Universal health care

Universal health care describes any system whereby all residents of a given jurisdiction, often a country, are covered by plans to pay for their medical needs as they arise.

This can arise in several ways:

• The free market creates conditions under which, between employer-provided plans, individually purchased plans, and charity, everyone is covered (the neoconservative ideal).
• As above, except the gaps in the free market system are covered by government-sponsored programs (current US system/Medicare, except for the "universal" part — or the coverage of gaps part, or the level of "need" addressed part...).
• A system where one single organization, whether private or public, pays for all care, theoretically at a regulated and affordable cost to the covered.
• A tax-supported government program is set in place to pay for medical care for all who partake of it, with medical professionals operating private businesses which make money by providing care to individuals, which is paid for by said government program at more-or-less set rates per service.
• A tax-supported government program is set in place to employ medical professionals to provide health care to the population.

The last two options are what people usually mean by "single-payer."

The first two do not succeed in providing health coverage for all, in practice. The third example is provided just to acknowledge the concept that single payer universal health care could arise in the private sector somehow.

The fourth and fifth are what we see in many countries of the world, with varying results and popularity.

Advantages of tax-supported single payer universal health care

• Health care for all!
• No direct health insurance costs for businesses or individuals. This lowers inflation and increases employment by reducing the financial burden on businesses to provide workers' healthcare benefits and its associated costs. (Who's more capitalist now?)
• Efficiency of scale and simplicity.
• Health care continuity not affected by employment status changes.
• Money invested in healthcare is spent only on healthcare and related administration, rather than on profit-making insurance companies. (This means that the doctors' main goal is to get you healthy/save your life; the current system in the US can encourage unnecessary, expensive testing and extended care.)
• Consistently longer life expectancy.
• Generally cheaper due to the above.

Disadvantages of tax-supported single payer universal health care

• People cannot opt-out of the system if they do want to die from easily preventable diseases.
• Drug companies may restrict access to newer drugs because they can't charge usury-style prices (unless drugs are covered separately through the private sector, which is common).
• The only motivating reason for quality and timely services is profit, apparently?
• Potentially higher taxes, which may be levied "unfairly" (i.e. taxing the rich people more).
• "Creeping socialism."
• Individuals have less incentive to live healthily. They can drink and smoke, for example, and not have to pay more for healthcare than someone who doesn't drink and smoke. They can take risky actions that have large payoffs for them when they win but large costs for everyone else when they lose.
• If doctors are not compensated appropriately, there could potentially be mild "shortages" in health care availability, ie. {{#replace:{{#replace:Canuckistan|_| }}|#| § }} and the UK.
• And most importantly, TV dramas would become exceptionally more boring.

Budget concerns

The costs of maintaining universal healthcare, or financial limitations in its implementation, have a tendency to increase over time.

For example, the United Kingdom's National Health Service (NHS) was founded way back in the 1940s. There have been huge advances in pretty much every branch of medical treatment during the decades that followed, including, for example, the development of effective cancer treatments, intensive care and life support technology, and vastly improved pharmacology. With these improvements in medicine comes the ability to treat more conditions and keep people alive for longer, and with universal healthcare comes the obligation to do so. Many of these treatments are highly expensive, and some rely on corporations such as those of the pharmaceutical industry, resulting in NHS money being routed back into the private sector. This is also compounded by increasing populations to serve and a boom in the elderly.

Hence the national cost of universal healthcare has gradually become more expensive (although the annual NHS budget amounts to slightly over $2000 per citizen, per year). This, along with measures taken in response to the rising costs, has resulted in restrictive budgeting and performance pressure at every level of the NHS, an unnecessarily competitive culture (including hospital league tables), marginalisation of some services, and moderate waiting lists for some forms of elective surgery and other treatments. Regardless of the positive advances which have caused them, these negative effects have been a major target for criticism, with short-sighted commentators regarding them as a sign that the quality of service offered by the NHS has declined, often based on widely-reported but rare incidents.

This link between improved medical possibilities and rising healthcare costs also leads some to believe that universal healthcare has become — or will become — unsustainable. Arguably, it may also lead to increasing ethical (and financial) dilemmas of the "when do we pull the plug?" kind. Obviously, this problem never occurs without universal health care, because the complete lack of taxes under such a system implies all patients are breathtakingly wealthy.

Examples of systems in use today

Map of countries with universal health care. If that's not convincing, then we don't know what is.

Australia

Australia is perhaps unusual in that it developed two universal health care systems in quick succession. In the early 70's, a newly-elected Labor government implemented a system named Medibank. When Australians decided, less than three years later, that they'd like some more conservative government instead, Medibank was restructured into a government-owned private health insurer — complete with a name change to Medibank Private to ensure there was no misunderstanding — as a first step towards selling it off. Before this could happen, Australians changed their mind again, voted in another Labor government in 1983, which set up a new universal health care scheme, Medicare, and kept Medibank Private as a government-owned business to earn a profit for the government and keep the other, smaller private health insurers in line.

Medicare, is nominally funded by a 1.5% Medicare Levy on income, but in practice it is funded out of general revenue. Medicare covers 100% of in-hospital costs, 85% of specialist costs and 75% of general practitioners' costs. Depending on how they want to run things, medical organisations may either charge the patient the full cost of their treatment (the patient takes their receipts to Medicare to receive the rebate), bill Medicare directly (a practice known as "bulk billing"), or do something in between. In addition, the Pharmaceutical Benefits Scheme (PBS) subsidises a wide range of prescribed medications, and functions as a sole-purchaser for anyone looking to sell medication in Australia, keeping prices of medication down through volume purchasing.

Visitors from countries with reciprocal relationships with Australia (for instance, New Zealand) have limited access to Medicare (though all patients in Australia have access to free hospital care, regardless of whether they are Australian or not). The Australian health system is generally considered to be among the best in the world, providing reasonably timely treatment at a low cost to the country. Australia spends approximately 9.8% of its GDP on health care, also making the Australian system among the cheapest in the world.

Conservative distaste for the idea that a national government should have some responsibility for the health and well-being of the citizens who pay its taxes, and some strategic schmoozing by for-profit health care lobbyists, has led to the bizarre situation of even the private health insurance industry in Australia being heavily dependent on government money. Private health insurance premiums are an income tax deduction — an in-effect subsidy, and individuals above a certain income level who do not have private health insurance are subject to a Medicare Levy surcharge.

It's not the first shot: that was the refusal of the then-Coalition opposition to support the original Medibank bill through the Senate. Or the Fraser Coalition government which undid universal health care less than six months after its introduction, creating a system whereby the better off would not pay into Medibank if they held private health insurance. Or the succession of right and centre right governments since 1990-ish that have introduced the health insurance rebate, the medicare surcharge levy, and the lifetime loading charge, all designed to push more and more people out of universal health care and into private health insurance. This is just the latest volley, and given that too few people (Gen-Y'ers who don't realise how good they had it) value universal health care to sustain it any more, it won't be long until Oz is back to an American-style system.

On the plus side, private health insurers and health care providers remain rather tightly regulated. Any premium increases are subject to government review and oversight, the premiums are generally modest — an individual can expect to have to spend no more than a day's earnings on their monthly health insurance premium, and policies tend not to be riddled with gotchas and exclusion, and they universally include allowances for eyeglasses, orthotic footwear, dentistry, physiotherapy, and even gym memberships and sporting equipment. The downside is that many questionable health practices with no proven benefits such as homeopathy, chiropractor, chelation therapy, crystal healing, acupuncture, etc. are also offered as an incentive coverage by private health insurers to attract customers. In 2013, Medicare clamped down on remedial massages being offered as a rebate, after it was found brothels were using it as an umbrella subsidy for their sex services. "The Lucky Country" indeed.

Canada

Under the Canadian Constitution, healthcare is a provincial responsibility. As a result, each province and territory has its own separate healthcare system (if you get treatment in another province/territory's healthcare system, your home province/territory's system gets hit with the bill), and the federal government enforces certain standards of care in each system. Healthcare in Canada is generally funded by a combination of sales tax and federal transfer payments (a great source of contention in federal/provincial and interprovincial relations). Some provinces also have a specific healthcare levy, while in the Western provinces they've had good results in using casino (or oil) revenues. While long wait times are often pointed at as a weakness, they are more likely resulting from the system's underfunding by a series of Liberal (centrist) and Conservative (right-wing, recently loopy) governments, which didn't necessarily have a commitment to the system and only hesitate due to the massive public support for socialized medicine. Hard to win an election when you give the source of national pride a kick to the 'nads, eh?

There has recently been a bit of controversy about the introduction of more privatization; supporters claim that it will improve access; detractors claim it will create a two-tiered system that gives better service to the wealthy. This has been due to one Supreme Court clusterfuck (Chaoulli v. Quebec) and suggestions from think tanks that should really know better. A good 30% of insurance is already paid through the private sector.

China

Since the dismantling of much of the Communist healthcare system under economic reforms, access to healthcare in China has deteriorated substantially. Citizens found they needed to save substantial sums to cover potential medical bills, depressing consumer spending, with patients in impoverished rural areas often refusing medical treatment for fear of costs. China's free-market healthcare success story proved beyond all reasonable doubt that privatized medicine is the perfect system!

The Chinese government, apparently not realizing what a success story it's healthcare system was, has since reformed the healthcare system with public insurance programs. Now, almost the entire population is covered by insurance, though it only covers about half of healthcare costs in most instances, though it is working on making healthcare affordable to everyone by 2020.

Costa Rica

Welcome to your new socialist paradise, Rush and Cato.

Cuba

Despite Fidel Castro's apparent consuming of infants and bathing in the blood of the innocent, Cuban healthcare is better than that of any other nation in the region.

Michael Moore's film Sicko depicted Cuba's the system as incredibly good, even among Guantanamo detainees. He then pulled an illegal stunt by bringing several ill first-responders from the 9/11 cleanup to Cuba and obtaining free care for them... which isn't so unusual since more than 5000 foreign patients traveled to Cuba in 2006 for a wide range of treatments including eye surgery, neurological disorders such as multiple sclerosis and Parkinson's disease, and orthopedics.

Republicans were quick to point to a hospital in Cuba with absolutely despicable conditions to show that health care in Cuba is not as good as people present it to be; the hospital in question is actually a volunteer hospital providing care to people who are against Castro's regime. It would honestly surprise us if a totalitarian government did provide adequate health care for dissidents. The USA (which arguably isn't totalitarian), on the other hand, certainly doesn't provide adequate healthcare for its poor or even all its freaking veterans!

Whether the system itself is really as good as claimed or not, Cuba is a major exporter of highly trained medical talent, with Cuban doctors involved in humanitarian efforts around the world. No, really. Oddly enough, America, which claims Cuba is evil and inhumane, has refused Cuban medical assistance during the aftermath of almost every major natural disaster, including Hurricane Katrina.

Denmark

All Danish citizens have the right to free treatment from general practitioners, specialists and public hospitals. Depending on personal income, it may also be possible to get financial support from the municipality for other health-related costs.

About 1.8 million Danish citizens are also members of Sygeforsikringen danmark (Health Insurance Denmark), a private mutual insurance company, which offers refunds of up to 85% on expenses not generally covered by the public health insurance, such as certain types of medicine, eyeglasses and dental care.

Government expenses for the public health care system amounts to ca. 14 billion, or about 2500 USD per citizen, per year. The system as a whole generally functions well, but is however plagued by certain structural problems that lead to inefficiency and dissatisfaction in certain sectors.

As a result of the 2001-2011 Liberal/Conservative government's not-so-subtle attempt at starving the beast, the private health-care sector in Denmark has expanded quite a bit in the later years, and the sale of private health insurance have been steadily rising. In 2010 it was forwarded that the then-prime minister, Lars Løkke Rasmussen, an avid admirer of the American health care system, had, in his period as Minister of Health, deliberately over-paid the private hospitals in Denmark in order to help them out-compete the public hospitals.

France

The French pay less money for their healthcare and get better treatment than most non-millionaire Americans. The disadvantage is that many hospitals need serious renovation, and getting extraordinary medical care or routine care on weekends, is unlikely (despite the utopia presented in Moore's film).

The vast majority of healthcare costs are covered by a public fund that (ranging from about 70% reimbursement to 85%), while long-term medical costs are reimbursed 100% by the government. General Practitioners are all privately employed but financed through these public funds. General Practitioners, however, are not required to act as gatekeepers, so patients can directly approach a specialist in order to avoid over-prescribing. "Additional coverage" insurance, which is mostly from not-for-profit, mutual insurers that work directly with the public system, provide funding for private doctors, while more advanced technology (think "MRI" vs. "X-ray" for a broken bone) and shorter wait times for routine care which can be purchased at a fairly minimal cost.

Germany

Germany has a universal health care system made up of both mandatory public insurance and private plans (the self-employed and high-wage workers can opt out of the public plan and obtain a private one). The conditions and prices of the public plan are mandated by the government, but supplied by a range of contractors who may include additional benefits. Its costs are shared equally between employers and employees, who have to contribute a fixed share of their monthly payroll regardless of income. The premiums of low-income workers are subsidized by the state, which also supplies coverage for the unemployed.

Comparatively little tax money goes into the system, but the premiums have a noticeable effect on the cost of labor. High-wage earners and the self-employed can sign up for any of the nation's 200 private health insurance plans — a broader choice than any American has. If a German who uses the public plan doesn't like their insurance company, they can switch to another, with no increase in premium. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. In Austria and Germany, if a doctor diagnoses a person as "stressed," medical insurance pays for weekends at a health spa.

Israel

Everyone living in Israel must sign up with one of four Health Maintenance Organizations (HMOs), and can switch between them once a year. The HMOs are required by law to operate as non-profit organizations and must offer the same basic package, which covers a wide range of medical procedures and medications. They can also offer their own additional health policies, but cannot deny anyone membership in one of their policies, although they can charge premiums based on age. The self-employed must pay their premiums, while employees must pay a partial premium deducted from their paychecks, with their employer covering the rest. Premiums are also deducted from pensions.

Japan

Everyone in Japan is required to get a health insurance policy, either at work or through a community-based insurer. Eighty percent of Japan's hospitals are privately owned — more than in the United States — and almost every doctor's office is a private business, though 70% of all treatment is paid by the government. "Private" in this case, however, is quite a bit different than in other countries: hospitals and clinics, by law, must be run completely by doctors and must be non-profit organizations. For-profit corporations aren't allowed to run hospitals or clinics. As well, health costs are tightly regulated by the government, and are negotiated by government officials and physicians--not insurance lawyers allowed. The tight regulation of costs is a big reason why the cost of healthcare in Japan is so low compared to almost everywhere else.

In Japan, waiting times are so short that most patients don't bother to make an appointment.

Netherlands

Dutch citizens may choose between private and public health care, where public health care consists of special programs provided by the same companies that offer private health care.

The maximum fees of these public programs are restricted by the government, a typical public health insurance including dental care costs around 80 euros a month. Health care for all minors (less than 18 years old) is free.

New Zealand

New Zealand's Accident Compensation Corporation is an insurance fund paid into by all employed citizens, which then funds treatment for accidents and provides a percentage of salary lost due to accidents. Public hospitals provide care to a large portion of the population with means-tested fees and long waiting lists in some cases, while private hospitals cater to the wealthy and the privately insured. The ACC has a "no fault" policy which removes the ability for people to sue for personal injury except under extreme circumstances or cases of gross negligence. Prescriptions are heavily subsidised, and almost all drugs are purchased via Pharmac, a government-run body with massive negotiating power.

Norway

Norway has a tax-funded mandatory system run by four Regional Health Authorities. For anyone below 16 years of age as well as pregnancy related issues there is no cost, while others pay a nominal fee for examinations, and pay for medication (some heavily subsidized). There is an upper annual cost limit (US$250 in 2015) per person; everything above that is free. Hospitalization and related ambulance services are always free. All have the right to a choice in hospitals. Health services are provided by a combination of public and private entities, where the private entities compete for government contracts. Dental care is, with some exceptions, not covered by the universal health care system, but is free for youths up to 18 years of age. Supplemental private health insurance also exists, usually as job fringe benefit, and is mostly used to get quicker access to services in non-urgent matters that does not require hospitalization.

Expenditure on healthcare is about US$9715 per capita per year, among the highest in the world.

Spain

Spain has a health system paid for by taxes. Quite centralized but it works quite well. Hospital care covered but patients sometimes have to wait for non-urgent treatment. Standard charge for prescription medicines with reductions for pensioners. People have the option of taking out private health insurance if they don't want to wait for their non-urgent operations.

Apart from the central system there is also a system of General Practitioners (aka. family doctors) who provide localised care. The quality of this service varies from the really outstanding to quite poor.

As far as dental treatment is concerned, urgent extractions are covered by the state system, but all other treatment is private.

In general Spanish people seem quite satisfied with their system, especially when compared with what they understand the American system to be.

Sweden

Sweden has a decentralized, primarily tax-funded system, governed by the regional councils. Typically, the patient pays a nominal fee for the examination, and the patient pays for their own medication. Both of these have an upper annual cost limit; if the patient reaches this limit, any additional health care or medication, respectively, for the duration of the year (counting from the first registered visit) will be provided free of charge. Urgent cases are always prioritized, and emergency cases are treated immediately.

Each visit to a doctor costs 150-300 SEK (roughly $23-$45). This entrance fee covers any further specialist visits deemed necessary by the doctor. The same fee is levied for ambulance services.

Dental care is not covered by the universal health care system, but is free for youths up to 18 years of age. A private healthcare system also exists, but is not broadly utilized.

United Kingdom

File:National-Health-Service.jpg

Leaflet concerning the launch of the NHS in England and Wales.

See also: Welfare policy of the United Kingdom

Britain's National Health Service is similar in principle to Spain's, ie. a centralized system paid for by taxes. Hospital care is covered but patients sometimes have to wait between consulting about an issue and beginning treatment; typically a maximum of 18 weeks for non-urgent treatment and 4 weeks for cancer care. People have the option of taking out private health insurance if they don't want to wait for their non-urgent operations or share a ward with the hoi polloi.

In England, and Northern Ireland, there is a flat charge for prescription medicines, but there are exemptions for the elderly, the very young, those on low incomes, expectant mothers — those who are terminally ill or suffer from certain chronic conditions like cancer or diabetes can apply for Medical Exemption Certificates for free prescriptions. Reduced price 'season tickets' are available for those on long-term medication. There are no prescription charges in Wales. In April 2011, Scotland abolished prescription charges for everyone.

Currently there is a determined effort by the current British Conservative Government to edge it closer to the American model by privatisation in various guises. This effort is fiercely opposed by the majority of the British populace, and 9 out of 10 doctors oppose the government's "Health and Social Care Bill" that will abolish Primary Care Trusts and place 80% of responsibility for finance on GPs, which is expected to lead to the hiring of outside private groups to manage hospital's financial matters. It was also opposed by the British Medical Journal, The Lancet, the British Medical Association, Royal ­College of ­Radiologists, Royal College of Paediatrics and Child Health, Royal College of ­Nursing, Royal College of GPs, the Faculty of Public Health, and the Royal College of Midwives — basically most doctors, specialists and hospital workers. Despite the almost complete opposition from experts, the bill was passed by the Conservatives in 2012. The NHS is done. It will reach a point where people will ask for it to be privatised, and no one will blame the Tories or look back at the back-door privatisation of it all. In the future, people will talk about the NHS like they talk about British Rail today. Everybody will forget that years of underfunding was the cause. Instead, and this is the sad part, people will blame other things like welfare scroungers/fat people/immigration/EU/pick your bogeyman once it happens.

There has been a concerted effort by Republicans as well to portray the NHS as vastly worse than it actually is, in order to derail US healthcare reform. It is certainly true that the British in general have much better health care than Americans, except for millionaires.

Dental care is not fully covered by the NHS, but the repercussions of this are not obvious, particularly to Americans who would never base a stereotype on such a shortfall. Dental care is free for those in full-time education, those on certain benefits, and those with certain medical conditions.

There is even a Twitter page of real British people expressing support for the NHS. This led to Twitter crashing when millions of Britons turned up to defend the NHS. The NHS supporters included Stephen Hawking, who said "I wouldn't be here today if it were not for the NHS." This was in response to an especially unresearched article claiming that Hawking, who has suffered from ALS for many years, would have been euthanised under the NHS.

United States of America

“ We Klingons believe as you do. The sick should die. Only the strong should live. ” — Kras

File:HC-Graph2.jpg

Everybody laugh at the right side of the American political spectrum.

Ah, yes. The American "system". In the US you have the right to own a gun; in the rest of the developed world you have the right to get healthcare. Two different ideas about what is important in life.

Due to a decision during WWII, health insurance became an untaxed benefit that employers could use as an incentive to get around wage freezes. Immediately after this decision pretty much all companies began offering health insurance, which continued even after the end of the war, and this coincided with an increase in quality and relevance of healthcare. Thus, when Presidents Truman and Eisenhower considered starting up a single-payer system, perhaps counterintuitively (as current railing against it tends to come from the right side of the political spectrum) the loudest opposition came from the labor unions, who considered this a massive threat to their interests; with a single-payer system, the unions would have one less incentive for workers to join them. They were successful in killing it, thereby setting it on the course that got it to the present day:

• People don't realize that America already provides free healthcare−they just do it in the least effective way possible. They only give you healthcare to prevent you from immediately dying. Then the hospital discharges you and hopes that you go to a different ER next week. It's like replacing your old tires with a brand new car, when you could just be paying for new wheels. (Preventative healthcare.) Not only do we provide free healthcare to the dying, we provide it to the elderly (Medicare), the poor (Medicaid), and the people with some of the most dangerous occupations in the country (Tricare and VA). Pretty much everyone except the young and healthy who cost so much less to provide for. We let the private insurance companies profit off those. Just one more case of "privatize profits, socialize losses".

• 15% of U.S. residents have no health care plan, nearly two-thirds of bankruptcy filings were linked to overwhelming medical bills, and at least 18,000 people die unnecessarily every year in the United States simply because they're uninsured. Oh you need a vaccination to go on vacation? Too bad. Go pay for it out of your own pocket. We don't give a shit about hepatitis. Oh you had to take an ambulance? Pay $2000 and don't pass go, asshole. Get cancer in the US? Enjoy your second mortgage. If you're poor and sick you basically are screwed due to the giant deductible (how does someone who has a household income of $70,000 pay for a $7500 deductible?), and if you're rich you can expect to pay about $20,000 a year. It's a nice racket. So when conservatives and libertarians whine about how high the taxes are in Sweden (yes, politicians are actively killing tens of thousands annually in the name of "freedom"), you really have to question their math skills.

• Despite campaigns by politicians on the center and left-wing, no national health care service seems likely to be enacted any time soon, due to the perceived association of "socialized medicine" with Communism, among other reasons. The state of Massachusetts, as of July 2007, has a rudimentary health care system based on providing state-funded subsidies to commercial health insurance providers, and early studies indicate that it's working. We love ya, Mitt!

• In that same July in a speech in Cleveland, Dubya asserted that America already had universal health care when he said, "People have access to health care in America. After all, you just go to an emergency room."

• Roman Catholics have been buying up American hospitals and sometimes own the only hospital in an area. This leads to them imposing their ethical system. No abortions, no contraception, no sterilization and a ban on many fertility treatments. A woman patient did not even know her medical insurance was Roman Catholic. She needed prompt medical help for a displaced IUD. Her medical provider refused help and made transfer to a different provider difficult. Transfer and medical help was only given after the ACLU got involved.

“ We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions. It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves. ” — Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU Illinois

• In 2000 a World Health Organisation report noted that the USA ranked 37th out of 191 member states for the quality of health care available to its citizens (France was top, the UK 18th, Colombia 22nd). Life expectancy is lower in the United States than in many other developed countries and problems with health care are part of the reason. Conservatives have cried foul over this report, despite the general conclusions being independently replicated on multiple occasions.

• The Southern Baptists officially opposed expanding public child health insurance on the strawman that fetuses will not be covered. However, the Democrats were idiots for allowing this strawman to become an issue, considering that public health insurance for pregnant women would be a good thing. In 2009, the Democrats wised up and added a section for covering pregnant women; the godless Southern Baptists still found a way to oppose this under the motto of "Love the fetus, hate the child."

• On September 9, 2009, a frustrated President Obama gave a speech before a joint assembly of both houses of Congress, outlining what he insists be included in such a bill and castigating people promoting what he termed "lies" about what such a bill might entail. Joe Wilson (R-SC) at one point heckled him, calling him a liar. Eventually Congress began debate on Obama's health care plan which garnered much of attention by news media and extensive analysis by pundits as it came toward a vote. Around this time the concept of "death panels" was first concocted by Caribou Barbie as a way to smear the upcoming reform. Finally, on March 23, 2010 the Affordable Care Act became law, having both massive support and criticism. In brief, the law lowers health care costs, holds insurance companies more accountable, provides more health care choices, and enhances the quality of health care for everyone. However, it is not a true universal health care system. (The only state to have any form of universal health care is Vermont, which passed a single-payer health care system in 2011.)

• Although never intended to be set up this way, hospitals are paid for the number of procedures being done instead of their outcomes. Private hospitals can use this to their advantage by buying out hospitals and practices, thereby gaining control of an enormous market area in a manner for which the only equivalents are the utilities companies. The concept of a free market in healthcare never existed to begin with, given that no one who isn't either a Münchausen's patient or committing some sort of fraud willingly enters into the market, and this removes any pretenses that such a thing is possible. Unlike the utilities, where government regulations control pricing, hospitals then hold people and insurance companies (aside from Medicare, see below) hostage, perform as many tests and procedures as possible, and gouge prices beyond recognition. 1500% markups for the cost of Tylenol or paper cups are very typical, and when applied to surgeries it is obvious how hospital administrators see using anything as a huge cash cow. Annual profit margins for many hospitals is in the $200 million a year range, and bear in mind that many of them are purportedly run as not-for-profit institutions. No hospital administrator can explain exactly how the prices got to be what they are, or how they negotiate prices with insurance companies. This is part of the game that insurance companies and hospitals play with each other; hospital charges $5k, insurance company negotiates down to $4k, hospital finds way to charge $10k, insurance company negotiates back down to $4k. The result being that if you don't have insurance, well, you can't negotiate and you get stuck with the $10k bill for a $4k procedure.

• In a similar vein, the drug companies charge 50% more for the same drug in the United States than they do in countries with a true universal healthcare system. In many cases there is only one drug or one manufacturer that makes a drug, which completely removes any pretenses of a "free market", but once again there are no price controls on drugs. Medicare is required to pay 6% above the average insurance-negotiated price for a drug, and Congress has forbidden Medicare from negotiating the price of a drug or declaring they will only pay for a specific drug. Drug companies will claim this is necessary for research and development, but this is obviously bullshit given that they're making enough money in other countries to feel a desire to aggressively market there too. The bullshit becomes even more apparent when you open up any drug company's financial statements and find that their marketing budget is more than double that of research and development.

• Doctors, even those working within a teaching hospital, are perfectly free to refer patients for special (and expensive) health services to private clinics in which they hold a financial interest—as shareholders, or board members. This happens on a scale that alarms some people and impoverishes others.

• Despite this, the United States does have certain forms of government-run health care, with Medicare for Americans over 65 and have relatively good life expectancy. Medicare has so many patients that hospitals are unable to bludgeon them into submission, and can generally be talked into a relatively more reasonable (though usually still exorbitant) price for services and equipment used. The main problems are with mortality among younger Americans. There is also Medicaid for the poor, and some health care through the veteran's administration for those that have served in the military. These systems very neatly separate the segments of the population that are likely to actually require a lot of expensive medical care and puts them on the public dole, while leaving the private sector to take care of the people for whom providing health insurance is likely to turn a profit.

• It's not even fiscally efficient. Health spending is 17.6% of GDP compared to a developed country average of 9.6%, and most of it goes to profit margins for private insurance companies. For-profit health care encourages the use of expensive procedures, drugs and medical equipment to treat relatively minor issues while the root of the problem is ignored. In other words, Americans spend far more for worse care ($947 per person on average compared to $487 per person in developed nations overall). You'd think this would raise alarm bells among "fiscal" conservatives, but this was completely ignored during fiscal cliff debates, with the proposed solution instead to cut Medicare.

• Tort reform remains a contentious solution. Some physicians perform a tremendous amount of tests with dubious utility in fear of frivolous lawsuits, if they cannot pay for malpractice premiums; while most are reasonable, those for doctors who perform riskier operations can be $40,000 a year, and depending on location, neurosurgeons and OB/GYN can be over $300,000 per year. Oh, and that's if they don't have to be underwritten at a higher rate for excessive accidents in the past. While the benefits of curbing liability has been exaggerated (mixed effects on patient outcomes and representing a spending reduction of less than 5%), the potential savings of a few billion in the context of a trillion-dollar system means it continues to be a policy option. While the Republicans are overwhelmingly responsible for the dysfunction of American healthcare, in the interest of fairness this is the one place where the Democrats are completely to blame; unlike most of the issues surrounding healthcare these tort reforms are relatively straightforward (several states have enacted measures to this effect already), but during the Affordable Care Act debate the Democrats refused to even negotiate this point.

• Even it's general effectiveness is limited: quality care as measured by the Commonwealth Fund is typically middle of the pack, and until the Affordable Care Act enacted certain restrictions, you were more likely to die of an infection or medical mishap in a US hospital than anywhere else in the OECD--millionaire or not.

• In fact, the single positive thing going for the US is cancer treatment, only topped by Japan in providing high-tech screening. But even that's given a "B" rating because of the lack of access.

This is why the rest of the developed world laughs at you America. Among other reasons.

External links

• A Conservative Convert To Socialized Medicine, The New York Times
• Comparing International Health Care Systems, the commies at PBS
• Single Payer FAQ - Physicians for a National Health Program