Socialized medicine

Socialized medicine is a term used primarily in the United States to refer to certain kinds of publicly-funded health care. The term is used most frequently, and often pejoratively, in the U.S. political debate concerning health care.

Jonathan Oberlander, a professor of health policy at the University of North Carolina, maintains that the term does not mean anything at all. Exact definitions vary, but the term can refer to any system of medical care that is publicly financed, government administered, or both.

The original meaning was confined to systems in which the government operates health care facilities and employs health care professionals. This narrower usage would apply to the British National Health Service hospital trusts and health systems that operate in other countries as diverse as Finland, Spain, Israel, and Cuba. The United States' Veterans Health Administration, and the medical departments of the US Army, Navy, and Air Force would also fall under this narrow definition. When used in this way, the narrow definition permits a clear distinction from single payer health insurance systems, in which the government finances health care but is not involved in care delivery.

More recently, a few have used the term more broadly to any publicly funded system. Canada's Medicare system, most of the UK's NHS general practitioner and dental services, which are all systems where health care is delivered by private business with partial or total government funding, fit this broader definition, as do the health care systems of most of Western Europe. In the United States, Medicare, Medicaid, and the US military's TRICARE fall under this definition.

Most industrialized countries, and many developing countries, operate some form of publicly-funded health care with universal coverage as the goal. According to the Institute of Medicine and others, the United States is the only wealthy, industrialized nation that does not provide universal health care.

The term is often used in the U.S to create an understanding that the health care system would be run by the government, thereby associating it with socialism, which has negative connotations in American political culture . As such its usage is controversial.

History of the term

When the term "socialized medicine" first appeared in the United States in the early 1900s, it bore no negative connotations. Otto P. Geier, chairman of the Preventive Medicine Section of the American Medical Association (AMA), was quoted in The New York Times in 1917, praising socialized medicine as a way to "discover disease in its incipiency," help end "venereal diseases, alcoholism, tuberculosis," and "make a fundamental contribution to social welfare." However, by the 1930s, the term socialized medicine was routinely used negatively by conservative opponents of publicly-funded health care." Universal health care and national health insurance were first proposed by U.S President Theodore Roosevelt. President Franklin D. Roosevelt later championed it, as did Harry S. Truman as part of his Fair Deal and many others.

However, at around this time it was ardently opposed by the AMA which distributed posters to doctors with slogans such as "Socialized medicine ... will undermine the democratic form of government." Ronald Reagan once recorded a disc exhorting its audience to abhor the "dangers" which socialized medicine could bring. Other pressure groups began to extend the definition from state managed health care to any form of state finance in health care.

In more recent times the term came up again in the 2008 U.S presidential election by Republicans. In July 2007, one month after the release of Michael Moore's film Sicko, Rudy Giuliani, the front-runner for the 2008 Republican presidential nomination, attacked the health care plans of Democratic presidential candidates as socialized medicine that was European and socialist, Giuliani claimed that he had a better chance of surviving prostate cancer in the U.S than he would have had in England and went on to repeat the claim in campaign speeches for three months before making them in a radio advertisement. After the radio ad began running, the use of the statistic was widely criticised by FactCheck.org, PolitiFact.com., by The Washington Post and others who consulted leading cancer experts and found that Giuliani's cancer survival statistics to be false, misleading or "flat wrong", the numbers having been reported to have been obtained from an opinion article by Giuliani health care advisor David Gratzer, a Canadian psychiatrist in the Manhattan Institute's City Journal where Gratzer was a senior fellow. The Times reported that the UK Health Secretary pleaded with Guilliani to stop using the NHS as a political football in American presidential politics. The article reported that not only were the figures 5 years out of date and wrong, but that US health experts disputed both the accuracy of Mr Giuliani’s figures and questioned whether it was fair to make a direct comparison. The St. Petersburg Times said that Giuliani's tactic of "injecting a little fear" exploited cancer, which was "apparently not beneath a survivor with presidential aspirations." Giulliani's repetition of the error even after it had been pointed out to him earned him more criticism and was awarded four "Pinnochios" by the Washington Post for recidivism.

Health care professionals have tended to avoid the term because of its pejorative nature, but if they do use it they do not include publicly funded private medical schemes such as Medicaid. Opponents of state involvement in health care tend to use the looser definition.

The term is widely used by the American media and pressure groups. Some have even stretched use of the term to cover any regulation of health care, whether publicly financed or not. The term is often used to criticize publicly provided health care outside the US, but rarely to describe similar health care programs in the US, such as the Veterans Administration clinics and hospitals, military health care, nor the single payer programs such as Medicaid and Medicare. The term is almost always used to evoke negative sentiment toward health care reform that would involve increasing government involvement in the U.S health care system.

Medical staff, academics and most professionals in the field and international bodies such as the WHO tend to avoid use of the term. Outside the US, the terms most commonly used are universal health care or public health care. According to health economist Uwe Reinhardt, "strictly speaking, the term 'socialized medicine' should be reserved for health systems in which the government operates the production of health care and provides its financing". Still others say the term has no meaning at all.

In more recent times the term has gained a more positive reappraisal. Documentary movie maker Michael Moore in his documentary Sicko pointed out that Americans do not talk about public libraries or the police or the fire department as being "socialized" and nor do they have negative opinions of these. Media personalities such as Oprah Winfey have also weighed in behind the concept of public involvement in healthcare. A 2008 poll indicates that Americans are sharply divided when asked about their views of the expression socialized medicine, with a large percentage of Democrats holding favorable views, while a large percentage of Republicans holding unfavorable views. Independents tend to somewhat favor it.

History

The first system of socialized medicine based on compulsory insurance with state subsidy was created by Otto von Bismarck after the Franco-Prussian War of 1870. Socialized health care was implemented by the Soviet Union in the 1920s. New Zealand was the first country with a mixed economy to provide the direct provision of health care by the state when, in 1939, it provided mental health services free of cost to the recipient following the passing of the Social Security Act of 1938. After World War II in the 1940s the United Kingdom established its National Health Service which was built from the outset as a comprehensive service. A socialized model was used in China in from the 1950s to the 1970s during the first two decades of communist rule. Cuba adopted socialized medicine in the 1960s under the leadership of Fidel Castro. Also in the 1960s, the United States initiated its Medicaid program to help poor mothers and their children.

Examples

Australien

Main article: Health care in Australia

In Australia, primary health care remains the responsibility of the federal government, elements of which (such as the operation of hospitals) are overseen by individual states. The current system, known as Medicare coexists with a private health system. Medicare is funded partly by a 1.5% income tax levy (with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance.

Kanada

Main article: Health care in Canada

Health Canada, a federal department, publishes a series of surveys of the health care system in Canada based on Canadians first hand experience of the health care system. The following data are from the latest report.

Waiting times

Although life threatening cases are dealt with immediately, some services needed are non urgent and patients are seen at the next available appointment in their local chosen facility.

The median wait time in Canada to see a special physician is a little over four weeks with 89.5% waiting less than 3 months.

The median wait time for diagnostic services such as MRI and CAT scans is two weeks with 86.4% waiting less than 3 months.

The median wait time for surgery is four weeks with 82.2% waiting less than 3 months.

Some, especially in the US, see waiting as a form of government rationing. Canadians, however, see it as a fairer form of allocation of available resources than the system in place before Medicare, when lack of buying power meant there were people who were effectively waiting indefinitely for access but could not get it due to insufficient insurance or other available funds. These people were never counted in any official way and their waiting time was never measured. The queuing system is seen as both fair and transparent.

If resources in Canada were always available when needed, this could indicate a level of over provision (or under utilization) which would increase average costs but reduce personal inconvenience and discomfort. As queues lengthen then this indicates a need for more resources in that area which may need to be funded by government. This then is a political choice made by government which is accountable to the people in the normal democratic fashion.

Prescription drug costs

Although Canadians get the services of their physicians and hospitals included, they do have to meet the cost of prescription drugs themselves. Many take out insurance for this but this is not compulsory. Some people do meet some expenses themselves out of pocket.

34.3% of adults reported having no out of pocket costs for prescription drug costs. 96.2% of adults pay less than 5% of their disposable income on prescription drugs.

Overall satisfaction rate

85.2% of Canadians reported that they were "satisified" or "very satisfied" with the way health care services are provided in their country and an even higher number (89.8%) rated their physician in the same way though slightly lower ratings were awarded to hospitals (79.9% being "satisified" or "very satisfied").

Cuba

Main article: Healthcare in Cuba

Finnland

Main article: Healthcare in Finland

Finland has a highly decentralized three level socialized system of health care and alongside these, a much smaller private health care system. Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical care costs and the remaining one third by the national insurance system (nationally funded), and private finance (either employer funded or met by patients themselves). Private inpatient care forms about 3–4% of all inpatient care. In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Spectacles are not publicly subsidized at all although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.

The high proportion of taxtion meeting health care costs in Finland (60.8%) means that Finland falls into the cluster of European nations such as the UK, Spain, Denmark and Sweden that are more highly socialized than others such as Germany, France or Belgium (which are mostly funded by compulsory insurance). The quality of service in Finnish health care is considered to be good and according to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfacton with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%. Finnish health care expenditures are below the European average.

There are caps on total medical expenses that are met out of pocket for drugs and hospital treatments. All necessary costs over these caps are paid for by the National Insurance system. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health care costs.

Israel

Main article: Health care in Israel

Simcha Shapiro calls Israel's health care system "socialized medicine with a privatized option".[5]

Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.

Russia under the Soviet Union

Main article: Health in Russia § Reform

In the Soviet Union, the preferred term was "socialist medicine"; the Russian language has no term to distinguish between "socialist" and "socialized" (other than "public", Rus: obshchestvenniy/общественный, sometimes "collectivized" or "nationalized", Rus: obobshchestvlenniy/обобществленный).

Russia in Soviet times (between 1917 and the early 1990s) had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all citizens. Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.

The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse. The population’s health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.

Main source: OECD: Health care reforms in Russia

Vereinigtes Königreich

See Healthcare in the United Kingdom for a description of the services from the user perspective.

The National Insurance Act 1911 granted all workers of 16 years or over free medical coverage as well as unemployment benefits. In 1948 the system was extended to the entire population and a new service, the National Health Service or NHS was established. Today it is the world's largest publicly funded health service. It was set up on July 5 1948 to "provide healthcare for all citizens, based on need, not the ability to pay." It is funded by the taxpayer and in England it is managed by a government department, the Department of Health, which sets overall policy on health issues which, for the English NHS, are summarised in the NHS Constitution for England. There are four separate health services for each of the three constituent nations (England, Scotland, and Wales) and one for Northern Ireland. In practice, they work closely together and provide a seamless service based on the same core principles.

The NHS is committed to providing quality care that meets the needs of everyone, is free at the point of need, and is based on a patient's clinical need, not their ability to pay.

Choice

Every person in the UK has the right to choose to register with any general physician of their choice practising in their area. If the GP has contracted to provide NHS services, as virtually all do, then all consultations with the GP will be free of charge to the patient. An NHS GP is usually not allowed to refuse to register a patient and patients usually choose to maintain a relationship with that GP over a long period in order to maintain continuity. All treatments are offered on the basis on the informed consent of the patient and, when a referral is made to a specialist at a hospital, the patient can choose which hospital to be referred to. A web site informs patients which NHS hospitals in their area offer the referred service and gives details of the quality, service indicators (such as number of procedures each year and percentage of successful outcomes) as well as details of the wait times (if any) for that service. NHS patients will have a choice of providers, including at least one private provider, all of which will receive the standard NHS tariff for the standard NHS level of care. The patient can make the appointment themselves at home using the internet or obtain assistance from the GP or his staff to make the booking.

Some people choose to be treated in private hospitals which may have more modern surroundings and waiting times can be shorter. Most private treatment options are at the patient's own expense, but sometimes the NHS may have sub-contracted work to a private operator in which case the NHS will offer to pay for episodes of care in a private facility. Patients choosing to go fully private will have to pay for that episode of care themselves (including the cost of folllow up care and medications) or through insurance.

In a recent survey, ninety percent of NHS patients and ninety two percent of independent sector patients were able to get to the hospital of their choice for treatment or had no preference of hospital. Only seven percent of NHS and five per cent independent patients had been unable to get to their preferred hospital.

Finanzierung

The estimated cost of the NHS in England in 2008 is £91.7 billion (this excludes the cost of health care in Scotland, Wales and Northern Ireland). Funding for the NHS is met from tax and national insurance contributions paid by all persons over the age of 18 and employers in the UK. There is no direct correlation between national insurance payments and health care costs because UK National insurance is part of much wider plan for social insurance, funding health care, retirement pensions and other social security benefits such as Jobseeker's Allowance, Incapacity Benefit, Bereavement Benefits, and Maternity Allowance. Unlike other benefits paid from National Insurance, health care entitlement is not dependent on a person's National Insurance contribution history but is instead dependent on a person's right to be permanently resident. Temporary residents such as tourists are only entitled to free emergency care.

Quality

In an international comparative study of the health care systems in six countries (Australia, Canada, Germany, New Zealand and the United States), the British health care system was ranked in first place for quality of care. It also gained first rank position for equity and efficiency and a top place ranking for performance overall. Donald Berwick the American Professor of Health Policy and Management at the Harvard School of Public Health and who assisted in the modernization of the NHS begun by Tony Blair was particularly involved in the area of health quality. This was an area he admits that, at that time, he was a novice in, but acknowledged that "in the decade between about 1998 and 2008, the UK accumulated more knowledge and more expertise per capita than almost any other nation I know about how to improve healthcare as a system". He went on to say "In some ways the period between the publication of the Modernisation Plan for the NHS in 2000 and the third election of Tony Blair seems to me a golden era for the pursuit of improvement in the NHS. I daresay that no other country did quite so well at a national scale.". Improved services are now being delivered closer to the patients' homes, reducing cost, improving quality, and providing a more convenient patient focused service.

Primary care

At the core of the service are the general practitioners (GPs or family doctors) who are responsible for the care of patients registered with them. GPs are mostly self-employed doctors that choose to contract with the NHS to provide services to patients commissioned by primary care trusts. Some have employment contracts with GP practices and a few are directly employed by the local primary care trust. Self-employed GPs have considerable freedom in the way that they choose to work. Most GPs are therefore paid a capitation fee and certain performance related payments. Patients are free to register with any GP in whose practice catchment area they live. NHS prescribed drugs are subsidized by the taxpayer, in some cases fully subsidized. For example if the person is being treated in medical setting or at home by an NHS medical professional, or if the person is under 18 or over retirement age, or if the patient lives in an area such as Scotland where the local NHS has decided to meet the cost of all drugs. All cancer drugs will be free of charge from April 2009. In England, people of working age usually pay a fixed price of £7.10 (or about US$11) for each prescribed drug collected from a retail pharmacy. The pharmacy invoices the cost of the drugs (less any fixed price patient contribution) to the NHS .

Hospitals

Only GPs (NHS or private) can refer their patients to a hospital (NHS or private) for acute care. Most patients choose to be treated in NHS run hospitals. Private hospitals mostly specialize in routine surgery and do not have the range of equipment that is available in NHS general hospitals. They do not, for example, provide Accident and Emergency services. In the event of an unforeseen emergency following surgery in a private hospital, a patient might be transferred to the nearest NHS emergency department, and then later moved back again. Some people therefore think it is safer to be in a public hospital for all but the most routine of surgeries. The quality of care in NHS hospitals is comparable to that in private hospitals and the services obtained (medicines, surgeons and other care workers, and even meals) are free of charge to the patient, whereas private hospitals bill for these.Ambulance services, mental health, and ancillary services such as physical and occupational therapy, in-home and in-clinic nursing is met from the NHS budget. GPs do not follow their patients into hospital but each patient is referred to a specialist employed by the hospital. On discharge, the home GP receives a report back of the treatment(s) given and the results with recommendations for any follow up actions to be taken.

Electronic records

Most doctors and hospitals already keep electronic patient records, but a wide ranging IT upgrade programme is in progress to integrate these systems. Patients in England already can book their own hospital appointments electronically (either aided at the GP office or elsewhere via the internet), choosing a hospital and time to suit their needs and some can already access their summary care records electronically. The English NHS was the first G8 country to fully implement a digital Picture Archiving Communications System (PACS) to store and retrieve x-ray and other scans in all of its hospitals nationally.

Future IT developments are primarily about integration synergies, such as data sharing, such as electronic prescriptions (direct to the pharmacy) and quality management recording. Patients can choose to have their personal GP and hospital medical records mirrored centrally. In this way their complete medical history will be fully available at any hospital or doctor's office in the country at any time.

Waiting times

• GP appointments - 41 per cent of UK patients reported being able to get a same day appointment with their GP, with 13 per cent reporting having to wait 6 days or more (2004 data).
• Hospital referrals - For hospital treatment, a timer for Referral to Treatment (RTT) starts running when a GP first agrees to refer a patient to the hospital. A number of steps then typically follow. The first hospital appointment must be booked; all tests completed; a diagnosis made; a follow up appointment (if necessary); an appointment made for inpatient treatment (if appropriate); or the patient prioritized to a waiting list (if there is waiting list for that procedure - about one third of hospital admissions are from a waiting list). At some point, hospital treatment will commence at which point the clock stops. The hospitals are targeted to complete these steps within 18 weeks. The 18 week RTT targets is met for 90% of patients in England found to need admission (and 95% for those for whom outpatient treatment was sufficient). Two thirds of patients needing a hospital admission experience RTTs of under 12 weeks.
• Accident and emergency treatment - There is a maximum four-hour wait for treatment in accident and emergency. Patients are triaged and treated according to clinical priority so that those requiring emergency life saving treatment are treated immediately.

The latest patient survey data compares satisfaction levels regarding wait times in NHS and independent (private) sector care. Seventy nine percent of NHS patients were either very satisified or fairly satisfied with wait times to see a specialist, compared to eighty seven percent of independent sector patients.

Other statistics

NHS hospitals in England carried out almost 13 million inpatient admissions in the NHS reporting year 2006/07. Of these admissions 36% were emergencies, 13% had been deferred for medical or social reasons and 35% were admitted from a waiting list. 15% were admitted for other reasons (such as maternity care or childbirth. 99.6% of hospital admissions took place on time as planned. Only 0.02% of all planned admissions were cancelled and not subsequently admitted within the following 28 days. Performance data for all hospitals for all common procedures (such as number of similar operations per year, clinical and patient ratings, wait times, re-admission rate) are publicly available on-line at the main NHS web site.

There is popular support for the NHS. The Healthcare Commission also undertakes regular surveys of patients' opinions of the NHS. In its most recent survey (2007), the experience of hospitals in England was rated by inpatients as follows: excellent (42%), very good (35%), good(14%), fair (6%) and poor (2%).

Vereinigte Staaten

See also: Health care in the United States, Health care reform in the United States, and Health insurance in the United States

The Veterans Health Administration, the military health care system, and the Indian Health Service are examples of socialized medicine in the stricter sense of government administered care, although for limited populations.

Medicare and Medicaid are forms of publicly-funded health care which fits the looser definition of socialized medicine. Medicare is not a free service. There are certain deductibles, premiums and co-pays which must be paid by the insured. Entitlement is subject to prior eligible employment criteria. Although most seniors will be entitled to Part A (Hospital) coverage, seniors must contribute the first $1,068 of hospital care up to 60 days, and increasing amounts thereafter until the point at which when 150 days of hospital care is reached at which point all costs fall on the senior and not on the government. Part B coverage (Medical) requires a monthly premium of $96.40 (and possibly higher) and the first $135 of costs per year also fall to the senior and not the government.

A poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive, indicated that Americans are currently divided in their opinions of socialized medicine, and this split correlates strongly with their political party affiliation. Two-thirds of those polled said they understood the term "socialized medicine" very well or somewhat well. When offered descriptions of what such a system could mean, strong majorities believed that it means "the government makes sure everyone has health insurance" (79%) and "the government pays most of the cost of health care" (73%). One-third (32%) felt that socialized medicine is a system where "the government tells doctors what to do". The poll showed "striking differences" by party affiliation. Among Republicans polled, 70% said that socialized medicine would be worse than the current system. The same percentage of Democrats (70%) said that a socialized medical system would be better than the current system. Independents were more evenly split, with 43% saying socialized medicine would be better and 38% worse. According to Robert J. Blendon, Professor of Health Policy and Political Analysis at the Harvard School of Public Health, "The phrase ‘socialized medicine' really resonates as a pejorative with Republicans. However, that so many Democrats believe that socialized medicine would be an improvement is an indication of their dissatisfaction with our current system." According to Humphrey Taylor, chairman of The Harris Polls, "Only just over one third of adults think that socialized medicine would be worse than what we have now, and majorities associate the words with popular policies such as Medicare and a government guarantee that everyone has health insurance. Clearly socialized medicine is not the scary bogeyman it used to be."

Physicians' opinions on "socialized medicine" have evolved. A 2008 survey of doctors, published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.

Political controversies in the United States

See also: Health care economics

Although the marginal scope of free or subsidized medicine provided is much discussed within the body politic in most countries with socialized health care systems, there is little or no evidence of strong public or other pressure for the removal of subsidies or the privatization of health care in those countries. The political distaste for government involvement in health care in the U.S is counter to the trend in other developed countries which has generally been towards political pressure for more rather than less government financing or involvement in health care.

In the United States, neither of the main parties is in favor of a socialized system which would put the government in charge of hospitals or doctors but they do have different approaches to financing and access. Democrats tend to be favorably inclined towards a reform involving more government control over health care financing and citizens' right of access to health care, whereas Republicans are broadly in favor of the status quo or else a reform of the financing system to give more power to the citizen, often through tax credits.

Supporters of government involvement in health care argue that government involvement ensures access, quality, and addresses market failures specific to the health care markets. When the government covers the cost of health care, there is no need for individuals or their employers to pay for private insurance.

Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research.

Both sides have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

Cost of care

Socialized medicine amongst industrialized countries tends to be more affordable than in systems where there is little government involvement. A 2003 study examined costs and outputs in the U.S and other industrialized countries and broadly concluded that the U.S spends so much because its health care system is more costly. It noted that "...the United States spent considerably more on health care than any other country...[yet] most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. ". The researchers examined possible reasons and concluded that input costs were high (salaries, cost of pharmaceutical), and that the complex payment system in the U.S added higher administrative costs. Comparison countries in Canada and Europe were much more willing to exert monopsony power to drive down prices, whilst the highly fragmented buy side of the U.S health system was one factor which could explain the relatively high prices in the United States.

Other studies have found no consistent and systematic relationship between the type of financing of health care and cost containment; 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 these funds.

Some supporters argue that government involvement in health care would reduce costs not just because of the exercise of monopsony power, e.g. in drug purchasing , but also because it eliminates profit margins and administrative overhead associated with private insurance, and because it can make use of economies of scale in administration. In certain circumstances, a volume purchaser may be able to guarantee sufficient volume to reduce overall prices while providing greater profitability to the seller, such as in so-called 'purchase commitment' programs..Economist Arnold Kling attributes the 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.

Milton Friedman has argued that government has weak incentives to reduce costs because "nobody spends somebody else’s money as wisely or as frugally as he spends his own". Others contend that health care consumption is not like other consumer consumption. Firstly there is a negative utility of consumption (consuming more health care does not make one better off) and secondly there is an information asymmetry between consumer and supplier.

Paul Krugman and Robin Wells argue that all of the evidence indicates that public insurance of the kind available in several European countries achieves equal or better results at much lower cost, a conclusion that also applies within the United States. In terms of actual administrative costs, Medicare spent less than 2 percent of its resources on administration, while private insurance companies spent more than 13 percent. The Cato Institute argues that the 2 percent Medicare cost figure ignores all costs shifted to doctors and hospitals, and alleges that Medicare is not very efficient at all when those costs are incorporated. Some studies have found that the U.S wastes more on bureaucracy (compared to the Canadian level), and that this excess administrative cost would be sufficient to provide health care to the uninsured population in the US.

Notwithstanding the arguments about Medicare, there is overall less bureaucracy in socialized systems than in the present mixed U.S system. Spending on administration in Finland is 2.1% of all health care costs, and in the UK the figure is 3.3% whereas the U.S spends 7.3% of all expenditures on administration .

Quality of care

Some in the U.S claim that socialized medicine would reduce health care quality. The quantitative evidence for this claim is not clear. The WHO has used Disability Adjusted Life Expectancy (the number of years an average person can expect to live in good health) as a measure of a nation's health achievement and has ranked its member nations by this measure . The U.S ranking was 24th, worse than similar industrial countries which have very high public funding of health such as Canada (ranked 5th), the UK (12th), Sweden (4th), France (3rd) and Japan (1st). But the U.S ranking was better than some other European countries such as Ireland, Denmark and Portugal which came 27th, 28th and 29th respectively. Finland, with its relatively high death rate from guns and renowned high suicide rate came above the U.S in 20th place. The British have a Care Quality Commission that commissions independent surveys of the quality of care given in its health institutions and these are publicly accessible over the internet [6]. These determine whether health organizations are meeting public standards for quality set by government and allows regional comparisons. Whether these results indicate a better or worse situation to that in other countries such as the U.S is hard to tell because these countries tend to lack a similar set of standards.

Taxation

Opponents claim that socialized medicine would require higher taxes but international comparisons do not support this. The ratio of public to private spending on health is lower in the U.S than that of Canada, Australia, New Zealand, Japan, or any EU country. Yet the per capita tax funding of health in those countries is already lower than that of the United States .

Taxation is not necessarily an unpopular form of funding for health care. In England, a survey for the British Medical Association of the general public showed overwhelming support for the tax funding of health care. Nine out of ten people agreed or strongly agreed with a statement that the NHS should be funded from taxation with care being free at the point of use.

An opinion piece in The Wall Street Journal by two conservative Republicans argues that government sponsored health care will legitimatize support for government services generally, and make an activist government acceptable. "Once a large number of citizens get their health care from the state, it dramatically alters their attachment to government. Every time a tax cut is proposed, the guardians of the new medical-welfare state will argue that tax cuts would come at the expense of health care -- an argument that would resonate with middle-class families entirely dependent on the government for access to doctors and hospitals."

Innovation

Some in the U.S argue that if government were to use its size to bargain down health care prices, this would undermine American leadership in medical innovation. It is argued that the high level of spending in the U.S health care system and its tolerance of waste is actually beneficial because it underpins American leadership in medical innovation which is crucial not just for Americans, but for the entire world.

Others point out that the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it and question the costs and benefits of some medical innovations, noting, for example, that "rising spending on new medical technologies designed to address heart disease has not meant that more patients have survived."

Access

One of the goals of socialized medicine systems is ensuring universal access to health care. Opponents of socialized medicine say that access for low-income individuals can be achieved by means other than socialized medicine, for example, income-related subsidies can function without public provision of either insurance or medical services. Economist Milton Friedman said the role of the government in health care should be restricted to financing hard cases. Universal coverage can also be achieved by making purchase of insurance compulsory. For example, European countries with socialized medicine in the broader sense, such as Germany and Holland, operate in this way. A legal obligation to purchase health insurance is akin to a mandated health tax, and the use of public subsidies is a form of directed income redistribution via the tax system. Such systems give the consumer a free choice amongst competing insurers whilst achieving universality to a government directed minimum standard.

Compulsory health insurance or savings are not limited to so-called socialized medicine, however. Singapore's health care system, which is often referred to as a free-market or mixed system, makes use of a combination of compulsory participation and state price controls to achieve the same goals.

Rationing

Some argue that in countries with socialized medicine governments use waiting lists as a form of rationing but there is little evidence to prove this. Waiting lists in socialized system record all those in need and give highest priority access to those in greatest need. Some think that this is more humane than rationing via the patient's ability to afford the necessary health insurance coverage (and associated co-pays, deductibles, exclusions, and cap excess), and where a person who may have greater need is rationed out on affordabilty grounds to someone who may be in lesser need.

Waiting statistics in socialized systems are an honest approach to the problem of those waiting for care and inform the public debate about how much national funding should be provided for health care. Some people in the U.S are rationed out of care by unaffordable care or denial of access by HMOs and insurers or simply cannot afford their co-pays or deductibles even if they have insurance. These people are waiting an indefinitely long period and may never get the care they need, but their numbers are simply unknown because they are not recorded in any official statistics.

Some argue that waiting lists result in great pain and suffering but again the evidence for this is unclear. In a recent survey of patients admitted to hospital in the UK from a waiting list or by planned appointment, only 10% reported that they felt they should have been admitted a lot sooner than they were. 72% reported that the admission was as soon as they felt necessary Medical facilities in the U.S do not report waiting times in national statistics as is done in other countries and it is somewhat of a myth to believe that there is no waiting for care in the U.S Some argue that waiting in the U.S could actually be as long as or longer than in other countries with universal health care.

Opponents of socialized medicine in the U.S say that healthcare is rationed in non-socialized systems through individual choice but it is not clear what percentage of people who have been denied care by their insurer or HMO, or for whatever reason find themselves unable to afford care, would concede that their inability to access care has been a matter of their free choice.

In the UK, private health insurance contracts are more likely to ration health care than the public NHS system. Some large insurers exclude many common treatments and health servicesthat are freely available from the NHS.

Political interference and targeting

Some in the U.S express concern that politicians or their created bureacracies may end up restricting their access to the health care they need or may force them to pay for health care that they feel they do not need.

In the former Soviet Union, political direction of the health care system probably had caused distortions in clinical priorities creating an unbalanced system which favoured hospitals over general practitioners. But political interference does not always lead to bad medicine and lack of it does not lead to high cost. In European countries such as France and Germany, there is very little political interference in the supply side of the health care system beyond financing and setting public obligations but medicine there remain highly rated regardless of public financing. In others such as Japan, the health care system appears to work well even though the supply side is largely private but working within a pricing framework that severely contains costs.

In the UK, where most health care is delivered by government employees or government employed sub-contractors, political interference is quite hard to discern. Most supply side decisions are in practice under the control of medical practitioners and boards comprising the medical profession. There is some antipathy towards the target-setting by politicians in the UK. Even the NICE criteria for public funding of medical treatments were never set by politicians. Nevertheless politicians have set targets, for instance to reduce waiting times and improve choice. Academics have pointed out that the claims of success of the targeting are statistically flawed. The veracity and significance of the claims of targeting interfering with clinical priorities are often hard to judge. For example, some UK ambulance crews have complained that hospitals were deliberately leaving patients with ambulance crews to prevent an Accident and Emergency department (A&E, or emergency room) target time for treatment from starting to run. The Department of Health vehemently denied the claim, because the A&E time begins when the ambulance arrives at the hospital and not after the handover. It defended the A&E target by pointing out that the percentage of people waiting 4 hours or more in A&E had dropped from just under 25 percent in 2004 to less that 2 percent in 2008 . The original Observer article reported that in London, 14,700 ambulance turnarounds were longer than an hour and 332 were more than 2 hours when the target turnaround time is 15 minutes. However, in the context of the total number of emergency ambulance attendances by the London Ambulance Service each year (approximately 865,000), these represent just 1.6% and 0.03% of all ambulance calls. The proportion of these that attributable to patients left with ambulance crews is not recorded. At least one junior doctor has complained that the 4-hour A&E target is too high and leads to unwarranted actions which are not in the best interests of patients.

Political targeting of waiting times in England has had dramatic effects. The National Health Service reports that the median admission wait time for elective inpatient treatment (non-urgent hospital treatment) in England at the end of August 2007, was just under 6 weeks, and 87.5 per cent of patients were admitted within 13 weeks. Reported waiting times in England also overstate the true waiting time. This is because the clock starts ticking when the patient has been referred to a specialist by the GP and it only stops when the medical procedure is completed. The 18 week maximum waiting period target thus includes all the times taken for the patient to attend the first appointment with the specialist, any tests called for by the specialist to determine precisely the root of the patient's problem and the best way to treat it. It excludes time for any intervening steps deemed necessary prior to treatment, such as recovery from some other illness or the losing of excessive weight .

See also

• Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
• Healthcare in Taiwan, 6 percent of GDP (~1/4 US cost), universal coverage by a government-run insurer with smart card IDs to fight fraud.
• Publicly-funded health care
• Worldchanging's simple argument for Why We Need Government-Run, Universal, Socialized, (call it whatever you want) Health Insurance (4.5 stars on YouTube with 34K views) from Andy Lubershane at Worldchanging