Steel-Man Series: Universal Healthcare (Part 2)
[Writer’s Note: This was originally posted on my website on 3/23/2020 and is the second part of a 3-part piece. There is no podcast covering this article yet, but I do plan on recording one eventually.]
In Part 1 of the steel-man series on universal healthcare, I went over several different definitions for terms used in arguments for Part 2 and Part 3. In this part, I will go over arguments that cover how universal healthcare is utilized around the world, how affordability can prevent patients from using their healthcare, and health outcomes in different countries. The data and sources used in the argument and critique come from the least bias sources I could find. If the sources had a bias, they would be more Left leaning. All arguments and critiques were made to validate or dispute the statement given at the top of each section. Overlapping arguments will be considered at the conclusion of the final article.
Many of these arguments have been made by advocates of universal healthcare for years, but the arguments often have a strong progressive bias that lead to bad-faith claims that assume the motives of the opposition. The same goes for conservative critiques. Those bad-faith arguments will be left out of this commentary to establish a more airtight argument that can only be disputed, not by citing another source for an alternative data set, but by citing other sets of data that can further explain the original data set results. No arguments that can be completely dismissed or assume bad intentions will be used in this series. All sources used will be hyperlinked or cited at the end of the article.
I did my best to partition the main steel-man arguments, pro-universal healthcare arguments (which expands on the main steel-man argument), and conservative critiques in an easy way to follow. I hope this helps avoid confusion. Let the steel-manning begin.
Argument 1: Most of the developed countries in the world have some form of universal healthcare coverage
Pro-universal healthcare steel-man argument:
True. As I have stated before, most developed countries comparable to the U.S. have some form of universal healthcare coverage, and even some countries declare healthcare as a right. As of today, 18 countries offer universal healthcare coverage including: Australia, Canada, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, the Netherlands, New Zealand, Norway, Portugal, the Slovak Republic, Slovenia, Sweden, Switzerland, and the United Kingdom1. This leaves out the fact that most of them have better healthcare outcomes at a lower price, which I will get to in later arguments so I will not address those points yet. If these developed countries provide coverage for all their citizens, then why is the U.S. lagging behind?
Pro-free market healthcare critique response:
Many countries have different systems. This not only includes healthcare systems, but in terms of their constitutions (or lack thereof) to enshrine rights, type of government, economics systems, justice systems, national energy programs, immigration law, national defense implementation, and many other systems of government. This weakens the argument that if everyone else does it, so should we. There are many things about America that are unique and should probably remain unique. This also neglects the fact that many of these countries use different types of universal coverage that works best for their people. To copy a specific country’s healthcare policies and expect those to translate to the U.S. population and have the same outcomes is not a reasonable expectation. So, although this is a valid point, it is not a good point by itself. But if you make this point in combination with other characteristics of the healthcare systems of these countries, such as health outcomes or cost, then this argument becomes fairly strong. Because of this, we should consider this argument combined with the other arguments moving forward.
Argument 2: Waiting in line for healthcare is not as bad as not being able to afford healthcare
Pro-universal healthcare steel-man argument:
Waiting in line sucks. Whether it be waiting to see the doctor or waiting in line to get on a roller coaster, although one is more critical than the other. But the narrative on waiting times in countries with universal healthcare is over-blown and does not seem empirical. According to data compiled by the OECD in 2016, 21.8% of patients in the U.S. skipped consultation with a healthcare provider due to cost-related access problems as compared to comparable countries with an average of 9.3% [1]. These cost-related access problems included not visiting a doctor, nurse, or allied healthcare professional. The same source has patients in the U.S. skipping medical tests, treatments, and follow-ups with a healthcare professional at a rate of 19.5% compared to a comparable country average of 7.7% [2], and U.S. rate of skipping prescriptions due to cost at 18.1% compared to a comparable country average of 7.5% [3]. A 2016 Commonwealth Fund International Health Policy survey of adults asking patients from different countries the last time they saw a doctor or nurse on the same or next day last time they needed medical care, only 51% of patients from the U.S. were able to make a same-day appointment when in need of care compared to a 57% comparable country average. These surveys found not only do Americans wait for care slightly more than average, but do not follow through with care due to cost much more than other comparable countries. This means there is less access, driven by cost, in the U.S. free market healthcare system than in universal healthcare systems.
Pro-free market healthcare critique response:
These are good points to consider when arguing for healthcare efficiency. A free market system should allow for the best quality of care, at a reasonable price, with a supply that can keep up with the demand. Unfortunately, the U.S. does not have a fully free market healthcare system, a critical point which will be made several times throughout this article, and therefore, cannot offer the same characteristics of a typical free market commodity. Since the U.S. has a mixed system, that must be considered when surveying these patients. Countries with universal healthcare coverage will have fewer options for coverage, especially in single-payer systems, but the U.S. has Medicare, Medicaid, and private insurance coverage. The point here is, wait times might be affected depending on the private or public coverage option. Statistics on wait times for Medicare/Medicaid versus private coverage have been hard to find, I suspect mostly because firms commissioned to research the American healthcare system are paid by pro-universal healthcare advocates (this is what I found during my research). Trying my best to find these relationships, I looked at stats published by the Commonwealth Fund International Health Policy survey in 2017 for people over the age of 65, or in other words, individuals eligible for Medicare in the U.S. who were classified as “high-need” (with 3 or more chronic conditions) were 3 times more likely to have cost-related access problems compared to comparable countries. The point I am making here is, if we assume something like Medicare-for-all would bring us closer to countries with universal healthcare, then we would think rates of cost-related access problems would be closer in groups covered by government healthcare. What this data set might actually be saying is U.S. patients might be unhealthier on average, driving up medical needs, that then drives up cost and drives down access. This point does hurt the narrative that universal healthcare drives down cost compared to a free market solution, something I will address in a later part, but still does not explain high costs driving away people from accessing their healthcare.
The point made about not accessing healthcare because of cost is valid, but does not disarm the longer waiting times or ration of care arguments. Scheduling regular checkups or visits for non-threatening ailments can drive up wait times, especially in the U.S. where those smaller visits are most likely covered under our employer-based health insurance… for some reason. When it comes to requiring an appointment with a specialist, the OECD found in 2016 a waiting time of more than four weeks to see a specialist only occurred 27.6% of the time for patients in the U.S. compared to 43.8% of the time for comparable countries on average [4]. The availability of specialty doctors for difficult surgeries or specific types of care is just as important, if not more so depending on the circumstances one finds themselves in. A good example of this is Canadians coming across the boarder to pay extra for quicker care or for more effective medical treatment (mostly for cancer). The same study finding only 51% of U.S. patients saw a nurse of doctor the same or next day last time they needed care, only 43% of Canadian patients had that same luxury making them the lowest ranked country on the list of comparable countries to the U.S. on the topic. The Canadian healthcare system, which is a single-payer system, is rated among the worst of the comparable countries on most metrics revolving around wait times.
Both systems have their access issues. Public markets limit access using time, and private markets limit their access with cost. I am not sure if we can say one is more moral than the other. Universal healthcare is a part of the current day Democratic party agenda because inequality based on economic status is high on their radar so limiting access by cost is a big problem to them. The Republican party sees error in this logic because limiting access by time leads to rationing allowing politicians to dictate who gets access to what care when. The truth is, limiting care based on cost is a hard bargain, but limiting care based on time allows only those who are powerful, and often rich, to unlimited healthcare. The best argument for a free market solution is, if you can’t afford the iPhone, settling for an Android is better than fashioning your own cup-and-string communication system, which is what happens when a powerful, centralized government can reject your access based on any metrics they deem fit in the future. Just as any free market good or service, access to that market gets easier with more options because of more competition.
Argument 3: People in countries with universal healthcare have better health outcomes
Pro-universal healthcare steel-man argument:
The ultimate goal of healthcare is to increase the health outcomes of those that healthcare entity is serving. The healthcare outcomes in the U.S. does not seem to compare well with healthcare outcomes in comparable countries who use some form of universal healthcare. The most important metric, being life expectancy, is something the U.S. is falling behind on compared to similar countries. According to data compiled by the OECD in 2017, the life expectancy of a U.S. citizen is 78.6 years old compared to an average life expectancy of 81.9 years old in comparable countries despite the U.S. having the highest spending [5]. The U.S. also has the highest infant mortality rate among the same countries at 5.6 deaths per 1,000 live births compared to a 3.7 deaths per 1,000 live births average in 2015 according to the same source [6]. Combine poor healthcare outcomes relative to comparable countries with universal healthcare and the high price tag, it is reasonable to believe the U.S. is doing healthcare wrong and should adopt at least some of the healthcare policies that show a higher correlation with better healthcare outcomes.
Life expectancy is a common health statistic used when defending universal healthcare. This is because the goal of good healthcare is to live longer lives. Citing the infant mortality rate is another useful statistic because it closes the loop on healthcare outcomes, meaning, metrics at the beginning of life and at the end of life do not reflect positively on the current healthcare system in the U.S.
Pro-free market healthcare critique response:
What these statistics do not address is the culture of health represented in each of the countries. We all want to live longer, and we all want to make it out of the delivery room in good health. That is a given. But it is what we do between birth and death that puts stress on our healthcare systems, and Americans do not perform well when it comes to maintaining a healthy lifestyle. An unhealthy lifestyle is a major contribution to poor health outcomes no matter how high quality the care is. According to the Commonwealth Fund (data compiled by OECD), 40% of the U.S. population is reported as obese as of 2016 as compared to a 22.5% average for comparable countries in their most recent reporting years. The OECD data also shows Americans consume 63.8 kgs of sugar per capita per year compared to 43 kgs per capita per year average of comparable countries (2013) [7]. There is no secret that Americans live on foods pumped full of preservatives from grocery stores rather than buying organic foods from a food market. This is in part because of the diversity of cultures in the U.S. New immigrants and people close to their family’s culture from their place of origin tend to eat foods and dishes traditionally eaten in that culture, but those foods are often not grown in the U.S. In order to access those foods, they are shipped in from other countries or grown in the U.S. in a climate not suited for that fruit or vegetable (if applicable). In order for those foods to not go bad during transit or to survive the conditions of unnatural growth, preservatives, pesticides, and hormones are added. Those additives do a good job preserving the food but are not good for the human body. Popular dishes from other countries are also recreated by U.S. producers to give the same general flavor catered to a more general population. Think tacos from Mexico compared to tacos from Taco Bell. This “Americanized” Tex-Mex knockoff is an unhealthy alternative to a real soft-shell Mexican taco. Farm-to-table meals are much more uncommon in the U.S. than other countries. This turns this “healthcare” problem into a “culture” problem, an underlying cause we will see more in this series. You cannot expect the average American who has access to every food imaginable to have the same health outcomes as someone from Norway who is eating fresh-caught fish from their backyard no matter what the healthcare system covers.
Infant mortality rate is something we should be concerned about, but it is not caused by unsanitary delivery rooms and bad medical delivery practices, at least in the U.S. According to Reuters, 13% of deaths within one year after birth are caused by medicals problems developed shortly after birth, 31% by birth defects or congenital malformations, and 43% by sudden unexpected death in infancy (SUID). It is hard to say those deaths, especially the ones closer to birth, can be stopped by universal healthcare. It is a better argument that they can be stopped with healthier practices when pregnant, and, as I reviewed before, if Americans are unhealthier in general, there is a higher chance they are unhealthier when pregnant. The 43% of deaths caused by SUID are often a result of poor sleeping arrangements that cause the infant to suffocate while sleeping. Pro-paid parental leave advocates cite this as a reason for employer mandated or government sponsored paid parental leave, but that is a subject for another time.
The critique of this argument is strong because comparing health outcomes has much more to do with overall healthy behavior than universal coverage. I did not even bring up the fact that the U.S. leads the world in most cancer survival rates and treatments for tough or rare diseases. There is a good reason as to why the U.S. leads in those categories that has to do with innovation that I will get to later (Part 3) in this article.
End of Part 2
This concludes Part 2 of the steel-man series on universal healthcare. There is much to digest and there is more coming including the following arguments in Part 3: (4) The cost of healthcare is much lower in countries with universal healthcare, (5) we have the technology and the systems setup that will make universal healthcare easy to administer to everyone efficiently, and (6) healthcare is a human right, period. I hope this exercise will help bring more honest debate and expose the damaging effects of straw-manning arguments that result in weak positions and ideas. Thank you for reading.
OECD.stat Database References (Citations):
- Health Care Quality Indicators — Definition: Survey responses who have not visited a health professional (e.g. doctor, nurse, or allied health professional) because of costs (i.e. actual out-of-pocket payments for services) — Country (INPUT): Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Periods (INPUT): 2016 — Indicator (INPUT): Consultation skipped due to costs — Gender (INPUT): Total — Age Group (INPUT): 16 years and over — Value (INPUT): Age-sex standardized rate per 100 patients
- Health Care Quality Indicators — Definition: Survey responses who have skipped a medical test, treatment (excluding medicines), or other follow-up that was recommended by a health professional (e.g. doctor, nurse, or allied health professional) because of costs (i.e. actual out-of-pocket payments for services) — Country (INPUT): Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Periods (INPUT): 2016 — Indicator (INPUT): Medical tests, treatment or follow-up skipped due to costs — Gender (INPUT): Total — Age Group (INPUT): 16 years and over — Value (INPUT): Age-sex standardized rate per 100 patients
- Health Care Quality Indicators — Definition: Survey responses who have not filled out a prescription for medicine/collect a prescription for medicine, or skipped doses of because of costs (i.e. actual out-of-pocket payments for services) — Country (INPUT): Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Periods (INPUT): 2016 — Indicator (INPUT): Prescribed medicines skipped due to costs — Gender (INPUT): Total — Age Group (INPUT): 16 years and over — Value (INPUT): Age-sex standardized rate per 100 patients
- Health Care Quality Indicators — Definition: Survey responses who reported waiting four weeks of more for getting an appointment with a specialist — Country (INPUT): Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Periods (INPUT): 2016 — Indicator (INPUT): Waiting time of more than four weeks for getting an appointment with a specialist — Gender (INPUT): Total — Age Group (INPUT): 16 years and over — Value (INPUT): Age-sex standardized rate per 100 patients
- Health Status — Definition: Life expectancy at birth is the average number of years that a person can be expected to live — Variable (INPUT): Total population at birth — Measure (INPUT): Years — Country v: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Year (INPUT): 2017
- Health Status — Definition: The number of deaths of children aged under one year of age that occurred in a given year, expressed per 1,000 live births — Variable (INPUT): Infant mortality, No minimum threshold of gestation period or birthweight — Measure (INPUT): Deaths per 1 000 live births — Country (INPUT): Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Year (INPUT): 2015
- Non-Medical Determinants of Health — Definition: All forms of sugar, sweeteners, expressed in kilograms (kgs) per capita per year — Variable (INPUT): Sugar supply — Measure (INPUT): Kilos per capita per year —Country (INPUT): Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States — Year (INPUT): 2013
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