Talk:Socialized medicine

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Contents 1 auto-archive 2 CLAIMS versus FACTS 3 Innovation section 4 Deletion of BNP Quote 5 George Mason University - why so many sources connected to this one university?? 6 increased bureaucracy ? From where??? 7 Support and Criticisms section revamp 8 proposed merge to Universal health care 9 NY Times reference on "slow" medical care (for aged) 10 Cost of care section 11 Doopdoop edits of May 27

[edit] auto-archive

I am going to be bold and set up an auto-archiver - this page is now so long...--Gregalton (talk) 07:53, 19 February 2008 (UTC)

Gregalton, may I suggest that we slow down the auto-archiver at this point? I think once every 60 to 90 days would be fast enough. Thanks for taking this on! --Sfmammamia (talk) 02:02, 29 February 2008 (UTC)

Will do. Note that I set it so frequent only because the page is so active - right now it is at 190k, 250k may be a point (I understand) where some browsers have issues. If you agree, I'll set it to 50days and see how it works.--Gregalton (talk) 06:06, 29 February 2008 (UTC)

I'm tweaking to 40days before archiving - page is getting long again due to activity. Messages here if there are complaints about this.--Gregalton (talk) 07:16, 4 March 2008 (UTC)

I'm tweaking again to 60days - not now as long as it had been getting. We shall see.--Gregalton (talk) 07:46, 12 April 2008 (UTC)

[edit] CLAIMS versus FACTS

I am worried that the support and criticism section is now mentioning claims and not staying focussed on facts. Anyone can claim anything and it may or may not be substantiated by incontravertible data. I think we should stay focussed on factual data. If a claim is made, the foundation for that claim should be examined. For example, the section says that proponents claim government involvement will increase quality and that opponents says it will reduce quality. What is the reader to make of all this? If are going to allow such claims and counter claims we must at least to try to understand the evidence for such claims and counterclaim.--Tom (talk) 00:20, 29 March 2008 (UTC)

WP:V and WP:ASF allows sourced facts about opinions. Also sometimes claims have factual basis, sometimes claims have a more theoretical justifications. Details about such claims (including factual and theoretical justifications) should be added in separate sections below (see the Costs section for an example). --Doopdoop (talk) 00:31, 29 March 2008 (UTC)

I think if an opinion is based on some facts or a well founded theory then that is OK. If an opinion is based on prejudice and not substantiated by factual data then it really has no place in WP unless it is very widely held. The article you added by Sherry A. Glied is full of assumptions that she does not even try to substantiate. Its based on several premises which may or may not be true. I therefore regard even that article as suspect as a source. --Tom (talk) 08:35, 2 April 2008 (UTC)

IMHO Sherry A. Glied paper is a good example of research that is based on facts and appropriate statistical techniques. --Doopdoop (talk) 20:43, 2 April 2008 (UTC)

I'd have liked to give you some examples but the paper has now become pay-per-view and I'll not waste my money paying to download it. . . . but an example was that it just assumed that free market maximised efficiency in the allocation of resources. The assumption was implicit throughout. But as we have seen in many examples in this and many other articles, this is an assumption that is not always true. From another perspective it also values people (or rather the wealth or insurance they have or may not have access to) as commodities. In practice, a low income mother with 4 children is likely to be every bit as valuable to her children and husband and perhaps to the rest of society as a similar mother with a higher income is to her loved ones. A free market health system does not recognize this very important value. --Tom (talk) 02:06, 3 April 2008 (UTC)

I really don't want to get into a wrestling match over this one, but I would point out that the vast majority of economic research is of necessity based on at least some theoretical and methodological assumptions. Those assumptions can, of course, be be challenged and perhaps even refuted. But Dr. Glied is hardly the first economist to publish research based on a particular set of economic assumptions. You might want to look at her CV. She's a well known, well-qualified economist. This particular work may be flawed - if so, let's find another source that explains why and how. But Dr. Glied's too serious an academic for us to reject her work out of hand. EastTN (talk) 14:39, 3 April 2008 (UTC)

I agree - this is too important a paper to throw into doubt based on criticism (but I haven't read it yet). That said, Tom, you're mixing up two different points (both standard in economics): 1) when there are significant market failures and externalities, maximum efficiency may not be achieved from simple free market (and of course, full free market in health care is probably only in failed states anyway); 2) efficiency does not tell you much about distributional equity (however one might wish to call it). The latter is a choice of the political system. (And there's a complex meta-argument about whether some degree of distributional equity has positive externalities on a societal level). (Okay, there's about thirty levels of complex meta-arguments)--Gregalton (talk) 15:10, 3 April 2008 (UTC)

Please note that Dr. Glied specifically analyzed various funding schemes in terms of distributional equity and has found that they have only limited impact - i.e. the subject of the paper is your second question. The first question (efficiency) was also analyzed in the same paper, and the paper found "Using data across the OECD, I find that almost all financing choices are compatible with efficiency in the delivery of health care". --Doopdoop (talk) 21:30, 3 April 2008 (UTC)

This is only partly on-topic: I am skimming the paper quickly, but I can find no reference to socialized medicine at all in Glied's paper.--Gregalton (talk) 14:09, 9 April 2008 (UTC)

I urge anyone interested to read the paper. It has been mostly misrepresented in the discussion above and in most of the press reporting on her article that I have seen - if anything she is advocating for MORE progressivity in health care provision, and she is certainly not advocating "free market" provision of health care - rather a mix of financing. The widely-reported conclusion about financing having not much effect on cost has neglected the conclusion that other aspects of market organisation can and do affect efficiency. "In terms of public financing, the results suggest that forms of revenue collection that tax both older adults and young people are more equitable, over the lifecycle, than those that tax younger people and cover older people. The greatest redistributive benefits of public health financing occur among middle-aged people who become seriously ill or disabled. Differential mortality and relatively equal health status among survivors make public financing of benefits to the elderly less redistributive. In terms of the mix of public and private financing, the potential for public health insurance to crowd out other forms of redistributive benefits, without generating significant redistribution themselves, suggests that a mixed financing system may be the optimal way to balance efficiency and equity in health care."

To sum up, the elderly are taxed less but receive much care (especially in the US), whereas it would be more progressive to provide more health insurance to the middle aged (young people need less health care, old people - due to survivor bias according to wealth - tend to be wealthier, and hence burden of lack of health insurance falls on the poor middle-aged). The widely-reported conclusion that Canada's health care system is "not very progressive" is a gross simplification - it is less progressive than it should be / could be, partly because it provides fairly high-end care to the elderly with little taxation, and the elderly represent those that were wealthy enough to live longer. (This ignores the question of the political system, which - since Medicare for the elderly in the US is strongly associated with Social Security - played a key role in how the system was structured. As Krugman and others have pointed out, the Medicare system for the elderly was a political trade-off - provide universality for some of the population to keep political support. Likewise universality in Canada and elsewhere.)

The conclusion on financing leaves out the part that "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 the funds." This does not necessarily contradict any part of "socialized medicine" or government involvement, either directly or through regulation. Her point is that the "technical efficiency depends on the systems used to pay providers." She also has a number of caveats to this point about financing: "There are many reasons that this happy outcome may not occur in the health care system and the market may bid prices up too high. Provider monopoly power or other related payment inefficiencies, however, do not affect the choice of financing system. Payment rates may also, in theory, be established independent of the form of financing, although this may be practically difficult to achieve. For example, by using regulation, systems with decentralized revenue collection can achieve the same monopsony payment rates that centralized payment systems can." In other words, government regulation may still be needed to achieve efficiency due to market failures.

She fairly succinctly and completely throws into question how private insurance may work in practice (even if theoretically possible to do efficiently): "In practice, the existence of employer-sponsored insurance, the preferential tax treatment of premiums, and the existence of substantial risk selection between plans may make it more difficult for private insurance systems to achieve efficiency in the delivery of services."

Finally, on costs, she also obliquely refers to the progressivity of "innovation": "These patterns suggest that focusing the marginal public health care dollar on skilled nursing days, access to general practitioners, and care associated with conditions that manifest in mid-life will have a more progressive effect than focusing additional tax dollars on elective surgical procedures or specialist care." In other words, using tax dollars for high-cost, "innovative" procedures that benefit the wealthy may be net regressive.

She is also fairly clear throughout that the progressivity of the financing system is part and parcel of the progressivity/equity of the tax system, which is worthy of further consideration.--Gregalton (talk) 15:32, 9 April 2008 (UTC)

[edit] Innovation section

Forgive me for asking, but what does the new innovation section tell us about socialized medicine? --Tom (talk) 08:26, 2 April 2008 (UTC)

The NY Times article is also rather inaccurate. MRI is attributed as a US innovation, but the application of NMR to MRI was as much a British discovery as an American one. I know this because my own teacher of physics in the 1970's was himself a student under a professor at Nottingham university (who I guess must have been Peter Mansfield) who washugely influential in this work and I can vivdly recall my teacher's excitement of himself being close to what seemed to be such a huge step forward. Mansfield shared the Nobel prize with an American for this work. The earlier Nobel prize for NMR discoveries were shared by a European and an American. Even more startling is that the CT scanner is also credited as an American innovation, but the first CT scanner was in fact developed in the UK by a British company! Come on!!! --Tom (talk) 08:56, 2 April 2008 (UTC)

It gets worse!! The article states that "in the last 10 years...12 Nobel Prizes in medicine have gone to American-born scientists working in the United States, 3 have gone to foreign-born scientists working in the United States, and just 7 have gone to researchers outside the country". Looking at Nobel Prize in Physiology or Medicine in the last 10 years shown (1998-2007) I see that the United States (Population 304 million) has 16 accreditations and the United Kingdom (population of 62 million) has 7 accreditations. In other words, even a cursory glance at some real facts reveals that a country (which happens to have socialized medicine) achieves about double the rate of Nobel prizes than one which mostly does not. Now I would not have the audacity to argue that the form of medicine delivery in the UK has any connection to this amazing achievement, but trying to use the socialized medicine article to argue that socialized medicine fails to deliver innovation and Nobel prizes is pulling my nose way beyond that which I can bear. I think this entire section is without merit.--Tom (talk) 09:26, 2 April 2008 (UTC)

The Innovation section adds nothing to this article, other than a reference to one opinion piece by one American academic. Notable perhaps, as a supporter of the current American system, but hardly meriting a section of its own in this article. The cited article doesn't make any mention "socialized medicine", yet is being used an argument against it by a Wikipedia editor, not the article itself. It is also very hard to present a balanced viewpoint of the argument, unless someone else can produce a notable cite for the other side. As Tom notes above, the argument has significant flaws, but unfortunately his figures would be considered original synthesis. So I'd say unless the whole argument can produce at least three more cites of greater relevance, at least one opposing, it should be removed. Or at the very least abridged and placed deep in the Criticisms section where it belongs. --Escape Orbit ^(Talk) 10:33, 2 April 2008 (UTC)

Krugman and Wells have already dealt with this. ""new medical technology" is the major factor in rising spending: we spend more on medicine because there's more that medicine can do. Third, in medical care, "technological advances have generally raised costs rather than lowered them": although new technology surely produces cost savings in medicine, as elsewhere, the additional spending that takes place as a result of the expansion of medical possibilities outweighs those savings." There's much more detail, but in simplistic terms, innovation doesn't lead to that many lives saved if people can't access it: "one study found that among Americans diagnosed with colorectal cancer, those without insurance were 70 percent more likely than those with insurance to die over the next three years." (Not that treatment of colorectal cancer is so very innovative). In terms of effectiveness in saving lives, hand-washing by doctors and nurses is one of the most cost-effective measures; unfortunately, the soap lobby is insufficiently incentivized. Another interesting study recently was that use of "innovative" (expensive) drugs in Canada tends to be far lower than in the US - not because of cost (drugs in use were studied), but because advertising severely restricted. (Note that as I recall, the health outcomes were no worse).

But as above, the Cowen quote does not appear to mention socialized medicine.--Gregalton (talk) 11:09, 2 April 2008 (UTC)

Mark Thoma (Dept of Econ, U. of Oregon) also has some good analysis: [1]. The best point I read on Cowen's piece being "changing the yardsticks": apparently the goal is no longer to improve health but to win research prizes. Perhaps an obvious choice for a university department, not so obvious for society as a whole. (No data provided on actual results of innovation, except for the same data showing ... high spending for poor results).--Gregalton (talk) 11:19, 2 April 2008 (UTC)

Thanks for the Krugman and Wells article. Interesting stuff. It mentions Taiwan and a move to Single payer there. Not something for this article but perhaps something that should be in Single-payer health care. I don't have the time to add it but perhaps User:Doopdoop does ;) (TFIC).

Based on the comments here, and a re-look at the source, I have deleted the section. As noted, there is little to no connection to socialized medicine made in the source, and its comparative claims appear to be inaccurate and unsubstantiated. The section was built, essentially, on one economist's opinion. --Sfmammamia (talk) 16:46, 2 April 2008 (UTC)

One other comment -- this paragraph has also been added to Health care reform in the United States, where it seems more relevant to me. --Sfmammamia (talk) 16:48, 2 April 2008 (UTC)

As Escape Orbit requested, I have added three more cites. --Doopdoop (talk) 20:56, 7 April 2008 (UTC)

As far as I can tell, none of these citations meet any of the points made by EscapeOrbit: they do not mention socialized medicine, and appear to be opinion pieces. Unless there's a compelling reason to keep this in this article (as opposed to some other article), I'll delete later.

Note that the sentence "The Cato Institute argues that socialized medicine would stifle lifesaving research and innovation" is blatant misrepresentation of the article cited (the Cato institute may argue this elsewhere, but this article does not). I'm deleting this immediately because of this.

As a final comment on this section, I'd note that the Cato article makes much of the use of "differing datasets" in the WHO report - while this same standard applied to the Cowen article would result in simple rejection as absurd simplification (NHI spending on research vs "All EU core countries" spending - are these even remotely comparable?).--Gregalton (talk) 06:25, 8 April 2008 (UTC)

I see that the innovation section has been reinstated. I fail to understand why. It does not once mention Socialized Medicine and does not even try to explain why its content is relevent to this article. A connection has not been established. Socialized medicine is about the delivery and financing of health care. Medical innovation is only tangentially connected to this. Also, the comparisons in the article and references are to "Europe" verses the "USA" which does not really map to "socialized medicine" versus "non socialized medicine" (if such a pure comparison could even be made because no country is purely one or the other). One might well be tempted to conclude that the reason so much money is invested in the US is merely that is where so much money is being spent (and where, it seems, there are few value-for money type controls in the US as for example is done in the UK by the National Institute for Clinical Excellence"). But that is pure speculation on my part.--Tom (talk) 09:06, 8 April 2008 (UTC)

As socialized medicine has many synonyms, it is sometimes refered to by other names in the sources, for example CATO piece that Gregalton deleted contrasts free-market medicine with "WHO's idea of government-provided universal health care", so the sentence that Gregalton deleted is a fair summary of what was written in the source, and I would like to restore it. Tom argues that medical innovation is only tangentially connected to socialized medicine, however Cowen opposes reforms that promote socialized medicine because they would stifle innovation. --Doopdoop (talk) 18:09, 8 April 2008 (UTC)

This (i.e. "socialized medicine has many synonyms") sounds like your own interpretation. Cowen merely contrasts Europe and the US and makes a broad reference to a European model without actually defining it (-hardly surprising because there is a wide variety of models across Europe, and if he had done so he would trip at the first hurdle). You seem to be doing an awful lot of interpolation to say that "Cowen opposes reforms that promote socialized medicine". That rather makes this your interpretation and therefore WP:OR. Cowen does not addresses socialized medicine at all. He is just argues that the US spends a lot more on medical research than Europe because the US spends more on health care, that there are different attitudes in the US than in Europe towards failure, and that European researchers work in the US because the salaries are higher there. Cutting that expenditure could hit research is the implication, but there is nothing about socialized medicine.

And as we said earlier, he seems to have got his facts wrong about the U.S. system leading to preminance in the 6 most important applied technologies of the last 25 years as well the reading and interpretation of data regarding pure research as measured by Nobel prizes. Britain seems relatively to have done as much even though it has a socialized system. It would be rather difficult to check the absolute numbers regarding expenditure and he seems to have just one source for that data. But I am not inclined to do any checking.

For this reason, and the reason that other editors seemed to agree with my earlier comments about relevance and factual correctness, I am going to delete this again.--Tom (talk) 06:25, 9 April 2008 (UTC)

The Kling summary also seems to gloss over (at least part of) the argument Kling makes in his book (not sure whether the Kling quote was properly used / linked to the book in one of the intermediate versions): "attributing our 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." See New England Journal of Medicine Review. Compare this to the argument that Kling makes as summarized in the article: "Arnold Kling says that America's role in medical innovation is crucial not just for Americans, but for the entire world". I can't compare the article content since not provided.

But at any rate, that whole section is still out of place in socialized medicine article and glad to see it gone (at least until EscapeOrbit's points can be met).--Gregalton (talk) 12:09, 9 April 2008 (UTC)

Please read the first paragraph of Cowen's article. It is refers to "advocates of national health insurance", and national health insurance schemes are covered by socialized medicine article, so innovation section should be restored. --Doopdoop (talk) 22:31, 9 April 2008 (UTC)

That rather depends on what you mean by National Health Insurance and also by Socialized Medicine. As we have seen, the meanings of these words can be very flexible. I don't think you can sit in the author's head and understand precisely what he or she did mean by that.--Tom (talk) 09:03, 12 April 2008 (UTC)

[edit] Deletion of BNP Quote

DoopDoop has deleted several times now the long standing quote from the minority right wing party, the British National Party about its support for the core principles of the NHS and its criticisms of free market health care. The stated reason for the deletion is "undue weight" --- i.e. that this is a minority view not held by others. I beg to differ. The party itself may be a minority party, but the line it takes on health care is very mainstream. People in the UK do give high support for the principles of the NHS (as witnessed by survey data on attitudes to the NHS and mirrored in the views of all the political parties). Even the ultra right wing BNP. This is the reason for including the BNP quote. If even a minority right wing party supports so called "socialized medicine" and rejects notions of private sector efficiency, holding up its view of the failure of health care in the U.S. as a case in point, the popularity of "socialized medicine" in the UK is firm indeed. It is not a minority view lending undue weight. I want the quote added back. It seems to have been deleted because it does not reflect the view of the deleting editor. Or am I just too cynical?--Tom (talk) 23:27, 11 April 2008 (UTC)

DoopDoop is right. The party is a minority and it is undue weight. Extrapolation from their viewpoint to saying something about greater public opinion is your (or some other editor's) extrapolation. You're probably making a very good point, but it's not cited as such. --Escape Orbit ^(Talk) 23:33, 11 April 2008 (UTC)

The point is that medicine in the UK is most definitely not a LEFT/RIGHT issue as it seems to be in the U.S. Even far right parties (and most people in the UK would regard the BNP as far right) have a distain for free market when it comes to health care. How can one explain that issue without referal to the BNP's own sayings on the matter? I disagree that reporting this gives undue weight. It is just a short explanation in the section on the UK to give readers an understanding of how socialized medicine is viewed there. It is quite different from the view common in the U.S. and therefore needs to be understood. --Tom (talk) 09:13, 12 April 2008 (UTC)

The point is made there now in a short sentence, which should be enough given that this is a relatively marginal party.--Gregalton (talk) 09:19, 12 April 2008 (UTC)

Most people would in the UK would regard the BNP as far right; however, this could be a good example of how traditional notions of "left" and "right" can break down, especially at the extremes of the political spectrum. The BNP supports capital punishment, removal of non-whites from Britain, and other policies that are generally seen as right/extreme right wing. But it also (last time I read any of their literature - there is no mention of it on the BNP wikipedia page, and I don't want to dignify them by adding to the hits on their own website) supports various policies such as economic protectionism, provision of social housing, the NHS, etc, that are usually seen as left wing. (Or would be, if they were provided to everyone; they are not too keen on immigrants having access to the last two items). Wardog (talk) 18:20, 3 June 2008 (UTC)

I still remain puzzled at this. How is that the views of one economist (and I am referring to the recently added stuff from Tyler Cowen, who is not even a health economist), and just representing his own views, can be aired in the section on innovation (even though his arguments are demonstrably riddled with inaccuracies and were clearly not peer reviewed), whilst the views of a national political party (which was ranked 8th by popular vote out the 50 or so parties that took part in the 2005 British election) are considered to be undue weight?--Tom (talk) 06:03, 14 April 2008 (UTC)

[edit] George Mason University - why so many sources connected to this one university??

How is it that George Mason University springs up eternal in matters related to socialized medicine? Several articles quoted in the WP article are from people connected to or working at this university. Even David Gratzer, writer and critic of socialized medicine and especially Canada's health care system (and infamous for being the source of Rudy Giulliani's doubtful statistics on prostate care under socialized medicine) was awarded a prize by this university. The predominance of sources from this one university seems decidely odd. Is there something going on here? Is this also WP:Undue?--Tom (talk) 08:50, 14 April 2008 (UTC)

I have read quite many GMU sources and accordingly I tend to use them, however when Kborer returns he will be able to supply additional references from Mises Institute and other sources, so there is no WP:Undue problem. --Doopdoop (talk) 19:19, 14 April 2008 (UTC)

Ha Ha Ha Ha. But this has nothing to do with you poviding these references... the connection is there from all angles. Why does this particular institution, supposedly an academic institute, manage to generate so many connections to this topic? They never seem to be neutrally written and are always antagonistic towards government and health care. Most universities take a scrupulously academic and detached view of topics they examine, but this one sems different. There is always a story with a moral based on a certain econo-political philosophy.--Tom (talk) 22:21, 14 April 2008 (UTC)

Have you heard of Chicago school from the so called University of Chicago ? --Doopdoop (talk) 17:24, 15 April 2008 (UTC)

George Mason is a legitimate academic institution. I'm not familiar with their faculty, but it wouldn't be surprising if GMU does have a number of faculty members who share similar views - that's pretty common in any academic organization. It's also not particularly sinister - people work together, learn from each other, and attract others with similar academic points of view. I don't have any special interest in defending George Mason, but "ad alma mater" attacks aren't any more useful than ad hominem attacks - ultimately, they are just distractions that can all too easily breed ill will. The health policy literature is full of work from academics all over the world - if we want a different point of view, let's just bring in more sources. EastTN (talk) 19:35, 15 April 2008 (UTC)

George Mason University, as a whole, may be a legitimate academic institution, but its economics dept is completely suspect. The Mercatus Center, a RW and corporate-sponsored think tank, is run by members of the GMU economics faculty. It's from this paid-for think that Doopdoop gets much of his "material". J.R. Hercules (talk) 00:20, 24 April 2008 (UTC)

Interesting argument. Are you willing to describe as "suspect" any any college or university department whose faculty are associated with the the Roosevelt Institution, the Center for Progressive Reform, the Center for American Progress, the Institute for Policy Studies or the Center for Economic and Policy Research? We're very close to saying "no, I'm not gonna listen to anything they say because they're just a pack of conservatives/leftists/right-wing nuts/wild-eyed radicals/(insert your favorite red-meat demons) who're in bed with corporate money/superannuated 60's radicals/the religious right/Godless anti-American atheists/(insert another, broader set of your personal demons)." It's fine to disagree with DoopDoop (or anyone else, for that matter). It's fine to think that he's throwing anything he can in to try and support his understanding of the world. But we're going too far when we start making blanket judgments about entire academic departments at large, well recognized public universities. (And if we go down that road, understand that others are going to make exactly the same kind of judgments about our favorite institutions based on their own world views - and we aren't always going to like the result.) EastTN (talk) 15:15, 24 April 2008 (UTC)

I mostly agree with EastTN. I actually read Cowen's blog from time to time - he's interesting on micro-economics/behaviour etc. I think looking at that blog would give some idea of what is going on: GWU has a fair number of "libertarian"-identified economics profs who are pretty good at getting info out on the internet and in the news. Period. I don't think there's that much more there: people looking on the internet for these points of view will likely find GWU-related links.

Apart from Kling (who I don't think is formally associated with the school), I don't think their analysis of healthcare adds much. And Kling wrote an interesting book noting costs are high because of fancy, mostly useless technology (I'm massively simplifying), followed by a bunch of anecdotes in various opinion pieces noting this person, that person and then their dogs were saved by technology blah blah blah. What about the people who weren't treated at lower cost? That's not analysis.

At any rate, I don't think this is very fruitful - counter opinion pieces with better sources. Cowen makes broad claims (written well), others do much more in-depth research (which then gets mis-quoted by Cowen and others in the press and even WP).--Gregalton (talk) 15:27, 24 April 2008 (UTC)

Oh, and thanks for the info on Mercator or whatever it's called.--Gregalton (talk) 15:32, 24 April 2008 (UTC)

Another connection to GMU and anti-socialized medicine articles. I Googled the term today and up popped this article http://www.townhall.com/Columnists/WalterEWilliams/2007/02/14/do_we_want_socialized_medicine by one Walter E. Williams who serves on the faculty of GMU as John M. Olin Distinguished Professor of Economics. There is definitely something fishy about the economics department of this university. The quoting of lurid newspaper articles (some more than 5 years old!) as support for a general argument against socialized medicine does not really smack of academic rigour IMHO.--Tom (talk) 15:39, 6 May 2008 (UTC)

[edit] increased bureaucracy ? From where???

The article currently states that "Some opponents claim that increased bureaucracy costs more money" implying I presume that government delivered health care is more bureaucratic.

What increased bureacracy is there? Insurance companies do not add value to the health management process. They are a source of costs not benefits. They are the source of a lot of bureacracy in insurance based systems. England and Finland do not have this layer of bureaucracy (except in their small private health sectors). The public sector system has none of this bureaucracy and I do not see that it is replaced with another layer elsewhere. The doctor makes the final decision, not the doctor AND an insurance clerk. There are no claims forms filled out in the NHS. There ís no client billing. No insurance billing. No concept of the individual patient being a cost centre. All in all there would seem to me to be a LOT LESS bureacracy in socialized systems. If we repeat the claims of certain people, they should be identified and their claims should at least be backed by some credible research so that it can be verified. Otherwise this is just a lot of hot air.--Tom (talk) 16:11, 17 April 2008 (UTC)

One source is Milton Friedman's Free to Choose: "Dr. Gammon was led by his survey to promulgate what he calls a theory of bureaucratic displacement: the more bureaucratic an organization, the greater the extent to which useless work tends to displace useful work -- an interesting extension of one of Parkinson's laws. He illustrates the theory with hospital service in Britain from 1965-1973. In that eight year period hospital staffs increased in number by 28%, administrative and clerical help by 51%. But output, as measured by the number of hospital beds occupied daily, actually went down by 11%. And not, as Dr. Gammon hastened to point out , because of any lack of patients to occupy the beds. At all times there was a waiting list of patients to occupy the bed. At all times there was a waiting list for hospital beds of around 600,000 people. Many must wait for years to have an operation that the health service regards as optional or postponable." -- P.144 --Doopdoop (talk) 20:55, 17 April 2008 (UTC)

Uwe Reinhardt has criticised Milton Friedman's point here as being ridiculously simplistic: (paraphrasing) "does Milton Friedman believe that the output of a health care system is measured by beds?" "Health" is clearly not the number of beds (occupied or not). In any system, there will be empty beds, even when there is a waiting list, because they are in the wrong place, the wrong specialties, simple "friction" between one patient coming in and another out, etc. The lack of comparison to before/after (or any other system) makes this study no better than an anecdote, and a very dated one at that.

Given that one of the biggest cost/health improvements in the last thirty-forty or so years has been the recognition that patients *not* in hospital often do as well or better (at far lower cost) than those in hospital, so Friedman's comments are hopelessly dated.

Compare this to Krugman, Wells and others who have documented how much the administrative costs of the U.S. private insurance systems are - precisely because the insurers spend considerable amounts *not* treating people, *declining* treatment, and determining in advance who should have insurance or not. The administrative costs of the 'socialised/universal' parts of the U.S. medical system are by far the lowest compared to every other part of the U.S. healthcare system.--Gregalton (talk) 06:03, 18 April 2008 (UTC)

Well of course, the comparison that health output can be measured by the sheer number of hospital beds is of course ridiculous. But there is almost certainly a simple explanation for the observation that hospital beds declined in number after health was effectively nationalized. In the immediate post war years in the UK there was extremely poor housing (both due to pre-war poverty as well as the aftermath of German bombing) and tuberculosis (TB) was a huge problem. I recall that there were large numbers of sanatoria holding people in isolation for TB and other illnesses. Also there were large numbers of mental institutions. In the later post war years, following improvements in medicine, social housing and the treatment of mental illness, many of these institutions began to close. It is hardly surprising therefore that there was a drop in hospital beds over this period, but this is equated with health improvements not a drop in health care productivity! Milton Freidman was surely losing his mind in his latter years! --Tom (talk) 17:30, 18 April 2008 (UTC)

This is what Patricia M. Danzon actually says about this....

"In addition to forgone benefits, government health care systems have hidden costs. Any insurance system, public or private, must raise revenues, pay providers, control moral hazard, and bear some nondiversifiable risk. In a private insurance market such as in the United States, the costs of performing these functions can be measured by insurance overhead costs of premium collection, claims administration, and return on capital. Public monopoly insurers must also perform these functions, but their costs tend to be hidden and do not appear in health expenditure accounts. Tax financing entails deadweight costs that have been estimated at over seventeen cents per dollar raised—far higher than the 1 percent of premiums required by private insurers to collect premiums."

And where does she get this information? Seemingly from a paper by one Patricia M. Danzon comparing health care administration costs in Canada and the US. I have not read that paper in detail, but the comparison is about between government insurance in Canada and pluralistic private insurance in the U.S. It is a comparison between one country's Single-payer health insurance system and another country's pluralistic private insurance system. It is not about government administered health care (socialized medicine). I would also add, that a comparison between two specific countries' costs does not allow us to extend the analysis to all countries with one system and all countries with another, and certainly not about costs in countries such as England or Finland. Administration and managment costs in the NHS have historically been about 5-6 per cent of the total costs (see http://www.publications.parliament.uk/pa/ld199900/ldhansrd/pdvn/lds06/text/60123w02.htm). This compares to the Danzig estimate of 7.6 per cent in the U.S. health insurance industry alone!. On top of this must come management and administration costs in U.S. hospitals and other medical practices. Which seems to me to indicate that the U.S. must have a much higher precentage of bureaucratic costs than does the UK.--Tom (talk) 18:18, 18 April 2008 (UTC)

I've modified the wording of the argument to: "Some opponents argue that government bureaucracy is less efficient than private bureaucracy" and added a fact tag. I believe this wording more closely reflects the anti-government argument, but it still needs to be supported by a cite. Mind you, I don't think the argument is all that supportable by actual comparative data, but this is, in fact, the claim they make. --Sfmammamia (talk) 18:39, 18 April 2008 (UTC)

Milton Friedman's argument (excerpt is above) is reflected in the previous version. --Doopdoop (talk) 21:10, 18 April 2008 (UTC)

Ms. Danzon leaves out the information asymmetry costs that must be dealt with by an insurance company (unless there is a randomization or universality feature): see Krugman & Wells, [2].

The quote from Friedman above does not seem to clearly attribute increased bureaucracy as a necessary feature of government-run systems. That appears to be an assumption that (from the quote above) does not necessarily follow.--Gregalton (talk) 10:11, 19 April 2008 (UTC)

A more recent source of date than Friedman on administrative costs: New England Journal of Medicine study. This finds that administrative costs in U.S. are 31% of total healthcare spending, 17% in Canada. So much for bureaucracy.--Gregalton (talk) 12:33, 19 April 2008 (UTC)

I personally believe (based on my reading of NEJM, BMJ, Paul Krugman, etc.) that government-run or managed systems like Canada and the UK, and the government-run sector of the U.S. health care system, have lower administrative costs than the private sector of the U.S. health care system. (Although I'm open to new evidence.)

Nonetheless, I think that a WP entry should give the best arguments for the lower administrative costs of government, and also for the lower administrative costs of the private sector. In WP style, we can't just decide which side is right and delete the wrong side. I'd certainly like to see the evidence for and against Danzon's argument.

Many people argue, for example, that if George W. Bush were running the government health care system, the private market would be more efficient. Nbauman (talk) 23:08, 19 April 2008 (UTC)

I agree that (if we are going to continue having a section on 'socialized medicine' where none of the sources refer to socialized medicine at all) the arguments should be presented. They should be presented with some balance, however, and with at least some recognition of how much they correspond to reality in numbers.

At the moment, it does not read that way. There's the usual blah-blah-blah about govt bureaucracy, with all the actual facts relegated to a point lower down. Another thing that is incredibly unbalanced in all these sources is the bland and frankly idiotic assumption that bureacracy is purely a government issue, as opposed to large organisations (including private). It is widely recognised in economics/industrial organisation theory that there are trade-offs between economies of scale, "market-like" and other incentives, and organisational complexity and costs, and that these issues apply to the private sector as well, but these complex issues get reduced by the ideologues to "govt = bureaucracy."

This needs to be seriously re-edited to get some balance: if the vast majority of academic literature says administrative costs are lower in govt-run systems, the article should reflect that with some prominence.--Gregalton (talk) 10:36, 20 April 2008 (UTC)

Anyway the total cost levels are more important, and specific types of costs should be discussed in the article only after discussing total healthcare costs. I haven't seen any good studies about healthcare administrative costs, there is just a propaganda - one side shouts "Medicare has just 2% administrative costs", another side replies "these costs are just shifted from purely admninistrative workers to doctors and good administration has also benefits, not only costs. And monopolistic government systems suffer from Parkinson's law. Toyota has higher administrative costs than Yugo etc. etc. etc.". Have you seen any serious scientific studies about healthcare administrative costs (book review by Krugman doesn't count)?

And I just don't think that many sources have the bland and frankly idiotic assumption that bureacracy is purely a government issue, they just have an assumption that bureaucracy in private organizations is a little bit less idiotic and a little bit more efficient than the government bureaucracy. --Doopdoop (talk) 20:47, 24 April 2008 (UTC)

The claims about specific types of costs (bureaucracy) were put front and centre by you.

And I don't agree with your characterisation of propaganda re Medicare costs: Krugman cites "Health Care", the other cite is from NEJM. Krugman and Wells state they've reviewed the available evidence, which is quite unanimous.

Compare this to the Cato opinion piece "Five Myths" ('a quarterly message on liberty') which is difficult to distinguish from propaganda - not a single citation on this claim nor any throughout, as well as some blatantly absurd points. Comparing waiting times for the elderly in Canada and the US - precisely the sub-group with full government healthcare - and claiming this debunks government provided medicine is pretty rich.

As for bureaucracy of govt-provided medicine, I assume that the example he leads with (the hospital providing staff to sign people up) is one of the costs "pushed" to doctors - a cost that would simply not exist under universal, govt-provided health care of almost any type; at any rate, it's just a claim, not a reliable study or source. (Anecdotally, some doctors of my acquaintance in the US far prefer Medicare patients for admin reasons - Medicare pays, promptly, whereas claims from private insurance get dragged out, returned, delayed, etc - these are also costs "pushed" to doctors).

I will check, but I believe his claim about Canadian hospitals "loving" US patients (and queue-jumping for cash, etc) is simply false. And of course, no US figures on those "waiting" for procedures.--Gregalton (talk) 06:26, 25 April 2008 (UTC)

The original quote from Friedman about wateful bureaucracy lies in the bureaucracy created by third party approvals in systems where expenditures on health need to be approved, whether by an insurance company or the government. The context is nothing at all to do with socialized medicine. In pure forms of socialized medicine such as in the UK or Finland there are no third party approvals, so this level of bureaucracy just cannot apply in those circumstances. Friedman does go on to quote someone called Max Gammon who is particularly critical of what he sees as a creeping structural bureacracy in the NHS with nurses becoming more focussed on administration rather than patient care. Now, I had never heard of Max Gammon before and a search using his name on the BBC website produced no result whatsoever. The man may have these views but clearly he is not a significant figure in UK health care. The arguments are not unfamiliar but they are not widely held. It is a minority view and therefore should not be treated as if it represented some wider truth. It simply doesn't.

There is plenty of evidence that administration costs in government run health care systems are lower as Nbauman has described. And as Gregalton describes, there are assumption leaps in the text that are not justifiable.

The edit as it currently stands implies that government health care is more bureaucratic and more expensive which is simply untrue and not supported by factual data gleaned from the references provided. I am therefore deleting the text that says "opponents argue that increased bureaucracy costs more money".--Tom (talk) 02:32, 26 May 2008 (UTC)

Edit does not imply government healthcare is more bureaucratic. It just implies that opponents argue that it is. --Doopdoop (talk) 21:12, 27 May 2008 (UTC)

Doopdoop has reverted this disputed phrase 10 times over the last seven weeks, despite objections here by several different editors and reverts by more than a single editor. I have asked him on his talk page to work more constructively toward consensus here. Over this same period, I have proposed a couple different approaches to making this point in a more accurate, neutral way. I restate them here:

Some opponents argue that the government bureaucracy created in socialized systems is less efficient than private bureaucracy, thereby increasing costs...

Some opponents argue that the government bureaucracy created in socialized systems is less efficient than private providers in a free market, thereby increasing costs...

I continue to oppose DoopDoop's version of this phrase as an inaccurate oversimplification of the argument in the source. I request that we stop the revert war on this phrase and work constructively here toward consensus language. If you agree with me, may I request that you make suggestions here, and add your thoughts to DoopDoop's talk page regarding his editing behavior? --Sfmammamia (talk) 00:19, 5 June 2008 (UTC)

I have inserted your second version as a basis for minor improvements in future. --Doopdoop (talk) 20:07, 5 June 2008 (UTC)

[edit] Support and Criticisms section revamp

This section was at one time split simply between arguments for and against with references to data supporting or contradicting these claims. New sctions have now been added at the front of this section which now make the whole thing look a mess. I think it would be helpful to get back to laying out the arguments for and against in a more concise and logical way. I will give some thought as to how this could be done, but if anyone else has any ideas please join in. The important thing I think is to take the arguments that are used For and against and look to see how they are justified. That may mean getting away from just listing "arguments for" and "argumemts against" as different people will see them differently. For example "higher taxes" (a perceived negative) could also mean "no health insurance costs for business" (a perceived positive). It may mean splitting up the section as ISSUES and subdividing it into areas such as COST, CHOICE, RATIONING, EFFICIENCY, OUTCOMES, INNOVATION etc.. I personally would live to expose the widely distributed false statements made by some (e.g. that socialized medicine in France killed thousands of elderly by allowing doctors to be on vacation during a heatwave, and that British hospitals are so short of cash that they turn over the bedsheets between patients rather than washing them). Such arguments are widely held in the US and yet bear no relationship to the truth.--Tom (talk) 10:40, 4 May 2008 (UTC)

The point's well taken that whether something is an "advantage," "feature," "characteristic," or "disadvantage" can depend on the point of view of the observer. It could also be very useful to discuss the fundamental trade-offs that face anyone seriously interested in reforming a health care system (e.g., cost versus quality versus access, who pays, etc.), if we could do that without original research or synthesis. If practical, it could provide a very nice framework for most of the key arguments (e.g., "opponents in the US stress the importance of lower taxes and individual autonomy over universal access and uniform benefits"). I'm less excited by the idea of trying to decide which arguments are "justified" or not - many countries have decided that no direct health insurance costs for businesses justifies higher taxes. As of yet, the US hasn't (or, more properly, hasn't to the same extent - there is a payroll tax that's used to support Medicare, and general revenues support Medicaid). These are political decisions, not technical ones. We can, and should, address particular facts that are used to support the various arguments pro and con, but the kind of factoids you mentioned aren't really where the debate lies. Other more important questions, such as which kind of financing system results in the most innovation, are virtually impossible to answer empirically (I'm old enough to remember when there was an active debate over whether the old Soviet system was more economically efficient than the capitalist systems in Europe and the US - that debate wasn't settled until long after the Soviet Union was in obvious collapse, when it was too late to matter to anyone other than Fidel Castro). EastTN (talk) 15:32, 5 May 2008 (UTC)

Framing the discussion in terms of the debate in the United States could be misleading. This is not an article about the health care debate in the United States. Maybe those arguments you talk about are appropriate for a U.S. specific article, e.g. Health care in the United States or Health care reform (which seems to be about the U.S. in spite of the name). This article is about socialized medicine which has a long track record in many countries. It would be better to see how the structure of medicine delivery and finance in those countries affects outcomes/choice/quality/equity and so on. It should focus on the broad range of arguments used in those countries. Focusing in solely on the U.S. and espcially using mostly U.S. based sources would be unbalanced. Much of the information about socialized medicine in other countries that I have read which has been published in the U.S. in the context of the U.S. debate has very little relationship to reality and just seems reflect the bias of the writer or publisher. I'm still interested to hear the opinions of other editors before this revamp gets under way. I certainly don't think we should make changes before this has been fully discussed on these pages. I still need to find the time to layout my own suggestions--Tom (talk) 08:25, 6 May 2008 (UTC)

I have no desire to hijack the article and turn it into one on the US health care debate - that's what we created the Health care reform in the United States article for. But finding the right focus for this one seems tough to me. The article is, at least based on the title and lead at the top, ostensibly discussing the definition and usage of a term that's primarily used in the US. Granted, the focus of this article shouldn't be completely centered on the US, but just as there are better places to talk about US health care politics, there are other articles that may be better suited for discussing how various forms of "socialized medicine" work in other countries (e.g., Publicly-funded health care, Single-payer health care, National health insurance and Universal health care). Honestly, I think we'd be better off discussing what the nations you mention do in those articles, discussing the US debate in US-centric articles, and making this more of a political-science (or perhaps political rhetoric) article dealing with the way the term "socialized medicine" is used in political debate - but it doesn't look like that's going to happen. My thought was that to build on your suggestion of identifying key issues by identifying the trade-offs between them. I don't think the arguments pro and con are going to go away (both sides seem to anxious to make their case to just let it go), and I don't think we can simply declare that "con" arguments from the US are off limits. But, if we can identify the critical policy trade-offs involved, then we have a framework to discuss the arguments in a way that isn't US-centric. In retrospect, it was perhaps unfortunate that I chose a US argument as my illustration, but the value of a good conceptual framework is that it makes things easy to balance. "Opponents in the US stress the importance of lower taxes and individual autonomy over universal access and uniform benefits" can be balanced with "European and other proponents of a National Health Service type approach to universal coverage believe that considerations of social equity outweigh any loss of autonomy, and that the efficiency and public health benefits of universal coverage with a standardized benefit package more than justify the higher taxes required." Some things would likely be a wash - "both sides claim . . . studies have shown mixed results, with . . . " I honestly think that sort of approach would make it much easier for readers to think through the issues and to really understand where each side is coming from. EastTN (talk) 16:03, 6 May 2008 (UTC)

I proposed such a structure on this page back in March (see above), and while there were some supportive comments, it was also clear to me that even arriving at a topic list that would secure consensus was going to be more effort than I was willing to put into it. The back-and-forth that occurred on the innovation section alone was an example. I still support the general approach. --Sfmammamia (talk) 18:17, 6 May 2008 (UTC)

I just went back and looked at your prior suggestion - and the resulting discussion. Heck if I know how we develop a consensus. It would be nice, though, and I'd be willing to help with the editing if we could make it work. EastTN (talk) 18:36, 6 May 2008 (UTC)

You know, there is a whole academic literature on the question of how to evaluate the pros and cons of a health care system. Here's a recent book review from the New England Journal of Medicine:

NEJM, 20 Mar 2008, 358(12):1310, Book reviews: Just health: Meeting health needs fairly, by Norman Daniels. Reviewed by Samuel Y. Sessions. Theory of just health. "Fundamental question" of social justice for health: "What do we owe each other to promote and protect health in a population and to assist people when they are ill or disabled?" 3 focal questions: (1) Inequality is only fair if it results from talent and effort, not lack of opportunity, and health is required for fair opportunity. (2) Health inequalities are unjust if they result from "socially controllable factors." This includes education, income and wealth distribution, and workpalce organization. (3) Resources are limited. Since values differ, it is unlikely that agreement can be reached on allocation, so fair procedures should be used to decide.

One of the jobs that an academic advisor can do is to warn students when they're undertaking a research task that is so difficult as to be impossible. This could be one of those tasks. Maybe you can find somebody who has already done the job, and provided us with a framework in which to develop the debate. Or maybe the point-by-point comparison won't work. Maybe the best we can do is give some of the major arguments for "socialized medicine," and the main arguments against, in separate sections, section by section.

There are 2 obvious ways to organize it: (1) By topic or issues, such as cost, choice, outcomes, etc. (and deciding what those topics should be is a difficult job in itself) (2) By advocates, such as the Cato Institute (they're the ones who started the whole debate), the British advocates of socialized medicine of whom there are many in the British Medical Journal, etc. There may be another way to organize it. But you have to pick one organizing schema or another; you can't mix them all together. Nbauman (talk) 03:15, 7 May 2008 (UTC)

You're right, there are lots of ways to approach it - and the article is going to be a real mess until we pick one and go with it. The schemes I've found most helpful have been the ones that identify trade-offs (e.g., comprehensiveness of coverage versus cost). There are a couple of reasons for this. They don't, in and of themselves, presuppose that any one position is better than another. They tend to frame things as policy continua, rather than starkly binary, black/white, either/or choices, which leads to a more nuanced and realistic discussion - and by talking about continua you can cover a variety of approaches in a single discussion. They also seem to lead to discussions of underlying values (e.g., " . . . place more emphasis on . . . while see . . . as more important . . .").

We could, as you suggest, use one section to describe the case advocates present in support of "socialized medicine" and another to describe the case opponents present against it. It's tricky, though, because we'd have to decide whether we were presenting the "typical" case, an "exhaustive" case, or the "best" case for both sides - and we'd have to decide exactly what the cases were for and against. Right now the definition of "socialized medicine" seems pretty vague to me - it could encompass a variety of systems with some pretty important policy differences between them. That does seem to be the default way we're headed, though. If so, maybe we just need to get happy with it and make it work.

I don't think we want to organize it by advocate - there are too many potential entities on each side, and we'd likely end up with a lot of duplicative text. Does it really help to parse out the differences between Cato, Heritage, and AEI on the one side, and the British advocates versus the Canadian advocates versus the Kaiser Family Foundation on the other? Maybe it does, but if so, we probably need to rename and refocus the article.

Organizing by topics works for me, but I do think it's most useful if we don't just talk about cost in one section, what's covered in another, and who's covered in another, but highlight the connections between the various design issues. I really don't know what the best approach is, but I do believe there are real and important policy differences that are getting lost in the current wikipedia articles on health care and health care reform. It would be nice for the undergrad reading the articles to come away with an appreciation for why each side takes the position it does. EastTN (talk) 14:37, 7 May 2008 (UTC)

The main issue I think we will come up against is source material and balance. Most of the negative arguments against socialized medicine come from the US where certain interest groups seem hell bent on opposing its widespread adoption in that country, and others seem to be overcoming "the bogeyman" image of socialized medicine and have begun to argue for it. The arguments from the opponents would have more credence if those arguments were used in countries with socialized medicne and if there was popular pressure from within those countries calling for its abolition. The stark fact is that there is none. I am not aware of any significant group in the UK advocating the wholesale abandonment of tax funded health care that is free at the point of use. In fact over 90 percent of the UK population agreed with the statement that healthcare should be funded by taxation and free at the point of use. I know of no campaign in Finland either where I live now. Finns are one of the most satisfied national groups in Europe when it come to rating their hospital care. Therefore we also have the contra problem - you do not see much material from countries such as the UK or Finland praising their health care system and advocating it over other systems because nobody in their right mind would ever try to put the system back the way it was before the system was socialized. Therefore most of the material we have does seem to come from the US, which is heavily biased (on both sides perhaps). We had a long argument as I recall about rationing with some editors arguing that the free market does not ration health care but socialized systems do. It is nonsense like that makes me despair. --Tom (talk) 18:32, 7 May 2008 (UTC)

I'm not sure it's so surprising that the bulk of the arguments against this approach come from the one major industrialized nation that hasn't adopted it and in which it's under active political debate. It seems reasonable that most of the empirical evidence on how nationalized systems work would come from nations that have them; most of the empirical evidence on how free market systems work would come from countries that have them; and most of the current arguments for and against either approach would come countries where there's an active political debate. That's why my preferred approach would be to talk about publicly funded systems and universal coverage in the appropriate articles, with facts on how they work but no "point/counterpoint" debate about whether they're a good idea or not, cover the US debate in articles dedicated to it, and make this article a political science one on how the term "socialized medicine" is used rhetorically in US politics. If Finns are happy with their system, it doesn't seem likely that the debate's going to be terribly relevant to them. If they wanted to know what people in the US are saying to each other about health care, they could look to the US-specific articles. That would seem the appropriate place to put what US analysts on both sides have to say about the Finnish system in the course of the US debate. As long as there's no active debate in Finland, there doesn't seem to be any need to clutter up an article on the Finnish system with arguments either pro or con. That's why I'd really rather pull these arguments out of the "international" articles. If anything, all I'd put in those articles would be a fairly benign set of advantages and disadvantages. EastTN (talk) 20:33, 7 May 2008 (UTC)

You miss the point. If there were issues about quality, cost, innovation, access, that people in countries like the UK, Finland and Spain thought that a free market solution could solve, there would be people (and particularly political parties) arguing for that to happen. But I don't see any (certainly not in UK or Finland - I don't know about Spain). Privatization of parts of the NHS went ahead did happen in the early 1990s (hospital cleaning and catering in some places) but the results were lower costs (welcomed) AND poorer staff salaries/benefits and lower quality (not welcomed). The Blair reforms in the last 15 years or so have also created a mixed outcome. Some medical services and hospital construction projects have been outsourced, but many in the NHS argue that the NHS could have achieved the same or better if the funding had been placed in public rather than private hands. So the arguments in the US may be genuinely felt, but they don't seem to reflect reality as it relates to socialized medicine where it is practiced. I think that is highly siginficant. --Tom (talk) 16:14, 10 May 2008 (UTC)

Tom, I think your point support EastTN's position. If there's little debate about so-called socialized medicine in the countries that have it, then most of the support/criticism section in this article should be moved to an article strictly about such debate in the US. I think Health care reform in the United States is a perfect candidate. --Sfmammamia (talk) 17:45, 10 May 2008 (UTC)

But having this article pointing to examples from Cato and the like without challenging those claims here would be unbalanced. WP readers in the US need to get a more balanced view of socialized systems. The stuff put out by CATO, CPA, the Manhattan Institute and the like is totally distorted. I have not been editing here for the past year or more just to have all the balance that I have added swept away into another article. That would be unbalanced. --Tom (talk) 20:17, 10 May 2008 (UTC)

Tom, I agree that this article should not point to examples from Cato and the like without challenge, but I disagree that this is what is being proposed. Moving the US-centric support and criticisms to a US article would not leave the remaining article open to that kind of imbalance. As has been argued in the past, if this article points out that the term itself is pejorative, it appropriately addresses the perceptual imbalance you seem so concerned about. This article should then point to other articles, such as Universal health care and publicly funded health care and the articles on specific countries' implementations, such as National Health Service (England) for implementation details. --Sfmammamia (talk) 21:36, 12 May 2008 (UTC)

I don't think anyone said that the arguments put forward by Cato et al. shouldn't be challenged. That certainly wasn't my intent. The question I want to raise is where they should be challenged. Almost all of the criticisms currently being made of the various forms of national health insurance, single-payer health care or "socialized medicine" are being made in the context of the US political debate. But the way things have developed in wikipedia, the debate has spilled across a half dozen or more articles, many of which would seem to have little if anything to do with either the US health care system or US politics. The result has been a lot of confusing, duplicative text mucking up articles that would otherwise be much more understandable, approachable and useful to the typical reader.

If we pull both the criticisms of and arguments for "socialized medicine" out of the international articles and put them in a US-specific article, we can deal with them in one place. It would also seem appropriate to me, for instance, to note in the article on the British National Health Service that there is little opposition to the system within Britain. Then, if we have a source for someone making the argument you described above, that this demonstrates that socialized medicine works well because otherwise there'd be political opposition in countries that use that system, we would put it in the US-specific article as an argument "for."

The end result would be better for both US and non-US readers. A British reader, for instance, could go to articles on the NHS and national health insurance and read about how his system works, without having to wade through a bunch of arguments from the US that he doesn't care about. A US reader could go to an article on the US health care debate and read about what both sides say - he could also go to the article on the NHS and read about how that system works without having to wade through the US debate again. If the British reader wants to know what's going on in the US, he can go to the US-specific article as well, and it will be clear to him that all of the arguments flying back and forth (both "pro" and "con") are happening in the context of that specific political debate. Neither one of them should be mislead or confused, or feel that his system is being shortchanged. It might not be the best of all possible solutions, but what we have now is truly a mess. EastTN (talk) 21:53, 12 May 2008 (UTC)

Wikipedia is a global encyclopedia, so if an American debate is significant from a global perspective (and I believe it is), it should remain in all relevant articles. --Doopdoop (talk) 19:12, 13 May 2008 (UTC)

By reference or in summary form, sure, but if we mean including a full discussion then this approach applied more generally would make any encyclopedia unmanageable - every article would have to include a full discussion of every relevant related topic. For example, a similar case could be made for the relevance of the central limit theorem to any article dealing with statistics, the epsilon-delta definition of a limit to any calculus-related article, or atomic theory to any article dealing with chemistry. We don't want to go overboard and chop things up too much (and I do believe we may have some unnecessary articles in the health care area), but there's value in breaking things into separate but linked articles that allow readers to take things in digestible pieces while still moving around and finding what they need. EastTN (talk) 19:43, 13 May 2008 (UTC)

US-specific articles should have more detailed support/criticism sections than the global articles (for example views of famous politicians could be mentioned there but not in the global article). --Doopdoop (talk) 19:51, 13 May 2008 (UTC)

[edit] proposed merge to Universal health care

I have proposed that this article be merged to Universal health care. To avoid fragmenting discussion, please leave comments at Talk:Universal health care#Proposed merge. Thanks. --Ryan Delaney ^talk 02:36, 6 May 2008 (UTC)

[edit] NY Times reference on "slow" medical care (for aged)

This could equally go in any number of articles here to support the assertion (like Kling's point) that more money spent, procedures, expensive innovation and the like may do very little indeed to improve the quality of care (or even life expectancy): For the Elderly, Being Heard About Life's End. I'm sure many who have experienced the emergency care procedures applied to the elderly can see how the "default response" of many medical systems is often to provide care where it may not be needed or helpful (I have, and can support).--Gregalton (talk) 15:42, 6 May 2008 (UTC)

[edit] Cost of care section

I have deleted (twice now) the section that says

"Consumers want unfettered access to medical services; they also prefer to pay through insurance or tax rather than out of pocket. These two needs create problems for cost-efficiency" and a refererence to a commercial web site selling a book by the author of the claim.

I have deleted this for several reasons.

The first is that the claim (that users want unfettered access) may sound reasonable, but it is unsubstantiated and in any case, even if it was true, it does not say anything about socialized medicine versus alternative delivery forms.

The second is that the claim that the article said that "These two needs (unfettered access and insurance) create problems for cost-efficiency" which may be a claim made in the book, but it is not explained. What are the problems for cost-efficiency? And pray tell, what is the relevance to socialized medicine?

I see that Doopdoop has added the sections back claiming they are relevant, but there is no supporting explanation. --Tom (talk) 22:49, 15 May 2008 (UTC)

These sentences are a good background for the whole cost of socialized medicine debate, taking form a reliable source (a book the reform of healthcare). --Doopdoop (talk) 22:48, 17 May 2008 (UTC)

Please try harder.

What does "Users want unfettered access to health care" tell us about socialized medicine?

The book also claimed that "people prefer to pay through insurance". But in the UK, people prefer to pay for health care through taxation (which is why I added tax to that sentence). Opinion surveys and the actions of political parties prove this. So the book, which you say is good background, was wrong to make such a sweeping suggestion as it clearly does not apply in the UK which has a largely socialized system financed by taxation in line with peoples' wishes. Many democracies finance health care through an income related contribution. What reference does the author give for the claim that payment via insurance is prefered? It isn't in Canada, Britain, France, Finland, Denmark, Sweden, Spain and many many other countries.

And finally it talks about these two "needs" being a problem for cost-efficiency. But the article does not explain what they are. What are these problems and in particular how do these problems relate to socialized medicine?

I trust you will be able to answer the above questions in a way that will satisify most readers. Otherwise it is just using WP for promoting a book. If the views expressed in the book are contraversial then the article should reflect that.

My own take on the Cost of Care section and Socialized medicine is simply this. All health care has to be paid for and the issue is simply whether the wealthy should have better access to health care than the poor. In countries that have socialized medicine (for which I mean the loose definition of a fully publicly funded health care) there is a deliberate attempt to provide a level access to everyone regardless of means (to each according to his/her needs) and an attempt to meet the cost from taxation (from each according to his/her means), which is of course a basic socialist tennet. But it also aligns with the philosophies of most of the world's religions, so it is an age old idea based on ancient philosophies. --Tom (talk) 16:35, 18 May 2008 (UTC) & updated --Tom (talk) 13:24, 19 May 2008 (UTC)

Some of this disagreement isn't necessary - the book was written in the context of the current US system, which is why it talks about insurance rather than taxation. That's the economic choice most Americans currently face (insurance versus direct out-of-pocket payment), so it's the one discussed in this particular book. The broader principle is an important one, though, and it's consistent with what we see in a variety of everyday financial decisions. Most consumers prefer third-party reimbursement (whether that be through an insurance program, or a tax-supported government program) to direct out-of-pocket spending. It's less visible, and the psychology is different - even if we know better, it doesn't feel like we're paying. We see this effect a lot in retirement programs - people who would not put money in savings or investment for retirement, will participate in an employer-sponsored retirement plan that's funded through payroll deduction (especially if it's tax-advantaged). The contributions never show up in take-home pay, and once the election to participate is made, you don't have to continually make the choice to save the money rather than spend it. It also makes spending more predictable, and thus easier to budget for. As a result, people will opt for insurance or tax-based programs even when they increase the total cost due to administrative overhead and other system inefficiencies.

This is relevant to any form of third-party reimbursement for health care. The same psychology that creates the preference for third party reimbursement affects consumer behavior when seeking health care. Because there is little or no direct out-of-pocket cost at the time care is received, people are more likely to seek care. This effect is recognized by both proponents and opponents of third-party reimbursement, and is used in arguments in support of both sides. Proponents argue that high out-of-pocket costs cause people to forgo care that they need, in order to avoid the cost. Opponents argue that if out-of-pocket costs are brought too low, people will seek unnecessary and wasteful care. There are no easy answers, because in the US at least good research can be found on the one hand to demonstrate that some people do indeed forgo care that they need because it's too expensive, and on the other hand to demonstrate that a great deal of unnecessary, wasteful and in some cases counter-productive care is provided to people who don't have to pay for it directly (and that most Americans have no idea what the real cost of their health care or health insurance is, because they never see the full bill). Then we start dancing on the head of a pin trying to decide exactly how much health care is "just right." (The effect is well-recognized enough that reflecting the impact of additional benefits on utilization is written into the regulations governing the actuarial bids that private insurers submit to CMS to participate in the Medicare Part D program - the additional "induced utilization" for an enhanced Part D plan has to be separately identified and included in the supplemental premium paid by the enrollee, so the government doesn't end up footing the bill for it.)

Bottom line, most of us don't want to be faced with a large, unexpected bill if we need to take a sick child to the doctor - we'd rather have an insurance or social program (or rich uncle) to take care of it for us. We really, really don't want to be faced with a catastrophic bill if our spouse is diagnosed with a terminal illness. But once we know someone else is picking up the check, it's going to start affecting our behavior at least marginally. That preference, and the resulting effects on patterns of care usage, should be understood by anyone seeking to design or manage a health care system, whether the system be public or private. It's also the basis for many of the arguments about what type of system is most effective, and which methods of controlling health care utilization are most appropriate. EastTN (talk) 14:09, 19 May 2008 (UTC)

That explains a little about what the book is saying, but I still am not sure what the text in the article is trying to say about socialized medicine. The premise of the section of the book as you explained seems to be that if health care is free then demand will rise and hence spending will rise (especially if it is re-imbursed spending and the user is free to choose his own treatments). Well of course that does not happen in socialized systems such as the UK or Finland where health care is mostly free of charge to the user. This is because they are essentially not re-imbursing systems. They entrust doctors to judge what is both good for the patient and cost effective; in effect to allocate precious public resources between patients. This is so-called "gatekeeper function" prevents wasteful spending and encourages only cost effective spending because they have to work within a spending cap for ALL patients. Furthermore performing unnecessary medicine does not bring in more salary for doctors (or income for their employers) because because they already have an assured salary as public employees. And it certainly does not encourage so called "defensive medicine" (i.e that done merely to avoid potential malpractise lawsuits which could wreck a doctor's livelihood). I would think therefore that this book should regard socialized solutions as being an effective solution to this problem of overspend risk. Do you know if it does?

I still think DoopDoop should explain the relevence of the text to socialized medicine. We need to have this buttoned down. Otherwise the text belongs in another article such as Health care reform.--Tom (talk) 16:41, 20 May 2008 (UTC)

First of all, I tend to agree that the current text doesn't do a good job of explaining how this all relates. But if we're going to try and cover the arguments for and against "socialized medicine" in this article (which I really do think would be better handled in an article such as Health care reform or Health care reform in the United States), then the discussion is relevant.

You make an important point when you note that socialized systems use health care providers to perform a gatekeeping function. (As an aside, that concept isn't unknown in the US - many HMOs were organized around the use of "gatekeeper" primary care physicians who authorized any use of specialists or hospital services. The tight control of access to care through these gatekeepers was one of the primary complaints against HMOs back in the 1980's & 1990's, and most health plans in the US no longer use them.) US opponents of a socialized system argue that if you make health care "mostly free of charge to the user" then, all other things being equal, patient demand for services will go up. Of course, in any real system "all other things" won't be equal - there will have to be some method for controlling spending levels. (As another aside, US proponents of reform have often been disingenuous about this point, by denying that there would be any form of "rationing" in a national system. In my opinion, that's not helped their case.) Several methods have been suggested in the US debate: formal "gatekeeping" systems with uniform national treatment guidelines and utilization targets; "global budget" systems where system-wide spending targets are set and then used to set budgets for hospitals, physician practices, and labs which would ultimate determine how much was spent on care each year; a variety of suggested programs for promoting more cost-effective care, etc.

The crux of the US debate comes down to this: if we have to have some mechanism for controlling overall health spending (and I think that all serious analysts would say that we do), then what works best? Making care essentially free and using administrative systems to control utilization, or making patients pay part of the cost of care and using market mechanisms to control spending? For whatever reason, many Americans have a visceral dislike for administrative barriers to care. As I mentioned above, that's not just true when considering government systems; it's also one of the biggest complaints about health insurance companies. People, including myself, really don't like requirements that they get pre-authorization for a procedure, or a referral from a primary care "gatekeeper" before going to a specialist, etc. On the other hand, we don't much care for having to pay a lot for care. More than that, without appropriate subsidies or other targeted programs for low-income individuals, market-based mechanism can create inequities for people who cannot afford to participate in the market. (As another aside, one underlying problem of the US system that's not well recognized are the "categorical" eligibility requirements for Medicaid. Being poor isn't enough to qualify - you also have to be a child, parent of an eligible child, disabled or elderly. Non-disabled, non-elderly singles and childless couples are out of luck, even if they have absolutely zero income. Two-thirds of the uninsured have family incomes below 150% of the federal poverty level. In other words, if Medicaid covered everyone below 150% FPL, it would cut the uninsured problem in the country by more than half.)

I don't have a lot of personal effort invested in this particular article, so I really don't feel like I have a dog in this fight. But if the article is going to talk about the arguments for and against socialized health care systems, I do think it's important to talk about how such a system controls spending, and the debate over whether administrative mechanisms are a better approach than market-based mechanisms for allocating health care resources and controlling overall spending levels. EastTN (talk) 18:37, 20 May 2008 (UTC)

I deleted this again and it has been added back. The Kling argument is about third party payment systems where the payer (be it a private insurance company or the government acting as an insurer) pays another party... i.e. a hospital or medical practitioner or other health service provider. The health care provider has no incentive to spend the money wisely because costs will (usually) be re-imbursed. In pure socialized systems such as in the UK, where the government is both health care provider AND controls the budget for health care for everyone, this problem is considerably reduced because if money is spent unwisely on person A there is less to spend on person B. In other words in pure socialized systems there are only two parties... just the patient and the health care provider (which holds the financial pot for EVERYONE's healthcare). This issue is perhaps more pertinent to single-payer health insurance bút not really to socialized medicine. This is why I am so adamant that the text "Consumers want unfettered access to medical services; they also prefer to pay through insurance or tax rather than out of pocket. These two needs create problems for cost-efficiency" is misplaced. The argument (which leads from the the text) applies less to purely socialized systems than it does to say free market private insurance based health care systems. --Tom (talk) 19:34, 3 June 2008 (UTC)

Kling's argument also applies to fully socialized systems in democratic countries (exception is dictatorships where government is completely unresponsive to the wishes of consumers to have unfettered access to healthcare). --Doopdoop (talk) 20:17, 4 June 2008 (UTC)

It cannot apply in the UK or Finland (which are pure forms of socialized medicine because they are both government run and financed) because health care costs are NOT spent by one group and reimbursed by another. The Kling argument was the separation of spender and payer creates no incentives for the spender to be as economical as if it were, for a example, a person spending his/her own money. That applies as much to private medical insurers as it does to public insurers like Medicare. Because of this it cannot be an argument that tells us anything about socialized medicine. The argument does not hold in countries such as Finland or the UK because the health care provider also holds the financial pot. Therefore I fail to see how you can say "also applies to fully socialized systems.." - please explain your logic in extending Kling's argument of third party reimbursement as if it were something unique and/or only applicable to socialized medicine. It just isn't.

It applies to the UK because costs that are spent on any individual are reimbursed by all other people. Voluntary nonsocialized insurance might reduce this problem due to competition. --Doopdoop (talk) 20:02, 5 June 2008 (UTC)

You are not following the argument at all and have just created another one! The issue is about Kling's argument which is the segregation of payers and spenders in a re-imbursement model. But in the UK and Finland, payers and spenders are the same (public budgets for health care are held by the agencies providing health service). Your argument (that costs that are spent on any individual are reimbursed by all other people) applies to all insurance reimbursement systems, private or public and completely sidesteps the argument that Kling makes. Socialized systems (by the strict definition) are not reimbursement systems at all. So Kling's argument has nothing to tell us about strict definition socialized systems, and if we take the loose definition, what applies to public re-imbursement programs could equaly apply to private one. The second point you raise (the allegation that public bureacracies are more expensive than private ones because of a lack of competition) is a completely different issue and therefore a diversion. Let's stick to what Kling actually says.--Tom (talk) 15:38, 7 June 2008 (UTC)

You have misunderstood Kling. Pleas read this [3]. It is obvious that in the UK and Finland "consumers enjoy the peace of mind of having their medical services paid for by a third party". --Doopdoop (talk) 21:31, 8 June 2008 (UTC)

Absolutely not. It confirms what I say. Its about reimbursement systems and spenders (health providers) who don't worry about cost. In socialized systems, there is a careful balance act to ensure that spend delivers both good health care and value for money. It is in fact the opposite of what you are arguing.

You chose to focus on "consumers enjoy the peace of mind of having their medical services paid for by a third party"... well private health insurers pay an insurance premium and may receive more or less value in health care services than they paid in. It is exactly the same with socialized medicine except we are talking about taxes and not insurance premiums. The main dilemma Kling refers to is where there is "unrestricted access, where consumers and doctors can choose medical procedures without bureaucratic interference or government budget limits". That seems to apply to some private health care systems that Kling describes but it does not apply to socialized systems where there is always a balance drawn between spend and benefit. Hence I intend to delete your edit. Kling was NOT talking about socialized medicine!--Tom (talk) 13:28, 9 June 2008 (UTC)

[edit] Doopdoop edits of May 27

This question is directed at editor Doopdoop but is being published here for others to see. You have reinstated certain texts which have been disputed on this page and which have been previously removed from the article for reasons already explained in some detail on this talk page. You have done this without making any proper attempt to explain your actions. This seems to be non-constructive editing. Please explain why you feel these edits are needed so that the community of editors can better understand you and to determine whether they agree with your desire to include these texts in the article. I am particularly keen to understand the relevance to the article which is socialized medicine (i.e. publicly financed medicine which may or may not be delivered by government agencies, according to your preferred definition).--Tom (talk) 22:48, 28 May 2008 (UTC)

Which diff are you interested in? --Doopdoop (talk) 20:05, 29 May 2008 (UTC)

I am sure you can read the comments here and use WP to identify differences. I am asking you to justify reinstating texts that have been removed for reasons already given. Assume that I mean all of it.--Tom (talk) 08:39, 30 May 2008 (UTC)

At least indicate the time zone you meant (May 27 in Buenos Aires is very different from May 27 in Sydney). --Doopdoop (talk) 19:01, 30 May 2008 (UTC)

I refer to the three edits you made to this article on this date (in US time)... according to my time zone you did not make any edits ti this article on the day either side so there can be no misunderstanding.--Tom (talk) 13:56, 4 June 2008 (UTC)

I'll try to present better explanations in edit summaries and in appropriate sections of talk page. --Doopdoop (talk) 19:59, 5 June 2008 (UTC)