Socialized medicine

Socialized medicine is any health care system that embodies the fundamental principle of socialism, namely reduced individual liberty in favor of increased centralized control. In practice, socialized medicine is a health care system that is primarily financed and administered by the government. Definitions vary on the nature of the centralized control, with some stating that heavy government regulation constitutes socialized medicine, while others require outright government ownership of health care facilities and employment of health care professionals. The narrow definition permits a clear distinction from single payer health insurance systems where the government finances health care but is not involved in care delivery.

An example of socialized medicine is the network of British National Health Service hospital trusts, where the government employs health care workers directly. Similar systems operate in other countries such as Finland, Spain and Cuba. The United States' Veterans Health Administration, and the U.S. Army, Navy, and Air Force medical departments also fall under this definition but are not usually publicly associated with the term. The U.S. Medicare and Medicaid programs, Canada's Medicare system, the UK's NHS general practitioner and dental services are systems where health care is delivered by private business with partial or total government funding according to the broader definition.

The term was coined in the U.S. as a pejorative by word association with socialism and continues to be used to evoke negative sentiment towards public control of the health care system in that country. Around the world, most industrialized countries, and many developing countries, operate some form of publicly-funded health care with universal coverage as the goal. According to some sources, the United States is the only wealthy, industrialized nation that does not provide universal health care.

History

The first system of socialized medicine based on compulsory insurance with state subsidy was created by Otto von Bismarck after the Franco-Prussian War of 1870. Socialized health care was implemented by the Soviet Union in the 1920s. New Zealand was the first country with a mixed economy to provide the direct provision of health care by the state when, in 1939, it provided mental health services free of cost to the recipient following the passing of the Social Security Act of 1938. After World War II in the 1940s the United Kingdom established its National Health Service which was built from the outset as a comprehensive service. A socialized model was used in China in from the 1950s to the 1970s during the first two decades of communist rule. Cuba adopted socialized medicine in the 1960s under the leadership of Fidel Castro. Also in the 1960s, the United States initiated its Medicaid program to help poor mothers and their children.

At the meeting of the World Health Organization in Alma Ata, Kazakhstan in 1978, a global covenant was signed proclaiming that the provision of medical services must be the responsibility of national governments.

Terminology

Origin

The term began as a pejorative phrase adopted in 1920s and 1930s United States politics by conservative opponents of publicly operated health care with a hostility to programs similar in nature to socialism and communism. Publicly operated health care was first proposed by U.S. President Theodore Roosevelt. President Franklin D. Roosevelt later championed it, as well as did many others, but it was ardently opposed by the American Medical Association (which distributed posters to doctors with slogans such as "Socialized medicine ... will undermine the democratic form of government."

Current usage

Hostility to socialism remains a common basis of objection to universal health care by those generally opposed to expansion of government, social services and other redistributory policies. According to others, the the term is just a scare tactic. in popular movies such Sicko, in which Michael Moore points out that Americans do not refer to their fire departments, police or public library services as socialized, and by popular media personalities such as Oprah Winfrey.

Some health care professionals prefer to avoid the term because of its pejorative nature, but if they do use it, they will use it according to the strict definition . Opponents of state involvement in health care tend to use the looser definition.

The term is sometimes used in the U.S. to describe health care systems that have large amounts of public financing. As such, the term is often applied to other single-payer health insurance systems, such as national health insurance where the government contracts with private medical practices to provide the service under rules and regulations for payment. Examples include Medicare systems in Canada, Australia and the US, Germany's health care system, and Britain's NHS general practitioner service.

The term is widely used by the American media and pressure groups. Some have even stretched use of the term to cover any regulation of health care whether publicly financed or not. The term is often used to criticize socialized health care outside the U.S., but rarely to describe socialized health care programs in the U.S. such as the Veterans Administration clinics and hospitals, military health care, nor the single payer programs such as Medicaid and Medicare. The term is sometimes used to evoke negative sentiment towards public control of the health care system in that country.

Medical staff, academics and most professionals in the field and international bodies such as the WHO tend to avoid use of the term. Outside the U.S., the terms most commonly used are universal health care or public health care.

According to the health economist Uwe Reinhardt, "strictly speaking, the term 'socialized medicine' should be reserved for health systems in which the government operates the production of health care and provides its financing".

Still others say the term has no meaning at all.

Examples of socialized medicine

Cuba

Main article: Healthcare in Cuba

Finland

Finland has a highly decentralized three level socialized system of health care and alongside these, a much smaller private health care system. Responsibility for health care is devolved to the municipalities (local government), Primary health care is obtained from district health centers employing general practitioners and nurses that provide most day-to-day medical services. The general practitioners are also gatekeepers to more the more specialized services in the secondary and tertiary care sectors. Secondary care is provided by the municipalities through district hospitals where more specialist care is available. Finland also has a network of five university teaching hospitals which makes up the tertiary level. These contain the most advanced medical facilities in the country and they are where Finnish doctors learn their profession. These are funded by the municipalities, but national government meets the cost of medical training. These hospitals are located in the major citites of Helsinki, Turku, Tampere, Kuopio, and Oulu.

There is a high level of co-operation between the various sectors which all have access to computerised patient data. Since the 1980s, the planning system for basic health care has been extended and now plans not just health care services but also care homes for the elderly and day care for children creating a fairly seamless cradle to grave system.

The separate private health care system is very small. Between 3 and 4 per cent of hospital in-patient care is provided by the private health care system and the remainder by the public or socialized system. Physiotherapy, dentistry and occupational health services are the main areas where the private sector is most used, although the municipalities by law also have to provide basic dental services. Employers are obliged by law to provide occupational health care services for their employees, as are educational establishments for their students as well as their staff. Only about 10 per cent of the income of private sector income comes from private insurance. Most is paid for out of pocket, but a significant share of the cost is reclaimable from the National Insurance system KELA. Spectacles, however, are not publicly subsidized.

A Patient’s Injury Law gives patients the right to compensation for unforeseeable injury that occurred as a result of treatment or diagnosis. Health care personnel need not be shown to be legally responsible for the injury thus avoiding the development of a litigious blame culture and the development of defensive medicical practices. To receive compensation, it is sufficient that unforeseeable injury as defined by law occurred. A law on patients’ status and rights, the first such law in Europe, ensures a patient’s right to information, to informed consent to treatment, the right to see any relevant medical documents,and the right to autonomy.

Finland's health care services are more highly socialized than the European average. The quality of service in Finnish health care is considered to be good and according to a survey published by the European Commission in 2000, Finland has the highest number of people satisfied with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%. Finnish health care expeditures are below the European average.

Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical care costs and the remaining one third by the national insurance system (nationally funded) and patients themselves by direct charges and fees for service. Direct fees to residents meet about 10 percent of the cost of social welfare and health medical care in Finland. There are caps on total medical expenses that are met out of pocket for drugs and hospital treatments. All necessary costs over these caps are paid for by the National Insurance system.

Main source: Finland report on Health Care Systems in Transition (WHO)

Israel

Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who must register with one of the four sick funds, known as Kupat Holim. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.

United Kingdom

See Healthcare in the United Kingdom for a description of the services from the user perpective.

The National Health Service or NHS is the world's largest socialized health care system. It was set up on July 5 1948 to "provide healthcare for all citizens, based on need, not the ability to pay." It is funded by the taxpayer and managed by a government department, the Department of Health, which sets overall policy on health issues. There are four separate health services for each of the three constituent nations (England, Scotland, and Wales) and one for Northern Ireland. In practice, they work closely together and provide a seamless service based on the same core principles.

"The NHS is committed to providing quality care that meets the needs of everyone, is free at the point of need, and is based on a patient's clinical need, not their ability to pay." (Source: NHS website)

The core of the service are the General Practitioners (GPs or family doctors) who are responsible for the care of patients registered with them. GPs are private doctors that choose to contract with the NHS to provide services to patients paid for by the government and not the patient. They are paid a capitation fee and certain other payments according to work they do and their performance. Patients are free to register with any GP of their choice in their locality. GPs can prescribe medicines for collection at a local pharmacy. Patients of working age pay a fixed price (presently £6.65 or about US$13--except in Wales where prescriptions are free) for each drug prescribed regardless of the amount of drug prescribed or the cost to the pharmacy. The pharmacy invoices the cost of the drugs (less the fixed price patient contribution) to the NHS. GPs can refer their patients to a hospital for more specialized services and for surgery. GP referrals are needed to see any hospital specialist. Most patients choose to be treated in NHS run hospitals. The quality is comparable to private hospitals and the services obtained (medicines, surgeons and other care workers, and even meals) are free of charge to the patient, whereas private hospitals bill for these. Ambulance services, mental health, and ancillary services such as physical and occupational therapy, in-home and in-clinic nursing, and certain care for the sick elderly in nursing homes are met from the NHS budget. The cost to the taxpayer in 2007 is £104 billion or about £152 per person per month. Funding for the NHS was originally designed to be raised through National Insurance as part of wider plan for social insurance funding pensions and other social security benefits. The tax still exists today and is still theoretically hypothecated, but in practice there is no direct correlation with expenditures and no link at all between payment and entitlement to health care.

There is popular support for socialized medicine in the UK. In opinion polls carried out regularly, IPSOS-MORI asks people which of the following two statements best reflects their thinking about the NHS. "The NHS is crucial to British society and we must do everything to maintain it" (chosen by 78%) and "The NHS was a great project but we cannot maintain it in its current form" (chosen by 20%) . None of the main political parties or even the fringe parties propose adopting a different health care system. The UK's centre-right Conservative party says its policies are aimed at "Protecting and improving our health service by putting patients back at the heart of the NHS, and trusting the professionals to ensure that they are able to use their skills to make the fullest possible contribution to patient care.". Even the ultra-right-wing British National Party says that "socialised medicine is not just a hallmark of a decent society, but economically rational as well. If one leaves behind capitalist-romantic theories about private-sector efficiency and looks at real-world privatised medicine, which may be observed in America, it is an obvious disaster. It is vastly more expensive and delivers mediocre results outside of luxury care. Britain spends about ⅓ the money per person and has public health statistics roughly equivalent to America, except for the fact that the bottom ¼ of Britain's population is vastly healthier."

A member of Margaret Thatcher's government, Nigel Lawson, described the NHS in his memoirs as "the closest thing the English have to a religion." The Thatcher administration made only minor changes to the system, and although many state industries were privatized, the state health sector was not one of them.

The Health Care Commission undertakes regular surveys of patients' opinions of the NHS. In its most recent survey (2006), experience of hospitals in England was rated by those who responded to the surveys as follows: “excellent” (41%), “very good (36%)”, “good”(15%), “fair” (6%) and “poor” (2%).

United States

The Veterans Health Administration, Medicare, Medicaid, the military health care system, and the Indian Health Service are examples of socialized medicine in the USA, although for limited populations.

Support

The benefits of socialized medicine (according to the narrow definition) include the following.

• Avoids over-production that can occur in free market health care

In most free-market situations, the consumer of health care is entirely in the hands of a third party who has a direct personal interest in persuading the consumer to spend money on health care in his or her practice. The consumer is not able to make value judgements about the services judged to be necessary because he or she may not have sufficient expertise to do so. This, it is claimed, leads to a tendancy to over produce. In socialized medicine, hospitals are not run for profit and doctors work directly for the community and are assured of their salary. They have no direct financial interest in whether the patient is treated or not, so there is no incentive to over provide. When insurance interests are involved this furthers the disconnect between consumption and utility and the ability to make value judements. Others argue that the reason for over production is less cynically driven but that the end result is much the same.

• No for-profit insurance companies are involved. This removes the incentive to deny or restrict care

A criticism leveled at insurance based systems, especially when insurance is done for profit, is that insurance companies make more money when they deny or restrict the care they to their policyholders. Socialized medicine is essentially insured by the community and so there is no profit motive present. If the socialized system under provides, the community applies political pressure to get additional provisions. In demoncracies, the normal political process achieves this.

• The system is better geared to keep the nation healthy

It is usually cheaper and easier to deal with disease in the early stages than to deal with it once it has advanced too far. Britain's NHS, for example, rewards doctors through a Quality and Outcomes Framework to actively take steps that will improve the quality of health of the nation. Finland's nurses can grant discounted access to fitness facilities run by the municipalities (which also run the hospitals) for those patients for whom improved fitness will improve their health.

Supporters of socialized medicine would contend that there is a fundamental disconnect with the interests of patients in a free market with employer funded health insurance and private hospitals. For profit hospitals mostly make profits by treating the unhealthy. Investigating and treating illness is what generates profits. For profit insurance companies tend not to fund preventative care because this costs the company money but the savings are likely to be achieved by another insurer because of the tendency to switch insurers over time. Critics of socialized medicine would contend that the government has no reason to reduce the costs since it can always transfer them onto someone else by raising taxes.

• Making health care affordable to all raises national productivity and the reduces the level of human misery

• Centralized planning can maximize investment returns to reduce average costs when provider and payer are the same entity

For example, medical imaging technology, which has a high capital cost, is used most efficiently if there is a high throughput of patients. The average cost of an exam will be lower at higher throughput rates as high fixed capital costs are recouped across a high number of patients. A centrally planned health care system can guarantee a high throughput rate at a Magnetic Imaging Resolution (MRI) unit because it has an almost perfect knowledge of demand and supply conditions it can acquire new units and/or retire old units to meet anticpated demand in order to ensure a high rate of use.

For example the UK's NHS has increased MRI throughput rates over the past 10 years and are now handling about 4000 exams per unit per year, an increase of about 26% since 2001. There is evidence of oversupply in the US. For example, in the US, between the years 1985 and 2000 investors had installed MRI units at a much faster rate than the demand for scans such that average throughput rates actually fell, from 3,143 per year to an estimated 2,361 per year. Based on US data at 2001 prices, the average cost of a scan of unit running at 2,000 scans per year was 440 dollars per scan compared to 281 dollars per scan at a rate of 4,000 exams per year.

• Countries where health care is provided mostly by government tend to spend less on health care overall than similar countries with a more mixed health care system.

This may be due to a number of factors such as regulations, marketing, underwriting, profits, which are not present or present to a lesser extent in government delivered care. There may also be other centralizing efficiencies such as bulk purchasing, IT, payroll, lower spend on defensive medicine and fewer potentially expensive litigations for malpractice. Spending on administration in Finland is 2.1% of all health care costs, and in the UK the figure is 3.3%. The US spends 7.3% of all expenditures on administration.

• Socialized systems that provide universal health care give expression to a collectivist view that health care is a right for everyone and that there is also a moral duty on the well to care for the sick. Filmaker Michael Moore, promoting Sicko says it should be re-labelled as "Christianized medicine" because it is what Jesus would do.

Cynics have countered that if it was relabelled as such then the US could not introduce it because it would then violate the rule of separation between Church and State.

• Where there is a large common risk pool, such as where the state delivers health care to large national or regional populations (such as those in Britain, Spain and Finland for example) pre-existing conditions do not affect a person's access to medical services. The same is true of Canada's health care system.

In free market health care with multiple insurers, insurers employ actuaries and load premiums against insured persons with pre-existing conditions or limit the cost available. In practice this means that the healthiest and youngest people are offered low rates and are more likely to afford wide coverage. On the other hand, sicker, older people end to have to pay higher premiums, and may have their coverage restricted or denied, especially in areas related to pre-existing condtitions.

• In narrowly defined socialized systems, where the state delivers health care to the national population (such as those in Britain, Spain and Finland for example,) changing employer does not have health care consequences. The same is true of Canada's health care system.

People are free to change employer, move to a new location, without ever leaving the risk pool and in the knowledge that a pre-existing condition will not affect the ability to get treatment and will not affect their future medical expenses.

• In National Health Care schemes, coverage is usually well understood by the population as a whole because there is one scheme. The coverage rules are often mentioned in the press and are therefore become known to many people.

• Low cost to the patients which can lead to earlier detections.

In some countries with a socialized health service, the state assumes the major costs of medical treatment and medicines at the time of need. Patients may be required to pay a capped contribution before the state begins to assumes the remaining costs of their treatment. For example in Finland the cost of a hospital visit is €22 (€11 in a smaller clinic), and in the UK all hospital and GP services are free. There is evidence that the cost of even a basic consultation in the United States deters some people from seeking medical advice. This can have serious consequences if the condition is discovered late where early diagnosis could save later costs and discomfort in the long run or even save a life.

• Socialized systems have long term patient relationships and can make investments on the back of this assumption.

This happens because there is a long term relationship with the patient and the preservation of records has long term benefits. Investment in IT is one often cited example where health care providers in socialized systems have access to electronic records of patients tests online and where computer systems can check for example incompatible drug combinations and that drugs are administered to the right patient. Some for profit systems find this investment hard to justify because the provider-patient relationship is not guaranteed to last long enough to justify the investment. Patients in the US are more likely to report that doctors are unable to trace the results of test than patients in other countries and inappropriate drug administration is much less likely to happen in VA hospitals and clinics than happens in private sector care.

• Coverage is set in order to maximise the health benefit under the funding arrangements

The government sets the framework for determining how the health care system delivers treatments to patients. Health care professionals work within the framework to determine what treatments are offered and on what basis and to whom. Typically crieria are established to maximize the health benefit that is delivered within the allocated funding. For highly expensive interventions, measurements of quality adjusted life years QALY are sometimes taken to calculate the cost/benefit ratio of a particular interventions in particular circumstances to formulate simple rules of guidance for clinicians. Doctors make decisions about the care of individual patients within the guidance of these rules in much the same way as an insurance company applies rules evenly to health insurance policyholders.

Patients for whom certain treatments are determined to be not effective or cost effective in their circumstances may be denied public funding for those treatments but will usually be free to pay for them themselves from their own pocket.

Criticisms

Some criticisms of socialized medicine are

• Higher Taxes:

A country which adopts a totally tax funded socialized form of health care will have to increase the average tax rate by an amount equivalent to the cost of providing health care and administering the system. Offsetting this in whole or in part will be savings equivalent to the entire revenues of the health insurance industry, which will cease to exist all together, and all other direct medical fees paid to medical providers such as non-insured treatment, co-payments and deductibles, and prescription drug costs.

Some countries use a payroll tax in whole or in part to fund health care which may be levied on both employers and employees. Other countries (e.g. Switzerland) use a compulsory national insurance funding model with a flatter rate contribution system less related to income. Contributions for such programs can be considered as a form of taxation even if the funds do not pass through government hands.

• Waiting times: Critics often contend that socialized medicine is characterized by long waiting times for treatment.

For example, the National Health Service reports that the median admission wait time for elective inpatient treatment (non-urgent hospital treatment) in England at the end of August 2007, was just under 6 weeks, and 87.5 per cent of patients were admitted within 13 weeks. 0.04% of those waiting were waiting more than 26 weeks. The median wait time has reduced slowly over a 3 year period from about 10 weeks in 2004 to its present level of about 6 weeks. Similarly, the median wait time for a first GP referral to a specialist was just over 3 weeks. 92% of patients were seen within 13 weeks. According to some supporters of socialized medicine, more recent UK statistics on waiting can also be misleading and overstate true waiting times. This is because under the new 18 week maximum target, the clock starts ticking much sooner, when the patient has been referred to a specialist by the GP. It only stops when the medical procedure is completed or the patient has been fixed on some regime to cure or mitigate the problem. The waiting period thus includes all the times taken for the patient to attend the first appointment with the specialist, any tests called for by the specialist to determine precisely the root of the patient's problem and determining the best way to treat it. It may also include any intervening steps deemed necessary prior to treatment, such as recovery from some other illness or the losing of excessive weight. Some transient medical conditions are not at all easy to diagnose. Therefore the so-called wait time may contain certain absolutely necessary and unavoidable activities which most people would not regard as "wait time" at all.

Supporters of socialized medicine say there is also waiting in free market medicine because of normal scheduling or because the price mechanism can force some to wait. Those that cannot afford their treatment at the price level determined by the free market (or by a combination of the free market and state regulations that are common in most countries) because they cannot afford insurance premiums, are denied coverage by their insurer, or cannot afford to take out loans to cover their medical costs, or cannot obtain private charity, have to wait until they can afford their treatment. The numbers of people waiting in the free market is only known to hospitals and the insurance companies and is not recorded in governmental statistics. In socialized medicine, it is not the price mechanism but the relative need of the patient as determined by medical professionals (who may also be civil servants) that determines waiting times. In a socialized system, the numbers waiting are recorded in governmental statistics which informs the public debate about how much national funding should be provided for health care.

Surveys on waiting times for certain elective procedures suggest that whereas such respondents are intolerant of long waits, exceeding three to six months, they can be quite sanguine about short and moderate waits, depending on the severity of the symptoms.

Critics say the patient's "need" as defined by a doctor constitutes an arbitrary criterion for the distribution of health care .

• Health care rationing

Critics of socialized medicine argue that medical resources are rationed in socialized systems so that some people are either denied care or have to wait for it.

Supporters would argue that rationing also happens in free market health care with the market price determining on the demand side who can afford health care and who cannot, and on the supply how much care is available.

In a democracy, the people through the democratic process are free to determine how much of their money as taxpayers should be spent on health and what services are covered and which are excluded. They also determine how much should be paid by users at the time of consumption and how much is paid as a form of insurance by way of tax. Both the allocation of overall funding to health and the allocation between areas and within an area to individual patients can become a topic of ending political debate. Within the medical profession, professional bodies may established bodies (such as NICE in the UK) which examine the cost effectiveness of treatments and set 'rational' guidelines as to how allocations should be made.

If a person is "rationed out" of the public health care service (perhaps because the treatment is not considered effective or cost effective enough to warrant intervention) they will be able seek alternative treatment in the private sector. If they cannot afford private care, they may have to go without.

Some have argued that government regulations impose extra costs in free market health care that distort the price mechanism and make health care too expensive.

• Cancellations: Critics of socialized systems say that cancellations are a feature of the system.

As an incentive to reduce cancellations in UK NHS hospitals, regulations were introduced to force the NHS trust to perform a cancelled operation with the following 28 days or else give the patient the opportunity to have the surgery done at a private hospital of his own choice at the trust's own expense. As a result, the percentage of operations carried out on time has risen to almost 99%..

• Bureaucracy: Critics in the United States often claim that "socialized" or public medicine would introduce additional government control over the provision of health care and increase costs.

However, administrative costs in US private sector health care are in fact higher than those in the public sector health care system . One often-cited study by Harvard Medical School and the Canadian Institute for Health Information put the total administrative costs at 31 percent of U.S. health care spending.

Supporters of the free market medicine would contend that these costs arise out of the substantial level of government regulation that exists in the United States's health care sector. According to a Cato Institute study, this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.

• Choice: Critics sometimes argue that choice is restricted in socialized systems because individuals are not allowed a public sector alternative or are required to pay twice when one is available--once to subsidize the socialized system and a second time for their private care.

In some countries with socialized medicine, such as the UK, patients are offered a choice of general practitioner, all of whom are self-employed or work in private partnerships employing all practice nurses, doctors and clerical staff. In addition, some hospital services are sub-contracted to the private sector, so that patients can choose from a range of providers International comparisons of quality of care and health outcomes generally rank the UK above the U.S.

The degree to which waiting in a socialized system affects choice varies from country to country. In the UK for example, a person is free at any time to seek treatment faster in the parallel free market medical system, but they will have to pay the full cost of their private treatment on top of their contribution to the national health care service. In Finland, it is possible to get some funding from the Social Insurance System for private sector delivered care. In Canada the right to jump the queue in this fashion has been discouraged in some provincial legislation and outlawed in others..

• Capacity: Critics argue that central planning is inefficient and under investment leads to capacity shortages and that a lack of willingness to invest in expensive technology leads to shortages in areas such as MRI scanning. Some would argue that only the price mechanism in free market health care can allocate resources efficiently and that political pressure often leads to shortages in socialized systems.

Supporters of socialized medicine would contend that reports in the press and emanating from pressure groups are sometimes distorted and misleading.

• A right to health care

Opponents of socialized medicine contend that no one has a right to health care. [[1]] According to this view, the individual and not the government or doctors should get the choice to determine what amount of health care coverage, if any, is appropriate for his or her needs.

Supporters would argue that everybody has a right to health care and it is therefore logical for the government to set down minimum standards of care available to all and to determine how the cost burden should be shared.

• Subsidies are incentives for unhealthy behavior

Critics argue that subsidizing health care costs creates incentives for individuals to engage in unhealthy behaviors (smoking, overeating, engaging in unsafe sex) because individuals do not have to bear the costs of their own actions. As such, individuals who do take care of themselves are, in effect, paying for the carelessness of others.

Supporters would argue that the issue of health care costs is not a significant behavioral driver. If it were, then Europeans would be expected to be more overweight and have a worse HIV rate than Americans. But this is simply not the case .

2008 U.S. Presidential election

The issue of health care in the 2008 U.S. presidential election has caused a resurgence in use of the term by Republicans. "Say something too kind about single-payer and there's a Republican around the corner ready to brand you a socialist," wrote Laura Meckler in a Wall Street Journal news story. "Say something too harsh and you will alienate many on the left wing of the party." For example, in a July 2007 campaign speech, Republican presidential candidate Rudy Giuliani made a direct connection between socialized medicine and socialism, saying "the American way is not single-payer, government-controlled anything. That's a European way of doing something; that's frankly a socialist way of doing something. That's why when you hear Democrats in particular talk about single-mandated health care, universal health care, what they're talking about is socialized medicine." Giuliani also quoted statistics from his health care advisor, Canadian psychiatrist David Gratzer, to support his claim that he had a better chance of surviving prostate cancer in the U.S. than he would have had in England. According to cancer experts cited in fact check articles by the Annenberg Public Policy Center's FactCheck.org, the St. Petersburg Times and its PolitiFact.com, The New York Times, The Washington Post, and The Times, Giuliani's statistics were "false" and very "misleading" and his conclusions were complete "nonsense".

The St. Petersburg Times and Congressional Quarterly's PolitiFact.com said: "Rudy Giuliani used cancer statistics from a conservative journal to compare the U.S. and the U.K. but the stats are wrong and the underlying comparison is faulty at best."

The ad caused a stir in medical circles after the group that did the research issued a statement condemning the misuse of its numbers.
“I find it personally distasteful to have Mr. Giuliani exploiting cancer patients to make a political statement,” said Andrew Vickers, associate attending research methodologist at New York’s Memorial Sloan-Kettering Cancer Center.
Vickers, who moved here from Britain several years ago, said Giuliani’s ad was irresponsible. “As a prominent individual who is a cancer survivor, I would think it’s more incumbent on him to be accurate in the way he uses cancer statistics,” he said.

The Washington Post said: "The former New York mayor has had personal experience battling prostate cancer, but he's confused about the stats, according to several experts we consulted."

"When you introduce screening and early detection into the equation, the survival statistics become meaningless," said Howard Parnes, chief of the Prostate Cancer Research Group at the National Cancer Institute. "You are identifying many people who would not otherwise be diagnosed."
"You can't say that it's better to have prostate cancer here or in some other country," with a developed health care system, said Brantley Thrasher, chairman of the Department of Urology at the University of Kansas, who also serves as a spokesman for the American Urological Association.

Princeton University economist Paul Krugman said that Giuliani's statistics were "just wrong" and "scare tactics," and accused Giuliani of "simply lying" by calling Democratic presidential candidates' health care proposals "socialized medicine."

In response, Canadian psychiatrist and Giuliani health care advisor David Gratzer said: "The mayor is right."

Krugman and others have compared statistical apples to oranges. My 44% figure, replicated by economist John Goodman and others, looks at a snapshot in time, based on decade-old OECD data; Krugman's 74% is a five-year relative survival rate from government sources today.

Annenberg's FactCheck.org found no merit in Gratzer's response:

Marie Diener-West, professor of biostatistics at Johns Hopkins Bloomberg School of Public Health, said Gratzer's attempts to calculate cancer survival rates were “inappropriate” and “very misleading."
Peter Albertsen, professor and chief of urology at the University of Connecticut Health Center, called Gratzer's calculations a “very dangerous thing to do” and “complete nonsense.”

Nor did The Washington Post, which awarded Giuliani and Gratzer's response the same "Four Pinocchios" rating (reserved for "whoppers") it awarded Giuliani and Gratzer's original claim:

"You would get an F in epidemiology at Johns Hopkins if you did that calculation," said Johns Hopkins professor Gerard Anderson, whose 2000 study "Multinational Comparisons of Health Systems Data" has been cited by Gratzer as a source for his statistics.
Five-year prostate cancer survival rates are higher in the United States than in Britain but, according to Howard Parnes of the National Cancer Institute, this is largely a statistical illusion.
Both Anderson and Parnes say that it is impossible, on the basis of the available data, to conclude that Americans have a significantly better chance of surviving prostate cancer than Britons.
"We have invited the Giuliani campaign to name a reputable prostate cancer researcher or epidemiologist who will publicly endorse the candidate's claim."

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