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A Word About Socialized Medicine

by Art Myatt

In the customary way of speaking, "socialized" medicine is contrasted with "private" medicine. We might say, "I wouldn't want to have socialized medicine in this country and have the government controlling it all; I would rather stick with the private system we have now." We might say this without giving it any thought at all. No thought at all is practically required, because "private" is the wrong word, and "socialized" is the wrong word, and even "system" is the wrong word to describe the current conditions for the practice of medicine in the United States.

I remember the actual private practice of medicine. In 1948, when I was four years old and very sick with the measles, my father got Dr. Woods to come by our house to look at me and to prescribe medicine. Dad paid cash. Of course, I only remember bits and pieces of this experience, but I have no reason to imagine my dad was lying about paying cash or about how vigorously he insisted that Doc Woods come right now. The story goes that this did not happen during normal office hours, but that my dad went to the doctor's house, four blocks distant, and pulled him away from the dinner table.

Now that is the private practice of medicine, as direct as it can be. No contract was involved, no government officials were invoked (Luckily, Dr. Woods did not call the police to have my dad thrown out of his house.), no third party was in any way responsible for providing services or for paying for them. There was just the patient's family and the doctor. There was no outside party involved, no forms filled out, no approval for a treatment plan required, no question of which local pharmacy would recognize the means of payment for the prescription medicine. They all recognized cash.

A very real confusion arises when the case against "socialized" medicine is argued by contrasting it to "private" medicine. Aside from cosmetic surgery or New Age healing practices not covered by any health insurance, there is hardly any true private medicine practiced in this country. As soon as there is some third party involved in the transaction between the patient (or the patient's family) and the medical practitioner, the medicine is not private any more.

In a way it is wrong to say that the subject is "medicine," because the real subject is who is responsible for selecting the doctor and who is responsible for paying for the treatment and who is responsible for providing the treatment. A broken arm gets a cast whether the medicine is private or socialized. It is all those other things that are different. We are really talking about different types of financial coverage for medical treatment, not about the medicine itself. However, it's a useful shorthand to say "medicine" instead of "medical coverage," and we can stick with it.

"Socialized" medicine is usually taken to mean medical care provided or at least paid for out of taxes by the government. By this definition, the Medicare and Medicaid programs are prime examples of socialized medicine precisely because they are financed by taxes. Politicians who argue against socialized medicine are generally intending to argue against Medicare and Medicaid. They would like to imply that socialized medicine is necessarily the product of a socialist government, but this is not true.

By the above definition, Medicare and Medicaid are not the only programs of socialized medicine currently in effect in America. All the medical care provided to the millions of soldiers and sailors in the armed forces and extended to all their family members is also socialized medicine. It is provided by the government and paid for by taxes. The health care coverage provided to the additional millions of government employees is also paid out of taxes, which makes those programs also examples of socialized medicine even if they look like fee-for-service or HMO-type insurance plans.

Consequently, Newt Gingrich and Trent Lott (to mention a couple of prominent politicians on the federal level) and Governor Engler of Michigan and his wife Michelle and their triplets are all beneficiaries of socialized medicine, even while they are also opponents of it. Well, no doubt the triplets are still too young to have an opinion on the subject, but the others are definitely opponents of socialized medicine - for the rest of us.

"Socialized" actually has a much broader meaning than just a government-operated tax-financed program. Whenever a formerly private function has been taken over or controlled by the whole society or by a definable group within the whole, we say that function has been "socialized." The government is one obvious definable group and medicine is one obvious definable function, but there are plenty of others.

Work has generally been socialized. A long time ago, a pair of shoes would typically be custom-made by an independent shoemaker who ran his own business and owned his own tools. That was private work strictly according to the classic model. It is not typical of the way shoes are made today. They are produced in quantity with standard sizes by a number of people working in a shoe factory, sold through some distribution network, and ultimately purchased by persons who likely have never met the producers. While there are a few custom shoemakers left, these are exceptions to the rule that the work of making shoes has been socialized.

Food has been socialized. Way back when, most of the population grew or hunted most of their own food, or purchased it directly from the people who did grow or hunt. While deer meat and home-grown tomatoes do still show up in the diet of Americans at the end of the Twentieth Century, most of us neither grow nor hunt our own Big Macs, fries, and Cokes. Food is typically a commodity produced, packaged, distributed and sold by a network of corporations, and the consumer is so distant from the producer that, once again, the one probably has never even seen the other.

Transportation has been so thoroughly socialized that most of us can hardly picture any other kind. Even if you build your own car, it has to be licensed to be driven anywhere, and you have to be licensed to drive it. When you and it are licensed, the driving takes place on public rights-of-way, on road surfaces created and maintained by the government, in accordance with regulations about stopping, turning, signaling, speeds, etc. It is socialized, socialized, socialized - and if you don't believe it, there are lots of nice highway patrolmen, judges, and so on who will forcefully convince you.

The practice of medicine has clearly been socialized as well. This is not the customary way to think of it, but it is none the less true. Typically, (with nominally "private" medicine) a company buys group health insurance for its employees and their families from some type of health insurance company. The employer is the third party and the insurance company is the fourth. If the patients are seeing not just a single physician but a group practice, there is a fifth party as well. When they go to a hospital, there is a sixth party to consider. The type and amount of coverage could be determined by a union contract, which would mean a seventh party - and so on.

In this situation, the patient is not responsible for paying for the medical care. The insurance company is responsible for paying the medical staff and the hospital. The employer, not the patient, is responsible for paying the fees to the insurance company. The patient can't pick any doctor; the patient can only pick among the ones on the insurance company's list who are accepting new patients. Frequently, the insurance carrier simply assigns the patient to a doctor the patient has never heard of . Then, likely as not, the insuring organization decides what treatments and medicines the doctor can or cannot use for a particular patient. So far we have not even mentioned the State and Federal laws that affect the situation or the various reasons any one party might sue any other.

The rules, the contracts, the legal obligations of any one party to all the others, have gotten so entangled that no one person even understands it all. What we commonly call "private" medicine is socialized, socialized, socialized - though it is neither run by the government nor supported by taxes.

The patient and the doctor are actual people, but the other parties are all incorporated. That's why "corporate" medicine is a much more accurate term than "private." You might call this model "business-controlled" medicine, or "profit-driven" medicine, or ‘bureaucratic" medicine, depending on which aspect of influence on the doctor-patient relationship you want to emphasize. "Corporate" is a more or less neutral term which implies all of the particular elements mentioned above. When the practice of medicine has been socialized by corporations, we are correct in calling it corporate medicine.

It did not take a socialist government to socialize work, food, transportation, and so on. These things were just naturally socialized in the course of historical development. The practice of medicine has been socialized the same way. It used to be private, and now it is not. It is socialized.

This should not be hard to comprehend, though it does go against the grain of the ideology which wants to say that all government is socialism and bad while all corporate actions are competitive, efficient, private, and good. If your commitment is to ideology, you may never understand how so-called private medicine is actually socialized. If your commitment is to developing a practical interpretation of how the world works and to using language that helps in this effort, you already understand.

Of course, corporate medicine does not apply to the more than 40 million uninsured people in this country. "Haphazard" and "irregular" are probably better descriptions for the medical care they get. If you are poor and uninsured, you are stuck with over-the-counter medicine and prayer until you have such an acute problem that you need hospitalization as a charity case or you need an undertaker. You just have to take your chances.

In America, there really is no coherent system. We have a remnant of private medicine, a lot of corporate medicine, a substantial amount of public medicine, and altogether too much of taking your chances. Any given person may be subject to each of these forms in the course of an ordinary lifetime.

In this country, many people have been trained to think that the tax-supported form of socialized medicine is automatically horrible. It is certainly can be horrible. Indeed, there are plenty of examples of terrible practices in this type of medicine.

It is possible for instance to point to multiple things that are wrong with socialized medicine as practiced in the former Soviet Union, now Russia. One obvious problem with the former Soviet Union is that the society is not a free and democratic one. If the society as a whole is controlled from the top down, socialized medicine in that society will be no different.

Any country or society can only have the kind of medicine which is possible there. If the elite group that runs the system does not respect the rights of the individual members of the society, medicine in that society will not pay much attention to the rights of patients in the system. If the government and every other institution in the society is a bureaucratic nightmare that is not responsive to the needs of the ordinary person, the organization of medicine will be the same. If political considerations override the personal in the general society, that will still be true in the practice of medicine. If the resources of the society generally are depleted and the economy functions poorly, the medical system of that society will not have the medicines and the equipment that is needed to treat all the sick people properly.

The real example of Russia is only one major source of the idea that socialized medicine is terrible. Great Britain, which has not had a healthy economy since sometime before World War II, is another. Certainly, tax-supported medicine could not thrive while it was controlled by the successive conservative governments of Margaret Thatcher and John Major. They were ideologically opposed to its being successful, and the current British government, nominally a Labor government, is actually not much better on this score.

There is no particular reason to anticipate that public medicine in America would be like that in Russia or Great Britain. British and Russian cars are not like American cars. Russian and British wages are not like American wages. American politics are not like Russian politics or British politics. How then could tax-financed medical insurance systems be the same? We have every reason to expect that public medicine in America could set a good example for the rest of the world.

In America we have individual rights and freedom. It follows that these should also be carried into an American system of public medicine. In terms of technical resources, we have the best in the world, and these would not disappear if the medical insurance coverage became a government program instead of a corporate one. What is missing in the current system of corporate medicine is equal access for all citizens to the resources that exist in plenty. A tax-financed universal health insurance would correct that, and provide other benefits besides.

However, there is no denying that we also have insensitive bureaucrats in America, people whose idea of doing their government job is as far removed from public service as possible. We also have plenty of people in government and in business whose idea of a successful career is to enrich themselves at the expense of anybody at all, and whose idea of morality is not getting caught breaking the law. No doubt, people like this would show up in public medicine just as they do now in corporate medicine. Public disclosure of the detailed budget of every medical institution would go far to limit their opportunities. Vigorous prosecution of individuals for fraud will also help to discourage them.

The current problem is that medicine has been socialized not for the benefit of the general public but for the benefit of the corporations. If medical insurance for your family is tied to your current job, then you are tied to your job. You may feel lucky to have such excellent coverage as your employer provides. These may be golden chains and velvet ropes, but they are chains and ropes none the less.

If you have a serious, chronic, or expensive condition, the medical insurance carrier will be pleased to limit your coverage or to drop you altogether if it is legally possible to do so. They are happy to abandon non-profitable patients as frequently as they are allowed. Often, the people who need expensive treatments end up being covered by public medical programs when they ought to have been covered by their corporate insurer. This makes some corporate profits better, makes public programs more expensive, and does nothing good for the society as a whole.

With corporate medicine as in corporate culture generally, the ideal is to make a profit from whatever business the company is in. Not just a legitimate or reasonable profit, either. The best companies, by their own standards, are the ones that make spectacular profits, that pay millions in salaries to their top executives and millions more in stock options and such. That is the American Way. HMOs and other sorts of medical insurance companies are no different.

Employers are trying to pay the minimum possible amounts for coverage that will be good enough to keep their employees on the job. Insurance carriers are trying to make the maximum profits from these fees. The host of insurance carriers are spending a noticeable fraction of their income advertising for new customers. As little of the insurance carrier's income as they can possibly manage will go to paying for medical supplies, hospital fees, and the incomes of medical professionals.

The second great benefit that a tax-paid universal health insurance plan would bring is that a far greater proportion of every dollar spent for medical care would go to actual medical care. A universal coverage would have no reason to compete with itself for new business, so we would be spared the image ads on TV and newspapers. It would not pay absurdly high salaries and bonuses to its administrators. It would not be trying to make a profit for its stockholders. The administrative expenses of medical practices, hospitals, and so on would be drastically less than at present, when doctors have to deal with dozens of different insurance packages with dozens of sets of rules and dozens of different forms for the same type of treatment. The money saved in these respects could easily pay for the care of those not now covered by any insurance.

Universal public health insurance should be better at cutting the cost of medical care than the present corporate system. It is in Japan and in Canada, two places where the general population is healthier than in the United States. It would be comforting for all of us to know that we will have access to medicine when we need it, as we all will sooner or later. It would give every individual freedom to change jobs without worrying about possible loss of medical coverage for family members.

It is true that some people now working for the various kinds of corporate insurers would be out of their jobs. This would be one aspect of cutting unnecessary costs. At least they would still have medical coverage while they are hunting for new jobs - a much better situation than they would have now if, for whatever reason, they were laid off.

Common reactionary political ideology contrasts the wonderful private medicine that we supposedly have with the terrible socialized medicine we might have to put up with if we allow those wicked socialists to force it upon us. The purpose of this terminology is simply to prevent realistic discussion of the system we do have and how it might be changed to better serve the populace. The real choice is between corporate (socialized) medical coverage and public (socialized) medical coverage. With either choice, or with the mixed system we actually have now, private medicine is still available for anyone who actually wants it and can afford it.

If, in an election, we were ever offered a real choice between corporate medicine and universal public health care, I suspect that corporate medicine would soon disappear. Why, in this supposedly democratic country, do we not have the choice?