we have now, instead, covers 85% of our population, many with woefully inadequate health insurance that has ridiculously high copays and deductibles, and leaves 15% (perhaps a bit less now with expansion of Medicaid under "Obamacare") with nothing.]

If you think we can't do that, I must ask you why.

There are two possible answers that come immediately to mind.  The first is that we are a lot dumber than the Brits, and although that is possible, I don't think so. The second is that we cannot do that without eliminating all of the waste associated with having a for-profit health insurance industry, in which many dollars intended to be spent on health care are, instead, spent on administration (twice what the government spends for Medicare administration), and profit, and seven-figure executive salaries.  If you guessed that the second possibility may really be a big part of the problem, go to the head of the class.

I must now ask you to consider a simple question.  If you work for a living and have employment-based health insurance, it's called a benefit of employment. That means you worked for it.  You earned it.  And every dollar that you earned that is spent on health insurance premiums is, in principle, a dollar that should be spent on health care.  Looked at the other way, every such dollar that is not spent on health care is a dollar wasted.  So, every dollar that a health insurance company diverts to profit, to eye-popping executive salaries, and to excessive administrative costs is a dollar wasted.  Looked at even less charitably, every such dollar spent on those other things is a dollar stolen from you.

The solution?  Eliminate the health insurance industry.  If we do that, we must have a new way to finance health care.  What would that be?  Re-read the first two paragraphs.  And now you know the answer to the question posed in the title of this essay.  Utopia or dystopia?  Neither.  It is, plainly and simply, what we must seriously consider if we hope to have a system for financing and providing health care that works for everyone, rather than the absurdly fragmented and wasteful non-system we have now.

Feel the Bern

Many of you who have been victims of Facebook's facilitation of my political proselytizing are now keenly aware of my support for the candidacy of Vermont Senator Bernie Sanders for president.

What follows are a few thoughts I shared with another FB poster, someone I don't know and have never met and likely never will.

To offer context, much of it is rooted in comparison with Hillary Rodham Clinton.

My correspondent thinks Hillary has a more refined understanding of foreign policy issues than anyone else in the race.

It is possible to have the most refined understanding and still be wrong.  I think my understanding of the Levant (an almost forgotten term resurrected by John Kerry) is more "refined" than that of most Americans, and I thought the invasion of Iraq might actually accomplish something useful.  I thought the long-term outcome could be a stable democracy in Iraq that would help the entire region move forward toward peace and security.

I was, I now believe, flat wrong.

I'm not sure we know what Hillary thought about it over the last dozen years, or even what she truly believes now.

Sanders, on the other hand, thought it was a mistake even when Iraq was still called Mesopotamia, and he has (wisely) seen no reason to change his mind.

I like a man who chooses positions on issues wisely.  Is he a foreign policy geek?  Perhaps not.  Can he be trusted to make sound foreign policy decisions, faced with an array of complex options?  I believe so.

Then I was reminded of the undeniable advantage of the experience of having served as secretary of state when a foreign policy crisis arises.  So here we are at the campaign commercial about the 3 AM phone call again, only then (2008) Hillary's experience didn't yet include service as a member of the cabinet.

There were plenty of people who thought the peanut farmer from Georgia would be clueless about foreign policy, and many people still blame him for some of the mess that developed in Iran with the overthrow of the Shah.  But that was only the first draft of history, and he is now getting credit for the lack of US involvement in war during those years, so perspective is an ever-changing thing.

My partner in this discourse then wondered "what this wonderfully principled man (Sanders) would be able to accomplish with a Congress full of loons."

I like a man who can be described as "wonderfully principled," I think he can get elected if people will step out of their echo chambers, or take their fingers out of their ears and stop saying "LA-LA-LA-LA" and just listen, and I think a Congress full of loons can be bent to the will of a president who gets the people behind him.

Were you listening when Sanders reminded us that the Walton (Walmart) family has more wealth than the "bottom" 140 million Americans?  What about when he talked about how it is unconscionable that the average American college graduate has to work many years to be free of the burden of educational debt? (So, don't go to college?  Not everyone is cut out to be a plumber or an electrician.)  Were you plugging your ears, because you have a job with health insurance as a benefit - although you have to pick up the lance and the shield to get them to pay for stuff - when Bernie called us out as the only First World nation without universal access to health care and a rational mechanism for funding it?

Perhaps inevitable is the skepticism about whether Sanders could accomplish much of anything as president, given the dominance of the Republican obstructionists in Congress.  Seriously, have you been paying attention to the monkey-wrench-in-the-works approach of the House Freedom Caucus, that group of 40-odd far-right congressmen prepared to shut down government to prevent continued funding for Planned Parenthood, settling instead for the resignation of John Boehner as speaker?

Well, the same question could be asked about any Democrat, although one might imagine Hillary learned something from Bill's experience in working with Newt Gingrich.  But this is not 1994.  It's far worse.  And my correspondent noted that the current occupant of the Oval Office campaigned on a theme of change and has been stymied more often than not.

That is a fair point.  But Obama disappointed me by putting his oratorical skills on the shelf after he won the election in '08 instead of using them to shape public opinion and get the people to turn the flames up high under the derrieres of Members of Congress.

No, instead he chose to try to work with a Congress that is controlled by the wealthy, the powerful, and the multinational corporations.

Obama knew when he took office that pursuing his agenda would take a revolution.  Sanders knows that, too.  Barack didn't follow through.  I'm convinced Bernie would.

Realizing that the perspective of the "opposing" argument must seem awfully gloomy, my debate partner then simply admitted inability to share my optimism. I was ready with a reply to that:

You can share my optimism.  I have plenty, and would be more than happy to spare some for you. You may have some difficulty sharing my vision, but when I look at Bernie, I see a man with integrity, high principle, and the courage of his convictions.  I see a man who is willing to be the TR of the third millennium, to launch peals of thunder from the bully pulpit and stir the masses to demand reform, to bring low the high and mighty who use their wealth and power for nothing but the accumulation of more wealth and power.

It is time to use the federal government for something important and worthwhile: to rebuild the middle class and to bring many of the poor up into that middle class.

Today's corporate robber barons don't even have the redeeming virtues of Rockefeller or Mellon or Carnegie, who realized they had an obligation to use a substantial chunk of their amassed wealth for philanthropy, building institutes and universities and endowing museums, even if it may have been partly to get their names all over them.

No, now it is all about wholly unrestrained greed, accumulating wealth for its own sake.  It is inviting revolution.  That revolution needs a leader.

HRC might be a good president.  She will never lead a revolution.

Bernie Sanders, that Brooklyn-born independent thinker from Vermont, is the man for the times.