@CP –
Thank you for your response and clarifying some of your points. Clearly you are quite happy with the UHC in Spain. I will not argue with your feelings and impressions of your system. You mention UHC is not a pie-in-the-sky possibility, and acknowledge but accept many of its inherent flaws. Despite your satisfaction, many of your arguments for the system are precisely what I fear.
Instead of trying to match you point for point, as I would have to write a thesis, I’ll just summarize by responding to one of your closing statements. (I am not trying to ignore many of your thoughtful contributions, but it would take me considerable time and effort to respond and I unfortunately do not have the resources to do so right now, but I certainly welcome your comments.)
You also say, “As a final point, I cannot understand your last comment. You seem to imply that I would get a better (paid) medical insurance if UHC was not in place in Spain. In all honesty, I can’t see the logic in that.” Because you cannot see the logic in that doesn’t mean it does not exist. I have clearly outlined my logic in this post and if you disagree with me, then it is on the most fundamental philosophical level. In short, you believe a socialist system, where the government decides the allocation of wealth, goods, and services will direct such wealth, goods, and services to their most highly valued use and that individuals are either incapable or immoral and have an inability to decide on their own. If you do believe that, you will have plenty of well-intentioned company, but we will not agree.

Why would anyone think universal health care would be any different? Will increasing the role of the third party’s decision-making provide additional choice, freedom, and lower costs? Will universal health care really be “free?”

While I can't even remotely pretend that I understand the intrincacies of the USA health care system, I'd like to point out that there is a persuasive argument in favor of universal health care: It actually works. I'm European (Spanish, to be exact) and, simplifying a little, within most of my continent UHC is both good enough for most people and directly taken for granted.

When compared to an almost completely private system (such as in the USA), this reveals an interesting choice, in that healthcare is seen as a basic need and right for citizens and the state strives to provide a good level of coverage to everybody. This includes medical consultation expenses (which are largely free to the user) and drugs - expensive drugs are partly paid for by the government. From my perspective, even conceding that private insurance works wonders in the USA, the absence of UHC strikes me as a triumph of raw liberalism over the idea of a 'welfare state'. Which is not necessarily bad, but kind of goes against our (European, I mean) "cultural genes".

Note that there is no gratuity for medical expenses in this system (for Spain, at least); having to pay up even though I had contracted a private medical insurance (and possibly a rather serious amount, to top it) is something that always struck me as funny when in the USA...

You mention that this kind of system is not well suited to promoting choice. I won't pretend that I have the same choice here with the UHC that you would have in the USA with private insurance, mostly because I never really had an experience with the American system (although I did nominally have it for 6 months). However, you neglect to mention that not everybody is a successful Gen-X/Y'er earning $50000+/yr who can easily afford (or get from their employer) expensive medical insurance (and/or the associated gratuities). There is *a lot* of people (poor people, to put it bluntly) for which the current USA system simply does not work, and these people get absolutely _no_ choice as of today. Would giving those people a decent, guaranteed healthcare count as "increasing choice"? I think that's an interesting point to consider. Remember the European choice I talked about before: people first, "raw" profit second.

In addition to that, if I want to, I can (and actually do!) get some kind of private insurance which guarantees me faster response times, freedom of choice and wider coverage when compared to the UHC (which I can always rely upon if I need/want). There are a rather large number of companies offering private health insurance here in Spain, so I would not say I am without choice. Also, as the UHC is the "measuring stick", I get very attractive conditions (no gratuities, wide coverage, access to private hospitals, complete freedom of choice within affiliated M. D.'s, ...) at a very competitive price (something like $25/month).

Finally, although I don't have any overwhelming evidence to offer, I think that having a UHC system in place does have some other intangible benefits (again related to the idea of a government actively caring for their citizens). For instance, the organ donor rate in Spain is very high, and indeed the whole organ transplant system is seen as a model by many other countries. I'm fairly convinced that not as much people would feel inclined to donate their own organs, or those of a deceased familiar, if the "organ market" was brokered by some other entity than the one responsible for the UHC.

Just my $0.02. I have always been intrigued about the details of the USA system, so maybe I can learn something in this process :) Cheers to all!

@torbjorn rive -

Thanks for weighing in.

You ask, "First of all you’re assuming, and merely assuming that: The answer is that universal health care will only result in a deepening of the current problems and a degradation of care."

I'm not really posing an assumption, but far more importantly, a question to the reader. Based on the empirical information I've provided about the woes of the current system, do you also conclude (as I do) that a degradation of quality and choice will follow? And if not, what is the logical conclusion when analyzing the situation with economic principles of supply and demand in mind?

Of course, if we don't philosophically agree on what I consider the non-empirical laws of supply and demand, I'm afraid we'll both be spinning our wheels, but I hope that further clarifies my goal with that statement.

You also say, "Is that because the system will no longer be capital oriented? If so, then there is a fundamental problem with social/corporate values. Imagine that you assume they’ll care less when they make more money. It’s like accepting defeat."

Your wording is very clever here, so I'm having a tough time with it. Suffice it to say, you haven't accurately captured what I meant to say, so I'll reiterate and try to clarify.

Certainly the American system represents one of the "freest" options around, if that is what you mean by "capital-oriented." But even at that, it is woefully far from a true capitalist system. I think the current problems are due to government failure, not market failure. I don't actually think it is capital-oriented enough to to offer the type of choices that come in a market-based system.

You say, "Also, employer-based plans are not free either. I don’t know if anyone else examines their paycheques, but we’re paying for corporate benefits on a monthly basis, just like I do with Provincial taxes for my healthcare system. I don’t mind so much because the system is in place, and then stronger." Perhaps I didn't say this explicitly, but I was by no means inferring the current third-party systems were free either. I was simply trying to point out the glaring fallacy that many people still think UHC is by some ridiculous miracle, free.

Thanks for your input and opportunity to clarify what I was trying to say.

@Deadhedge - by all means, expound away! I welcome any further elucidation on this topic. Like I said, my post covered only one aspect of the current system.

Tell me more about what you mean when you say, "Thus our current system matches our values." Do you mean that on a fundamental level, we Americans believe in health care for all?

People aren't getting the care that they need, anyway.

"I know many people who skip off to the emergency room at the first sign of heartburn. Because a third party foots the bill, they don’t care about the cost, using more care than they actually need."

Outside of the hypochondriacs, there are millions of Americans with chronic health problems. The system works until you have a serious condition that requires more than just one hospital visit.

These people cannot rely on a model that takes supply and demand into account. They don't care about pioneering R&D, because they are just trying to survive- and they often simply can't afford to.

Of course UHC will not be free. But it sure would save those employers who are paying for worker's healthcare a LOT of money, which means more jobs, which means more growth.

As a result there is a sort of blindness that occurs in the payment and pricing of health care costs and reimbursement. Think about it. If you have the luxury of being covered by your employer’s health plan, do you even look at your total bill? If you do, do you flinch when you see it? No, because you probably have a much smaller percentage or co-pay than the total figure meaning you aren’t discriminating about costs of services or how necessary they are.

Milena, you're spot on about this. I see this as part of the reason health insurance companies take so much heat for the current state of health care in America, while the providers (doctors and hospitals, who charge the high rates) and the pharmaceutical companies (who own the patents and charge the high costs) have been relatively unscathed so far.

I know some insurance companies are trying to make the real costs of care more visible to their members. The worst thing they did was to hide these costs back in the HMO days. Nowadays it's all about transparency: here's what you paid for coverage; here's what XYZ Insurance was billed by the provider for the service you received; here's what it actually cost you. Oh, and here's a Health Savings Account made up of your money to pay for it, so you can watch that balance go down.

Now try to ignore the total bill and not flinch when you see it.

@ Tim:

But it sure would save those employers who are paying for worker’s healthcare a LOT of money, which means more jobs, which means more growth.

Ugh, I wish it were that simple ... but sometimes, an employer saving money only means increased reportable profits, which means more shareholder value, which means more shareholders, not more employees.

The fact that universal health care isn't free is no longer the issue. The issue is whether there is any possible way that it won't cost American employees more than the current broken system does. I have my doubts about that.

Milena,
What I mean with American values is that we think that "deserving" groups should get as much as they want because they "earned" it. I think that we like the idea of being able to solve something by curing something tons of resources into.

However, I don't think that we belive in health care for all, especially if it means that in exchange for everyone having immunizations that means that only half of the 90 years old would get that total knee replacement.

With my point about 1/3 of the US having national health care (Medicaid and Mediare) is a contradiction in our values above. We are closer to UHC than we think. The bigggest change will be taking the profit model out of the system like Norcross pointed out.

Ultimately, I think that the best model will be a 2 tier system with basic evidence-based preventative services covered. This is services that everyone agree worth it for everyone. If someone wants more health care, than they buy a supplement plan.

UHC is ultimately a system of rationing since demand will always outstrip supply. Every country rations in their own way.

The other issue that a lot of the Gen Y members don't realize is that employer sponsored HC can lock you into a job. If you have a pre-existing condition and your current benefits cover it, you can end up in a situation where your abilities to change jobs are limited. (Full time employees have to be accepted, but not part time)

You will have more freedom to change jobs if your healthcare benefits are not tied to your employment.

The other problem is the dearth of general internists/family docs due to low wages. Since medicare/medicaid (and thus most other health plans) pay per procedure, you get better wages by becoming specialized. There is little financial incentive to become a general MD between lower wages and high initial costs.

With evidence-based preventative services, I am referring to benefits that have been clearly demostrated to improve outcomes and be cost-effective. For example, every dollar spent on pre-natal care saves $4 because you don't have a 2 pound baby that spends 2 months in the hospital. Also, pre-natal care has proven to improve birth weight. Thus, that is a service that is both clinically and economically good to offer. In my plan, that would be included for everyone.

Now, 3-D imaging isn't proven to really be always more effective than the current test and it's a lot more expensive. That would be something that should not be covered by UHC. However, you will have people who want it and will pay for it and you'll have insurance companies who will pay claims, do quality review, and contract with imaging centers and will provide the benefit, companies that want to make 3-D imagers, and providers who want to use them. So let the market reign with supplemental health benefits.

I believe that this solution accomplishes the goal of providing access to provenly effective health care for all (but not all health care). This 2 tier system is also indicative of our values of the 2 Americas where you can buy more if you want (like education). Canada limits the private health care market because they don't believe in a 2 tier system. However, if we (america) our honest with ourselves, we'll provide a basic level of benefit to all (like public schools) and let those who can buy up (like private schools).

It's not comfortable to let a 2 tier system develop with health aka a human life but I believe that it's the best system for america's values. It also keeps the profit incentive of health care innovation in tact because there is still a market for the latest and greatest which is another key value of our health system.

@Milena It's good to read more about your point of view. I would have to say that underutilization of resources also drives up costs of health care. As much as you might have people running with a sniffle to the emergency room, you also have people who never go to the doctor for years until a major problem emerges. There is a reason why the saying exists, "An ounce of prevention is worth a pound of cure."

I would bet that the number of the people who wait too long outweighs the number of hypochondriacs. I sure there are statistics that address that.

Implementing UHC reduces the financial burden for the resource-constrained small business as well as increased overall productivity from less time missed due to illness.

@Deadhedge I think that we are ultimately headed toward a 2-tier system as you described like the UK has. It's basically the same as the public education system where you pay a premium for choice. The Centers for Disease Control and Prevention already have a toolkit of evidence-based prevention best practices. If I can remember the exact name, I will post the link.

Hi Milena,

I'm a believer in Social-assisted healthcare because I currently live in that system here in Candada. My health problems are certainly minimal, so there's only so much I can contribute to this discussion.

First of all you're assuming, and merely assuming that: The answer is that universal health care will only result in a deepening of the current problems and a degradation of care.

Is that because the system will no longer be capital oriented? If so, then there is a fundamental problem with social/corporate values. Imagine that you assume they'll care less when they make more money. It's like accepting defeat.

Also, employer-based plans are not free either. I don't know if anyone else examines their paycheques, but we're paying for corporate benefits on a monthly basis, just like I do with Provincial taxes for my healthcare system. I don't mind so much because the system is in place, and then stronger.

Good article, and I look forward to reading more about your overview in the next instalment.

@Milena,
I am a Gen Xer who has worked in health care the whole time as a Peace Corps Volunteer, psych clinician, admin person, hospitals, primary care, county health departments, and insurance. That was intentional as I think that you need exposure to all parts of the healthcare industrial complex in order to understand it. I am in insurance right now and my boss has rightfully taught me that if we don't get our act together, we are going to all become government employees. As far as talking about "my plan", it just means that I have an opinion that I have thought about. It is basically Ezekial Emanuel's plan.

@Vanessa, we do have all the evidence-based prevention best practices that we need and the research has been done. The tricky part is drawing the line and deciding what gets covered and what doesn't. Oregon did that with its Medicaid program and drew the line when the money ran out.

@Vanessa -

Certainly untimely attention to medical problems increases risk and cost. It would seem that increased costs through the third-party system come first, thereby increasing prices so poor put off preventive care, thereby further increasing prices when the problems are magnified as such. Indeed a vicious snowball effect.

Also, that link you provided is great, a wealth of information for those interested in the preventative aspects of health. I think everyone should set aside a few minutes to check out the site.

And I'm sure you know I love that it is a non-federal initiative, an example of the very thing I was talking about on your post! I enjoying hearing about private citizens doing good things of their own volition!

@Milena

Thanks for your reply. I'm sorry about any misunderstandings in my previous post. I apologize for anything which might have come across as rude or ignorant of your points. I'll try to clarify things a bit.

First, with regards to A, I also don't know where I said that :) I suppose the misunderstanding arises from:

"you neglect to mention that not everybody is a successful Gen-X/Y’er earning $50000+/yr who can easily afford (or get from their employer) expensive medical insurance (and/or the associated gratuities)"

I can see how that was confusing and apologize for that. However, I did not want to focus on employers providing insurance or not. In fact, if you have a nice job, you can already pay for your insurance yourself, and, as you note in your post (in what, for me, was one of the most interesting points you raised), having your employer provide insurance for you probably works more to their advantage than to yours. In fact, it is also somewhat common for employers here to pay for private health insurance (whole or in part) as a benefit, although not nearly as 60%.

The essential point I wanted to make is that you basically get no insurance if you are unemployed or in a subpar job, since you get no insurance from your employer and have no money to pay for it yourself (as anecdotal evidence, although thankfully I didn't need to pay a dime, I found the gratuities I would have had to endure pretty expensive). UHC works as a kind of safety net for these people. Of course, you are always going to get slackers and abusers of the system; that's pretty much human nature (as you pointed out). But for people having a genuine need of it (I think we will agree that there is plenty), having UHC really makes a difference. You do mention the poor not getting the coverage they need, but, as I understood it, it was more of a passing reference than anything in depth.

With regards to B, I can see how I didn't correctly explain myself and I apologize for that. I am aware of what you mention and am sorry to have caused you any frustration. My specific comment was in regards to "choice", or the perceived diminishing of it with an UHC system. While I acknowledge (now and in my original post) that a fully private system probably leads to more available choices to people already in the position to pay for a private insurance (+ gratuities, etc), the fact is that no insurance equals no choice, so UHC automatically increases choice for a significant amount of people who can't afford to have private insurance.

In fact, you are asserting that putting a UHC system in place will automatically make some of the available insurance options disappear in a way that will directly impact the customer. I don't have nearly the same knowledge of the system that you do, so, most likely, you are correct in that; although European experience shows that diverse private insurances and UHC can coexist, I can concede that an ecosystem with UHC can not support as many players in the private insurance arena.

However, unless that reduced number of players does actually impact the customer (e.g. by reduced coverages or increased gratuities), then UHC does not impair your choice in any way. Sure, I would have more "choice" if I could still buy, say, a Ford T as my car, but I don't feel that my ability to get a good car to drive is limited by that absence.

If you are getting private healthcare right now, from whatever the source, you can continue to get it once UHC is there. I can only see your freedom of choice being impacted if the insurance of your choice disappeared, or somehow increased cost or removed coverages, due to the appearance of UHC, _and_ you weren't able to get any other insurance which would fit the bill equally (or better). Again, I don't know for sure, but I don't see that as likely. In fact, UHC would essentially be a free, basic competitor to other medical insurances, and competition is supposed to benefit the customer. And experience shows that there is a thriving market for private healthcare even with UHC in place.

On the other hand, if you don't have any insurance because you can't afford it, having UHC in place makes a huge difference.

I did not mean to imply that UHC is the absolute best system. For instance, the waiting times for non-critical tests or consultations are long by American standards, sometimes in the range of weeks. And, of course, you won't get the luxury of straight hours with the same doctor, nor anything of the sort. (Of course there are private insurances with these kind of coverages, if you want to pay for them). I merely wanted to point out that UHC systems are not some kind of mysterious pie-in-the-sky ideas, but that they work reasonably well in the real world.

As a final point, I can not understand your last comment. You seem to imply that I would get a better (paid) medical insurance if UHC was not in place in Spain. In all honesty, I can't see the logic in that. As I have pointed out, having UHC in place helps me (if anything), since paid medical insurance really has to be significantly better than UHC to be worth my money. (An example of this is something in which most Spanish medical insurances, even the most basic, compare favorably to the USA: no gratuities for doctor consultations or hospital stays. Not a penny.) And if I became disenchanted with my current insurance provider (or wanted/needed to save money), they know that I not only have the choice of changing to other paid insurance, but also of fully relying in UHC. (Which would probably be perfectly fine for my needs, by the way). I do not see where I get a "decreased choice".

The only part where I could understand your argument is that I can't opt out of the UHC system if I decide to get a private insurance, so I end up paying twice for my insurance. However, it gets more complicated than that, since the payment (which is made through a deduction on paychecks which is later compensated in part in your tax return) goes towards the whole 'welfare' system (basically retirement pension and unemployment funds in addition to UHC), and there is a compensation in the fact that the system also covers me when I am not employed, via unemployment support for a limited time and (of course) UHC. And, although you get nice perks with private insurances, some of the UHC facilities really are excellent; as an example, most Spanish women give birth at public hospitals, even those having private insurances, due to the wealth of resources available at them (which tend to be very large). In any case, an 'opt-out' clause could always be added to deal with that objection.

Again, I apologize for any misunderstandings and thank you for taking the time to respond to my comment. Have a nice day!

@CP - I'll re-post what I wrote to @torbjorn rive above as he proposed similar objections.

To Torbjorn, “First of all you’re assuming, and merely assuming that: The answer is that universal health care will only result in a deepening of the current problems and a degradation of care.”

I’m not really posing an assumption, but far more importantly, a question to the reader. Based on the empirical information I’ve provided about the woes of the current system, do you also conclude (as I do) that a degradation of quality and choice will follow? And if not, what is the logical conclusion when analyzing the situation with economic principles of supply and demand in mind?

Of course, if we don’t philosophically agree on what I consider the non-empirical laws of supply and demand, I’m afraid we’ll both be spinning our wheels, but I hope that further clarifies my goal with that statement.

CP - I apologize for my terse response, but your comments are quite lengthy, warranting much more time and attention than I'm able to give. I am not trying to offend you, and have tried to give you due credit for your personal beliefs and contributions to this conversation.

UHC as outlined in the US may also provide for private insurance, so my argument is why make certain people pay double for coverage (for the "free" coverage and private supplemental). This is a socialist idea however you slice it. While I never mentioned radical communism, nor did I intend to imply you were a radical communist, but I do oppose socialism in all its forms, even at its mildest and possibly partly capitalized structure in Spain.

I am not placing a value judgement on your preferences, I clearly indicated you have every right to enjoy the system you currently do. I also believe all men are capable and moral, and I think government intervention in this system will serve to its detriment, not its success.

@CP -

How did you know "opt-out" was the magic word? ;)

I appreciate your comments. As for the socialist talk, it is a socialized system we are talking about. I hope I didn't mislead you into thinking I was going to offer a variety of solutions to the health care problems, which would of course include UHC as it is an option, but one I oppose. I plan to talk about my personal preference for a solution but we haven't gotten that far yet.

You are also right, I oppose public education too, so I hope you understand that I try to remain philosophically consistent. Most people think I'm nuts. I don't mind.

I believe in classical liberal ideology, specifically, limited government and a flat tax where anyone who makes below a certain income level ($35-40K) should pay zero tax. I believe that police, military, and infrastructure are "public goods" and that which individuals cannot provide for themselves.