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My question relates to a simple fact, that to many Europeans it seems that every time a President of the USA is committed to create a real Public Health service, the people seem to act against their efforts.

There are no street movements to support his efforts and also the people seem to be averse to such kind of project.

In Europe (and in Canada too) there are Public Health services that work very well. In Italy (my country) where things are often disorganized in many sectors, the Public Health system works so well that in many branches of medicine some of the world's most important centers of excellence are Italian public hospitals.

In USA, if you don't have insurance (and consequently a job) or you are retired and you get a cancer or some other severe disease, you have few chances to survive because care and diagnostic tests are very expensive, and few people can afford them without insurance.

Also I know that insurance contracts may be interrupted by the companies that realize that you have become a problem for them and there are no laws that protect the people against such kind of behaviors.

Is this true?

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    Maybe they heard how well it worked out for the veterans? – user1873 Dec 3 '14 at 15:02
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    For every story like yours about how awsome nationalized health care is in Europe and Canada, I can give you many of the horror ones from same Europe and Canada. Many-months waits for procedures or exams. Inability to get access to really advanced treatment. Etc... – user4012 Dec 3 '14 at 15:12
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    I'm pretty sure I remember seeing a survey which showed that most people were in favor of most of the ACA provisions (such as the one @jalynn2 mentioned), but disapproved of Obamacare as a whole. Which is entirely irrational behavior, but people are irrational creatures. – Bobson Dec 3 '14 at 15:38
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    @DVK It depends on what you mean by “nationalized healthcare” but if you look beyond anecdotes, the picture is clear. European countries have widely different systems, some of them a little better in one respect or another but they all achieve similar outcomes from much lower costs and with better coverage. – Relaxed Dec 3 '14 at 16:23
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    @user1873 A single-payer system is significantly different from the VA, which is a single-provider system. – jalynn2 Dec 3 '14 at 17:19

10 Answers 10

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Note: This answer is not singling out any specific healthcare plan

At the highest level of abstraction:

Americans are actually not against the concept of the public at large getting healthcare.

Opponents of public healthcare are really opposed to policies that might be required in order to make that a reality.

  • Acquiring funds to fund a Health-care by increasing taxes, cutting spending on other programs, or going into debt
  • Conscripting "private" companies to provide for the healthcare system by compelling them to do business in a way that might cause them to lose money.
  • Requiring citizens to pay for health insurance(either private insurance, or taxes for a universal insurance plan
  • Imposing rules and regulations on insurance plans in general that don't necessarily meet everybody's needs.
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    Very interesting reply. I mark it as useful. Thanks. – Guba Dec 12 '14 at 21:29
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    The problem with that first bullet point is this - if a company is paying $9000 dollars to a private insurer, and pays $8000 in increased taxes, instead, under a public system for that same employee, those against will say "My God! $8000 per employee in increased taxes! Madness!" while ignoring the fact that the company is paying $1000 less for health insurance for that employee. – PoloHoleSet May 23 '17 at 18:39
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    What may be behind the first point could be the reluctance to pay for somebody else's health care. A private system, as in the US, more or less requires everyone to pay for their own health care. In a public system, everyone pay for everybody else's health care too. – Dohn Joe May 28 '18 at 11:16
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Most of what you may have heard is not quite true anymore. Obama's reform was very successful in addressing some of the most glaring issues with the US healthcare system, even if many people in the US might not know exactly what's in it and actually welcome some of the most important measures while somehow declaring themselves opposed to the law itself.

It's however still true that the US healthcare system as a whole is much more expensive than just about any other system out there. It's difficult to measure precisely how much this impacts health outcomes (say life expectancy) but what does happen frequently is not so much that people get no care at all but rather that they go bankrupt to pay for it.

Furthermore, it might be tempting to lump all European systems together because most of them perform reasonably well (it's one of the few areas where Europe is indisputably better than the US), achieving similar outcomes for a fraction of the (US) cost, but those systems are actually very very different from each other.

Whether it's to praise them or deride them it's common to think of Europe's healthcare systems as somehow “public” but that's a gross oversimplification. I don't know that much about Italy but depending on the country, you can find everything from private insurance (mandatory or as an overlay, for profit or not) to private practices and clinics. Only a few countries have a state-run healthcare delivery system, free at the point of delivery (like the UK's NHS). Most of them have different forms of private and public healthcare providers coexisting within an insurance-based system in which the insurers can be private companies, independent not-for-profit entities or some mix of the two.

Basically the new US system is somewhat comparable to that of Switzerland or the Netherlands, with some peculiarities resulting from the federal structure of the US and the situation before the reform. It's based on private companies offering heavily regulated insurance contracts, with a “mandate” making this insurance mandatory, and some subsidies to make it affordable.

And while healthcare in Switzerland and the Netherlands tends to be slightly more expensive than elsewhere in Europe, they achieve roughly similar outcomes than other European countries for a much lower price than the US. The obvious conclusion is that the existence of a regulated (private) insurance system isn't the only cause of the gap in costs between the US and the rest of the world. The costs of care itself is and even a “public option” or “Medicare for all” (i.e. a European-style universal insurance) would not instantly solve that problem.

Beyond ideological preferences, there are several very good reasons why Obamacare had to be the way it is and not a public healthcare provider or a state-run “single payer” insurance system (like Canada's). The most important ones are:

  • Many people were happy with the existing system. They got insurance through their employer, had access to excellent care and might not even notice the cost of it all until they get some serious condition or employment/insurance trouble. They were unlikely to welcome any radical changes to their own insurance contracts.
  • You have to contend with the power of the existing players (path dependency). Neither private hospitals nor powerful insurance companies would be happy to give up their business for some sort of purely public system.

One way to get a quick overview of all this are the Healthcare Triage videos posted by Aaron Carroll. His blog (with a few co-authors) also has a lot of relevant information (including on the costs question) with links to the research literature.

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    @Guba VA = Veterans Affairs. Retired military (and families) in our country are entitled to use the VA system of hospitals and doctors which is set up as a single-payer system. – user1530 Dec 6 '14 at 17:35
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    @Guba I am not American and I am not convinced the US system is particularly good. My point is (1) your nephew could probably get cheaper care and would have been covered by some form of affordable mandatory insurance or have access to healthcare free of charge just about anywhere in Europe (including, for example, in countries with exclusively private insurance like the Netherlands) and (2) the US has very large public components (both insurance and actual healthcare delivery) to its healthcare system (but limited to specific population). – Relaxed Dec 6 '14 at 18:46
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    Given those two facts, it's silly to assume that a reasonably efficient healthcare system has to be organized like the one in any given European country (because they all achieve similar outcomes in widely different ways) or that the main difference between the US and other systems is that the US system would be “private” while the others are “public”. – Relaxed Dec 6 '14 at 18:50
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    Now, to answer the “why USA people seem not taking this problem so bad”, the fact is that they are taking this problem very seriously. Healthcare reform is possibly the biggest thing Obama has done in his two terms as president. It was very controversial as well so one way or another many people care a lot about it (even if only to oppose it on purely partisan or ideological reasons). – Relaxed Dec 6 '14 at 18:57
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    Given all that “Why are people opposed to a public system?” is almost meaningless and “Why don't people care?” or “Why are they opposed to universal access to healthcare?” are misleading questions (because in fact they do care). The real question is: Why does the effort to make coverage universal come so late and through such a complex system? That's what I am addressing at the end. – Relaxed Dec 6 '14 at 19:01
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There are 3 answers:

  1. On a high level, people in USA trust free markets more than central planning, for a large amount of economic activity. Health care being one of them.

    Discussing whether that trust is founded or not on Americans' part is somewhat outside the scope of the question which merely asks "why do people".

  2. Most of the issues you hear discussed in USA stem NOT from presence or absence of public health system, but from structural failings of US healthcare "insurance" industry and other unrelated issues (e.g. tort litigation atmosphere and consequent practice of defensive medicine).

    Please note that the quotes around "insurance" are there on purpose.

    What we have in USA isn't real "insurance" - which is typically implied to be catastrophic insurance.

    Also, most insurance companies possess government-imposed monopoly, thus preventing competition from improving their product.

  3. On a lower level, you're mistaking anecdotes for facts.

    You hear some cases where health system in USA fails. As is the nature of things in our world, those cases are heard and trumpeted WAY out of proportion to their actual amount or significance, both because the media thrives on showcasing the bad, and because political forces supporting public health system want them to be.

    However, there are plenty of cases - both anecdotal and systematic - where public health systems fail compared to US's private ones. From abysmal state of health care in USSR, to mega-month wait for procedures in UK/Canada that are done in under a month in USA, to people not having access to advanced treatments that simply aren't available outside USA, to horrible failures in NIH (or as @user1873's comment mentioned, in the public health system that USA does have - Veteran's Affairs medical system).

    Each system has its own strengths, weaknesses, and tradeoffs.

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    practically nothing about the US healthcare system is free market so I'm not really sure why you put that in your answer. – Ryathal Dec 3 '14 at 16:01
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    (-1) It's the waiting list scares stories which are anecdotes. The US system is vastly more expensive (I mean a factor 2 or more) than European systems with very little to show for it. That's the basic fact. – Relaxed Dec 3 '14 at 16:25
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    #3 isn't correct. Most rankings of health care quality put us far from #1. Compared to the rest of the world, we do fail in comparison. – user1530 Dec 3 '14 at 17:03
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    @DVK That argument has been debunked many times (see e.g. this). It does not make a big difference incidentally. Even if you want to put it all on tort law, you still can't imply that it's a toss up or some reasonable trade-off. There is one system with average outcomes and vastly higher costs than a whole bunch of universal systems with all manners of public/private combinations. That's a basic fact that needs to be acknowledged instead of offering rumors or anecdotes regarding the UK or Canada. – Relaxed Dec 3 '14 at 18:41
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    Tyler makes a good point, too. In this country, there's a faction that's simply against government in general. – user1530 Dec 3 '14 at 22:05
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In a word, money.

Most years, healthcare CEOs are the highest compensated CEOs. Compensation, both direct and indirect, can be challenging to calculate, so depending upon whose numbers one examines one will find a different answer. However, in almost every analysis, healthcare CEOs have the highest median compensation.

The Organisation for Economic Co-operation and Development, or OECD, was founded in 1961 and is comprised of 34 member nations. The OECD originated in 1948 as the Organisation for European Economic Co-operation, or OEEC. Among the issues for which OECD collects and analyzes data is health.

There is even an Excel format spreadsheet one can download that contains key indicators of health from OECD statistics.

In my view, one of the best numbers to examine is Total Expenditure On Health as a percentage of GDP. The OECD average is 9.3 percent. The lowest is 5.4 percent in Turkey. The second highest is 11.8 percent in the Netherlands. The U.S. spends the most at 16.9 percent. That's 43 percent more than the Netherlands, 82 percent more than the OECD average, and 213 percent more than Turkey.

Here is a graphic showing the data from a couple of years ago. Current numbers are little changed from these, and the image makes it's clear the U.S. is completely off the chart.

OECD expenditures on health

If one examines the chart closely, one will notice a breakdown between public and private expenditure. In terms of public expenditure, we are indistinguishable from any other OECD nation. Private expenditure is where we are off the chart.

Among other data metrics one needs to examine are health outcomes, and despite our massively higher expenditures on health, we in the U.S. do not have the best health outcomes. Infant mortality rate, measured in deaths per 1,000 live births, is one of the most shocking. At 1.1, Iceland has the lowest. 4.0 is the OECD average, and 3.45 is the OECD median. At 6.1, the U.S. is #31 with a higher infant mortality rate than 30 of the 34 OECD nations. Only Turkey, Chile, and Mexico have a higher infant mortality rate.

Each of the 33 other OECD nations--not the U.S.--have some form of single payer or universal healthcare.

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    While this is highly indicative of the problems with the US health system, it doesn't explain why the people are averse to a better public health system. – curiousdannii Jan 17 '18 at 5:14
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    Money buys propaganda, which works on people – Kennah Jan 18 '18 at 16:09
  • So? You haven't mentioned any propaganda, or anything, which would explain why many US people are averse to a public health system! – curiousdannii Jan 18 '18 at 16:34
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    Back to what I first said. In a word, money. Take the money out of politics, and things will change. Corporations know this, so they've been fighting for years to support politicians willing to put judges on courts who will side with corporations. – Kennah Jan 22 '18 at 4:16
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There are a number of theories as to why many Americans oppose a "public health system" (by which I take it you mean publicly funded via taxation or something similar). I suspect that the answer is a mixture.

  1. On principle they are suspicious of any government program to do pretty much anything.

  2. US government programs tend to be inefficient, bureaucratic and slow.

  3. The US healthcare industry is a powerful and well funded lobby who are good at getting their point of view across. The industry does not want to be replaced by a government service, so they take every opportunity to tell the American public that it would be bad for them, and the public broadly believe them.

  4. Endowment Effect: people value their existing health care more than the potential future benefits of a new system.

  • One could even say that answer 2 is a feature, not a bug, that is a result of answer number 1. Americans as a whole do not trust their own government. – hszmv May 29 '18 at 20:16
  • On the other hand maybe 1 is a bug and 2 is the unfortunate consequence. Government programs tend to be rule-bound and underfunded because people do not trust them. This makes them slow and inefficient, causing people to trust them even less. – Paul Johnson May 30 '18 at 7:47
  • Considering the Constitution was written with tight constraints on what government can and cannot do and they specifically limited the Federal Government the right to claim power they didn't give it, I would say that the Founders were quite concerned with central government overreach. – hszmv May 30 '18 at 17:04
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I am not an American, but here is my guess.

In Europe public healthcare is usually financed by the state from the taxes collected and other state incomes. And most taxes collected in Europe are proportional or progressive, that is the rich are taxed the more.

Conversely, in the USA the proposed system of universal healthcare works as a per-person tax. In other words in simplified terms the poor and the rich will pay the same sum, and there is a cap (some really impoverished are provided with some subsidy though). So this tax is regressive (the richer person pays less share of his income). Thus it is an extremely right-wing measure, comparable to per-person tax introdused by the Teatcher's government in the UK.

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    This addresses those that are against Obamacare specifically due to the regressive nature of it. But there's a bigger faction that's simply against government health care to begin with (regardless of whether the taxes are regressive or progressive). – user1530 Dec 5 '14 at 16:30
  • There are subsidies for households with up to 400% of the federal income poverty level, which apparently covers more than half of the population and not merely a minority of very poor people. Are all European healthcare systems really much more progressive than that? Would be interesting to find a quantitative comparison. – Relaxed Dec 5 '14 at 17:22
  • Once again, thank you for your opinion, but you don't answer about my question that is to confirm or deny my impression about the people attitude to be in favor or against (I feel the second) the possible public healthcare system in USA. – Guba Dec 6 '14 at 11:33
  • @Guba AFAIK the USA has a system of state hospitals for retired military which is considered very good, and many people consider it fortunate if they managed to get to these state hospitals this or that way because they work more efficiently than the private ones. – Anixx Dec 6 '14 at 23:45
  • AFAIK ? What does it mean ? However I'm glad to hear that retired soldiers have good free medical assistance. And I think that is quite natural that these structures are better than private ones, because people working here do it for spirit of service and not only for money. – Guba Dec 12 '14 at 22:00
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Based on your comments, it sounds like you're asking a more direct question: Are americans against a public health care system?

The answer is yes and no. Many are, many aren't.

As to some theories as to why some are against it:

  • Insurance Companies. Insurance is a big industry. Big industries have a lot of sway with politics in this country. A single payer public healths system would greatly affect the insurance industry. Insurance companies have lobbying power and employ a lot of people.

  • Politics. There have been previous attempts at getting a single payer system going in this country. One example would have been in the 60s, where Reagan pushed against it: http://en.wikipedia.org/wiki/Political_positions_of_Ronald_Reagan#Healthcare (related: see above bullet point and below bullet point)

  • The insurance model was working OK. The private insurance model where most employers were a part of the system was actually a pretty decent system only until more recently. Why fix what isn't broken?

  • We're stubbornly independent. Aside from Myanmar, we're the only country on the planet that hasn't adopted the Metric system. We're one of only 4 nations on the planet still sticking with Fahrenheit temperatures. We insist that Football is to be played with helmets and a squished ball. Sometimes we do things for no other reason than to be different. :)

  • Where we do excel at healthcare, we really excel. Our existing health care had some really low lows, but also some really high highs, so there's some arguments that we don't want to suppress those highs with a single payer system.

Notes:

  • Not everyone is against a single payer in this country. Lots of people are very much for a single payer system.

  • We actually have some single payer systems in this country that work pretty well--such as the VA system (their record keeping issues aside) and Massachusetts' system.

  • As others have stated, we've made some headway towards resolving some of the bigger issues. The big one is access to insurance. Obamacare has greatly increased the number of people that now can afford insurance.

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    Don't forget Medicare as a very successful single-payer system. – jalynn2 Dec 3 '14 at 17:22
  • The insurance model was working OK for healthy people who had insurance. Not so well for people without insurance or the chronically ill. – jalynn2 Dec 3 '14 at 17:23
  • @jalynn2 sure, but my point is for a long time, most people could get affordable insurance (at least, a lot more than over the past decade or so). If 'most' people are satisfied, alas, that's often all it takes to keep the status quo. – user1530 Dec 3 '14 at 17:28
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    agreed that employer-sponsored health insurance was much more prevalent in the past. – jalynn2 Dec 3 '14 at 17:29
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    @Guba my answer was meant to answer your question: why people are adverse to universal health care. So I suppose to answer the short question: yes, a lot of people are against public health care. (But a lot of people are for it.) – user1530 Dec 6 '14 at 17:34
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Because Americans have been lied to by the American right-wing for decades, and told that government health care is Socialism, which according to Jonah Goldberg and Dinesh D'Souza, to name only two, is the same as Fascism, and Fascism is Nazism, so supporters of government health care are literally as bad as the Nazis.

I wish I were making this up, but I am not. Much of it started with The Road to Serfdom. There is no end of right-wing propaganda on the topic.

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Abortion. A deal breaker for a significant portion of the population, both pro and against. It is immoral for the anti-abortion side to pay for abortions in any way and equally held dear to the other side is the right to choose. It's a litmus test for politicians. No one gets elected holding a middle ground position on this issue. Prevents consensus on any plan because it cannot be left out or left in, even if there was agreement on the socialism vs free market issue. For instance the Catholic Church has always wanted a public plan but preached against Obamacare for including abortion coverage. There are other socialized programs in the U.S. that enjoy popular support, such as national parks, NASA, military, social security, so if a solid plan was properly marketed as a moral and national imperative at the right time the U.S. would get behind a socialized plan. If it were not for the issue of abortion.

  • And how does this tackle the question? Please, do not post comments as answers. – Alexei May 29 '18 at 6:00
  • I really doubt that abortion is really that one core issue which breaks health insurance in the US. It might be one argument which is used to mobilize people against it, but it's certainly not the main issue. – Philipp May 31 '18 at 8:13
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One component would the US Veteran Health Administration- a single government health system and despite costing 65 billion dollars is a complete shambles. It fails to meet any standards it sets for itself and is avoided by all US military veterans who have any choice. Seeing what a disaster that is, Americans could not possibly what it expanded to all Americans.

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    I understand that this is widely believed, but it's not really true. In fact, the US VA Administration is the largest public health provider in the world, and is widely admired. There are periodic "scandals" relating to recordkeeping, or wait times, but these are a function more of the political environment in the US than actual care quality. It does a very good job with an exceptionally challenging patient population, and was among the first to implement electronic medical records (EMRs), lowering readmission rates, and bolstering preventative care. – Curt May 29 '17 at 21:52
  • foxnews.com/politics/2009/06/24/… Political environment is part of VA. – user2617804 May 30 '17 at 0:34
  • @Curt The VHA provides health care for 9 million veterans and costs $65 billion / year. The UK NHS provides health care for 65 million people and costs $160 billion per year. The patient populations are not comparable of course, but there is no way that the VA is bigger than the NHS. – Paul Johnson May 31 '18 at 7:49

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