Recently I published an article titled “The case for universal healthcare”. In response, a fellow writer called “Dissenting Academic” released a point by point “rebuttal” of my article. If you feel like wading through a cesspool of fallacious arguments and misrepresented statistics, I would highly recommend it.
While I commend Dissenting Academic for questioning my arguments, and his paper was well written, I commend him more so for his ability to consistently miss the point of almost every argument I make without fail. In all seriousness, however, I feel that Dissenting Academic put fourth many substantial arguments which I believe productively move the discussion along, and I hope to do the same in this essay.
Healthcare Deaths and Wait Times
The first argument Dissenting Academic puts fourth is his contention with my usage of studies which show that lack of healthcare contributes to around 45,000 deaths a year. Dissenting Academic then asserts that wait times in Canada contribute to even more deaths than lack of healthcare in America. While i’m open to the idea that the study I cited is inaccurate (Other studies have found that the number is more like 26,000 or 22,000 deaths annually due to lack of healthcare coverage), once you get into the 10 thousands the specific numbers seem irrelevant. Besides, the number of deaths is largely irrelevant to my point anyways. What I more so take issue with, and what I believe to be the more relevant point, is Dissenting Academic’s comment about wait times. He claims,
“Regardless, let’s assume the number is 45,000 a year. Well, Canada’s wait times alone has us beat. The Fraser Institute published a studymeasuring the effect of wait times on mortality of women in Canada. The study finds the increase in wait times has resulted in between 25,000 and 63,000 additional deaths in females over a sixteen year period.
If you multiply this by two (to account for men) and extrapolate to America’s population size this brings us to over 44,000 deaths a year on the low end. Nothing is fixed by single-payer healthcare in this regard, and if you use the more accurate middle estimate, things only get worse.”
Firstly, out of laziness or dishonesty, Dissenting Academic takes the number of female deaths and multiplies it by two to account for men. What he doesn’t take into account, however, is that this same study explicitly stated there is no significant relationship between wait times and male mortality rates. Therefore, Dissenting Academic is exaggerating his data by 50 percent. However, the larger fundamental issue with Dissenting Academic’s argument is the assertion that these wait times exist because of Canada’s public healthcare system. If Dissenting Academic is attempting to make the argument that Canada has longer wait times because they have a more public healthcare system than the US, how come he leaves out the fact that the UK performs better in regards to timeliness of care than Canada and the US, despite having a more public system than both countries. In fact, the UK, Switzerland, the Netherlands and Germany all scored higher than the US as far as timeliness of care despite having more public systems. The correlation just doesn’t add up. Dissenting Academic has therefore committed a cherry picking fallacy by picking a specific data point to support his narrative while ignoring the larger picture which doesn’t. Furthermore, despite what Dissenting Academic would have you believe, Canada’s wait times are due to under funding and poor coordination. To help me illustrate my point, author Andre Picard writes:
“What distinguishes the countries that have markedly better results than Canada – like the Netherlands and the Nordic countries – is the cohesiveness of the system, and the emphasis on primary care… In Canada, by contrast, we have very much a sickness-care system, with many silos, and very little coordination. There is far more crisis management than planning and political interference is commonplace. And, as the data in the new CIHI study highlight, patients are often left to navigate the complex system on their own, and too often fall between the cracks.”
Therefore, even if Dissenting Academic’s figures regarding wait times were accurate, it would be irrelevant to the argument regarding medicare for all, because Canada’s public healthcare is not the root cause of the long wait times, and countries with even more public systems than Canada perform even better than the US when it comes to timeliness of care.
Supply & Demand
The next point Dissenting Academic brings up, as well as the most prominent as he admits, is regarding the disparity between supply and demand in the US. On this issue, Dissenting Academic writes the following:
“Since at least the 1980’s, the amount of people (note: not the percentage of people, the actual amount of people) graduating from medical school has been stagnant. We have had the same amount of people graduate from medical school every year. Along with this, the population has grown over 100 million and people have gotten older, therefore requiring more care. Milton Friedman pointed out this very same issue in 1992. The supply does not meet the increasing demand.
By simple laws of supply and demand, this is a very easy issue to recognize. I bring this up a lot in the article so I’ll refer to it as the “supply-demand issue of single-payer” simply because single payer offers literally no solution to this problem. I have yet to see a response to this problem in particular.”
Dissenting Academic is partly right on this point: There is an increasingly dangerous disparity between supply and demand within the US healthcare system. However, this is an extremely complex issue which Dissenting Academic doesn’t seem to fully understand. There are plenty of things we can and should do to combat this disparity. For example, we could hire more physician assistance and nurse practitioners to ease physicians’ work loads. We could increase residency positions so we would have more doctors. We could reduce the frequency of recertification tests. We could shift much of the care from primary care physicians to nurse practitioners and others. Allowing nurse practitioners to perform primary care alone could easily mitigate much of the damage. For reference, according to one study, Americans could experience a shortage of nearly 120,000 physicians by 2030. For contrast, there are more than 270,000 nurse practitioners in the US with just as much education as primary care physicians, with more graduating every year. Simply letting these nurse practitioners take the roll of primary care physicians could largely reduce the crisis. None of these measures, however, necessitate a free market system over a single payer system. Besides, a public healthcare system very well may incentivize more people to work in the medical field. According to a medscape medical news reader poll, 68 percent of medical professionals say they support the US moving to a medicare for all system, with 52 percent strongly supporting. The reason for this is the overwhelming amount of paperwork and complexity associated with a private healthcare system which wouldn’t exist under a public healthcare system. A more simplistic approach very well might incentivize more people to go into the healthcare industry. It’s also worth noting that we have to take into consideration the exponential advancement of technology. As we’ve seen, automation is taking up more and more jobs, including in the healthcare industry. Therefore, in time automation will begin alleviating much of this demand shortage at a continued and exponential rate, which will diminish much of the problem.
Healthcare Prices And Regulation
The next argument Dissenting Academic makes in his article is a fairly obvious one. I’ll let him say it in his own words
“Woah what do you know? The US government spends a lot on healthcare as is. It’s almost as if we don’t have a true free market system and the issues provided by our current system are largely based upon our current spending level and intervention in the healthcare market.”
after a brief explanation of the history of regulation and healthcare prices, Dissenting Academic then goes on to say,
“Crazy how that works out, isn’t it? It’s almost as if regulations cause prices to go up and limit the market’s ability to operate efficiently.”
So, there we have our next argument: The reason healthcare costs are so expensive is because of scary government regulation. While he’s right to an extent, regulation in some aspects has made prices go up, he’s not right that the way to most effectively lower prices would be through a free market. Furthermore, even if he was right, free market healthcare is riddled with so many problems this point would be irrelevant, but i’ll get into that later. The issue with his argument is that much of the reason for our expensive system is inherently baked into the fact that it’s a private system, and would not vanish in the absence of regulation. For example, overhead and administrative costs contribute largely to the cost of healthcare in the US, which can be directly attributed to the profit motive of a market based system and would not vanish under a free market. Under a free market, healthcare companies would still waste billions on advertising and administration, which drives up the cost of healthcare. Under a free market system, companies will still screw over the consumer as much as possible to make a maximum profit, which drives up the cost of healthcare. Furthermore, the market mechanisms which usually keep costs down rely on the consumers ability to gouge quality in relation to cost. These market mechanisms, however, are not present in the healthcare industry due to the gap of understanding between the provider and the consumer. It takes a mouth and a functioning tongue to gouge the quality of an apple; It takes a complex knowledge of anatomy and medical science to gouge the quality of a liver surgery. Even if people were able to gouge quality, many problems which can arise out of poor healthcare can take years to manifest. In the healthcare industry, just like in any other industry, providers of medical care have every incentive to cut corners and exploit the consumer to the greatest extent possible, and unlike many other industries they are enabled to due so in the absence of regulation. Because a single payer system would be 1. less complex and 2. wouldn’t have a profit incentive, we have reason to believe it would be more cost effective than a free market system. In his article, Dissenting Academic points to the fact that since the 60’s healthcare costs have been going up, and he blames it on regulation. However, he ignores two important details. 1. Healthcare costs continued to increase in the 1980’s, despite Reagan’s large push towards deregulation. 2. It wasn’t just the US that had healthcare costs rise since that period, global healthcare costs have been rising as well. My favorite fact about what Dissenting Academic is saying, however, is the following: Dissenting Academic is trying to make the point of: ‘Oh, look how cheap healthcare used to be before all this regulation’ and uses that to try to make the point that a more free market would be more cost effective than single payer. Here’s the problem though, even if you go back to when the US healthcare market was much more free and costed less, most other countries with single payer still payed less than us. For example, in 1960 the cost of healthcare in the US was only 5 percent of its GDP. Pretty good, right? In the UK, however, which had a public healthcare system, the cost of healthcare in 1960 was just 3 percent of its GDP. The UK isn’t the only country with public healthcare which had a more cost effective system even when the US was more of a free market, however. In fact, most countries did. This pretty much defeats Dissenting Academic’s entire point.
Healthcare Quality- Again
The next point Dissenting Academic lays out is his contention with my assertion that America has merely average healthcare quality despite costing more and covering less people. He refutes this by talking about health outcomes- Then he remembers the studies I pointed out which deal more with objective quality of care rather than health outcomes, and switches his argument to “Well, just cause we have average satisfaction and objective healthcare quality doesn’t mean we should have single payer, it just means we should change to something else.” First, Dissenting Academic points out some important caveats when it comes to US health outcomes, specifically we have high rates of suicide and obesity, for example. He says,
“There are a few ways we can look at this. One is through mortality rates. Mortality rates are lower for cancer related deaths in America but higher than average for circulatory related diseases, this being the main area dragging the US down. If you controlled for the amount of obesity in America this would likely go away.
The amount of obesity is not a healthcare related issue but a culture related issue. The same goes for suicide relates which also bring down the American mortality rate. Healthier diets are preferred in European countries while America has a large issue with this obviously. America also eats a lot of fast food. As William Titshaw at the blog The MegaThink illustrates, fast food is a moderate-strong predictor of obesity. This is not a healthcare issue; this is an American issue.”
First of all, I could argue that suicide rates are due to a lack of proper mental healthcare, and obesity rates are due to a lack of prevention on the part of our healthcare systems. However, I won’t get too much into that, because these are minuscule points. So, let’s look at aspects of healthcare which don’t have to do with these outcomes by looking at the source Dissenting Academic recommends, the Peterson-Kaiser health system tracker. According to this source, The US has higher rates of medical, medication, and lab errors than comparable countries, 30 day mortality for heart attacks and ischemic stroke are lower in the US than in comparable countries, rates of post op sepsis in the US are about average compared to comparable countries, rates of post op suture ruptures in the US are above average, rates of surgical items/foreign body’s left inside the patient are about average in the US compared to other countries, five year survival rates for cervical cancer are slightly lower than average in the US, and are slightly higher for colorectal and breast cancer. As we can see, US healthcare quality even not taking into account health outcomes such as obesity and suicide, are average. This is the point I made in my original article.
Dissenting Academic then refrains to “Yes but even if US healthcare is average, that doesn’t mean we should have single payer it just means we should have something other than our current system!” I’ll let him say it in his own writing.
“Yes, there are some countries that have socialized healthcare that have higher satisfaction rates than the United States. There are countries that are still less satisfied than the United States. No one is claiming the current system is good. Just that it is better than if America had a single payer system.
He also points out that America is ranked 5th out of 11 countries in terms of healthcare quality. Okay? Once again this does not mean healthcare in America should become single-payer like the other countries, only that it should be changed. Tl;Dr: Not an argument for single payer, just against modern US healthcare.”
Healthcare quality is better than if we had a single payer system? Why? We are literally dead average in comparison to other countries with public healthcare systems, how can you extrapolate from that information the conclusion that “hm, this must mean our system is of better quality than a single payer system.” We have literally no reason to believe this to be true, that was my entire point. However, his broader point is that this is not an argument that we should have single payer, it is merely an argument against our current system. This is something Dissenting Academic continuously echoes throughout his article, and it genuinely puzzled me for a short while trying to figure out what point he thought he was making. I believe Dissenting Academic is attempting to make the accusation that comparing a current system to another system and showing that the other system would be more efficient is not an argument for said system because there are other possible systems, which it seems could be applied to any argument ever. Oh, you’ve shown that raising the minimum wage would be better than what we have now? Well, Dissenting Academic, actually that’s not an argument for raising the minimum wage because we could enact universal basic income more efficiently as a means of giving the working people money. You’re merely arguing against the current system, not for raising the minimum wage. I may be misinterpreting what Dissenting Academic is trying to say, and if this is the case I request he correct me, cause I’m genuinely very confused regarding the origins of this thought process. Besides, this is irrelevant because I address why a free market wouldn’t work in the healthcare market anyways at the end of my article, which Dissenting Academic conveniently only tackled half of- and poorly.
Coverage, Minimum Wage, And Taxes
The next segment of Dissenting Academic’s article attempts to refute my accusation that increasing coverage would be beneficial to competition nationally and internationally. First, he writes:
“But seriously, why is the idea just falling out of consideration we should take the bill off of the employer, allow the employer to pay a higher wage, and put the bill on the employee.”
Ok, let’s do some math. I know from previous statements, Dissenting Academic is for a 10.10 dollar minimum wage. So, let’s say a worker is working full time, 160 hours a month. At minimum wage, that worker would make 1,616 a month. However, seeing as how the average cost of healthcare is around 440 a month, you would have to subtract that. In this scenario, a worker earning minimum wage and paying his own healthcare bill would wind up with about 1,176 a month, and that’s under the assumption that he’s only paying for his own. Now, let’s compare that to a current minimum wage owner who doesn’t have to cover their own medical bill. The current minimum wage is 7.20. If you multiply this by 160 you get 1,152 a month. So, the monthly earnings of someone making a 10.10 dollar minimum wage and paying their own medical bill is a whopping 24 dollars a month higher than the earnings of someone who makes minimum wage today and doesn’t cover their own medical bill. Newsflash: 80 percent of workers live paycheck to paycheck. 40 percent of Americans can’t cover an unexpected 400 dollar expense. Income inequality has been increasing for years. Almost half of welfare recipients are working full time. The working people need economic support, not an extra 24 a month. Besides, even if the people did buy their own insurance we would still be paying a needless amount of money into administrative costs and such which drives up the overall cost to the economy while evidently not yielding better results, making it pointless. If we went with Dissenting Academic’s idea, less people would be covered, it would still be inefficient to the macro economy, we’d have people being exploited because of the profit incentive mixed with the customers inability to gouge quality, but at least you’d get a pay raise of less than 1 dollar an hour! A true populist hero, this man is.
The next argument Dissenting Academic makes is a bit more silly
Yes, his plan technically saves employers money because they no longer have to pay for insurance for their employees. Although, the people at the top of the employer chain will be paying most of the bill for this single payer system so it’s not like much changed.
Yes, that’s largely what I’m getting at. As it is right now, all employers pay their employees medical insurance. If it was only the top disproportionately paying into it, that’s taking more from the top to benefit the bottom, which encourages competition. This is essentially redistribution. Once we can accept that taxing the rich disproportionately to pay into a system which benefits the working people is essentially a redistributive policy, which it seems Dissenting Academic has, we can have a more informed discussion regarding the affects. As extensive studies from the International Monetary Fund has shown, redistribution is good for the economy. As researcher and deputy director of the IMF states,
what my work shows is that on average – over many countries and across many time periods – the redistributive fiscal (tax and transfer) policies that (advanced and developing) countries have pursued have not been harmful. A key objection to redistributive policies is that they damage economic efficiency – but the damage on average appears to be small unless redistribution is extreme. And the resulting increase in equality has a remarkably robust protective effect on both the level and the sustainability of economic growth.
What Dissenting Academic doesn’t realize is that taking more money from the “Top of the employer food chain” To benefit workers and smaller business owners is good for growth and it’s good for competition.
Dissenting Academic then asserts again that de regulating healthcare would cost less and put more money into the workers pocket. Sigh.
If we remove the regulations on businesses to have to pay this bill and we deregulate the healthcare market and stop most spending into it, basically making it a free market system, then maybe assume the wages rise for the employees, let’s see what happens. The employee has more money, pays less in taxes, and pays less for a healthcare plan. This altogether means he/she saves more by having the free market system.
As I already pointed out, the costs are largely due to administrative complexity. Furthermore, the complexity (which leads to waste) is built into the private system. It’s no secret sick people are less profitable for healthcare insurance companies because they suck up most of the costs by being sick, while healthier people are more profitable. This is what economists called cherry picking and lemon dropping: health insurers will do things to make it harder for sick people to deal with health insurance, such as punishing the sick with higher copays and deductibles and placing restrictions on preauthorization: economists call this adverse selection. Because of this and a plethora of other things, needless wasteful complexity is built into the profit motive of a free market healthcare system, so this delusion that if we just get rid of regulations everything will be cheap and perfect is silly. The sentence that really sticks to me is “the employee has more money, pays less in taxes, and pays less for a healthcare plan.” Yeah, expect the employee would, as shown earlier, get a negligible increase in their buying power, we have no reason to believe healthcare costs would go down substantially, and despite Dissenting Academic’s framing that decreasing taxes would lead to the working people having more money, the social programs which are propped up by taxpayer money account for some of the best quality of living for working people in countries like in Scandinavia for example.
Dissenting Academic then goes on to say the following
Furthermore, the idea this puts more money in the employees pocket, especially in comparison to a free market system is ludacris. Let’s assume we start a progressive, social democratic system where people have many programs provided to them. This would definitely increase taxes on everyone and therefore, the person would have insurance, but he would still have less money in his pocket.
No. Taxes would go up, but not to the same extent as dissenting academic is saying, and certainly not to the extent where the people would be paying more in taxes than they would on a healthcare premium. Keep in mind, rich people would be disproportionately paying into this system. We could pay for this through a wealth tax, partly a value added tax, a more progressive estate tax, ending corporate loopholes, etc. the effect on the average person would undoubtedly be a net benefit. You think people would be paying more under single payer because of increased taxes? Wow, that’s quite the assertion considering the U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person. Furthermore, as one rand study shows, under single payer taxes would go up, but premiums, deductibles, and co-pays would be zeroed out, leaving most people with more money on net. This idea that taxes would be more expensive than what Americans currently spend is pure nonsense that Dissenting Academic pulled out of thin air.
Dissenting Academic then asserts,
The plans provided by employers are usually pretty bad. Many companies, such as Wal-Mart find ways to pay for the cheapest healthcare possible (obviously) and so the workers are stuck with a healthcare package they don’t even like. If we just take that away and deregulate the healthcare market, the employee would be much more satisfied.
Wow! Dissenting academic is trying to argue in favor of free markets by bringing up a company which blatantly runs on exploitation (as he himself alluded to) and performs great in the market! I wonder if he sees the irony. In all seriousness, however, this is just silly. Dissenting Academic acts as if the healthcare providers themselves wouldn’t do the exact same thing to the consumers in order to make maximum profit.
Then, in reaction to my point that more workers having healthcare would lead to a more productive work force, Dissenting Academic says
But this assumes people will be much healthier under a single payer system. I’ve already illustrated the falsity of this point. People are unhealthy because they are fat. Obesity rates are very high in America and the deaths match it. Most health issues where America is leading in the death rate for can largely be attributed to obesity.
This would be a sound argument, except it’s not at all because generalized health outcomes have absolutely nothing to do with whether or not increasing coverage would make the population more healthy. This is a ridiculous argument. Recent studies have found that healthier workers are more productive. Further studies have found that people with healthcare are healthier. So, if healthier people are more productive and people with healthcare are healthier, it almost seems as if giving more people healthcare would make them more productive, but I guess that’s just a crazy theory.
Free Market Healthcare
If you don’t recall, at the end of my initial argument I explained that because a free market requires voluntary and consensual transactions, in the absence of insurance it is not a free market because in an emergency scenario the consumer is in no position to shop around for the best price or negotiate. However, so long as insurance exists, without regulation a person purchasing insurance is gambling their life, putting it in the hands of a profit seeking company which has every reason to exploit them, and will only see the results of said gamble when their life is on the line. Dissenting Academic’s response to this argument was… less than compelling.
First of all, it’s your personal responsibility to purchase insurance and educate yourself enough to do so. This whole point that we shouldn’t have freedom in our healthcare provider or make decisions of this matter is not going to hold up. It’s a subjective view, not an objective case against the free market. The system works so let it work.
It’s the workers personal responsibility to purchase insurance? Okay? That’s not relevant, what i’m saying is even if they purchase insurance they cannot be sure that insurance company will come through when they need it without regulation. This is just a silly immoral libertarian talking point,”Oh, the worker is going to be exploited through this system because of faulty incentives and a lack of regulatory mechanisms? Well, it’s really the workers fault for not having enough money or knowledge to not be exploited.” Bourgeoisie boot licking at its finest. I’ve already explained how insurance companies are inherently exploitative and especially towards sick people who are unprofitable, therefore I am not in the slightest convinced by the personal responsibility argument, nor should anybody be with an in tact moral compass. I think this is a really bad point which doesn’t require much of a response, so i’ll just leave you with a quote from Maria Svart, the national director of the democratic socialists of America about this issue:
it’s absurd and cruel to insist that working people have the time, expertise and money to shop around for prices and providers while they are sick. Do you want the best trained surgeon, or the cheapest one?
Let’s look at his next point,
Second of all, when you’re in an emergency situation you will likely be billed afterwards. You can negotiate how much your insurance company covers you after the emergency. If you go to the emergency room in the hospital right now, they will treat you right away and you will be billed afterwards. This is kind of a misinterpretation of the current hospital system in America.
Again, he misses the point. I literally just provided the rebuttal to this in my last paragraph so i’m not going to go through it again, but essentially the fact that somebody has health insurance doesn’t make the industry not exploitative, and without insurance any transaction which takes place in an emergency scenario is unconsensual. The next argument Dissenting Academic makes is that “well what if we just got rid of insurance” which I already dealt with the problem with such a proposition so we can skip over that.
Finally, in response to my point about how under a free market healthcare system poor people would have to get healthcare and healthy more wealthy people wouldn’t get it as much forcing providers to raise prices, Dissenting Academic writes (before again bringing up the supply and demand issue I already addressed):
Healthcare is demand inelastic so if people have to pay for it, obviously they will.
First of all, demand is only inelastic for people who need it, which isn’t most people. Second, That’s literally my point. Sick people have to pay for healthcare, so they will. However people who don’t have to cause they aren’t sick typically won’t as much which causes insurers to raise prices on the sick/typically poor. The result is unreasonably high prices on the poor and less healthy people purchasing healthcare cause they’re being priced out by insurers having to raise prices on the sick to continue to make a profit. This is why there would be less coverage and more exploitation. To combat this as I alluded to earlier company’s would cherry pick and lemon drop which inherently drives up costs and exploits people who need healthcare. Essentially my argument was “sick people have to pay for it anyways which leads to exploitation” and dissenting academics response is “no it’s fine cause sick people have to pay anyways.” Ok? In the first half of his essay Dissenting Academic brings up some truly important caveats, but in this section he seems to just miss the point of every argument I make completely.
Dissenting Academic also conveniently neglected to cover one of my most prominent points, that being the costumers inability to gouge quality and even cost. In the healthcare market you don’t get much information on quality and cost, because the personal bill you receive is only loosely related to the services you receive. The healthcare market is unlike normal markets for a variety of reasons, as economist Kenneth Arrow explains: Providers know more about medicine and procedures than patients do, therefore the information is asymmetrical. Patients in an emergency situation cannot make decisions regarding who they want providing them. People’s need for healthcare is unpredictable, unlike most goods. The doctor-patient relationship requires a level of trust which is unparalleled by most industries. Payment in an emergency scenario comes after care, making it different from a normal market. With all these defects, why would one expect healthcare to behave like a normal market? You can bring up examples of free market healthcare in very specific cases like laser eye surgery which work well on a micro scale- believe me i’ve read every example I could find of free market healthcare examples, but all come with important caveats and aren’t evidence that a free market could work for the macro economy.
In conclusion, while Dissenting Academic’s paper was well written and interesting to dissect, I don’t believe it made a compelling case for free market healthcare or against single payer.