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It is true that today a secular — and in some cases rabidly atheistic — tendency dominates libertarianism. But this has not always been the case. Those who emphasized the sovereignty of the individual citizen, resistance to a centralized bureaucracy, and the benefits of unfettered free market capitalism eventually coalesced into the libertarian movement that we know today. The Social Gospelers pulled together across denominational lines to advocate for a heightened awareness of labor conditions in the country.

But the movement had a theological side; its clergy tended to emphasize the corporate, collective nature of salvation. Moreover, many were willing to embrace evolutionary theory as a means of explaining human origins. Such a naturalistic perspective led to a willingness to see human beings as the product of their material and social environment. Like many in the Progressive Era, the reform-minded period before World War I, the Social Gospelers believed that legislation and government regulation could change Americans for the better by changing the social environment in which they lived.

By focusing attention on the social context that drives individuals to sin, the social gospel seemed to downplay the individual, embodied experience of salvation that American evangelicals have traditionally sought. While the social gospel lost much of its impulse during the economic boom following the war, popular interest in the movement reignited during the Great Depression of the s.

To resist this renewed influence — and defend capitalism — the alliance between business and religious leaders sought to reemphasize individual spiritual regeneration and to downplay the effects of social constraints on individual choices. In , Rev. Hutchinson of Chrysler. Facing the daunting task of resisting nearly five decades of entrenched liberal Protestant teaching and the harsh reality of the Depression, Fifield recruited preachers and laymen eager to resist the massive redistribution of wealth envisioned by President Roosevelt.

His appeal was simplistic but effective. In order to undermine government-sponsored economic redistribution, the ministers and laymen Fifield hired focused on the spiritual causes of poverty rather than the social concerns of the Social Gospelers. Opitz, the Austrian economist Ludwig von Mises, and the anarchist Murray Rothbard, Faith and Freedom moved many clergymen to embrace its anti-tax, non-interventionist, anti-statist economic model. While secular libertarianism triumphed, the remnants of its Christian heritage persisted among a small cadre of thinkers and activists who were reluctant to completely jettison Christ from the economy.

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Spiritual Mobilization helped a generation of theologically and economically conservative clergy find an alternative to the Social Gospel, New Deal, and communism that resonated with their traditional values, pro-business sympathies, and Christian faith. Faith and Freedom encouraged clergymen to see government as a problem, not a solution. Born in New York City in to survivors of the Armenian Genocide, Rushdoony knew the dangers of centralized power all too well. Therefore, during the s Rushdoony set about to provide a systematic theological justification for Christians to reject public education and embrace locally organized, independent Christian schools.

Deploying a unique blend of libertarianism with the most rigorous Calvinistic theology he could muster, Rushdoony delivered a series of lectures on Christian education. As a theologian Rushdoony saw human beings as primarily religious creatures bound to God, not as rational autonomous thinkers. Following the lead of the Reformed theologians Herman Dooyeweerd and Cornelius Van Til, 16 Rushdoony argued that all human knowledge is invalid if it is not rooted in the Bible. For Christians, that means a three-in-one Christian God is the source of reliable human knowledge.

There is no middle ground, no compromise. Following such earlier Presbyterian luminaries as A. Hodge and J. In many of the Faith and Freedom articles published during the s and s, Rushdoony saw a reservoir of popular discontent with compulsory public education and he hoped to develop it as an explicitly Christian resistance to the authority of centralized political structures. In this sense, Rushdoony was a shepherd in search of a flock and the libertarians looked more promising than alternatives. When Edmund Opitz helped secure Rushdoony a position with a small but influential libertarian organization known as the Volker Fund in , Rushdoony moved to exert his unique brand of Calvinist-inspired libertarianism on the organization.

He began writing a host of position papers that attacked public education, reinterpreted American history in starkly Christian terms see box , and advocated for the regeneration of America along explicitly Christian lines. After some internal wrangling, the Fund fired Rushdoony in , but the separation was gentle, giving Rushdoony the necessary resources to write two more books.

As libertarianism evolved into a more mainstream movement, it forced most of its religious defenders to the side. Rushdoony was but one casualty in this process. By the time he left the Fund, however, he had secured enough experience as a grant writer and public lecturer to set his own course. In the process of forming Chalcedon, Rushdoony decided to mentor an ambitious college student who shared his passion for libertarian economics and Christianity.

Their relationship would prove one of the most fascinating — and volatile — in the history of the Christian Right. Dominionist theology generally and Christian Reconstruction specifically would not be what they are today without Gary North. North demonstrated a willingness to reach out across sectarian boundaries in order to engage folks who were not quite as Christian as Rushdoony might have preferred, and directly engaged politically active conservatives, something Rushdoony largely avoided unless he could maintain strict control over their theological allegiances.

As a result of his popular appeal and tireless advocacy of the Reconstructionist world-view, one could argue that North did more than any other Reconstructionist short of Rushdoony to reconstruct the world for Christendom. Beginning in Rushdoony helped North secure a series of jobs working for the Volker Fund and the Foundation for Economic Education. He had worked for two of its most important organizations and maintained friendly relationships with men like Opitz, among many others. Rushdoony brought him to Chalcedon to research the relationship between biblical law and laissez-faire economics.

North threw himself into a project that he has yet to finish. Since he has spent a minimum of ten hours a week, fifty weeks a year writing a commentary on biblical economics. Most notoriously, North predicted that the Y2K computer glitch would lead to the total collapse of the global economy, leaving Christians in the United States to pick up the pieces. North, unlike Rushdoony, believes that the eternal human social institution is the Christian church.

In the event of the catastrophic collapse of such transient institutions as the federal government, churches will step into the void left by its implosion. Rushdoony envisioned the church and family as two separate, exclusive spheres. For Rushdoony the family is the primary social unit while the church represents a limited ecclesiastical organization of believers in Christ.

Conversely, North believed men owed their allegiances to a church first and the family second. Like all aspects of Reconstructionist theology, these two perspectives have real-world consequences. Long before North and Rushdoony publicly parted ways, North had already aggressively sought out political influence. In he worked in Washington, D.

When American society collapses under the combined weight of massive foreign debt, military overstretch, and internal decadence, North hopes to have a network of churches ready to step into the breech. In preparation, he has written book after book aimed at educating Christians on how to live debt free, avoid electronic surveillance, and develop the skills necessary for surviving economic collapse.

For all their tension, North and Rushdoony did agree on one point: the Kingdom of God would emerge over time. They disagreed on the conditions of this emergence. North on the other hand constantly warned of impending disaster. At the moment of cataclysmic collapse, Godly men could suddenly step forward and rule. In , North and Rushdoony had a very public falling out and the two never spoke again. This dispute led to a deep rift in the Reconstructionist camp. Interestingly, the rift between Rushdoony and North was arguably good for the movement because it led to a vital upsurge in competing publications.

Bahnsen in particular had been an important rising star in the movement. His major theological work, Theonomy in Christian Ethic s, 28 was widely read and reviewed. Second, as I noted above, Gary North managed to alienate himself from practically everyone inside and outside of the movement because of his overconfident tone and failed predications of looming societal collapse.

Third and most importantly, Rushdoony ceased to be the driving intellectual and fundraising force of the movement. Most mainstream accounts since the s portray Rushdoony as a stern patriarch ruling over an influential theological fiefdom. The image painted by movement insiders and financial documents suggests this popular conception is partly an illusion. This image of a declining movement is also supported by the deterioration of financial support for the Chalcedon Foundation. The departure of Howard Ahmanson, Jr.

He was a close friend of the Rushdoony family and had bankrolled Chalcedon along with other conservative causes during the s and s. Where does Christian Reconstruction stand today? Many popular attacks on Rushdoony overestimate his influence on Bush and the GOP and misread his ideas as a cloaked desire to take over the government by hook or crook.

With their anti-interventionist, libertarian ethos, those inspired by Christian Reconstructionism tend to fall into the principled camp and a good many see national electoral success as a sign of ideological weakness. Their rigid theological consistency also leaves them reluctant to compromise with Republicans and more moderate evangelicals. As a result, Reconstructionists are as likely to disengage from politics as they are to engage in it.

Rushdoony himself is the model for this antagonistic stance toward national politics. In the s, he became increasingly disgusted with partisan politics and worked to disengage from cooperative political action. While it has been widely reported that Rushdoony served as an original member of the Board of Governors of the Council for National Policy CNP , a secretive right-wing organization cofounded by the evangelical minister and coauthor of the Left Behind novels Tim LaHaye, 31 it is less widely known that Rushdoony severed his ties with the group in the lates.

Rushdoony and other Reconstructionists famously signed a series of COR Christian World View documents that highlighted points of Christian consensus in their resistance to secular humanism. Exodus Mandate is a ministry organized by Rev. Ray Moore, Jr. Moore explicitly acknowledges his debt to Rushdoony and other Reconstructionists. Bruce N. The resolution they proposed for the annual meeting calls for the formation of an alternative K school system to be administered by Christian churches.

Even though the Chalcedon Foundation has fallen on hard times since Rushdoony died in February , Reconstructionism is hardly dead. Through the careful, persistent promotion of his theology, Rushdoony managed to spread his ideas far and wide. Arguably, with his passing the intellectual impetus behind Reconstructionism specifically and Dominionism more broadly is on the wane. Tough choices must be made. Others worry that the most needy or least able to fight for themselves will be left waiting.

Should healthcare be rationed? No one can fail to be moved by heartbreaking stories of people suffering and unable to get healthcare they want or need. But compassion is a sentiment, not a policy. We tend to talk about healthcare in the philosophically abstract. Is healthcare a right or a privilege?

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In reality, it is neither. Healthcare is a commodityand a finite one at that. There are only so many doctors, hospitals, and, most important, money to go around. After all, every dollar spent on healthcare is one not spent on education, infrastructure, or defense. President Obama is right about the unsustainable trajectory of healthcare spending. Under current trends, that will increase to 48 percent of GDP by At that point, government healthcare programs like Medicare and Medicaid alone will consume 20 percent of GDP.

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Quite simply, we cannot provide all the healthcare everyone might want. Sure, there are efficiency savings to be had here and there. But savings from things like greater emphasis on preventive care, better evidence as to best practices, and electronic medical records are unlikely to be realized for years, if at all. Any healthcare reform will have to confront the biggest single reason costs keep rising: The American people keep buying more and more healthcare.

At its most basic, no one wants to die. If a treatment can save our lives or increase quality of life, we want it. Therefore, in the long run, the only way to spend less on healthcare is to consume less healthcare. Someone, sometime, has to say no. Take just one example. If everyone were to receive a CT brain scan every year as part of an annual physical, we would undoubtedly discover a small number of brain cancers earlier than we otherwise would, perhaps early enough to save a few lives.

But given the scans cost, adding it to all annual physicals would quickly bankrupt the nation. False hope. The real debate, therefore, is not about whether we should ration care but about who should ration it. Currently, that decision is often made by insurance companies or other third-party payers.

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Obama and congressional Democrats want to shift that decision-making power to the federal government. Some, frustrated by the insurance-based rationing of the current system, naively believe that putting the. When Michael Moore, in Sicko, showcased emotional tales of people denied experimental treatment by insurance companies, he implied that a government-run system would certainly pay for it.

The reality, however, is that every government-run healthcare system around the world rations care. In Great Britain, the National Institute on Clinical Effectiveness makes such decisions, including a controversial determination that certain cancer drugs are too expensive. But these are approved only if it can be shown they extend life by at least three months and are used for illnesses that affect fewer than 7, new patients per year.

Free-market healthcare reformers, on the other hand, want to shift more of the decisions and therefore the financial responsibility back to the individual. People should have the absolute right to spend their own money on whatever they want, including buying as much healthcare as they want. And, if they are spending their own money, they will make their own rationing decisions based on price and value.

That CT scan that looked so desirable when someone else was paying may not be so desirable if you have to pay for it yourself. The consumer himself becomes the one who says no. Of course, as a compassionate society, we may choose to help others pay for some care. Thats a worthwhile debate to have.

But our resources are not unlimited. Choices will have to be made. And, therefore, the real question should be: Who will make those choices? The only way to spend less on healthcare is to consume less healthcare. This article appeared in the August issue of U. Associated Press photojournalist Noah Berger captured this thousand-word image near the Occupy Oakland demonstrations last month. Many Cato Liberty readers will get it immediately. They can stop reading now. For everyone else, this image perfectly illustrates the ethos of what I call the Church of Universal Coverage.

Like everyone who supports a government guarantee of access to medical care, the genius who left this graffiti on Kaiser Permanentes offices probably thought he was signaling how important other human beings are to him. He wants them to get health care after all. He was willing to expend resources to transmit that signal: a few dollars for a can of spray paint assuming he didnt steal it plus his time. Unfortunately, the money and time this genius spent vandalizing other peoples property are resources that could have gone toward, say, buying him health insurance.

Or providing a flu shot to a senior citizen. This genius has also forced Kaiser Permanente to divert resources away from healing the sick. Kaiser now has to spend money on a pressure washer and whatever else one uses to remove graffiti from those surfaces e. The broader Church of Universal Coverage spends resources campaigning for a government guarantee of access to medical care. Those resources likewise could have been used to purchase medical care for, say, the poor.

The Churchs efforts impel opponents of such a guarantee to spend resources fighting it. For the most part, though, they encourage interest groups to expend resources to bend that guarantee toward their own selfish ends. The taxes required to effectuate that warped guarantee reduce economic productivity both among those whose taxes enable, and those who receive, the resulting government transfers.

In the end, that very government guarantee ends up leaving people with less purchasing power and undermining the markets ability to discover cost-saving innovations that bring better health care within the reach of the needy. Thats to say nothing of the rights that the Church of Universal Coverage tramples along the way: yours, mine, Kaiser Permanentes, the Catholic Churchs. I see no moral distinction between the Church of Universal Coverage and this genius. Both spend time and money to undermine other peoples rights as well as their own stated goal of health care for everybody.

Of course, it is always possible that, as with their foot soldier in Oakland, the Churchs efforts are as much about making a statement and feeling better about themselves as anything else. This article appeared on February 7, on Cato Liberty. But his response bears clarification and emphasis. Improving population health generally means helping people live longer.


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To paraphrase, Reinhardt then writes: If helping people live longer were our objective in health reform, we could do better than universal coverage. But health reform is not solely or primarily about helping people live longer. It is also or primarily about other things, like relieving the anxiety of the uninsured. I applaud Reinhardt for acknowledging a reality that most advocates of universal coverage avoid: that universal coverage is not solely or primarily about improving health. Will Reinhardt go further and acknowledge that, since universal coverage is largely about some other X-factor s , that necessarily means that advocates of universal coverage are willing to let some people die sooner in order to serve that X-factor?

This article appeared on October 21, on Cato Liberty. The main theme was the contrast between Rwandas compulsory health insurance system and the as-yet-non-compulsory U. Sunny Ntayomba, an editorial writer for The New Times, a newspaper based in the capital, Kigali, is aware of the paradox: his nation, one of the worlds poorest, insures more of its citizens than the worlds richest does. He met an American college student passing through last year, and found it absurd, ridiculous, that I have health insurance and she didnt, he said, adding: And if she got sick, her parents might go bankrupt.

The saddest thing was the way she shrugged her shoulders and just hoped not to fall sick. I dont see anything absurd here, but I do see something remarkable. Dialysis is generally unavailable. As are many treatments for cancer, strokes, and heart attacks, making those ailments death sentences more often than in advanced nations. Life expectancy at birth is 58 years, compared to 78 years in the United States. Rwandan children are 15 times more likely to die before their first birthday 7 vs. If you want to meet some Rwandan kids struggling to make it to age 5, read my friends blog, Life of a Thousand Hills.

And yet, the saddest thing is a healthy-but-uninsured American college student. What the Times sees as a paradox isnt really a paradox. Yes, the poorer nation has a higher levels of health insurance coverage. But the wealthier nation does a better job of providing medical care to everyone, insured and uninsured alike. The Times reports that Rwandas national health insurance system isnt fancy, But it covers the basics, including the most common causes of deathdiarrhea, pneumonia, malaria, malnutrition, infected cuts.

Surely, the Times must know that anyone walking into any U. The same is true of other acute conditions, like heart attacks and strokes, for which uninsured Americans receive better treatment than insured Rwandans. True, some uninsured Americans end up filing for bankruptcy, but lets be clear: while bankruptcy is no day at the beach, suffering. As for dialysis, the United States already has universal coverage for end-stage renal disease through the Medicare program. The Healthcare Economist puts it this way: Would you rather be sick in the United States without insurance or sick with insurance in Rwanda?

You get the point. If theres a paradox here, its that insurance status does not necessarily correlate with access to medical care: uninsured people in the wealthy nation actually have better access to care than insured people in the poor nation. An even bigger paradox, though, is Rwandan attitudes toward the United States. More than any other nation, we create the wealth that purchases those and other treatments for Rwandans and other impoverished peoples.

The United States is probably closer to providing universal access to medical care for its citizensand, indeed, the whole worldthan Rwanda. Rwandas universal system leaves 8 percent of its population uninsured. Though official estimates put the U. The real paradox is here that Rwandan elites think the United States is doing something wrong. Heres one answer: Rwandas government explicitly guarantees health insurance to its citizens, and for some people that guarantee has value apart from any health improvements or financial security that may result.

Binagwaho said, Rwanda can offer the United States one lesson about health insurance: Solidarityyou cannot feel happy as a society if you dont organize yourself so that people wont die of poverty. Set aside that a permanent third-world bureaucrat is telling the United States how to keep people from dying of poverty. Binagwaho cannot feel happy without that government-issued guarantee. How might such a guarantee increase happiness? It could make people happier by reassuring them that they themselves will be healthier and more financially secure self-interest , or that others will be altruism.

Yet altruism and self-interest probably cannot explain the happiness benefits that people enjoy when governments guarantee health insurance. As I have argued elsewhere, the jury is out on whether broad health insurance expansions like ObamaCare result in better overall health; they may, but it is entirely possible that they would not. The jury is also out on whether ObamaCare will produce a net increase in financial security.

It will subsidize millions of low-income Americans, but it will also saddle them with high implicit taxes that could trap millions of them in poverty. Meanwhile, ObamaCares new taxes will reduce economic growth and destroy jobs. If such a guarantee doesnt improve health or financial security, its not worth much in terms of altruism or self-interest.

But theres another potential happiness benefit that might accrue to supporters of a government guarantee of health insurance: it could make them happier by allowing them to signal something about themselvese. If people use a government guarantee of health insurance in this way, that could explain why Rwandan elites feel bad for uninsured Americans. They may feel empathy for uninsured Americans because they perceive the American electorate has not sent uninsured Americans a valuable signal We care about you!

Meanwhile, the act of expressing pity for uninsured Americans allows Rwandan elites to signal something about themselves We are compassionate! Robin Hanson has a lot to say about why people might use health insurance and medical care to signal loyalty and compassion. My hunch is that this is an under-appreciated reason why some people support universal coverage: a government guarantee of health insurance coverage provides its supporters psychic benefitseven if it does not improve health or financial security, and maybe even if both health and financial security suffer. If thats the case, then were facing the same problem that Charles Murray identified in Losing Ground, his seminal work on poverty: Most of us want to help.

It makes us feel bad to think of neglected children and rat-infested slums. The tax checks we write buy us, for relatively little money and no effort at all, a quieted conscience. The more we pay, the more certain we can be that we have done our part, and it is essential that we feel that way regardless of what we accomplish. To this extent, the barrier to radical reform of social policy is not the pain it would cause the intended beneficiaries of the present system, but the pain it would cause the donors. The real contest about the direction of social policy is not between people who want to cut budgets and people who want to help.

When reforms finally do occur, they will happen not because stingy people have won, but because generous people have stopped kidding themselves. One thing is for certain. When Rwandan elites pity uninsured Americans, there is something very interesting going on. While Im at it, the health-policy advice I offered to China and India also applies to Rwanda: Does not the fact that these countries lack the fiscal resources required for universal coverage because of their.

For things that might just deliver greater health improvements? In a profession where universal coverage is a religion, such questions are heresy, I know. China and India are in the process of a slow climb out of poverty. It is entirely possible that the best thing those governments could do to improve [health care] markets and population health would be to enforce contracts, punish torts, contain contagion, and nothing else. Of course, if Rwandan elites support universal coverage largely because they want to signal something about themselves, this advice may fall on deaf ears.

This article appeared on June 21, on Cato Liberty. I have blogged before about the Church of Universal Coverage, my affectionate term for those whose support for universal health insurance coverage is impervious to reasonor would be, were they to subject it to reason. I read something today that has me wondering whether the Church might be waking up to the fact that it is indeed a religion. Mitch Daniels R health care agenda. Although I have no empirical evidence to support the assertion that SCHIP is a beneficial and effective way to invest in childrens health, I worked to expand the program.

I was not able to base this expansion on empirical evidence because there is none. The lack of actual evidence of the benefits for children is simply damning to the program. Public policymakers need more than just a conviction that SCHIP works and is worthy of public investment. We need facts. I mean, wow. I see three possible outcomes. One, all that cognitive dissonance causes Roobs head to explode.

Two, the Church hierarchy dispatches its goons to burn this heretic at the stake for noticing that their god has no clothes. Three, the Left decides to hell with it, admits that it has a religion, and files for tax-exempt status. This article appeared on July 7, on Cato Liberty. In case my last post didnt convince you that universal coverage is a religion, here is its apostles creed: To believe in universal health care is to believe that we can do more and do better, all at oncethat it is possible to have hospitals full of high technology and emergency departments with room for all comers; that it is possible for people to choose their doctors and have a say in their treatments; that it is possible to make the economy more free and more efficient; and that it is possible to do all of this for everybody, not just an economically or medically privileged few, in a way we can all find affordable.

I may think that government often serves the few at the expense of the many, that people respond to incentives, that tradeoffs are unavoidable, that there may be better ways to promote health, and that introducing coercion into human affairs creates more problems than it solves.

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But just try telling that to someone who believes. Tanner Cato Institute Policy Analysis no. These critics contend that by adopting a similar system the United States could solve many of the problems that currently afflict its health care system. As Krugman says, The obvious way to make the U. To a large degree, America spends money on health care because it is a wealthy nation and chooses to do so.

Economists consider health care a normal good, meaning that spending is positively correlated with income. As incomes rise, people want more of that good. Because we are a wealthy nation, we can and do demand more health care. But because of the way health care costs are distributed, they have become an increasing burden on consumers and businesses alike. Health insurance premiums rose by a little more than 6 percent in , faster on average than wages. Unchecked, Medicaid spending will increase fourfold as a percentage of federal outlays over the next century. Although the number of uninsured Americans is often exaggerated by critics of the system, approximately 47 million Americans are without health insurance at any given time.

The Institute of Medicine estimates that some 44,, annual deaths are due to medical errors,14 while a study in The New England Journal of Medicine suggests that only a little more than half of American hospital patients receive the clinical standard of care. Direct charges to patients would be prohibited or severely restricted. Private insurance, if allowed at all, would be limited to a few supplemental services not covered by the government plan. The government would control costs by setting an overall national health care budget and reimbursement levels.

However, a closer look at countries with national health care systems shows that those countries have serious problems of their own, including rising costs, rationing of care, lack of access to modern medical technology, and poor health outcomes. Countries whose national health systems avoid the worst of these problems are successful precisely because they incorporate market mechanisms and reject centralized government control.

In other words, socialized medicine worksas long as it isnt socialized medicine. Measuring the Quality of Health Care across Countries Numerous studies have attempted to compare the quality of health care systems. In most of these surveys, the United States fares poorly, finishing well behind other industrialized countries.

This has led critics of the U. There are several reasons to be skeptical of these rankings. First, many choose areas of comparison based on the results they wish to achieve, or according to the values of the com-parer. This study bases its conclusions on such highly subjective measures as fairness and criteria that are not strictly related to a countrys health care system, such as tobacco control. For example, the WHO report penalizes the United States for not having a sufficiently progressive tax system, not providing all citizens with health insurance, and having a general paucity of social welfare programs.

Indeed, much of the poor performance of the United States is due to its ranking of 54th in the category of fairness. Notably, the WHO report ranks the United States number one in the world in responsiveness to patients needs in choice of provider, dignity, autonomy, timely care, and confidentiality. Difficulties even arise when using more neutral categories of comparison. Nearly all cross-country rankings use life expectancy as one measure.

In reality though, life expectancy is a poor measure of a health care system. Life expectancies are affected by exogenous factors such as violent crime, poverty, obesity, tobacco and drug use, and other issues unrelated to health care.


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  • As the Organisation for Economic Co-operation and Development explains, It is difficult to estimate the relative contribution of the numerous nonmedical and medical factors that might affect variations in life expectancy across countries and over time. In the United States, very low birth-weight infants have a much greater chance of being brought to term with the latest medical technologies. Some of those low birth-weight babies die soon after birth, which boosts our infant mortality rate, but in many other Western countries, those high-risk, low birth-weight infants are not included when infant mortality is calculated.

    For example, Michael Moore cites low infant mortality rates in Cuba, yet that country has one of the worlds highest abortion rates, meaning that many babies with health problems that could lead to early deaths are never brought to term. Whether the disease is cancer, pneumonia, heart disease, or AIDS, the chances of a patient surviving are far higher in the United States than in other countries. For example, according to a study published in the British medical journal The Lancet, the United States is at the top of the charts when it comes to surviving cancer.

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    Among men, roughly The news is even better for women: the five year-survival rate is The countries with the next best results are Iceland for men Most countries with national health care fare far worse. For example, in Italy, In Spain, just 59 percent of men and And in Great Britain, a dismal Eighteen of the last 25 winners of the Nobel Prize in Medicine are either U. For example, 44 percent of Americans who could benefit from statins, lipid-lowering medication that reduces cholesterol and protects against heart disease, take the drug.

    That number seems low until compared with the 26 percent of Germans, 23 percent of Britons, and 17 percent of Italians who could both benefit from the drug and receive it. But just 20 percent of Spanish patients and 10 percent of Germans receive the most recent drugs. Regardless, there is no dispute that more health care technology is invented and produced in the United States than anywhere else. Note: U. Data from Obviously there are problems with the U. More must be done to lower health care costs and increase access to care.

    Both patients and providers need better and more useful information. The system is riddled with waste, and quality of care is uneven. Government health care programs like Medicare and Medicaid threaten future generations with an enormous burden of debt and taxes. Health care reform should be guided by the Hippocratic Oath: First, do no harm.

    Therefore, before going down the road to national health care, we should look more closely at foreign health care systems and examine both their advantages and their problems. Many of the countries with health systems ranked in the top 20 by the World Health Organization, such as San Marino, Malta, and Andorra, are too small to permit proper evaluation, or their circumstances clearly limit the applicability to the U.

    Accordingly, this study will look at 12 countries that appear to hold lessons for U. Types of National Health Care Systems National health care, or universal health care, is a broad concept and has been implemented in many. There is no single model that the rest of the world follows. Each countrys system is the product of its unique conditions, history, politics, and national character, and many are undergoing significant reform.

    Single-Payer Systems Under a single-payer health care system, the government pays for the health care of all citizens. It collects taxes, administers the supply of health care, and pays providers directly. In effect, this replaces private insurance with a single government entity. Typically, the government establishes a global budget, deciding how much of the nations resources should be allocated to health care, and sets prices or reimbursement rates for providers.


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    In some cases, providers may be salaried government employees. In others, they may remain independent and be reimbursed according to the services and procedures they provide. In the strictest single-payer systems, private insurance and other ways to opt out of the system are prohibited. Employment-Based Systems Countries with employment-based systems require that employers provide workers with health insurance, often through quasi-private sickness funds.

    These insurance funds may operate within or across industry sectors, with benefits and premiums set by the government. Often premiums are simply a form of payroll tax paid directly to the fund. Providers remain independent and reimbursement rates are negotiated with the funds, sometimes individually, sometimes on a national level. Germany has long been the model for an employment-based system. Managed Competition Managed competition leaves the provision of health care in private hands but within an artificial marketplace run under strict government control and regulation.

    Individuals have a choice of insurers within the regulated marketplace and a choice of providers. Although the government sets a standard benefits package, insurers may compete on price, cost sharing, and additional benefits. Switzerland is the clearest example of a managed-competition approach to universal coverage, although the Netherlands has also recently adopted a similar system. The Clinton health plan, the Massachusetts health care reform, and most of the proposals advocated by the current Democratic presidential candidates are variations of managed competition.

    Some countries, such as France and Japan, impose significant cost sharing on consumers in an effort to discourage overutilization and to control costs. Other countries strictly limit the amount that consumers must pay out of pocket. Some countries permit free choice of providers, while others limit it. In some countries there is widespread purchase of alternative or supplemental private insurance, whereas in others, private insurance is prohibited or used very little. Resource allocation and prioritization vary greatly.

    Japan spends heavily on technology but limits reimbursement for surgery, while France has exceptionally high levels of prescription drug use. Outcomes also vary significantly. Canada, Great Britain, Norway, and Spain all heavily ration health care or have long waiting lists for care, while France and Switzerland have generally avoided waiting lists. At the same time, France, Italy, and Germany are struggling with rising health care costs and budget.

    And some countries such as Greece have fallen far short of claims of universal coverage. With all of that in mind, consider the following prominent national health care systems. France Some of the most thoughtful proponents of national health care look to France as a model of how such a program could work. Jonathan Cohn of theNew Republic has written that the best showcase for what universal health care can achieve may be France. However, it does so in large part by adopting market-oriented approaches, including consumer cost sharing. Other aspects of the system appear to reflect French customs and political attitudes in such a way that would make it difficult to import the system to the United States.

    France provides a basic level of universal health insurance through a series of mandatory, largely occupation-based, health insurance funds. These funds are ostensibly private entities but are heavily regulated and supervised by the French government. Premiums funded primarily through payroll taxes , benefits, and provider reimbursement rates are all set by the government.

    In these ways the funds are similar to public utilities in the United States. The largest fund, the General National Health Insurance Scheme, covers most nonagricultural workers and their dependents, about 83 percent of French residents. Separate insurance plans cover agricultural workers, the self-employed, and certain special occupations like miners, transportation workers, artists, clergy, and notaries public.

    Another fund covers the unemployed. These larger insurance schemes are broken down into smaller pools based on geographic region. Overall, about 99 percent of French citizens are covered by national health insurance. The French health care system is the worlds third most expensive, costing roughly 11 percent of GDP, behind only the United States 17 percent and Switzerland Payroll taxes provide the largest source of funding. Employers must pay In addition, there is a 5.

    Thus, most French workers are effectively paying Finally, dedicated taxes are assessed on tobacco, alcohol, and pharmaceutical company revenues. In reality, they have not been sufficient to keep the programs finances balanced. The National Health Authority sets a global budget for national health care spending, but actual spending has consistently exceeded those targets.

    This actually shows improvement over , when the system ran an Some government projections suggest the deficit in the health care system alone could top 29 billion by and 66 billion by In most cases, the services covered are explicitly specified in regulation. However, some implicit benefit guarantees occasionally result in conflicts over what benefits are and are not fully covered.

    As a result, French consumers pay for roughly 13 percent of health care out of pocket, roughly the same percentage as U. For example, while 20 U. No regulations specify what benefits must be included in coverage or mandate guaranteed issue; and pre-existing conditions may be excluded. The only significant restriction requires guaranteed renewability after two years of coverage.

    The amount of reimbursement, minus the copayment, is based on a fee schedule negotiated between health care providers and the national health insurance funds. These fee schedules operate similarly to the diagnostic-related groups DRGs under the U. Although reimbursement levels are set by the government, the amount physicians charge is not.

    The French system permits providers to charge more than the reimbursement schedule, and approximately one-third of French physicians do so. The government also sets reimbursement rates for both public and private hospitals, which are generally not allowed to bill beyond the negotiated fee schedules. While fees are restricted, private hospitals called cliniques , which account for 37 percent of all short-stay hospital beds and half of all surgical beds, control their own budgets, whereas public hospitals operate under global annual budgets imposed by the Ministry of Health.

    Health care technology that the National Health Authority has categorized as insufficient medical service rendered cannot be purchased by public hospitals, and its use at cliniques is not reimbursable. Volume 40 Issue Dec , pp. Volume 39 Issue 4 Dec , pp. Volume 38 Issue 4 Dec , pp.

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