Michigan is indeed a good test. I wish Sayed didn't have a beard and his wife didn't wear a hijab because it makes it harder but the vote will prove if Progressives can win a somewhat conservative state or not. Personally I strongly urge Democrats to stay together and vote for the Democratic candidate regardless of whether or not he is ideal to you. Figner crossed for Michigan Remember what the other side is - and the other side isn't out to help you or America.
Thank you for your comment. I support all but two of your comments, that about El Sayed’s beard and that about his wife’s hijab. I understand your point. You are being realistic, accepting of white and other non-Muslim American views. You intend no harm.
But, I’d ask all readers to think:
- the US, like the rest of the ‘West’ is steadily becoming less ‘white’ (demographic change fuelled by population change, not ‘cultural replacement’)
- “look beyond the veil”, a comment once passed by a British, Muslim, journalist. That is to say, ‘don’t judge a book by its cover’ in other words.
Your comments are good.
I have no right to criticise, but I’d like readers to ‘look beyond the veil’ as it were.
The situation in Israel/Palestine is so dangerous, the rise in anti-semitism and in islamophobia are both so dangerous. Please don’t let the malicious get away with using these issues for malign ends.
Kind regards,
Anthony
Ps: if anyone wants to see where my ‘Look beyond the veil’ quote comes from, search for Remona Aly (journalist). The article was printed in the Guardian newspaper, perhaps 10-15 years ago.
Thank you. As a religious "none" old white guy I think we should vote for him BECAUSE he is a Muslim (in addition to his awesome credentials).
Diversity is good. Key to a healthy society that doesn't become inbred and isolated from new ideas.
All the cool guys on TV and movies now have beards :) I don't get the hijab. It must be hot in this weather. But then I don't get why women would wear stilettos, or why guys would shave their heads or why I had very long hair as a kid...
I like to consider what's inside a human - let's forget about the fashion or religious statements. Who cares. Why care? It's all about how we treat each other, right?
I appreciate all of the comments. I hardly think any of us would spend time reading the substacks or peoples comments if we didn't care deeply about what's taking place in our country. I can understand Sarah's point about El Sayed's wife wearing the hijab. But I have to believe that the name "El Sayed" will evoke a stronger response than his wife's hijab. republicans are literally unable to disqualify this regimes policies and protectionism of pedophilia. Barrack Husein Obama was a name that evoked the same reaction by the one and only pedophile president in the oval office today. He's the one that made Barrack Obama's birth certificate conspiracy theory famous. And oh how the Christian acquaintances I once had, loved to talk about him being a Muslim.
A little while ago Dr. Richardson talked about how new unexpected alliances are being formed today just like they were before, during and after the civil war. The people who we vehemently thought as our enemies could become our allies and those we thought as allies will become our enemies. I believe the wisdom in that observation may be highly understated.
I remember Theodora. I grew up in, then, strongly Catholic Ireland in the sixties, when veils (hijabs for Catholic nuns and nursing sisters) and cassocks/ habits (thobes & jubbas for Catholic priests and friars) were regular clothing.
I've no idea about the black color, but the head covering for Christian women comes from many teachings in Corinthians. I was raised in the Episcopalian faith. When I was a boy, the church kept head coverings for women who forgot to bring a hat to the service.
Prior to about 1920, those same teachings forbad Christian women cutting their hair and, in most groups, allowing any man other than her husband from seeing them with it down and loose. That changed with the "flapper" era.
I was told that they actually cut their hair when they get married. After that, they wear a wig. Providing those wigs used to be big business in Manhattan.
It's just a thing. Horses with ample and resplendent manes and tails are considered more attractive. I would guess that gorgeous hair is equated with good health and thus breeding potential.
Many--most--Christian female monastic orders were founded a millennia or more ago, when married Christian women--nuns being considered "married" to Jesus--were expected to wear head coverings, and clothing that covered every inch of exposed flesh. Basically wearing Hijab.
Black and white clothing colors not only constitute a uniform, but have deep spiritual significance to followers of Judeo-Christian and Islamic religious sects.
Contemporary with Nuns' (black) habits most male priests and monks wore black, or dark coloured clothing. It was supposed to mark them as "servants of God". The world was a little chillier then, especially in Europe.
Note: a lot of ministers still affect dark clothing. Makes them look more threatening.
They wear it becauae they are nuns and the Catholic Church hadn't changed in millenia. The habits nuns wore in the 60s and 70s were reminiscent of how women dressed in the Middle Ages. (I actually thought it was cool)
Thank you, Bill. We don’t need to understand why people do their own private choices of dress, tattoos, shaved heads, but by keeping focused on their inside humanity, we find so much more good, likeness and togetherness.
"Hijabs are worn by Muslim women for a variety of reasons. For some, it represents the transition into maturity. Some choose to wear the hijab as a way of proudly expressing their Muslim identity. Many people wear the covering in observance of cultural or familial regulations. Naturally, a lot of Muslim women decide not to cover themselves. Some decide to reserve wearing it for religious events solely.
Furthermore, Muslim women who have decided to wear it and uphold their modesty do so out of a desire to obey Allah, who is the one who has commanded women to cover all of their adornments.
Also, Women are commanded to wear the hijab as a protection against abuse and enticing others. This is because women are the object of desire and the target of the sexual gaze in most cases.
The prophet Muhammad commanded his wife to cover up with headscarves, which is how the hijab obligation in Islam began.
Furthermore, Islam places a high value on the hijab since it is seen as a directive from Allah and is mentioned in the Quran and Hadith. It is a way for women to maintain their dignity and modesty. Also, wearing a hijab encourages Muslim women to live their lives by Islamic values and acts as a reminder of their religious beliefs." source - Riwaq Al Quran website.
... and we never question why teenage/20s bros always wear hats, hoodies, or sometimes both, western women wear hats at the races. The one defining feature of the Middle East is that it's HOT and sunny. Head coverings make sense. And saudi men wear robes and headdresses, bedouins are covered head to toe, israeli men wear yarmulkes, etc. I've been to the ME many times on business and the professional women I work with, 99+% of whom are Muslim, tell me it's a personal choice to wear a hijab or other head covering though more and more there are, especially young, women without head covering. This summer I wore a hat almost every day outside during daylight. The point is, it's not a big deal, except for those who want to make trouble.
I constantly wear a hat outside, usually a ball cap. I don't remember when I started, but it was probably over 45 years ago. My wife makes fun of me for heading back into the house if I forget.
Yes, if they hold public office and believe in the commands of a heavenly dictator. If they wear maga hats or swastikas they follow commands of earthly dictators as well.
Oh this is tiresome. I wish we'd all shave our heads and wear t-shirts and jeans. Look the same, be treated the same. Show our private selves only to those who care about us.
When I read the word "they" I pause. Every faith or religion or cult has observant folks and those who are "meh". So in reality there is a "sub-they" that adheres to the slavery of dogma. Most of the others are on again and off again.
Then there are those like me. I think I am a "recovering Christian". I reject a lot of what the Bible says. Not going to kill a son or listen to burning bushes.
In short, a whole lot of people are not "they" despite their heritage or early childhood programming.
“They” don’t have to be extreme, all they have to do is believe… like that you can live forever depending on what you think! “They” distort the very nature of reality.
When I read comments by people like you who make excuses for the nonsense we see in the world today, it’s no wonder things are getting worse.
Now Jesus is supposed to be the one, and he said not to forget the old laws, that would be the Old Testament.
You can cherry pick what you want, but numbers 31:18 says it all: you can take a virgin for yourself if she breaks the second Commandment.
And me thinks most people are “they,” like every single one who starts “chanting” after someone sneezes. Why do you all do that? Is that polite? To me polite would be letting someone merge into traffic where these guys all tightened up.
>a nobel prize winning US economist posts political-economic criticism of US economics,
>>it gets fewer likes and reblogs than the average facebook post (of equal volume),
>>> followed by a thoughtful comment, structured like a modern internet comment with a reasonable perspective,
>>>>followed by a reply structured like a traditional email/letter that goes out of its way to clarify the intent against harm while communicating an important distinction
>>>>> and here's my nerdy ass analyzing the emergent dynamics of internet comments, old enough to recognize the latter style and young enough to recognize the former style
.....maybe not *EVERYTHING* in the world is awful bullshit. Maybe.
I am hoping he has more Economics to say about this because it has been estimated that we could cover the entire population with Traditional Medicare for a little over half of our present total healthcare outlay. If we were to create a hybrid picking and choosing the best features of Traditional Medicare with the best features of Medicaid, the savings would be even more. And eliminate Medicare Advantage. Rein in Big Pharma - there is a huge amount of overcharging there. Create a hybrid training program for Nurse Practitioners and Physicians Assistants and then let them practice autonomously. They can handle the simple, straight forward stuff like snotty noses, simple uncomplicated hypertension and diabetes - diseases for which there are well established treatment protocols.
PK says, "And the U.S. would stop wasting large sums on pointless administrative costs." At a rough estimate, the "pointless administrative costs" consume $0.50 of every dollar US governments spend on healthcare.
My logic is as follows: Canada spends $5,184 USD per person per year on healthcare. US governments spend $8,554 USD. The Canadian government spending covers all citizens, US spending about half. Canadians have a slightly higher life expectancy, so we can assume healthcare quality is at least as good.
... also...
Canada is not particularly efficient. Germany and Holland have a much lower cost of healthcare administration per capita.
... so...
I suggest it is reasonable to assume that the US can be at least as efficient as Canada in administering healthcare, and the current cost US governments pay for healthcare administration is at least 50%.. likely more.
I am sure a huge savings would come from the elimination of third party managers, pharmacy benefit managers, and those sorts of companies…the clearest parasites in the world of private insurance.
The UK’s NHS and other European national health organisations all bargain down unit prices with pharma through scale (70 million, 80 million and 80 million respectively). ‘There are no free lunches’ applies to US single-user health insurance choices too…
One reason Canada's healthcare costs are so high is physician salaries. First expense is hospitals, second is physician salaries. Physicians make more money in Canada than in Europe. Physician salaries are higher in the USA, although I wonder what percentage of an American physician's income goes to malpractice insurance.
Wonder no longer! Between 3 and 5% of net physician income goes to malpractice insurance. The finger pointing at increased liability costs in healthcare is an old trope that was always a distraction from serious rent-seeking and other bad behavior elsewhere.
Vast majority of Canadian physicians are not salaried. They work fee for service. Each physician covers their own overhead (staff, office, supplies, insurance) and benefits.
Administration, not all of which is pointless, covers perhaps as much as 20% or US healthcare expenses all told - nowhere near 50%. Canada is healthier than the US for a number of cultural/lifestyle reasons that have little or nothing directly to do with healthcare (smoking and drinking rates, stress, obesity rates, etc). Also, individual units of healthcare are more expensive in the US than in Canada and other nations because of economic protectionist and subsidy policies that again have nothing to do with actual healthcare. Yes, all this needs to be addressed and fixed, but the 50% claim is misleading and lets some of the bad actors off the hook.
I just checked the National Health Expenditure database (NHEX). It does say that administration accounts for 15-25% of every dollar spent on healthcare in the US... as opposed to 3% in Canada. I lumped monopoly pricing and administration together... a disservice to those of you actually working to make the system better... my appologies.
for a money-mad culture, Americans sure are weird about health care...think of what all that money going to insurance companies and their billionaire CEOs could do on the ground
Since your proposal would seriously reduce the profits of all levels of the medical industry, it would be vehemently opposed by all those involved in it.
While I agree that we could almost certainly provide better treatment for the entire population for less than what we currently pay to essentially deny treatment to part of the population, please be careful with claims that it would be half as much as current total expenditures, especially since the government already pays out better than half the total. At the end of the day we'd pay less total, but most of what we currently pay for denial of treatment would get paid for treatment. A huge whopping reason the US pays more total in healthcare than most other countries is a matter of lifestyle and (mis)education, not healthcare (or lack thereof). Yes, we can reduce rent profits in pharmaceuticals and other corners of the industry, but we're never going to bring costs to heel without some other serious societal changes. And before anyone says otherwise, I have been a vocal proponent of doing away with private insurance altogether, or relegating it to only secondary coverage, for about four decades now. And I am including the basic liability portion of car insurance, basic life insurance, and basic property insurance in that! YOU cover your own risk, SOCIETY covers societal shared risk and unavoidable externalities through aggressively progressive taxation.
But people younger than the current minimum age for Traditional Medicare would be paying into the hybrid system with their premiums either as a direct buy in or through a tax assessment. The numbers are based on the cost of the British system.
There are some authors that never require a paid subscription to comment and others that only lock comments on some of their posts. It’s a good thing they can’t figure that out.
I have always been an optimist - that everything in the world isn't bullshit. Still, I find it more and more difficult to maintain that optimism in the world we are currently faced with. A complete change in House and Senate; a rational adjustment in the Supreme Court and bringing a "loose cannon" president under control would make things more "right."
As I have said forever and will continue to say,"Religion has no place in politics or government"! Sticking "under god" in our country's pledge of allegiance was wrong and dangerous then; it is wrong and dangerous now. Cling to the belief of your choice if you must; just don't pre-judge others for theirs. Peace, Love and Brotherhood, people!
I am not disagreeing with your statement, and this may sound trivial, but it has proven significant in practice:
When you put "Religion has no place in politics or government" in the same thought as "Sticking 'under god' in country's pledge of allegiance" you conflate "government" with "state."
You can be a loyal American and oppose the government... and... the UK can elect a Muslim as mayor of London and still have the church of England as part of the state.
Bottom line: Don't let the state's imperfections distract you from fixing the government.
Republicans forgive, or rather ignore, rapists, wife beaters, fraudsters, pedophiles, felons, while Democrats won't forgive beards, hijabs, a laugh ...
Lovely response. I agree with you though I totally understand what Sarah is saying and why. For me, this is another way that Ds let Rs control the narrative. Ds need to call hate what it is whenever it shows up like this - bigoted and xenophobic. It is superficial judgement passed on someone solely based upon external factors. We have a parade of neat and tidy white men and perfect little white women currently running this country, and yet they are heinous humanoids. Obviously what one looks like or how their name sounds means nothing. Words are important but actions matter more. Trump and many of his posse showed their ugliness before they ever stepped into our government. Their actions were loud and clear. El Sayad has an existing reputation and should be assessed based on that. So to circle back, instead of hand wringing, Ds need to circle the wagons and refute this racist bs repeatedly every single time it is brought up as though it should even be a legitimate factor or concern. If Rs can elect and/or keep rapists, pedos, abusers, etc in office, then Ds should be able to unquestioningly and unapologetically back someone with dark skin, a beard, and a hajib wearing wife.
But they all need to be Democrats. We have to take away the ammunition we have stupidly given the Republicans by renaming the party Democratic socialists. I would bet a $1000 a Republican operative convinced some liberal Democrat to adopt the socialism tag to set them apart. Stop using it because Trump is already crowing about how he was right and the Democrats a communists. Communists! How has this even gotten any traction without pushback! Oh yeah the Republicans are always on message.
1) Most of them are actually Social Democrats not Democratic Socialists. They are distinct and different. Once again, Americans misuse terminology, never mind it is an unnecessary distinction in a two party system, so people get confused. Though either name would be sneered at and weaponize by Rs. And again, this is also fueled by Ds eating their own rather than fighting the actual outside threat.
2) The extreme leap from these liberal Ds to communism is such an obvious, fear mongering ploy that the Rs are desperately and relentlessly pushing. Unfortunately, many Americans are too stupid, lazy, and/or apathetic to see it for the farce that it is and dismiss it as such. And, while Rs have no trouble screaming communism, too many Ds are too timid to scream fascism back at them…which actually is far, far closer to how Rs are currently operating than communism is to any of the liberal Ds.
Beards and hijabs are cultural artifacts having little or nothing to do with the beliefs of original Islam. Besides which, you can see any number of MAGA Christian acolytes wearing large and sometimes downright in-your-face crosses every day. When I was a girl, btw, my christian church required that women wear hats on Sunday. Nobody thought anything of it and the custom just faded away as times changed.
That’s the problem those who are currently in control will fight to stay in control for as long as possible. They don’t realize they’re fighting a long term losing battle. People can deal with slow evolution not rapid revolution. To too many everything is happening too quickly. Politians capitalize on fear.
And see them kill their daughters for holding hands with a boy. See how they keep their daughters out of school, how they kill their wives - that was also in The Guardian just this last week.
They’re all medieval cults and you can’t stop them but you don’t need to support them. Like, look how they have you all chanting after people sneeze.
The most religious places on earth are also the most backward places on earth because of a reason. They will kill us all as they overpopulate the planet with their beliefs.
Morality is about the well-being of others and has nothing to do with rituals and superstition.
Next look up numbers 31:18, it says you can take a virgin for yourself if she breaks the second Commandment as Christians, Muslims and Jews all follow the Old Testament. Jesus said to keep the old laws.
Right.
Neurosciences explain behavior, they say that a functional mind doesn’t have to try to be honest. This explains why the Buddha was spreading the golden rule 500 years before Jesus. Imaginary beings are not needed.
Yes, Im frankly sick to death of the Middle East "crises". I have been hearing about this for years and years. Their fighting started in the 1960s. I wouldn't be surprised if it wasn't a cottage industry by now. Munitions firms are sure making a killing. (not apologizing for that) Even in Michigan where El Sayed got money from Palestinian organizations and Stevens got money from AIPAC.
Well, two of tRump’s thugs are bearded and one of them is quite brown. Dr. Krugman also wears a beard. So why does Dr. El-Sayed’s beard trouble you? As for his wife’s hijab, is it any different from the custom of ultra orthodox Jewish women not being allowed to show their hair? People’s religious beliefs and cultural practices are none of anyone else’s business unless they’re trying to convert you, and I have yet to meet anyone from either faith who tried it on me. The only god-botherers who have ever tried were (or claimed to be) christians.
I don’t think the initial comment was snarky; it was an arguably mis-guided (definitely well-intentioned) concern about how elections work.
Cultural issues are complex. While I definitely do not think any of the religious “costumes” under discussion should get in the way of evaluating individuals on their merits, I personally can’t help thinking they are all retrograde expressions of male supremacy.
I agree because I’m an atheist and my opinion of all faiths is similar to yours—they are all ways of exerting power over people, especially women. Nuns’ habits have changed over the years and don’t look as much like burkas as they did when I was a child.
Because I’m afraid they’d be wanting everyone to abandon all the technological innovation that have made our lives easier and safer (although not always). Also, because I’m an atheist and don’t want any religious extremists to be governing us any more than they are already trying to do.
If you mean the old-fashioned head scarves worn by ladies like the late Queen Elizabeth, I must admit I don’t know why they bothered. But I love beautiful scarves to brighten up an otherwise boring outfit. It’s a fashion thing.
My bet is he could shave and she could dress more conventionally (in your mind) and a whole different set of complaints would emerge. Nope, I don’t believe in catering to that kind of bigotry. Would it bother you if it was an orthodox Jewish candidate in a yarmulke and his wife covering her hair?
I've been wrong before, but I've been right about 90 percent of the time when I do predict a race. But at this point I'm still qualifying my opinion; if gas prices soar, if war breaks out again with significant casualties, the Democrat is likely to win. Otherwise I don't think so. I wouldn't bet money on this race this far out. I once worked in political polling; the 55% odds you mention mean nothing at this point, with this Democratic candidate, in this state. But again, circumstances could change things enough to allow El-Sayed to pull it off. Ask me a month out and I'll probably be confident enough to make a definite call.
Well, I do--and I will!! As will many good people in Michigan who don't judge people by how they look or what religion they've chosen...Mike Rogers is an old pol has-been joke.
Rogers has his own baggage as someone who abandoned Michigan for Florida and came back just to run for office. While this is mentioned in Michigan, you don't hear it much in the national news on this race.
esp those aspects of appearance under their control. brown skin? cool. big honking cross, religious costume items...not so cool. tho I suppose useful in that it reveals a lot, gives fair warning (nutjob alert!)
The race in Michigan is a tossup and running Stevens as the AIPAC candidate may have been problematic as well. Hopefully El Sayed will motivate young voters to come out.
If Stevens had won the nomination I would have stayed home or voted 3rd party in November. AIPAC support means no vote from me. But El Sayed can only win if the price of gasoline really soars or large numbers of body bags are coming home from the Middle East.
Well that would be just great and the Republican who gets elected would have gotten even more money from AIPAC and El Sayid got money from Amani Barakat, the chair of the Al-Awda (Palestinian Right of Return Coalition)
I take no side because there has been fighting over there for 60 years and will continue for another 60 years because now an industry has developed and will be impossible to dislodge.
I didn't think Trump would win in 2016, but I predicted both of Obama's wins way ahead of election time. And I predicted Trump would win in '24 after Harris beat him in the debate but the polls didn't move.
You didn’t think Trump would win twice, both elections versus a woman? Of course he was going to win.
The same with Obama - and the democratic party is making the same mistakes over again that the republican party made back then. McCain: Palin. A woman as VP. It was a no-go for Americans. 2012: Romney was a Mormon, and a lot of people are prejudiced against Mormons. Now let’s think - what else are Americans, including Michigan, prejudiced against?
No, I didn't think Trump would win in 2012. Clinton was a terrible candidate with a lot of baggage, and her campaign manager was a Vermont boy barely out of his teens, but I didn't think someone as intellectually and morally bankrupt as Trump could be elected president. I don't know enough of the kind of people who put him over the top in the swing states. That's on me.
If Biden had retired and the Democrats had had a competitive primary, and if, say, Gretchen Whitmer had become the nominee, she would have beaten Trump in '24. She would have carried Michigan, Wisconsin, and PA.
Yep. I have no fucking idea what’s wrong with the democratic party - I’ve even considered Trump might have paid off the DNC to nominate unelectable candidates even in areas like Michigan that should be a sure thing (A republican hasn’t won there in 25 years).
This should have been a sure thing victory for democrats, and somehow they found a way to lose, just like in 2024. The only way Trump was ever getting in office again was democrats making a catastrophic mistake and running a woman again. And they did it.
The same with Texas. Some of the tide was turning and here they come with a candidate 100% guaranteed to lose in a year that they might have won if they’d ran someone all voters would be okay with.
About the beard, if you look around beards seem to be popular with conservatives. Show me a bald or shaved headed dude with a billy-goat beard I will show you a MAGAt. Also although IMHO beards especially the gray ones make you look older, many seniors who skew conservative sport beards.
I’ve been looking over the comments to follow your comments. It looks to me like a parallel discussion is occurring, quite apart from your points in spirit.
I just wanted to affirm that I appreciate your views, and I’m sorry if/ to the degree that the points you made seem to be interpreted differently to your original statement.
Your statement ends with:
“Fingers crossed for Michigan. Remember what the other side is - and the other side isn’t out to help you or America”.
Dr. Krugman, please stop calling people in terms of color. I am stunned indeed a person of your intellect call Mr. Sayed brown. What color would you call Asians then? The only classification that is allowed is Israels (Jews) and Gentiles. Then white and non-white by Repulicans. You are a publid figure ane set a standard and in that you have responsibility.
Colors are commonly used to describe people in general categories. Skin and hair color are major distinguishing characteristics in many societies where there are significant differences. Skin color is a major factor in MAGA. I'd prefer a color blind society, but its not what we have.
esp when the colors are more terms than descriptions...
sayed and wife look pretty pale to me...reminds me of the idiocy of calling a whole lot of people black who literally aren't...even afro-american doesn't cut it when a lot of so called AAs are at least or more euro-american. wish we could get to looking at skin color the way we whities accept our varying hair and eye shades
Halley Stevens has shown so much class by enthusiastically supporting El Sayid and working for a Democratic sweep. I hope she still has her congressional seat.
So if a Muslim’s hijib (for modesty) and a beard are what scares maga and trump evangelicals, how do you think real Americans feel about all the lying, lawbreaking, & bigotry trump evangelicals (not even real Christians) make us feel when they wear the cross while spewing hate, rhetoric, racism, bigotry, & propaganda ?
I do hope all democrats come together soon. If they do, we can win everything.
“I wish Sayed didn't have a beard and his wife didn't wear a hijab because it makes it harder” - that’s some racists ass bullshit right there. Check yourself and do better.
Every country that has universal government-funded health care also has supplemental private insurance, and most working people get that insurance, which provides access to newer and more expensive treatments. Canada, UK, France, etc. all have that system. So basic healthcare for all, plus a more capitalistic system. But the key is: basic healthcare for all that isn’t provided as emergency medical care.
Quick fact-check: Only 13% of people in England have supplemental private insurance. 95% in France do. 25% in Portugal. 28% in Spain. 10% in Norway and Sweden. 32% in Denmark.
France is the outlier, for some reason, but the rates are mostly rather low and I'm not sure how much of them are blue-collar working class. Obviouisly there must be differences among countries of what is covered and why people would get supplemental insurance but it's not "most working people".
France's statutory health insurance covers roughly 70% to 80% of standard medical costs. The remaining balance and specific categories—such as dental, optical, and extra doctor fees—are traditionally funded by prepaid private or complementary insurance (mutuelles), which over 95% of the population carries to avoid steep out-of-pocket expenses. In other words, that figure is not really dealing with day to day stuff. You can do the same in the UK if you want.
(Real) Mutuelles (there are "fake" ones...) are coop-like (i.e., not for profit) structures, often started by unions. Ours is run by the Press union (with strong communist leanings...You may clutch your pearls if so inclined !) because I worked for a newspaper until I retired.
Many of these mutuelles also run "health centres" ("centres de santé"), at least in large cities, offering GPs, specialists, dentists, pharmacy, opticians, etc...at regulated costs (i.e., within the limits set by the National Insurance system--you can always go elsewhere and pay more; many do).
I only use a Centre de santé for dental, because we have a local GP we like and other specialists as needed. The most I ever paid was 1,000 or 1,500 € for three dental implants (four teeth). Everything else is reimbursed.
Is dental covered by the NHS? It's not in Canada, although it's free for children now, and we have some Dentacare for poor seniors. I have no problem finding a dentist. What's the issue in the UK?
The financial settlement to dentists in the UK is so far short of the costs involved. For example, the price of ceramic fillings vs metal amalgam fillings, and many other items used in day-to-day dentistry, the negotiations between the dentists and the UK department responsible for health stopped (in truth) many, many years ago. Both sides are effectively unable to progress negotiations because of lack of disposable cash. PDP will be depressed by the similar impasse in the UK for the funding of social care (non-medical care to US Americans) for the frail/ disabled/ elderly ….. not nearly enough cash-on-the-table regardless of how ‘nice’ the politician speaking is (or how white and regular their pearly whites are on your tv screen either).
The only thing that annoys me is that I am edging towards ‘senior’ status (I’m in my mid-sixties, a ‘kid’ still…), and having contributed for many years through taxes (like US Americans, the UK isn’t really so different), it annoys me to be told that I am ‘too expensive’ now when it is much harder to contribute the difference (snarky face emoji inserted here).
Dental is covered by the NHS. The problem is finding an NHS dentist who will take new patients. This has been a problem for many years. Dentists attribute closures and service changes to problems with recruitment and increased running costs. They say the money they receive from the NHS, and the contract requirements (including financial penalties), make it impossible to provide a proper service. Hopefully now Labour are in power, and more specifically Andy Burnham (although I may be over-optimistic here) things may improve. Essentially there are perverse anti- incentives. Dentists earn the same for one filling in a patient as for 10, but plainly the amount of time and effort is different. Hence I would like the idea of a secondary level of insurance. British people do not want to be taxed anymore, as the tax burden falls disproportionately on lower paid people. It's all part of the mess left by 14 years of Tories, i.e., turkeys voting for Christmas.
I’m not prone to pearl clutching. 😁 And yes, the supplemental insurance markets can be more complex than simply “for profit.”
Um… in case ICE is monitoring this conversation: COMMUNIST?!!? Well you should be deported to Russia. Oh, right, we like Russia now. I mean CUBA! Deport you to Cuba!
Since you are now Canadian, you are not allowed to malign Cuba anymore. Canadians love Cuba. Americans hear nothing but propaganda about Cuba, and believe it all. If it were not for the US embargo, Cuba would be different. I do not support its government, but I'd rather live there than Saudia Arabia or China to name a few. Speaking of healthcare, Cuba's main industry was tourism mainly by us Canadians. Second was Medical Tourism. Physicians in Cuba are well trained, and Americans used to go there to get excellent medical treatment that they cannot afford in the USA.
There is another component to the supplemental insurance. European countries play the generic waiting game with new drugs and medical technologies. They either don’t cover them, or they inappropriately reference price them to inferior but cheap generics, so companies don’t market them to the government. Once the drugs go generic, the governments add them to their formularies. So people who want access to the newer, more safe and/or effective medicines get the supplemental insurance. What people don’t want to talk about: this cost-shifts discovery to the US market.
I’d agree with Sarah Samuels’ comment. Generic drugs come online when a Pharma company’s patent license lapses; the active compounds in the generic & the original drugs are identical, but the ‘fillers’ can be different.
Also, licensing authorities take into account the clinical ‘urgency’ of the newly licensed medication: how many lives?/ how many more years of life? does it provide per unit cost. So, medications that are demonstrably able to prolong life / improve outcomes (this is where the debate comes in) are approved by licensing authorities, even where very expensive.
For further information about this, look at NICE (UK) website (www.nice.org.uk).
Lastly, please remember that the great majority of innovation in medicines is developed already within the US. Doesn’t it strike you as odd that others pay less than US Americans do for these medicines? This difference often comes down to the ability of other providers (the UK’s NHS for example) to bargain down unit prices because of their scale vs US private sector insurance companies. The UK’s population (c 70 million) is large by comparison to any US insurance provider’s client base.
This all brings the discussion back to the core of Paul Krugman’s article today: the US Government ALREADY drives the economy of healthcare provision in the US to a HUGE degree. Follow the money, don’t swallow everything that is said by parties with an interest in the outcome.
They were approved within 6 months of each other, so their clinical trial programs overlapped. Eliquis isn’t considered second gen. That said, it has significantly lower bleeding risk, so they are not equivalent on safety.
Not necessarily-generally two major sources of drug approvals in the world Brussels and Washington-essentially most of either hemisphere follows that lead. I have seen cases where a drug developed by an American company gets approved in Brussels before Washington-it is a major celebration because it is worth as much as US approval. Thus, there are drugs from US not available Europe and vice versa. Generally, when that happens there is an essentially equivalent drug approved in the country where the drug has not been approved. Western Europe has a higher life expectancy than we have
Generic drugs are not "cheap"; they cost less but are EXACTLY the same as the brand name; generic is NOT inferior. SAFE? Nonsense. Yes, people have private health insurance to get newer and more effective drugs, like extended release of the same drug. I have drug coverage in my private plan, but it only covers the generic version; insurance companies are not stupid and pay for brand name. Geez!
You completely misread my note. I never said a branded and generic drug with the same IP were different.
I wrote that newly approved drugs are generally safer and more effective than older generics. Referencing pricing is a price-setting policy, whereby a government can say: this new drug is the same as an old generic, therefore I’ll only let you charge the cheap generic price for the new drug, even though the new drug is an entirely different drug and is safer and/or more effective.
Not sure what you mean by safe. Often newer drugs are more effective, and some have fewer side-effects, but the term "safe" has certain implications as to meaning.
So I'm in the midst of brain storming a proposal for a new US system.
And your point about this innovation aspect was one of the primary reasons I felt there still needed to be private insurance. You need a discovery layer.
Take a look at my proposal if you have the time (it's a bit long)
But parts 7 and 17 are relevant to the drug point.
70% of Canadians have private insurance. 10% of Germans only have private insurance and 35% have supplemental private insurance. DREES reports that 96% of the French have supplemental private insurance. About 26% of Spain.
I stand by the proposition that there is a second, supplemental private insurance market in countries that have government insurance and a substantial number of people, certainly those who can afford it, get it.
I'm a bit confused about what private insurance here means. In Canada, for example, I have Blue Cross. That doesn't pay for anything that the government medical plan covers: surgeries, broken legs, visits to doctors, MRIs .... it covers drugs (although there are plans for those who can't afford drugs), some therapies like massage, etc., some dental....sometimes a. private room instead of a ward....but it doesn't give better access, more treatments, faster treatments, better doctors, better care. My neighbour who is penniless and me who is not get the same care if we have cancer.
Actually, and I’m sorry to say this, you don’t. Cancer is a great example. Here’s a list of new cancer drugs the Canadian government has approved but won’t pay for. You won’t have access to them (unless you pay out-of-pocket and they are expensive) but someone with private Canadian insurance is likely to have access to:
Yes, that is why 'private insurance' needs to be more carefully used. I know that some drugs are expensive, and only available through plans or insurance, but for that, everything is equal. At least in my province. I wait in the same line as the poor, the unemployed, the billionaire, and the schoolteacher. I get seen by the same doctor, scheduled the same for surgery, our beds are next to each other. When one thinks of it, it's an exercise in democracy, unlike the elite systems in the US. Perhaps there's a connection in its road towards oligarchy.
While true for primary care, it is less true for specialist care. Average wait times to see a specialist in Canada are easily 3 months. Private insurance can speed the time to see a private specialist.
Sure, stand by that, which is changed from your original claim from "most working people get that insurance" to "a substantial number of people" so it's good that we get more correct through dialog, but my response would be that at least all people have basic coverage for the bulk of health problems, even if it's not the most premium version, and that's head and shoulders above the raw capitalism where most people can't afford health care (like most of the very poor capitalists "third world") or the premiums drain us exhaustingly (like the imperial core, the USA).
You’re right that I was thinking Canada and France when I said “most.” And Germany (there was a time when that number exceeded 50%). But all of those countries do have private supplemental insurance.
We don’t disagree that basic coverage should be provided to everyone. If you break a leg, it should be free to have it set and cast. But let’s not labor under the illusion that the wealthy don’t buy insurance for better care. They do.
There definitely is a market for private supplemental insurance in many countries that have Universal Healthcare. BUT, It all depends on what a government plan covers. Some do not cover dental, massage therapy, private hospital rooms, drugs. Many Canadians have it because those are not covered; the big one is dental.
70% of Canadians have private insurance? huh, not me or anyone I know (except now the old people's dental, which covers part of the cost - private company but the plan is subsidized by the govt)
France's system pays for 100% of chronic and major illness. The supplemental is for glasses, office visits, dental and the like. It is not accurate to say private insurance lets you access newer and better care in most of these countries.
It is fair, and it is true. France began reimbursing for Semaglutide and Tirzepatide for obesity one month ago. Five years after US commercial insurers started paying for it. They significantly delayed reimbursement for Keytruda and Opdivo.
Does France have an obesity epidemicdemic...not of the scale we do. Are office visits going g to bankrupt anyone..no. it is not fair nor a true comparison.
France restricts access to innovative medicines that are more effective and safer. All EU countries do. One of the reasons people purchase private insurance in France to get access to those drugs.
People in Canada who have middle-class jobs generally have supplemental medical insurance. Ditto for many working-class people with unionized positions. In all, about 70% of Canadians have private supplemental health insurance.
Indeed. As a Canadian, our coverage is patchy, because it is administered by each province or territory. Basic hospital and medical care is covered everywhere, but drug coverage is all over the map, as are things like physiotherapy. Dental care is another issue, too, with coverage now available (through the efforts of the federal New Democratic Party) for Canadian residents with a family net income below $90,000, who don’t have a plan through work or another social program.
I don’t think Canadians would ever consider themselves socialists, much less communists. Capitalism is alive and well in Canada, but most Canadians would say our healthcare system needs to be better supported by the government, not less.
"while Medicare is immensely popular, with an 82 percent favorable rating in the most recent KFF survey. Medicaid, government health insurance for lower-income Americans, comes in at 73 percent. This is in sharp contrast to public views about private insurers, who are widely disliked if not hated and accused of denying essential care."
Yes. There is probably a connection between the hatred of private insurers and the fact that 51 of our American billionaires are healthcare executives. You can't make maximum profits if you approve all doctor-recommended medical procedures and medicines.
Translated: "In Spain we have universal health insurance, meaning for everyone, whether they work or not, and it covers all healthcare and pharmaceutical services."
Yeah in France too. Not happening here for a long time. But remember Spain has 50 million people. The US has 350 million people. It might be worthwhile looking at Medicare for all state by state.
Most importantly: never allow a private insurance system sidelining the basic government funded "universal" healthcare system to exist and cherry pick the most affluent and healthy people. Germany has basically the same kind of parasitic private insurance grift going and year-over-year the government system gets undermined more, while being also abused as a piggy bank for the private system by funding stuff that privately insured people basically get for free like hospital reforms and subsidies for hospitals & doctors in rural areas.
Oh not to forget: all those covered by unemployment insurance are bankrolled by the contributions of the ones paying into the government system.
So contributors to government healthcare are getting screwed over disproportionately funding the healthcare system and wellfare, while allowing rich affluent people to avoiding to contribute and private insurance to siphon off the people with the lowest risk profile.
I don’t disagree. But it may be a way to get the US to accept universal coverage, assuring the public that rich can still buy more and better. We seem to like it that way. 😖
I think you’ve nailed the problem there, Tracy. “We seem to like it that way”.
I come from the Republic of Ireland (the health service is funded by extortionately expensive insurance, not quite as bad as the US but sort of ‘half ways across the Atlantic’) and I have lived and worked (a hospital physician) in the UK for thirty nine years, where very few people could ever afford the price of the healthcare, with all its limitations, they currently receive. There’s nothing intrinsically wrong with a centrally funded health service… but it’s cost. We bicker over differences in provision systems, but it’s always expensive. I would nonetheless return to the core argument in Paul Krugman’s piece today, about the existing centrality and economic clout of the US Federal Government in provision of healthcare across all sectors of US society.
My own political interpretation that follows that is, ‘don’t let yourselves be misled by grandstanding political and media statements’. You (US Americans) already pay expensively for the majority of US healthcare coverage through taxation; follow the money, not the sloganeering, to improve the provision.
Oh, his point is both clear and true. People without health insurance get their care in emergency rooms, which must treat them by law, with bills they cannot and do not pay. So the American public picks up that bill, which means the government supports is actually even greater than PK is stating.
I am Canadian, exactly what do you mean by my private insurance covers "newer and more expensive treatments"? My private insurance covers semi-private hospital rooms, dental$$, prescription drugs, ambulance, allied medical like psychotherapy. Regardless of having supplemental private insurance, if I get cancer, I get the same treatment, and do not get to jump the queue. True, when I got my free cataract surgery, at the top eye hospital by a top opthamologist, only the basic lens was covered, and not all the fancy tests required ($50 out of pocket). Oh, BTW my private insurance did not cover a lens upgrade. Canada is starting to add Pharmacare: free insulin and birth control, both of which make huge financial sense, and save tax payers $$$.
In Canada, government funded healthcare excludes dental and drugs (although government help for drugs does kick in after certain amount). Supplemental policies cover these exclusions.
Supplemental insurance in most of those countries is there to cover gaps in the coverage, such as drugs, optical, private rooms, dental services or alternate therapies like chiropractic that weren't part of the programs when they were formed decades ago. They generally aren't for access to newer or more expensive treatments.
When these programs were founded decades ago, like Medicare in the 1960s, most prescription drugs were a few dollars a month and not a cost burden on the public. Some of the universal coverage countries updated their plans, some did not.
What you’re saying is not completely true. Government insurance often does not cover newer, more effective and/or safer drugs. They delay coverage, often until the drug goes generic and is much cheaper. The supplemental plans will typically pay for those drugs. It’s one of the reasons people get those plans.
It's a selling point for the insurance in a few countries. The newer drugs are not necessarily more effective or safer, just more expensive, which is why they aren't covered in the basic drug formulary. Usually it doesn't become part of the formulary until the price is negotiated into a more reasonable range. In the US they wouldn't be part of the preferred coverage if the insurance company had an agreement with a different equivalent drug.
If all they covered were expensive drugs that weren't part of the regular drug formulary, then the price must be sky high as no one would buy it unless you were using one of those drugs.
With few exceptions, the new drugs are more effective and/or safer. Look at the statins. The PROVE-IT trial showed the newer statins prevented more CV events than the older. Tirzepatide produced significantly more weight loss than semaglutide. Pharma companies don’t do a lot of trials testing equivalence, they test superiority.
GLP-1 is the last drug I would use as an example. What we have is a frenzy of off-label prescriptions for a highly overpriced diabetes drug being used as a weight loss miracle where the benefit disappears after you stop taking it.
Pharma companies only care about sales and stock price, not safety. They have turned GLP-1 into a lifestyle drug, not one that serves its intended purpose.
You’re incorrect on all points. Not only do they significantly reduce CV events, tirzepatide also resolved NASH in 90% of patients, an incredible breakthrough. They reduce chronic kidney disease. They have been shown to reduce cancers and addictions and will soon have those additional indications.
Yes, some 60%+ patients will regain weight after stopping drug, and, though the majority do not regain it all. And… so what? 100% of type 1 diabetics will die of complications of diabetes if they stop taking insulin. Chronic diseases, like hypercholesterolemia, hypertension, diabetes are chronic diseases and require chronic medication. If it significantly reduces mortality, then it is worth it.
And you are woefully behind on pricing. The GLP-1 orals are now $50 per month in the US.
Here is a list of recent cancer drugs Canada does not cover. The list is longer, these are just some examples off the top of my head, and there are lots of new drugs for many diseases Canada does not cover. You can bet when they go off-patent that Canada will cover them. There are private plans that cover these drugs.
I live in Canada. I know what happens here. YOU ARE MAKING STUFF UP!
Private supplemental insurance in Canada DOES NOT supply "newer and more expensive treatments". It provides extended periods of non-necessities, like therapeutic massage, which is limited to a half-dozen treatments a year under BC Health. (Other provinces may vary, particularly Alberta, which is headed toward a US model of insurance, and their health is already declining. for it.)
I can call my doctor in the morning and see him in the afternoon.
One time, I had excruciating tummy pain. My doctor had me checked in to the nearby hospital in under an hour. Within two hours, I had a bed and an IV, both for pain relief and to "encourage" a bowel movement.
Private supplemental insurance would not have changed that situation one bit.
My ex was diagnosed with ovarian cancer. She was "under the knife" in less than a month. Private supplemental insurance would not have changed that one bit.
For one thing, for-pay medical care IS ILLEGAL in most provinces! You simply CANNOT "cut the line" by paying more! You simply CANNOT get "newer and more expensive treatments" by paying more! This is CERTAINLY true in BC, which if you'd done any research at all, you would have discovered!
You've been listening to FOX News. STOP IT! YOU DON'T KNOW WHAT YOU'RE TALKING ABOUT!
Yes! As a UK resident, there is plenty of private health insurance, often used for elective surgery to get quicker treatment. But if you are very ill, or in a road accident, the NHS is the place to be. The doctors are far more experienced in emergency treatment or intensive care.
My knowledge of the US system is largely from the writings of Atul Gawande - he wrote excellent articles on the fraud of US Medicare from over treatment and scanning due to doctors owning an interest in a hospital. An obvious conflict of interest. In contrast he praised the Mayo clinic for having salaried doctors who were more careful about unnecessary procedures, and had better outcomes at lower cost.
The cost of everything in a hospital or surgery being billed and reclaimed on insurance is extraordinary - surely a prime driver of massively higher healthcare costs in the US as a percentage of GDP. The French live longer than Americans and spend far less of national income.
Far from being “Socialist” and ideological - the origins of the UK NHS are WWII. With almost the entire country involved in the war effort for 6 years, it seemed pointless wasting time and money on billing and bookkeeping. All doctors and hospitals were involved in treating soldiers or workers to the best of their ability. There was no labour to spare for accounting and red tape - the government just funded it all, it worked, people got healthier. After 1945 why go back to the old ways? Hence the NHS.
Canada here. never got health insurance. far's I know, it's for (shrug) private rooms and like that - newer and more expensive treatments? not aware of any such (except maybe in alberta)
Long ago, I interviewed a Republican candidate for governor who had a novel idea for dealing with healthcare: Completely eliminate ALL health insurance. No private insurance, no Medicare, no Medicaid. Just everyone on their own.
Doing this would force people to shop for healthcare, and that would drive down prices as people sought out the best care for the best price. Like shopping for a car or dishwasher. It would also stop people from "wasting" healthcare, which was what people were doing because the cost was hidden by insurance. Thus insurance made healthcare seem like it was free, and anytime people can get something for free, well, they're going to use it whether they need it or not!
I pointed out that, by law, colonoscopies are free. So how many colonoscopies had he gotten this year since they're free? "That's not what I mean," he said.
About shopping for healthcare, how does one shop for care when having a heart attack? "That's not what I mean," he said.
Okay, how would you shop for treatment if you have a glioblastoma if you don't even know what a glioblastoma is? "That's not what I mean," he said.
Turned out that the only scenario he'd actually thought about was someone going for a regular check-up or getting treatment for a minor injury like a sprained ankle. This is the quality of thought that goes into most every conservative proposal regarding health and healthcare. And now under Bobby Brainworm (RFK,Jr.), it's being carried to an extreme that will kill thousands in the decades to come.
People are going to the doctor because they have nothing better to do! Of course! Good to finally hear some common sense from well off folks who have never worried about such things.
That's a common one from the phony "prices are so high because people go to the doctor for every sniffle and overuse the system" crowd of consultants. The statement is total crap. Do you know anyone who wants to spend hours waiting in a doctors office. If they do, then they need a different type of doctor.
This is just another false excuse to keep the current failed system.
"Let the market handle it" is pure libertarian baloney. Who has more negotiation power with the medical industrial complex, you or a big insurance company?
This isn't about you and old Doc Smith down the street. Doc Smith is now owned by the local mega-hospital system which is designed to dominate the area providers and create pricing power to counter the insurance companies.
What they're afraid of is, that if everyone has access to medical care, they will have to wait longer to see a doctor. That is, they want to grab all of the available medical care for themselves.
There is such a thing as scarcity in medical care. It may not be EVERY TIME, but there are well known shortages of doctors. And this makes it so that some people have to wait (especially if they are on medicaid), and some people don't (if they have great insurance or are willing to pay more).
Are you sure you understand how markets and economics work? Just because in some cases markets aren't a 'zero sum game' doesn't mean that scarcity isn't a part of people's experience. Carolyn is right that if we had medicare for all (especially if doctors weren't able to favor private payers) it would even out who has to wait for care like medicaid people and people with crappy in-network care do. And she is right that people with money want to capture the better care for themselves - the rest of people be damned to the crumbs.
I do understand that scarcity is a problem. Where I live, we're having a serious crisis due to a lack of primary care physicians. This has turned into a chokepoint for every other specialty as folks with private insurance can't see a PC and thus can't get a referral to the specialist they need to see for some emergent condition.
But healthcare is not a zero-sum game. And turning the U.S. to a single-payer system would free up resources--both human and financial--to help alleviate many of the current shortages. (My primary care physician works 6 days a week, two of which are devoted entirely to paperwork to get private insurers to pay him for services rendered.)
I didn't say it was a zero sum game. But, scarcity still exists, and scarcity is all that is required for the wealthy to reasonably worry about longer wait times for themselves if access to health care is leveled.
It takes 10-15 years of university training and residency to become a specialist.
If the demand for specialists is based on just the size and age of the population 10-15 years from now, it is much easier for universities to forecast how many places they'll need and for students to calculate how much debt they're willing to take on.
If you include employer willingness to pay higher insurance premiums in the forecast, the calculation is more difficult. Higher risk means higher cost, and lower supply.
Scarcity is a problem because the system encourages certain specialties and the number of new interns are limited by federal law limiting the doctor numbers and Medicare funding for each teaching hospital.
The US is the biggest rationer of healthcare based on the ability to pay. About 30% of Americans are either uninsured or underinsured. A significant percentage of Americans have health insurance but don't have the money available to actually use it. Largely due to the big increases in deductibles and copays over the past 20 years.
I don't think you can really say this. What if the government didn't subsidize the training of new doctors at all? Would the number of interns be zero? NO. It would be lower than now because it would be solely (or more) driven by market forces alone. The fact that they subsidize it increases the 'cap' from the one that would exist if there were no subsidy to the one that results from subsidies. Thereby, the statement that 'scarcity exists because federal law caps the number of interns' is a twisting and dubious statement.
Hospitals can now pay the cost themselves if they wanted to. Scarcity exists because the supply of doctors doesn't meet the demand. The AMA uses that to keep salaries high. American doctors are the highest paid professionals in the world.
About 10,000 potential doctors can't get an internship due to lack of funding or space. Also, the US and Canada require two more years of college to become a doctor compared to most any other country, which doesn't have to be related to their future career.
If you think there is a doctor shortage now, universal care will make it even worse. At present, about one-third of Americans have inadequate insurance. Open those floodgates and the demand for medical services will skyrocket. Unfortunately, the medical industrial complex isn't doing much to fix the problem.
The irony is that our current system is already doing this. There is a shortage of medical professionals of all types. I am sure some are discouraged from ever even entering the profession while others have left out of frustration. People retire, practices merge/consolidate or close, owners demand they see X number of patients per day, etc. Everyone I know who has needed a new doctor, for whatever reason, has had to wait at least 3 months to get in with someone, and that is usually after spending a significant amount of time calling around to find someone who is both taking new patients and their insurance. (And hopefully you can stay with that person if your employer changes your insurance.)
A personal anecdote, I have a child who was diagnosed with scoliosis. Pediatrician noticed in July and ordered X-rays. Still July, referred us to the spine clinic at the local children’s hospital which couldn’t get us in until November. They prescribed a brace. Orthotics was booked through March, though I called every day and managed to get in in February. Brace came in April. We’re now on a regular cycle in the system, so it’s no longer an issue getting all of our regular appointments, but the “set up” took 9 months…with “good” insurance in a metropolitan area.
Nope. PPO. In fact, insurance has never been an issue. I have never once had to contact them nor have they ever contacted us regarding coverage, to deny or otherwise. We do not need any approvals or official referrals for anything. But neither has it offered us any sort of “advantage”. It was an anecdote responding to Carloyn’s comment, that some against socialized healthcare make it out like a zero sum game that will harm them. I was pointing out that it is already what they fear because of privatization - profit above all else. Availability of services and/or providers is a very real choke point in our current system. Now certainly people with lots of money may utilize boutique or truly private medical options, but for those of us in the regular system, it’s not that it will become too much demand for too few providers…it’s that it already is that because the push to maximize profit for private companies has broken our healthcare system (though it was never great to begin with).
What the donor class is afraid of is, the more people having more access to medical care, the less power the donor class has over them, full stop. How many, many times have you heard someone complain they can't quit their job because of the insurance?
Did your Republican candidate for governor also consider the stock market to be a socialist institution that he would take steps to abolish if elected?
A large part of US healthcare may be a PRIVATE market, but it is not FREE market due to the disparity in information between providers and consumers.
The stock market is a government regulated and enforced institution that manages the flow of investment information and payments. A single-payer healthcare system achieves lower costs by managing the flow of information and money... exactly whose money varies a lot from country to country; it is not always all taxpayer dollars.
My point: Even if ideological differences impede implementing the most efficient system, substantial improvements can be made without spending more tax dollars or abandoning market principles.
That candidate was an imbecile who promptly vanished beneath the waves after getting something like 2 votes in the primary. But his views, though waaaaay far out there at the time, are slowly bleeding from the fringes toward the mainstream of Rightwing thought.
For non-Rightwingers, it is important to know that the vast majority of conservatives have a child's understanding of how the world works. They're about on the level of a 6-year-old, though even that might be too generous. To them, much of the world runs on magic and wishes. OF COURSE tax cuts for the wealthy help everyone else. OF COURSE getting rid of regulations makes everything better. OF COURSE we need a rigorous hierarchy. No need to think about these things, nor examine any of our experiences with them over the last half a century.
Insurance is meant to deal with risk and unexpected large expenses. If insurance does not work the other way to pool large groups is though government programs because they can spread risk costs over many people.
Some types of healthcare do not even fit the risk model, as you point out, regular checkups are not dealing with risk, it is simply regular maintenance.
I have often felt that these two things should be separated.
Not to mention the benefits of mass pooling of premiums to fund expensive treatments that ordinary folks can't begin to afford. Most of us try pretty hard to avoid illnesses and injuries, so it's not like we're scheming how to take advantage of medical care. I sure don't know anyone whose favorite way to spend time is seeing the doctor.
And the Internet is full of useful medical knowledge, so our first instincts don't have to be to schedule an appointment to see if we should be concerned about that new thing we just noticed in the shower. When the websites of prestigious clinics have detailed descriptions and images of virtually anything you're curious about, it's straightforward to make some preliminary determinations about seeking further advice.
Yes, it's quite possible to jump to conclusions that the lump you just discovered is indeed that rare and deadly disease, and be quite wrong. Doctors spend a lot of time correcting their patients' erroneous online- research diagnoses, but it's been my experience that, more often, we're relieved to learn that what we're concerned about is benign and common, and what the likely treatment options might be, before we take up the doc's valuable time.
But I digress. Simply stated, pooling of premiums allows ordinary folks to get treatment they can't otherwise afford. That's important, and something critics like your simpleminded libertarian antagonist just don't want to understand.
What that candidate seemed to have missed is that most of the very expensive healthcare services are in an incredibly inelastic portion of the market.
It's why I'm always skeptical about the "price transparency" arguments pushed by that side. If you need an MRI right now, are you really going to go MRI shopping?
Since you seem to be pretty intuitive in your thinking, take a look at the proposal I've been formulating for a new US system.
It's long, but maybe give it a skim. I'm looking for as much rational criticism as I can get to see where my thinking is flawed.
Excellent website that shows the distribution of health care costs per person, following a more-or-less Zipfian distribution, with most ppl costing very little, and a few costing a lot.
E.G., the top 1% account for 23% of spending, the top 5% for over half.
FWIW, primary care is not nearly so skewed, so capitation is safe at relatively low numbers, and Direct Primary Care practices are financially viable, and would be at lower monthly costs if more widely available. Adverse selection skews them to higher need ppl in general.
I don't understand why so many USians keep saying universal Healthcare can't work. While administrators keep getting rich, we pay premiums and co pays and get denied procedures that we need. We really do need to rally, people, against oligarchs and billionaires.
If you listened to Fox News right wing propaganda all the time you might be saying the same things. They spout on about how universal health care costs more (it costs far less) and rations care (not nearly as much as the US) and how people from foreign countries are traveling to the US to get their health care needs met (actually the opposite, more Americans go elsewhere). It is nothing more than one scare tactic after another.
Curious why people think health care tied to your job is a good idea. It is widely variable in cost and coverage and ties you to an employer when you may have better ideas of what to do with your life.
Asking as a retired Canadian physician who had a hundred thousand chats with patients about their preferred course of action.
Employer-sponsored insurance sucks. It’s a terrible idea whose time should be over. Speaking as a blue state American voter (and admirer of Canada 🇨🇦) who has despised this arrangement for years.
The history is that it came about as a pay supplement during WW2 when there were wage controls on employees.
When Truman brought up universal health coverage after the war, the unions were against it. Their reasoning was that soon everyone would be in a union and have health care coverage through the union or their employer.
Employer sponsored health care plans in the US are generally not insured. An employer of any size usually self-funds the benefits from the employer cash. This way they are not subject to the state insurance laws and coverage requirements, just the minimal federal laws. Even though the plan might be administered by a large insurance company on behalf of the company it is not guaranteed by the insurance company, They are more expensive to administer because practically no two plans are the same.
If you are covered by a self-funded health plan and the company goes bankrupt, your health insurance disappears and you might be on the hook for any amounts they haven't paid to your providers.
Employment related healthcare is a good idea for insurance companies: They collect premiums to cover to people healthy enough to have a job, and discontinue coverage when people become too unhealthy to work.
I'm not being sarcastic: Google details on the 1929 founding of Blue Cross by charging Dallas teachers $0.50 per month. The business case really did include collecting premiums from employed people while avoiding payouts to people to sick to stay employed.
It creates job-lock, manifests a bunch of economic externalities in the labor market, and is just a bad way of delivering healthcare to the US population.
Consider this. You have two firms in the same industry, hiring from the same labor pool.
One is a large firm, that has some leverage to get new workers because they can offer better healthcare benefits, since they have access to a group plan for all their workers.
Second is a small firm, who has no access to a group plan because their workforce is too small.
The small firm simply can't compete on the same compensation playing field.
It's why the best option for transition is capture current employer healthcare spending in a fixed payroll tax for a national insurance pool, and have a small employee payroll tax serve as their portion of the "premium".
That way, no particular job is in control of your healthcare, but they ARE paying for most of it.
I'm currently developing my own proposal for a US healthcare system. It may not be particularly relevant to you as a Canadian. But your position as a physician may give me good insights into where my proposal is flawed, or what aspects might be good ideas.
I will second Laura's comment. Before I get to the meat of my reply though, since you are not in the US, is to briefly note that a US employer and employee share the costs of health insurance. Typically the employer pays the bulk of the insurance premiums, but the employee does pay the remainder of the premium, plus additional co-pays when actual medical care is provided (ie. Dr's visits).
My first thought to help pay for this "medicare for all" (MFA) approach is to take the money paid by the employee and employer and commit it all to the additional taxes necessary to fund this type of operation. In this fashion, the costs to the employer would mostly remain constant, as well as the employee. Would this be enough to fund MFA? Probably not, but it would seem the least disruptive to most people and would results in smaller tax increases.
Also, I think the birth of the employer funded health care was cirica the 20's, where it was used as a perk to try and recruit talent. Like anything, once established, it is difficult to change one there is momentum.
So I did a very preliminary calculation (and my numbers ended up in line with calculations done by the CBO), and a 17% total combined payroll tax would probably be enough to cover a universal healthcare system (whether M4A or another universal system). This assumes current Medicare taxes are absorbed into it (not in addition to them), and it also assumes current general fund allocation toward healthcare spending remains.
A 12%/5% Employer/employee split would capture the current average employer/employee premium spending. So payroll would stay roughly the same, and wages would likewise stay roughly the same.
If your employer offers above average benefits, switching to this payroll system to fund healthcare would likely save them money, and put upward pressure on wages in those jobs.
I'm currently developing my own proposal for a US healthcare system. I'm soliciting good insights into where my proposal is flawed, or what aspects might be good ideas.
Employer-sponsored health insurance in the US really breaks down at times when you lose a job. In that case you can switch to the Marketplace or keep your insurance at your own expense. Either way, it’s a significant new expense at the same time you lose your paycheck.
The rich want it this way and the politicians do what they tell them. It keeps the poor and middle class desperate and in line. There is no defensible argument for why our healthcare system is still like this. Same goes for everything else wrong with the country. It's just greed and corruption every time.
Any politician championing private health insurers is politically tone-deaf to the general hatred people have toward private health insurers. When United Healthcare's CEO was gunned down, there was an outpouring of sympathy toward the shooter. Why? Because the CEO had made his name and fortune by denying care and killing men, women, and children for profit.
The United States is one of the only countries on Earth that just can't seem to figure out how to deal with healthcare. We shovel more money at healthcare than any other country, and the results we're achieving are steadily worsening as overall health AND life expectancy fall behind the rest of the world.
Perhaps the reason our health care dollars in this country are directed to the high profit industries such as the pharmaceuticals and invasive procedures while those looking towards functional medicines or wholistic treatments are dismissed and are forced to totally pay out of pocket, in spite of being less costly compared to invasive procedures. Our current industrial medical complex supports invasive treatments over less invasive procedures because it is profitable and not necessarily effective. Therefore profit is the driver in our current climate.
Derelict, most USians are paid "slave wages:" just enough for food, shelter and clothing. With no pay raise and increasing inflation, they are suffering. This causes both mental and physical anguish, both of which contribute to poor health outcomes. Dental care is unaffordable for many, causing tooth loss. Poor dentition leads to poor nutrition. Poor nutrition leads to disease, disability and premature mortality.
Prof. Krugman you are superannuated, as am I. Have you done a comparison of your prescription costs to identical medicines in Portugal? If so, did your hypertension go up? I recently did this exercise vis a vis Spain. My hypertension certainly went up. Identical medications cost less than a third in the EU. "But the medical *system* is worse there," I hear say some folks say. Highest life expectancy of any city in Europe? Madrid. Higher than NY, too.
As an Afghan ally who was left behind after serving alongside the U.S. military, I understand very well what it means when a system does not work fairly for everyone. I appreciate your point that healthcare in America is already strongly supported and regulated by the Obama and Biden administrations. The important thing for me is that every American, regardless of their income or background, should have access to good healthcare. I also hope that America will remember its Afghan allies who served beside its soldiers and keep the promises that were made to us. Thank you for continuing to speak about fairness and justice.
I have several military-retiree relatives, and they love their government-funded Tri-Care and consider it better than standard Medicare.
"TRICARE and Medicare are not competing choices for most people because they work together through TRICARE for Life rather than opposing each other. Once you turn 65 and are retired military, you generally need both: Medicare acts as your primary insurance, and TRICARE acts as a zero-fee secondary "wraparound" supplement that covers leftover costs."
This is similar to what I tell people in online debates who don’t want to lose their employer coverage — MFA can be the basic standard, and employers who want to do so can offer coverage for additional things that Medicare doesn’t cover.
Private insurance in the US is done through four companies that are so big, they are four of the top 20 companies on the stock exchange-United Health, Elevance, CVS Health, and Cigna. They are for profit and payout billions in stock buybacks. There is no analogue in any other high income country. They are so big they control not just insurance but medical providers and pharmacies. Their innovation consists of things that are uniquely American, like $7,000 deductibles that makes accessing healthcare impossible (e.g. Bronze Plans). No other country has hundreds of thousands of bankruptcies each year from medical debt. No other country has a system where you have no idea what your bill is going to be. No other country has a system where your family loses your healthcare when you lose your job (though you can keep it with COBRA if you can manage $2,800 per month with no paycheck). These 4 companies have been created through corruption. Without control of the political system through money, this world would not exist.
You forgot the barrier and racism being set up and launched at El-Sayed by establishment Democrats. WTF is wrong with everyone? He is a genius and a Rhodes Scholar. Who cares what his religion or skin color is. He is intelligent and will bring new and thoughtful ideas to Congress. I am a registered Independent. In my view, he is a far better choice than the trifecta of uneducated and moronic holy rollers we’ve had on the right: Lauren Boebert, Tommy Tuberville, and MarkWayne Mullins. Their combined IQ is about 70. We need change. He may be it.
It's worth remembering in the debate over "socialized" medicine that Donald Trump has the finest socialized medical care in the world and I have yet to hear him complain about it.
" Roughly speaking, employment-based health plans can’t discriminate based on medical history — that is, they can’t deny coverage to employees with pre-existing conditions "
But insurance companies and can do price their offerings to a specific company based on the health of their employees. I worked for a small company where we had a couple of cases of cancer (completely unrelated to work) and our premiums skyrocketed. This is a huge cause of age discrimination, too. It really doesn't make sense to define a risk pool as the employees of a single company.
I’m sick and tired of paying for insurance company parasites. United Healthcare leads the way with its upcoming of Medicare Advantage. AARP has long taken almost $1 billion per year from UnitedHealthcare in return for the exclusive right to sell UnitedHealthcare to its members.
Even the AARP’s top health policy staffer admitted to me that she would never buy UnitedHealthcare Healthcare’s Medicare Advantage Plan because it would deny her choice of hospitals and doctors as well as rip off American taxpayers, herself included.
Let’s finally stop being conned by Republicans and health insurance companies!
My younger brother asked me if he should get an AARP membership (my mother loved the organization). I advised him against it. I could never make any sense of the United Healthcare policies (one from column A & two from column B?), so I'm with Aetna and David is with Blue Cross.
It's interesting to know why we have employer paid health care anyway. During WWII, there were wage freezes in effect. To help attract workers, companies offered health insurance in lieu of raises when they couldn't raise wages. It's an historical artifact.
I have a chronic pain condition so I access healthcare a lot. It has been once fight after another to get to my current treatment plan. I spent years of additional suffering to jump through their hoops and I’m a very persistent and knowledgeable patient. It’s obscene what they do to people. Time to take it down.
Consider what happens to American who loose the insurance fight, but still have the chronic pain: Taking pain killing medication without medical supervision leads to addiction. Addiction in the US is at least three (3) times higher than in Canada and Mexico. So it does happen. In other words, if the US fixed its healthcare system, the illegal drug trade would fall by 66%.
This is a persistent but false theory about opioid addiction, reinforced by profitable court judgements against companies marketing pain medications, saying they caused the opioid epidemic.
Simply not true.
There are two populations, with only a little overlap:
Ppl w chronic pain who use opioids to control symptoms
Ppl with severe mental health problems who use opioids to control symptoms.
" opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use."
Of course there are articles repeating the same fallacy.
Thank you for the additional documentation. I do tend to forget that mental health matters. Your reminder helps.
Even if the supervised use of opioids causes some addiction (which you have identified as a fallacy), that would not explain why US opioid addiction is at least 400% higher than in Canada and Mexico as both Canada and Mexico deal with the same pharmaceutical companies and draw their medical training from the same sources.
Americans who cannot afford to pay for medical care, self medicate. Good to know that the NIH acknowledges this is a problem.
Less acknowledged inside the US is the fact that so many Americans self-medicating drives more than half the illegal drug trade throughout the Americas.
"The US National Academy of Sciences reports rising mortality for US adults, most steeply for White adults with a secondary education or less. The rise is largely attributable to deaths of despair (suicide and poisoning by alcohol and drugs) with strong contributions from the cardiovascular effects of rising obesity."
A wonderful article with graphics illuminating Case & Deaton's data.
It's not a giant leap to think that the massive transfer of wealth from the 90% to the top 1% has something to do with this, and also why voters reject incumbent presidents.
I wish it were possible to count the number of people who will stop at that table comparing private insurance to Medicare and just dismiss everything else by saying since the latter costs more per person it is proof of waste/fraud/abuse. That kind of factoid based pseudo analysis is a key driver of why we can't have meaningful discussions about issues like this. The rest of the argument, which is clearly laid out as well, doesn't matter to people once they have a single data point they can use to justify their entrenched positions.
A second note: I'd love to see an analysis of cost based on inflation at the point of service because of the insurance system. I once had a minor procedure at regular doctor's visit. Less than five minutes. Required a bandaid. Insurance covered everything but I got a copy of the itemized charges and the bandaid - one, singular, not a supply, exactly like the many I had at home - was $50. Figuring out how this happens is beyond my abilities but I'd sure love someone to explain it so we can then think about policy to stop it. Because that is waste, fraud, and abuse.
as a Canadian visiting US, my daughter went to hosp for prescription - doc took 5 min. we thought the $300 payment was a bit much but owell. got home and a follow-up bill of 3K arrived in mail. I will say this about private insurance - our travel insurance covered it all, no questions
Michigan is indeed a good test. I wish Sayed didn't have a beard and his wife didn't wear a hijab because it makes it harder but the vote will prove if Progressives can win a somewhat conservative state or not. Personally I strongly urge Democrats to stay together and vote for the Democratic candidate regardless of whether or not he is ideal to you. Figner crossed for Michigan Remember what the other side is - and the other side isn't out to help you or America.
Hi Sarah.
Thank you for your comment. I support all but two of your comments, that about El Sayed’s beard and that about his wife’s hijab. I understand your point. You are being realistic, accepting of white and other non-Muslim American views. You intend no harm.
But, I’d ask all readers to think:
- the US, like the rest of the ‘West’ is steadily becoming less ‘white’ (demographic change fuelled by population change, not ‘cultural replacement’)
- “look beyond the veil”, a comment once passed by a British, Muslim, journalist. That is to say, ‘don’t judge a book by its cover’ in other words.
Your comments are good.
I have no right to criticise, but I’d like readers to ‘look beyond the veil’ as it were.
The situation in Israel/Palestine is so dangerous, the rise in anti-semitism and in islamophobia are both so dangerous. Please don’t let the malicious get away with using these issues for malign ends.
Kind regards,
Anthony
Ps: if anyone wants to see where my ‘Look beyond the veil’ quote comes from, search for Remona Aly (journalist). The article was printed in the Guardian newspaper, perhaps 10-15 years ago.
Thank you. As a religious "none" old white guy I think we should vote for him BECAUSE he is a Muslim (in addition to his awesome credentials).
Diversity is good. Key to a healthy society that doesn't become inbred and isolated from new ideas.
All the cool guys on TV and movies now have beards :) I don't get the hijab. It must be hot in this weather. But then I don't get why women would wear stilettos, or why guys would shave their heads or why I had very long hair as a kid...
I like to consider what's inside a human - let's forget about the fashion or religious statements. Who cares. Why care? It's all about how we treat each other, right?
As a European layman, I wish for the US more people like you. The idea of freedom I used to associate with your country lives in your words.
I appreciate all of the comments. I hardly think any of us would spend time reading the substacks or peoples comments if we didn't care deeply about what's taking place in our country. I can understand Sarah's point about El Sayed's wife wearing the hijab. But I have to believe that the name "El Sayed" will evoke a stronger response than his wife's hijab. republicans are literally unable to disqualify this regimes policies and protectionism of pedophilia. Barrack Husein Obama was a name that evoked the same reaction by the one and only pedophile president in the oval office today. He's the one that made Barrack Obama's birth certificate conspiracy theory famous. And oh how the Christian acquaintances I once had, loved to talk about him being a Muslim.
A little while ago Dr. Richardson talked about how new unexpected alliances are being formed today just like they were before, during and after the civil war. The people who we vehemently thought as our enemies could become our allies and those we thought as allies will become our enemies. I believe the wisdom in that observation may be highly understated.
I agree Mark. The Revd. King’s remark about ‘the arc of history’ will come true, I hope.
Meanwhile, Good Luck, buckle up, and ‘Blinkers off’ to us all.
Nuns also wore head covering and some still do. I do wonder why they are almost always black which is even hotter than paler colors.
Because men decided that’s what nuns should wear. Ugh!
I remember Theodora. I grew up in, then, strongly Catholic Ireland in the sixties, when veils (hijabs for Catholic nuns and nursing sisters) and cassocks/ habits (thobes & jubbas for Catholic priests and friars) were regular clothing.
Our memories should guide us here.
Yeah but they were priests and nuns not lay people. That's part of the job. Priests dress like normal people when they are out and about.
Has nothing to do with Muslims covering their hair.
aren't priest "normal" people, fireman, cops, surgeons, nurses steel workers, BB, NBA, hunters wear different clothes on their jobs. Why is Muslims wearing hijabs a problem?
I've no idea about the black color, but the head covering for Christian women comes from many teachings in Corinthians. I was raised in the Episcopalian faith. When I was a boy, the church kept head coverings for women who forgot to bring a hat to the service.
Prior to about 1920, those same teachings forbad Christian women cutting their hair and, in most groups, allowing any man other than her husband from seeing them with it down and loose. That changed with the "flapper" era.
Orthodox Jewish women also cover their hair.
Who came up with the idea that hair was so lasvacious?
I was told that they actually cut their hair when they get married. After that, they wear a wig. Providing those wigs used to be big business in Manhattan.
It's just a thing. Horses with ample and resplendent manes and tails are considered more attractive. I would guess that gorgeous hair is equated with good health and thus breeding potential.
Men.
Orthodox Jewish women cut off their hair when they marry, no? Isn't that rather odd? And then go on to wear wigs. Hair, it seems, is really dangerous!
Nuns wear black because black is the classical colour of purity.
Although it may be a "chicken and egg" thing, in western culture/religions.
Many--most--Christian female monastic orders were founded a millennia or more ago, when married Christian women--nuns being considered "married" to Jesus--were expected to wear head coverings, and clothing that covered every inch of exposed flesh. Basically wearing Hijab.
Black and white clothing colors not only constitute a uniform, but have deep spiritual significance to followers of Judeo-Christian and Islamic religious sects.
Contemporary with Nuns' (black) habits most male priests and monks wore black, or dark coloured clothing. It was supposed to mark them as "servants of God". The world was a little chillier then, especially in Europe.
Note: a lot of ministers still affect dark clothing. Makes them look more threatening.
They wear it becauae they are nuns and the Catholic Church hadn't changed in millenia. The habits nuns wore in the 60s and 70s were reminiscent of how women dressed in the Middle Ages. (I actually thought it was cool)
It was actually quite hot in summer!
Excellent comments. I agree with everything you said.
Thank you, Bill. We don’t need to understand why people do their own private choices of dress, tattoos, shaved heads, but by keeping focused on their inside humanity, we find so much more good, likeness and togetherness.
It's what's inside a person that counts. Everything else is just window dressing.
"Hijabs are worn by Muslim women for a variety of reasons. For some, it represents the transition into maturity. Some choose to wear the hijab as a way of proudly expressing their Muslim identity. Many people wear the covering in observance of cultural or familial regulations. Naturally, a lot of Muslim women decide not to cover themselves. Some decide to reserve wearing it for religious events solely.
Furthermore, Muslim women who have decided to wear it and uphold their modesty do so out of a desire to obey Allah, who is the one who has commanded women to cover all of their adornments.
Also, Women are commanded to wear the hijab as a protection against abuse and enticing others. This is because women are the object of desire and the target of the sexual gaze in most cases.
The prophet Muhammad commanded his wife to cover up with headscarves, which is how the hijab obligation in Islam began.
Furthermore, Islam places a high value on the hijab since it is seen as a directive from Allah and is mentioned in the Quran and Hadith. It is a way for women to maintain their dignity and modesty. Also, wearing a hijab encourages Muslim women to live their lives by Islamic values and acts as a reminder of their religious beliefs." source - Riwaq Al Quran website.
... and we never question why teenage/20s bros always wear hats, hoodies, or sometimes both, western women wear hats at the races. The one defining feature of the Middle East is that it's HOT and sunny. Head coverings make sense. And saudi men wear robes and headdresses, bedouins are covered head to toe, israeli men wear yarmulkes, etc. I've been to the ME many times on business and the professional women I work with, 99+% of whom are Muslim, tell me it's a personal choice to wear a hijab or other head covering though more and more there are, especially young, women without head covering. This summer I wore a hat almost every day outside during daylight. The point is, it's not a big deal, except for those who want to make trouble.
Last year, I think, or the year before, a young woman in Iran was murdered for getting on a train without a head covering. Remember?
I constantly wear a hat outside, usually a ball cap. I don't remember when I started, but it was probably over 45 years ago. My wife makes fun of me for heading back into the house if I forget.
Anyone who can't deny the idea that a heavenly dictator commands thoughts or actions is not qualified to hold any public office.
You mean Haredi Jews, Roman Catholics, Evangelicals and "Christian" Nationalists?
All of the above and others unnamed.
So you object to Christians who wear crosses on chains around their necks?
Yes, if they hold public office and believe in the commands of a heavenly dictator. If they wear maga hats or swastikas they follow commands of earthly dictators as well.
Oh this is tiresome. I wish we'd all shave our heads and wear t-shirts and jeans. Look the same, be treated the same. Show our private selves only to those who care about us.
Well, if my brothers and I were to shave our heads, the various scars would make us look very different.
They care.
The Quran says a Muslim has three choices when they meet a non-believer:
1. Convert
2. subjugate
3. Kill them
That’s How they treat each other and us.
The irony is you’ll never see a group of non-believers riot in the street over a cartoon.
They’re all medieval cults… except for the Scientologists, that’s the most modern version of fanciful thinking there is.
No wonder the world is going to hell.
Pun intended
When I read the word "they" I pause. Every faith or religion or cult has observant folks and those who are "meh". So in reality there is a "sub-they" that adheres to the slavery of dogma. Most of the others are on again and off again.
Then there are those like me. I think I am a "recovering Christian". I reject a lot of what the Bible says. Not going to kill a son or listen to burning bushes.
In short, a whole lot of people are not "they" despite their heritage or early childhood programming.
Think you missed it.
“They” don’t have to be extreme, all they have to do is believe… like that you can live forever depending on what you think! “They” distort the very nature of reality.
When I read comments by people like you who make excuses for the nonsense we see in the world today, it’s no wonder things are getting worse.
Now Jesus is supposed to be the one, and he said not to forget the old laws, that would be the Old Testament.
You can cherry pick what you want, but numbers 31:18 says it all: you can take a virgin for yourself if she breaks the second Commandment.
And me thinks most people are “they,” like every single one who starts “chanting” after someone sneezes. Why do you all do that? Is that polite? To me polite would be letting someone merge into traffic where these guys all tightened up.
Wearing stilettos is a choice. Wearing a hijab is usually demanded by the husband or conservative Islam.
substack is a phenomenal ecosystem.
>a nobel prize winning US economist posts political-economic criticism of US economics,
>>it gets fewer likes and reblogs than the average facebook post (of equal volume),
>>> followed by a thoughtful comment, structured like a modern internet comment with a reasonable perspective,
>>>>followed by a reply structured like a traditional email/letter that goes out of its way to clarify the intent against harm while communicating an important distinction
>>>>> and here's my nerdy ass analyzing the emergent dynamics of internet comments, old enough to recognize the latter style and young enough to recognize the former style
.....maybe not *EVERYTHING* in the world is awful bullshit. Maybe.
I am hoping he has more Economics to say about this because it has been estimated that we could cover the entire population with Traditional Medicare for a little over half of our present total healthcare outlay. If we were to create a hybrid picking and choosing the best features of Traditional Medicare with the best features of Medicaid, the savings would be even more. And eliminate Medicare Advantage. Rein in Big Pharma - there is a huge amount of overcharging there. Create a hybrid training program for Nurse Practitioners and Physicians Assistants and then let them practice autonomously. They can handle the simple, straight forward stuff like snotty noses, simple uncomplicated hypertension and diabetes - diseases for which there are well established treatment protocols.
PK says, "And the U.S. would stop wasting large sums on pointless administrative costs." At a rough estimate, the "pointless administrative costs" consume $0.50 of every dollar US governments spend on healthcare.
My logic is as follows: Canada spends $5,184 USD per person per year on healthcare. US governments spend $8,554 USD. The Canadian government spending covers all citizens, US spending about half. Canadians have a slightly higher life expectancy, so we can assume healthcare quality is at least as good.
... also...
Canada is not particularly efficient. Germany and Holland have a much lower cost of healthcare administration per capita.
... so...
I suggest it is reasonable to assume that the US can be at least as efficient as Canada in administering healthcare, and the current cost US governments pay for healthcare administration is at least 50%.. likely more.
I am sure a huge savings would come from the elimination of third party managers, pharmacy benefit managers, and those sorts of companies…the clearest parasites in the world of private insurance.
You are spot-on, HC.
The UK’s NHS and other European national health organisations all bargain down unit prices with pharma through scale (70 million, 80 million and 80 million respectively). ‘There are no free lunches’ applies to US single-user health insurance choices too…
One reason Canada's healthcare costs are so high is physician salaries. First expense is hospitals, second is physician salaries. Physicians make more money in Canada than in Europe. Physician salaries are higher in the USA, although I wonder what percentage of an American physician's income goes to malpractice insurance.
And my husband asks, what percentage of a younger doctor's salary in the US goes to paying off his or her student loans?
Wonder no longer! Between 3 and 5% of net physician income goes to malpractice insurance. The finger pointing at increased liability costs in healthcare is an old trope that was always a distraction from serious rent-seeking and other bad behavior elsewhere.
Vast majority of Canadian physicians are not salaried. They work fee for service. Each physician covers their own overhead (staff, office, supplies, insurance) and benefits.
The U.S. system is designed to make sure they take all our money before we die. Good health is secondary.
Administration, not all of which is pointless, covers perhaps as much as 20% or US healthcare expenses all told - nowhere near 50%. Canada is healthier than the US for a number of cultural/lifestyle reasons that have little or nothing directly to do with healthcare (smoking and drinking rates, stress, obesity rates, etc). Also, individual units of healthcare are more expensive in the US than in Canada and other nations because of economic protectionist and subsidy policies that again have nothing to do with actual healthcare. Yes, all this needs to be addressed and fixed, but the 50% claim is misleading and lets some of the bad actors off the hook.
Don't forget that the military and dependents and many veterans get "socialized" medical care.
I just checked the National Health Expenditure database (NHEX). It does say that administration accounts for 15-25% of every dollar spent on healthcare in the US... as opposed to 3% in Canada. I lumped monopoly pricing and administration together... a disservice to those of you actually working to make the system better... my appologies.
👍 x both, from me for this.
for a money-mad culture, Americans sure are weird about health care...think of what all that money going to insurance companies and their billionaire CEOs could do on the ground
Since your proposal would seriously reduce the profits of all levels of the medical industry, it would be vehemently opposed by all those involved in it.
There are ways to sweeten the deal for docs... and I think we are at a sea change moment with society vs. the Megacorps.
While I agree that we could almost certainly provide better treatment for the entire population for less than what we currently pay to essentially deny treatment to part of the population, please be careful with claims that it would be half as much as current total expenditures, especially since the government already pays out better than half the total. At the end of the day we'd pay less total, but most of what we currently pay for denial of treatment would get paid for treatment. A huge whopping reason the US pays more total in healthcare than most other countries is a matter of lifestyle and (mis)education, not healthcare (or lack thereof). Yes, we can reduce rent profits in pharmaceuticals and other corners of the industry, but we're never going to bring costs to heel without some other serious societal changes. And before anyone says otherwise, I have been a vocal proponent of doing away with private insurance altogether, or relegating it to only secondary coverage, for about four decades now. And I am including the basic liability portion of car insurance, basic life insurance, and basic property insurance in that! YOU cover your own risk, SOCIETY covers societal shared risk and unavoidable externalities through aggressively progressive taxation.
But people younger than the current minimum age for Traditional Medicare would be paying into the hybrid system with their premiums either as a direct buy in or through a tax assessment. The numbers are based on the cost of the British system.
And the pass through of elimination of the the profit of for-profit insurance companies.
Substack does not have the audience of Facebook and apparently the Russian troll farms have not invaded it yet.
Well, you have to pay to play (comment) on Substack, and Putin is running out of funds. 😉
There are some authors that never require a paid subscription to comment and others that only lock comments on some of their posts. It’s a good thing they can’t figure that out.
I have always been an optimist - that everything in the world isn't bullshit. Still, I find it more and more difficult to maintain that optimism in the world we are currently faced with. A complete change in House and Senate; a rational adjustment in the Supreme Court and bringing a "loose cannon" president under control would make things more "right."
As I have said forever and will continue to say,"Religion has no place in politics or government"! Sticking "under god" in our country's pledge of allegiance was wrong and dangerous then; it is wrong and dangerous now. Cling to the belief of your choice if you must; just don't pre-judge others for theirs. Peace, Love and Brotherhood, people!
I am not disagreeing with your statement, and this may sound trivial, but it has proven significant in practice:
When you put "Religion has no place in politics or government" in the same thought as "Sticking 'under god' in country's pledge of allegiance" you conflate "government" with "state."
You can be a loyal American and oppose the government... and... the UK can elect a Muslim as mayor of London and still have the church of England as part of the state.
Bottom line: Don't let the state's imperfections distract you from fixing the government.
Neither does big money or big corporate interests.
Our Constitution clearly calls for the "Separation of church and state".
Republicans forgive, or rather ignore, rapists, wife beaters, fraudsters, pedophiles, felons, while Democrats won't forgive beards, hijabs, a laugh ...
Lovely response. I agree with you though I totally understand what Sarah is saying and why. For me, this is another way that Ds let Rs control the narrative. Ds need to call hate what it is whenever it shows up like this - bigoted and xenophobic. It is superficial judgement passed on someone solely based upon external factors. We have a parade of neat and tidy white men and perfect little white women currently running this country, and yet they are heinous humanoids. Obviously what one looks like or how their name sounds means nothing. Words are important but actions matter more. Trump and many of his posse showed their ugliness before they ever stepped into our government. Their actions were loud and clear. El Sayad has an existing reputation and should be assessed based on that. So to circle back, instead of hand wringing, Ds need to circle the wagons and refute this racist bs repeatedly every single time it is brought up as though it should even be a legitimate factor or concern. If Rs can elect and/or keep rapists, pedos, abusers, etc in office, then Ds should be able to unquestioningly and unapologetically back someone with dark skin, a beard, and a hajib wearing wife.
heinous humanoids - love it! (but not them)
But they all need to be Democrats. We have to take away the ammunition we have stupidly given the Republicans by renaming the party Democratic socialists. I would bet a $1000 a Republican operative convinced some liberal Democrat to adopt the socialism tag to set them apart. Stop using it because Trump is already crowing about how he was right and the Democrats a communists. Communists! How has this even gotten any traction without pushback! Oh yeah the Republicans are always on message.
There are two things that gnaw at me.
1) Most of them are actually Social Democrats not Democratic Socialists. They are distinct and different. Once again, Americans misuse terminology, never mind it is an unnecessary distinction in a two party system, so people get confused. Though either name would be sneered at and weaponize by Rs. And again, this is also fueled by Ds eating their own rather than fighting the actual outside threat.
2) The extreme leap from these liberal Ds to communism is such an obvious, fear mongering ploy that the Rs are desperately and relentlessly pushing. Unfortunately, many Americans are too stupid, lazy, and/or apathetic to see it for the farce that it is and dismiss it as such. And, while Rs have no trouble screaming communism, too many Ds are too timid to scream fascism back at them…which actually is far, far closer to how Rs are currently operating than communism is to any of the liberal Ds.
I'd vote for a guy with dreadlocks who wore dresses and heels if he runs as a Democrat.
Beards and hijabs are cultural artifacts having little or nothing to do with the beliefs of original Islam. Besides which, you can see any number of MAGA Christian acolytes wearing large and sometimes downright in-your-face crosses every day. When I was a girl, btw, my christian church required that women wear hats on Sunday. Nobody thought anything of it and the custom just faded away as times changed.
That’s the problem those who are currently in control will fight to stay in control for as long as possible. They don’t realize they’re fighting a long term losing battle. People can deal with slow evolution not rapid revolution. To too many everything is happening too quickly. Politians capitalize on fear.
Look beyond the veil…
And see them kill their daughters for holding hands with a boy. See how they keep their daughters out of school, how they kill their wives - that was also in The Guardian just this last week.
They’re all medieval cults and you can’t stop them but you don’t need to support them. Like, look how they have you all chanting after people sneeze.
The most religious places on earth are also the most backward places on earth because of a reason. They will kill us all as they overpopulate the planet with their beliefs.
Morality is about the well-being of others and has nothing to do with rituals and superstition.
Next look up numbers 31:18, it says you can take a virgin for yourself if she breaks the second Commandment as Christians, Muslims and Jews all follow the Old Testament. Jesus said to keep the old laws.
Right.
Neurosciences explain behavior, they say that a functional mind doesn’t have to try to be honest. This explains why the Buddha was spreading the golden rule 500 years before Jesus. Imaginary beings are not needed.
Yes, Im frankly sick to death of the Middle East "crises". I have been hearing about this for years and years. Their fighting started in the 1960s. I wouldn't be surprised if it wasn't a cottage industry by now. Munitions firms are sure making a killing. (not apologizing for that) Even in Michigan where El Sayed got money from Palestinian organizations and Stevens got money from AIPAC.
Well, two of tRump’s thugs are bearded and one of them is quite brown. Dr. Krugman also wears a beard. So why does Dr. El-Sayed’s beard trouble you? As for his wife’s hijab, is it any different from the custom of ultra orthodox Jewish women not being allowed to show their hair? People’s religious beliefs and cultural practices are none of anyone else’s business unless they’re trying to convert you, and I have yet to meet anyone from either faith who tried it on me. The only god-botherers who have ever tried were (or claimed to be) christians.
Whenever I see a snarky comment about hijabs online, I ask how they feel about nuns’ habits.
I don’t think the initial comment was snarky; it was an arguably mis-guided (definitely well-intentioned) concern about how elections work.
Cultural issues are complex. While I definitely do not think any of the religious “costumes” under discussion should get in the way of evaluating individuals on their merits, I personally can’t help thinking they are all retrograde expressions of male supremacy.
I agree because I’m an atheist and my opinion of all faiths is similar to yours—they are all ways of exerting power over people, especially women. Nuns’ habits have changed over the years and don’t look as much like burkas as they did when I was a child.
some nuns now dress 'regular'
That’s true.
Thank you for reminding me—I can’t believe I completely forgot about nuns!
Nuns wear habits because its their job. Like construction workers wear hard hats and baseball players wear caps.
and the Amish have different modes of attire as well
Would you vote for an Amish man?
Why not vote for an Amish man or woman? The Amish do tend to stay out of politics.
No.
Why wouldn't you ?
Because I’m afraid they’d be wanting everyone to abandon all the technological innovation that have made our lives easier and safer (although not always). Also, because I’m an atheist and don’t want any religious extremists to be governing us any more than they are already trying to do.
What about whit ladies wearing scarves???
If you mean the old-fashioned head scarves worn by ladies like the late Queen Elizabeth, I must admit I don’t know why they bothered. But I love beautiful scarves to brighten up an otherwise boring outfit. It’s a fashion thing.
My bet is he could shave and she could dress more conventionally (in your mind) and a whole different set of complaints would emerge. Nope, I don’t believe in catering to that kind of bigotry. Would it bother you if it was an orthodox Jewish candidate in a yarmulke and his wife covering her hair?
Or Amish? Or a white lady covering her 'do?
I would vote for El-Sayed if I lived in Michigan, but he has almost no chance of winning this election.
I’m hoping you’re very wrong on this!
I predict he wins it
I wish we could bet, John. I'd put 20 bucks on Rogers winning. Again, I would vote for El-Sayed.
This climate and his message will win the day. If he doesn’t shame on their voters who will be harmed
I've been wrong before, but I've been right about 90 percent of the time when I do predict a race. But at this point I'm still qualifying my opinion; if gas prices soar, if war breaks out again with significant casualties, the Democrat is likely to win. Otherwise I don't think so. I wouldn't bet money on this race this far out. I once worked in political polling; the 55% odds you mention mean nothing at this point, with this Democratic candidate, in this state. But again, circumstances could change things enough to allow El-Sayed to pull it off. Ask me a month out and I'll probably be confident enough to make a definite call.
Well, I do--and I will!! As will many good people in Michigan who don't judge people by how they look or what religion they've chosen...Mike Rogers is an old pol has-been joke.
I agree with your characterization of Rogers. But then, aren't there dozens of old pol has-been jokes getting elected all the time?
Rogers has his own baggage as someone who abandoned Michigan for Florida and came back just to run for office. While this is mentioned in Michigan, you don't hear it much in the national news on this race.
Too many. We don't need another one. They're useless.
Here’s the problem: That’s what you’re getting because of the candidate you chose - except the old pol will be a republican and not a democrat. enjoy!
Maybe not you, but most people judge people by how they look.
esp those aspects of appearance under their control. brown skin? cool. big honking cross, religious costume items...not so cool. tho I suppose useful in that it reveals a lot, gives fair warning (nutjob alert!)
So pretty much the kind of person that Americans vote for now.
The race in Michigan is a tossup and running Stevens as the AIPAC candidate may have been problematic as well. Hopefully El Sayed will motivate young voters to come out.
If Stevens had won the nomination I would have stayed home or voted 3rd party in November. AIPAC support means no vote from me. But El Sayed can only win if the price of gasoline really soars or large numbers of body bags are coming home from the Middle East.
Well that would be just great and the Republican who gets elected would have gotten even more money from AIPAC and El Sayid got money from Amani Barakat, the chair of the Al-Awda (Palestinian Right of Return Coalition)
I take no side because there has been fighting over there for 60 years and will continue for another 60 years because now an industry has developed and will be impossible to dislodge.
Ummm...according to whom??
According to me. My track on political predictions is pretty strong, but of course I can be wrong.
Ya, but we thought The Dump would never win, either. Twice. Or a man of color would win, either. Twice.
I didn't think Trump would win in 2016, but I predicted both of Obama's wins way ahead of election time. And I predicted Trump would win in '24 after Harris beat him in the debate but the polls didn't move.
You didn’t think Trump would win twice, both elections versus a woman? Of course he was going to win.
The same with Obama - and the democratic party is making the same mistakes over again that the republican party made back then. McCain: Palin. A woman as VP. It was a no-go for Americans. 2012: Romney was a Mormon, and a lot of people are prejudiced against Mormons. Now let’s think - what else are Americans, including Michigan, prejudiced against?
No, I didn't think Trump would win in 2012. Clinton was a terrible candidate with a lot of baggage, and her campaign manager was a Vermont boy barely out of his teens, but I didn't think someone as intellectually and morally bankrupt as Trump could be elected president. I don't know enough of the kind of people who put him over the top in the swing states. That's on me.
If Biden had retired and the Democrats had had a competitive primary, and if, say, Gretchen Whitmer had become the nominee, she would have beaten Trump in '24. She would have carried Michigan, Wisconsin, and PA.
Yep. I have no fucking idea what’s wrong with the democratic party - I’ve even considered Trump might have paid off the DNC to nominate unelectable candidates even in areas like Michigan that should be a sure thing (A republican hasn’t won there in 25 years).
This should have been a sure thing victory for democrats, and somehow they found a way to lose, just like in 2024. The only way Trump was ever getting in office again was democrats making a catastrophic mistake and running a woman again. And they did it.
The same with Texas. Some of the tide was turning and here they come with a candidate 100% guaranteed to lose in a year that they might have won if they’d ran someone all voters would be okay with.
Funny but wearing a great big cross on your neck is considered a plus, but a hijab is so bad. 😤
Appeal to the majority of voters to win.
About the beard, if you look around beards seem to be popular with conservatives. Show me a bald or shaved headed dude with a billy-goat beard I will show you a MAGAt. Also although IMHO beards especially the gray ones make you look older, many seniors who skew conservative sport beards.
Hi Sarah.
I’ve been looking over the comments to follow your comments. It looks to me like a parallel discussion is occurring, quite apart from your points in spirit.
I just wanted to affirm that I appreciate your views, and I’m sorry if/ to the degree that the points you made seem to be interpreted differently to your original statement.
Your statement ends with:
“Fingers crossed for Michigan. Remember what the other side is - and the other side isn’t out to help you or America”.
That is where our focus should be.
Regards, again,
Anthony
I'm sorry that the demonization of Muslims works on so many people that they inherently fear facial hair and a piece of cloth.
Markwayne Mullin has a beard. Pam Bondi and Hakeem Jeffries both made the personal choice to wear crosses. Let’s not buy into double standards.
Dr. Krugman, please stop calling people in terms of color. I am stunned indeed a person of your intellect call Mr. Sayed brown. What color would you call Asians then? The only classification that is allowed is Israels (Jews) and Gentiles. Then white and non-white by Repulicans. You are a publid figure ane set a standard and in that you have responsibility.
Colors are commonly used to describe people in general categories. Skin and hair color are major distinguishing characteristics in many societies where there are significant differences. Skin color is a major factor in MAGA. I'd prefer a color blind society, but its not what we have.
esp when the colors are more terms than descriptions...
sayed and wife look pretty pale to me...reminds me of the idiocy of calling a whole lot of people black who literally aren't...even afro-american doesn't cut it when a lot of so called AAs are at least or more euro-american. wish we could get to looking at skin color the way we whities accept our varying hair and eye shades
Halley Stevens has shown so much class by enthusiastically supporting El Sayid and working for a Democratic sweep. I hope she still has her congressional seat.
indeed
So if a Muslim’s hijib (for modesty) and a beard are what scares maga and trump evangelicals, how do you think real Americans feel about all the lying, lawbreaking, & bigotry trump evangelicals (not even real Christians) make us feel when they wear the cross while spewing hate, rhetoric, racism, bigotry, & propaganda ?
I do hope all democrats come together soon. If they do, we can win everything.
Your vote is not a valentine, it's a chess move.
T
“I wish Sayed didn't have a beard and his wife didn't wear a hijab because it makes it harder” - that’s some racists ass bullshit right there. Check yourself and do better.
Every country that has universal government-funded health care also has supplemental private insurance, and most working people get that insurance, which provides access to newer and more expensive treatments. Canada, UK, France, etc. all have that system. So basic healthcare for all, plus a more capitalistic system. But the key is: basic healthcare for all that isn’t provided as emergency medical care.
Quick fact-check: Only 13% of people in England have supplemental private insurance. 95% in France do. 25% in Portugal. 28% in Spain. 10% in Norway and Sweden. 32% in Denmark.
France is the outlier, for some reason, but the rates are mostly rather low and I'm not sure how much of them are blue-collar working class. Obviouisly there must be differences among countries of what is covered and why people would get supplemental insurance but it's not "most working people".
France's statutory health insurance covers roughly 70% to 80% of standard medical costs. The remaining balance and specific categories—such as dental, optical, and extra doctor fees—are traditionally funded by prepaid private or complementary insurance (mutuelles), which over 95% of the population carries to avoid steep out-of-pocket expenses. In other words, that figure is not really dealing with day to day stuff. You can do the same in the UK if you want.
(Real) Mutuelles (there are "fake" ones...) are coop-like (i.e., not for profit) structures, often started by unions. Ours is run by the Press union (with strong communist leanings...You may clutch your pearls if so inclined !) because I worked for a newspaper until I retired.
Many of these mutuelles also run "health centres" ("centres de santé"), at least in large cities, offering GPs, specialists, dentists, pharmacy, opticians, etc...at regulated costs (i.e., within the limits set by the National Insurance system--you can always go elsewhere and pay more; many do).
I only use a Centre de santé for dental, because we have a local GP we like and other specialists as needed. The most I ever paid was 1,000 or 1,500 € for three dental implants (four teeth). Everything else is reimbursed.
Not inclined to clutch my pearls. I'm in the UK, and I think I'd quite like a similar system. Trying to get a dentist here can be a challenge.
Is dental covered by the NHS? It's not in Canada, although it's free for children now, and we have some Dentacare for poor seniors. I have no problem finding a dentist. What's the issue in the UK?
Hi to Susan and PDP and Tracy,
The financial settlement to dentists in the UK is so far short of the costs involved. For example, the price of ceramic fillings vs metal amalgam fillings, and many other items used in day-to-day dentistry, the negotiations between the dentists and the UK department responsible for health stopped (in truth) many, many years ago. Both sides are effectively unable to progress negotiations because of lack of disposable cash. PDP will be depressed by the similar impasse in the UK for the funding of social care (non-medical care to US Americans) for the frail/ disabled/ elderly ….. not nearly enough cash-on-the-table regardless of how ‘nice’ the politician speaking is (or how white and regular their pearly whites are on your tv screen either).
The only thing that annoys me is that I am edging towards ‘senior’ status (I’m in my mid-sixties, a ‘kid’ still…), and having contributed for many years through taxes (like US Americans, the UK isn’t really so different), it annoys me to be told that I am ‘too expensive’ now when it is much harder to contribute the difference (snarky face emoji inserted here).
Regards,
Anthony
Dental is covered by the NHS. The problem is finding an NHS dentist who will take new patients. This has been a problem for many years. Dentists attribute closures and service changes to problems with recruitment and increased running costs. They say the money they receive from the NHS, and the contract requirements (including financial penalties), make it impossible to provide a proper service. Hopefully now Labour are in power, and more specifically Andy Burnham (although I may be over-optimistic here) things may improve. Essentially there are perverse anti- incentives. Dentists earn the same for one filling in a patient as for 10, but plainly the amount of time and effort is different. Hence I would like the idea of a secondary level of insurance. British people do not want to be taxed anymore, as the tax burden falls disproportionately on lower paid people. It's all part of the mess left by 14 years of Tories, i.e., turkeys voting for Christmas.
dental care in Canada is for any senior who applies - covers a lot but not all of the cost
I’m not prone to pearl clutching. 😁 And yes, the supplemental insurance markets can be more complex than simply “for profit.”
Um… in case ICE is monitoring this conversation: COMMUNIST?!!? Well you should be deported to Russia. Oh, right, we like Russia now. I mean CUBA! Deport you to Cuba!
Since you are now Canadian, you are not allowed to malign Cuba anymore. Canadians love Cuba. Americans hear nothing but propaganda about Cuba, and believe it all. If it were not for the US embargo, Cuba would be different. I do not support its government, but I'd rather live there than Saudia Arabia or China to name a few. Speaking of healthcare, Cuba's main industry was tourism mainly by us Canadians. Second was Medical Tourism. Physicians in Cuba are well trained, and Americans used to go there to get excellent medical treatment that they cannot afford in the USA.
That was a joke. I’ve visited Cuba. What we’re doing now is a crime!!
I am not in the US and will not visit in the foreseeable future, given the current "administration"...but thank you for your warning 😊
I got my Canadian citizenship a month ago thanks to grandad. My husband calls it my get-out-of-jail-free card. 😊
There is another component to the supplemental insurance. European countries play the generic waiting game with new drugs and medical technologies. They either don’t cover them, or they inappropriately reference price them to inferior but cheap generics, so companies don’t market them to the government. Once the drugs go generic, the governments add them to their formularies. So people who want access to the newer, more safe and/or effective medicines get the supplemental insurance. What people don’t want to talk about: this cost-shifts discovery to the US market.
I’d agree with Sarah Samuels’ comment. Generic drugs come online when a Pharma company’s patent license lapses; the active compounds in the generic & the original drugs are identical, but the ‘fillers’ can be different.
Also, licensing authorities take into account the clinical ‘urgency’ of the newly licensed medication: how many lives?/ how many more years of life? does it provide per unit cost. So, medications that are demonstrably able to prolong life / improve outcomes (this is where the debate comes in) are approved by licensing authorities, even where very expensive.
For further information about this, look at NICE (UK) website (www.nice.org.uk).
Lastly, please remember that the great majority of innovation in medicines is developed already within the US. Doesn’t it strike you as odd that others pay less than US Americans do for these medicines? This difference often comes down to the ability of other providers (the UK’s NHS for example) to bargain down unit prices because of their scale vs US private sector insurance companies. The UK’s population (c 70 million) is large by comparison to any US insurance provider’s client base.
This all brings the discussion back to the core of Paul Krugman’s article today: the US Government ALREADY drives the economy of healthcare provision in the US to a HUGE degree. Follow the money, don’t swallow everything that is said by parties with an interest in the outcome.
Regards
Anthony
A case just now in Denmark. Xarelto vs Eliquis.
The blod thinners Xarelto and Eliquis are two very equivalent products. Eliquis might be a tiny bit but in general not much better.
Xarelto has run out of patent protection in February 2026, while Eliquis in Denmark has patent protection until November 2026.
Original Xarelto 20mg/day price went from €2.77 per day in 2025 to Generic €0.06 per day on August 3. 2026.
A huge 98% saving (mostly) for our taxes/government.
Eliquis will be on patent until November 2026. The Danish retail cost of two 5mg pills daily is €2.77 as of August 3. 2026.
The Danish health authorities told GPs in February to switch all Eliquis prescriptions to Xarelto prescriptions.
Lars :)
They were approved within 6 months of each other, so their clinical trial programs overlapped. Eliquis isn’t considered second gen. That said, it has significantly lower bleeding risk, so they are not equivalent on safety.
Not necessarily-generally two major sources of drug approvals in the world Brussels and Washington-essentially most of either hemisphere follows that lead. I have seen cases where a drug developed by an American company gets approved in Brussels before Washington-it is a major celebration because it is worth as much as US approval. Thus, there are drugs from US not available Europe and vice versa. Generally, when that happens there is an essentially equivalent drug approved in the country where the drug has not been approved. Western Europe has a higher life expectancy than we have
Generic drugs are not "cheap"; they cost less but are EXACTLY the same as the brand name; generic is NOT inferior. SAFE? Nonsense. Yes, people have private health insurance to get newer and more effective drugs, like extended release of the same drug. I have drug coverage in my private plan, but it only covers the generic version; insurance companies are not stupid and pay for brand name. Geez!
You completely misread my note. I never said a branded and generic drug with the same IP were different.
I wrote that newly approved drugs are generally safer and more effective than older generics. Referencing pricing is a price-setting policy, whereby a government can say: this new drug is the same as an old generic, therefore I’ll only let you charge the cheap generic price for the new drug, even though the new drug is an entirely different drug and is safer and/or more effective.
Not sure what you mean by safe. Often newer drugs are more effective, and some have fewer side-effects, but the term "safe" has certain implications as to meaning.
So I'm in the midst of brain storming a proposal for a new US system.
And your point about this innovation aspect was one of the primary reasons I felt there still needed to be private insurance. You need a discovery layer.
Take a look at my proposal if you have the time (it's a bit long)
But parts 7 and 17 are relevant to the drug point.
https://commonwealthanalyst.substack.com/p/american-health-security
70% of Canadians have private insurance. 10% of Germans only have private insurance and 35% have supplemental private insurance. DREES reports that 96% of the French have supplemental private insurance. About 26% of Spain.
I stand by the proposition that there is a second, supplemental private insurance market in countries that have government insurance and a substantial number of people, certainly those who can afford it, get it.
I'm a bit confused about what private insurance here means. In Canada, for example, I have Blue Cross. That doesn't pay for anything that the government medical plan covers: surgeries, broken legs, visits to doctors, MRIs .... it covers drugs (although there are plans for those who can't afford drugs), some therapies like massage, etc., some dental....sometimes a. private room instead of a ward....but it doesn't give better access, more treatments, faster treatments, better doctors, better care. My neighbour who is penniless and me who is not get the same care if we have cancer.
Actually, and I’m sorry to say this, you don’t. Cancer is a great example. Here’s a list of new cancer drugs the Canadian government has approved but won’t pay for. You won’t have access to them (unless you pay out-of-pocket and they are expensive) but someone with private Canadian insurance is likely to have access to:
* Talvey
* Itovebi
* Carvykti
* Sarclisa
* Enhertu
* Loqtorzi
* Imdelltra
Yes, that is why 'private insurance' needs to be more carefully used. I know that some drugs are expensive, and only available through plans or insurance, but for that, everything is equal. At least in my province. I wait in the same line as the poor, the unemployed, the billionaire, and the schoolteacher. I get seen by the same doctor, scheduled the same for surgery, our beds are next to each other. When one thinks of it, it's an exercise in democracy, unlike the elite systems in the US. Perhaps there's a connection in its road towards oligarchy.
While true for primary care, it is less true for specialist care. Average wait times to see a specialist in Canada are easily 3 months. Private insurance can speed the time to see a private specialist.
It means better access, just as concierge medicine does here. Those who can afford it, will gladly pay for it.
yeah, canadian here puzzled by the insurance thing
Is it legal to have private insurance, or pay cash, to for example get a surgery done on a quicker timetable?
Sure, stand by that, which is changed from your original claim from "most working people get that insurance" to "a substantial number of people" so it's good that we get more correct through dialog, but my response would be that at least all people have basic coverage for the bulk of health problems, even if it's not the most premium version, and that's head and shoulders above the raw capitalism where most people can't afford health care (like most of the very poor capitalists "third world") or the premiums drain us exhaustingly (like the imperial core, the USA).
You’re right that I was thinking Canada and France when I said “most.” And Germany (there was a time when that number exceeded 50%). But all of those countries do have private supplemental insurance.
We don’t disagree that basic coverage should be provided to everyone. If you break a leg, it should be free to have it set and cast. But let’s not labor under the illusion that the wealthy don’t buy insurance for better care. They do.
There definitely is a market for private supplemental insurance in many countries that have Universal Healthcare. BUT, It all depends on what a government plan covers. Some do not cover dental, massage therapy, private hospital rooms, drugs. Many Canadians have it because those are not covered; the big one is dental.
70% of Canadians have private insurance? huh, not me or anyone I know (except now the old people's dental, which covers part of the cost - private company but the plan is subsidized by the govt)
France's system pays for 100% of chronic and major illness. The supplemental is for glasses, office visits, dental and the like. It is not accurate to say private insurance lets you access newer and better care in most of these countries.
Yes. See how much luck you have trying to get your private insurance to pay for any newer drugs or procedures.
It is fair, and it is true. France began reimbursing for Semaglutide and Tirzepatide for obesity one month ago. Five years after US commercial insurers started paying for it. They significantly delayed reimbursement for Keytruda and Opdivo.
Does France have an obesity epidemicdemic...not of the scale we do. Are office visits going g to bankrupt anyone..no. it is not fair nor a true comparison.
France restricts access to innovative medicines that are more effective and safer. All EU countries do. One of the reasons people purchase private insurance in France to get access to those drugs.
Im a physician, those innovative and newer drugs are often overhyped and under deliver. I don't see a problem with a system that weighs practicality.
People in Canada who have middle-class jobs generally have supplemental medical insurance. Ditto for many working-class people with unionized positions. In all, about 70% of Canadians have private supplemental health insurance.
Indeed. As a Canadian, our coverage is patchy, because it is administered by each province or territory. Basic hospital and medical care is covered everywhere, but drug coverage is all over the map, as are things like physiotherapy. Dental care is another issue, too, with coverage now available (through the efforts of the federal New Democratic Party) for Canadian residents with a family net income below $90,000, who don’t have a plan through work or another social program.
I don’t think Canadians would ever consider themselves socialists, much less communists. Capitalism is alive and well in Canada, but most Canadians would say our healthcare system needs to be better supported by the government, not less.
Do you live in Canada?
"while Medicare is immensely popular, with an 82 percent favorable rating in the most recent KFF survey. Medicaid, government health insurance for lower-income Americans, comes in at 73 percent. This is in sharp contrast to public views about private insurers, who are widely disliked if not hated and accused of denying essential care."
Yes. There is probably a connection between the hatred of private insurers and the fact that 51 of our American billionaires are healthcare executives. You can't make maximum profits if you approve all doctor-recommended medical procedures and medicines.
Who fund Super PACs.
En España tenemos seguro médico universal, es decir, para todo el mundo, trabaje o no, y cubre todas las prestaciones sanitarias y farmacéuticas.
Translated: "In Spain we have universal health insurance, meaning for everyone, whether they work or not, and it covers all healthcare and pharmaceutical services."
Yeah in France too. Not happening here for a long time. But remember Spain has 50 million people. The US has 350 million people. It might be worthwhile looking at Medicare for all state by state.
It was introduced in Canada one province at a time. The provinces still run the systems.
Same as New Zealand
Most importantly: never allow a private insurance system sidelining the basic government funded "universal" healthcare system to exist and cherry pick the most affluent and healthy people. Germany has basically the same kind of parasitic private insurance grift going and year-over-year the government system gets undermined more, while being also abused as a piggy bank for the private system by funding stuff that privately insured people basically get for free like hospital reforms and subsidies for hospitals & doctors in rural areas.
Oh not to forget: all those covered by unemployment insurance are bankrolled by the contributions of the ones paying into the government system.
So contributors to government healthcare are getting screwed over disproportionately funding the healthcare system and wellfare, while allowing rich affluent people to avoiding to contribute and private insurance to siphon off the people with the lowest risk profile.
I don’t disagree. But it may be a way to get the US to accept universal coverage, assuring the public that rich can still buy more and better. We seem to like it that way. 😖
I think you’ve nailed the problem there, Tracy. “We seem to like it that way”.
I come from the Republic of Ireland (the health service is funded by extortionately expensive insurance, not quite as bad as the US but sort of ‘half ways across the Atlantic’) and I have lived and worked (a hospital physician) in the UK for thirty nine years, where very few people could ever afford the price of the healthcare, with all its limitations, they currently receive. There’s nothing intrinsically wrong with a centrally funded health service… but it’s cost. We bicker over differences in provision systems, but it’s always expensive. I would nonetheless return to the core argument in Paul Krugman’s piece today, about the existing centrality and economic clout of the US Federal Government in provision of healthcare across all sectors of US society.
My own political interpretation that follows that is, ‘don’t let yourselves be misled by grandstanding political and media statements’. You (US Americans) already pay expensively for the majority of US healthcare coverage through taxation; follow the money, not the sloganeering, to improve the provision.
Regards,
Anthony
Oh, his point is both clear and true. People without health insurance get their care in emergency rooms, which must treat them by law, with bills they cannot and do not pay. So the American public picks up that bill, which means the government supports is actually even greater than PK is stating.
Still sounds better than the situation in the UK tbh.
I am Canadian, exactly what do you mean by my private insurance covers "newer and more expensive treatments"? My private insurance covers semi-private hospital rooms, dental$$, prescription drugs, ambulance, allied medical like psychotherapy. Regardless of having supplemental private insurance, if I get cancer, I get the same treatment, and do not get to jump the queue. True, when I got my free cataract surgery, at the top eye hospital by a top opthamologist, only the basic lens was covered, and not all the fancy tests required ($50 out of pocket). Oh, BTW my private insurance did not cover a lens upgrade. Canada is starting to add Pharmacare: free insulin and birth control, both of which make huge financial sense, and save tax payers $$$.
The co-pay for my cataract surgery was several hundred dollars, here in the States.
In Canada, government funded healthcare excludes dental and drugs (although government help for drugs does kick in after certain amount). Supplemental policies cover these exclusions.
Supplemental insurance in most of those countries is there to cover gaps in the coverage, such as drugs, optical, private rooms, dental services or alternate therapies like chiropractic that weren't part of the programs when they were formed decades ago. They generally aren't for access to newer or more expensive treatments.
When these programs were founded decades ago, like Medicare in the 1960s, most prescription drugs were a few dollars a month and not a cost burden on the public. Some of the universal coverage countries updated their plans, some did not.
What you’re saying is not completely true. Government insurance often does not cover newer, more effective and/or safer drugs. They delay coverage, often until the drug goes generic and is much cheaper. The supplemental plans will typically pay for those drugs. It’s one of the reasons people get those plans.
It's a selling point for the insurance in a few countries. The newer drugs are not necessarily more effective or safer, just more expensive, which is why they aren't covered in the basic drug formulary. Usually it doesn't become part of the formulary until the price is negotiated into a more reasonable range. In the US they wouldn't be part of the preferred coverage if the insurance company had an agreement with a different equivalent drug.
If all they covered were expensive drugs that weren't part of the regular drug formulary, then the price must be sky high as no one would buy it unless you were using one of those drugs.
With few exceptions, the new drugs are more effective and/or safer. Look at the statins. The PROVE-IT trial showed the newer statins prevented more CV events than the older. Tirzepatide produced significantly more weight loss than semaglutide. Pharma companies don’t do a lot of trials testing equivalence, they test superiority.
GLP-1 is the last drug I would use as an example. What we have is a frenzy of off-label prescriptions for a highly overpriced diabetes drug being used as a weight loss miracle where the benefit disappears after you stop taking it.
Pharma companies only care about sales and stock price, not safety. They have turned GLP-1 into a lifestyle drug, not one that serves its intended purpose.
You’re incorrect on all points. Not only do they significantly reduce CV events, tirzepatide also resolved NASH in 90% of patients, an incredible breakthrough. They reduce chronic kidney disease. They have been shown to reduce cancers and addictions and will soon have those additional indications.
Yes, some 60%+ patients will regain weight after stopping drug, and, though the majority do not regain it all. And… so what? 100% of type 1 diabetics will die of complications of diabetes if they stop taking insulin. Chronic diseases, like hypercholesterolemia, hypertension, diabetes are chronic diseases and require chronic medication. If it significantly reduces mortality, then it is worth it.
And you are woefully behind on pricing. The GLP-1 orals are now $50 per month in the US.
Here is a list of recent cancer drugs Canada does not cover. The list is longer, these are just some examples off the top of my head, and there are lots of new drugs for many diseases Canada does not cover. You can bet when they go off-patent that Canada will cover them. There are private plans that cover these drugs.
Talquetamab/Talvey: Relapsed/refractory multiple myeloma
Do not reimburse — final Feb. 27, 2025
Sotorasib/Lumakras: KRAS G12C-mutated NSCLC
Do not reimburse — final Feb. 29, 2024
Toripalimab/Loqtorzi: Recurrent/metastatic nasopharyngeal carcinoma
Do not reimburse — Feb. 2, 2026*
Nab-paclitaxel + gemcitabine: Previously treated advanced pancreatic cancer
Do not reimburse
Lurbinectedin/Zepzelca: Small-cell lung cancer
Do not reimburse
Tepotinib/Tepmetko: MET-altered advanced/metastatic NSCLC
Do not reimburse
Idecabtagene vicleucel/Abecma: Relapsed/refractory multiple myeloma
Do not reimburse
You're making stuff up. STOP IT!
I live in Canada. I know what happens here. YOU ARE MAKING STUFF UP!
Private supplemental insurance in Canada DOES NOT supply "newer and more expensive treatments". It provides extended periods of non-necessities, like therapeutic massage, which is limited to a half-dozen treatments a year under BC Health. (Other provinces may vary, particularly Alberta, which is headed toward a US model of insurance, and their health is already declining. for it.)
I can call my doctor in the morning and see him in the afternoon.
One time, I had excruciating tummy pain. My doctor had me checked in to the nearby hospital in under an hour. Within two hours, I had a bed and an IV, both for pain relief and to "encourage" a bowel movement.
Private supplemental insurance would not have changed that situation one bit.
My ex was diagnosed with ovarian cancer. She was "under the knife" in less than a month. Private supplemental insurance would not have changed that one bit.
For one thing, for-pay medical care IS ILLEGAL in most provinces! You simply CANNOT "cut the line" by paying more! You simply CANNOT get "newer and more expensive treatments" by paying more! This is CERTAINLY true in BC, which if you'd done any research at all, you would have discovered!
You've been listening to FOX News. STOP IT! YOU DON'T KNOW WHAT YOU'RE TALKING ABOUT!
Yes! As a UK resident, there is plenty of private health insurance, often used for elective surgery to get quicker treatment. But if you are very ill, or in a road accident, the NHS is the place to be. The doctors are far more experienced in emergency treatment or intensive care.
My knowledge of the US system is largely from the writings of Atul Gawande - he wrote excellent articles on the fraud of US Medicare from over treatment and scanning due to doctors owning an interest in a hospital. An obvious conflict of interest. In contrast he praised the Mayo clinic for having salaried doctors who were more careful about unnecessary procedures, and had better outcomes at lower cost.
The cost of everything in a hospital or surgery being billed and reclaimed on insurance is extraordinary - surely a prime driver of massively higher healthcare costs in the US as a percentage of GDP. The French live longer than Americans and spend far less of national income.
Far from being “Socialist” and ideological - the origins of the UK NHS are WWII. With almost the entire country involved in the war effort for 6 years, it seemed pointless wasting time and money on billing and bookkeeping. All doctors and hospitals were involved in treating soldiers or workers to the best of their ability. There was no labour to spare for accounting and red tape - the government just funded it all, it worked, people got healthier. After 1945 why go back to the old ways? Hence the NHS.
Canada here. never got health insurance. far's I know, it's for (shrug) private rooms and like that - newer and more expensive treatments? not aware of any such (except maybe in alberta)
Thank you Tracy!! I wish your post was on every billboard across America!!💔🇺🇸
Is this really true? https://en.wikipedia.org/wiki/Universal_health_care_by_country
Exactly. Even for government insurance in the US, there is supplemental private insurance.
Long ago, I interviewed a Republican candidate for governor who had a novel idea for dealing with healthcare: Completely eliminate ALL health insurance. No private insurance, no Medicare, no Medicaid. Just everyone on their own.
Doing this would force people to shop for healthcare, and that would drive down prices as people sought out the best care for the best price. Like shopping for a car or dishwasher. It would also stop people from "wasting" healthcare, which was what people were doing because the cost was hidden by insurance. Thus insurance made healthcare seem like it was free, and anytime people can get something for free, well, they're going to use it whether they need it or not!
I pointed out that, by law, colonoscopies are free. So how many colonoscopies had he gotten this year since they're free? "That's not what I mean," he said.
About shopping for healthcare, how does one shop for care when having a heart attack? "That's not what I mean," he said.
Okay, how would you shop for treatment if you have a glioblastoma if you don't even know what a glioblastoma is? "That's not what I mean," he said.
Turned out that the only scenario he'd actually thought about was someone going for a regular check-up or getting treatment for a minor injury like a sprained ankle. This is the quality of thought that goes into most every conservative proposal regarding health and healthcare. And now under Bobby Brainworm (RFK,Jr.), it's being carried to an extreme that will kill thousands in the decades to come.
People are going to the doctor because they have nothing better to do! Of course! Good to finally hear some common sense from well off folks who have never worried about such things.
That's a common one from the phony "prices are so high because people go to the doctor for every sniffle and overuse the system" crowd of consultants. The statement is total crap. Do you know anyone who wants to spend hours waiting in a doctors office. If they do, then they need a different type of doctor.
This is just another false excuse to keep the current failed system.
"Let the market handle it" is pure libertarian baloney. Who has more negotiation power with the medical industrial complex, you or a big insurance company?
This isn't about you and old Doc Smith down the street. Doc Smith is now owned by the local mega-hospital system which is designed to dominate the area providers and create pricing power to counter the insurance companies.
What they're afraid of is, that if everyone has access to medical care, they will have to wait longer to see a doctor. That is, they want to grab all of the available medical care for themselves.
Healthcare viewed as a zero-sum game. Every time I go to the doctor means someone else CAN'T go to the doctor.
It doesn't work that way.
There is such a thing as scarcity in medical care. It may not be EVERY TIME, but there are well known shortages of doctors. And this makes it so that some people have to wait (especially if they are on medicaid), and some people don't (if they have great insurance or are willing to pay more).
Are you sure you understand how markets and economics work? Just because in some cases markets aren't a 'zero sum game' doesn't mean that scarcity isn't a part of people's experience. Carolyn is right that if we had medicare for all (especially if doctors weren't able to favor private payers) it would even out who has to wait for care like medicaid people and people with crappy in-network care do. And she is right that people with money want to capture the better care for themselves - the rest of people be damned to the crumbs.
I do understand that scarcity is a problem. Where I live, we're having a serious crisis due to a lack of primary care physicians. This has turned into a chokepoint for every other specialty as folks with private insurance can't see a PC and thus can't get a referral to the specialist they need to see for some emergent condition.
But healthcare is not a zero-sum game. And turning the U.S. to a single-payer system would free up resources--both human and financial--to help alleviate many of the current shortages. (My primary care physician works 6 days a week, two of which are devoted entirely to paperwork to get private insurers to pay him for services rendered.)
I didn't say it was a zero sum game. But, scarcity still exists, and scarcity is all that is required for the wealthy to reasonably worry about longer wait times for themselves if access to health care is leveled.
It takes 10-15 years of university training and residency to become a specialist.
If the demand for specialists is based on just the size and age of the population 10-15 years from now, it is much easier for universities to forecast how many places they'll need and for students to calculate how much debt they're willing to take on.
If you include employer willingness to pay higher insurance premiums in the forecast, the calculation is more difficult. Higher risk means higher cost, and lower supply.
Scarcity is a problem because the system encourages certain specialties and the number of new interns are limited by federal law limiting the doctor numbers and Medicare funding for each teaching hospital.
The US is the biggest rationer of healthcare based on the ability to pay. About 30% of Americans are either uninsured or underinsured. A significant percentage of Americans have health insurance but don't have the money available to actually use it. Largely due to the big increases in deductibles and copays over the past 20 years.
I don't think you can really say this. What if the government didn't subsidize the training of new doctors at all? Would the number of interns be zero? NO. It would be lower than now because it would be solely (or more) driven by market forces alone. The fact that they subsidize it increases the 'cap' from the one that would exist if there were no subsidy to the one that results from subsidies. Thereby, the statement that 'scarcity exists because federal law caps the number of interns' is a twisting and dubious statement.
Hospitals can now pay the cost themselves if they wanted to. Scarcity exists because the supply of doctors doesn't meet the demand. The AMA uses that to keep salaries high. American doctors are the highest paid professionals in the world.
About 10,000 potential doctors can't get an internship due to lack of funding or space. Also, the US and Canada require two more years of college to become a doctor compared to most any other country, which doesn't have to be related to their future career.
If you think there is a doctor shortage now, universal care will make it even worse. At present, about one-third of Americans have inadequate insurance. Open those floodgates and the demand for medical services will skyrocket. Unfortunately, the medical industrial complex isn't doing much to fix the problem.
The irony is that our current system is already doing this. There is a shortage of medical professionals of all types. I am sure some are discouraged from ever even entering the profession while others have left out of frustration. People retire, practices merge/consolidate or close, owners demand they see X number of patients per day, etc. Everyone I know who has needed a new doctor, for whatever reason, has had to wait at least 3 months to get in with someone, and that is usually after spending a significant amount of time calling around to find someone who is both taking new patients and their insurance. (And hopefully you can stay with that person if your employer changes your insurance.)
A personal anecdote, I have a child who was diagnosed with scoliosis. Pediatrician noticed in July and ordered X-rays. Still July, referred us to the spine clinic at the local children’s hospital which couldn’t get us in until November. They prescribed a brace. Orthotics was booked through March, though I called every day and managed to get in in February. Brace came in April. We’re now on a regular cycle in the system, so it’s no longer an issue getting all of our regular appointments, but the “set up” took 9 months…with “good” insurance in a metropolitan area.
Is this an HMO? I found the HMOs to be over subscribed naturally because it’s the less expensive out of pocket option.
Nope. PPO. In fact, insurance has never been an issue. I have never once had to contact them nor have they ever contacted us regarding coverage, to deny or otherwise. We do not need any approvals or official referrals for anything. But neither has it offered us any sort of “advantage”. It was an anecdote responding to Carloyn’s comment, that some against socialized healthcare make it out like a zero sum game that will harm them. I was pointing out that it is already what they fear because of privatization - profit above all else. Availability of services and/or providers is a very real choke point in our current system. Now certainly people with lots of money may utilize boutique or truly private medical options, but for those of us in the regular system, it’s not that it will become too much demand for too few providers…it’s that it already is that because the push to maximize profit for private companies has broken our healthcare system (though it was never great to begin with).
What the donor class is afraid of is, the more people having more access to medical care, the less power the donor class has over them, full stop. How many, many times have you heard someone complain they can't quit their job because of the insurance?
a great blessing coming from universal is that health care is not tied to employment
Did your Republican candidate for governor also consider the stock market to be a socialist institution that he would take steps to abolish if elected?
A large part of US healthcare may be a PRIVATE market, but it is not FREE market due to the disparity in information between providers and consumers.
The stock market is a government regulated and enforced institution that manages the flow of investment information and payments. A single-payer healthcare system achieves lower costs by managing the flow of information and money... exactly whose money varies a lot from country to country; it is not always all taxpayer dollars.
My point: Even if ideological differences impede implementing the most efficient system, substantial improvements can be made without spending more tax dollars or abandoning market principles.
That candidate was an imbecile who promptly vanished beneath the waves after getting something like 2 votes in the primary. But his views, though waaaaay far out there at the time, are slowly bleeding from the fringes toward the mainstream of Rightwing thought.
For non-Rightwingers, it is important to know that the vast majority of conservatives have a child's understanding of how the world works. They're about on the level of a 6-year-old, though even that might be too generous. To them, much of the world runs on magic and wishes. OF COURSE tax cuts for the wealthy help everyone else. OF COURSE getting rid of regulations makes everything better. OF COURSE we need a rigorous hierarchy. No need to think about these things, nor examine any of our experiences with them over the last half a century.
Good points.
Insurance is meant to deal with risk and unexpected large expenses. If insurance does not work the other way to pool large groups is though government programs because they can spread risk costs over many people.
Some types of healthcare do not even fit the risk model, as you point out, regular checkups are not dealing with risk, it is simply regular maintenance.
I have often felt that these two things should be separated.
yes! "that's not what I meant"
Not to mention the benefits of mass pooling of premiums to fund expensive treatments that ordinary folks can't begin to afford. Most of us try pretty hard to avoid illnesses and injuries, so it's not like we're scheming how to take advantage of medical care. I sure don't know anyone whose favorite way to spend time is seeing the doctor.
And the Internet is full of useful medical knowledge, so our first instincts don't have to be to schedule an appointment to see if we should be concerned about that new thing we just noticed in the shower. When the websites of prestigious clinics have detailed descriptions and images of virtually anything you're curious about, it's straightforward to make some preliminary determinations about seeking further advice.
Yes, it's quite possible to jump to conclusions that the lump you just discovered is indeed that rare and deadly disease, and be quite wrong. Doctors spend a lot of time correcting their patients' erroneous online- research diagnoses, but it's been my experience that, more often, we're relieved to learn that what we're concerned about is benign and common, and what the likely treatment options might be, before we take up the doc's valuable time.
But I digress. Simply stated, pooling of premiums allows ordinary folks to get treatment they can't otherwise afford. That's important, and something critics like your simpleminded libertarian antagonist just don't want to understand.
What that candidate seemed to have missed is that most of the very expensive healthcare services are in an incredibly inelastic portion of the market.
It's why I'm always skeptical about the "price transparency" arguments pushed by that side. If you need an MRI right now, are you really going to go MRI shopping?
Since you seem to be pretty intuitive in your thinking, take a look at the proposal I've been formulating for a new US system.
It's long, but maybe give it a skim. I'm looking for as much rational criticism as I can get to see where my thinking is flawed.
https://commonwealthanalyst.substack.com/p/american-health-security
Excellent website that shows the distribution of health care costs per person, following a more-or-less Zipfian distribution, with most ppl costing very little, and a few costing a lot.
E.G., the top 1% account for 23% of spending, the top 5% for over half.
Great graphs!
https://nihcm.org/publications/the-concentration-of-u-s-health-care-spending
FWIW, primary care is not nearly so skewed, so capitation is safe at relatively low numbers, and Direct Primary Care practices are financially viable, and would be at lower monthly costs if more widely available. Adverse selection skews them to higher need ppl in general.
I don't understand why so many USians keep saying universal Healthcare can't work. While administrators keep getting rich, we pay premiums and co pays and get denied procedures that we need. We really do need to rally, people, against oligarchs and billionaires.
If you listened to Fox News right wing propaganda all the time you might be saying the same things. They spout on about how universal health care costs more (it costs far less) and rations care (not nearly as much as the US) and how people from foreign countries are traveling to the US to get their health care needs met (actually the opposite, more Americans go elsewhere). It is nothing more than one scare tactic after another.
Curious why people think health care tied to your job is a good idea. It is widely variable in cost and coverage and ties you to an employer when you may have better ideas of what to do with your life.
Asking as a retired Canadian physician who had a hundred thousand chats with patients about their preferred course of action.
Employer-sponsored insurance sucks. It’s a terrible idea whose time should be over. Speaking as a blue state American voter (and admirer of Canada 🇨🇦) who has despised this arrangement for years.
The history is that it came about as a pay supplement during WW2 when there were wage controls on employees.
When Truman brought up universal health coverage after the war, the unions were against it. Their reasoning was that soon everyone would be in a union and have health care coverage through the union or their employer.
Employer sponsored health care plans in the US are generally not insured. An employer of any size usually self-funds the benefits from the employer cash. This way they are not subject to the state insurance laws and coverage requirements, just the minimal federal laws. Even though the plan might be administered by a large insurance company on behalf of the company it is not guaranteed by the insurance company, They are more expensive to administer because practically no two plans are the same.
If you are covered by a self-funded health plan and the company goes bankrupt, your health insurance disappears and you might be on the hook for any amounts they haven't paid to your providers.
Employment related healthcare is a good idea for insurance companies: They collect premiums to cover to people healthy enough to have a job, and discontinue coverage when people become too unhealthy to work.
I'm not being sarcastic: Google details on the 1929 founding of Blue Cross by charging Dallas teachers $0.50 per month. The business case really did include collecting premiums from employed people while avoiding payouts to people to sick to stay employed.
It's terrible.
It creates job-lock, manifests a bunch of economic externalities in the labor market, and is just a bad way of delivering healthcare to the US population.
Consider this. You have two firms in the same industry, hiring from the same labor pool.
One is a large firm, that has some leverage to get new workers because they can offer better healthcare benefits, since they have access to a group plan for all their workers.
Second is a small firm, who has no access to a group plan because their workforce is too small.
The small firm simply can't compete on the same compensation playing field.
It's why the best option for transition is capture current employer healthcare spending in a fixed payroll tax for a national insurance pool, and have a small employee payroll tax serve as their portion of the "premium".
That way, no particular job is in control of your healthcare, but they ARE paying for most of it.
I'm currently developing my own proposal for a US healthcare system. It may not be particularly relevant to you as a Canadian. But your position as a physician may give me good insights into where my proposal is flawed, or what aspects might be good ideas.
It's long, but take a look if you have the time.
https://commonwealthanalyst.substack.com/p/american-health-security
I will second Laura's comment. Before I get to the meat of my reply though, since you are not in the US, is to briefly note that a US employer and employee share the costs of health insurance. Typically the employer pays the bulk of the insurance premiums, but the employee does pay the remainder of the premium, plus additional co-pays when actual medical care is provided (ie. Dr's visits).
My first thought to help pay for this "medicare for all" (MFA) approach is to take the money paid by the employee and employer and commit it all to the additional taxes necessary to fund this type of operation. In this fashion, the costs to the employer would mostly remain constant, as well as the employee. Would this be enough to fund MFA? Probably not, but it would seem the least disruptive to most people and would results in smaller tax increases.
Also, I think the birth of the employer funded health care was cirica the 20's, where it was used as a perk to try and recruit talent. Like anything, once established, it is difficult to change one there is momentum.
So I did a very preliminary calculation (and my numbers ended up in line with calculations done by the CBO), and a 17% total combined payroll tax would probably be enough to cover a universal healthcare system (whether M4A or another universal system). This assumes current Medicare taxes are absorbed into it (not in addition to them), and it also assumes current general fund allocation toward healthcare spending remains.
A 12%/5% Employer/employee split would capture the current average employer/employee premium spending. So payroll would stay roughly the same, and wages would likewise stay roughly the same.
If your employer offers above average benefits, switching to this payroll system to fund healthcare would likely save them money, and put upward pressure on wages in those jobs.
I'm currently developing my own proposal for a US healthcare system. I'm soliciting good insights into where my proposal is flawed, or what aspects might be good ideas.
It's long, but take a look if you have the time.
https://commonwealthanalyst.substack.com/p/american-health-security
Employer-sponsored health insurance in the US really breaks down at times when you lose a job. In that case you can switch to the Marketplace or keep your insurance at your own expense. Either way, it’s a significant new expense at the same time you lose your paycheck.
The rich want it this way and the politicians do what they tell them. It keeps the poor and middle class desperate and in line. There is no defensible argument for why our healthcare system is still like this. Same goes for everything else wrong with the country. It's just greed and corruption every time.
Any politician championing private health insurers is politically tone-deaf to the general hatred people have toward private health insurers. When United Healthcare's CEO was gunned down, there was an outpouring of sympathy toward the shooter. Why? Because the CEO had made his name and fortune by denying care and killing men, women, and children for profit.
The United States is one of the only countries on Earth that just can't seem to figure out how to deal with healthcare. We shovel more money at healthcare than any other country, and the results we're achieving are steadily worsening as overall health AND life expectancy fall behind the rest of the world.
Perhaps the reason our health care dollars in this country are directed to the high profit industries such as the pharmaceuticals and invasive procedures while those looking towards functional medicines or wholistic treatments are dismissed and are forced to totally pay out of pocket, in spite of being less costly compared to invasive procedures. Our current industrial medical complex supports invasive treatments over less invasive procedures because it is profitable and not necessarily effective. Therefore profit is the driver in our current climate.
Derelict, most USians are paid "slave wages:" just enough for food, shelter and clothing. With no pay raise and increasing inflation, they are suffering. This causes both mental and physical anguish, both of which contribute to poor health outcomes. Dental care is unaffordable for many, causing tooth loss. Poor dentition leads to poor nutrition. Poor nutrition leads to disease, disability and premature mortality.
Prof. Krugman you are superannuated, as am I. Have you done a comparison of your prescription costs to identical medicines in Portugal? If so, did your hypertension go up? I recently did this exercise vis a vis Spain. My hypertension certainly went up. Identical medications cost less than a third in the EU. "But the medical *system* is worse there," I hear say some folks say. Highest life expectancy of any city in Europe? Madrid. Higher than NY, too.
As an Afghan ally who was left behind after serving alongside the U.S. military, I understand very well what it means when a system does not work fairly for everyone. I appreciate your point that healthcare in America is already strongly supported and regulated by the Obama and Biden administrations. The important thing for me is that every American, regardless of their income or background, should have access to good healthcare. I also hope that America will remember its Afghan allies who served beside its soldiers and keep the promises that were made to us. Thank you for continuing to speak about fairness and justice.
Dr Krugman, have you also considered the government’s expenses for healthcare for our military and families and government employees and retirees?
I have several military-retiree relatives, and they love their government-funded Tri-Care and consider it better than standard Medicare.
"TRICARE and Medicare are not competing choices for most people because they work together through TRICARE for Life rather than opposing each other. Once you turn 65 and are retired military, you generally need both: Medicare acts as your primary insurance, and TRICARE acts as a zero-fee secondary "wraparound" supplement that covers leftover costs."
This is similar to what I tell people in online debates who don’t want to lose their employer coverage — MFA can be the basic standard, and employers who want to do so can offer coverage for additional things that Medicare doesn’t cover.
Private insurance in the US is done through four companies that are so big, they are four of the top 20 companies on the stock exchange-United Health, Elevance, CVS Health, and Cigna. They are for profit and payout billions in stock buybacks. There is no analogue in any other high income country. They are so big they control not just insurance but medical providers and pharmacies. Their innovation consists of things that are uniquely American, like $7,000 deductibles that makes accessing healthcare impossible (e.g. Bronze Plans). No other country has hundreds of thousands of bankruptcies each year from medical debt. No other country has a system where you have no idea what your bill is going to be. No other country has a system where your family loses your healthcare when you lose your job (though you can keep it with COBRA if you can manage $2,800 per month with no paycheck). These 4 companies have been created through corruption. Without control of the political system through money, this world would not exist.
Add the private insurers who manage Workers Compensation, and you get the property and casualty corporations
You forgot the barrier and racism being set up and launched at El-Sayed by establishment Democrats. WTF is wrong with everyone? He is a genius and a Rhodes Scholar. Who cares what his religion or skin color is. He is intelligent and will bring new and thoughtful ideas to Congress. I am a registered Independent. In my view, he is a far better choice than the trifecta of uneducated and moronic holy rollers we’ve had on the right: Lauren Boebert, Tommy Tuberville, and MarkWayne Mullins. Their combined IQ is about 70. We need change. He may be it.
70 is generous
It's worth remembering in the debate over "socialized" medicine that Donald Trump has the finest socialized medical care in the world and I have yet to hear him complain about it.
Small quibble:
" Roughly speaking, employment-based health plans can’t discriminate based on medical history — that is, they can’t deny coverage to employees with pre-existing conditions "
But insurance companies and can do price their offerings to a specific company based on the health of their employees. I worked for a small company where we had a couple of cases of cancer (completely unrelated to work) and our premiums skyrocketed. This is a huge cause of age discrimination, too. It really doesn't make sense to define a risk pool as the employees of a single company.
And I have seen companies get rid of people who are driving up health insurance costs. Very quietly, of course...like it was the person's idea.
I’m sick and tired of paying for insurance company parasites. United Healthcare leads the way with its upcoming of Medicare Advantage. AARP has long taken almost $1 billion per year from UnitedHealthcare in return for the exclusive right to sell UnitedHealthcare to its members.
Even the AARP’s top health policy staffer admitted to me that she would never buy UnitedHealthcare Healthcare’s Medicare Advantage Plan because it would deny her choice of hospitals and doctors as well as rip off American taxpayers, herself included.
Let’s finally stop being conned by Republicans and health insurance companies!
My younger brother asked me if he should get an AARP membership (my mother loved the organization). I advised him against it. I could never make any sense of the United Healthcare policies (one from column A & two from column B?), so I'm with Aetna and David is with Blue Cross.
It's interesting to know why we have employer paid health care anyway. During WWII, there were wage freezes in effect. To help attract workers, companies offered health insurance in lieu of raises when they couldn't raise wages. It's an historical artifact.
Thanks for mentioning that. I was trying to remember that historical issue.
I have a chronic pain condition so I access healthcare a lot. It has been once fight after another to get to my current treatment plan. I spent years of additional suffering to jump through their hoops and I’m a very persistent and knowledgeable patient. It’s obscene what they do to people. Time to take it down.
Consider what happens to American who loose the insurance fight, but still have the chronic pain: Taking pain killing medication without medical supervision leads to addiction. Addiction in the US is at least three (3) times higher than in Canada and Mexico. So it does happen. In other words, if the US fixed its healthcare system, the illegal drug trade would fall by 66%.
This is a persistent but false theory about opioid addiction, reinforced by profitable court judgements against companies marketing pain medications, saying they caused the opioid epidemic.
Simply not true.
There are two populations, with only a little overlap:
Ppl w chronic pain who use opioids to control symptoms
Ppl with severe mental health problems who use opioids to control symptoms.
https://www.sciencedirect.com/science/article/pii/S0376871616300011
"•Initial source of drugs is largely irrelevant in progression of opioid abuse.
•Self-treatment of psychiatric issues motivates initial and sustained opioid abuse."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741109/
" opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use."
Of course there are articles repeating the same fallacy.
Thank you for the additional documentation. I do tend to forget that mental health matters. Your reminder helps.
Even if the supervised use of opioids causes some addiction (which you have identified as a fallacy), that would not explain why US opioid addiction is at least 400% higher than in Canada and Mexico as both Canada and Mexico deal with the same pharmaceutical companies and draw their medical training from the same sources.
Americans who cannot afford to pay for medical care, self medicate. Good to know that the NIH acknowledges this is a problem.
Less acknowledged inside the US is the fact that so many Americans self-medicating drives more than half the illegal drug trade throughout the Americas.
The problem is not (only) the health care system- we need to ask-
"Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations—Insights From Neuroscience and Anthropology"
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2788767#
"The US National Academy of Sciences reports rising mortality for US adults, most steeply for White adults with a secondary education or less. The rise is largely attributable to deaths of despair (suicide and poisoning by alcohol and drugs) with strong contributions from the cardiovascular effects of rising obesity."
A wonderful article with graphics illuminating Case & Deaton's data.
http://tinyurl.com/NYT2020DeathsOfDespair
Case & Deaton's groundbreaking article:
https://www.pnas.org/doi/10.1073/pnas.1518393112
& book https://press.princeton.edu/books/hardcover/9780691190785/deaths-of-despair-and-the-future-of-capitalism
It's not a giant leap to think that the massive transfer of wealth from the 90% to the top 1% has something to do with this, and also why voters reject incumbent presidents.
https://www.commondreams.org/news/white-paper-sanders-rand-tax
and if you simply must put up with the pain, it's hard to sleep and your blood pressure goes up.
I wish it were possible to count the number of people who will stop at that table comparing private insurance to Medicare and just dismiss everything else by saying since the latter costs more per person it is proof of waste/fraud/abuse. That kind of factoid based pseudo analysis is a key driver of why we can't have meaningful discussions about issues like this. The rest of the argument, which is clearly laid out as well, doesn't matter to people once they have a single data point they can use to justify their entrenched positions.
A second note: I'd love to see an analysis of cost based on inflation at the point of service because of the insurance system. I once had a minor procedure at regular doctor's visit. Less than five minutes. Required a bandaid. Insurance covered everything but I got a copy of the itemized charges and the bandaid - one, singular, not a supply, exactly like the many I had at home - was $50. Figuring out how this happens is beyond my abilities but I'd sure love someone to explain it so we can then think about policy to stop it. Because that is waste, fraud, and abuse.
So would I.
Simply have to take the pricing out of their hands.
as a Canadian visiting US, my daughter went to hosp for prescription - doc took 5 min. we thought the $300 payment was a bit much but owell. got home and a follow-up bill of 3K arrived in mail. I will say this about private insurance - our travel insurance covered it all, no questions