What Michael Moore hasn't done is lie in a corridor all night watching his severed toe disintegrate in a plastic cup

Kurt Loder reviews Sicko [via HnR]:

What's the problem with government health systems? Moore's movie doesn't ask that question, although it does unintentionally provide an answer. When governments attempt to regulate the balance between a limited supply of health care and an unlimited demand for it they're inevitably forced to ration treatment. This is certainly the situation in Britain. Writing in the Chicago Tribune this week, Helen Evans, a 20-year veteran of the country's National Health Service and now the director of a London-based group called Nurses for Reform, said that nearly 1 million Britons are currently on waiting lists for medical care — and another 200,000 are waiting to get on waiting lists. Evans also says the NHS cancels about 100,000 operations each year because of shortages of various sorts. Last March, the BBC reported on the results of a Healthcare Commission poll of 128,000 NHS workers: two thirds of them said they "would not be happy" to be patients in their own hospitals. James Christopher, the film critic of the Times of London, thinks he knows why. After marveling at Moore's rosy view of the British health care system in "Sicko," Christopher wrote, "What he hasn't done is lie in a corridor all night at the Royal Free [Hospital] watching his severed toe disintegrate in a plastic cup of melted ice. I have." Last month, the Associated Press reported that Gordon Brown — just installed this week as Britain's new prime minister — had promised to inaugurate "sweeping domestic reforms" to, among other things, "improve health care."

Moore's most ardent enthusiasm is reserved for the French health care system, which he portrays as the crowning glory of a Gallic lifestyle far superior to our own. The French! They work only 35 hours a week, by law. They get at least five weeks' vacation every year. Their health care is free, and they can take an unlimited number of sick days. It is here that Moore shoots himself in the foot. He introduces us to a young man who's reached the end of three months of paid sick leave and is asked by his doctor if he's finally ready to return to work. No, not yet, he says. So the doctor gives him another three months of paid leave — and the young man immediately decamps for the South of France, where we see him lounging on the sunny Riviera, chatting up babes and generally enjoying what would be for most people a very expensive vacation. Moore apparently expects us to witness this dumbfounding spectacle and ask why we can't have such a great health care system, too. I think a more common response would be, how can any country afford such economic insanity?

As it turns out, France can't. In 2004, French Health Minister Philippe Douste-Blazy told a government commission, "Our health system has gone mad. Profound reforms are urgent." Agence France-Presse recently reported that the French health-care system is running a deficit of $2.7 billion. And in the French presidential election in May, voters in surprising numbers rejected the Socialist candidate, Ségolène Royal, who had promised actually to raise some health benefits, and elected instead the center-right politician Nicolas Sarkozy, who, according to Agence France-Presse again, "plans to move fast to overhaul the economy, with the deficit-ridden health care system a primary target." Possibly Sarkozy should first consult with Michael Moore. After all, the tax-stoked French health care system may be expensive, but at least it's "free."

I'm not sure what's more impressive:  the review itself or the fact that Kurt Loder is apparently a thoughtful guy.  What next - Kari Wuhrer writing for The Economist? Gideon Yago with a massively popular blog?  Oh wait...

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Thoughtful?

Well, he's not so thoughtful as to make sense. Whoever heard of there being 'unlimited' demand for healthcare? I live with healthcare free at the point of source, and did indeed avail of the opportunity to hang around oncology departments far more than most, but not because I wanted to. And, strangely enough, hospitals aren't packed out with healthy people who want pills or a spot of chemo because, since it's free, it won't do their utility functions any harm.

What nonsense.

We can argue over what happens at the edges of interpretation and in A&E departments on Friday nights. We can even talk about some form of pricing. But let's start with the recognition that, for the most part, demand for healthcare is restricted to the sick. And, by the way, there are perfectly fine arguments out there stating that healthcare ought to be distributed according to who's ill, not according to capacity to pay.

Basic economics

If you know basic economics, you know what he's talking about, and you know he's right.

 

"let's start with the

"let's start with the recognition that, for the most part, demand for healthcare is restricted to the sick."

Well, if you believe this, you should be seeing, and hearing, what we french people do. Here's a sample, heard in in a discussion by some public administration employees:

"I'll have to take the week of sick leave I'm supposed to have yearly, too, before the holidays."

That's what we get for forcing taxpayers to finance unlimited paid sick leave. I can (and on one occasion did) go see a doctor and get a week or two of sick leave for no good reason. There even are whole fraud schemes based on this, where fake companies fakely employ people who are then declared sick, so they receive compensatory wages from the Sécurité Sociale. Later they "fire" the employees so they also get unemployment benefits for three years. Each of these operations defraud the taxpayers of tens of millions of euros. This is so pervasive that the previous director of one of the "Caisse principale d'assurance maladie" resigned over the uproar it caused. Starting fraud kits are even being sold around !

So, no, you cannot say with a straight face that demand for such service is mostly limited to the sick.

But let's start with the

But let's start with the recognition that, for the most part, demand
for healthcare is restricted to the sick. And, by the way, there are
perfectly fine arguments out there stating that healthcare ought to be
distributed according to who's ill, not according to capacity to pay.

Healthcare isn't handed out to humanity to be distributed. Healthcare, like cars, cheese and armchairs is produced. There are people who work to produce healthcare, pharmaceutical companies, doctors, nurses, surgeons. These people were not born to serve the sick, they chose to do so, and very often, they expect to make a living out of it. Division of work means other people are going to produce other things and they will eventually exchange it for healthcare. When you speak about [b]distributing[/b] healthcare, you assume it has been produced. There are two fundementally identical ways to "distribute" healthcare.

a) You force doctor, nurses, surgeons to produce healthcare and you decide who gets it. This is distribution.

b) You force other people to produce other goods (not healthcare) you take it from them and you give it to healthcare producers so that you can distribute it according to your plan.

Of course, what you meant is that doctors, nurses, and surgeons should voluntarily chose to help people who cannot afford their service, I don't think you'd defend slaverly, would you?

 

 

Average or Marginal?

On average all of the wealthy, industrialized nations have pretty good healthcare. On the margin all of them suck in some way.

Whoever heard of there being 'unlimited' demand for healthcare?

Throughout emergency rooms and critical care facilities in the US
demand seems to outstrip supply. Waiting lists and waiting to get on
waiting lists is sufficient to claim demand far outstrips supply in
Canada and Europe. I will grant that 'unlimited' is hyperbole.

But let's start with the recognition that, for the most part, demand for healthcare is restricted to the sick.

Preventative care? And what is 'sick'?

 

David Masten

"Whoever heard of there

"Whoever heard of there being 'unlimited' demand for healthcare?"

As soon as healthcare becomes "free" (as in "paid by others"), the demand explodes, as is evidenced by the crowded emergency rooms in France. There is, according to hospitals, four times too many people who go to ER for no good reason, than those who have a good reason to.

So, you're right, it's not "unlimited", it's just four times in excess.

I would go further than

I would go further than that: as long as healthcare is free (as in free for the grabbing), any increase in its production will be immediately and totally absorbed by an increase in the demand. In this interpretation, demand for healthcare is absolutely unlimited and permanently saturates the limited offer.

Should a new scanner machine be bought by an hospital, and it will immediately attract people and doctors eager to use it. Should more beds be made available, and the number and durations of hospitalisations grow as well. Should there be an overproduction of drugs, and there immediately are people to grab them, if not for treating imaginary symptoms then for reselling on the african black market.

Also, the fact that people continue calling it "free" when it costs a significant portion of the GDP (10 to 15%) is depressing.

I strongly support Kari

I strongly support Kari Wuhrer doing almost anything.

Agence France-Presse

Agence France-Presse recently reported that the French health-care system is running a deficit of $2.7 billion...

...a year. Total deficit, accumulated since the 50s, is over 100 billion euros. Our healthcare budget system has never been balanced.

My doctor fled to Switzerland last December, and does not regret it one bit. His replacement has disappeared without a trace after just three months, meaning I no longer have a doctor available at hand with access to my medical history.

I suggest Mr Moore come here and "enjoy" the same healthcare I do. No, not the service itself, which is mostly private and rather efficient, but the collective financing of it, which is purely communistic (being put in place by decree by communists under order from Moscow back in 1946). Being so insanely wasteful makes it cost nearly half of one's salary (for me: 1500 euros out of a 3200 euro monthly salary, a proportion that can run much, much higher the higher the salary, of course). Being perpetually bankrupt (both financially and morally) makes it cost lives (15000 elderly people in 2003, 145 more people just a couple months ago, these are just the tips of many icebergs, I could add horror stories from handicapped friends or various gloomy euthanasia reports, regular stories of abuse of old patients or retarded people, inhumane treatment of chronically diseased or crippled people, etc... all stemming from one root cause: the illegal state monopoly the system still enjoys and abuses even though the European Union abolished it in 1994).

If you read french this blog has a lot of detailed info about the french healthcare system: http://quitter_la_secu.blogspot.com/

When I first read the post

When I first read the post title, I read "What Michael Moore hasn't done is lie" which seemed very suprising !

A Long Response

Well, that's what I get for leaving grumpy emails on people's blogs! Right: apologies for the long comment to come!

Constant, what element of basic economics is it that I don't get? If we're talking demand curves, well I understand them very well. And while I'm quite sure that low prices for healthcare increases demand and extends it to the merely neurotic or people who won't wait 'til their pharmacy opens on Monday, I'd say it demand is pretty price inelastic, at least at the lower end of the scale (ie, between 'cheap' and 'free').

The 'unlimited' comment is probably just hyperbole, but it reflects a deeper problem with Loder's sort of thinking. The assumption is that free healthcare encourages malingerers. My claim is not that there isn't a relationship between demand and price, or even that there is a total lack of malingerers availing of free healthcare. It's that the relationship isn't as simple as Loder lets on and that when a market is, to a large extent at least, restricted to people who are unwell, using price to dole out scarce healthcare resources will not lead to those who deserve healthcare the most getting priority.

There is plenty of evidence that, when prices for healthcare (via private insurance in the US, for instance) are high, plenty of sick people don't avail of healthcare, sometimes with catastrophic results.

Jesrad, the conversation you report highlights something important: that people in France (and elsewhere I can assure you!) exploit sick leave, and GPs' surgeries, to get time off work. And yes, I'll acknowledge that they may be less inclined to behave like this if they had to cough up for the doctor's time (by the way, I'm not entirely in favour of free-at-source healthcare). But that doesn't refute the point that I reiterated in my response to Constant. I suppose this is where we're going to be at loggerheads. You obviously read your example as providing a good reason for dumping free healthcare. I read it as a sad case of the perverse, but marginal on the whole, incentives created by free-at-source healthcare. Moreover, I regard the incentives created by 'market-priced' healthcare to be even less palatable.

Arthur B, congratulations at construing my comment as advocacy of slavery! The arguments I was referring to are (Quelle Horreur!) moral arguments. Michael Walzer's Spheres of Justice is rather good on all this.

Your response to my comment has two elements: the 'produced' element and the 'distribution' element.

On the fact that healthcare is produced, of course it is. Incentives for healthcare-producers (you started this!), I believe, ought to be devised through a free market. In other words, if demand for nurses outstrips supply, then it might be a good idea to bump up nurses' wages (and perhaps throw money at educators to train more of them). I suspect that we agree on this.

But, and here's the distribution bit that I suspect you don't like, since I have a moral stance that suggests that there ought not to be a link between personal wealth and access to healthcare, to the product if you like, then I think that the state ought at least step in to pay for healthcare of those who cannot afford it themselves. And why ought the state force taxpayers to stump up for the healthcare of people who they didn't actually infect? Because, in a decent society, it's quite simply the right thing to do. People have a fundamental interest in their own health in a way that they don't have an interest in porches or cakes or trips to the cinema. Now, that's not necessarily a call for the sort of entirely public system that Britain has. Personally I think there may be space for some reduction in free-at-source provision. And there are a range of ways to create fair access to decent healthcare. My claim is that a 'free-market' pricing is not one of those ways.

Anyway, I can believe that Loder's believe in a simple demand curve for healthcare is spectacularly simple-minded without having this moral stance, but that is my stance!

Sorry for the long post. I hope my longwinded reply to the replies isn't too boring!

Oh, and finally, I only found this site through Frank McGahon a few days ago and it's marvellous! Keep up the good work!

community blog

Ciarán,

Glad you like the site. Part of the "new" features of the site include the reader blog aggregator. While I realize you have your own blog, feel free to post disagreements with us there (or in the comments sections like you've just done); you'll probably get more people reading by posting on the aggregator. We'd love to get more people who disagree with us posting there. And if you have civil non-libertarian blog friends, invite them over too.

What you're neglecting

Constant,
what element of basic economics is it that I don't get? If we're
talking demand curves, well I understand them very well. And while I'm
quite sure that low prices for healthcare increases demand and extends
it to the merely neurotic or people who won't wait 'til their pharmacy
opens on Monday, I'd say it demand is pretty price inelastic, at least
at the lower end of the scale (ie, between 'cheap' and 'free').

What you're missing is this: the price mechanism is how the market works. The supply curve meets the demand curve at the price. Medicine goes to those willing to buy at the price, and from those willing to sell at the price. If medicine is provided free then the price mechanism is eliminated. You can't just do away with the price mechanism and expect things somehow to work the same as they did before, because the way they worked before was by the price mechanism. It's like removing the central gear from a clock and then expecting the clock to still tell time just the way it always did. It's like removing a car's crankshaft and expecting it still to go.

If you eliminate prices then there is really no choice but to find a substitute - to find some other means of determining who provides how much medicine and to whom. Thus - rationing. One form of rationing is queues, which Mr. Loder mentioned.

a deeper problem with Loder's sort of thinking. The assumption is that free healthcare encourages malingerers. My claim is not
that there isn't a relationship between demand and price, or even that
there is a total lack of malingerers availing of free healthcare. It's
that the relationship isn't as simple as Loder lets on

Mr. Loder's point does not rely on either any moral evaluation ("malingerer") of those seeking medicine, or an oversimplification of the issue. In fact, the less simple the issue gets, the more acute the problem becomes - the problem which is addressed by the price mechanism and, absent the price mechanism, would need to be addressed in some other way. I can really make no sense of your own argument except to interpret you as saying that even without the price mechanism, somehow the right amount of medicine would get to the people who need it, and neither too much medicine would be produced and consumed, nor too little. That's a pipe-dream - that somehow things will just take care of themselves without either prices or rationing. And your defense of your pipe-dream is that things are even more complex than Mr. Loder believes they are. Well, if the world is even more complex than a world in which price mechanisms are needful, then all the more reason to disbelieve your pipe-dream that things will somehow just take care of themselves without either prices or rationing.

 

Rationed by Price

Jonathan, I'll stick with the obscurity of my own domain thanks very much: at least that way I can pull the plug if it all gets too much! As long as you don't mind my unending comments!

Constant, thanks for the clarification. You'll be disappointed to hear, however, that those lovely neat microeconomics 101 graphs, with their perfect information and other assumptions, aren't the end of the story. How useless economics would be if they were.

Real markets are far more interesting than that. Think the recent upheaval caused by information economics for one thing. But you're right: there's no point in me just saying that the world is complicated without saying how. So here goes!

I think one part of your misunderstanding of the specific situation re healthcare is that you associate rationing with Soviet-style queuing or the books our Grandparents carried around during and after WWII. You're right, that's rationing, but it's only one sort. Don't forget that the price mechanism is nothing more than another rationing technology. And, when it comes to the likes of Mars Bars, it's a pretty efficient technology. The price is tweaked, as you pointed out, until demand is more or less the same as supply. Those who would prefer to spend their money on other things go and do so. So let's get over our argument is over whether you have rationing or non-rationing of scarce resources. We both know that rationing will happen. Our argument is over technology. That is: what is the best means for rationing healthcare?

What I said in the comments above is that I think the price mechanism is a pretty bad way to ration healthcare. The pool of people whose tastes extend to demanding healthcare is not commensurate with the available population as a whole. It is only made up of people who feel unwell. So who drops off the demand curve as you up the price? It depends on how you ask for the money. If it's at the hospital or GP's door, you'll certainly quickly get rid of people who really ought to go home and sleep whatever they have off (or at least we can hope that that's all that's wrong with them). Which is great. But you'll also get rid of people who have no money once you monetise distribution and, you'll get rid of people who have very little money (with 'money' including access to credit) as the price goes up. Indeed, as costs are sometimes distributed over time, you might even get some people who go for treatment then drop out mid-way as their funds dry up.

If you have up-front costs like health insurance you hit the same problem except more so. Foregoing now for possible future events is more difficult when you don't know if those events will actually happen and have a very tight budget (which is why poor people don't tend to have a range of insurance products). Possible future bills never seem as pressing as actual present bills. Problem is, if someone has the misfortune to fall ill, but didn't opt for insurance, they can be in very deep trouble. Foregoing healthcare is not the same as foregoing those Mars Bars. And we know that poor people are responsive to price in market systems: they present with illnesses later than people who can pay and then suffer the sometimes dire and expensive (for them and/or the taxpayer) consequences of having to be treated for more advanced illnesses. This, for instance, is particularly a problem in private oncology, big multi-site tumours being far more of a problem than little single-site tumours.

Using price to ration healthcare is bad because, when the demand shakedown happens, healthcare will not be doled out to the people most deserving of it. It will be doled out to the people most willing to pay. And since one's health tends to become a subject of overriding concern when you're sick, 'most willing to pay' is very often code for 'most able to pay.' Not only does this have profound public health consequences. It is quite simply wrong.

Now, I'd love to be in a world where healthcare was rationed by triage specialists figuring out who is most in need. As you suggest, however, a world entirely that perfect is a pipe dream. Other costs are imposed in place of price: time spent queueing being the most obvious of them.

But actually, that pipe dream almost exists, though often in a far more haphazard manner than anyone would like. Queueing costs tend to be high but, in A&E departments and regarding waiting lists, they are not distributed evenly. Generally some triage mechanism sorts out those who need to be seen to more urgently from those whose problems are not so pressing. Of course these mechanisms fail at times but for the most part they are actually rather effective. They are certainly more effective at sorting the severity of problems than wealth.

A second element to this is that, at a grander, often state level, decisions are made as to what can be made available to people given the resources that are available. This, for instance, is the job of Britain's atrociously-named NICE. So, you have a two-stage rationing of supply. NICE figures out what resources are worthwhile and triage specialists sort out the queue. It's not pleasant, but it's more pleasant than sorting demand out based on credit card limits.

Of course, this all comes apart a bit at the seams if supply crashes, as happened in the UK through the 1980s, because demand for a free-at-source product will remain pretty constant. So the queues will get longer. But again, is pricing people out of the waiting room a fair solution? Is it a fair rationing mechanism for healthcare?

So: to make a long story short. We are both talking about rationing. You want rations to be distributed according to personal wealth. I want rations to be distributed according to who triage specialists (who often include your GP) think need healthcare the most. We both advocate flawed systems but I think ultimately you're the one who's being naive in presuming that all markets are described by simple demand and supply curves or that markets can distribute all things fairly. You are either naive or cruel. You cannot talk about the price mechanism 'addressing' the problem without acknowledging what that means.

Ciarán: You seem to be

Ciarán: You seem to be associating all healthcare spending with emergency room treatment - in which case it would be reasonable to defer to the triage specialist's opinion as to which emergency merited priority. Once you leave the ER, as you point out, things get more complicated. This is directly relevant to your dismissal of the price mechanism as, even under the specific circumstances of the market for ill people, this mechanism contains information inaccessible to "triage specialists". It's a (relatively) trivial matter to allocate care in a crowded ER where everyone is there in front of you and you have most of the information you need. This simply doesn't scale up.

 I also wonder how end-of-life care fits into your model. I'm sure you're aware that vast sums are spent extending the life of terminally ill people by mere days. I don't see why everybody else should have to pick up the tab for this, but equally, I don't see that it ought to be a doctor's decision to pull the plug. This is a decision about how one values an additional day and it ought to be the patient/family's choice based on how they value that additional day relative to the foregone expenditure.

(Incidentally, you might be interested to learn that two of the Catallarchy bloggers here are MDs)

I'm just pointing out a truth

You want rations to be distributed according to personal wealth. I want
rations to be distributed according to who triage specialists (who
often include your GP) think need healthcare the most. We both advocate
flawed systems but I think ultimately you're the one who's being naive
in presuming that all markets are described by simple demand and supply
curves or that markets can distribute all things fairly. You are either
naive or cruel. You cannot talk about the price mechanism 'addressing'
the problem without acknowledging what that means.

I didn't say anything about what I want. I just said that medicine has to be rationed one way or another. That's what Mr. Loder said which you called complete nonsense, and all I did was explain that. You obviously agree. But recall that you appeared to dismiss that valid point as complete nonsense, and it was not, it is not, and finally in your elaboration you are agreeing with it, and phrasing your remarks in a way that acknowledges the need for some form of rationing.

That was my point and I will stick to it, though there is more that I am dying to say on the general subject. I need to leave the computer (July 4).

Rationing and Desert

Ciarán:

Two points. First, rationing by price is superior to most other forms of rationing in that it tends to increase the quantity supplied. Capping the price at a certain level and then rationing health care may produce a more desirable distribution of a given amount of health care (desirable to the one doing the rationing, at least). But letting the price rise will result in more health care being supplied.

Also, you said, "using price to dole out scarce healthcare resources will not lead to those who deserve healthcare the most getting priority." You say "deserve," but it sounds an awful lot to me like you mean "need." These are distinct concepts. In a market economy, ability to pay is arguably a fairly good proxy for desert, at least in adults. Need is not.

Ciaran, cut the mumbo jumbo.

Ciaran, cut the mumbo jumbo. Do you force healthcare provider to work as slaves or do you steal from other people? It's either-or, there's no other way. Which is it. Do you hold doctors or taxpayers at gunpoint, which is it?

Arthur, I suggest you go and

Arthur, I suggest you go and ask a healthcare worker in a nationalised system whether they consider themselves to be "slaves".

I expect puzzlement to be a typical response

Perhaps they might be suffering from "false consciousness"?

Not what he said

He didn't say that they are slaves. He gave that as one of two options. The other option is probably the one that Ciaran has in mind. Nationalized health care in the real world, which Ciaran is presumably using as a model, is not based on slave work by health workers themselves but on taxes, which are, as Arthur points out, collected coercively.

 

 

Thanks

Frank: fair point. I'm willing to concede that elasticity of price varies from place to place in the medicine world. Demand for more urgent treatment is inelastic, with those who cannot raise funds simply excluded (barring charitable acts) while - at the other end - demand for pharmaceutical products is pretty elastic. I defend my position on this and a few related points in discussion with you over here, though I was sleepy when I wrote it.

Constant, I hope you enjoyed July 4! I think though that you're being a bit hard on yourself: you seemed to be doing much more than clarifying Loder for me in your previous comment. And, as I pointed out, Loder does explicitly draw a distinction between (good) pricing and (bad) rationing. Still, sorry if you feel that I misread you.

Arthur B if you think what I've written here is mumbo-jumbo, I can assure you that it's the tip of the iceberg! Still, while big picture jibes of the 'agree with me or you're a NAZI!' variety are always satisfying to write, they're just not very interesting to respond to.

I'm not quite sure that we've (or rather I've) chosen the correct post for a discussion about this. Loder's piece is a bit of a red herring and I'm stuck trying to defend my crochety go at him and a Grand Philosophy of the State. I should have waited for a GPS post alone! Still, you've all forced me to go away and read up on all of this. So thanks.

Apparently one element in the debate is over the - perhaps more interesting than our discussion - issue of health as a thing that individuals both produce and consume (whereas we've treated individuals solely as consumers here) over a lifetime.

While I don't think any of us are going to agree in a hurry, I'd love to know if libertarians like your good selves (putting the basket of narrower markets aside for a moment) make of demand for health over a lifetime by individuals who both produce and consume it? In one way it's good for you: you can claim that people make lifelong health choices and why ought we think we know better than they do as to how they price it? My beef with that would be to wonder whether there's a moral problem with the fact that there's a clear link between health and wealth - should subsidies be available to those who cannot afford the high costs of better health. I'd also be concerned at market failures. For instance, how are information deficits to be closed so that individuals are tooled up to make decisions about their health? But that's for another day!

I didn't say you were a nazi

I didn't say you were a nazi at all. I said your plan for distribution could only work if you either forced healthcare provider to work for your or force other people to work for you so that you use their wealth to buy healthcare yo who you deem deserves it. I am asking which plan you would favor. If these plans seem "nazi" to you, I invite you to draw the necessary conclusions by yourself.

I didn't say you said...

I didn't say you said I was a Nazi. I said that your jibe was of the 'you're a Nazi' variety. Quite a different thing!

Moreover, Frank is busily demolishing me on my own blog but as far as his response to your comment here goes, I'm delighted to agree!

Why do you keep evading the

Why do you keep evading the question ?

I genuinely want to know if, in order to distribute healthcare according to a certain rule you plan to:

a) force healthcare providers to work for your purpose
b) force people to give you the proceed of their work so you can buy healthcare for you
c) another solution I didn't think of