what if everybody got health care the way I can?

So yesterday I went to my health clinic here at Purdue. I went to have a followup appointment and get a refill on a prescription I’ve had since last September of so. I went to the Purdue University Student Health (PUSH) center. It’s quite a comprehensive clinic; I’ve had everything up to and including minor surgery there. For a more major procedure a couple years ago, I went to a local hospital. (Part of the Indiana University system, actually.) Having some sort of health plan is mandatory for all grad students; some people have preexisting plans, others get on the school plan like me. I pay extra every year to add an optional dental plan. Mental health is included, with a counseling center where I can get free therapy sessions from licensed therapists. Physical therapy is particularly comprehensive, and I will gladly be a hypocrite about college sports in enjoying the fruits of a large sports medicine department. Another nice advantage: all of my info is associated with my student account, which they access by swiping my ID. It’s got my health insurance info, it’s got all of my medical records, and it’s got my prescription history. It also is linked to my financial account, so I can have what they charged automatically deducted from my next paycheck.

For this procedure yesterday, I called and made an appointment a couple days ago, went to my appointment with a doctor of internal medicine, got the visit for free, got charged $15 for some bloodwork, then went to the pharmacy school next door and got my prescription for $20. In three months, I’ll go back and do it again.

Heavily subsidized health insurance is one of the reasons that my quality of life is so much better as a graduate student than it was before I started, whatever my long term job prospects. For a guy with a back that an orthopedist once called “structurally compromised,” knowing that I can get cheap treatment, prescriptions, and physical therapy doesn’t just improve my physical health. It dramatically reduces my stress. Back when I was cobbling together odd jobs, medical problems were an avalanche, a crisis. It was a constant low-level fear that would occasionally spike into “I genuinely don’t know what I’m going to do.”

None of this is free, for me or for the system. As I said, I pay a small fee-for-service for most things. I also pay a lump-sum fee at the beginning of the year; it works out to $40 a month or so. The school surely subsidizes that in a number of ways. I’m sure there are people who would make the case that this is really a largesse made possible on the backs of exploited undergrads. I think that’s mistaken; my health insurance is part of my compensation for teaching, and it comes along with a quite low wage by any standards. But either way, it’s a separate discussion. What’s important here is: the system works because of pooled risk and pooled resources. I have attended three public universities of three different sizes. In each case, the quality and comprehensiveness of the on-campus medical facilities was associated with the size of the total student body. The bigger the school, the better the medical care. I don’t have data to say if that’s true writ large, but I’m willing to guess that it is. What works in funding medicine is for people to pool risk; everybody pays, and most people are healthy most of the time so they don’t take a lot out of that pool, but everyone benefits from the existence of facilities and coverage that could only exist with an adequately sized pool.

This isn’t a simple or straightforward relationship. I’m sure there’s tiny liberal arts colleges with endowments big enough to permit great medical facilities. The tangled thicket of subsidies and payments involved in my medical center are certainly hard to extrapolate from simplistically. But I do think that the fact that Purdue has a 40,000 student community is a direct and important factor in the quality and range of services. For now it’s an educated guess, but it makes intuitive sense to me.

So what if, instead of a large public university population pooling risk and resources, the 300+ million Americans pooled risk and resources? The United States government, given the ability to negotiate as the dominant or only payer, could make remarkable progress in restraining the cost of health care. Given how inordinately expensive the American system is, there is surely room for cost cutting to occur while keeping medicine economically viable. What’s more, unlike the United States government, Purdue does not control a fiat currency, have a central back, or enjoy the ability to print money. The government has a profound ability to weather periods of funding shortfalls that is unlike most any other organization in the world. Standardizing the payment system would also make it easier to eliminate waste in terms of billing and records. Unlike every other doctor’s office I’ve ever been to, PUSH does not have an endless fumbling of charts and folders by a dedicated, salaried support staff, as far as I can tell. The ease of using the ID for record keeping helps eliminate at least some of that. This is similar to the national health system in France.

As for me, the cost to the consumer in such a system is not $0. I think that there’s a misconception that socialized health care or single payer represents a system where government pays for everything. I would support a system based on, say, a 1/3 consumer – 2/3 health plan split, with a cap on total payments for any individual period of care so that no one is wiped out financially be catastrophic injury. My health care is heavily subsidized, but medical costs still represent a non-trivial amount of my total annual income. That’s appropriate, given the importance of health care. What’s essential is that care is not denied because of an inability to pay.

If this were all theoretical, I would understand the level of resistance. But it’s not theoretical. Most other industrialized, technologically advanced countries are able to provide adequate health care to almost all of their people without leaving the individuals or countries bankrupt. It isn’t easy and it isn’t perfect, anywhere, but it’s possible– and at a far lower cost, in terms of percentage of GDP, than we pay here.

There are issues. You can very fairly make the point that a college population is necessarily younger and healthier than a national population, which means the cost shifting has to be more dramatic and more punishing for the young and healthy. There’s also the question of what the analog for the health clinic is for the rest of the country; unless we have true single payer, will we get the kind of situation where doctors turn away Medicaid patients, precisely because of those cost savings? Would a series of federal health clinics, designed to compete with for-profit hospitals and doctors, help or hurt? And of course, there’s the basic fact that a lot of the countries that have effective health care systems simply have far more progressive tax structures, and implementing one here seems nearly impossible in an environment where Democrats fight upper middle class and upper class tax hikes as much as Republicans do.

I don’t know the answer to those questions. I do know that the ability to receive adequate health care, at a cost that is not economically crippling, is one of the most positive changes that’s occurred in my adult life. And I think if you’ve experienced the kind of fear that  comes with health problems when you have no  coverage, and then experienced the security of knowing you can survive getting hurt or sick, you’ll come to see this as a basic matter of human and civil rights. Whether it comes from iteratively improving Obamacare, or replacing Obamacare, everyone should have the ability to get health care in the way I currently can.


  1. Freddie:

    You are my favorite socialist. Why did you shy away from saying that “doctors and nurses need to be paid less” and hospitals and pharmaceutical corporations need lower profits?

    That’s my problem with all the talk about “single payer.” It hides the football, which is that imposed price controls (or whatever you want to call it) will lower costs, which will probably lower the spectactular increase in wages in the health care sector. If you think it’s unfair (which I think is totally possible (and that it’s weirdly lumpy in unfair ways)), then supporters of single payer should come out and say it.

    I’m not a supporter of single payer, and I can. Why can’t you?

    1. I think doctors need to be paid less, and inevitably will be, although I suspect that will represent a smaller proportion of the eventual cost savings we require than you think. But, sure: American doctors need to be paid more in line with their international counterparts, which means doctors in general and certain specialties like anesthesiologist in particular have to be paid less.

      1. It probably has to do with our different conceptions of “where the money is going.” I tend to think (maybe I am wrong) that it’s mostly going to labor.

        1. I don’t know; it would take more access to the facts than I have right now. I don’t doubt that the pay for medical professionals has to go down, although for straightforward progressive reasons I think that should result more from a nurse who makes $60K a year than from a surgeon who makes $400K. I imagine that the vast gulf in the price America pays for health care and the price France or Japan pays has to include a major tithe to some corporate entities, but it’s an empirical question.

  2. Your proposal sounds kind of like the French system, where the French government does an 80-20 split with people (you can get private insurance to cover the 20%, often through your employer). The German system has something like that too where the premium is set by the Ministry of Health, although the administrative side of it is a complex mix of non-profit sickness funds operating at the state/lander level. Both work extremely well, so I’d be in favor of it.

    Yeah, doctor pay is probably going to have go down a lot. You might be able to make up for some of that if the system defrays some of the costs of medical school, or shortens medical school and residency periods. Lots of new doctors go to work as salaried staff in a clinic or hospital these days anyways, so they might take the lower pay if it came with better hours and more support. The American Medical Association will still fight it tooth and nail on behalf of existing doctors, but they’d be fighting that battle anyways against insurance companies and the consolidating hospital chains.

    It’d be good to toss in some supply side reforms as well. More nurse-practitioners, more doctor and hospital ability to delegate tasks to non-doctor medical staff like Physician Assistants, and so forth. I’m kind of hoping that IT and computer capabilities help out a bit here, like that IBM Watson that they’re trying to train to spot cancer.

  3. Look into the salaries of PUSH doctors. The reason why Purdue University health care is so cheap, is because the doctors don’t get paid do much.

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