Socialized medicine is a term used to describe a system for providing medical and hospital care for all at a nominal cost by means of government regulation of health services and subsidies derived from taxation.[1] It is used primarily and usually pejoratively in United States political debates concerning health care, because of the U.S. culture's historically negative associations with socialism.[2][3][4][5][6] The term was first widely used in the United States by advocates of the American Medical Association in opposition to President Harry S. Truman's 1947 health-care initiative.[7][8][9]
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Jonathan Oberlander, a professor of health policy at the University of North Carolina, maintains that the term does not mean anything at all.[10] Exact definitions vary, but the term refers to any system of medical care that is publicly financed and government administered. If the system of care is publicly financed and privately delivered, it is called a single-payer system. This is what Canada has.
The original meaning was confined to systems in which the government operates health care facilities and employs health care professionals.[10][11][12][13] This narrower usage would apply to the British National Health Service hospital trusts and health systems that operate in other countries as diverse as Finland, Spain, Israel, and Cuba. The United States' Veterans Health Administration, and the medical departments of the US Army, Navy, and Air Force would also fall under this narrow definition. When used in this way, the narrow definition permits a clear distinction from single payer health insurance systems, in which the government finances health care but is not involved in care delivery.[14][15]
More recently, American conservative critics of health care reform have attempted to broaden the term by applying it to any publicly funded system. Canada's Medicare system and most of the UK's NHS general practitioner and dental services, which are systems where health care is delivered by private business with partial or total government funding, fit this broader definition, as do the health care systems of most of Western Europe. In the United States, Medicare, Medicaid, and the US military's TRICARE fall under this definition.
Most industrialized countries, and many developing countries, operate some form of publicly funded health care with universal coverage as the goal. According to the Institute of Medicine and others, the United States is the only wealthy, industrialized nation that does not provide universal health care.[16][17]
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 socialism, which has negative connotations to some people in American political culture.[18] As such its usage is controversial,[4][5][6][19] and at odds with the views of conservatives in other countries prepared to defend socialized medicine such as Margaret Thatcher.[20]
When the term "socialized medicine" first appeared in the United States in the early 1900s, it bore no negative connotations. Otto P. Geier, chairman of the Preventive Medicine Section of the American Medical Association (AMA), was quoted in The New York Times in 1917 as praising socialized medicine as a way to "discover disease in its incipiency," help end "venereal diseases, alcoholism, tuberculosis," and "make a fundamental contribution to social welfare."[21] However, by the 1930s, the term socialized medicine was routinely used negatively by conservative opponents of publicly funded health care who wished to imply it represented socialism, and by extension, communism.[22] Universal health care and national health insurance were first proposed by U.S President Theodore Roosevelt.[23][24][25] President Franklin D. Roosevelt later championed it, as did Harry S. Truman as part of his Fair Deal[26] and many others. Truman announced before describing his proposal that: "This is not socialized medicine".[22]
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."[27] According to T.R. Reid (The Healing of America, 2009):
"The term ['socialized medicine'] was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman's proposal for a national health care system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to health care must be a communist. And the phrase has retained its political power for six decades."[8][9]
The AMA conducted a nationwide campaign called Operation Coffee Cup during the late 1950s and early 1960s in opposition to the Democrats' plans to extend Social Security to include health insurance for the elderly, later known as Medicare. As part of the plan, doctors' wives would organize coffee meetings in an attempt to convince acquaintances to write letters to Congress opposing the program.[28] In 1961, Ronald Reagan recorded a disc entitled Ronald Reagan Speaks Out Against Socialized Medicine exhorting its audience to abhor the "dangers" which socialized medicine could bring. The recording was widely played at Operation Coffee Cup meetings.[28] Other pressure groups began to extend the definition from state managed health care to any form of state finance in health care. President Dwight Eisenhower opposed plans to expand government role in healthcare during his time in office.[22]
In more recent times, the term was brought up again by Republicans in the 2008 U.S presidential election.[29] In July 2007, one month after the release of Michael Moore's film Sicko, Rudy Giuliani, the front-runner for the 2008 Republican presidential nomination, attacked the health care plans of Democratic presidential candidates as socialized medicine that was European and socialist,[30][31] Giuliani claimed that he had a better chance of surviving prostate cancer in the U.S than he would have had in England[32] and went on to repeat the claim in campaign speeches for three months[33][34][35][36][37][38] before making them in a radio advertisement.[39] After the radio ad began running, the use of the statistic was widely criticised by FactCheck.org,[40] PolitiFact.com,[41] by The Washington Post,[42] and others who consulted leading cancer experts and found that Giuliani's cancer survival statistics to be false, misleading or "flat wrong", the numbers having been reported to have been obtained from an opinion article by Giuliani health care advisor David Gratzer, a Canadian psychiatrist in the Manhattan Institute's City Journal where Gratzer was a senior fellow.[43] The Times reported that the UK Health Secretary pleaded with Guilliani to stop using the NHS as a political football in American presidential politics. The article reported that not only were the figures 5 years out of date and wrong, but that US health experts disputed both the accuracy of Mr Giuliani’s figures and questioned whether it was fair to make a direct comparison.[44] The St. Petersburg Times said that Giuliani's tactic of "injecting a little fear" exploited cancer, which was "apparently not beneath a survivor with presidential aspirations."[45] Giulliani's repetition of the error even after it had been pointed out to him earned him more criticism and was awarded four "Pinnochios" by the Washington Post for recidivism.[46][47]
Health care professionals have tended to avoid the term because of its pejorative nature, but if they do 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, whether 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 in the US, such as the Veterans Administration clinics and hospitals, military health care,[52] nor 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 U.S health care system.
Medical staff, academics and most professionals in the field and international bodies such as the WHO tend to avoid use of the term. Outside the US, the terms most commonly used are universal health care or public health care. According to health economist Uwe Reinhardt, "strictly speaking, the term 'socialized medicine' should be reserved for health systems in which the government operates the production of health care and provides its financing."[53] Still others say the term has no meaning at all.[50]
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 nor do they have negative opinions of these. Media personalities such as Oprah Winfey 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]
The first system of socialized medicine based on compulsory insurance with state subsidy was created by Otto von Bismarck after the Franco-Prussian War of 1870.[56] Socialized health care was implemented by the Soviet Union in the 1920s.[57] New Zealand was the first country with a mixed economy to initiate the direct provision of health care by the state when, in 1939, it provided mental health services free of cost to the recipient following the passing of the Social Security Act of 1938.[58] After World War II in the 1940s the United Kingdom established its National Health Service, which was built from the outset as a comprehensive service, and most of Europe followed suit in the immediate post-war years with systems varying from universal insurance coverage funded by the state, to universal healthcare provision by the state. A socialized model was used in China in from the 1950s to the 1970s during the first two decades of communist rule.[59] Cuba adopted socialized medicine in the 1960s under the leadership of Fidel Castro.[60] Also in the 1960s, the United States initiated its Medicaid program to help poor mothers and their children.[61]
In Australia, primary health care remains the responsibility of the federal government, elements of which (such as the operation of hospitals) are overseen by individual states. The current system, known as Medicare coexists with a private health system. Medicare is funded partly by a 1.5% income tax levy (with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance.
In an international comparative study of the health care systems in six countries (Australia, Canada, Germany, New Zealand and the United States), found that "Australia ranks highest on healthy lives, scoring first or second on all of the indicators," although its overall ranking in the study was below the UK and Germany systems, tied with New Zealand's and above those of Canada and the U.S.[62] Healthy lives was a measure of the degree to which people can lead a healthy life and combined three factors in the assessment. Mortality amenable to health care (deaths per 100,000), the Infant mortality rate, and healthy life expectancy at age 60 (average of women and men).
A global study of end of life care, conducted by the Economist Intelligence Unit, part of the group that publishes the Economist magazine, published the compared end of life care, gave the highest ratings to Australia and the UK out of the 40 countries studied, the two country's systems receiving a rating of 7.9 out of 10 in an analysis of access to services, quality of care and public awareness.[63]
Health Canada, a federal department, publishes a series of surveys of the health care system in Canada based on Canadians first hand experience of the health care system. The following data are from the latest report.[64]
Although life threatening cases are dealt with immediately, some specialist services needed are non-urgent and patients are seen at the next available appointment in their local chosen facility.
The median wait time in Canada to see a specialist physician is a little over a month with 89.5% waiting less than 3 months.[64]
The median wait time for non-urgent diagnostic services such as MRI and CAT scans[65] is about half a month with 86.4% waiting less than 3 months.[64]
The median wait time for elective surgery is a month with 82.2% waiting less than 3 months.[64]
Although Canadians get the services of their physicians and hospitals included, they do have to meet the cost of prescription drugs themselves. Many take out insurance for this but this is not compulsory. Some people do meet some expenses themselves out of pocket.
34.3% of adults reported having no out of pocket costs for prescription drug costs. 96.2% of adults pay less than 5% of their disposable income on prescription drugs.[64]
85.2% of Canadians reported that they were "satisfied" or "very satisfied" with the way health care services are provided in their country and an even higher number (89.8%) rated their physician in the same way though slightly lower ratings were awarded to hospitals (79.9% being "satisfied" or "very satisfied").[64]
At the end of 2008 the government published its reform plan clarifying government's responsibility by saying that it would play a dominant role in providing public health and basic medical service. It declared "Both central and local governments should increase health funding. The percentage of government's input in total health expenditure should be increased gradually so that the financial burden of individuals can be reduced," The plan listed public health, rural areas, city community health services and basic medical insurance as four key areas for government investment. It also promised to tighten government control over medical fees in public hospitals and to set up a "basic medicine system" to quell public complaints of rising drug costs.[66]
The plan was passed by the Chinese Cabinet in January 2009. The long-awaited medical reform plan promised to spend 850 billion yuan by 2011 to provide universal medical service and that measures would be taken to provide basic medical security to all Chinese.[67]
Finland has a highly decentralized three-level public system of health care and alongside this, a much smaller private health-care system.[68] Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical-care costs, with the remaining one third paid by the national insurance system (nationally funded), and by private finance (either employer-funded or met by patients themselves).[68] Private inpatient care forms about 3–4% of all inpatient care.[68] In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Spectacles are not publicly subsidized at all, although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.[68] The government announced in 2009 that Kela would re-imburse the cost of private dental-hygiene work, starting in 2010.[69]
The percentage of total health expenditure financed by taxation in Finland (78%)[70] is above the OECD average and similar to the levels seen in Germany (77%) and France (80%) but below the level seen in the UK (87%). The quality of service in Finnish health care, as measured by patient satisfaction, is excellent. According to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfaction with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[71] Finnish health care expenditures are below the European average.
There are caps on total medical expenses that are met out-of-pocket for drugs and hospital treatments. The National Insurance system pays all necessary costs over these caps. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health-care costs.[72]
Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.[73]
In the Soviet Union, the preferred term was "socialist medicine"; the Russian language has no term to distinguish between "socialist" and "socialized" (other than "public", Rus: obshchestvenniy/общественный, sometimes "collectivized" or "nationalized", Rus: obobshchestvlenniy/обобществленный).[74][75]
Russia in Soviet times (between 1917 and the early 1990s) had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all citizens. Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.
The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse.[76] The population’s health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.
Main source: OECD: Health care reforms in Russia
See Healthcare in the United Kingdom for a description of the services from the user perspective.
The National Insurance Act 1911 created a system of medical and unemployment insurance for all male workers of 16 years of age or older.[77] The system, funded through four pennies per week from the employee, three from the employer and two from the government (Lloyd George's so-called "ninepence for fourpence") was at first received with some trepidation by the medical profession but was eventually seen to have been a generally good thing.[78] In 1948 the system was extended to the entire population and a new service, the National Health Service or NHS was established.[79] Today it is the world's largest publicly funded health service.[80] It was set up on July 5, 1948 to "provide healthcare for all citizens, based on need, not the ability to pay." It is funded by the taxpayer and in England it is managed by a government department, the Department of Health, which sets overall policy on health issues[81] which, for the English NHS, are summarised in the NHS Constitution for England. There are four separate health services for each of the three constituent nations (England, Scotland, and Wales) and one for Northern Ireland. In practice, they work closely together and provide a seamless service based on the same core principles.
The NHS is committed to providing quality care that meets the needs of everyone, is free at the point of need, and is based on a patient's clinical need, not their ability to pay.[82]
Every person in the UK has the right to choose to register with any general physician of their choice practising in their area.[83] If the GP has contracted to provide NHS services, as virtually all do, then all consultations with the GP will be free of charge to the patient. An NHS GP is usually not allowed to refuse to register a patient and patients usually choose to maintain a relationship with that GP over a long period in order to maintain continuity. All treatments are offered on the basis on the informed consent of the patient and, when a referral is made to a specialist at a hospital, the patient can choose which hospital to be referred to.[84] A web site informs patients which NHS hospitals in their area offer the referred service and gives details of the quality, service indicators (such as number of procedures each year and percentage of successful outcomes) as well as details of the wait times (if any) for that service. NHS patients have a choice of providers, including at least one private provider, all of which receive the standard NHS fee for the standard NHS level of care. The patient can make the appointment themselves at home using the internet, or obtain assistance from the GP or his staff to make the booking. However, the patient cannot access medical services such as specialists without a referral from the GP.
Some people choose to be treated in private hospitals. Most private treatment options are at the patient's own expense, but sometimes the NHS may sub-contract work to a private operator, in which case the NHS offers to pay for care in a private facility. Patients who choose to go fully private for a particular health care episode must pay for it themselves (including the cost of follow up care and medications) or obtain funding from an insurance policy. An exception has been made for terminal cancer patients who can choose to receive care in both NHS and private settings simultaneously and use the NHS to pay for part of their drug cost themselves if the cost is above a threashold set by the NHS.[85]
In a recent survey, ninety percent of NHS patients and ninety two percent of independent sector patients were able to get to the hospital of their choice for treatment or had no preference of hospital. Only seven percent of NHS and five per cent independent patients had been unable to get to their preferred hospital.[86]
The estimated cost of the NHS in England (the most populous part of the United Kingdom) in 2008 is £91.7 billion.[87] Funding for the NHS is met from general taxation. Healthcare entitlement is not dependent on a person's citizenship or taxation history but is instead offered to all legal residents. Temporary visitors such as tourists are only entitled to free emergency care, and will be charged by the NHS for all other services.
In an international comparative study of the health care systems in six countries (Australia, Canada, Germany, New Zealand and the United States), the British health care system was ranked in first place for quality of care. It also gained first rank position for equity and efficiency and a top place ranking for performance overall.[62] Donald Berwick the American Professor of Health Policy and Management at the Harvard School of Public Health and who assisted in the modernization of the NHS begun by Tony Blair was particularly involved in the area of health quality. This was an area he admits that, at that time, he was a novice in, but acknowledged that "in the decade between about 1998 and 2008, the UK accumulated more knowledge and more expertise per capita than almost any other nation I know about how to improve healthcare as a system". He went on to say "In some ways the period between the publication of the Modernisation Plan for the NHS in 2000 and the third election of Tony Blair seems to me a golden era for the pursuit of improvement in the NHS. I daresay that no other country did quite so well at a national scale."[88] Improved services are now being delivered closer to the patients' homes, reducing cost, improving quality, and providing a more convenient patient focused service.[89] The life expectancy at age 65 in the UK is 17.2 years for males and 19.9 years for females,[90] which is almost exactly the same as that for the U.S. (17.2 and 20.0 respectively).[91] A global study of end of life care, conducted by the Economist Intelligence Unit, part of the group that publishes the Economist magazine, published the compared end of life care, ranked UK at the top of the 40 countries studied, receiving along with Australia a rating of 7.9 out of 10 in an analysis of access to services, quality of care and public awareness.[63] The study also noted that "while palliative care is available through public medical insurance," in the U.S., "patients must relinquish curative treatments to be eligible for reimbursements," while in the UK, "both courses of treatment may be pursued" at the same time by patients.[92]
At the core of the service are the general practitioners (GPs or family doctors) who are responsible for the care of patients registered with them. GPs are mostly self-employed doctors that choose to contract with the NHS to provide services to patients commissioned by primary care trusts. Some have employment contracts with GP practices and a few are directly employed by the local primary care trust. Self-employed GPs have considerable freedom in the way that they choose to work.[93] Most GPs are therefore paid a capitation fee and certain performance related payments. Patients are free to register with any GP in whose practice catchment area they live. NHS prescribed drugs are subsidized by the taxpayer, in some cases fully subsidized. For example if the person is being treated in medical setting or at home by an NHS medical professional, or if the person is under 18 or over retirement age, or if the patient lives in areas such as Scotland or Wales where the local NHS has decided to meet the cost of all drugs.[94][95][96] All cancer drugs will be free of charge from April 2009.[97] In England, people of working age usually pay a fixed price of £7.10 (or about US$11) for each prescribed drug collected from a retail pharmacy.[98] The pharmacy invoices the cost of the drugs (less any fixed price patient contribution) to the NHS.[99]
Only GPs (NHS or private) can refer their patients to a hospital (NHS or private) for acute care.[100] Most patients choose to be treated in NHS run hospitals. Private hospitals mostly specialize in routine surgery and do not have the range of equipment that is available in NHS general hospitals. They do not, for example, provide Accident and Emergency services. In the event of an unforeseen emergency following surgery in a private hospital, a patient might be transferred to the nearest NHS emergency department, and then later moved back again. Some people therefore think it is safer to be in a public hospital for all but the most routine of surgeries.[101] The quality of care in NHS hospitals is comparable to that in private hospitals and the services obtained (medicines, surgeons and other care workers, and even meals) are free of charge to the patient, whereas private hospitals bill for these.[102] Ambulance services, mental health, and ancillary services such as physical and occupational therapy, in-home and in-clinic nursing is met from the NHS budget.[103][104] GPs do not follow their patients into hospital but each patient is referred to a specialist employed by the hospital. On discharge, the home GP receives a report back of the treatment(s) given and the results with recommendations for any follow up actions to be taken.
Most doctors and hospitals already keep electronic patient records, but a wide ranging IT upgrade programme is in progress to integrate these systems.[105][106][107] Most patients[108] in England can use Choose and Book to arrange their own hospital appointments electronically (either aided at the GP office or elsewhere via the Internet), choosing a hospital and time to suit their needs and some can already access their Summary Care Records electronically.[109] The English NHS was the first G8 country to fully implement a digital Picture Archiving Communications System (PACS) to store and retrieve x-ray and other scans in all of its hospitals nationally.[110]
Future IT developments are primarily about integration synergies, such as data sharing, such as electronic prescriptions (direct to the pharmacy) and quality management recording. Patients can choose to have their personal GP and hospital medical records mirrored centrally. In this way their complete medical history will be fully available at any hospital or doctor's office in the country at any time.[111]
The RTT system was introduced because of faults with the previous wait time recording system. For instance the wait times were sometimes overstated because some patients with multiple health problems made it unwise to treat them. Some may have been grossly overweight and the delay in treating them was more due to the time needed for them to slim down to improve their likely outcome. On the other hand, there were accusations that to meet wait time targets, physicians in some hospital may have been holding back placing patients in true need onto the waiting list, or delaying doing so by calling for more tests, thus making the wait times shorter than they really were. Sometimes patients put off medical procedures for their own reasons (a holiday perhaps, or perhaps until after a family event such as a wedding). For these reasons the government now uses the RTT method of calculation, which allows clock stopping (in the case that the patient could not be treated immediately for on ongoing health reason) or deducting the time if the patient's own choice from a list available admission dates was longer than the first available admission date. The RTT method also prevents the massaging of wait times through tactical behaviours. The effect has been that hospitals have had to become more focused on fixing the causes of delays and ensuring that diagnostic test times are as short as possible. Effective wait times have been drastically reduced, even allowing for the fact that RTT times now include time—such as for diagnostics testing—that was not included in previous statistics.
There is a maximum four-hour wait for treatment in accident and emergency. Patients are triaged and treated according to clinical priority so that those requiring emergency life saving treatment are treated immediately.[115]
The latest patient survey data compares satisfaction levels regarding wait times in NHS and independent (private) sector care. Seventy nine percent of NHS patients were either very satisfied or fairly satisfied with wait times to see a specialist, compared to eighty seven percent of independent sector patients.[116]
NHS hospitals in England carried out almost 13 million inpatient admissions in the NHS reporting year 2006/07. Of these admissions 36% were emergencies, 13% had been deferred for medical or social reasons and 35% were admitted from a waiting list. 15% were admitted for other reasons (such as maternity care or childbirth.[117] 99.6% of hospital admissions took place on time as planned.[118] Only 0.02% of all planned admissions were cancelled and not subsequently admitted within the following 28 days. Performance data for all hospitals for all common procedures (such as number of similar operations per year, clinical and patient ratings, wait times, re-admission rate) are publicly available on-line at the main NHS web site.[119]
There is popular support for the NHS.[120] The Healthcare Commission also undertakes regular surveys of patients' opinions of the NHS. In its most recent survey (2007), the experience of hospitals in England was rated by inpatients as follows: excellent (42%), very good (35%), good(14%), fair (6%) and poor (2%).[121]
The Veterans Health Administration, the military health care system,[122] and the Indian Health Service are examples of socialized medicine in the stricter sense of government administered care, although for limited populations.
Medicare and Medicaid are forms of publicly funded health care, which fits the looser definition of socialized medicine. 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 and not the government.[123]
A poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive, indicated that Americans are currently divided in their opinions of socialized medicine, and this split correlates strongly with their political party affiliation.[124] Two-thirds of those polled said they understood the term "socialized medicine" very well or somewhat well. 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 where "the government tells doctors what to do". 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. 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". [124]
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.[125]
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 unique counter to the trend found in other developed countries
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.
Supporters of government involvement in health care argue that government involvement ensures access, quality, and addresses market failures[126] 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.
Both sides have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.
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.[127]". 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.
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.[128]
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,[129] but also because it eliminates profit margins and administrative overhead associated with private insurance, and because it can make use of economies of scale in administration. In certain circumstances, a volume purchaser may be able to guarantee sufficient volume to reduce overall prices while providing greater profitability to the seller, such as in so-called 'purchase commitment' programs.[130] Economist Arnold Kling attributes the present cost crisis mainly to the practice of what he calls "premium medicine," which overuses expensive forms of technology that is of marginal or no proven benefit.[131]
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".[132] 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.[133]
Paul Krugman and Robin Wells argue that all of the evidence indicates that public insurance of the kind available in several European countries achieves equal or better results at much lower cost, a conclusion that also applies within the United States. In terms of actual administrative costs, Medicare spent less than 2 percent of its resources on administration, while private insurance companies spent more than 13 percent.[134] The Cato Institute argues that the 2 percent Medicare cost figure ignores all costs shifted to doctors and hospitals, and alleges that Medicare is not very efficient at all when those costs are incorporated.[135] Some studies have found that the U.S wastes more on bureaucracy (compared to the Canadian level), and that this excess administrative cost would be sufficient to provide health care to the uninsured population in the US.[136]
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.[137]
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.[138] The U.S ranking was 24th, worse than similar industrial countries that have very 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.[139] 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.
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.[140]
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.[141]
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."[142]
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.[143][144] 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.[145]
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[146] 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."[147]
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.[148] Economist Milton Friedman said the role of the government in health care should be restricted to financing hard cases.[132] Universal coverage can also be achieved by making purchase of insurance compulsory. For example, European countries with socialized medicine in the broader sense, such as Germany and Holland, operate in this way. A legal obligation to purchase health insurance is akin to a mandated health tax, and the use of public subsidies is a form of directed income redistribution via the tax system. Such systems give the consumer a free choice amongst competing insurers whilst achieving universality to a government directed minimum standard.
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 free-market or mixed system, makes use of a combination of compulsory participation and state price controls to achieve the same goals.[149]
Part of the current debate about health care in the United States revolves around whether the Affordable Care Act as part of health care reform will result in a more systematic and logical allocation of health care. Opponents tend to believe that the law will eventually result in a government takeover of health care and ultimately to socialized medicine and rationing based not on being able to afford the care you want but on whether a third party other than the patient and the doctor decides whether the procedure or the cost is justifiable. Supporters of reform point out that health care rationing already exists in the United States through insurance companies either denying coverage for pre-existing conditions or applying differential pricing for this coverage, or issuing denial for reimbursement on the grounds that the insurance company believes the procedure is experimental or will not assist even though the doctor has recommended it.[150] A public plan insurance plan was not included in the reform but some argue would have added to health care access choices,[151][152] and others argue that the central issue is whether health care is rationed sensibly.[153][154]
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[155] or that waiting lists in the U.S. are sometimes longer than the waiting lists in countries with socialized medicine.[156] 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 England 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[157] 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 Government and the wider community.[158][159][160] 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.[161] 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.[162]
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 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 recognises there has to be a logical trade off between spending on expensive treatments for some against, for example, caring for sick children.[163] 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 web sites 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 Investors Business Daily and Fox News.[164] 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.[165] 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; war risks. Chronic illnesses, such as diabetes and end stage renal disease requiring dialysis are also excluded from coverage.[165] 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.[165] 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.
Palin had alleged that America will create rationing "death panels" to decide whether old people could live or die, again widely taken to be a reference to NICE. U.S. Senator Chuck Grassley alleged that he was told that Senator Edward Kennedy would have been refused the brain tumor treatment he was receiving in the United States had he instead lived a country with government run health care. This, he alleged, would have been due to rationing because of Kennedy's age (77 years) and the high cost of treatment.[166] The UK Department of Health said that Grassley’s claims were “just wrong” and reiterated health service in England provides health care on the basis of clinical need regardless of age or ability to pay. The chairman of the British Medical Association, Hamish Meldrum, said he was dismayed by the ‘jaw-droppingly untruthful attacks’ made by American critics. The chief executive of the National Institute for Health and Clinical Excellence (NICE), told The Guardian newspaper that "it is neither true, nor is it anything you could extrapolate from anything we've ever recommended" that Kennedy would be denied treatment by the NHS.[167] The business journal Investment Business Daily recently claimed mathematician and astrophysicist Stephen Hawking, who has ALS and speaks with the aid of an American accented voice synthesizer, would not have survived if he had been treated in the British National Health Service. Hawkings is British and been treated throughout his life (67 years) by the NHS and issued a statement to the effect he owed his life to the quality of care he has received from the NHS.[167][168][169]
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.[151][170][171] 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).[172][173] 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.[151] 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.[171]
Supporters of private price rationing over waiting time rationing, such as The Atlantic columnist Megan McArdle, argue time rationing leaves patients worse off since their time (measured as an opportunity cost) is worth much more than the price they would pay.[153] Opponents also state categorizing patients based on factors such as social value to the community or age will not work in a heterogeneous society without a common ethical consensus such as the U.S.[151] Doug Bandow of the CATO Institute wrote government decision making would "override the differences in preferences and circumstances" for individuals and that it is a matter of personal liberty to be able to buy as much or as little care as one wants.[174] Neither argument recognizes the fact that in most countries with socialized medicine, a parallel system of private health care allows people to pay extra to reduce their waiting time. The exception is that some provinces in Canada disallow the right to bypass queuing unless the matter is one in which the rights of the person under the constitution.
A 1999 article in the British Medical Journal, stated "there is much merit in using waiting lists as a rationing mechanism for elective health care if the waiting lists are managed efficiently and fairly."[170] Dr. Arthur Kellermann, Associate Dean for health policy at Emory University, stated rationing by ability to pay rather than by anticipated medical benefits in the U.S. makes its system more unproductive, with poor people avoiding preventive care and eventually using expensive emergency treatment.[152] Ethicist Daniel Callahan has written U.S. culture overly emphasizes individual autonomy rather than communitarian morals and that stops beneficial rationing by social value, which benefits everyone.[151]
Some argue 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.[175] 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 wait times in the U.S could actually be as long as or longer than in other countries with universal health care.[176]
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.[152][177]
Some in the U.S express concern that politicians or their created bureaucracies may end up restricting their access to the health care they need or may force them to pay for health care that they feel they do not need.
In the former Soviet Union, political direction of the health care system probably caused distortions in clinical priorities, creating an unbalanced system that favoured hospitals over general practitioners. Political interference, however, does not always lead to bad medicine, and lack of it does not lead to high cost. In European countries such as France and Germany, there is very little political interference in the supply side of the health care system beyond financing and setting public obligations but medicine there remain highly rated regardless of public financing. In others such as Japan, the health care system appears to work well even though the supply side is largely private but working within a pricing framework that severely contains costs.
In the UK, where most health care is delivered by government employees or government employed sub-contractors, political interference is quite hard to discern. Most supply side decisions are in practice under the control of medical practitioners and 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 improve choice. Academics have pointed out that the claims of success of the targeting are statistically flawed.[178] 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 were deliberately leaving 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 4 hours or more in A&E had dropped from just under 25 percent in 2004 to less than 2 percent in 2008.[179] The original Observer article reported that in London, 14,700 ambulance turnarounds were longer than an hour and 332 were more than 2 hours when the target turnaround time is 15 minutes.[180] However, in the context of the total number of emergency ambulance attendances by the London Ambulance Service each year (approximately 865,000),[181] these represent just 1.6% and 0.03% of all ambulance calls. The proportion of these that attributable to patients left with ambulance crews is not recorded. At least one junior doctor has complained that the 4-hour A&E target is too high and leads to unwarranted actions that are not in the best interests of patients.[182]
Political targeting of waiting times in England 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 per cent 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 times taken for the patient to attend the first appointment with the specialist, 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.[183]