Socialized medicine
Socialized medicine is a term used in the United States to describe and discuss systems of
Background
The original meaning was confined to systems in which the government operates health care facilities and employs health care professionals.
More recently, American conservative critics of
Most industrialized countries and many developing countries operate some form of publicly funded health care with universal coverage as the goal. According to the
Jonathan Oberlander, a professor of health policy at the University of North Carolina, maintains that the term is merely a political pejorative that has been defined to mean different levels of government involvement in health care, depending on what the speaker was arguing against at the time.[10]
The term is often used by conservatives in the U.S. to imply that the privately run health care system would become controlled by the government, thereby associating it with
History of term
When the term "socialized medicine" first appeared in the United States in the early 20th century, it bore no negative connotations. Otto P. Geier, chairman of the Preventive Medicine Section of the
Government involvement in health care was ardently opposed by the AMA, which distributed posters to doctors with slogans such as "Socialized medicine ... will undermine the democratic form of government."
The AMA conducted a nationwide campaign called
In more recent times, the term was brought up again by
Health care professionals have tended to avoid the term because of its pejorative nature, but if they use it, they do not include publicly funded private medical schemes such as Medicaid.[3][48][49] Opponents of state involvement in health care tend to use the looser definition.[50]
The term is widely used by the American media and pressure groups. Some have even stretched use of the term to cover any regulation of health care, publicly financed or not.[51] The term is often used to criticize publicly provided health care outside the US, but rarely to describe similar health care programs there, such as the Veterans Administration clinics and hospitals, military health care,[52] or the single payer programs such as Medicaid and Medicare. Many conservatives use the term to evoke negative sentiment toward health care reform that would involve increasing government involvement in the US health care system.
Medical staff, academics and most professionals in the field and international bodies such as the
In more recent times, the term has gained a more positive reappraisal. Documentary movie maker Michael Moore in his documentary Sicko pointed out that Americans do not talk about public libraries or the police or the fire department as being "socialized" and do not have negative opinions of these. Media personalities such as Oprah Winfrey have also weighed in behind the concept of public involvement in healthcare.[54] A 2008 poll indicates that Americans are sharply divided when asked about their views of the expression socialized medicine, with a large percentage of Democrats holding favorable views, while a large percentage of Republicans holding unfavorable views. Independents tend to somewhat favor it.[55]
History in United States
The Veterans Health Administration, the Military Health System,[56] and the Indian Health Service are examples of socialized medicine in the stricter sense of government administered care, but they are for limited populations.[57]
Medicare and Medicaid are forms of publicly funded health care, which fits the looser definition of socialized medicine.[citation needed] Part B coverage (Medical) requires a monthly premium of $96.40 (and possibly higher) and the first $135 of costs per year also fall to the senior, not the government.[58]
A poll released in February 2008, conducted by the
Two thirds of those polled said they understood the term "socialized medicine" very well or somewhat well.[59] When offered descriptions of what such a system could mean, strong majorities believed that it means "the government makes sure everyone has health insurance" (79%) and "the government pays most of the cost of health care" (73%). One third (32%) felt that socialized medicine is a system in which "the government tells doctors what to do".[59] The poll showed "striking differences" by party affiliation. Among Republicans polled, 70% said that socialized medicine would be worse than the current system. The same percentage of Democrats (70%) said that a socialized medical system would be better than the current system. Independents were more evenly split, with 43% saying socialized medicine would be better and 38% worse.[59]
According to Robert J. Blendon, professor of health policy and political analysis at the Harvard School of Public Health, "The phrase 'socialized medicine' really resonates as a pejorative with Republicans. However, that so many Democrats believe that socialized medicine would be an improvement is an indication of their dissatisfaction with our current system." Physicians' opinions have become more favorable toward "socialized medicine".[59]
A 2008 survey of doctors, published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.[60]
Political controversies in the United States
This article is written like a debate. |
Although the marginal scope of free or subsidized medicine provided is much discussed within the political body in most countries with socialized health care systems, there is little or no evidence of strong public pressure for the removal of subsidies or the privatization of health care in those countries. The political distaste for government involvement in health care in the U.S. is a unique counter to the trend found in other developed countries.[citation needed][dubious ]
In the United States, neither of the main parties favors a socialized system that puts the government in charge of hospitals or doctors, but they do have different approaches to financing and access. Democrats tend to be favorably inclined towards reform that involves more government control over health care financing and citizens' right of access to health care. Republicans are broadly in favor of the status quo, or a reform of the financing system that gives more power to the citizen, often through tax credits.[citation needed]
Supporters of government involvement in health care argue that government involvement ensures access, quality, and addresses market failures[61] specific to the health care markets. When the government covers the cost of health care, there is no need for individuals or their employers to pay for private insurance.
Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research.[62]
Cost of care
Socialized medicine amongst industrialized countries tends to be more affordable than in systems where there is little government involvement. A 2003 study examined costs and outputs in the U.S. and other industrialized countries and broadly concluded that the U.S. spends so much because its health care system is more costly. It noted that "the United States spent considerably more on health care than any other country ... [yet] most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries.[63] The researchers examined possible reasons and concluded that input costs were high (salaries, cost of pharmaceutical), and that the complex payment system in the U.S. added higher administrative costs. Comparison countries in Canada and Europe were much more willing to exert monopsony power to drive down prices, whilst the highly fragmented buy side of the U.S. health system was one factor that could explain the relatively high prices in the United States of America. The current fee-for-service payment system also stimulates expensive care by promoting procedures over visits through financially rewarding the former ($1,500 – for doing a 10-minute procedure) vs. the latter ($50 – for a 30–45 minute visit).[citation needed] This causes the proliferation of specialists (more expensive care) and creating, what Don Berwick refers to as, "the world's best healthcare system for rescue care".[citation needed]
Other studies have found no consistent and systematic relationship between the type of financing of health care and cost containment; the efficiency of operation of the health care system itself appears to depend much more on how providers are paid and how the delivery of care is organized than on the method used to raise these funds.[64]
Some supporters argue that government involvement in health care would reduce costs not just because of the exercise of monopsony power, e.g. in drug purchasing,
Milton Friedman has argued that government has weak incentives to reduce costs because "nobody spends somebody else's money as wisely or as frugally as he spends his own".[68] Others contend that health care consumption is not like other consumer consumption. Firstly there is a negative utility of consumption (consuming more health care does not make one better off) and secondly there is an information asymmetry between consumer and supplier.[69]
Notwithstanding the arguments about Medicare, there is overall less bureaucracy in socialized systems than in the present mixed U.S. system. Spending on administration in Finland is 2.1% of all health care costs, and in the UK the figure is 3.3% whereas the U.S. spends 7.3% of all expenditures on administration.[73]
Quality of care
Some in the U.S. claim that socialized medicine would reduce health care quality. The quantitative evidence for this claim is not clear. The WHO has used Disability Adjusted Life Expectancy (the number of years an average person can expect to live in good health) as a measure of a nation's health achievement, and has ranked its member nations by this measure.[74] The U.S. ranking was 24th, worse than similar industrial countries with high public funding of health such as Canada (ranked 5th), the UK (12th), Sweden (4th), France (3rd) and Japan (1st). But the U.S. ranking was better than some other European countries such as Ireland, Denmark and Portugal, which came 27th, 28th and 29th respectively. Finland, with its relatively high death rate from guns and renowned high suicide rate came above the U.S. in 20th place. The British have a Care Quality Commission that commissions independent surveys of the quality of care given in its health institutions and these are publicly accessible over the internet.[75] These determine whether health organizations are meeting public standards for quality set by government and allows regional comparisons. Whether these results indicate a better or worse situation to that in other countries such as the U.S. is hard to tell because these countries tend to lack a similar set of standards.
Taxation
Opponents claim that socialized medicine would require higher taxes but international comparisons do not support this; the ratio of public to private spending on health is lower in the U.S. than that of Canada, Australia, New Zealand, Japan, or any EU country, yet the per capita tax funding of health in those countries is already lower than that of the United States.[76]
Taxation is not necessarily an unpopular form of funding for health care. In England, a survey for the British Medical Association of the general public showed overwhelming support for the tax funding of health care. Nine out of ten people agreed or strongly agreed with a statement that the NHS should be funded from taxation with care being free at the point of use.[77]
An opinion piece in The Wall Street Journal by two conservative Republicans argues that government sponsored health care will legitimatize support for government services generally, and make an activist government acceptable. "Once a large number of citizens get their health care from the state, it dramatically alters their attachment to government. Every time a tax cut is proposed, the guardians of the new medical-welfare state will argue that tax cuts would come at the expense of health care -- an argument that would resonate with middle-class families entirely dependent on the government for access to doctors and hospitals."[78]
Innovation
Some in the U.S. argue that if government were to use its size to bargain down health care prices, this would undermine American leadership in medical innovation.[79][80] It is argued that the high level of spending in the U.S. health care system and its tolerance of waste is actually beneficial because it underpins American leadership in medical innovation, which is crucial not just for Americans, but for the entire world.[81]
Others point out that the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it[82] and question the costs and benefits of some medical innovations, noting, for example, that "rising spending on new medical technologies designed to address heart disease has not meant that more patients have survived".[83]
Access
One of the goals of socialized medicine systems is ensuring universal access to health care. Opponents of socialized medicine say that access for low-income individuals can be achieved by means other than socialized medicine, for example, income-related subsidies can function without public provision of either insurance or medical services. Economist
Compulsory health insurance or savings are not limited to so-called socialized medicine, however. Singapore's health care system, which is often referred to as a
Rationing (access, coverage, price, and time)
Part of the current debate about
Opponents of reform invoke the term socialized medicine because they say it will lead to health care rationing by denial of coverage, denial of access, and use of waiting lists, but often do so without acknowledging coverage denial, lack of access and waiting lists exist in the U.S. health care system currently[90] or that waiting lists in the U.S. are sometimes longer than the waiting lists in countries with socialized medicine.[91] Proponents of the reform proposal point out a public insurer is not akin to a socialized medicine system because it will have to negotiate rates with the medical industry just as other insurers do and cover its cost with premiums charged to policyholders just as other insurers do without any form of subsidy.
There is a frequent misunderstanding to think that waiting happens in places like the United Kingdom and Canada but does not happen in the United States. For instance it is not uncommon even for emergency cases in some U.S. hospitals to be boarded on beds in hallways for 48 hours or more due to lack of inpatient beds[92] and people in the U.S. rationed out by being unable to afford their care are simply never counted and may never receive the care they need, a factor that is often overlooked. Statistics about waiting times in national systems are an honest approach to the issue of those waiting for access to care. Everyone waiting for care is reflected in the data, which, in the UK for example, are used to inform debate, decision-making and research within the government and the wider community.[93][94][95] Some people in the U.S. are rationed out of care by unaffordable care or denial of access by HMOs and insurers or simply because they cannot afford co-pays or deductibles even if they have insurance.[96] These people wait an indefinitely long period and may never get care they need, but actual numbers are simply unknown because they are not recorded in official statistics.[97]
Opponents of the current reform care proposals fear that U.S. comparative effective research (a plan introduced in the stimulus bill) will be used to curtail spending and ration treatments, which is one function of the National Institute for Health and Care Excellence (NICE), arguing that rationing by market pricing rather by government is the best way for care to be rationed. However, when defining any group scheme, the same rules must apply to everyone in the scheme so some coverage rules had to be established. Britain has a national budget for public funded health care, and recognizes there has to be a logical trade off between spending on expensive treatments for some against, for example, caring for sick children.[98] NICE is therefore applying the same market pricing principles to make the hard job of deciding between funding some treatments and not funding others on behalf of everyone in the insured pool. This rationing does not preclude choice of obtaining insurance coverage for excluded treatment as insured persons do having the choice to take out supplemental health insurance for drugs and treatments that the NHS does not cover (at least one private insurer offers such a plan) or from meeting treatment costs out-of-pocket.
The debate in the U.S. over rationing has enraged some in the UK and statements made by politicians such as Sarah Palin and Chuck Grassley resulted in a mass Internet protest on websites such as Twitter and Facebook under the banner title "welovetheNHS" with positive stories of NHS experiences to counter the negative ones being expressed by these politicians and others and by certain media outlets such as Investor's Business Daily and Fox News.[99] In the UK, it is private health insurers that ration care (in the sense of not covering the most common services such as access to a primary care physician or excluding pre-existing conditions) rather than the NHS. Free access to a general practitioner is a core right in the NHS, but private insurers in the UK will not pay for payments to a private primary care physician.[100] Private insurers exclude many of the most common services as well as many of the most expensive treatments, whereas the vast majority of these are not excluded from the NHS but are obtainable at no cost to the patient. According to the Association of British Insurers (ABI), a typical policy will exclude the following: going to a general practitioner; going to accident and emergency; drug abuse; HIV/AIDS; normal pregnancy; gender reassignment; mobility aids, such as wheelchairs; organ transplant; injuries arising from dangerous hobbies (often called hazardous pursuits); pre-existing conditions; dental services; outpatient drugs and dressings; deliberately self-inflicted injuries; infertility; cosmetic treatment; experimental or unproven treatment or drugs; and war risks. Chronic illnesses, such as diabetes and end stage renal disease requiring dialysis are also excluded from coverage.[100] Insurers do not cover these because they feel they do not need to since the NHS already provides coverage and to provide the choice of a private provider would make the insurance prohibitively expensive.[100] Thus in the UK there is cost shifting from the private sector to the public sector, which again is the opposite of the allegation of cost shifting in the U.S. from public providers such as Medicare and Medicaid to the private sector.[citation needed]
Palin had alleged that America will create rationing "
Some argue that countries with national health care may use waiting lists as a form of rationing compared to countries that ration by price, such as the United States, according to several commentators and healthcare experts.[86][105][106] The Washington Post columnist Ezra Klein compared 27% of Canadians reportedly waiting four months or more for elective surgery with 26% of Americans reporting that they did not fulfill a prescription due to cost (compared to only 6% of Canadians).[107][108] Britain's former age-based policy that once prevented the use of kidney dialysis as treatment for older patients with renal problems, even to those who can privately afford the costs, has been cited as another example.[86] A 1999 study in the Journal of Public Economics analyzed the British National Health Service and found that its waiting times function as an effective market disincentive, with a low elasticity of demand with respect to time.[106]
Supporters of private price rationing over waiting time rationing, such as
A 1999 article in the
Some argue that waiting lists result in great pain and suffering, but again evidence for this is unclear. In a recent survey of patients admitted to hospital in the UK from a waiting list or by planned appointment, only 10% reported they felt they should have been admitted sooner than they were. 72% reported the admission was as timely as they felt necessary.[110] Medical facilities in the U.S. do not report waiting times in national statistics as is done in other countries and it is a myth to believe there is no waiting for care in the U.S. Some argue that wait times in the U.S. could actually be as long as or longer than in other countries with universal health care.[111]
There is considerable argument about whether any of the health bills currently before congress will introduce rationing. Howard Dean for example contested in an interview that they do not. However, Politico has pointed out that all health systems contain elements of rationing (such as coverage rules) and the public health care plan will therefore implicitly involve some element of rationing.[87][112]
Political interference and targeting
In the UK, where government employees or government-employed sub-contractors deliver most health care, political interference is quite hard to discern. Most supply-side decisions are in practice under the control of medical practitioners and of boards comprising the medical profession. There is some antipathy towards the target-setting by politicians in the UK. Even the NICE criteria for public funding of medical treatments were never set by politicians. Nevertheless, politicians have set targets, for instance to reduce waiting times and to improve choice. Academics have pointed out that the claims of success of the targeting are statistically flawed.[113]
The veracity and significance of the claims of targeting interfering with clinical priorities are often hard to judge. For example, some UK ambulance crews have complained that hospitals would deliberately leave patients with ambulance crews to prevent an accident and emergency department (A&E, or emergency room) target-time for treatment from starting to run. The Department of Health vehemently denied the claim, because the A&E time begins when the ambulance arrives at the hospital and not after the handover. It defended the A&E target by pointing out that the percentage of people waiting four hours or more in A&E had dropped from just under 25% in 2004 to less than 2% in 2008.[114] The original Observer article reported that in London, 14,700 ambulance turnarounds were longer than an hour and 332 were more than two hours when the target turnaround time is 15 minutes.[115] However, in the context of the total number of emergency ambulance attendances by the London Ambulance Service each year (approximately 865,000),[116] these represent just 1.6% and 0.03% of all ambulance calls. The proportion of these attributable to patients left with ambulance crews is not recorded. At least one junior doctor has complained that the four-hour A&E target is too high and leads to unwarranted actions that are not in the best interests of patients.[117]
Political targeting of waiting-times in Britain has had dramatic effects. The National Health Service reports that the median admission wait-time for elective inpatient treatment (non-urgent hospital treatment) in England at the end of August 2007, was just under 6 weeks, and 87.5% of patients were admitted within 13 weeks. Reported waiting times in England also overstate the true waiting-time. This is because the clock starts ticking when the patient has been referred to a specialist by the GP and it only stops when the medical procedure is completed. The 18-week maximum waiting period target thus includes all the time taken for the patient to attend the first appointment with the specialist, time for any tests called for by the specialist to determine precisely the root of the patient's problem and the best way to treat it. It excludes time for any intervening steps deemed necessary prior to treatment, such as recovery from some other illness or the losing of excessive weight.[118]
See also
- Appeal to fear in defense of established economic interests
- Health care compared– tabular comparisons of the U.S., Canada, and other countries not shown above.
- Publicly funded health care
- Social medicine
- Socialization (economics)
- Universal health care
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But if the stories ... lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That's rationing too, by ability to pay.
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