scumble on 6/9/2008 at 09:34

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I'm not sure why more people don't note the distinction between centralised and decentralised functions. I suppose it's partly because the centralised bit of government is really too powerful - and I'd say that about the UK or the US. I don't have a problem with an organisation like the NHS, I just don't think it is sustainable as a vast centralised bureaucracy. Unfortunately, a local government authority can't afford to run health services because the population pays most tax to the central authority, and local authorities depend on grants to run services properly. I suppose that applies more to the UK system, but I know Federal grants can be important for State governments. Either way the central authority attempts to control expenditure across a nation, usually at a far remove from actual local problems which vary from region to region.

The trouble with national politics is that "issues" are abstracted to the point where they lose a lot of meaning. Grand things are said, people get all excited about "change" or whatever, but what relation does it have to what will actually happen once it filters through the creaking machinery of the system?

SD on 6/9/2008 at 13:13

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America spends more on healthcare than any other country. It is by no means the best healthcare system out there (and a sixth of the people have no coverage).

I honestly can't recommend (http://www.prospect.org/cs/articles?article=ten_reasons_why_american_health_care_is_so_bad) Ezra Klein (no relation) enough on the subject. He has as good a grasp of the problems with healthcare in the United States as anyone. In particular, his (http://www.prospect.org/cs/articles?articleId=12683) The Health of Nations article is illuminating.




That's (http://en.wikipedia.org/wiki/Negative_liberty) negative liberty, the libertarian/classical liberal belief that there should be as few restrictions on people's lives as possible.

Liberals, however, also believe in the concept of (http://en.wikipedia.org/wiki/Positive_liberty) positive liberty. This is where our support for universal healthcare, public education etc etc comes from. Liberals recognise that true freedom and liberty is more than the removal of constraints, it is also giving people the tools and means to flourish as individuals, and occasionally that will require taxpayers' money, governmental programmes and shared risk, as well as personal responsibility. "Freedom isn't living on your own unmolested in a desert, it is living in a thriving community where people can choose to access any opportunity that their ability and desires leads them."




"Governmental interference" has nothing to do with it. American healthcare is so expensive because of the bureaucracy of private insurance companies. Compare it to the efficiency of Medicare. And drug prices are sky-high because government doesn't use its collective power to bargain costs down, like (for example) (http://en.wikipedia.org/wiki/National_Institute_for_Health_and_Clinical_Excellence) NICE does in the UK. It's less to do with "greedy doctors", and far more to do with unnecessary middlemen creaming off huge profits and cherry-picking the "best" patients while government umms and aahs and does nothing about it.

(Although I must say, even America's bloated, overpriced health insurance system would be preferable to your desire to revert to the Dickensian days of charity-supplied health services. Go read Oliver Twist and let me know how poorhouses would be an improvement on what we have).




This is why provision of healthcare (hell, provision of most things) should be devolved down to a regional level, where people can decide what works best for them locally. This does not mean that the funding for healthcare cannot be obtained through general national taxation.

Starrfall on 6/9/2008 at 14:06

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Providing for safety of self and property is ensuring a standard of living. For someone complaining about having words put in your mouth you certainly are knee-jerking fafhrd's to the furthest extreme possible.

I mean if you really have a problem with the government ensuring standards of living then you have a problem with things like free paved roads or police forces or judicial systems that allow you to recover damages if someone wrongs you or food packages having to contain what they say they contain and so on. Let's not let the boogeyman of socialism make us irrational.

Gryzemuis on 6/9/2008 at 14:56

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I'm a bit late.
But you seem to be pretty aggresive to "dumb" people.



FYI, North America consist of Mexico, the USA, Canada and .... uh, uh, Greenland. Greenland ? Yep, a provence of the european Kingdom of Denmark. So saying that North America has not traces of Europe is just as dumb. Good luck flaming other people for being dumb during the rest of your brilliant life.

heywood on 6/9/2008 at 15:39

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Regarding the efficiency of Medicare: Medicare has relatively low administrative costs compared to other government programs (about 2% of payments). However, Medicare does not employ doctors, run hospitals and clinics, make capital investments, inventory supplies, negotiate with drug companies, etc. Medicare's payments go into the private health care system which pays for all of the above. So you can't compare Medicare's administrative costs to the overhead of private health care bureaucracy, because Medicare's administrative costs only include processing enrollments and claims. The rest of the bureaucratic costs are counted in the claim amounts that Medicare pays. And the average amount that Medicare pays in claims per patient per year is more than double that of private insurers.

Now, regarding your claim that health care in the US is so expensive because of the bureaucracy of private insurance companies: I've seen reports saying the overhead of private health care bureaucracy is as low as 10-12% or as high as 25-30% depending on whose advocacy group is doing the study. These percentages are not anywhere near high enough to explain the rate of cost growth, and they're not going up as the cost of health care rises.

Frankly, the rising cost of health care in the US is just as puzzling to me as the rising cost of education. I don't think there is a simple answer. But certainly bureaucracy is not the major reason. And neither is profit motive. Last I heard, about 1/3 of the insured are covered by not for profit providers. I've switched back and forth between for profit and not for profit insurers as I've changed jobs, and at least in my experience there's been no major difference between the two in terms of premiums or quality of care. Further, hospital costs are probably the fastest growing segment of overall health care costs but the vast majority of hospitals in the US are not for profit.



It's a long story, but it boils down to a fundamental argument over the role of government that goes back to the founders of this country. Let me try to provide the background:

First you have to understand that the US government was formed through a contract between the states which explicitly specifies the responsibilities and powers of the federal government. And one of the original 10 founding amendments (the "Bill of Rights") says that all powers not explicitly granted to the federal government are reserved to the states and/or the people. Providing social welfare is not among the powers and responsibilities under the Constitution, so under a strict or literal interpretation, programs like Social Security and Medicare would be illegal. The legality of these programs is based on a Supreme Court decision back in the 1930s during the Great Depression when Social Security was enacted. The court, under the threat of being expanded and packed, ruled that Social Security was permissible by implication under the clause of the Constitution which grants Congress the power to levy taxes. This precedent has been used as the basis for the legality of other social welfare programs like Medicare.

There has been an active debate going all the way back to our founders over the clauses which grant Congress the power to levy taxes and the power to regulate commerce between the states. Alexander Hamilton, in writing the Federalist Papers, argued that the Constitution granted Congress broad authority through implication under the taxation and commerce clauses. This became known as the doctrine of implied powers. Thomas Jefferson, James Madison, and John Adams argued that the taxation clause only granted Congress the right to tax in fulfillment of its enumerated powers (such as raising armies) and argued for a literal interpretation of "regular commerce among the several states". This became known as the Constitution doctrine, or in modern times, strict constructionism.

Prior to the 1930s, Constitution doctrine was dominant. Since the 1930s, the doctrine of implied powers has been dominant. Most of the federal social welfare programs and regulatory agencies were created in either the 1930s or the 1960s under Supreme Courts which leaned towards a very liberal interpretation of implied powers. The fight between these opposing judicial doctrines is always one of the biggest issues in federal elections, because the President appoints justices and the Congress confirms them.

The traditional conservative view in the US is that providing for social welfare is a state and/or local issue, not a federal issue. As a result, you'll find that unemployment insurance, job training, welfare, and disability programs vary from state to state. The more liberal states tend to have more programs with greater benefits along with more bureaucracy and higher taxes to pay for them. Health care is moving in the same direction. Massachusetts enacted a universal coverage program based on private insurance which combines state subsidies and benefits with individual and employer mandates. This program came from a conservative governor (Mitt Romney). California is now following suit, under a moderate Republican governor. This is the way the US is going to deal with the problem of the uninsured, not by nationalizing health care.