In any discussion about healthcare, there are two overarching, interrelated issues. The first is the question addressed in this article: how to provide a healthcare system that works for everybody, keeps cost down and quality high. The second is how to ensure a generally healthy population to start with. This question involves food industry regulation combined with massive information campaigns, perhaps categorizing sugar as a drug like nicotine and then imposing a high tax to make it expensive to add to processed food (there was a time when sugar was a rare treat; now it's in absolutely everything), heavily penalizing false or misleading advertising, ensuring that organic labeling actually means something, building communities around opportunities to socialize so that people don't sit at home watching a screen, creating state-subsidized rec centers that offer the chance of cheap access to work-out equipment etc. etc. etc.
One of the biggest problems facing all countries is the fact that humans are becoming less and less healthy. How about some careful thought by the big brains on how to fix that on a global scale.
I am the Democratic nominee for Congress in Kentucky's 2nd District. I have been mentioning Taiwan's health care system for months, thanks for this article. Hopefully a new Congress will be able to wrestle control of health care away from the large pharmaceutical corporations and the health insurance industry. I recently asked a French citizen if people in France (home of another superior health care system) complained about their health care. He said yes, some complain, mostly about taxes, until they get sick... then they love it.
2
I believe the author never lived in Taiwan and used its health insurance. If he did so, he would have totally different opinions especially in rural area. Health insurance is the only ACTUAL social welfare service in Taiwan and already at the edge of bankruptcy.
Taiwan has fantastic population based research that is used to assess risk factors and clinical outcomes for a wide variety of conditions.
Mike C, NY, Taiwan is far more culturally and ethically diverse than you appreciate:
https://www.zo.uni-heidelberg.de/md/zo/sino/research/09_abstract-2.pdf
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It's unhealthy when getting rich from sickness care is the aim of the profiteer. Taiwan is a healthier country than America. The USA is a sick nation state.
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@Colenso
I agree! In the US, there is a built-in incentive to keep people sick.
As has become customary in the NYT, there is no discussion of the influence of money in politics and how this in turn disallows any real reform in health care in the US. This is the biggest impediment towards a single payer system that would consist of Medicare for all. The Democrats are little better than the Republicans in this regard: they had their chance when they were the majority in Congress and had Democratic presidents with whom to work, and they failed us every time, with Hillary Clinton heading up the Jackson Hole debacle back in the '90s, in which single payer wasn't ever discussed.
7
Over 40 years in medicine, I learned a few things. The only ones who grew and prospered in the medical “industry” were insurance, pharmaceutical companies, and biotech devices. And then the new “management services”. The insurance pharmacy benefit formularies that won the entire lottery of patients , by contracting with A SINGLE PHARMACEUTICAL BENEFIT PLAN OWNED BY A PHARMACEUTICAL COMPANY.
The pressure on providers to spend less time on actual hands on care and more time on Insurance demands...SHRINKS PATIENT CONTACT. 20% OF TIME TO PATIENT. 80% OF TIME MANAGING EHR (medical software), BILLING SOFTWARE, LENGTHY AUTHORIZATION PROCESSES. FIGHTING FOR PATIENTS TO GET THE right DRUG, NOT THE INDUSTRY DICTATED ONE. BATTLING SHRINKING STAFFING. BATTLING PRESSURE TO SEE MORE “ NUMBERS” of patients.
We aren’t paid to see or care for patients. We get paid based on RVUs. RELATIVE VALUE UNITS. We have to chop patient services into multiples of categories, run algorithms, and see which combination pays the most.
I am so grateful that I was in medicine when it was an ART & Science, hands on.
Doctors are leaving in droves, because it isn’t what they signed on for...taking an oath to protect the patients. “First Do no Harm.”
Our disintegrated system is harmful to patients, healthcare providers, and our national wellbeing.
Sincere aloha
4
Obviously this is an example for the United States of how to develop a modern healthcare system for all. The question is whether we have the guts to do it.
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Having lived there for several years, all i say is that is that I received some of the BEST medical attention in my life and low copays. I didn't go into debt unlike I am currently in the US.
The US could do it, but the insurance industry would be virtually eliminated, IMO. And no one wants to kill the golden calf.
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This article doesn't begin to cover the most important question it asks in the heading: HOW is this done? What factors made it possible to move to single-payer? How was the reform introduced and the industries involved made to cooperate? What issues did they encounter making the transition and how were they addressed? What are they doing to deal with the issues that single-payer systems encounter? What does the Taiwan experience tell us about the conditions that would be needed in the USA for the same kind of transition to happen?
5
Please stop using the throwaway line "a single-payer system like that found in Medicare," and others like it.
"Single-payer" means quite literally that there is single payer for health care. That's the economic power of single-payer plans. They control prices, and they simplify the administrative burden not just for the payer, but also for doctors, hospitals, pharmacies, and employers. Comparison with Taiwan and Canada suggests we would save around 20% of health care costs, by virtue of simplified administration is a single-payer system.
Medicare functions as a large, unified payer for a large portion of the U.S. health care economy, but it isn't the single payer. Making it the single payer would realize savings and efficiencies far beyond those it accomplishes now.
8
How is college, medical school and post graduate medical training paid for in Taiwan ? What is the system for determining legal liability for harm caused by medical service providers or drug makers, and do the medical service providers carry liability insurance ? Chinese culture promotes the group while American culture promotes the individual. All in all, how did the medical service community in Taiwan react to reduced income ?
3
This is pretty simple. Greed. American doctors demand more money than anywhere else for their services. Many for profit hospitals charge outlandish prices. Drug prices are the highest in the world.
In Quebec you can get an MRI in a private clinic which is not reimbursed by government Medicare for less than 25% of the cost of one performed 30 miles away across the border in the USA.
4
I was waiting to see if cost controls were mentioned. Does Taiwan cap drug and equipment prices? The 3 legged stool is low cost, high quality and complete access. Pick any two. Can't have all 3.
2
In my experience in Taiwan, especially since the new system came in in 1995, you can have all three. Taiwan most definitely controls drug and device prices and continuously monitors spending and outcomes to adjust prices in ways that encourage the best care. It is so good, I can't imagine why anyone who has experienced it wouldn't want it!
5
It's simply a matter of political will. President Kennedy understood that when he paraphrased a Frank O'Connor story that describes Irish boys hopping over brick walls until they come to one too high to easily go over, at which point everyone tossed their cap over the wall. There was no choice but to follow.
3
I'm happy to see an article about health care systems in Asia. The debate--and reporting--over health care reform suffers from Eurocentrism. Universal coverage does exist in Asian countries, too. The Times seems to be pushing the boundaries with this article, and also the articles on Singapore's system.
One of the reasons my one-year stay in Taiwan became a ten-year stay was because of the excellent and affordable health care coverage there. Dental care was also included, and not separated from regular insurance coverage--a linkage supported by modern medical science. Hospitals and clinics also offered evening and Saturday morning hours. You didn't always need to miss school or work for doctor or dentist visits, as we do here in the States. The waiting rooms or offices were more spartan than in the States--plain plastic chairs instead of cushioned sofas--for instance, and for reasons partly cultural and partly cost-saving, but the medical equipment that mattered was high standard and up-to-date.
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Regarding the degree of difficulty of Taiwan's system change, it shouldn't be overlooked that the two previous major health insurance programs for public and private sector workers were both government run. Taiwan has never had
much of a private health insurance industry. Thus, the upgrade involved combining and greatly expanding two already existing systems, in itself a big job, but it didn't involve telling a whole industry that they were going to have to change their whole business model or go out of business, as coverting to single-payer would involve in the US.
3
Although the population of ROC is only less than California and Texas, but the federal tax and fee is not only redistributed to the 2 states.
The numbers of physician differ.
California . . . . . . . . . . . . 27.8
Texas . . . . . . . . . . . . . . 23.2
Vermont . . . . . . . . . . . . . 38.2
Colorado . . . . . . . . . . . . 29.1
ROC . . . . . . . . . . . 19.03
And there are quantity control in the physiccian in the ROC.
Only 1,300 students (include the senior high school students who graduated several years ago ) who could attend the physician education in the ROC each year, while the number of physician is less than most developing countries in the world.
3
By the way, suddenly found that there are so many physicians in the D.C.
https://www.cdc.gov/nchs/hus/contents2016.htm
Table 83. Active physicians and physicians in patient care, by state: United States, selected years 1975–2013
State 2013 Number per 10,000 civilian population
United States 29.4
Alabama 22.4
Alaska . 25.0
Arizona 25.5
Arkansas . 21.5
California . 27.8
Colorado . 29.1
Connecticut 38.4
Delaware . 27.4
District of Columbia 74.7
Florida . 27.2
Georgia 23.4
Hawaii . 30.8
Idaho 19.2
Illinois . 30.1
Indiana . 23.3
Iowa 23.2
Kansas 25.4
Kentucky . 24.6
Louisiana . 27.2
Maine . 33.7
Maryland . 40.9
Massachusetts 47.0
Michigan . 31.5
Minnesota . 31.1
Mississippi 19.5
Missouri 28.9
Montana 23.1
Nebraska . 26.0
Nevada 20.3
New Hampshire 32.0
New Jersey 33.5
New Mexico . 25.2
New York . 39.4
North Carolina 26.4
North Dakota . 25.3
Ohio 31.4
Oklahoma . 22.3
Oregon 30.7
Pennsylvania . 35.1
Rhode Island . 40.2
South Carolina 24.1
South Dakota . 24.6
Tennessee 27.7
Texas . 23.2
Utah 22.6
Vermont 38.2
Virginia 28.1
Washington 28.4
West Virginia . 27.1
Wisconsin . 27.9
Wyoming . 19.5
1
whenever I see statistics for DC, my sense is that they are reflective of our larger urban areas, and that the remainder of most states are much lower on most stats. Doesn't always hold true, but it is likely a good starting point. Cities are more alike than different, and the diseconomies involved in rural areas are also more alike than different from each other.
Huge inefficiencies in rural places. Economies of scale are usually worth pursuing, and it seems unwise to subsidize those who choose to live where those economies don't exist, unless we have awesome amounts of surplus that aren't needed to meet basic human needs in efficient places.
Just as States are laboratories of democracy, so are countries the laboratories of health care. We don't need to reinvent the wheel. Study health care systems around the globe, and choose one that with a few adjustments would fit the U.S.. Let's learn from the mistakes and successes in other countries. Taiwan's system may or may not be a good fit for the U.S.. When our founding fathers wrote the constitution, they first looked at what worked and what failed in other countries. Let's follow their example and put it to use on health care.
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No, no. You don't get it. We don't have a health system, we have an illness-management-for-profit system. Health is NOT the point. Profit is the point.
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Yes, it's called capitalism, in which we practice human sacrifice in the service of profit.
4
No other country in the world pays its medical personnel what we pay here - Pharma sales reps, hospital administrators, nurses, PAs, doctors, etc. In order to cut costs and bring us in line with other countries a huge cost curve would need to be bent down. Do you really think that the Lobbyists in Washington would ever let this happen? No. It.Will.Never. Happen.
4
It is a little more interconnected than that. It would be anyone involved with a medical school for instance - including the secretaries. All kinds of supply chain companies that support anything in healthcare. The IT industry. 20% of the working population wouldn't need a lobbyist. It would take one election cycle or less.
Doctors' salaries in Taiwan run between $36,000 and $80,000 per year for most doctors. China is recruiting away top Taiwanese doctor specialists. Bigger question - If docs rate of pay generally is at around $70,000 per year, what will an ICU nurse be paid? A floor nurse? A medical assistant? The wages of a large segment of the working US population would plummet under those circumstances, and tax revenues would tank. A lot of docs would either retire or do something else, or just go for self pay only and just work less. The government would expand into a big VA system.
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You are correct - the whole medical industry, from top to bottom, has higher salaries than anywhere else. Hospital administrators, drug salesmen, head nurses, MRI technicians - everyone makes more than they would for similar jobs in other industries. This is a very good living for millions of people, which is one of the reasons it would be very difficult to cut costs.
3
I'm not sure the author understand that what might work for a small population may not work for a large one. Taiwan has a population slightly bigger than New York state. Less than One Tenth of the population of the US. That makes it much easier for their Government to control. Our Government would need to become much bigger to have a fully state-run healthcare system.
Taiwan isn't perfect though. It would be hard to argue it's better than what we have now. They have low nurse and doctor staffing levels. This has led to an outbreak of pneumonia, shock, cardiac arrest, and urinary tract infections in their hospital system. Oh, and they also do not have adequate long term care...
"Premiums are paid for by the government, employers and employees."
- The Government gets its money from the Employers and Employees in the form of taxes. So why list Government as one that pays? It's misleading.
1
"Oh, and they also do not have adequate long term care..."
As compared to who?
3
The premiums are separate from income taxes, which are paid into the national treasury. The NHI premium is a separate deduction from my salary, which my employer sends along with their contribution to the agency running the insurance program. Also, there hasn't been an "outbreak" of pneumonia, etc. The levels are slightly higher than usual because of the shortage of nursing staff (which the US also has).
4
The "edge" where costs could drop dramatically is the price of big pharma, where "profit" exceeds any reasonable Return on Investment, particularly when part of that investment is through NIH. It would be a particularly important model to project internationally standardized pricing on pharma to then measure and compare different national health options. For that matter, the simpler model would be to invest in different state models in the US and compare their savings - in dollars, lives, treatment, and other metrics like income, race, language, etc. It's frankly shocking that the US "system" has so long ignored it's own capacity for diverse models in developing cost-benefit options.
4
Federalism isn't being used to encourage innovation. Certainly not under this administration, and not even under the ACA, which had too many compromises to appease congressional DINO's (a/k/a "Blue Dog Democrats") and the health insurer and big pharma lobbies. Any move to increase states' "flexibility" is just code for facilitating a race to the bottom. We can start with allowing the opt-out to Medicaid expansion and go from there.
1
To reexamine your premise on state laboratories, check out Oregon and it's coordinated care organizations delivering medicaid.
Points that truly concern me: (1) doctors complaining about too much work for too little pay and (2) growing shortage of doctors. This detail, somewhat deep in the article, could be real trouble in the future because it takes so many years to educate and adequately train physicians. Another point that concerns me: reimbursement to physicians goes down after a reasonable number of patients are seen. If you make your living as a mechanic, for example, there are set prices for replacing tires or brakes, etc. For as many years as physicians have to sacrifice going to school, being interns, and paying off student debt, I believe that they will want to be paid well to offset that period of sacrifice and deal with the stress of being in a busy practice. The shortage of physicians occurs because people conclude the stress of it all is not worth it.
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I think the reimbursement going down is to discourage hospitals (which also run outpatient clinics) from overworking their salaried doctors. The shortage is not across the board, but only in certain specialties, such as ob-gyn. The latter is partly a result of the sharp decrease in childbearing over the past couple decades. I've read that the US has a shortage of GPs and is oversupplied with specialists.
2
I can certainly agree that we would not want doctors that are overworked. You are insinuating that you are satisfied with the govt. telling you how much you can work and earn. Yes? What if the workload exceeds the capabilities of the health system to handle? The article did say that there were shortages, and understanding natural human behavior would indicate that if compensation does not increase for the increase in effort required by doctors or those training to be doctors, then obviously the shortages will get worse.
What can Taiwan Teach? Just wait until what Taiwan learns first. Single-Payer is a disaster in Sheep's clothing. It relies on rationing, necessary long lines and results in a medical system that is completely inferior. The message from wealthy Canadians who travel to the US for treatment should be enough of a lesson to learn from.
I know a Taiwan couple who emigrated to the US and thought they had good health insurance. Then in the 90s, the husband developed Parkinson's, and they found out how good insurance companies can be at not paying for what is supposedly covered. At that point, it was too late to switch insurance companies because the husband now had a "pre-existing condition." So they moved back to Taiwan, where all the latest treatments for Parkinson's are available. Taiwan is also the recipient of medical tourism from countries like Japan. Even though such tourists are not covered by Taiwan's health insurance, they feel that the quality of care and reasonable cost make it worth the trip.
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Where do you get your information to back up your statements? "They feel that the quality of care and reasonable cost make it worth the trip."
You are aware that many from Canada travel to the US for care because they can't or don't want to wait for the treatment in Canada. It seems that Canada has single payer.
Check the numbers and STOP watching "Faux News" for your information about this subject because what you espouse is totally incorrect. The numbers of so-called "wealthy" Canadians as you describe it is, at best, or some elective surgery is minimal. Why do Canadians have a lifespan that is now almost THREE years longer than their American counterpart, whom , for the first time in 30 years lifespan was recently reported, is actually now dropping?
You might also want to check medical tourism whereby tens of thousands of Americans are travelling abroad every year for treatment that they either cannot get in the U.S. or cannot afford. Thailand has a hospital designated for that purpose alone. Canadian hospitals are overwhelmed with Americans
attempting to get treatment they cannot get at home.
Those are the facts, not fiction.
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A few questions....
Does Taiwan have millions of illegal immigrants preying off their system who likely are not paying taxes? What percentage rates are their residents paying to pay for the healthcare? The article stated it is based on income, but how much? 40% of income? 50%? 10%?
2
2% of my income each month, and I am toward the higher end of the salary scale.
6
Interesting that you failed to acknowledge the simple and irrefutable point/question. Does Taiwan have a huge, by some numbers 8 to 10 percent of the total population, illegal immigrant issue that uses a significant allocation of subsidies and services that the general population must pay for?
Or do they have a strict immigration policy in which illegals are considered as criminals and required to leave? That's a pretty important aspect of providing a system that is going to be bankrolled by those considered as citizens. I'm curious as to why you chose to ignore it.
"Does Taiwan have millions of illegal immigrants preying off their system who likely are not paying taxes?"
The USA does not have millions of illegal immigrants preying off their system who likely are not paying taxes. Repeated studies show: "The foreign-born (especially the undocumented) use disproportionately fewer medical services and contribute less to health care costs in relation to their population share, likely because of their better relative health and lack of health insurance."
Neither do illegal immigrants get welfare, even though they do pay taxes.
"Undocumented immigrants do not qualify for welfare, food stamps, Medicaid, and most other public benefits. Most of these programs require proof of legal immigration status and under the 1996 welfare law, even legal immigrants cannot receive these benefits until they have been in the United States for more than five years."
1
I did find the article interesting and it sounds like Taiwan is working through a solution that works for them. I did notice the socialist view of wealth re-distribution. This is fine if you are already wealthy, But it suppress the average citizens ability to obtain wealth it you are taxed more for health insurance based on you wages. The cost should be equally shared by all. Poverty level citizens should be exempt from paying anything. Also the economies were not accurately compared.
This article has almost no hard financial facts. A commenter here has already stated that, as we have known from William Bradford 1620 on, if there is no incentive to work harder, the doctors don't. That is not the American ethic.
We do have Medicare for all in the US. You just have to do what I did...pay into it for 40 years with zero benefits to be able to pay for your insurance when you are of Medicare age and finally be covered. The "Medicare for all" crowd wants all of the benefits now without putting their money into the pool for 30-50 years to fund the system before being given the coverage.
Doctors are paid so pitifully low now that the average (or even above average) American would not believe it. It is is important to point out that hospital expenses/charges are not doctor charges...and that doctor reimbursement is decided upon by Medicare, Medicaid, or private insurance, and the doctor has no say in it (exceptions are elective plastic surgery and dermatology, chosen by the patient outside the insurance system).
Besides, those people who ask for "single payer" are grossly unaware of how little the government pays (and even private insurance, though it pays more). With the government (Medicare, Medicaid), we don't have single payer..we have single underpayer or single nonpayer. So I ask those demanding single payer...just who do you think the payer, who actually pays the value, will be?
3
This is an excellent and rational comment.
You complain the article has few financial facts, then you make several erroneous claims, to wit:
General Practitioner doctors in the United States receive an average of $185,000 per year. Specialists receive more than double that. Both salary figures are double the average of the 1st-world nations worldwide. The GP figure is about 30% higher than the country with the second highest paid doctors: Great Britain.
For cited sources and proof, go to: https://sites.google.com/site/toddledermanauthor/home/speaker-for-the-po...
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Your are neglecting to mention that when doctor's salaries are higher what are their overall costs that, of course, will reduce what they ultimately receive as income. I know malpractice insurance premiums are many times higher in the U.S. than other countries with universal care and in a hospital/clinical environment, administrative costs are many times higher as well.
There is a reason for those higher salaries and it boils down to overall costs to run the healthcare system in America which at 18% of GDP is much higher than any other country that has universal care, yet, in the case of America, only 37th in lifespan, the lowest of any of them.
In the ongoing fight for single payer in California, a Lewin Group analysis, http://www.pnhp.org/news/2005/january/lewin_group_analysis.php, found that single payer "...would save the state $343.6 billion in health care costs..." from 2006 to 2015 had then-Governor Arnold Schwarzenegger not vetoed the legislation.
This would have been a great point for Sanders and Klobuchar to make in showing that single payer is actually more cost effective than the current system.
Using the Lewin Group analysis I found that while I was paying approximately $14,000.00 a year for medical insurance, under the proposed single payer system the total would be approximately $5,400.00 (11.95% tax vs. the insurance company premium), returning $8,600.00 to my pocket.
The $5,400.00 would be paid for by “…an employer payroll tax equal to 8.17 percent of wages and salaries for all employees…” and “…an employee payroll tax equal to 3.78 percent of wages and salaries for all workers.”
No more for-profit insurance company premiums! It should be noted that the single payer system above provided full coverage vs. the high premium, high deductible, high coinsurance insurance company policy. A real no-brainer!
2
My insurance premium is $546 a year and it is great insurance.
Can America do anything big anymore?
Not a chance. It is consumed by unadulterated greed and the worship and influence of wealth by those we elect to represent us at every level of government.
This country may not last thru this century as it destroys itself from within. WE are no longer "one" nation.
6
I lived in Taiwan for 3 years and had multiple procedures done at hospitals, clinics, and dentist offices. It works.
9
No surprises to any who have the capacity to understand and have been paying attention to what other societies do. Our problem is that Conservative districts have controlled local governments so thoroughly they've managed to dumb down the U.S. to the point that many citizens are opposed to those measures that help them and in favor of those that don't. The evidence? They elected Trump. Further evidence? They put Congress in the control of Conservatives and arch conservatives.
Sure, Taiwan has shown single payer works. Other nations have shown advanced health care works and for far less money.
But the U.S. is controlled by an Oligarch not much interested in that data, and the Oligarch has created an electorate to support them.
First, you have to overcome that electorate by converting it and creating one that opposes the Oligarch.
Then the Oligarch comes down, and positive progressive change comes about.
7
I think you are mistaken. We don't need Govt run health insurance.
You miss the huge obvious points in every single payer utopia dreamed of and especially the reality single payer systems. They are all budget controlled and ultimately services and access and payments get chopped. If you don't think so, look up the history of the VA. There you go. Single payer system. Wonderful. Unless of course you actually have to use it for 100 percent of your needs.
US healthcare providers don't have to accept Medicare and Medicaid patients because there are lots of patients with other kinds of insurance. Under the old system in Taiwan, the health insurance could only be used at designated public providers, so private providers tended to be small. Under the new (since 1995) system, everyone is required to have the insurance and can use it at any licensed provider, public or private. The latter have been only too glad to have access to 23 million potential patients with insurance, and have greatly expanded their facilities, another reason for the staff shortages. The government does indeed control costs, which is what makes the system viable and affordable. I gladly trust this system with 100% of my healthcare.
The big picture if you look closely enough is that Taiwan spends less and has had a reduction in quality. That's the big picture. Also, the position Taiwanese doctors seem to say is " We are paid too little to work too hard" should be explored before we implement a similar system. However, I have no issue looking at a major change like this really closely. We should just make sure everyone sees the real math and any changes on their own health care expenses in the form of taxes, lost benefits, or anything else. Eyes wide open. Personally I would institute a medicare for all premium based option( key word option) immediately and mandate true catastrophic policies that protect people from losing their life savings while being universally affordable as a first step. Equitable dug pricing in line with the rest of the world would be an absolute. I am ready for a change.
4
Some "real math" is that wealthy people pay far too little for Medicare. The premium is capped at a level that is simply unfair. Medicare recipients whose income exceeds some percent, maybe 250%, of the average income for recipients should pay a market rate for their coverage. The wealthy have great supplemental insurance for drug coverage and any potential out-of-pocket expenses related to a surgical procedure or Doctor's visit. Knees, shoulders, hips are being done by the millions. The system simply cannot afford it. Premiums need to be raised.
Part of the "real math" in Taiwan is that everyone, including foreigners here for over 6 months, is required to join the system. I have been in Taiwan for 43 years, paying the premiums every month but rarely using it until 2002, when age started to catch up with me. I have never resented paying those low premiums. I have a Taiwan friend whose kidney disease eventually required a transplant, and I remember her comment about how healthcare changed in the mid-90s with the new insurance system--it became far more patient-centered. Under the new system, all licensed providers are "in network," and to attract the 23 million potential patients with insurance cards, they compete on the quality of the care and patient experience. Even in a large medical center, it is amazing the amount of personal attention just an ordinary patient gets, in a system that is also incredibly high-tech. One update to the article--it is now faster and less expensive to see a specialist through a referral from a GP. They made this change on purpose so that specialists could focus on their specialties and patients would arrive having completed a basic physical.
5
Sounds like a good care experience. I looked closely at Taiwan doctor salaries, and keep finding that average doctor salaries come in between 60K and 77K a year, lower earlier on and higher after 8 years. China is now stealing specialists from Taiwan at a very high rate from what I am reading. Also, the medical lawsuit rate in Taiwan is very high as well. Forgetting how someone in the US with 200K to 300K in schooling debt could make it on 65K a year, I wonder what the average salary for nurse in Taiwan is from a downstream perspective. Again, eyes wide open.
I am so tired of reading articles like this. Not because I disagree with them. Quite to the contrary. When will we be able to read the article recapping the story about how we finally got smart, told Big Pharma and Big Insurance where to go, and followed the lead of all the other developed countries of the world on health care?
28
The US can't even get rid of the one cent coin and the dollar bill. It can't do the small things, let alone the big things.
The US suffers from Not Invented Here syndrome, an overestimation of the quality of healthcare provided to the population as a whole, and a private health sector that cares more about taking profit at every point than in health outcomes.
Yes, there are issues with geography and population size, but countries like Canada and Australia deal with healthcare provision in rural and remote areas better than the US.
21
In part it is because the wealthy run things and their care is great. Hospitals like Eisenhower, Cleveland, Mayo are building super suites for their wealthy clients. Fireplaces, special meals, special concierge Doctors, 24 hour responses.....Health care is for the rich because they run the show.
I agree with the other Taiwan commenters that the health-care here is as good or better than that in the US. Back in 2003 the system was severely tested by SARS, but came through with flying colors. Not only did that experience hasten the adoption of digital medical records, our insurance cards now have an IC chip that records every charge made, where and what for, making it much easier to keep track of patients during a developing epidemic. Also, a 2015 amusement park explosion resulted in nearly 500 young people with severe burns, but Taiwan was able to provide them with excellent care.
6
One time I was traveling with friends in Taiwan and a person in the group suffered an injury so we went to the local hospital. He received an X-ray, had the results immediately interpreted and was seen by the physician, and received his prescription medicine all within a few hours. The total cost to him was $30 as a non-citizen, non-insured (would be totally free if he were Taiwanese). It was a truly eye-opening experience that demonstrated the efficiency and affordability of the system in comparison to that of the US's .
22
One time I was traveling in Chile, I became acutely ill with an infection. The hotel manager summoned a physician at midnight who came to me within an hour. He wrote a prescription which a hotel maid filled for me within a half-hour. I recovered without sequellae. The charges to me were the equivalent of $75.
One time I was travelling in St. Louis, and I became acutely ill with the same infection as above. I presented to an emergency room and was admitted for five days. I recovered without sequellae. The charge to me, partially borne by Blue Cross-Blue Shield, was $2,250.
10
yeah, but G.E. wasn't getting a huge royalty from the MRI machine, the docs weren't pushing drugs for drug companies, and they don'y have our non-profit for profit hospitals.
Some countries choose wisely between profit and care. We always defer to the former.
2
In describing the success of the Taiwan’s Single Payer Healthcare, Caroll and Frakt cite the failed efforts of Vermont, Colorado and California to institute similar plans but do not even refer to the New York Health Act which, in 2017, passed the New York Assembly by an overwhelming majority and, in the State Senate, is short one vote. Paid for by a progressive tax on earned and unearned income the New York Health Act would save all but the wealthiest 2% of New Yorkers the expense of what they are currently paying.
Under the provisions of the bill, New Yorkers will be covered for all medically necessary services, including: doctor, hospital, preventive, mental health, reproductive health care, dental, vision, hearing, prescription drug and medical supply costs. Patients would regain free choice of doctors (rather than having to find an in-network physicians and hospitals) and doctors would regain autonomy over patient care. One wonders why The New York Times consistently fails even to mention the New Health Act, especially at a time when deficits in the newly approved US Tax Act will begin to whittle away at entitlements to make up for losses caused by extravagance to the rich.
19
Going single payor is easy peasy for patients. In private care, your doctor hands you the bill, but in the first day of universal care, she sends it to the single payor. The doctor no longer needs a clerk just for fighting with insurers.
Patients would do well to keep tabs on what is spent, as it may flag unnecessary yet profitable suggested treatments no matter how they are paid for.
Medical services remain the same.
4
What is considered the patient today by the healthcare industry is simply the insurance company that pays them. The sick and dying are just the mechanism to get paid. Insurers don't care what it costs, they just raise the premium.
1
Although single-payer health insurance faces tough opposition from the private insurance industry, Big Pharma, and other private, for-profit interests in health care, along with their allies in government there is no reason why well-informed & organized citizenry , including all health care professions, cannot prevail over these greedy vested interests. The 4 decade long, slow motion private corporate take over has resulted in today's U.S. system of unaccountable private corporations and Wall Street entities. A tiny fraction of .001% individuals /oligarchs/corporations not only own & control our economic system, but now even the government itself through huge campaign donations to both political parties with many conditions and strings attached to our Congress & President benefiting them at the expense of everyone else.
Still, don't sell America short. Abolition of slavery, women’s suffrage , civil rights were considered unrealistic, and yet the movements to achieve these goals were ultimately victorious.
On a practical level, our existing Medicare program, one that mental health/physical health care professionals, hospitals and others are very familiar with gives a readymade framework for a universal, single-payer system. This existing infrastructure will help smooth the transition to s.p., and thoroughly debunks the belief that just because the USA is such a large country, now over 330 million, we cannot provide universal, quality and affordable health care for all.
12
I hope we don't move to Medicare for all. My parents are on Medicare, and their choices of doctors and facilities are much more limited than the employer provided insurance my family utilizes. Medicare would definitely be a step down for us, and I imagine, most Americans.
I beg to differ. I have been on Medicare for 10 years and have a huge array of insurance programs available to me, both PPO and HMO with an array of primary care and specialist physicians. There are Medicare Advantage plans and Medicare Supplemental plans to consider as well as plain old Medicare. Hospital choices are also plentiful.
I recommend you undertake a study of all of the programs available to your parents before choosing a plan. Medicare is not a step down from anything and it is well run and very considerably less expensive than employer plans.
We have not had any limitations on the physicians we use. Perhaps we don't pay much attention because we have superb supplemental insurance. Knee replacement cost: $150. shoulder replacement cost: $75. Both performed by highly rated and recommended physicians. We pay far too little for the great care we get.
The first US President to recommend single payer health care was Teddy Roosevelt. The AMA was against it then. Now they would welcome it. Medicare today is more equitable and efficient than any insurance company. We need single payer Medicare from cradle to grave. We need to compensate doctors for quality of care, not quantity. We need to allow Medicare to negotiate a fair price for drugs. And of course, we need to elect a government that represents its constituents, not corporations.
In order to elect a government that is not corrupt like the one we have now, is to ensure an adequate education of our children. The sad fact of our country, is that a poorly educated populace elected the con men that are destroying our democracy.
5
As the following link demonstrates single payer when initially proposed in the US it did so with the support of the AMA. One reason for the AMA's change of heart on the single payer system was that it was designed along the same lines as the German program and with the advent of WW I, the single payer proposal lost much of its backing.
Granted, there were other obstacles to the adoption of a single payer system here in the the US, and the linked article goes in greater detail on the politics of the time.
www.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us
Any nationwide form of health care is the highest expression of equality. This is why the US doesn't want it and, sadly, will probably never do it. The GOP basically believes that only the wealthy deserve to be healthy. They gleefully throw individuals and small businesses under the bus with the rest of the 'trash,' and their supporters don't care even when they're among those discarded.
14
I sum up Taiwan health care in two words: science & service. There is no struggle w financial nor liability formalities. They get right to the medical matter.
Medicare for All Single Payer health insurance system has not happened in the United States because doctors representing this option were not allowed to participate in the process of creating the Affordable Care Act. In fact, two doctors advocating for Single Payer health insurance were physically escorted out of a public panel discussion event during the formation of the ACA. It's remarkable how obvious the NY Times' bias against Medicare for All is, since, for another example, in this article they do not mention at all how Single Payer was shut out of the process.
8
Yup. The ACA is such a Rube Goldberg setup because it was designed in a way that appeased the big pharma and health insurance lobbyists, and Congressional Democrats in swing states/districts, who feared that supporting anything that looked or smelled like single payer would doom them at reelection time (and then they all got Tea Partied to death anyway).
1
In this country, the ruling party won't even support health care for kids. That's where it's at in the good ol' US of A.
22
25 states are drafting legislation to move to single-payer healthcare. New York Health has passed the Assembly overwhelmingly and needs ONE more senator have a majority in the state senate.
Most Americans want Medicare for All, even 40% of Republicans. If 40% of the NY state senators represented the will of their constituents, NYers would have more comprehensive benefits than Medicare provides for 25% less than what we're paying now AND NY businesses would be more competitive. (visit www.nyhcampaign.org) But we don't have 40% supporting it, or 20% or 5% (it would be law if 3% of Republicans supported it)
Why don't our representatives enact laws their constituents want? Special interests! Big Pharma and health insurance spend billions in lobbying and campaign contributions to protect their record-breaking profits.
In NY, we are so close — Republicans in Albany should be worrying about being the Party of Trump & the Tax Bill. WHEN (not IF) NY Health becomes law, the rest of the states will follow, just as Saskatchewan led Canadian provinces to better coverage, better public health, at far less cost and with better cost controls.
Yes, Taiwan has done well for its people, but NY can do better.(Campaign for NY Health)
10
The US has not been hemmed in by its past. We have been constrained by our those most selfish.
6
Do they have gerrymandering, Deplorables, and unlimited corporate spending on politics and lobbying in Taiwan?
4
I attended a one day forum on the American opiate crisis at Duke University this August. The Global Health Program of Duke organized this conference.
An important delegation from the Taiwan Single Payer Plan was in attendance.
The tacit, if not the explicit, consensus of the panelists and the organizers was that the USA will have to adopt many aspects of single payer health insurance plan in order to stem this monster of an epidemic.
One of the harsh realities is that our physician and other provider work force is so degraded by our overly expensive, overly complicated education and reimbursement system. that we will need to rethink how we finance medical education.
That problem simply does not exist in Taiwan.
A study done at Princeton by the NBER demonstrated that our weaker and offshore medical schools produce physicians who are grossly over-prescribe opiates.
https://globalhealth.duke.edu/events/take-our-pain-away-patients-practic...
Bohdan A. Oryshkevich, MD, MPH
1
It would seem that we could offer free tuition to anyone that is accepted by any accredited medical school. I would pay more in taxes for a Doctor's scholarship fund. I would simply donate even f the donation was not deductible. Come on Democratic candidates, get creative. The Republicans certainly won't.
1
I read at the top of this column these words: THE NEW HEALTH CARE. Then I wonder why there are only 47 comments, since I believe health care is a major and continuing concern for all Americans.
I visit Health and discover that this article is not listed there, the place where I normally look for articles dealing with health. This article is listed only at TheUpshot, perhaps not visited by anywhere near the number of readers who visit Health.
I should be able to make this point directly to TheUpshot but see no link so I must file as a comment, never to be read by a Times Editor.
Common problem especially at Times Race/Related where an Email address is provided but where the Emails apparently are never read.
Only-NeverInSweden.blogspot.com
Dual citizen US SE (key information when writing about health, see comment at 11 recommend)
1
After the last several months, I honestly do not believe Republicans want Americans to have access to affordable, universal healthcare. From what I can tell, they are trying to destroy such basic expectations, though it is beyond me why they are doing this. I believe they will destroy what remains of this country before they would ever acquiesce to something like single payer healthcare. We are in a very difficult position.
19
yep, they want to return to the time before FDR, their nemesis, when the poor and elderly starved and died on the curb after working their lives in a monopolist's factory.
1
Let's tell the truth, shall we? The United States is not failing to create a single-payer healthcare system because of "political stalemate", or due to being "hemmed in by history." It has been prevented from desperately needed health reform by the abject cruelty of the Republican Party.
Further, its healthcare system is comprehensive, covering every resident of the country, offers excellent health care, and does it for one-third the cost relative to GDP as the United States.
TR Reid wrote extensively about Taiwan's system in his book "The Healing of America." Not only Taiwan, but also Switzerland completely overhauled its healthcare system in the 1990's.
We need "experts" to stop covering for the Republican Party, and point out that that party is to blame for the lack of reform. Period.
40
Or it could be the Chinese are just smarter and more organized than Americans. The past 18 months pretty much proved this point.
I'm an American Expat, retired in Taiwan. When the Upshot article (cited in this article) was published, I wrote to the NYT that I was disappointed at not seeing Taiwan in the list of health care systems being evaluated.
My father was a physician and I prepared intensively for a career in medicine (which did not come to pass.) But I am a knowledgeable consumer of health care and I would argue that Taiwan's system is even better than this article asserts.
During the seven months it took me to qualify for the health insurance system, I purchased my medications over the counter. The full price I was paying was only 1/3 of the copay I'd been paying in the US. A recent article in the NYT explored the fact that insured Americans can buy their medications more cheaply WITHOUT using their health insurance.
So are Americans being robbed by the Health Industry? You "bet your sweet bippy" on that!
38
@ Joschka - I have just had my 2d comment accepted in which I note that we readers would appreciate a better system for communicating with Editors and authors. URL to that comment: http://www.nytimes.com/2017/12/26/upshot/the-leap-to-single-payer-what-t...
I wonder who you wrote to and whether you got an answer. Perhaps the answer appears in the form of this article.
Each of us expats can report here on the benefits of leaving our country of birth but I am not so sure that even our democratic party representives are persuaded by our experiences. If they were they would not waste time complaining about Trump but would instead be writing proposals to be used perhaps in 2018 but definitely in 2020.
Only-NeverInSweden.blogspot.com
Dual citizen US SE
First comment just above yours at Readers' picks
4
The US certainly could pass a universal healthcare system. However bringing it to America will require a level of bold leadership that has not been seen since perhaps Roosevelt.
The big issue though is not the details. It is overcoming the HMO and pharmaceutical lobbies. They have control over the political system. It is known as "regulatory capture". It will involve overcoming the monied interests, the lobbyists that they pay for, and removing corrupt politicians under their influence from office.
A universal healthcare system costs about half as much as the current system.
https://www.ineteconomics.org/uploads/articles/ftotHealthExp_pC_USD_long...
A lot of that comes down to administrative costs which are a lot lower (way less need for billing and AR departments). Doctors too benefit from not having to fight HMOs and can use their professional judgement to decide what is needed.
The thing is though, look at that graph again. A good chunk of that double the price for Americans goes into the profit margins of HMOs and pharmaceutical companies. They know that, which is why they will fight it tooth and nail.
There's no reason why it could not be done. It costs less than the current mess in the US called healthcare. The problem is the vested interests will fight it like crazy. Overcoming them is the biggest barrier of all.
12
The United States of Corporations isn't interested in this. All our elected officials care about now is satisfying their rich campaign donors. Since they won't benefit from a health care system that works for the patients, doesn't make them medically bankrupt, won't tether them to the job there's not a good enough pay off for them to push for it. And if it involves any sort of price controls on the cost of drugs the pharmaceutical industry will scream about a lack of profits leading to a lack of new and ever more expensive drugs.
14
To wit: in 2014 I had what I supposed were symptoms of a heart attack. I went to E/R at 1 am. Got examined by physician, EKG, chest x-ray and blood enzyme test - all in 90 minutes. I paid US$200 for the complete visit. I walked out with diagnosis of a broken rib above my heart. ( I’m no m.d., just an old athlete).
8
I had a very similar ER visit here in Taiwan and I paid about US$20, not US$200.
I think you have an extra '0' in there.
3
My wife and I had difficulty conceiving. We worked with a very good doctor and our out-of-pocket expenses were so low that I don't remember the exact numbers. Our twins were born in Taipei. We wouldn't have been able to afford it had we been in the U.S.
3
I also had a similar ER visit here in Taipei, which cost me about $20. All the tests were covered by the National Health Insurance. My jaw dropped when I looked at the list of (necessary) tests and their cost, all covered.
Excellent article. Now let's further compare Taiwan and the United States. Taiwan is the size of one of the United States' smaller eastern states - half the size of West Virginia, a third the size of Maine. It's more homogenous, and as Jeremy Anderson pointed out is accustomed to one party rule. Converting the USA to single payor would be at least ten times harder. We will have to plan in detail, but it would be worth it.
8
That is true. But our challenge is to provide that level of care at that cost.
Canada is bigger than the USA, similar in culture, and has ten provinces, three territories, urban areas, rural areas, and very remote areas with a harsh climate where it is difficult to deliver health care.
Taiwan is just another example.
18
The Canadian System is less expensive for a variety of reasons. Despite the size of Canada, about 80 % of Canadians live within 60 miles of the USA and mostly in urbanized areas. The Canadian system tends not to purchase expensive new medical equipment and the Canadian system is structured to send many patients to the USA for the diagnosis and treatments not available in Canada or when the wait is too long in Canada. After all, the USA is an hour or two drive for most Canadians. The Canadian system is good because we Americans overspend. And name a single blockbuster drug developed by the Canadians. The USA is the powerhouse for new medicines and equipment, not Canada. But, we can learn much from the Canadian system.
Actually, Taiwan has a very lively two-part political system. Because the new insurance system gave access to all licensed providers to 23 million potential patients, the health-care community was all for it.
1
My brother-in-law lives half of the year in England, the other half in Taipei. He prefers to get his medical care, dentistry and eye care in Taipei. Says that the quality is as high or higher than in England.
5
And the quality is as high or higher than in the US as well.
Even my very limited Chinese is only a minor obstacle.
6
Heathcare service is like police service and firefighter service. It is there to protect Americans from harm to life and liberty and to empower them in their pursuit of happiness. It supports our declaration that all Americans are created equal.
Required Results of a New Healthcare Act:
One: Expand the number of people covered, beginning with children, veterans, and the poor.
Two: Do not reduce the benefits of any person now eligible.
Three: Do not increase the costs to any person now covered.
Four: Pre-existing conditions covered.
Five: U. S. Government to negotiate drug, device, and service prices.
Six: U.S. Government to allow purchasing drugs and devices from foreign sources.
Seven: Companies that drop participation are not allowed to have any U.S. Government business. https://www.theatlantic.com/health/archive/2017/05/why-so-many-insurers-...
Eight: Elected officials have the same coverage as ordinary Americans.
Nine: Preventive Life Style screenings with first visit of a calendar year
Ten: “Smart” electronic medical records (EMR)
Eleven: Artificial Intelligence Data Mining used to start treatments at the best time.
Twelve: No restrictions of funding for Planned Parenthood
Thirteen: Better policy on the disposition of “expired”, but still safe and effective drugs.
Fourteen: Mandatory reporting of fraud by all healthcare employees.
One approach would be Medicare/ Medicaid for all Americans.
14
As long as "Medicare / Medicaid" are freed from the legal restrictions on their ability to negotiate prices, I agree with you.
2
"a number of states — including Vermont... have made pushes for single-payer systems in the last few years. These have not succeeded... because there is less tolerance for disruption in the United States..."
Untrue. The Vermonters had zeal, but eventually ran up against the same stone wall that stops every single-payer effort: "Cost," a word that Professor Carroll only twice mentions fleetingly in his analysis. If Vermonters, some of the most liberal voters in the nation, had to back away from single-payer, why bother even ASKING Texans or Floridians?
If you want single-payer, be prepared to ask the citizens of America "How much are you willing to pay?"
4
Vermont never offered its citizens single-payer. The results of the implementation commission, hijacked by HMO/ACOs (for profit insurance companies) eliminated the savings single-payer achieves through simplifying billing. NOR did the Vermont plan included negotiating drug prices (although, to be fair, it's a small state so scale would not be in its favor). Yes, the voters "voted" for single-payer but the plan that their elected representatives received and that their Governor was asked to sign was NOT single-payer. Bait and switch, anyone?
2
Ok gang.let's go over it again, imo as this article proves, US is pretty much a third world country with our health system despite the fact we have some of the best doctors in the world.
Single payer or a system like it is the way to go. Let's make America great again in health care. Get rid of Trump and the republicans and change the system.
The sooner the better.
43
The first thing we need to do is figure out how the GOP persuaded Americans that the GOP, the source of this misery, should be given the levers of government!
5
While the current fiasco of a US health care system is primarily due to Republicans, the Democrats have to take some blame also - I would call it about 85/15%. The main obstacles are not just tribalism, but massive political donations by pharma and related.
Good question Joschka. I think Churchill said it best, and I am paraphrasing him, that Americans try everything in the beginning (ie get it wrong) but in the end get it right.
It was a combo of a republican base that will always
vote republican if Donald Duck was nominated plus Trump getting out the 5-7% of bigots that might not have voted plus tapping into rust belt states anger with loss of blue collar jobs to slave labor countries, plus an electoral system that favors the republicans plus a identity obsessed never met a war, Wall Street banker, trade agreement candidate like Hillary.
Trump may be a bigot, pathological liar, rabble rouser, admitted sexual predator, ego maniac demagogue but he is not stupid.
"This didn’t stop President Truman from considering and promoting a national health care system in 1945. This idea had a fair amount of public support, but business, in the form of the Chamber of Commerce, opposed it. So did the American Hospital Association and American Medical Association."
https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has-emp...
The private health insurance model is a superb system - for transferring wealth upward, which is why our corrupt political system will never allow it to happen here.
8
One very important difference is how Taiwan's political system functioned through the mid to late '90s. I was living in Taiwan at that time.
First, while it was a democracy, there was still single-party governance. The now-ruling DPP was in minority at the time and the KMT had controlled Taiwan's government without meaningful opposition since the 1940s.
Second, and much more importantly, the KMT was financed by a patronage system which would have made Boss Tweed green with envy. The party owned a number of profitable businesses from propane (the rumor was every tank we bought for the house was a six cent campaign contribution), to large civil engineering and construction firms that were awarded work on freeways and rail systems.
Party leaders proudly said this system allowed the party to respond to the voters and not to backers. While insurance companies protested loudly that this would hurt business, the KMT was able to safely ignore their pleas.
This frequently seedy system was dismantled in the early 2000s. Taiwan became a real two-party system and the DPP demanded the ancien regime divest their business holdings.
If it were 2017, I doubt Taiwan could have implemented the National Health Insurance program.
6
The issue isn't the payment model - it's the coverage model. As a very wealthy country - America can easily afford any healthcare system we choose to design - except one. The one we have based on tiered coverage.
http://hc4.us/PriceNotPayer
8
Excellent article. Thanks for the link.
I’ve worked in healthcare since the 1980s. I had my first child in MT at 19 yrs old. The hospital offered a discount; we paid $750 during my pregnancy and owed nothing further. Things have changed. My son was hit by a car in 1999. He was in the “self pay” tier because the payor was the driver’s auto insurance. These fees are not discounted as they are when insurance or Medicare/Medicaid is the payor. Needless to say, the $200,000 auto insurance award was quickly depleted.
I am a Medicaid RN Case Manager. Many on Medicaid pay nothing and have access to excellent healthcare. I am relieved that this population has access, however the disparity in cost and care is not sustainable. The middle class is losing. This summer my son fractured his elbow. I work for his health insurance company yet out of pocket costs were $5000. We charged the majority to a credit card.
My 31 yr old daughter is paying $20k for dental work that we paid $20k for when she was a teen. She has four congenitally missing teeth and her implants and veneers must be redone every 10-20 yrs. Dentists charge outrageous fees while the best dental insurance plan, which most people don’t have, pays max $1500/yr.
What needs to happen before we all rise up and say NO MORE?
10
"The one we have based on tiered coverage." Which is exactly what we want, NIMBY insurance - good healthcare for you, but nothing but the best for me and my family. If we want real candor, some [suicidal] candidate has to get up and say "Some people will have slightly worse coverage."
2
The basic difference is the principle of doing the best for most people - of course the system not perfect. Nothing ever is. To those who critique foreign health insurance systems for not being perfect or gleefully pick out the downsides are just Americans who are part of the problem. Americans are no longer the leaders, the problem solvers nor the innovators - we are being left behind by partisanship, lack of imagination and phony patriotism. Basically in most countries health care is basic, fundamental and available to most people. In the US you have to be rich because our system is skewed to the individual and those with money.
24
And under the current administration we are falling even further behind on US leadership. Your description of the problems are right on - especially the phony patriotism. GOP supporters brag about the stock market gains over the past year - but the simple fact is my 401k has done much better than the US stock market, as I have around 90% of my holdings in foreign equities (almost all Asia).
1
Funny how the article glosses over the downsides:oh, and they are having a shortage of doctors and chronic care is underperforming, rising costs.
And as another poster observed - what new ground breaking medical therapies have come out of Taiwan?
No, this is not the answer. To those who claim that such systems are "adequate" - talk about low expectations. Why do we have to be denied _superior and outstanding_ health care just because you are willing to settle for "adequate" and lack vision and imagination? The US didn't get where it is by settling for "adequate" just because that's what other people had.
No, the reason we can't have superior health care, the obstructionism from all sides, is because people lack vision and imagination, they lack the capacity to have more than one simple minded thought in their simple little heads at a time. And "single payer" is the epitome of simple minded ignorance.
The thing is, health care is fundamentally at least three distinctly _different_ problems requiring different forms of solutions. But stupid simple minded people insist on one solution for all that in the end solves none. "Regular" every day health care is different from acute health care, is different from chronic health care and cannot be adequately and appropriately addressed with a one size fits all answer. But people can't comprehend more than one thing at a time so they keep insisting on a chimera of a one size fits all answer.
3
"And "single payer" is the epitome of simple minded ignorance."
So explain to us why single payer is significantly less expensive compared to our system and produces far superior outcomes in all the countries that have adopted it?
7
As a physician, the above statement is completely flawed and uninformed. Access is critical. Single payer or any system in the US will always be difficult since much of healthcare the US is profit driven every step of the way. I am for single payor. The wealthy will always afford private care but it’s the strained middle class that is feeling the strain. We forget that healthcare within Medicaid is provided for the those the least able to pay, and it affords the basics of healthcare to those who need it the most.
9
And you forget that Medicaid is now in the GOP cross-hairs for drastic reductions and possible elimination.
This has been the GOP plan all along!
The US has inequality and gaps in all aspects including income, health, education, legal representation and access to the courts, that exceeds that of other industrialized nations and many other nations such as Taiwan, Singapore and Costa Rica. We are losing ground as the economic gains are redistributed to the top at the expense of the majority. Nothing is going to change until this trend is reversed. Our elected government officials are not representative of the electorate nor do their positions on the major issues. We are allowing our democratic heritage to be trampled on and trumped by unbridled greed and a pernicious notion of individualism.
Sad.
29
Health care will always be expensive in the USA, for many reasons. The populations of Taiwan and Texas are similar in size. But build one hospital in Taiwan and the entire population is within a two hour drive to that hospital. Even if 20 hospitals were built in Texas, many people would be far away from those hospitals. Texas deals with an innumerable number of non-paying undocumented aliens, meaning that others are forced to pay more. Before a national health plan could become law, the US constitution would have to be changed giving the federal government the clear right to implement a national plan. And what was the last blockbuster drug developed by Taiwan. Of course health care costs less in Taiwan because their situation is so different from the USA.
5
First, you have underestimated the size of Taiwan, second, there is no hospital in the world that can server 23 million people!
But even more importantly, it is astonishing how MANY hospitals there are here!
The hospitals run medical clinics in their facilities and there are many local private medical clinics.
In Taiwan, people are used to just about everything being close and easily accessible.
2
There are two major hospitals within a 5 minute drive of where I live. If I did not have Medicare, it would be cheaper for me to fly to Taiwan or South Korea and pay in full for a major problem.
The primary element for blocking change in the financing of the U.S. healthcare system is lack of leadership. Neither side has suggested a comprehensive expert panel to study the issue and then put forth viable alternatives for change. The primary hurdle prohibiting this needed first step is money in politics. Entrenched trade groups (Pharma, AMA, Insurance, AHA, etc.) all have an economic views that favors their constituencies and fund huge lobbying efforts to those ends. Until those dollars are somehow removed from the legislative landscape we will be saddled with a broken, unintegrated and increasingly ineffective healthcare system.
20
On the contrary! The Clinton administration did a comprehensive study (unfortunately in secret) and the Obama administration did an ever MORE comprehensive study. But the moneyed interests destroyed or limited both attempts.
2
Joschka is correct except the analyses are not secret. Both the GAO and the CBO studies from 1992-3 are available — both conclude that a single-payer approach would allow the US to provide universal coverage for less than the then current cost of coverage — with better cost controls, better public health outcomes, and possibly with enough savings for expanded benefits. You can find these at PNHP.org or just google for them.
4
Studies have been done but since they do not fit the agenda of too many elected officials they were ignored and/or brushed off.
1
Apparent to me that US leadership is more invested in status quo, ties to lobbyists and insurance executives, than learning how to deliver healthcare for all at reasonable cost.
35
It not so much the leadership as it is the money holders who simply don't want to pay for anything that does not flow only and directly to THEM.
1
I thank the Upshot for its efforts to introduce Americans to Health-Care systems totally unknown to the overwhelming of Americans. I hope that the Upshot collects all the presentations and provides a final guide to the nature of the categories used, single payer, universal health care, government run, and more.
I find the Swedish Universal Health Care system to be highly satisfactory and have 21 years of experience with it for me and my family. Since I also am a translator and manuscript reader-reviewer for medical researchers in several different major fields I get a good chance to learn about progress in some fields.
I would like the Upshot to take on one field that NPR in collaboration with Pro-Publica has taken on but with an important departure from NPR-PP.
That field is infant and maternal mortality. Much US research and parts of the NPR-PP presentations are fixated on "race" since the overall record of infant/maternal mortality for mothers designated as "black" is so poor. The Upshot could commission a report focused on the record in, for example, Sweden where it appears that first and second generation Sub-Saharan African women do very well. (Sweden does not classify people by "race" but the medical databases can be linked with databases providing country of birth).
Can explain at my blog if you want more.
Only-NeverInSweden.blogspot.com
Dual citizen US SE
19
saying that the average Taiwanese doctor earns $36K USD a year, while the average US doctor makes $150K a year is misleading for a few reasons. The first being that it assumes that the cost of living is comparable to the US, in Taiwan almost everything is significantly cheaper, successful doctors in Taiwan live a good life. Secondary, inequality in general is just lower in Taiwan, part of that is built into the way property taxes are handled, and part of that is built into a national healthcare system. Most importantly, the average sallary in Taiwan is only $12K a year, so the average doctor is making around triple the average sallary. This is in line for the US as well.
16
Well, not exactly. The average salary in the US is $37K, so the US doctor makes 5 times as much, not 3 times.
Furthermore, we do have higher inequality than Taiwan, so professionals in general make much more than the average salary. If we reduced doctor salaries while leaving the other professional salaries high, then we'd have trouble getting enough qualified doctors.
Taiwan is already experiencing some doctor shortages, and so are places like the UK and Germany. The idea that costs can be cut without impacting quality doesn't seem to work out in practice.
Here in the US, everyone demands top quality care, and wants to be seen by the most highly skilled doctors. This tends to get expensive.
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Also don’t forget the disparity in the cost of a medical education between Taiwan and the US. The average medical student will graduate with close to $200k in student loans. In Taiwan it costs a small fraction of that and their education is a 6-7 year combined undergrad/grad program that they start after HS (so 1-2 years less schooling to pay for). If medical education cost less in the US, we’d have doctors willing to work for less and a the population of people choosing medicine would more closely reflect the demographics of the US population.
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@ Megan - Thanks Megan for reminding me that if The Upshot is going to carry on a discussion of leading the USA to medical-care-for-everyone, not only must it provide direct comparisons of specific care problems (see my comment) but it also must provide direct comparisons of costs of becoming an MD in advanced countries.
In Sweden, a student graduating from the counterpart of US high school and presenting a very high GPA, can enter medical school and go through without paying any tuition. Compare that with the US where when I was at the University of Rochester, the future med student would have to complete 3 more years of college including taking a legendary organic chemistry course.
If the Times is going to go further it is going to have to present data.
Only-NeverInSweden.blogspot.com
Dual citizen US SE
The average doctor in Taiwan earns $36,311 a year, compared to the US average of $182,000.
Sure, there are differences in the overall levels of income across all professions, and purchasing power parity might give a different result, but this is still a huge difference.
This sort of thing is true in every country where they spend 9-12% of GDP on medical care, compared to 18% in the US. Doctors in these countries make a good living, but nothing like what they make in the US.
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Taiwan is absent the vicious tribalism that exists in the US, where "winning" or "losing" is much more important than "what works". I have been putting Taiwan forth as an example for years of how the US SHOULD go, but probably never will.
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