From a marginal return perspective, socialism is flawed, but yet it is rapidly becoming the de facto social policy in the western world.

The problem is that socialism does not help its intended beneficiaries.

and to a far greater degree in other places where socialism has already taken a much greater hold (read: Europe).

I saw people working for just enough weeks each year to collect unemployment benefits

I saw people go to the emergency room for a checkup, because it was easier than trying to make an appointment with a particular doctor. I actually went to an emergency room after being in a car accident, and having to wait for long periods of time (often an hour or more) between the brief moments when the doctor would poke his head in.
Rather, they have waiting lists for anything scheduled (which is why it’s quicker to go to the emergency room for a checkup, even if you have to wait for hundreds of other people and even some actual emergencies),

and the quality of your care, once you get it, isn’t any better than here.

ANNEX 4. WHAT EXPLAINS LOW WAITING TIMES
IN FRANCE, GERMANY AND THE UNITED STATES?
France
166. The French health care system is based on a health insurance system composed by a basic
compulsory public insurance and a supplementary insurance provided by private insurers and mutuelles. It
is also characterised by almost total freedom for people to choose and use private and public health care
services without a referral system.
167. Evidence. Imai, Jacobzone and Lenain (2000; p.2) report that “the health system in France is
regarded as delivering high quality services, with freedom of choice and generally no waiting lists for
treatments”.
168. Institutions. About 70% of beds are in public hospitals, which account for two-thirds of hospital
spending. Public hospital employees have the status of civil servants and are salaried. Public hospitals deal
with most of the emergency treatments, the bulk of major operations, including the life-threatening
conditions. Private clinics are often smaller and handle the bulk of minor surgery, for which their market
share can be very high, especially in the area of elective surgery.
169. Public hospitals are funded through global budgets which are set annually by the authorities and
allocated every month by the health insurance funds. Modest payments by patients top up these budgets.
Until recently, hospital budgets have been determined on the basis of the historic operating costs, with a
modest allowance made for their actual level of activity, the average case-mix specific costs of treating
certain diseases or expensive drugs. Private clinics are paid on a fee-for-service basis (both for doctors and
hospitals). Similarly, ambulatory care is provided primarily by doctors in private practice on a fee-for-
service basis. The authorities set official schedules of reimbursement which in a number of cases
correspond to the actual prices imposed on service providers. The system of ambulatory care provides easy
access to a specialist, in contrast to many other OECD countries, where a patient can consult a specialist
only through an out-patient consultation in a hospital, often with long waiting lists (Imai, Jacobzone and
Lenain, 2000).
170. Capacity. Table A2 shows how hospital acute care beds availability is among the highest in
OECD countries with 6.7 beds (per 1 000 population) in 2000, as opposed to 3.2 beds for the countries
with waiting times. Similarly, the number of practising physicians (per 1 000 population) is 3.3, as opposed
to 2.8 for countries with waiting times. The number of practising specialists is also higher than in countries
with waiting times but the difference is small (1.7 as opposed to 1.5; Table A3). Total and public health
expenditure per capita in year 2000 were respectively $2387 and $1810, as opposed to $2092 and $1585 in
countries with waiting times (Table A1).
171. Activity. Activity is also correspondingly higher. Table A5 shows how the number of total
discharges was equal to 250 (per 1 000 population) as opposed to 155 in countries with waiting times.
Table A6 also shows how the number of surgical procedure rates (per 100 000 population) in year 2000
was significantly higher for most of the procedures considered (with the exception of hysterectomy and
CABG).
172. Conclusion. The high capacity available in the hospital sector, combined with free access to
private hospitals (30% of beds) under public health insurance, together with fee-for-service remuneration
of the specialists and activity-related funding in private hospitals, explain the absence of significant waiting
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times in the French health care system. Private hospitals provide high volumes of minor elective surgery
and act as safety valve if queues build up for public hospitals.
Germany
173. The German health care system is characterised by a mixture of compulsory and voluntary health
insurance. In 1997 75% of the population had mandatory health insurance (for people whose income was
below a fixed level or unemployed). 13% had voluntary insurance through statutory sickness funds while
10%, in general civil servants, were covered by their employers. Most of the remaining population (mainly
high-income earners) had private health insurance. Less than 0.5% of the population were uninsured
(WHO, 2000).
174. Evidence. In Germany “Waiting lists and explicit rationing decisions are virtually unknown”
(WHO, 2000). A survey for cataract surgery based on self-reported mean waiting times suggested a value
equal to 35 days in 2000 (Wenzel, Reuscher, Aral, 2001; survey based on 450 institutions and 926
operating ophthalmologists).
175. Institutions. The health care delivery system is characterised by a clear institutional separation
between hospital care (inpatient), and primary and secondary ambulatory care administered through office-
based physicians. This separation has been recently lessened by allowing day-surgery in hospitals and a
limited amount of ambulatory pre- and post-inpatient care. Germany has no gate-keeping system, and
patients are free to select a sickness-fund-affiliated doctor of their choice. Of the 2030 general hospitals,
around 790 hospitals are in public ownership, 820 have private non-profit status and 420 are private for-
profit hospitals, with bed shares of 55%, 38% and 7% respectively.
176. Hospital budgets are established during negotiations between the sickness funds and the
hospitals. The budget specifies targets in terms of activity as well as per diems to be reached by the end of
the financial year. Activity above the target is only reimbursed at 25% for the fees and 10–15% for the
activity. If actual activity is lower than the target then it receives 40% of the difference (WHO, 2000).
Since 1993, hospitals have been allowed to offer surgery on an ambulatory or day-case basis.
177. However, minor surgery has been provided in the ambulatory sector under fee-for-service
arrangements in private practice for a long time (especially by ophthalmologists, orthopaedic surgeons and
other specialists). In 1991, day surgery accounted for almost 2% of sickness funds expenditure in the
ambulatory care sector. All ambulatory care, primary and outpatient secondary care, is provided by office-
based physicians (most of them working in solo practice).
178. Capacity. Table A2 shows how hospital acute care beds availability is among the highest in
OECD countries with 6.4 beds (per 1 000 population) in 2000, as opposed to 3.2 beds for the countries
with waiting times. Similarly, the number of practising physicians (per 1 000 population) is 3.3, as opposed
to 2.8 for countries with waiting times. The number of practising specialists is 2.2, as opposed to 1.5.
(Table A3). Total and public health expenditure per capita in year 2000 were respectively $2780 and
$2086, as opposed to $2092 and $1585 in countries with waiting times (Table A1).
179. Activity. Activity is also correspondingly higher. Table A5 shows how the number of total
discharges was equal to 197 (per 1 000 population) in 1999 as opposed to 155 in countries with waiting
times. Table A6 also shows how the number of surgical procedure rates (per 100 000 population) in 2000
was significantly higher for most of the procedures considered (with the exception of cataract).
180. Conclusion. Virtually universal health insurance combined with high hospital capacity and
extensive ambulatory day surgery (the latter remunerated with a fee-for-service mechanism), are likely
explanations for the lack of significant waiting times in the German health care system.
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The United States
181. About 86% of the U.S. population is covered by health insurance. About 14% of the population
has no insurance coverage, although subsidised programmes facilitate access for the 40 million uninsured
(Docteur et al., 2003). Most of the working-age population and their family are covered by employer-
provided insurance plans. Medicare, a publicly-funded program, covers the older population and some of
the disabled. Medicaid covers the poorest part of the population.
182. Evidence. Survey data suggest that there are very low waiting times for elective surgery in the
U.S. Blendon et al. (2002) reported the percentage of respondents to a phone survey in 2001, who had
experienced elective surgery in the last two years and who said they had waited longer than four months
for elective surgery. It was found that 5% of patients had been waiting for at least 4 months in the United
States, as opposed to 23% in Australia, 26% in New Zealand, 27% in Canada and 38% in the United
Kingdom. Carroll et al. (1995) found that the percentage of the respondents in need of elective coronary
bypass who had been waiting for more than three months was 0% in U.S., 18.2% in Sweden, 46.7% in
Canada, and 88.9% in the United Kingdom. Similarly, Coyte et al. (1994) found that surveyed patients in
need of knee replacement had a median waiting time of three weeks in the United States and eight weeks in
Canada (Ontario).
183. Institutions. Most health care facilities are privately owned. Hospitals are run either on a not-for-
profit or a for-profit basis. Under the Medicare programme, payments to hospitals, physicians and other
providers are determined by complex prospective payment systems. These systems provide the programme
with a high level of control over the price component of total spending, but not much leverage over the
volume of services.
184. The number of hospitals has fallen by 14% in the last decade (Docteur et al., 2003). Table A2
shows that the number of acute care beds was only 2.9 (per 1 000 population) as opposed to 5.5 for other
countries which do not report waiting times. This may be explained by the spread of managed care in the
private sector and by the use (note – Medicare PPS was introduced more than a decade ago) of
prospective payment systems by Medicare and some other payers, which furnish incentives to reduce the
length of stay and to increase the use of ambulatory care. Physician payment methods vary widely by payer
and type of practice from fee for service to capitation.
185. Capacity. Table A2 shows that hospital acute care bed availability is among the lowest in OECD
countries with 2.9 beds (per 1 000 population) in 2000, as opposed to 3.2 beds for the countries with
waiting times. The number of practising physicians (per 1 000 population) was 2.7 in 1999, the same as for
countries with waiting times. The number of practising specialists was 1.4, also very similar to the average
country with waiting times (Table A3). On the contrary, total and public health expenditure per capita in
2000 were much higher than in countries with waiting times. Total and public health expenditure were
respectively $4540 and $2005, as opposed to $2092 and $1585 in countries with waiting times (Table A1).
186. Activity. Table A5 shows that the number of total discharges was equal to 115 (per 1 000
population) in 1999 as opposed to 155 in countries with waiting times. However, this figure does not
include day cases. A 1996 survey suggested that about half of surgical procedures in the U.S. were carried
out as day cases. Table A4 suggests that such a share was only reached in waiting times countries in 2000
and that the share may have been considerably lower in 1996. Table A6 also shows that the number of
surgical procedure rates (per 100 000 population) in 2000 was significantly higher for knee replacement,
hysterectomy and CABG, but not for prostatectomy and hip replacement.
187. Conclusion. The United States spends much more on health care compared to all other OECD
countries. Although bed capacity is lower compared with countries without waiting times, day surgery
capacity is probably comparable or higher. The majority of providers of surgery is private and is highly
incentivised to meet demand by activity-related payments.

I have lived back east in CT in a mixed income, most were on welfare.

They are probably the laziest, most dishonest, whiny, ungrateful and miserable people I know.

I definitely do not intend to imply that these systems are not without problems. However, to dismiss them as "broken" to any significant degree would be a mischaracterisation, since again they appear to have given their nations very high human development indicators.

Was my argumentation sufficient to change your position?

Of course not. My position is based on anecdotal evidence that I have gathered over years.

Another relevant one is "Does [particular socialist program/system] improve [quality of life|poverty levels|overall happiness]?"

(You may notice a trend towards Policy Debate. My novice year's topic was on providing National Health Insurance. Of course we know that any welfare plan is doomed because it will lead inevitably to global thermonuclear war.)

I find it interesting that people can agree on some basic premises (e.g. poverty is bad) and yet disagree on whether welfare is a reasonable way of addressing the problem.

One question that I find far less interesting is "Does the government have the right to tax citizens to pay other citizens?"

In case you can't tell, I tend to favor policies to improve the economy as a whole, with the thinking that some of the largess will flow to people at all levels of society.

here is certainly some empirical evidence to support this line of thinking,

What's more is that this sort of thing is already happening in our country, and it has worked reasonably well during the last 20 or 30 years.

Even when the .com bubble burst there wasn't the same kind of collapse that was seen in the Great Depression,

My point is that I've come to this conclusion over time, and I have yet to see anything in the great social experiments of Europe to convince me that they have a better system and get me to support a significant change to the status quo.

On an essentially unrelated note, have you ever read Upton Sinclair's The Jungle? It usually is mentioned in literature and history classes as an early example of muckraking that led to establishing standards for food quality. What they don't often mention is that the book is supposed to be a great treatise on the need for socialism. The happy ending of the book only comes after the main character joins the socialist party (the book ends before they can steal his money and turn him out on the street like everyone else he encounters).

I was not expecting such honesty.