The American Health Care Conversation

Preface: Like many, I resolved to post more in the new year. Once a week in fact. I had not planned for any of those posts to be political. We’ve all had enough of that lately. That said, my social media feeds are overflowing with conversations about the ACA and I have something to say. Here it is.

In the face of plans to repeal the Affordable Care Act, our friends to the South are again talking about health care, health insurance and their options. Many of those I see in my social media feeds are angry and scared: they’re self-employed artists and entrepreneurs working in an emerging gig economy and — absent the ACA — without ready access to suitable health insurance.

Individuals and small groups present a conundrum for free market health insurance. There is potential for anti-selection, where a savvy person could expose the insurance company to significantly higher costs than anticipated by the premiums charged. Those with the most immediate need of health insurance are denied outright (pesky pre-existing conditions!) or subject to yuge premiums beyond the reach of people working in those groups.

The solution appears to many to be moving to a single payer system where the risks are spread across the entire population and the potential for anti-selection is eliminated. Sounds right to me, but, hey, I’m Canadian and a recovering actuary so I already knew that.

What interests and infuriates me (in equal measure) in the conversation about single payer is the combination of misunderstanding and misinformation offered up in opposition. While there are a number of articles and studies out in the world that are both better-researched and better-informed than I can provide in this space, there are some basic issues that seem to persist as stumbling blocks in the conversation.

It’s not really free. It comes out of your taxes.

Absolutely right. The thing of it is that Americans already pay more in taxes towards health care than, say, Canadians (I’ll use Canada not as an example of the pinnacle of single payer, but because I have a decent handle on the facts).


In Taxes.

In 2014, Americans paid US$4,541 per person in taxes to fund health care programs that only some of them receive. In the same year, Canadians paid US$3,753 in taxes for health care for everybody. Let that sink in.

If we let the government run it, costs and corruption will skyrocket.

Wait, are you trying to tell me that there is someone more corrupt than American financial institutions? Did I miss something?

Last I heard, twenty-five cents of every dollar that Americans spend on health care is used for marketing, review, administration and profit. That’s at least double the costs for most single payer nations. Also, the existing public health administration in the US is among the most efficient in the world.

What about those wait times? I’ve heard horrible things.

American health care leads the world in two areas — health care spending and access for those who can pay. If you can pay, you can have whatever the fuck you want right the fuck now.

Opponents of single payer cite examples of wait times and people who cross the border to get treatment in the US. Yep, those things happen, but they are anecdotes, exceptions. Some of those who do are actually covered by their Canadian insurance (we have a capacity issue, large geographic area and population density issues to deal with). My brother crossed the border some years back for a scan that he could get same day in the US.

Let’s say that 70 thousand Canadians go to the US for some form of medical care. That’s higher than the actual number, but makes the math nice.

70,000 out of 35,000,000. That’s 0.2%.

Compare that to the percentage of Americans who can’t get medical insurance and, by extension can’t get reasonable medical care. Even with the ACA, that’s ten percent of Americans.

So, by my back-of-the-envelope math, that’s what, 50 times worse? With the ACA. Without the ACA, the number is more like 80 times worse.

And that’s without talking about preventative care, health maintenance and overall outcomes.


I can’t help you with your slogans and jingoism. You hear socialism and think Russia (aren’t they your new best friend?) and China. I hear socialism and think … Denmark.

It’s just a label and if you need to reduce something as complex as comprehensive health care to a single word, there isn’t much to talk about.

One word isn’t enough to have a conversation.



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