by publius
As others have noted, Senator Baucus’s “white paper” is very big news. As one of the most conservative and business-friendly Dems, the fact that he’s signed on to such an aggressive Clinton/Edwards-type plan means that health care reform is on. The battle is really coming this time. And it’s incredibly exciting.
There are far more wonkish takes than I can provide – check out, e.g., Maggie Mahar (here and here), Ezra Klein (here and here), and Jon Cohn. But I’ll offer a few thoughts.
First, one of the understories here is the potential struggle between Baucus and Kennedy for ownership of the legislation. I’m an enormous Kennedy fan, and it would be incredibly satisfying (for obvious reasons) to give him one last major victory.
But still, we have to be clear-eyed about the legislative battle. Baucus brings some strategic political benefits that Kennedy does not. Most obviously, Baucus is better equipped to pull off a Nixon-in-China with respect to universal health care. He’ll necessarily provide Obama and the Dems more political cover during the war to come than Kennedy could. More importantly perhaps, letting Baucus take the lead could potentially reduce the opposition of insurers and Republicans who would feel more comfortable that they would get a voice in the process.
The problem, though, with letting Baucus run things is – and has always been – whether he can be trusted. That’s obviously a non-issue with Kennedy. He’ll fight ‘til his last breath to help deliver health care reform to the public. But if Baucus is serious – and today is a sign that he is – he’s a more likely Joshua, pragmatically speaking (i.e., he’s more likely to lead us to the promised land).
Second, the fact that health care reform is on in a big way is a testament to the Democratic primary – and to John Edwards in particular. Edwards forced the major candidates to spend a lot of time on health care, and forced them to think bigger and move left.
Today, we can see the benefits more clearly. Because Obama had to hone his arguments and sharpen his policy, he was in a stronger position both to attack McCain and to present his own positive vision of reform.
Even better, because Obama was pushed to talk about health care so early and often, his mandate now includes major health care reform. Campaign rhetoric matters, and that’s why it’s so critical to push candidates to talk about these issues before the election. Edwards did that – he opened the political space. And if reform passes, he deserves a lot of credit.
Anyway, it’s a very promising start. Coupled with the good signs out of Alaska, we may be on the verge of truly historic legislation – legislation that will tangibly improve millions and millions of lives, forever.
Elections matter.
Hee heh hee hee!
THREE votes!
Sorry but the idea that Hillary would not have made health care one of the pillars of her candidacy without Edwards is ridiculous.
I am a January07-strong supporter of Obama so I don’t have a dog in the Edwards fight but I have to tell you the myth that has been created about his role in the primaries annoy me.
Yes, there are themes he helped make more central but bottom line is that Hillary Clinton – whom I loathe – has made health care the center piece of her political career for twenty years and was intent on doing it right the second time around. And Obama’s preparation on health care has everything to do with having to face HER for six months rather than the limpless seven-people debate of last fall.
So credit JRE for the poverty thing. But crediting him for the health care focus is BS.
(1) You may perhaps pardon me if I am disinclined to give Edwards any credit for anything. His sudden conversion after the 2004 election to outspoken purity on every progressive issue despite his previous record was profoundly unconvincing, and the dissolution of Edwards’s so-called charitable foundation immediately upon the collapse of his Presidential ambitions this year certainly seemed to suggest that Edwards’s reinvented posture post-2004 was indeed a pose. (2) There is an obvious and unmentioned, not to mention tragic, reason why Sen. Kennedy will not be shepherding health care reform through the next Congress. Though it would seem appropriate if the bill could be dedicated to his memory.
Max is my senior senator. While this is not a perfect proposal, indeed it has several serious flaws, it is still a major step forward on this issue. Almost makes me want to take back a couple of the nasty things I’ve said about him over the years (but only a couple). I give him props for this, but he still needs to spend more time with his family.
As for Kennedy, there is simply no way this gets passed unless Kennedy gets some serious input. Whenever something big happens, Kennedy is a major player. Given the current situation, the best way is to let Baucus do the heavy lifting and let Kennedy get what he wants. And let Kennedy stand behind Obama when he signs it. And call the bill Kennedy-Baucus. It’s kind of like getting to the Pro-Bowl. You always get there the first time later than you should. And at the end of your career, you get there when you’re past your game. Kennedy has earned that kind of respect. And he still has enough power that you don’t want to cross him.
I agree with Benjamin. The centrality of health care as an issue has a great deal to do with Hillary — and the fact that she, like Kennedy, can be trusted to really *care* about the issue, it’s not something she’s adopting for expedience. She set Obama a firm bar, and the fact that she was in the race and fighting through June meant that health care never got off the table.
I also think Obama owes a good deal of his success to Hillary’s persistence and strength. During the spring I thought the drawn-out campaign was an incredible waste of time and money; I was wrong. Because Hillary kept fighting, Obama *had* to be organizing in state after state — and because the campaign kept at a high tension, he was able to raise the money to do so.
Clinton released her health care plan after Edwards did, right? Was that because her team was just disorganized or was that because she hadn’t been planning to focus on healthcare until Edwards raised the issue?
If it’s true that taxing health benefits is “on the table” in Baucus’ plan, then we need to be completely clear that it’s right off.
I understand the concept of going into negotiations with throwaways, but this is too dangerous an idea to play around with. It got rightly laughed off the stage when McCain brought it up, and it needs to get laughed off now..
Not to mention, the close primary campaign got Democrats interested and energized all over the country early on–not just the Obama supporters but the Clinton supporters too, who would eventually turn out again for Obama.
I remember reading about what a disaster the primary was for the Democrats, and then hearing my mother in Virginia describe the incredible, enthusiastic turnout for the Dem primary there, which was like nothing she’d ever seen before–and thinking something didn’t quite jibe here.
For those advocating for Clinton’s greater importance on health care than Edwards, I distinctly remember Clinton stating that she expected Universal Health Coverage to be something she would pursue in her second term.
And, indeed, google provides.
Clinton was badly burnt by the grand scheme method of trying for universal coverage in 1993, and clearly intended to go with incrementalism if she got a second try. Edwards was the one who pushed out a specific grand plan for his first term, forcing Clinton and Obama to follow suit.
Take a look at Poland’s health service status. Hospitals with enormous debts closing down, patients being evacuated to nearby hospitals… medicine doctors rejecting most urgent health cases over salary issues.
but still I pay two hundred $ monthly to keep this “dead corpse” going…
This is real “health hell”…
Millions and millions? Forever?
Probably not. The Progressive belief that market forces can be bent to their will by legislation and regulation is no different than insisting water can run uphill if only the right law is passed. Health care is delivered by health care professionals who, in the past, spent hundreds of thousands of their own dollars and many years of their lives to acquire the high end specialty skills that exist nowhere else in the world in accessible numbers. For this, they expect to be compensated and compensated well. Ditto for first class hospitals and out-patient treatment facilities.
Health care reform means limiting compensation for these professionals and these institutions. Controlling costs means exactly that: limiting compensation. Unless Progressives plan to draft doctors and nurses and force them to work for less, they will take their skills elsewhere or pursue lines of work that do not require another’s consent to their pay level.
As for the future, who will be willing to acquire high-end surgical skills when their compensation is subject to the whims of elected officials who win office by promising more for less? And who will stick around to teach these skills?
Your ‘millions and millions’ will someday receive primary care from RN’s and physician’s assistants–all fine for basic health services but a disaster for the kind of early detection diagnostics that save so many lives today. Government ‘gatekeepers’ will replace the current generation of insurance frauds whose sole role is to limit services and therapies such as surgery and long term physical therapy.
The same holds for drug research. On the regulation-happy, progressive left, drug companies are the epitome of evil. Yet, when was the last time anyone here or anyone you know of took a government-developed drug?
In few other areas does the left’s unmitigated hubris stand to do so much damage to so many and for such a long period of time. In reviewing this and so many other posts at this site, one trait that I find to be totally absent is any sense of self-doubt or trepidation in heading down this path. You are so certain you (‘you’ being the larger progressive left) are right on this irreversible, fundamental issue that the notion of staged, incremental experimentation isn’t contemplated–not even in passing.
Man, if only some other countries had experimented with universal health insurance, and helped discover the bugs and work them out through years of regulation, practice, and revision to address any of the issues mckinneytexas brings up. If only we were not attempting to embark upon such unexplored territory where no industrialized nation has gone before!
Clinton was badly burnt by the grand scheme method of trying for universal coverage in 1993, and clearly intended to go with incrementalism if she got a second try. Edwards was the one who pushed out a specific grand plan for his first term, forcing Clinton and Obama to follow suit.
As a former Edwards supporter who is incredibly, probably fatally, disappointed in him, I still think you need to give credit where it’s due. It doesn’t really matter what you think his motivations were, particularly since you will never know with certainty and precision what they were, but even so if you somehow did. Whether you like it or not, Edwards did have a very salutary effect on the Health Care political debate in the Primary, among others.
If you think that pure motivations in politics matter more than what is actually done, you must be, at some level, 13 years old.
All three Dems wanted and want universal health care. Edwards’ insight was that this was a moment of maximum leverage for progressivism, that it was not a time to be timid, that if you actually lead, you will be followed; that the forces arrayed against its goals are not going to change their minds if you just ask them to ‘be reasonable’. Both Obama and HRC were smart enough to appropriate that insight to some extent – Obama more, although on health care he tacked right (still looking for pure motivations and Perfect Honesty?). What matters is that it gets done – FINALLY! Edwards deserves credit for taking an ideological lead on this and other issues, whether you like him or or not. I would’ve been a more mediocre, mincing, boring season, and outcome, without him.
Max makes me extremely nervous, but I am guardedly excited. Health care reform should’ve been done yesterday.
Nate: what country has the level of specialized healthcare we have here, readily available, with matching successful outcome rates? Doctors in France are paid a pittance, compared to physicians here. Do you really think you get there, for peanuts, what you get here for fair market value?
Instead of claiming–without valid, outcome-based comparables–that other countries deliver for less what we already have, why don’t you–or anyone–explain how you get the necessary population of orthopedic surgeons, cardiovascular surgeons, oncologists, neurosurgeons, high-risk anesthesiologists, etc. to treat a population of 300,000,000 by paying them fifty or hundred thousand a year starting in their thirties (since they’ve spent their twenties acquiring their high end skills)?
Your dismissive attitude makes my point about progressive hubris far better than I could.
@Mckinneytexas:
You clearly misunderstand what healthcare reform is. It’s minimizing compensation to the third-party insurance companies, not to doctors and hospitals. We need look no further than Canada or (almost) anywhere in Western Europe to see how well this has worked. Higher life expectancies and better quality of life in general, with plenty of first-rate doctors getting properly compensated.
mckinneytexas: For starters, it’s a matter of rejecting your claim that universal health care is going to require doctors to be paid a “pittance”. Every other industrialized nation somehow manages to have doctors, medical research, AND insure their citizens so people are not regularly going bankrupt from medical costs. If you’re that concerned about the enormous expenses of medical school, then perhaps a better approach would be to make colleges more affordable, so more people could become doctors, and those who did didn’t end up with hundreds of thousands of dollars of debt to work off.
My dismissive attitude and sarcasm came about because your argument that “IT CAN’T BE DONE!” is completely falsified by many many examples of other countries managing to do exactly what you said can’t be done.
Kris–Canada is a single payer system that is hardly the ideal and has nothing to do with insurance company profits. Your post points up the fact that much of the progressive fervor for nationalized health insurance or health care or whatever you want to call it is a blend of hope trumping reason, ignorance of what ‘health care’ actually is and a child-like faith that doctors are fungible and in endless supply. Further, Western Europe-style mass health care isn’t even close to what most Americans receive today. Nor is health care reform about limiting insurance company profits (sure, cap their income and either services decline or they go out of business–what is your back up plan?). You cannot do more for less without cutting services and the prices paid for those services, which in turn is an obvious disincentive for anyone to take up the practice of medicine, build a new hospital or spend millions developing a new drug.
Further, do you understand ‘comparable outcomes’? Do you think Europeans receive the same prompt, high-quality high-end surgeries and therapies that Americans receive and with the same level of successful outcomes? If so, you are mistaken.
Finally, life expectancy is mainly a function of lifestyle choices and genetics. Comparing the US with any European country is, if not apples and oranges, pretty damn close. US demographics don’t match European demographics. Our Hispanic and African-American populations distort longevity statistics.
This is true, but probably not in the way you meant it.
I am confused by mckinneytexas’s claim that “life expectancy is mainly a function of lifestyle choices and genetics”. This seems to omit the kinds of social structural considerations that are necessary to account for findings such as that, for example, “The size of the gap between the wealthy and less well off–as distinct from the absolute standard of living enjoyed by the poor–seems to matter in its own right.”
http://www.bmj.com/cgi/content/full/312/7037/1004
(and, Off Topic: if anyone could point me towards instructions for suavely embedding links, I’d be much obliged.)
Nate, you’re right, it can’t be done, at least not in the sense of preserving the current level of care, both in terms of skilled physicians and ongoing drug and medical research. Pointing to Western Europe for quality medical care is like pointing to Western Europe as an example of an effective military establishment–there isn’t one, just a faint shadow of what once was.
If you are confused by the statement that life expectancy is mainly a function of lifestyle choices and genetics it’s because you don’t understand the significance of either, but let me try to illustrate: some people die at 18 or 23 or 45 of latent cardiac deficiencies, despite healthy diet, access to topflight medical care and no history of smoking, drug abuse or excess alcohol intake. Death in this instance is almost always a function of genetics. Others live well into their 90’s, despite poor lifestyle choices. This is also a function of genetics. Most of us, however, can trump genetics by smoking, obesity, alcohol/drug abuse, sedentary lifestyle, etc. So, there is your explanation.
mckinneyintexas, while I agree with you that there are some conceptual problems with national health care insurance proposals, I think that your dismissal of European health care is entirely too casual. Your case seems to be that Europeans live as long or longer than Americans because they have better genes, they get more exercise, and they eat better food. You seem to be declaring that Americans need a different health care system because they are fat, lazy slobs. That argument doesn’t carry a lot of weight with me.
But I would like to ask a broader question of the group. If we consider the rising costs of health care, we do not see all that money going into the profits of insurance companies. Most of it is going into more health care. If we want to lower health care costs, then we need to reduce the amount of health care that we dish out — which means cutting out any care that doesn’t appear to be cost-effective. A good example of this is provided by the recent sad case of the poor fellow in West Virginia who couldn’t afford dental care, had a nasty tooth abscess and the bad luck to have it travel to his brain, and ended up dying after two expensive emergency brain surgeries. Clearly, had society paid the trivial amount of money on basic dental care, society would have been saved the enormous cost of his emergency care. So how do we handle this problem?
Another, more fundamental question is, how much money is an American life worth? How much money are we taxpayers willing to spend to save a life? I suspect that most Americans lack the moral courage to specify this number, so we act as if it doesn’t exist, and then we end up spending absurd amounts of money where it can do little good, and withholding trivial amounts of money where it can do much good.
mckinneyintexas, I’d like to add another comment. I get the feeling that there isn’t a conservative in the country who can open his mouth without saying something denigratory about liberals. It’s as if conservatives are stuffed so full of anti-liberal feelings that, when they open their mouths, it takes enormous mental discipline to insert some comments about the issues into the freshet of anti-liberal material that comes flooding out. You seem to be one of the more disciplined conservatives in this regard.
Why yes, mckinneytexas at 12:01 describes something I believe we all understand. What is less clear is why we should, as in mckinneytexas’s post at 11:19, attribute differences between European and US outcomes so exclusively to “lifestyle choices and genetics” as to desist from efforts to improve our national distribution of healthcare access. The logic of mckinneytexas’s argument presupposes that “Hispanic and African American populations” somehow intrinsically produce poorer “choices and genetics”; but it seems that the relevant factor might not be something intrinsic to these populations, but rather, their having been produced as ‘poorer’ (under various pressures not adequately described as “choice”) by larger structures of inequality, since systems of inequality do, clearly, correlate with increased mortality (see findings in the health policy paper cited above).
Not to mention, the Miracle in Minnesota. If they just scrape together 207 more votes, Al Franken is IN!
Does anyone have good stats available in non-war years for a European/US cross comparison of life expectancy before the current European health care structures?
Also I would have sworn there was a multi dimensional analysis (7 factors) of life expectancy and health which had some surprising (non-conventional wisdom) nuggets in it, but I don’t want to rely on them from memory. Does anyone know which one I’m talking about.
mckinney –
Here is the Nationmaster search page for health stats by country.
Find me any category other than spending per capita where our public health stats are better than those of any other OECD country. I’m just looking for one.
I already get all my direct care from physician’s assistants and nurse practicioners. I see my primary care doctor about 20 minutes a year.
I already wade through a confusing blizzard of paperwork and permissions forms whenever I need anything above and beyond a physical.
I’ve already been through experience of stupid, wasteful hanging around in ERs.
I, or more accurately my sister, has already been through the bewildering through-the-looking-glass experience of arranging for long term care for an aging relative with a debilitating illness.
I’ve already watched my father jump through 1,000 hoops to avoid personal bankruptcy after another family member went through a lengthy and expensive terminal illness.
And all of that is with what is, for this country, *excellent* health coverage.
I’ll give the pinko socialist approach a spin and see how it turns out. For what we pay we could, I suppose, somehow do worse than what we have now, but I think we’d really have to work at it.
Thanks –
You cannot do more for less without cutting services and the prices paid for those services,
Since no one jumped on this, i will. You could do more with less (like 40%, I believe) right now, tomorrow, without changing anything except how health insurance is administered to people who have already have it. You don’t have to be a wonk to know that. The fact is, our health insurance ‘system’ is indefensable the way it is, irrational, Rube Goldberg. That is simply a fact, neither liberal or conservative. While C. Crawford raises a valid point about the rising costs of actual health care, that’s a deeper question. Americans don’t get twice the health care for the double $ we pay. We actually get less than countries which pay less!
Frankly, it’s baffling why anyone who is really conservative would defend the current system. If a ‘conservative’ ran a business the way we as a country run health care, and I was a board member of that company, I would vote to not only fire them, but sue them.
[i]Health care is delivered by health care professionals who, in the past, spent hundreds of thousands of their own dollars and many years of their lives to acquire the high end specialty skills that exist nowhere else in the world in accessible numbers. For this, they expect to be compensated and compensated well.[/i]
Which is why, for example, Doctors Without Borders does not exist.
[i]Health care reform means limiting compensation for these professionals and these institutions.[/i]
Uh, you realize that health insurance companies do this already, right? When I had my orthopedic surgery in 1999, my surgeon and hospital got paid about 80% of what they billed for, because that’s the amount my insurance was contracted with the hospital to pay under my plan.
“Further, Western Europe-style mass health care isn’t even close to what most Americans receive today.”
And tens of millions of Americans receive no health care at all, other than via band-aid treatment at ERs that then bill them for thousands of dollars.
But, hey, tough on them, right?
As it happens, I am right now still trying, after months, to find a local clinic to see a doctor at, after two different ER visits in the past 3 months, for which I’ve been billed over $3.5K.
But, gosh, I sure do appreciate how wonderful the current system is for me. And the tens of millions of losers like me.
And let’s not even get into the impossibility of finding dental care beyond simple extraction.
Meanwhile, want to either a) hook me up with a local clinic, or b) send me a few thousand to help out?
How to link.
I’m going to go out on a limb and offer some basic factors that I think should be included in any national health plan:
1. All persons younger than the age of 18 should have basic coverage at taxpayer expense. Children cannot be held responsible for the financial wherewithal of their parents.
2. All adults will receive minimum health care at taxpayer expense.
3. All adults will have the option to purchase insurance from the state for higher standards of care. The price of this option will be based on personal factors such as smoking and weight.
4. Definitions of the various standards of care will be based on statistical analysis of the costs of treatments versus the benefit in quality life years (is that the correct term?). Minimum standards of health care only include the treatments with the highest cost-to-benefit ratios. Higher standards accept higher cost-to-benefit ratios.
5. Emergency room treatment will be limited to stabilizing the patient. All persons whose insurance coverage does not include the treatment necessary will be denied treatment and allowed to die. This is important! If we cannot refuse treatment to bad cases, then we cannot control costs! Somebody has to make the hard decisions about life, death, and money. Right now we let insurance companies make those decisions. Shouldn’t we make that a public political decision that we all jointly make?
That’s a start. Have at it.
Glasgow–the incidence of smoking, alcohol use, obesity and relatively unhealthy diet is higher among Hispanics and African-Americans–poor and blue collar whites as well–and these lifestyle choices (or, in many/most cases, defaults since education or lack thereof plays a key role)degrade whatever genetic programming an individual might have. I assume genetics to be equal among ethnicities and the prevalence of negative, controllable lifestyle factors to be the reason for reduced life expectancy. Access to health care, hygiene issues and an understanding of preventative medical treatment are more prevalent among lower income cohorts than those with higher incomes.
Chris– name-calling and ad hominem generalizations aren’t my style, although I am human and get testy from time to time. More to the point, though, is that, before we do something as a country that is likely irreversible, I’d like to see the proponents withstand fair scrutiny and defend their position.
As for reducing the amount of health care we dish out, I am afraid that is exactly what reform is going to produce: rationed and limited health care. Your example, however, presents a broad array of human factors issues that underlie much of the inherent intransigence of the overall situation: you can’t make people go the the doctor, or brush their teeth, or dry their hair before going out in cold weather. People do things–or fail to do things–all the time that put them in the ER or the ICU.
Russell–I looked at your stats. What is a hospital: a building with 1000 beds and five nurses or something on the order of Sinai, MD Anderson or what have you? What is a doctor: someone with 12 years of med school and post-med school specialized training or the functional equivalent of an LVN with a jumped-up title? For sure, the heart transplant and liver transplant stats are simply wrong–we do more liver and heart transplants here in Houston than the numbers your source claims for the world leader–but according to that same source, there were no liver or heart transplants anywhere in the US.
That said, if you think I am defending the current system, I apologize for not being more clear. The current system is awful. I see a government run system being much, much worse.
jonnybutter is right: our present system is horribly inefficient, and a slow, incremental and focused study of the inefficiencies and how to address them is something I’d fully support. Turning the whole thing over to the Feds–look at the bang up job they are doing on the bail out–is taking a bad situation and making it much worse.
Gary Farber, where do you live, amigo? And what is wrong with you that you can’t find a doctor to treat you?
Band-aids at ER’s and being charged thousands? Uh, beg to differ. ER’s must take patients regardless of ability to pay and cannot release them until they are stable. People who can’t pay, don’t pay–happens all the time. One of my clients is an ambulance service under contract to a large Emergency Services District in Harris County, Texas. People routinely ride for free and get free ER treatment. No offense, but your complaints sound more like uninformed talking points.
But, I’d really like to know where you live and what is wrong that after several months, you can’t get treated?
mckinneyintexas, I agree with you on the general principle that government screws up most things. I just saw a great poster with the caption “Government: if you think the problems we create are bad, just wait until you see our solutions.” But I’d like to offer two counterpoints:
1. We’ve already got our toes in the water with taxpayer-supported emergency-room care for indigents. Worse, an alligator has grabbed our foot and is pulling us in. Either we cut the foot off or get pulled further in.
2. The fundamental decision at issue is “How much is a human life worth?” The American political system doesn’t have the courage to tackle this question, so we pass the buck to the insurance companies, and then condemn them on both sides: for being too chintzy and being too expensive. I don’t believe that this fundamental question should be left to insurance companies. I think that it is a matter of public policy. If a ten-year old somewhere dies because they didn’t get basic medical care, then I lose out on all the Social Security taxes that kid would have paid to keep me in comfort during my retirement. I want that kid getting proper medical care. Besides, he might grow up to be the next President…
Why in the world wouldn’t you (Chris) think first about cost benefit ratios as they are rather than worry so much about someone getting something they ‘don’t deserve’? And by the way, it’s a little bit dicey to ‘blame’ every adult for their income level. Smoking and obesity are real public health problems, but why chicken out on the larger, more difficult, more obvious one? Namely, catastrophic care and especially care in the last year of life? I don’t know the latest figures, but it’s well known that that’s where the big money is, and real ethcial dilemmas are. Does it make sense to routinely spend a million dollars on a 90 year old, very sick person to keep them alive for an extra 3 months? I’m not saying it’s easy to decide this stuff. But health care reform is not for chickens.
Health care reform is also not for moralizers.
“Gary Farber, where do you live, amigo?”
Y’know, if you’d bothered clicking my links, you’d know the answer to that, so I’m not really interested in repeating myself.
On the plus side, after weeks of calling endless times a day, and only either getting busy signals, or a filled voice-mail system, I’ve finally managed to actually reach a human at a local clinic who gave me the info that may get me hooked up with them; now all I have to do is get a friend to take off work to drive me there sometime next week to fill out the paperwork, which can’t be done other than in person, and then I can get an actual appointment with them (knock wood).
“No offense, but your complaints sound more like uninformed talking points.”
I so have to restrain myself from violating the posting rules.
I’m going to try to quit this thread now. Or I’ll say things I won’t regret.
I’m not sure what this means, but it certainly is true that hospitals recoup their indigent-care losses by passing the expense onto the insured, or (ugh) the cash-payers.
So, we already do have some form of socialized medicine, only it’s horribly inefficient to the point where “by accident” fails to deride it sufficiently.
As for reducing the amount of health care we dish out, I am afraid that is exactly what reform is going to produce: rationed and limited health care.
Again, health insurance companies do this now – they ration and they limit.
mckinneyintexas….
You may want to entertain the notion that you may not know as much as you think you do about health care and the uninsured.
“Gary Farber” and “uninformed” are not two things that go together. Particularly when it’s about things he’s experienced.
I beg pardon for using this thread this way, particularly as it may just be coincidence, but if the person with the initials “A L” who just sent me a $10 donation, with a non-working reed.edu email address, is reading this, if you’ll send me a working email address at gary underscore farber at yahoo dot com, I’ll send you a proper thank you, which I can’t currently do, as although I know your name, I don’t see a working email address for you online, other than possibly having to sign up for Facebook, which I don’t particularly want to have to do. Thank you. And thanks for the $10!
Russell–I looked at your stats.
Great.
So, other than amount spent per-capita (public or private money), which one shows us as better off than any other OECD country?
Surely, if your point of view has merit, there must be *some* metric by which we, in the US, receive better health care than all similar countries that have relatively more socialized systems.
I’m asking for one. Any one. You pick.
I see a government run system being much, much worse.
Based on what? What you’ve presented here are assertions based on your own imaginings. Nothing more.
Show me the numbers.
And what is wrong with you that you can’t find a doctor to treat you?
He doesn’t have private health insurance, and he doesn’t have a truckload of cash.
There are millions and millions of people just like him in that regard.
But nice try making it, somehow, Gary’s fault.
We all get that you think further government intervention in the health care market would be bad, bad, bad.
What you have utterly failed to do is demonstrate why any of us should agree with you.
Thanks –
Gwangung: “‘Gary Farber’ and ‘uninformed’ are not two things that go together. Particularly when it’s about things he’s experienced.”
Perhaps not. But he describes a fact pattern that, quite frankly, seems a bit extreme and filling in the blanks doesn’t seem too much to ask.
And he is just wrong on his assessment of ER’s. If ‘wrong’ is more palatable than ‘uninformed’, the please consider my statement amended accordingly.
jonnybutter–end of life medial care is a hugely perplexing issue.
Phil–yes, that is exactly what health insurers do. There are differences, however, between private companies and the Feds. First, you can switch health insurers, at least in theory, but we’ve only got one government. Second, you have a better chance in court against a private insurer than you do against the government. Third, with a private insurer, there is a contract that the insurer can be held to.
Yes, the present system is awful. Expanding what we have and extending it to everyone is a huge undertaking, most likely beyond the limited abilities of an already very large and very expensive federal government.
And, yes, the rationing that now goes on is already limiting the number and quality of high-end specialty applicants, which was my main point many posts below.
“I assume genetics to be equal among ethnicities and the prevalence of negative, controllable lifestyle factors to be the reason for reduced life expectancy. Access to health care, hygiene issues and an understanding of preventative medical treatment are more prevalent among lower income cohorts than those with higher incomes.”
Okay … so then why shouldn’t we compare US health statistics to Western European health statistics?
First, you can switch health insurers, at least in theory, but we’ve only got one government.
In practice, I cannot do this. My company picks a health plan and I don’t get to choose. I could spend 20% of my income buying healthcare on the individual market, but that’s not really a practical option. As long as I stick with my job, I have no choice in insurance providers.
Second, you have a better chance in court against a private insurer than you do against the government.
I have approximately zero chance of beating my insurer in court. This is because I am not independently wealthy. I cannot afford to hire a team of attorneys and experts needed to compete with the team that my insurer keeps on retainer. Moreover, terms of my insurance may require that conflicts with my insurer MUST be settled via arbitration in a process that is strongly tilted in favor of the insurer.
Third, with a private insurer, there is a contract that the insurer can be held to.
Not really. Since I lack the power to effectively pursue legal remedies against my insurer, I can’t do much if they decide to ignore the contract, which makes it a worthless piece of paper.
And he is just wrong on his assessment of ER’s.
Sez you.
end of life medial care is a hugely perplexing issue.
Glad you noticed that.
the rationing that now goes on is already limiting the number and quality of high-end specialty applicants
My understanding is that folks now in medical school can’t get into high-end specialties fast enough. The thing nobody wants to be is a GP.
I could be wrong. Do you have any evidence to the contrary? Or is this just more assertion on your part?
Yes, the present system is awful.
Well, it could certainly be worse, but for what we pay it’s pretty damned bad.
Still interested in that one lonely metric by which our system is better than anyone else’s.
Thanks –
johnnybutter, I am in complete agreement with you regarding the care we lavish upon people at the end of their lives. We simply cannot afford to devote so many resources to providing some extra months of hospitalization for people who are dying. It would be nice if we could afford it, but until we make sure that all the easily and cheaply preventable stuff is handled, this end-of-life care should take a back seat.
Anyone who would like a scan of my two WakeMed ER bills, and the additional radiology charge ($45.00), and physician’s charge ($284.00 for the first; haven’t received the second one yet)), from the two ER visits I already frigging linked to ($1,012.00 and $1,371.00), please send me your email address, and I will fax you a copy of my bills, and the dunning letter I’ve already received, as soon as I have access to the scanner downstairs (which might not be until the weekend).
I also reserve the right to consider socking you in the nose should we ever meet, if you receive your copies, and have implicitly called me a liar over their existence.
(I’m not normally moved to threats of violence, but major pain, while having only 3 remaining hydrocodone, and being told that I’m “wrong” about personal experiences, pushes me unusually in that direction; I said I should stop posting to this thread.)
I agree with you on the general principle that government screws up most things
Pernicious horseshit. My two cents, take it FWIW.
The fundamental decision at issue is “How much is a human life worth?”
No, by God, it is not.
The fundamental decision at issue is what the goal of a health care system is.
If it’s to maximize profits to private entities, then we’re doing just fine, thank you very much.
If it’s to actually deliver a useful level of health care to actual people, then we are not.
We already, today, spend more public money than any other OECD country, AND more private money. The problem is not the amount of money we are throwing at the problem.
WE ARE ALREADY SPENDING THE MONEY.
The problem is *where the money goes*.
Dig?
Thanks –
Russell: Still interested in that one lonely metric by which our system is better than anyone else’s.
Just to point out one metric (I think there are more but I don’t have time to research) – 5 year cancer survival rates.
The age-adjusted 5-year survival rates for all cancers combined was 47.3% for men and 55.8% for women, which is significantly lower than the estimates of 66.3% for men and 62.9% for women from the US Surveillance, Epidemiology, and End Results (SEER) program (P < .001).
I’ll go with 66 over 47 myself.
I’m for universal healthcare myself, but I’m also sympathetic to many of mckinney’s points.
And mckinney – Gary’s dilemma is part of the reason I came around to support universal healthcare.
5 year cancer survival rates.
OC, thanks for this. The link you gave is password protected, can you tell me who it was that had the lower survival rate?
I’m for universal healthcare myself, but I’m also sympathetic to many of mckinney’s points.
I have nothing against mckinney. I just don’t see any information behind his (or her) statements. They are assertions based on what appears to be an a priori dislike for government action.
Not good enough.
Thanks –
As is obvious to anyone poor, as I’m hardly the only one to point out innumerable times, I’m hardly the only person not served by our current health insurance scheme.
Regarding five-year cancer survival rates, isn’t part of the problem that the US overtreats as well as undertreats? Because we pay doctors based on how much work they do, they tend to diagnose and treat some very small cancers that are unlikely to ever prove dangerous. Note that one of the biggest outliers involves prostate cancer. The US is extremely aggressive about screening older men for prostate cancer, but the tests used have a high false positive rate, so we end up “treating” lots of people who either have no prostate cancer or who would have died from other causes long before prostate cancer became an issue. Run that through the statistics and you end up “proving” that Americans are more likely to survive cancer even the mortality rate is about the same. This writer has more.
Russell, you argue that the fundamental question is not “how much is a human life worth” but instead “where does the money go”. I assure you, the money is not going into a Swiss bank account for greedy insurance companies. Yes, insurance companies are making a profit, but that profit is not a significant component of the huge costs of health care. The primary factor that drive up health care costs is a misallocation of our medical resources. We spend too much money on keeping dying people alive a little bit longer, and we spend too little money on simple health care that would prevent medical emergencies — and then we spend enormous amounts of money handling the emergencies.
In order to get a better allocation of medical resources, we need to establish clear priorities for who gets how much health care. That, fundamentally, boils down to the question of how much a quality life year is worth to us. Once we have established a clear system for establishing priorities, then we can start bringing down the cost of health care. But if we continue to tackle this problem in an emotional manner, insisting that we intervene at the last minute to keep everybody alive as long as possible, then we’ll keep spending trillions and getting little for our expenditures.
OC, thanks for this. The link you gave is password protected, can you tell me who it was that had the lower survival rate?
Russell, the article is a synopsis of a Lancet article and which compares “Europe” to the US. Its probably worth registering to read. However, what is not clear just what is included in “Europe”, but it seems likely that parts of Eastern Europe are, and possibly Turkey. A more interesting comparison would be to the major western European countries, although, unfortunately for Jes, we seem to do better here than the UK.
russell: That’s weird. I’ll try it again:
link
If that doesn’t work, here’s the Telegraph on the same study with a chart.
Turb: True, but the numbers here are an average for all cancers.
OK Chris, I’m going to ask you to document some of your statements. It doesn’t have to be exhaustive, I’m just looking for a simple reality check.
I’m not doing this to bust your chops, I’m doing it because we’re talking about how we want to allocate money. Whenever you talk about allocating money, you need to show numbers.
insurance companies are making a profit, but that profit is not a significant component of the huge costs of health care.
What are the major health insurance companies in the US, and what are their profit numbers for any recent year?
What proportion of the amount we spend on health care ($2.6 trillion in 2006) does that represent?
I’m leaving pharma out, you can include that if you like.
I’m also leaving out non-profit-related costs of including private insurance in the loop. For example, private administrative costs run about 7 percent, while Medicare’s (for example) runs about 2 percent.
A five percent differential on a total of 2.3 trillion is a big number.
We spend too much money on keeping dying people alive a little bit longer, and we spend too little money on simple health care that would prevent medical emergencies
How much did we spend on end-of-life care in any recent year?
How much did we spend on regular, preventative health care?
Can you give me an estimate of how much long-term health care money was saved as a result of the regular care given?
Can you give me any idea of the effect of the regular health care on outcomes?
If we go your way, some folks will die that could have lived longer. I want to see your numbers.
What do we get for letting them die?
And finally, a non-quantitative question:
In order to get a better allocation of medical resources, we need to establish clear priorities for who gets how much health care.
Who is “we”?
Thanks –
Does it make sense to routinely spend a million dollars on a 90 year old, very sick person to keep them alive for an extra 3 months?
I don’t know how “routinely” that happens. What I can be sure of is that the million dollars is income to somebody.
So let’s get something straight: we can, if we choose, deny 3 months of extra life to a 90-year old, but we don’t save any money unless we also deny the million dollars of income to somebody. Looked at that way, the answer to the “does it make sense” question is not clear. A bit less life, a bit less GDP — how is that a win-win?
The obvious rejoinder is: we could spend that million dollars on something “better”. One better thing might be treating hundreds or thousands of minor ailments and injuries afflicting younger, poorer people. That doesn’t reduce the nation’s “health care spending”, mind you. It neither “saves money” nor reduces the GDP. It simply trades off the last 3 months of 90-year-old’s life for maybe thousands of person-months of reduced discomfort for people like, say, Gary.
Note that people like Gary would already be buying the health care they need if they could afford it. In a system wherein they can not afford it, the trade-off is not available. The million dollars gets spent on something other than health care — assuming constant GDP. What something? Flat-screen TVs?
My point is that “the market” will not trade off expensive care for old rich people against necessary care for young poor people. It will at best trade off expensive care for old rich people against flat-screen TVs for the heirs of old rich people. That’s good if reducing the fraction of GDP going to “health care” is a paramount goal. But why should it be?
I don’t worry about how the GDP is divided between “health care spending” and everything else, any more than I worry about how it’s divided between, say, “information technology spending” and everything else.
–TP
Oh, lordy, russell, I don’t have the time to carry out the research program you request. If you choose to dismiss everything I’ve said because of that unwillingness, be my guest. However, let me offer some indirect evidence.
There’s no stampede to purchase stock in health insurance companies, and if there were, I’m sure that some of the beleaguered financial companies would have moved a good portion of their capital into the vastly more lucrative health insurance business industry, and the competition would eventually bring the profits down.
Next you ask who is the “we” in reference to my statement that we need to establish clear priorities for who gets how much health care. Currently, the answer to that question is “them” — the health insurance companies. I’m not too happy with that arrangement, and I really doubt that you are. When I refer to “we”, I am thinking in terms of “we, the people” as in the American republic. This is a political decision, but we have not had the courage to answer the question, so we punt it to the health insurance companies.
Now it’s my turn to ask a question. Imagine that you’re the local Health Care Czar. You have a million dollars to spend on the health of your small town. Would you rather spend that million dollars keeping Old Man Jenkins, 95 years old and dying of lung cancer, alive in intensive care for another three months, or would you rather spend it on health exams and basic vaccines for all the kids under age 10? If you decide against Old Man Jenkins, are you willing to stand up and say out loud, “I’ve decided to let Old Man Jenkins die so we can spend the money on the kids”?
I am so willing.
Tony, I agree that, if we treat all health care as a private expense, then it’s a wash either way. People will spend more or less money on their health care and live or die accordingly. Our problem, however, is that we no longer have that freedom to rely solely on private health care; we as a society have already decided that we will provide free emergency health care to everybody. The costs of that free health care are then transferred unequally across society, leading to a system that is manifestly unfair, as Gary can testify.
So we can either go to a truly private system (no tax benefits for health insurance by employers) and leave everybody on their own, or we can decide that we’re going to pay at least some of the costs of health care, and do so in a manner that is more fair than the current system.
I myself would very much like to see comprehensive health care provided to all children (although I don’t see any reason why the public should pay for the high-end care needed for some unfortunate children.)
I also don’t think it fair for taxpayers to pay for medical care for somebody who has lung cancer or emphysema after a lifetime of smoking.
life expectancy is mainly a function of lifestyle choices and genetics.
…
As for reducing the amount of health care we dish out, I am afraid that is exactly what reform is going to produce: rationed and limited health care.
Why would you worry about health care being rationed if it has no effect on life expectancy? If your premise is correct, we can simply shut down the entire US health care system, both public and private, with little effect on long term health.
Of course, if your premise is correct, the nation of Cuba managed to completely alter the lifestyle choices and genetics of their population in the space of a few years. Quite an accomplishment.
True, but the numbers here are an average for all cancers.
I believe an ungated version of the paper in question can be downloaded here. From it I extracted the following numbers:
As you can see, the top rated disparities are prostate, breast, thyroid, and colorectum cancers. In the US, at least three of those are screened for aggressively which leads to earlier detection. But earlier detection can muddle these statistics in two ways, both of which make the US look better than it really is. First, earlier detection means treating cancers that never become serious. Secondly, earlier detection means that the odds of people surviving five years, even if no treatment is done whatsoever, are higher.
The data isn’t wrong, but because of this confusion, drawing inferences about the quality of care based on this particular statistic is non-sensical. Compare total mortality rates instead. I did that for prostate cancer and concluded that the US and UK have roughly the same mortality rate: there is no 20% gap there.
Now it’s my turn to ask a question.
The difference between my questions and yours is that mine are real questions, that exist in the real world, and yours is a hypothetical one that you’ve made up to make the particular point you want to make.
You say that the problem with health care is that we spend too much money on end of life care.
That could actually be so. I don’t know if it is or not.
So my question to you was, basically, is your statement true? Can you point to anything that demonstrates that money spent on end of life care actually takes money away from other forms of care that might, net/net, result in better overall outcomes?
It’s an important question, because if we go your way, Mr. Jenkins actually dies three months earlier.
You do not appear to have an answer.
There also seem to be two assumption behind your argument that I think are worth questioning.
The first is that money spent on health care is totally fungible as regards its application. That is, any dollar not spent on end of life care is therefore readily available for something else, for instance preventive care.
The second is that the funds available for all kinds of health care are a kind of zero-sum pool. In other words, the only way to increase funding for preventive care is to take it away from end of life care (or something else, take your pick).
I completely agree that money spent on preventive care is nearly always money well spent.
I also tend to agree that a dollar spent on preventive care is *likely* to make a greater positive impact on overall outcomes than a dollar spent on end of life care.
None of that convinces me that the solution to the problem is to take dollars away from end of life care and give them to preventive care.
For instance, there may be *other* things — private entity administrative costs, for one very simple example — that I would sacrifice long before I’d sacrifice end of life care.
In short, I think what you’re offering is a false choice, and you’ve done exactly nothing to convince me otherwise.
Thanks –
OK, Russell, let’s do it this way: what if, as part of a new national health care program, we set up a national database on health care. Every case handled by the system goes into the database. It takes a long time, but we eventually get a database that can tell us the costs and benefits of any treatment regime. For each and every treatment, we can estimate the cost in dollars and the result in quality life years.
So now we sort this database on the ratio of cost to benefit obtained above. Then we draw a line at a certain level. Any treatment with a lower cost to benefit ratio gets automatically funded by the state. Anything with a higher cost to benefit ratio does not get funded.
You might counterargue that medical science is too complicated for this, every case is different, there are always oddball cases, etc. Yes, that’s all very true — but it doesn’t make the policy a bad one. Lots of drunk drivers make it home safely, but we still make drunk driving a crime based on the PROBABILITY that they’ll hurt somebody. In the same way, we don’t have to prove down to the last penny and last minute of predicted gain in quality life that our decision was correct. We set the values based on the evidence available to us. People live or die based on those estimates.
By the way, we don’t need to wait fifty years for such an analysis — that data is already hanging around in lots of different places. It’s not directly comparable, it’s not rigorous, but we could put together a team of medical experts to assemble a first approximation of the database above and start using it within five years.
So, how does that arrangement strike you?
So, how does that arrangement strike you?
It strikes me as kind of crummy.
The point of making health care available is to make health care available.
At a certain point, if you just don’t have the money, then maybe you have to do the kind of triage you’re talking about. Countries like, I don’t know, Azerbaijan or Mauritania might have to make choices like that.
We ALREADY SPEND MORE THAN ANY OTHER COUNTRY IN THE WORLD. By “spend more”, I mean we are in the top handful in public money spent per capita, AND THEN ON TOP OF THAT we are by far number one in private money spent. Not in absolute dollars. Per capita.
Allow me to drive this home just a bit more.
WE SPEND MORE, TODAY, ON HEALTH CARE IN THIS COUNTRY THAN THE ENTIRE GDP OF ANY OTHER COUNTRY ON EARTH, WITH THE EXCEPTION OF JAPAN AND GERMANY.
What we spend on health care in this country is about equal to the entire GDP of China. THE ENTIRE GDP OF A NATION OF 1.3 BILLION PEOPLE.
OK?
I don’t think you’re focusing on the right issues.
If you want to do the kind of triage you’re talking about, then things like organ transplants are right out. Treating burns over large parts of someone’s body, right out. Massive head trauma, right out.
Take those folks out back and give them two in the hat, because we can get far more bang for the buck elsewhere.
Sure, unlike end of life folks, maybe they’ll live for years after treatment. Also unlike end of life folks, maybe they’ll be so messed up that they’ll never be productive generators of wealth again. They’ll be sucking on the public teat for another 10, 20, 30 years or more.
Take them out back and shoot them.
Data point: a heart transplant costs about $300K-$350K. And that’s first year. How many preventive checkups can you buy for that much money?
Have I made my point?
It’s not a question of how much money we are spending. We spend an astounding, collosal, stupendous, mind-boggling amount of money on health care. We pour a virtual Niagara of greenbacks into the health care industry each and every day.
It’s not a question of HOW MUCH MONEY WE SPEND. Remember that we’re talking about the entire freaking GDP of China.
It’s a question of where the money goes.
If all of that money actually went to PROVIDING HEALTH CARE, I do not think we would be talking about Mr. Jenkins’ final three months.
Thanks –
Compare total mortality rates instead.
On total mortality rates from cancer the US does kind of middling. In the Nationmaster summary I’m citing here, we’re 9th out of 16.
The UK, Finland, Sweden, Austria, France, Norway, and Australia have better outcomes. UK’s best, it works down from there.
New Zealand, the Czechs, Ireland, Slovakia, Luxembourg, Hungary, Italy, and the Netherlands are worse. Netherlands is worst, it goes up from there.
Heads up marbel!
Note that the US has one of lowest percentages of daily smokers in the world. Given that, you might expect a better result.
We pay, by far, the most, and get, at best, mediocre outcomes.
Thanks –
OK, Russell, so let me get this straight. Your case is based on the fact that we are spending a humongous amount of money on health care. You therefore conclude that
“humongous” = “enough money to give everybody all the health care they need”
That doesn’t make sense to me.
You write: “If all of that money actually went to PROVIDING HEALTH CARE, I do not think we would be talking about Mr. Jenkins’ final three months.” OK, so if all that money is NOT providing health care, where do you think it goes? Into secret Swiss bank account? Are all the doctors and insurance companies part of some grand conspiracy to bilk the American public?
One thing you are clear about: you refuse to establish priorities. You want everybody to get all the health care medical science can provide. You claim that this wouldn’t cost more than we’re already spending. I don’t believe you. I believe that we have greater need for medical resources than we as a society can afford. That, in my mind, imposes upon us the requirement that we allocate those resources intelligently.
The thing that bothers me about your approach is that it refuses to acknowledge that health care, like every other economic good, is a finite resource that must be allocated in some fair and intelligent fashion. We don’t have an infinite supply of doctors, nurses, hospital beds, and medicines. You have no problem acknowledging that we must allocate things like gasoline, hamburgers, or education according to some priority system, but when we come to health care, because we’re dealing with obvious life-and-death issues, that rational thinking goes out the window. I believe that the refusal to maintain rationality in the face of health care issues is the underlying cause of our high health care costs.
Chris, might I suggest that figuring out where to draw the line on rationing care might not be the highest priority right now? The question is intriguing and it clearly has a hold on you intellectually but in general, the most interesting problems are rarely the most important problems. The bottom line is that right now patients and doctors limit care given to those with little chance of long term survival. How do I know? Because we don’t spend 100% of GDP on health care. Now, perhaps they don’t limit care sufficiently or systematically enough, but care is getting limited one way or another.
I see no reason to focus on this very interesting but difficult question until you can provide some numbers indicating what fraction of healthcare costs are consumed by end of life treatment. Note that while it is very easy to talk about “the last six months of life” in the abstract, doctors, lacking time machines as they do, generally don’t know when their patients’ last six months start. That introduces some practical difficulties with rationing care in the last few months of life.
One major issue in the US is overtreatment. When you pay doctors fees for treating patients, they’re going to treat patients whether or not the treatment is needed. Surgeons are going to perform surgery more often than is needed, internists will write more prescriptions than needed, and everyone will send patients out for more lab work and MRIs than is strictly needed. The problem with overtreatment is that it costs money but it also can make patients worse since every intervention carries with it some risk. Now, thinking about policies to deal with incentives for overtreatment within the context of our baroque and insanely structured health care system is difficult, tedious, and nowhere near as intellectually stimulating as late night dorm room bullshitting about deciding when society gets to pull the plug. Doing the hard work of thinking through those issues won’t allow you to pat yourself on the back for your brave moral clarity and commitment to rationality as evidenced by your willingness to make the hard moral choices that soft-headed folks like russell are too weak to contemplate. Nevertheless, such work is more likely to make a difference.
I would congratulate you on your willingness to make the hard choices that we soft-headed folk cannot imagine; I would, that is, if you had read up enough on the subject to describe what fraction of health care costs are related to preventable end of life care. Absent that, I think I’ll avoid joining you in the pain caucus.
mckinneytexas: No offense, but your complaints sound more like uninformed talking points.
Why do people always say “no offense” right before they say something howlingly offensive?
It becomes peculiarly ironic when you accuse someone who has personal experience of living long-term with ill health and no health insurance of making “uninformed complaints”, while yourself repeating a list of uninformed talking points you regurgitated direct from the Wingnut Central Committee without any thought or independent research. There really isn’t a one you missed, and meantime, apparently, personal experience and informed research can be offensively dismissed.
One thing you are clear about: you refuse to establish priorities.
Not so.
What I refuse to do is accept the priorities that you have asserted to be the necessary ones.
I refuse to do so because you haven’t demonstrated (a) what we get back that is worth three months of Mr. Jenkins’ life, and (b) that whatever we do get back is unavailable through any means other than letting Mr. Jenkins die.
You have also refused to address any point I’ve made other than my observation that we spend a hell of a lot of money on health care.
Why pick end of life care? There are many, many VERY expensive forms of health care that return very little in terms of overall outcome when compared to preventive care.
To the examples I’ve given above, I’ll add care for chronic diseases like diabetes and congestive heart failure. Stunningly expensive, and, at best, mixed outcomes.
Mental health care. Very expensive, and in many cases it is, at best, a holding action.
I could go on. Why pick on old folks? Why not throw these other folks under the bus?
The fact is that we do our best to make some kind of help available to all of these folks, even if we don’t get much back in return. We do it because they need the help.
The point of a health care system is to help people out. Not to maximize return on investment, not to pick and choose who will live and who will die.
If you want to get a real bang for your buck, what we really ought to do is make cigarettes illegal, and require everyone by law to walk 30 minutes a day.
Then let’s get soft drinks out of school cafeterias.
Then let’s make it illegal for corn syrup to be anything higher than the fifth ingredient in any processed food product.
Then let’s subsidize green markets selling fresh local produce in any town bigger than 10,000 people. Or any community of people that is currently underserved in terms of access to decent, fresh, unprocessed food.
All of that will get you great outcomes for dollar spent. And I do mean great outcomes.
Taking the body mass index of the average American down about 10% would change the public health landscape in this country. It would be a brave new world. And it’s simple and cheap to do.
Everybody in this country used to smoke. Now most people don’t. That was achieved with PSAs and a bunch of state and local laws limiting the places you can smoke in public.
Fabulous return on investment. I mean, really really fabulous.
All of that is called “public health”. That’s where *my* priorities lie.
If we get that far, then we can talk about pulling the plug on Mr. Jenkins.
I’m not trying to yank your chain. I’m just pointing out that, IMO, you’re not looking in the right places for value for dollar spent.
Thanks –
I wrote a long, last post and it disappeared. What follows is a much briefer version.
Generally, my evidence comes from doctors I know socially or professionally, many of who have or had teaching positions with Baylor College of Medicine or U of Texas Medical Branch in Houston. All are specialists. In terms of diagnostic tools, time interval between diagnosis and treatment or surgical intervention and outcome, i.e. success of the procedure, the US beats the socialized countries pretty handily. Next time around, I’ll try to have something more concrete. Right, I am really, really pressed for time.
Gary Farber: I went to your site and couldn’t find an email address, so here’s mine (mckinney@mckinneycooper.com). I read some of your earlier stuff and will try to drop by from time to time. I don’t question your personal condition at all, I am simply flummoxed that you can’t get treatment. Send me an email without attachments, if you’d be willing to do, and I will respond and you can judge my bona fides in private and out me if you think it merited. Where I disagree is your broad, sweeping statement about ER’s.
I am general counsel for a large, 14 ambulance (mobile intensive care unit)ambulance service that makes over 25,000 runs a year. In every instance, unless the patient refuses transportation in writing, the patient is transported to a hospital with condition-appropriate treatment facilities and is stabilized without regard to ability to pay. This is by federal law. As for long waits in the ER, that is largely a function of people using the ER as a primary care facility–a problem national health insurance or health care reform won’t fix anytime soon.
On the end of life stuff–the feds kept my dad (a retired naval officer, so he had pretty strong insurance) alive from age 80 to age 84 at a cost of $500,000. Was it worth it? A fair question, both my dad and I would agree.
My point about universality of coverage and benefits is that we can’t have it all, not by a long shot. We can’t compel people to be doctors or to be good doctors. We can’t reduce compensation and expect people to line up to work more and get paid less. We can’t, most likely, afford to underwrite poor lifestyle choices. We live in a fast food nation with high rates of obesity, smoking, alcohol and drug abuse, etc.
Statistics on gross numbers are misleading. What matters are qualitative comparisons. A Cuban doctor is not an American doctor, not by a very, very long shot. A ‘hospital’ is whatever you want it to be: a bed with a bedpan jockey or a fully staffed state of the art facility.
I really have to go. Bummer. This is a good thread.
More exactly: make it illegal for schools to permit the installation of soft drink machines in the schools. That’s something that ought to have been done at the local level a long, long time ago. Like, when it was first proposed.
BMI: not a good metric. My BMI is near to obesity (about 28), and I do tae kwon do three hours a week. I guarantee you that I can run two miles in substantially less than fifteen minutes. I’m not what you would call lean, but I’m in decent shape. I can do about a half hour of three-minute-round sparring, for example. Or do a hundred lunges, without making myself even a little bit dead.
BMI sucks, as a metric. It’s good generally, so bringing down the mean BMI would be a good thing; actually, better would be bringing the right tail of the distribution in. But people are all built differently, and trying to cram us all into a single mold is idiocy.
Again: when I was in college and swimming several miles a day, in addition to doing weight training after practice, I had a BMI of 25, which is the edge of overweight. Was I overweight, do you think? More to the point, do you think I was unhealthy? Would a doctor have told me I needed to lose weight?
Sorry. This is obviously a sore point with me. WII Fit keeps fussing at me about it.
The above makes me sound as if I work out like Prince Corwin making his comeback; that’s not quite the case. Still, I have a pretty awesome roundhouse kick for a guy in his upper forties.
OK, so if all that money is NOT providing health care, where do you think it goes?
Administrative costs. The paperwork and non-health-delivering bureaucratic interactions are much, much greater with a decentralized competitive insurance industry, and the costs of that are largely borne by providers and their staffs, who have to deal with multiple plans with multiple requirements and multiple exclusions and multiple everything else. Those costs go down significantly with a single-payer plan.
Of course, then we need to find jobs for all those people who are now being paid to figure out how to turn down claims. I’d rather have that problem.
Generally, my evidence comes from doctors I know socially or professionally, many of who have or had teaching positions with Baylor College of Medicine or U of Texas Medical Branch in Houston. All are specialists.
No wonder you’re so badly informed about the state of the US health system, if most of your “evidence” comes from people who, by the nature of their work, won’t have any idea about the patients who can’t get treatment.
My point about universality of coverage and benefits is that we can’t have it all, not by a long shot. We can’t compel people to be doctors or to be good doctors. We can’t reduce compensation and expect people to line up to work more and get paid less.
Yet other countries manage to have so much more than the US, at so much less cost. Besides your arrogant dismissal of personal testimony that comes from people who aren’t specialist medical professionals, mere uninsured patients down underfoot, you also don’t seem ever to have looked outside the borders of the US and noticed that every other developed country in the world has figured out how to resolve these issues that you ignorantly and stupidly present as insuperable.
BMI sucks, as a metric.
That’s cool. I’m happy to take it off the table.
My point was simply that there are better places than rationing end of life care to look if we’re interested in maximizing value for dollar.
I actually do understand Chris’s point. Even with the mind-boggling amount of money we spend, we can’t do everything.
I just don’t think that a hard-ass, per-case cost/benefit analysis of improvement of outcomes for dollar spent is the best way to go about things.
If for no other reason than in many cases it’s going to be ridiculously hard to do a useful quantitative estimate.
How long is Mr. Jenkins actually going to live?
What if he gets marginally better, and it costs less to keep him around?
What if Mr. Smith dies first, and so we actually *do* have a bed for Mr. Jenkins after all?
The kind of green-eyeshade thing Chris is talking about sounds good on paper, but I don’t think you can really do it in a very useful way. Health insurers and care providers try to do it now, and it’s not an easy task.
I have no, absolutely no, argument with Chris’ point that money spent on preventive care yields a greater benefit in terms of outcomes than money spent on any number of other, more problematic things. I just don’t think that does, or at least should, translate into “Don’t do the less economic things”.
For one thing, the population you’re serving with preventive care is largely healthy. Of course you can get a good benefit for the dollar.
Sick people, on the other hand, burn money like nobody’s business.
But structuring a health care system to exclude sick people seems, to me, to kind of miss the point. Which is, I think, most of my point.
The remaining part of my point is that it really does seem perverse to focus on managing scarcity in a context where the available pool of money is 16% of GDP.
For example:
OK, so if all that money is NOT providing health care, where do you think it goes?
My friend Jeff is a OB/GYN. He has a practice in NH. These days, he mostly does surgery.
A few times a year, Jeff goes to informational seminars sponsored by drug companies. For “informational seminar”, read “marketing junket”.
Typically these are in places like Miami or Vegas. They last a couple of days. Jeff’s lodging, meals, and entertainment are all paid for. Sometimes even airfare, I think.
He gets to bring a guest. He usually takes his father. Jeff attends his daily seminar for a couple of hours, then he and his dad hang out, eat some good food, see a show, and generally have a good time.
All of this, every dime, is paid for with your and my health care dollars.
I don’t begrudge Jeff the trips. I’m sure there is value in getting the word out about new drugs that are on the market, and how they should be best be used.
It is, really, all fine with me.
But any model of delivering health care that is going to pull the plug on Mr. Jenkins while still flying Jeff and his dad around the country every couple of months seems, to me, to be profoundly perverse and wrong.
The point of a health care system is to deliver health care. Sometimes that can be done economically. Hell, sometimes you can probably see a positive return for dollar spent.
But sometimes it just costs money to help people out.
If we *just don’t have the money*, that’s one thing. You can only do so much. I just don’t see that as actually being our problem, or at least our biggest or most important one.
There are bigger fish to fry than Mr. Jenkins. IMVHO, natch.
I’m sure I’ve said enough here, I’ll let it be now.
Thanks –
No quarrel there, russell. I think I’ve mentioned my appeal to authority on the topic; he says that Type II diabetes is going to crowd out pretty much everything else in terms of healthcare costs. Think on that: completely avoidable problem, antagonized in part by the willingness of adults to let their kids drink sugar water and sit on their asses watching TV after school.
There are things that are easy to do about that (take the Coke machines out of schools and youth centers), and there’s the not so easy (make people exercise, somehow, and penalize them for being overweight, somehow). Let’s at least consider doing the easy things. I think this is an area where wide agreement is at least possible.
I’m the one who brought up end of life care, and I didn’t do it to advocate for pulling the plug on ‘Mr Jenkins’. Russell makes the essential point above: you can’t rationalize the system at the margins. You must deal with it, well, systemically. And first you need to decide what the fundamental point of health care is (making profit vs caring for health). Then you need to see what your ‘budget’ is. Until that’s done, it’s futile to try to decide how to apportion resources.
BTW, this study and article are a couple years old, but said Dartmouth study found that the average (not median) Medicare spending in the last two years of life is just under 30k.
Ah, but this from that article:
Take half of your 30k and multiply it by those 4.7 million people and see what you get. It’s not huge, but a few billion here and there might just buy some threshold level of care for those otherwise unable to afford it.
I’m not any kind of fan of nationalized healthcare, I probably don’t need to say, but what we currently have in place is both wasteful and…um…not the ideal that a lot of conservatives seem to think is possible. Not even close. What would get closer would be to deny _all_ care to anyone who can’t pay for it, and I just can’t quite go along with that.
In every instance, unless the patient refuses transportation in writing, the patient is transported to a hospital with condition-appropriate treatment facilities and is stabilized without regard to ability to pay.
It is important to note that “stabilized” may be only treating the symptoms and not the underlying problem. I had a friend who had gall bladder issues. The emergency treatment (repeatedly) was to address the symptoms (pain) with morphine and then send the “stabilized” patient home. The friend was finally able to get employer provided health insurance and thus got the issue resolved, which because the situation wasn’t immediately life threatening, the ER (although they could recommend the treatment) was unable to provide.
Gary is not the only one who is being under served by the current system.
This discussion is winding down, so I’ll just reiterate the core point that I’ve been driving at. (I do so because it seems to be lost in all the lengthy discussions.)
Russell makes this point:
“I just don’t think that a hard-ass, per-case cost/benefit analysis of improvement of outcomes for dollar spent is the best way to go about things.”
And the essence of my argument concerns the means by which we make all of those individual decisions as to who gets how much health care. We have three ways to make this decision:
1. Let the health care insurance company people make that decision. They have a profit motive to reduce all care, and legal constraints on what they can get away with denying (which is a lot).
2. Establish, by political debate, a rational system for allocating medical resources based on how much money we, the taxpayers, are willing to spend.
3. Pay for any and all treatment that medical care professionals think appropriate.
Russell argues for the 3rd option on the grounds that we’re already spending so much money that it will surely be enough to handle the demand. I don’t believe that.
We can all agree that Option #1, the current system, is unacceptable.
If you have a better idea, come forward. If you don’t, then pick one of the three that I list.
Take half of your 30k and multiply it by those 4.7 million people and see what you get. It’s not huge, but a few billion here and there might just buy some threshold level of care for those otherwise unable to afford it.
Still utterly academic.
The way we talk about health care in the political realm is really neurotic, and AAMOF reminds me of a certain neurotic person I know. She has an irrational fear of going to her basement, which is where her washer and dryer are – she will go, but really resists doing it. So, she tends to wear very dirty clothes, which has lead to a rash. She is lonely and, er, randy, but won’t date in the summer because she doesn’t want her date to see her (minor) rash (never mind that her clothes are dirty). So, in her frustration, she overeats in the summer, which has led her to spend more money than she can afford on an expensive liquid diet, (not to mention how much she spends buying new clothes). That caused her to get behind in her bills, which caused a spike in credit card interest. So now she feels she can’t afford to visit her very sick father, and is in a crisis about it.
Each of her concerns, considered discretely, is quite rational. But worrying about any one of them misses the point.
We need to buck up and do the friggin’ laundry.
She has an irrational fear of going to her basement…
Not that it’s any of my business, but maybe your friend could find a boyfriend (or girlfriend, as the case may be) and do laundry at *their* house.
Kind of a win-win. Just a thought.
Thanks!
maybe your friend could find a boyfriend (or girlfriend, as the case may be) and do laundry at *their* house.
Of course you’re right, but it’s easier said than done. Her problem is that she can’t approach point b from point a without going through byzantine ever-more complex problems. Point b actually recedes further and further. She knows it’s ridiculous, believe me.
Our political neurosis ought to be a little easier to grapple with, since the body politic is, by definition, impersonal. Maybe not, though…
“Gary Farber: I went to your site and couldn’t find an email address,”
It’s under the copyright address. I regret that I didn’t notice that when I used the “back” function in composing my relevant prior comment, I didn’t realize that it had reverted to the earlier draft that didn’t give my email address, which is gary underscore farber at yahoo dot com.
“I am general counsel for a large, 14 ambulance (mobile intensive care unit)ambulance service that makes over 25,000 runs a year. In every instance, unless the patient refuses transportation in writing, the patient is transported to a hospital with condition-appropriate treatment facilities and is stabilized without regard to ability to pay.”
In the category of “uninformed” over “personal experience,” what your lack of actual personal experience does for you is fail to inform you of the difference between being treated (or transported — I’ve yet to have to use an ambulance, thank goodness, and thus have no personal experience with that, myself), and being billed.
Yes, if you go to an ER, you will be treated without being billed upfront. You will simply be billed the next month.
My guess, and understanding, although it’s purely second-hand, and thus could be wrong, is that being transported by ambulance is no different. I suggest asking your client if they, in fact, do not bill poor people.
I’ll be pleasantly surprised if the answer is “yes.”
And since all I claimed was that one receives huge (from the standpoint of an unemployed person, with no income, applying for disability, or the standpoint of any poor person, including those working low-paying jobs) bills after the fact, I have no idea why you’re busily, repeatedly, refuting something I never claimed (the notion that one won’t get treated at an emergency room).
Ditto your response to me about waiting times, about which I said nothing to you.
Now, it’s true that as an unemployed person, collection agencies have a hard time getting money out of me; but that seems neither here nor there to the fact that as a result of my last two months worth of 2 ER visits, I now have three thousand dollars worth of bills, one of which I’m already receiving notifications for about how my account will be turned over to a collection agency if I don’t commence monthly payments (and they do offer 12 months to pay, but again, that’s neither here nor there), and the same will happen with the more recent bill in another month or so.
Among the effects this has is limiting one’s willingness to go to an ER, or a followup clinic, unless the need is absolutely dire, unless one is simply carefree about increasing one’s debt. Thus my holding off on going to the ER for a week for my foot injury, until I absolutely couldn’t stand the pain and increased disability of being unable to walk, since I didn’t want that inevitable additional ~$1500+ bill. Thus my not going to the orthopedic clinic, despite the ER’s commands to be sure to do so, because I don’t want to add yet another several hundred dollars to my debt.
Thus my grouchiness about people who advocate emergency room treatment as sufficient or desirable as overall health care for the indigent.
As for finding general health care, when I was in Seattle, and Boulder, there were good, if under-funded, over-extended, clinics available, with nominal copayments ($20/visit for Boulder, and I’d be billed, but they wouldn’t follow-up beyond that if I couldn’t pay).
Here in Raleigh, North Carolina, there are two main clinics (one clinic, and one set of three, to be more precise); one of them is run by a ministry, and while theoretically open to all, I’ve yet to be able to reach a human by phone there; it’s 90% of the time a busy signal, and 10% of the time a recording that asks you to leave your name and number on a voicemail where they’ll call you back, but then the voicemail is full. I’m told that one can connect with them by showing up in person. This is more easily done if one a) has a car) and b) has a driver’s license.
The second set of clinics I’ve finally gotten in touch with, and hope to have a friend drive me to next week, as I previously said. I’m sure I’ll eventually post on how good or bad I find their services to be.
Do you still really want to see my bills?
“She knows it’s ridiculous, believe me.”
Being fully aware of the irrationality of symptoms of one’s mental illness doesn’t go very far at all, by itself, in overcoming one’s symptoms of mental illness. Word.
That’s why they call it “crazy.”
As for long waits in the ER, that is largely a function of people using the ER as a primary care facility–a problem national health insurance or health care reform won’t fix anytime soon.
That’s actually untrue — see, for example, the role of preventive care gatekeepers in the NHS, and Germany has something similar IIRC. It’s a question of the systemic incentives; if we were willing to pony up for such a system here — which in turn would require prioritizing preventive and primary care, which would in turn require doing something about those hideous medical school loans, etc. — then, coupled with universal coverage, it’s quite likely that our ER waits would be drastically reduced because the minor issues would be triaged elsewhere.
[Speaking of compensation: IIRC, German doctors are paid considerably less than American doctors but their medical school is free, which means that the compensatory angle is something of a wash, at least for GPs. And I know firsthand that at least some UK doctors are doing just fine.]
Full disclosure: I’ve just started to work in the EMR industry but I’m doing mainly back-end database work. Keeping the trains running on time, that sort of thing. So while I’ve been exposed to a lot of raw data in the past few months, it’s been peripheral to my actual work.
Yes, please send me your bills. And, yes, hospitals do send bills–they are typically highly negotiable. FYI, and I know because I’ve done this, you can negotiate rates for almost anything. And yes, they send them out for collection, which is a pain in the ass. My service bills everyone or their insurance, but it doesn’t pursue collection, hire a collection service, etc.
Send me your bills. I’d like to take a look at them. Send them by email and we’ll visit.
My service bills everyone or their insurance
I think this hints at one of those systemic problems within US health care. I believe it is well known that uninsured are billed at the full rate, a rate which can be discounted up to 80% for insurers after negotiations. They are billed because if they don’t pay, it’s marked as a loss and helps for taxes (especially if you are a not for profit hospital). However, as bean counters move in, the thought is that if you can pull out a small percentage from that, you have a nice addition to your cash flow. So, sic a collection agency on them. As this works down the hierarchy, if some people find their credit ratings ruined, or people who actually believe that one has an obligation to pay one’s bills end up with some crippling sense of indebtedness, well, you can’t make a health care empire without breaking a few patients (and their families).
“FYI, and I know because I’ve done this, you can negotiate rates for almost anything. ”
I have no money to spare. If I did, I’d need thousands for dental treatment and prefer to do something rather than just have no or few teeth after extractions. I don’t really have an option of taking a negotiated settlement, no matter how small, over letting them bill me, and just not paying, and having that on my credit account. I already have plenty of debts, which have prevented me from ever having a credit card. Dealing with such things is a luxury I can’t possibly afford. I simply prefer not to have more debt, however. (And right now I’m having pains that make me worry I may have a developing kidney stones, along with my gout and other ailments acting up, as well.) But I’ll send you copies of the bills when I can arrange to have them scanned sometime this weekend.