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December 04, 2007

Programs For The Poor Are Poor Programs

Kevin MD asks how single-payer advocates account for the failure of the Indian Health Service. I don't know enough about the IHS to say whether it's a failure, but for the sake of discussion, the answer is easy: As the saying goes, programs for the poor are poor programs. Native Americans are among the poorest, most marginalized, most disenfranchised constituencies in American life. That a charity program for them would be underfunded and rarely improved is among the least surprising facts you could possibly tell me. It's like asking why, in the private system, the poor seem to have it so bad. The answer is because they're poor. The virtue of single payer, and all integrated national systems, is that it puts the poor and downtrodden in the same system as the rich and politically powerful. If the rich want a decent system, then the poor get one too. In other countries, there's a word for this: Solidarity. In our country, we call it universalism.

Update: Or, as El Cid says in comments, "I am shocked, just shocked at any suggestion that a U.S. government program based on solemn promises to our native American communities is operated with anything less than perfect dedication."

December 4, 2007 in Health Care | Permalink

Comments

I am shocked, just shocked at any suggestion that a U.S. government program based on solemn promises to our native American communities is operated with anything less than perfect dedication.

Posted by: El Cid | Dec 4, 2007 11:51:01 AM

I was going to have a long post about the complications of bringing doctors to the reservations and the difficulties of providing hospitals and medical facilities for a poor area that is also very spread out. And the additional problem of providing health care only at the IHS buildings (which are on the rez) which restricts access to them to anyone who moves away.

Then I read the budget for the IHS is slightly less than four billion dollars to cover 1.9 million Native Americans. So for a group of people that will have more health problems (due to wealth issues) and is more spread out than and difficult to provide care for, the per capita cost of health care is around $2,100. It's no wonder that the health care provided is poor.

Posted by: Alex | Dec 4, 2007 12:11:26 PM

When we are all in the same boat then we are all much more keen on bailing, keeping it fixed and running.

Posted by: Hawise | Dec 4, 2007 12:18:29 PM

"The virtue of single payer, and all integrated national systems, is that it puts the poor and downtrodden in the same system as the rich and politically powerful. If the rich want a decent system, then the poor get one too."

So we all get the gray average system. Kind of like the USPS.

Posted by: ostap | Dec 4, 2007 12:21:21 PM

I like the USPS. They've always given me outstanding service, and even the busiest offices I go in help me out just as quickly and just as helpfully as any UPS or FedEx office I've gone in.

Posted by: El Cid | Dec 4, 2007 12:44:03 PM

Ezra,

The virtue of single payer, and all integrated national systems, is that it puts the poor and downtrodden in the same system as the rich and politically powerful.

This is obviously false. Even in a "single payer" system, the rich and politically powerful obtain superior health care through their private wealth and political connections. As has been pointed out before, the health-income gradient under the "single payer" health care systems in Britain and Canada is about the same as it is under the U.S. system. Rich and powerful people will always be able to get better health care than poor and downtrodden ones.

And this isn't just because there's really no such thing as a "single payer" system (in all nations, health care funding comes from multiple sources, and private wealth is always a big component.) Even within the "single-payer" component, standards vary enormously. Within Britain's National Health Service, for example, the quality of doctors and hospitals varies enormously according to where they are located. NHS services in poor and depressed parts of Britain tend to be much worse than NHS services in wealthy and vibrant areas.

Posted by: JasonR | Dec 4, 2007 12:51:50 PM

In our country, we call it universalism.

Actually, a good portion of the country calls it "SOCIALISM AND IT'S BAD BAD BAD!!!!" Which is a big part of the problem, of course.

Posted by: Stephen | Dec 4, 2007 1:04:19 PM

From the article that Kevin, M.D., cites in arguing that the failure of the Indian Health Service is a reason we shouldn't have universal health care:


But the Indian Health Service can't spend money it doesn't have, and it doesn't have much. America spends an average of about $5,000 per person per year on healthcare. For government programs that deliver healthcare directly, the per-person expenditure varies enormously: $5,200 by the Veterans Administration, more than $3,300 by the armed forces, $3,800 per federal prisoner, and $1,900 by the Indian Health Service. Money isn't everything, but without it you can't buy healthcare. And without it a dent will never be made in the health disparities of these people to whom our government has given its word.

Kevin tries to preempt discussion of how underfunded the IHS is, writing "And before you explain that it's underfunded, why do you have such blind faith that the government will appropriately fund a national single-payer system?" I have no such blind faith, though I suspect a constituency in the hundreds of millions will be to lobby for quality of service more effectively than the most disenfranchised constituency in this country's history. But the more important point is that underfunding most certainly is what is wrong with the IHS, not something inherent in the idea of universal health care.

Posted by: kth | Dec 4, 2007 1:10:46 PM

"So we all get the gray average system. Kind of like the USPS."
The amazing thing about being rich is if you don't like the gray average system you get for free, I'm sure someone around the country will be more than willing to paint some racing stripes on it for you for a small fee.

Posted by: flounder | Dec 4, 2007 1:32:36 PM

Since Mormons believe that American Indians are the 'Lost Tribes of Israel', who were turned red for losing touch with God, and will turn back into white people if the accept Mormonism, I wonder if Romney's answer to health care for Indians is to convert them and get rid of the IHS and BIA altogether?

Posted by: flounder | Dec 4, 2007 1:38:48 PM

The virtue of single payer, and all integrated national systems, is that it puts the poor and downtrodden in the same system as the rich and politically powerful.

Nope. This study by June and Dave O’Neill debunked that myth as it relates to Canada’s single-payer system. In Canada, just as in the US, poor people tend to be in poorer health than patients further up the economic ladder.

Posted by: Catron | Dec 4, 2007 2:18:34 PM

Native Americans do not vote.

Posted by: Floccina | Dec 4, 2007 2:24:19 PM

Why do I have such faith that the government will fund a national single-payer system?

Well, du-uh-- BECAUSE WE'RE WHITE!

This Kevin guy starts out being wrong when he claims that doctors don't like Medicare because it's hard to get reimbursed. Actually, doctors will tell you that they know what and when they'll be paid from Medicare, while it is the private insurance companies who require pre-approvals and try in every way to avoid paying.

He goes on to demonstrate incredible ignorance of how native Americans have been treated by white people. Calculating the stolen Trust Fund monies does not even address the issue of outright theft of Indian natural resources, or the opportunity costs to the Indians of being locked out of labor or commercial markets.

I hope he's a better doctor than he is commenter.

Posted by: serial catowner | Dec 4, 2007 2:41:58 PM

-Culture of Contentment_, Galbraith. Well worth reading.

Posted by: Phoenician in a time of Romans | Dec 4, 2007 4:25:17 PM

"The virtue of single payer, and all integrated national systems, is that it puts the poor and downtrodden in the same system as the rich and politically powerful."

Why do the rich and politically powerful from socialized medicine countries come to the US for medical treatment? I guess socialized medicine isn't good enough for them. It is good enough for the masses, but not the elite.

So, we will just downgrade our medical system so that all Americans have piss-poor medical care.

Posted by: abg | Dec 4, 2007 4:38:03 PM

Why do the rich and politically powerful from socialized medicine countries come to the US for medical treatment?

There needs to be a primer to which we can point people like abg who try to make arguments that have been refuted over and over and over and over.

Posted by: Stephen | Dec 4, 2007 5:12:11 PM

"Why do the rich and politically powerful from socialized medicine countries come to the US for medical treatment?"
They don't, unless they are getting plastic surgery.

Posted by: flounder | Dec 4, 2007 5:36:53 PM

Nope. This study by June and Dave O’Neill debunked that myth as it relates to Canada’s single-payer system. In Canada, just as in the US, poor people tend to be in poorer health than patients further up the economic ladder.

Catron: Ezra is making the claim that in single payer countries, rich and poor alike are in the same system. This is manifestly true, even if it is likewise the case that the wealthy can pay to queue jump, or access some or all of their treatments outside the tax-supported plan. I don't think anybody would argue with the proposition that wealthy people tend to enjoy better health than poor people, no matter what system is in place.

In fact, Canada's Medicare system -- since you bring it up -- while far from problem-free, provides robust healthcare access to the Canadian people as a whole -- without regard to income -- as a matter of law. By American standards it does so on an incredibly economical basis. Oh, and it remains extraordinarly politically popular and strongly supported by the public. Largely because it serves the entire population, rich and poor alike. Kinda like Social Security and Medicare in the United States. Which I suspect is Ezra's point.

Posted by: Jasper | Dec 4, 2007 7:09:34 PM

Um... the VA system incorporates a LOT of poor people
And they get included because they're low income.
I.e. -not- service-connected. Just plain vets.

Like me.
And like the veteran 26% of the homeless when they find their ways to a facility.

Posted by: has_te | Dec 4, 2007 8:25:14 PM

So KevinMD's question was this -- How do you explain the miserable failure of the single-payer funded Indian Health Service?

VERY simple answer ANY MD should be able to deduce before yelling at single-payer advocates:

1. The IHS is underfunded.
2. The Fire Department is not.

That really SHOULD be the end of the argument.

I'd like to see what a privately funded IHS would look like, if given the same amount of money per capita. Actually, I fear for the health of the people were that to happen, so no I don't want to see that.

With the caveat that I support a few different solutions to our mess, strictly speaking a Single-payer system would include ALL of us. ALL of us together have a damn lot more political power and say than some indians on a reservation who were screwed from the day we invaded their land and destroyed their culture.

Posted by: los anjalis | Dec 4, 2007 8:35:50 PM

Jasper,

In fact, Canada's Medicare system -- since you bring it up -- while far from problem-free, provides robust healthcare access to the Canadian people as a whole -- without regard to income -- as a matter of law.

You seem to have missed the point. From the abstract Catron cites:

We also find that Canada has no more abolished the tendency for health status to improve with income than have other countries. Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S.

So what's the point of having "rich and poor alike in the same system?" It doesn't seem do anything to reduce the health disparities between rich and poor.

Posted by: JasonR | Dec 4, 2007 8:54:32 PM

It remains extraordinarly politically popular and strongly supported by the public. Largely because it serves the entire population, rich and poor alike.

Equal access is meaningless, Jasper, if it doesn't move the dial on outcomes. Surely this is obvious, even to a "progressive."

Posted by: Catron | Dec 4, 2007 9:07:40 PM

Equal access is meaningless, Jasper, if it doesn't move the dial on outcomes. Surely this is obvious, even to a "progressive."

Canadians live longer than Americans, and suffer from lower rates of infant mortality. Moreover in Canada you're not going to go bankrupt because of medical bills; and you're not locked into a job that doesn't make sense for you because of health insurance; and if you're an entrepreneur, not being able to afford medical insurance coverage for your employees isn't an issue; and if you're a parent, your children need never go without medical coverage; and you'll never face a $2,000 a month COBRA bill to keep your family covered because you've been laid off. I call these pretty good "outcomes" -- especially for a system that's much cheaper than ours.

Posted by: Jasper | Dec 4, 2007 10:34:32 PM

Here was my response (the other single-payer advocate referenced).

Posted by: Graham | Dec 5, 2007 1:06:07 AM

So we all get the gray average system. Kind of like the USPS.

Or the police, or the armed services. "Gray average" indeed...

"So what's the point of having "rich and poor alike in the same system?" It doesn't seem do anything to reduce the health disparities between rich and poor."

The rich are always going to be healthier, because they have better diets, live in better surroundings, tend to be better educated, have less hazardous jobs etc. The point is that in Canada, even the poor get decent healthcare, and live longer than they would in a less civilized country.

Posted by: ajay | Dec 5, 2007 5:18:19 AM

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