HEALTH MATTERS: The (same old) 30 percent solution!


Part 3—Our long-standing bungled discussion:
It's a relatively minor point. But we've never understood why Medicare is described as "single-payer."

If by the word "payer" we refer to the sources of payment for the services of a program, Medicare wouldn't seem to be a "single-payer" program. Let's compare the Medicare program to the public schools.

When Parent A moves into Community X, he is allowed to send his children to his community's public school or schools.

No "co-pay" will be involved. The child shows up and gets enrolled. Parent A pays no monthly fee. Government moneys finance the school. Attendance is free to the parent's children—even if he has several!

You might call that system "single-payer," though no one ever does. It's true that public schools are financed by moneys drawn from several levels of government. But the "recipient" isn't charged a fee when he and his children receive the services of the public schools.

Medicare isn't like that. As the leading authority clearly explains, the federal government picks up the tab for some of the Medicare program's services. The Medicare "beneficiary" is stuck with the bill for the rest.

On Monday, we quoted that leading authority. We've never understood why you'd want to call this arrangement "single-payer:"

"No part of Medicare pays for all of a beneficiary's covered medical costs and many costs and services are not covered at all...On average, Medicare covers about half of the health care charges for those enrolled. The enrollees must then cover their remaining costs either with supplemental insurance, separate insurance, or out-of-pocket."

Why do we call that "single-payer?" (Why don't we call public schools "single-payer?") We don't know how to answer that question.

But then, our health care discussion, like all our discussion, is marked by our constant cluelessness. This isn't just true of the Okies, the hillbillies, and the rest of Those People, the ones who are found Over There.

We liberals are constantly massively clueless too! We've maintained our liberal cluelessness down through the recent generations, even as we mock the dumbness of The Others.

How clueless does the health care discussion remain in the face of our self-admitted liberal brilliance? Just consider one part of the health care discussion in last Friday's Washington Post.

In last Friday's Washington Post, three major columnists discussed our nation's clownish health care system. Charles Krauthammer and Fareed Zakaria actually flirted with the idea that Donald J. Trump may come around to supporting "single-payer" in the form of "Medicare for all."

Citing our current system's high costs and mediocre outcomes, Zakaria seemed to say that this would be a good idea. David Ignatius took that theme even farther as he discussed the lunacy of our prevailing arrangements.

Much of what Ignatius said was basically correct. As he started, he railed against our nation's twin health care demons—high costs joined to weak results:
IGNATIUS (3/31/17): Here’s a radical idea for reframing the health-care debate on the ruins of the GOP’s half-baked plan: Let’s listen to doctors rather than politicians. And let’s begin with a simple formula offered last week by the National Academy of Medicine: “Better health at lower cost.”

Better and cheaper. It’s hard to argue with that prescription.
Because the real health-care crisis in America is about delivery of care, more than the insurance schemes that pay the bills. Costs are continuing to rise, even as public health in America declines. We’re getting less for more. And the GOP’s proposal to starve Obamacare will make that downward spiral worse.


Americans don’t realize just how bad our system is. Health-care costs are far higher in the United States than in other developed countries, but our health is worse. That’s especially true among older whites without a college education—Trump’s core demographic—whose mortality rates are rising alarmingly.
As he started, Ignatius endorsed a proposal that's hard to reject. He suggested that we should receive better results at less cost.

Soon, though, the rubber was meeting the road. We Americans "don’t realize just how bad our system is," the columnist provocatively said. "Health-care costs are far higher in the United States than in other developed countries, but our health is worse."

According to Ignatius, we're paying much more than comparable nations, but we're getting worse health outcomes. Provocatively, Ignatius said we Americans don't understand how bad this actually is.

In our view, he then went on to prove his provocative point. In the following passage, Ignatius seemed to explain how bad the situation actually is. Unfortunately, this passage suggests that Ignatius himself may not grasp the apparent scope of the problem:
IGNATIUS: The problem certainly isn’t that America doesn’t spend enough. The United States now pays $3.4 trillion annually. But the Academy of Medicine study estimates that 30 percent of this money is wasted on unnecessary services, high prices, inefficient delivery, excess administration and fraud.

These problems long pre-date Obamacare. Health-care expenditures rose as a percentage of GDP from 5 percent in 1960 to 17.8 percent in 2015. The cost of government health programs has increased an astounding 63-fold since 1974, according to the Congressional Budget Office.

America’s problem is that it squanders money on the wrong things— expensive procedures and tests rather than preventive care and social programs. A study of premature deaths estimated that just 10 percent were the result of poor medical treatment, while 40 percent came from behavioral issues, such as obesity and alcoholism.
Are we spending more than other nations while getting less? That passage represents Ignatius' only attempt to quantify the problem.

To what extent are we spending too much? That passage suggests an over-spending rate resembling 30 percent. Post subscribers trembled with rage as they considered that figure.

They weren't exposed to these basic data, which seem to suggest a substantially larger problem:
Per capita spending, health care, 2015
United States: $9451
Canada: $4608
France: $4407
United Kingdom: $4003
Finland $3984
According to those basic OECD data, U.S. spending exceeded that of France by almost 115 percent! By way of contrast, Ignatius had described a possible solution on the order of thirty percent.

Dreaming an ambitious dream, Ignatius suggested that we should eliminate all sorts of bad medical practice. But uh-oh! This is how those numbers would have looked if we had eliminated all the "unnecessary services, high prices, inefficient delivery, excess administration and fraud" his formulation describes:
ADJUSTED FOR PERFECTION: Per capita spending, health care, 2015
United States: $6616
Canada: $4608
France: $4407
United Kingdom: $4003
Finland $3984
On a per capita basis, we still would have been outspending the French by almost exactly 50 percent! That's how the numbers would have looked after the pundit's solution.

Ignatius was working from an old official prescription. Years ago, we discussed the way that 30 percent estimate compares to the actual levels of spending described in the OECD data.

Years later, a bright and decent American journalist continues to work from that framework. To this day, we've never seen anyone try to explain the massive level of overspending which seems to be described in those startling OECD figures.

A few weeks ago, we published an award-winning series, "In Search of the USA 9400." In this report, we noted the fact that Paul Krugman called attention to this massive level of apparent overspending way back in 2005, in a series of New York Times columns.

That was almost twelve years ago. From then till now, our liberal world has piddled along in our standard state of outrage mixed with stupor. We know of no one who has tried to extend the critique Krugman offered back then.

We know of no one who has tried to explain those remarkable spending figures. We know of no one who has discussed the way those remarkable data relate to our country's constant failed attempts to provide universal care, even to the lesser breed, who voted for Donald J. Trump.

Might we mention the truth just once? We liberals are about as dumb as any such group has ever been. On balance, we're lazy, clueless, unkind and not real smart, but reliably self-impressed.

We also enjoy kicking down, quite hard, at the undeserving and stupid white underclass. We love to kick down at the massive dumbness of Them, the dumb breed found Over There.

We love kicking down at the dumbness of Them. Tomorrow, more on the constant, gobsmack-inducing, world-class dumbness of Us.

Tomorrow: Good for one thing only

Coming—progressives explain things to us: Progressive icon condescends to visit a "bleak little suburb"


  1. Somerby uses an analogy with public schools, claiming that public schools are single payer whereas medicare is not, because there are leftover costs assumed by the individual receiving care. This is a misleading analogy because there are many education-related costs that are not covered by public schools but are paid by parents.

    For one thing, athletic participation costs are borne by parents, not schools. Parents must pony-up for uniforms and shoes and summer training camps and attendance at away games as spectators and doctor visits for clearance to play, etc.

    For another thing, costs for enrichment to teach a child anything beyond the standard curriculum are paid by the parent. This includes music lessons, art lessons, science classes, kumon math and other tutoring, language lessons (if Chinese or Jewish), drama, dance, cooking, and visits to museums and places of interest. Children with talent are only in rare circumstances nurtured by the public school.

    The most important teaching happens in the five years before a child reaches public school. Schools do not pay for that. Parents do it for free. The toys, books, music, etc. that happen then are not reimbursed in any way.

    If a child has special needs, the parents often have to engage in major advocacy to get public schools to pick up any part of the costs of that child's additional teaching -- and this is true whether the child is blind or deaf, autistic, or has one of the number of physical disabilities that leave mind unimpaired by affect the body. Schools are notoriously bad at this and parents pay a lot out of pocket and in unpaid labor to help a child with such needs, often quitting a paying job to do so.

    So this is an awful analogy because healthcare and public education are closely similar in the ways that supposed single payer doesn't address the gaps and leaves those for the individual to pay.

    1. Your first statement betrays an inability to interpret what Bob wrote. He did not "[claim] that public schools are single payer whereas medicare is not."
      Are you the same person who consistently fails to comprehend what you have read?
      Of course, I could be wrong.

    2. I meant "your first sentence."

    3. If my understanding differs from your, of course I am the one who is wrong.

      Somerby says, referring to schools, "you might call that system single payer." I can see how his odd wording might have confused you. Somerby never says anything very directly. It is a way of avoiding responsibility for his views, much like humor is.

  2. Ignatius and Somerby both pretend that we are getting substandard care while paying too much for health care. This claim is made possible by comparing per capita costs to average outcomes such as infant mortality or longevity.

    Both know that for the higher income person, those health outcomes are not substandard and average lifespan is higher than for people with low income. That is because higher income people take advantage of preventative care and get treatment at the first sign of symptoms instead of waiting until diseases are harder to treat and more likely to cause complications or death.

    Instead Somerby pretends that we pay more for substandard doctors and hospitals. Our actual care is fine. It is the many poor and undereducated and transient or ignorant people who do not participate fully who bring down the public health numbers. Like that woman who wouldn't use her insurance because the doctor might find something she couldn't afford (or didn't want to deal with).

    We tolerate emergency room use by homeless people who visit over and over with chronic conditions that worsen because of lack of compliance with treatment protocols. We tolerate pregnancy without prenatal care. We tolerate silly people who won't vaccinate their kids because they believe pseudoscience instead of science. We tolerate a lifestyle based on poor nutrition and lack of exercise because we are a free nation with too much money and too much convenience. We tolerate overindulgence in alcohol, drugs, and dangerous behaviors to assuage boredom and unhappiness. We don't treat mental illness. So our quality of medical care varies widely, with the better educated people benefitting and the larger number of poor and uneducated people following practices and avoiding the care needed to achieve European standards of public health outcomes. It is a national disgrace but it has little to do with single payer and a great deal to do with the entrenched right to stupidity that we tolerate because we are a free country.

    But it is easier for Somerby to blame the medical profession and to believe that single payer will miraculously make that stupid woman visit her GP for her mammogram.

    1. Punch down, baby. Punch down!

    2. I don't think that everyone in France is in the top 20% of our income quartile, many other citizens of OECD countries with All-payer systems do have better access and health outcomes. They're also willing to live with higher levels of taxation and governments that are willing to cap health care cost and more importantly, pharmaceutical costs.
      There's nothing particularly "free" about a nation that considers access to health care as a privilege versus a right.

      Americans have just bought into the idea that reasonable levels of taxation are some how confiscatory. That's just the rich rigging our system to keep ridiculous amounts of wealth.

    3. Hitler and his buddies consider food and health care to be privileges not rights. He considered them things that had to be paid for by labor and contribution to the society. Those who could not contribute through productive labor and were a burden to others were exterminated, whether they were elderly, deformed babies, disabled adults, or people who would pollute the gene pool. This is where the idea that food and health care is not a right but a privilege leads. Efforts to do things like drug test people on welfare or receiving food stamps provide echoes of the dark times in Germany, but maybe only for those with a historical sense or who lived through that time.

    4. Like Ignatius, I wonder what kind of change you would expect to produce a nation where we did NOT "tolerate overindulgence in alcohol, drugs, and dangerous behaviors to assuage boredom and unhappiness."

      So we should induct people into the army at age 13 so that Big Brother could keep them from unhealthy lifestyles? What would a society look like where we did NOT tolerate such things? How would you force people to exercise? You'd add a jogging mandate to the insurance mandate?

      Ignatius seems to imply that there is some sort of social program that will reduce alcoholism and obesity. Or does the AMA proposal say something about that? Just curious.

    5. I think we have to change our expectation that our health care costs should approximate those of European countries with very different societies than ours.

      It is superficial to call for changes that cut obvious, big ticket items, like the book referenced below suggests. There are systemic differences that cannot be easily addressed that contribute much more to our cost differences.

      I would start with several kinds of public health campaigns, regulation of supplements and pseudoscience (magic cures using lasers, electromagnetism, copper, chelation, homeopathy), and government support for vaccination. I think these things are more urgent than negotiating for lower drug prices.

      Just as the war on drugs didn't work when it addressed only the supply side, medical costs need to be addressed from the consumer side, not just providers. I don't see any interest in that.

      In general, anti-poverty programs help lower the cost of medical care.

      But mainly, I'd like to see Somerby get off his high horse about these stats and start wrestling with the actual issues involved, which do NOT involve those ratty teachers with their infernal unions (or the medical equivalent).

    6. Anonymous at 4:11PM
      Electromagnetism? Everything you do involves electromagnetism. It's one of the fundamental forces of nature, like gravitation.

    7. I think you are starting to understand why this is pseudoscience.

  3. How exactly will single payer cause more Americans to walk or ride bikes, like they do in ?Europe, instead of driving everywhere?

    How will single payer get more Americans to eat fruit instead of chips, especially when fruit doesn't taste that good with beer?

    How will single payer get more Americans to vaccinate their kids, especially when our media keeps telling us this year's flu shot won't work but acupuncture (or this month's medical fad) cures everything?

    How will single payer make sure granny takes her meds properly when there are 27 of them and no one around regularly to help her see the labels on the bottles, much less make sure they get taken according to the instructions?

    You tell me how these problems would be addressed in any way by changing to a single payer system.

    1. No one claims that single-payer fixes poor health choices. Who is saying that?? But access and availability of health care is an important aspect of any well-functioning health-care system, no? And, as the ACA has shown, when people can actually afford and obtain health insurance, their health outcomes are better. Amazing, no?
      Healthier lifestyle choices would obviously also improve health outcomes and lower costs. That may be a matter of education, incentivization, etc. But we shouldn't deny coverage to someone because someone else makes poor choices.

    2. Poor health choices contribute to the extra amount Americans pay for their health care compared to Europeans, for example. We are not the same culture as exists elsewhere. That affects health care spending.

    3. Our society pays more for health care because many people use the health care system to meet other needs, provided in other ways in European countries. We are an extremely individualist country, whereas Europe is more collectivist. People in the US are more socially isolated, less likely to live in extended family situations, less likely to have relatives to care for them or a social support network when they are struggling.

      Many doctor visits involve psychosomatic illness. People who are anxious or stressed, depressed, lonely, adrift and without anyone to care for them, perhaps even without meaningful human contacts. Hospitals are places that care for people and give them attention. In the US, people more often confuse physical with emotional needs and the attention sought is not entirely physical. We treat anxiety and loneliness with pills, not human contact. In Europe this is not so much the case because families are stronger, less dispersed, elderly are cared for at home instead of in institutions, and people are less adrift and on their own, practically and existentially. We pay extra for this societal choice of disconnection and individualism.

    4. Then again 3:23 PM, UK/European health care official Mark Britnell writes in his book "In Search of the Perfect Health System" [LINK]:

      [QUOTE] There is an apocryphal Japanese story which tells of five old men sitting in their hospital beds talking about their well-being. They had been in hospital for the past 20 days and were wondering what had happened to their friend, the sixth patient on the ward, who wasn’t in his bed that morning.

      ‘Where is Keiichi?’ one of the men asked, only for another to reply: ‘He is feeling very unwell so he decided to go home.’

      This Japanese joke has a grain of truth in it. The demographic forces at play in Japan are monumental. Standing at 83.3 years, Japan has among the highest life expectancies on the planet, and the combination of longevity and a declining birth rate means the country is ageing rapidly.

      Over a quarter of Japanese people are over 65 and this group already accounts for more than half of Japan’s health spending. [END QUOTE]

      Back in 2008 NPR ran this report [LINK]:

      [QUOTE] Japan... has the longest healthy life expectancy on Earth and spends half as much on health care as the United States.

      That long life expectancy is partly due to diet and lifestyle, but the country's universal health care system plays a key role, too.

      Everyone in Japan is required to get a health insurance policy, either at work or through a community-based insurer. The government picks up the tab for those who are too poor.

      It's a model of social insurance that is used in many wealthy countries. But it's definitely not "socialized medicine." Eighty percent of Japan's hospitals are privately owned — more than in the United States — and almost every doctor's office is a private business.

      Dr. Kono Hitoshi is a typical doctor. He runs a private, 19-bed hospital in the Tokyo neighborhood of Soshigaya.

      "The best thing about the Japanese medical system is that all citizens are covered," Kono says. "Anyone, anywhere, anytime — and it's cheap."

      Patients don't have to make appointments at his hospital, either.

      The Japanese go to the doctor about three times as often as Americans. Because there are no gatekeepers, they can see any specialist they want.

      Keeping Costs Low

      Japanese patients also stay in the hospital much longer than Americans, on average. They love technology such as magnetic resonance imaging; they have nearly twice as many scans per capita as Americans do. [According to T. R. Reid's 2010 report in the Washington Post [LINK]: In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)]

      Professor Ikegami Naoki, Japan's top health economist, explains how Japan keeps MRIs affordable.

      "Well, in 2002, the government says that the MRIs, we are paying too much. So in order to be within the total budget, we will cut them by 35 percent," Ikegami says.

      This is how Japan keeps cost so low. [END QUOTE]


    5. As of 2014, according to the OECD [LINK], the United States was paying 16.9% of GDP or $9400 per capita for its health care while the corresponding figures for Japan were 10.3% of its GDP or $4100 per capita.

      According to Wikipedia [LINK]:

      [QUOTE] Japanese outcomes for high level medical treatment is generally competitive with that of the US. A comparison of two reports in the New England Journal of Medicine by MacDonald et al. and Sakuramoto et al. suggest that outcomes for gastro-esophageal cancer is better in Japan than the US in both patients treated with surgery alone and surgery followed by chemotherapy.

      Japan excels in the five-year survival rates of colon cancer, lung cancer, pancreatic cancer and liver cancer based on the comparison of a report by the American Association of Oncology and another report by the Japan Foundation for the Promotion of Cancer research.

      The same comparison shows that the US excels in the five-year survival of rectal cancer, breast cancer, prostate cancer and malignant lymphoma. Surgical outcomes tend to be better in Japan for most cancers while overall survival tend to be longer in the US due to the more aggressive use of chemotherapy in late stage cancers.

      A comparison of the data from United States Renal Data System (USRDS) 2009 and Japan Renology Society 2009 shows that the annual mortality of patients undergoing dialysis in Japan is 13% compared to 22.4% in the US. Five-year survival of patients under dialysis is 59.9% in Japan and 38% in the US. [END QUOTE]

    6. Survival may be better because of better screening resulting in earlier stage diagnosis and treatment. Kidney failure goes with diabetes which goes back to diet and lifestyle. Sorry but Japan is unlike the US in many important ways.

    7. I take it 11:24 PM you think you're so clever none of us realize you're making it up as you go. "Japan is unlike the US in many important ways."- that's your insight? Stick with, "U.S.A., U.S.A! Exceptional r us."

    8. Run out of things to quote from?

    9. Your point then is that quoting from knowledgeable sources isn't as impressive as being an endlessly riffing vapid contrarian like yourself. Yeah, we all ready knew that's what you think.

  4. I am so glad Somerby turned me on to the joy of kicking down. I am starting the kicking with Somerby himself. I don't know whether he's gotten stupider or I've gotten smarter since Trump's election but Somerby has got to be the stupidest person around these days and it pleasures me to kick him for it. After Somerby bashing, I don't feel much need to kick anyone else. My cat is grateful to him too.

  5. (Why don't we call public schools "single-payer?")

    Public schools are single provider. A single payer education system would be free vouchers for all.

    England has single provider health care. Health care professionals are employees of the government. (They also permit private health care.)

    1. Nonsense -- there is a single provider in neither health care nor education, in neither the US nor England.

      We have always had religious and private schools as alternatives to public school. They are privately funded.

      England does not have single provider health care. There are private doctors and hospitals that people can visit if they pay themselves.

      Vouchers don't provide alternatives. They provide a way to pay for an alternative. There is no reason why the public should pay for religious schools or for parents who wish to avoid integrated public schools for racist reasons. That's why we haven't had vouchers. The public has chosen not to fund alternative schools that exist due to religious or racial beliefs, due to the establishment clause in the Constitution.

    2. Anon 11:34, you will notice you get no response from Comrade DinC.

      6 days, or 6 weeks or 6 years from now he will come back and repeat the very same thing he wrote which you have forcefully and intelligently rebutted, without showing the slightest sign that he learned anything. He's a troll.

  6. A bigger problem for the US is the amount spent on medical treatments that don't work. So-called complementary or alternative medicine is bogus and yet people spend a great deal on it, and it is even incorporated into medical plans (such as HMOs) because people demand it and believe in it.

    "And less-affluent people spend a higher proportion of their income on these treatments. "While the mean per user out-of-pocket expenditure for complementary health approaches was $435 for persons with family incomes less than $25,000, those with family incomes of $100,000 or more had mean per user expenditures of $590," the team wrote."

    Here, too, there is a tax for stupidity that is higher for the undereducated, stupid lower income people who are more gullible and wind up paying a larger share of their income on treatments that simply do not work, even at the level of placebo.

    But we are a free country and our health care industry has decided to join the charletans instead of continuing to speak out against them, as it once did. But Somerby doesn't think that is a problem. He thinks it is OK if people are bilked, as long as a single payer is involved.

  7. Interesting new book about healthcare:

  8. I was puzzled when I first went on Medicare by the statements I was sent. The actual "cost" of the procedures I underwent were often two to three times larger than what Medicare paid, which every healthcare provider I have consulted over the last five years has accepted as "payment in full." I wondered who was paying the "full cost" of such procedures? Apparently the turnip you can squeeze blood out of, healthcare insurance companies. They do nothing to keep costs down as they simply pass them through to the policy owners.

    1. Not to blame you for doing nothing, but what can you do?
      What can we do?
      This is the moral hazard connected to health insurance. If we bother to review the charges, we do nothing because we don't have to pay out of pocket.
      Is it fraud when both parties are aware of egregious fees and bogus procedures, and settle for lower remittance?

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