Single Payer: Myths cured by the experience of Taiwan

An acquaintance of mine with a decade of life here posted this on Facebook about single payer. Here in Taiwan we have excellent health insurance. If only the US had this system, instead of its current one or the murderous plans the Republicans keep attempting to pass....

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I wrote this while on a recent train ride. It's long, but please don't think I'm crazy. I was bored and motivated at the same time.

This is on my mind a lot, and I only share because I think it can add clear perspective to a very confusing and clouded health care debate.

As someone who has lived under one version of Single Payer Health Care for the past 10 years, I would like to respectfully opine on some of the (many) falsehoods that are circulated by various (mostly conservative media) sources. I think it's totally cool no matter what opinion you hold.

I just hope to add to an informed and important debate.

So, about Single Payer -
- SP is not government-owned health care. Doctors do not necessarily work for the government. SP is priced and paid out by a single government-pooled source, and care is administered in the private sector (usually).

- SP does not stifle choice. I can literally go to any doctor/hospital/clinic in any city. Nobody is limited to doctors within their 'plan' or even geographical area. I usually pick the place with the best candy bowl at the desk.

- SP does not stifle competition. I have found SP to be far more of a 'free market' of care than I have ever experienced in the US (see above re choice). The best doctors and the best clinics get and retain the most patients and therefore make the most money.

- SP is kindof a socialist idea, sure, but really it's very much capitalist in the sense that the actual care is the service/product delivered by the physicians rather than the insurance 'plan' (see above). Associating SP with Venezuelan-style socialism is an oft-used farce that makes no sense. I think it's important to remember that every variation of US health care over the past several decades can neither be described as socialist nor capitalist, but rather, "rigged".

- SP does fix pricing at the national level, in a very good way. If this worries you, I can understand that. This worries me much less than how pricing of care and medicine has been handled in the US in recent history. Remember the insurance bills with all the fake prices? What was that all about?

- SP does not force doctors to provide services under the threat of force or law...any moreso than police are 'forced' to keep the peace. This is mostly in response to a guy named Ben Shapiro and many outlets that have repeated his ideas. I have no idea what he is talking about.

- SP does not ration care to the extent that has been described over and over in the US media. Wait times for vital care are not a problem. I'm sure there are outlier situations where patients were unhappy with care or not cared for properly, but I can say for certain that long wait times and rationing of care are definitely not systemic of SP in Taiwan.

- SP is not unaffordable. It is definitely cheaper than any recent version of US health care. Way cheaper. That's just math.

- SP does not require you to "pay for other people's health care" any more than any health care proposal that the GOP has presented over the past several months...unless we start allowing insurance companies to price customers out again (which the GOP is trying to do now)....in which case, people who run out of money will simply get the care and not pay for it (again, we all end up paying for that), or just die.

- SP is popular and it works, but the most important endorsement I can think of is this - For those who have experienced BOTH the US system of care and SP in some variation in a foreign country and are able to compare and contrast, the vast majority would favor SP. (see "Candian citizens who have lived in the US")

- SP has many different variations and hybrids, and amenities and aesthetics of care centers will usually fall in line with cultural expectations. In Taiwan for example, some hospitals and clinics lack a modern feel and may seem uncomfortable to someone who is used to more bells and whistles. That's because Taiwanese households, in general, do not have a lot of bells and whistles.

- SP is very good for small business and the working individual. Imagine a world where your health care has nothing to do with your employer. Imagine starting your own business and not having to worry about employee health benefits for that first person you hire.

- SP acknowledges that health care is a right. I know, it's not written in the constitution or whatever. Does anyone have a pen?

- SP also acknowledges that there is no solution to health care in the true free market. The nature and inelasticity of health care as a good makes it a lot different than sneakers and cell phones. I think that's just something we all have to accept.

- SP works very well in many countries. That doesn't mean it will have the same efficiency if implemented in the US. It could be even BETTER in the US. Because 'Merica.

- SP is not perfect. No health care solution is perfect.

- SP is not a curse. It can be a blessing.
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Health Care in Taiwan: a note on nurses

This chart from The Telegraph is making the rounds in the expat community here. It shows how Taiwan manages to have some of the world's cheapest, most affordable health care. We have a wonderful health care and health insurance system here. It is backed by a large research establishment that churns out paper after paper, along with numerous innovations, and excellent training programs for medical professionals that have a global reputation. I teach at one of the island's leading medical universities, and I also publish scholarly papers on nursing in Taiwan, so I have some small professional contact with the system. As a user, I can only say: it's wonderful.

However, like so many surprisingly affordable systems, it is based on exploitation. In Taiwan nurses must work overtime, but they only clock in eight hours at major hospitals around the nation. This abuse is winked at by regulators; without it the "system would collapse" (read: investors would extract fewer profits from the government subsidy program"). This abuse leads to many other abuses, which I plan to publish on someday when I no longer need employment at my university.

One of the most pernicious problems is the persistent shortage of nurses thanks to the crappy workloads and stagnant pay. The nursing situation is not different from other industries in this respect; Taiwanese bosses often treat workers like slaves, especially when their skin is too dark or they are of the wrong gender. This too is Taiwanese in another way: the success of the system depends on the exploitation and transmission of the fruits of female labor upward to the patriarch at the top. In any case this shortage dumps even more work on existing nurses, exacerbating turnover and leading to poorer patient care. The poorer patient care is partly masked because it is routine for families to move members into hospitals to care for their loved ones. This also holds health care costs down, a factor often missed when foreigners enthuse about the system.

Because of the brutality of this exploitation, many of my nursing students do not plan to become nurses. I have had innumerable conversations with my nursing students on the topic of "what to do now that I don't plan to become a nurse."

This situation lead eventually to public protests by nurses in recent years. I blogged on them in 2012...

After protests the government earmarked funds for increased nursing pay and to ease staff shortages and upgrade treatment. The Taipei Times reports on the totally predictable outcome...

Citing statistics compiled by the National Health Insurance Administration (NHIA), Taiwan Healthcare Reform Foundation researcher Lee Yun-ting (李芸婷) said that since 2009, the government has appropriated a total of NT$9.1 billion sourced from NHI income to hospitals nationwide in an effort to address the ever-worsening nurse shortage and nurse-patient ratios, including NT$2.5 billion last year and NT$2 billion this year.

“However, of the 492 hospitals and medical centers that received funding last year, only 49 percent actually used the money to hire more nurses or increase their incentives and overtime pay, with 14 percent failing to do so and 34 percent even reducing their nursing workforce,” Lee said.

Many hospitals also spent the money on items unrelated to nursing, like banquets, trips, and clothing. It's sick.

Hence, the next time you're in a Taiwan hospital, be kind to the nurse. She's had a hard day.
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[Taiwan] Don't miss the comments below! And check out my blog and its sidebars for events, links to previous posts and picture posts, and scores of links to other Taiwan blogs and forums!