The standard case for a single-payer health insurance system is pretty well known. Anyone can get care without courting financial ruin. Monumental personal decisions, like when to have a child or whether to leave or take a job, no longer hinge on the whims of an employer or the dysfunctions of the private insurance market. Surprise hospital bills, endless phone calls with insurance companies, juggling premiums, copays, and deductibles — all will be things of the past.
The case against single-payer often boils down to a single word: rationing. When critics peddle scare stories about Canadian or British “waiting lists,” they’re trying to conjure images of scarcity and austerity — the social-democratic equivalent of Soviet bread lines.
The truth, of course, is that you only have to look around to see that health care in America is already rationed. Try finding an in-demand specialist willing to take your “bronze-tier” insurance plan, or paying for high-priced specialty prescriptions out of pocket. Health care rationing is a fact of life in this country.
But there’s another important point to be made about single-payer and “rationing”: in many places around the world, national health insurance not only isn’t austere — it’s downright luxurious.
A Card up Their Sleeve
Americans, with our predatory health care system, can be easy to impress. The simple fact that the French can visit any health facility in the entire country, for example, seems astonishing. No provider is out of network, because there’s no such thing as a network. Instead, there’s a universal public insurance system that can’t turn applicants down, can’t terminate insurance, and almost never denies claims.
In France there’s no such thing as a deductible: insurance kicks in from the first euro billed. Since there’s no need to hire people to rifle through reams of paperwork and make judgment calls about denying claims and refusing coverage — and because the system has no stockholders to pay dividends to — the French insurance system spends next to nothing on paperwork.
Prices for treatments are fixed, and cost the patient next to nothing. For Americans accustomed to the need to change doctors every time they change plans, change plans every time they change jobs, and navigate things like claims denials, unpredictable charges, and endless paperwork, it seems extravagant.
But the conveniences don’t stop there. Since French providers aren’t carved up into networks, the government is able to issue what’s called a carte vitale, or “life card,” to all legal residents over the age of 15. With the patient’s permission, the card contains centralized information on the patient’s every medical visit, treatment, prescription, surgery and so on, going back to 1998. (Children’s records are stored on a parent’s card).
The physician inserts the carte vitale into a card-reader and the patient’s medical records pop up on a screen. Not only does it help doctors offer informed care, but it makes billing simple and eliminates much of the nightmare of transferring medical records. The physician logs the treatments, hits a button, and then waits roughly three days to be paid.
When doctors go on house calls, they take a portable card-reader with them. That’s right — in France they make house calls. Patients can request one anytime by calling a round-the-clock national hotline. The visit costs just thirty-one euros.
Cradle to Grave
The bare-bones austerity of American health care becomes truly glaring when we look at maternal, infant, and elderly care.
In Holland, anyone who gives birth to a baby is entitled to a kraamverzorgster, or in-home postnatal nurse, covered by the country’s basic government-funded health insurance. The kraamverzorgster watches over the health of the newborn and mother, provides medical advice, and helps out with bathing, diaper changes, and even laundry. The care workers employed in the nation’s kraamzorg system work an average of forty-nine hours over eight days per family. The program is universal and not income-dependent — a woman who works as a kraamverzorgster is entitled to a kraamverzorgster of her own.
France’s national health program has something similar, with nurses assigned to new mothers at home for the first week. It also includes access to a network of neighborhood clinics where new mothers can bring their infants at any time, even without an appointment. The clinics offer universal provision of postnatal physical therapies, including la rééducation périnéale, which helps mothers retrain the muscles of their pelvic floor. Lightly ridiculed in the American press as a symbol of French profligacy, the therapy actually decreases the incidence of urinary incontinence and improves women’s sex lives, while also making it safer and less painful to have more children should they choose to do so.
In Norway, where the system comes closer to what we might call true socialized medicine — where both the insurance and the provider systems are publicly run — new parents receive home visits from midwives on top of a generous allowance furnished by the state, which can be used however the parents see fit. The Norwegian government accomplishes this while spending significantly less per capita on health care than the United States.
In T. R. Reid’s The Healing of America, the American author asks a British friend to tally how much she spent having her baby in England. “Twelve quid,” she answers: two for a copy of the sonogram photo, ten for the taxi on delivery day. In the US, by contrast, women with insurance can expect to pay $3,400, and without insurance, the sky’s the limit. With childbirth so expensive, maternal hospital stays have gotten shorter: new mothers are sent home within a couple of days and typically have an ob-gyn checkup about six weeks after birth. Partly as a result, the US has the highest maternal death rate in the rich world — almost three times that of the UK.
Will You Still Feed Me?
Long-term care is another area where universal health care systems deliver the goods. Eight million Americans require long-term care services, most of them elderly. As many as two-thirds can’t afford to buy long-term care insurance, and Medicare doesn’t cover extended stays in nursing homes. Without coverage, the price of assisted living is comparable to private college tuition. As a result, many middle-class Americans’ best hope of affording long-term care is becoming eligible for Medicaid, which requires selling off assets and then draining nearly all personal savings to meet means-tested criteria.
The Scandinavian countries cover all long-term care through the state, both in-home and in residential facilities. Denmark, Germany, Holland, and Norway all offer generous state benefits and compensation to people who take time out of the labor force to care for loved ones. The Czech Republic and Poland offer state-funded allowances to elderly people in need of long-term care, similar to the Nordic child benefit model.
Japan, meanwhile, has implemented a universal, publicly funded insurance system specifically for long-term care, covering not just residential stays but also drop-in community centers for the elderly. It also pays for caregivers to help with minor chores, long before an elderly person becomes incapacitated — the point being to keep seniors in their homes and communities for as long as possible. When they do end up in assisted living facilities, they can benefit from the Japanese government’s heavy investments in developing robots to assist with residential elder care, spanning from interactive stuffed animals to machines that can transfer a patient from bed to wheelchair.
Japan implemented its long-term care insurance system when policymakers realized that changing family structures and rapid aging meant that relying on informal care would inevitably lead to a crisis like the one currently facing the United States. They made the choice to socialize care to avoid the dystopian scenario of millions of neglected, impoverished elderly moldering in underfunded institutions — precisely the scenario that American conservatives equate with public care systems.
In a study of long-term care insurance recipients, one regular at a Japanese senior community center said, “Since I’m injured and can’t move as well, I used to just lay there, stare at the ceiling and listen to the radio, and feel the changing of the seasons. Then someone from the Hana House recommended to me if I would like to go to the day services.” He described becoming active in crafting workshops at the center, which he claims increased his mobility. “Because of this place I’ve become a lot healthier.”
“First and foremost,” said another survey respondent, “I feel a sense of safety.”
Whose Death Spiral?
“Politicians pushing a single-payer system will promise a utopia”; but if they get their way, Americans will see the “shambles that will remain of our healthcare system once the death spiral concludes its destructive path,” warns The Federalist, a right-wing publication.
And yet the US, with the most capitalist, market-driven health care system of any developed nation, can’t boast of France’s postnatal vaginal rehabilitation therapy, Japan’s state-of-the-art elderly care robots, or Germany’s government-subsidized spa vacations for a ten euro copay. And with our raging opioid crisis, shocking infant and maternal mortality rates, and incidences of death from treatable illness, the private insurance-based system is already caught in a death spiral.
Luxury socialism isn’t just a meme — it’s a working theory that holds that social care, among other things, isn’t a zero-sum game. Marx and Engels saw that a society divided by class and driven by the profit imperative produces an abundance of resources alongside an abundance of unmet needs. Socialism, if it’s about anything, is about matching our resources to our needs, to improve our collective quality of life. Socialized health insurance — and the comforts it provides — would be a pretty good start.