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April 25, 2006

Terms Have Meanings

Responding to me, Ramesh Ponnuru writes:

I don't think [universal health care] is possible, actually. If you can't get an operation because your country's national health insurance system has you on a long waiting list, in what sense have you enjoyed "universal coverage"?

And if countries really did deny procedures through interminable waiting lists, that might be relevant. But waiting for an elective procedure -- no country I know of has waiting lists for emergency procedures -- that you then receive doesn't contravene the terms of health coverage at all. For Ponnuru's point to work, you'd need to define universal coverage as "instant access to any health procedure at all times." The actual definition of coverage, in contrast, is "inclusion in an insurance policy or protective plan." So if you're in, say, France, or Germany, or Canada, and all your procedures are paid for and you need never worry that your medical bills won't be covered, you have "enjoyed" universal coverage in exactly the sense the term intended.

Update: Jon Cohn has more. Waiting lists, it turns out, basically don't exist in France and Germany.

April 25, 2006 | Permalink


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Funny, there are a lot of waiting lines I'd have to join here in the good ol' U.S.A. if I wanted to get any number of procedures done. Does that mean I don't have "coverage" from Kaiser? Those bastards!

You're right, this debate is ridiculous beyond words.

Posted by: Brad Plumer | Apr 25, 2006 3:05:54 PM

"You're right, this debate is ridiculous beyond words."

Yes, but if we could resituate it in the realm where words still ruled, I think we could clarify it pretty quick.

Posted by: Ezra | Apr 25, 2006 3:08:31 PM

Canada does have waits in a couple of critical areas -- cancer treatment and orthopedic procedures being the most troubling. That said, I think alot of the problem stems from cuts in the mid-90s that saw healthcare spending fall from 10% of GDP in the earlier 90s to 9% of GDP in 2000. Since then, spending is back to 10% of gpd, but the system needs time to heal itself. It is also likely that wait time guarantees will be coming into play that will help.

Posted by: KP | Apr 25, 2006 3:19:24 PM

I am not sure that Ezra is completely right about this. I am a big supporter of single payer, but I have no illusions that there are going to be things that the national system isn't going to be able to cover, especially as much more expensive treatments for people with very serious, terminal illnesses come on line. At that point, just as HMO's "ration" care, the single payer is probably going to do it too. And one way that care is rationed is through waiting lists-- though it can also be done through triage, approval requirements, review boards, or denial of coverage altogether. (Oregon's Medicaid program makes a list of all the available procedures based on their cost-effectiveness, and simply draws a line on that list and doesn't pay for anything below the line.)

The proper question to ask Ponnuru is whether the health care system he champions avoids the same kind of rationing. It clearly doesn't. The only difference is whether people get a base level of care guaranteed to them, or whether 40 million plus get no care at all.

Posted by: Dilan Esper | Apr 25, 2006 3:29:43 PM

Orthopedic treatments are rarely urgent, they tend to be elective, if irritating. The fact of it is, though, that Canadians and Americans tend to experience similar waits for treatment (the difference being, Canadians always get it in the end). From this report:

To explore accessibility to patients, the survey asked about timeliness, twenty-four-hour availability, and financial access. Reports revealed striking between-country differences. The majority of adults in New Zealand and Australia said that they received appointments the same day the last time they were sick and needed medical attention. In contrast, only one-third or less of Canadian or U.S. adults reported such rapid access. Canadian and U.S. adults also reported long waits, with 20–25 percent waiting at least six days to get an appointment when sick, a waiting time rare in Australia or New Zealand.

Difficulty in getting care nights, weekends, or holidays was of significant concern in all five countries. Although problems were most widespread in the United States, majorities of adults in Australia and Canada also said that after-hours access was difficult. Even in New Zealand, where the rate of difficulty was lowest, one-third of adults viewed after-hours access as difficult.

Emergency room care. The emergency room (ER) serves as a sensitive indicator for how well care systems are responding to patients’ needs. ER use rates during the past two years were significantly higher in Canada and the United States than the other three countries (Exhibit 3). Canadian and U.S. adults were also more likely to have gone to the ER for care that their regular source could have provided if available. In these two countries, such ER visits accounted for about half of recent ER use. The survey also found use of the ER substituting for regular physician care in the other three countries, but to a lesser extent. Notably, adults in Canada and the United States were less likely than adults in the other countries to report rapid access to doctors when sick and more likely to say that after-hours access was difficult. In combination, these indicators signal widespread patient concerns about timely primary care access in both countries.

Posted by: Ezra | Apr 25, 2006 3:36:24 PM

Canada, France, etc., are also excellent places to go if you don't want to worry about other things too, like, you know, having a job. It's fun to wait in the welfare line, get liver cancer from drinking too much beer because you have nothing to do all day then wait in line at the hospital twice a month to get treated for liver cancer and a kidney transplant. That is if you don't totally flip out and join with 20,000 other people in the streets rioting and burning cars.

The joys of socialism.

Posted by: shoelimpy™ | Apr 25, 2006 3:37:58 PM

The joys of socialism.

I'm sold.

Posted by: Brad Plumer | Apr 25, 2006 3:44:10 PM

Canada's unemployment rate is a smidge over 6%, less than 2% higher than ours, and lacking the artifical lowering that comes from our massive incarcerated population or the number of folks who've simply stopped searching for work.

Posted by: Ezra | Apr 25, 2006 3:47:33 PM

It doesn't say much about good about the intelligence level at the Corner that they can't distinguish between a method of paying for health care from the availability of actual health care services themselves.

One would think everyone in the US knows that your MD has a thing called an appointment book, maintained by his/her office (and not the insurer). I routinely wait about 3 weeks for an appointment with my internal medicine MD (today's equivalent to a general practitioner). It never occured to me that this wait is a waiting list. I thought it was supply and demand.

But wait! Maybe Ramesh does know the difference but his job description says he must muddle all waters of rationality and truth, in this case by peeing in his drinking supply. Dumbfuck!

Posted by: JimPortlandOR | Apr 25, 2006 4:22:38 PM

There are a host of measures Europe can (and perhaps should) enact that could lessen unemployment without threatening their health care systems. Everything isn't of a piece.

Posted by: djw | Apr 25, 2006 4:23:11 PM

That is if you don't totally flip out and join with 20,000 other people in the streets rioting and burning cars.

And all because they don't want to be subject to the merit system as we are in the US. What a buch of babies!

Posted by: Fred Jones | Apr 25, 2006 4:23:50 PM

In a way, universal coverage would be more capitalistic than socialistic since one of the main reasons for having it is that it is less expensive than free-market healthcare.

Posted by: Steve Mudge | Apr 25, 2006 4:26:13 PM

Canada's current low unemployment is an anomoly, its only been in the last couple of years they've come out of double digits. And that still ignores France and the other European socialist countries.

If you're sold, Brad, why don't you move to France?

Posted by: shoelimpy™ | Apr 25, 2006 4:27:54 PM

The whole idea of lines with universal care is bogus I agree. ..quality is a issue that people with experience of multiple systems, foreign and domestic will have a harder time jumping on board with.

From living in Alaska I had many freinds in B.C. Canada. They gave us a hard time about having to pay for doctors, but still came to the US for some major operations.. but they had complaints about the quality of care, industrial feeling doctors, and availability of new proceedures. For some things they would even come to the US, mostly Seattle but sometimes to the local Alaskan hospitals. Not often but it happenned.

At other times I had been fortunate enough to experience towns with a 'local doctor' Small clinics with the wise old doctor that knew your name, could fix everything, and anything he couldnt he arranged for treatment somewhere else. Often on 'intuition' or experience he would send you out to the hospital right away for advanced care.

Now Im older, at my work I had Kaiser Permanente, an HMO for medical benefits. I realized early on what this meant. You could always go in, pay $15 and get a pain killer any time you wanted. But getting that doctor to sit down and understand the problem, and run through anything but the standard diagnosis just doesnt happen. ..after you've jumped through all the hoops, and walked through every diagnostic proceedure you finally get advanced treatment.

I also have the unfortunate experience of being in a car wreck north of the arctic circle, while being the literal starving college students. I was ok but 1 of my compatriots was less lucky. She broke a vertebrae in 3 places, and had very large lacerations. Note at this time we could barely make rent. As an emt I provided immediate care, until a paramedic arrived. From a nearby field we were medivaced (sp?) back to Fairbanks and she was treated at the hospitol.

There was no insurance, and no ability to pay, but we were treated.(Including a flight from the arctic circle) ..eventually, payment was made... years and years later.

So my point? our current system has a kind of universal care.. While chronic conditions may not be fixed emergency trauma is often taken care of.

People would like to take that local 'doc' and make him universal, but know that would never happen. What we will get is something akin to K.P. or the canadian system. So people fear losing the existance of the local 'doc' and personal care for the large corporate pharmacopia. Most people even now dont even have that kind of idealized doctor relationship, but the idea is still there.

Ideally we can come to an American compromise.. that allows for a base of care for all.. then more personalized care for those people that can/want to afford it.

The statistics may not be behind many of these anecdotal things. The ghost of their existence however will keep many people afraid of universal care until they're addressed.

Posted by: david b | Apr 25, 2006 4:33:43 PM

It has never been clear to me whether shoelimpy actually believes the comments that he/she/it types. Posts like this by 'annieangel' on the shoelimpy blog suggest to me that we have some kind of annoyance artist on our hands, rather than anyone expressing their genuine views. It's just not worth responding to people like this.

Posted by: Neil the Ethical Werewolf | Apr 25, 2006 4:38:02 PM

Miss Annie and myself are two separate people. I cannot believe that this subject has reached such epic proportions. I never thought I would have to deal with this shit on Ezra Klein, this is a blog I hold in high regard.

As for universal health care, I think it is important to look at the meaning of "universal." Does universal health coverage mean coverage of all health care, or only essential health care? How essential must essential health care be to be considered universal?

Posted by: shoelimpy™ | Apr 25, 2006 4:43:18 PM

For the love of God people!

Have Republicans stooped so low that now they're arguing universal coverage doesn't exist? How insane is that?

Universal health care is the idea that every one in a given nation is covered by health insurance. That's all it means, and it's been done in dozens of countries on this planet.

Does it mean you can get whatever procedure you want whenever you want it? No, but you sure as hell can't do that here! Private insurance won't let you get anything they don't deem medically necessary, and you have to wait months to get an appointment with a specialist, if they're accepting new patients.

The bottom line is our health care is twice as expensive, fails to cover 46 million people, has questionable quality, kills around 100,000 people a year from error, and for all this we have worse health indicators (i.e. lower life expectancy, higher infant mortality, etc).

Or, we can at least move to a system where everyone has health insurance. Or, you can believe the folks over at the Corner who are arguing that universal coverage doesn't exist.

What do you want?

Posted by: Kate | Apr 25, 2006 5:02:49 PM

As for universal health care, I think it is important to look at the meaning of "universal."...How essential must essential health care be to be considered universal?

Umm, genius, the "Universal" part is referring to who is covered. It's not referring to the care received. Otherwise, any individual person could claim that they personally have "universal" health care. But that clearly isn't what the debate is about. The meaning of universal in this context is pretty well established. It means everyone.

Now if you want to get into the definition of "health care", that's another issue. But seeing as how couldn't figure this part out, I'm not holding out much hope for your ability to participate in that debate.

Posted by: Vladi G | Apr 25, 2006 5:08:42 PM

So if I say that everyone in the country gets a free eye exam, that would count as universal health coverage because I am covering everyone?


Posted by: shoelimpy™ | Apr 25, 2006 7:05:10 PM

So if I say that everyone in the country gets a free eye exam, that would count as universal health coverage because I am covering everyone?

It's like arguing with a 3 year old. Except the child will eventually grow out of it, and shoelimpy clearly won't.

Posted by: paperwight | Apr 25, 2006 7:39:32 PM

shoelimpy showed up here after being banned from pandagon. Honestly, he always struck me as so over-the-top, I just ignored him.

Posted by: Constantine | Apr 25, 2006 8:06:49 PM

That is what you are saying if universal health coverage is related to the people getting the coverage, not the type of coverage.

I mean, Wal-Mart gives universal free eye exams. Eye exams are a part of health care. The United States already has a universal health care system!

Posted by: shoelimpy™ | Apr 25, 2006 8:22:32 PM

Don't bring Pandagon into this, please. I posted here long before the incident with Pandagon.

Posted by: shoelimpy™ | Apr 25, 2006 8:23:28 PM

Hee, shoelimpy's Blogging Points made me giggle. Normally trolls just give me the rage, but these guys are kind of cuddly.

Posted by: Hamilton Lovecraft | Apr 25, 2006 8:54:47 PM

It funny how folks in border states always talk about all their friends who come down to get work done at American hospitals. At least one study has found that there are an almost insignificant number of these cases. But, for the record, here is the counter anecdote:
When I was a kid and we were living in Denver, my father snapped his achilles tendon. It turned out to be cheaper for him to fly to Saskatchewan and have it repaired there (including the flight) than to have it done in Colorado.

Posted by: JP | Apr 25, 2006 11:57:29 PM

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