Ezra says that consumer-based medicine is a red herring:
Indeed, the reason people get medical care -- in particular expensive medical care -- is because their doctors tell them to. I have never in my life sat up in bed and thought, "huh, I should really get some laparoscopic surgery." If I get a surgery, it's because my doctor told me to. And if I can't afford it, I have to ignore his diagnosis.For that reason, if you want to safely cut back on care patients buy, you need to get doctors to stop recommending so much wasted care. You can do that in a few ways: Put them on salary rather than on fee-for-service deals, so they don't make more money when they recommend treatment. Create new research institutions that test the cost effectiveness of care so they have a better idea of which treatments are worth recommending. Offer bonuses for using proven therapies. Etc, etc. But this idea that the way to better run medical care is to rejigger the financial incentives so patients have to ignore their doctor's advice is really quite bizarre.
I actually agree with Ezra that consumer-driven medicine is unlikely to be much of a panacea. But I think he's wrong about the way that it reduces costs. Yes, it can save costs by forcing patients to forego useful procedures, but most consumer-driven advocates don't envision patients being uninsured; they just envision high deductibles to make them cost-conscious. More to the point, consumer costs don't just make patients attentive to cost-benefit analysis; they also change the way that doctors think about them. Doctors are much more willing to order tests charged to a faceless insurance company (generally one they've had unpleasant financial negotiations with) than they are to a live patient sitting right there in their office.
During the years that I was uninsured, I saw expensive East Side doctors, and doctors running Medicaid mills for the local housing projects. The common denominator was that as long as they assumed that I was insured, either by an employer or the government, they tended to order a lot of tests and procedures. The magic words "I'm uninsured" revealed that most of those tests had a very, very slim marginal benefit. We still ordered tests that were likely to yield useful information: thyroid function, breathing tests, and various other things that for reasons of age or previous medical history seemed likely to yield useful results. But given that I am not overweight and had none of the symptoms of diabetes, we canned the blood sugar tests. Likewise the EKG for my nonexistant heart symptoms, the assorted tests for incredibly rare autoimmune diseases, the hormone levels, and the cholesterol screen.
Since becoming insured, I've had all those tests, and more. They always come back fine, even my thyroid, which I've been waiting to lose to an autoimmune disease for almost ten years now. Meanwhile, I've had three disease scares from tests that showed borderline positive, five EKGs, three electrocardiograms, two chest x-rays (to be fair, one was at the behest of the WTC workers program), and probably more useless procedures that I can't remember. They haven't made me healthier; they've made doctors more secure, and test companies richer. Those categories of expenditures are ruthlessly trimmed by cost-sharing patients without much apparent cost in health.
There's another category that I'm not sure who is best equipped to deal with: the borderline useful. For example, I've had a camera stuck down my throat in order to discover that I had, not an exciting ulcer or scary stomach cancer, but boring acid reflux. Had I still been uninsured, I probably would have gotten a dose of antibiotics and antacids for the putative ulcer, and orders to come back if the problem didn't go away. Had it actually been stomach cancer, of course, that would have been bad . . . but almost no one at the age of 30 has stomach cancer. And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer.
It seems obvious that consumer-driven care is the only shot we have at eliminating those kinds of expenditures, which could trim a lot off our health care bills. Either the government, or private insurers, are self-evidently willing to pay for couture medicine in a way that other countries are not. What I don't know is whether we should be interested in eliminating this last category.
Are you *both* ignorant of the fact that the reason for all these excess tests is fear of lawsuits (and coinciding malpractice insurance requirements) ... or is that just Ezra?
The lawsuit threat is a red herring. Everytime I hear this from fellow physicians I offer them this thought experiment:
Say I give you some arbitrarily large sum of money - $1 million or so. I tell you that the money is yours to keep under one condition: whenever you feel the need to order a test or do a procedure primarily to avoid a lawsuit you pay for it out of this fund.
What do you think would happen?
The answer is that for about a month or so the physician would pay for some tests out of the fund but over time he would find new justifications for doing the same thing.
The lawsuit canard is an excuse for greed, laziness and the ego boost you get for showing the patients all the stuff you can do.
You make the statement that making doctors salaried rather than fee for service would reduce unnecessary procedures.
There are large segments of the medical profession that are already salaried -- the VA, Military, HMOs, etc..
Do you know of any studies that have looked at the question that salary doctors prescribe test, procedures, etc.,any differently than fee for service doctors?
If I have surgery my personal care or family doctor does not benefit financially from recommending I see a specialist that probably will prescribe surgery.
What evidence do you have that shifting to a system of salaried doctors would make any difference?
"...the ego boost you get for showing the patients all the stuff you can do."
As someone going through a bit of a medical mystery myself, I find huge panels of tests to be evidence of all the stuff the physician does not know.
As far as Klein goes, I found this post to be the least intelligent. Moral hazard isn't about ordering yourself more colonoscopies. Moral hazard is about not taking care of your health, because someone else pays the cost of your poor decisions.
MN, I'm not sure what the point of your thought experiment is. Doctors do not know which patients are likely to sue them. They do not know which cases will win (since it ain't a function of the merit of the case). They are, if rational, cognizant of their inability to figure how much they should take from the fund.
The malpractice insurer does this as best they can.
If you put a little more thought into your thought experiment, you'd figure that the *actual* result would be that the doctor would a) keep the money, and b) keep doing what his malpractice insurer has told him is sufficient to meet the requirement of the policy.
The costs of the insurance have little do with greed and everything to do with the unpredictability of the legal liability assigned to them. For most of the 90s, premiums charged were too much, but then as time progressed, judgments surged and they turned out to be too little. When things get that unpredictable, you have to charge a high risk premium.
Now it's my turn for a thought experiment. I'll give you $1,000,000 as seed money to start a malpractice insurer. What policies do you set?
On the salary vs fee for service point, this is endemic to all professions. With respect to legal services, is it better to pay a fixed fee, to pay by the hour or to offer a large contingency for success? This is debated and negotiated all the time. All 3 models exist both at the retail and the elite institutional level of the legal services market. Each has incentives and disincentives, which are obvious. None of them work all the time. No one way has proven superior to the others across all relatonships and it would be constructive if healthcare debaters would recognize that humans will always interact in a variety of ways over time, and move past posing the issue in a simplistic either/or binary fashion. I note that the medical profession does seem to lack an analogue to contingency fees but there is some of that creeping in in "value based" or "outcome based" compensation.
However, on the subject of biases in referrals, private insurers are definitely aware of this and try to constrain it in negotiating with practices. The provider group is constantly at risk of being driven down to a very marginal profit level per each in-group reference.
I am not a big fan of consumer driven healthcare notions, but were one to adopt that, it would be advisable to require all specialists to list their prices and appointment availability daily in a common database accessible on the web so as to ensure that the consumer could efficiently select the cheapest qualified provider available.
What MT 57 said. (I'm a lawyer myself.) In general, the salary method (i.e., for a business to hire an in-house counsel) is used when there is a large volume of predictable work. So this might work for a nursing home, which has a steady base of very sick customers, but not for most people, because their medical needs are episodic and unpredictable.
Note that very large transactional clients (e.g., banks) don't normally rely on in-house counsel for transactional work, nor do they put their outside counsel on a fixed retainer. They pay per deal, with fees based mostly on the number of hours worked.
"And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer."
Unless you're that lucky one in a million.
I'll keep saying it. Economic analysis should not be used when dealing with people's lives.
What solution to America's health care problem doesn't involve economic analysis?
For someone who claims to be an expert on the subject, Ezra Klein consistently demonstrates a remarkable ignorance of the basics and reality. If a little knowledge is a dangerous thing, Klein is very dangerous indeed, with a limited understanding of mid-20th century health care delivery modes and practices dictating his 21st century policy pronouncements. He's equally humorous when discussing the merits of other nations' health care systems, but that hasn't stopped usually equally misinformed but well-placed friends from touting him as the source authority.
"Unless you're that lucky one in a million.
I'll keep saying it. Economic analysis should not be used when dealing with people's lives."
Would catching the cancer now or in a month matter in the outcome of the patient? If not then you have just wasted a lot of money, and put the patient at risk for zero benefit.
This is a stop-gap measure. Eliminating "marginally useful" expenditures with a new system of incentives will provide a one-time drop in total spending, like when HMOs were introduced (spending growth slowed for a couple of years, then continued on as before). Consumer-driven medicine would have a similar effect (similar in its one-time nature; I don't know how big the effect will be).
The underlying problem is new, genuinely useful but expensive treatments that keep getting invented and paid for. We are not willing to overtly ration these by price, so they will keep getting invented, raising medical spending by 10% or more per year.
"Would catching the cancer now or in a month matter in the outcome of the patient?"
Ask a doctor. But without testing, I would think it would take much more than a month for a dangerous cancer to become apparent; by which time it might be too late to treat it. My understanding of how cancer works is the earlier it is caught, the better the chance of successful treatment.
"What solution to America's health care problem doesn't involve economic analysis?"
The one where all Americans are guaranteed it.
I'm not naive, of course there will be some cost/benefit analysis. I'm saying it should not determine whether a patient is given the best available care.
> I'm saying it should not determine whether a
> patient is given the best available care.
But the availability is determined by non-economical (that is political, bureaucratic, or a mix thereof) mechanisms. Are you willing to pin this slogan to the banner?
MN: "The lawsuit thing is a red herring." Hmmm, in that case we either have 15-25% of the $2 Trillion health care economy swimming around the economic sea, or every economist who has ever examined the effect of the practice of defensive medicine is wrong. Much of the care that is prescribed for defensive purposes does not generate revenue for the ordering physician's practice (offense). There is simply no amount of care that a physician can order that is sufficient if just a little more will further insulate against a lawsuit (defense). With any due respect I probably speak for many more of our physician breathren than do you.
In our office we present a treatment plan to a patient without knowing the insurance status of that patient. If she is without insurance or has a very high deductible plan we discuss the rationale behind each diagnostic and therapeutic step, as well as the relative risk (as well as it may be known) of foregoing any of the above. If the patient opts not to pursue our insurance-blind recommendations we have them sign a document stating that they are declining to follow our suggestions. We are probably kidding ourselves, but we feel that we are safer from torts if we do so.
True tort reform will remove at least some of the "extra medical care" that is ordered for the sole purpose of preventing a lawsuit, thereby reducing one aspect of provider demand. Exposing the patient to the cost of recommended care, as Megan was in the care of her chronic condition at a time when she did not have traditional health insurance, will engange the patient as a financial stakeholder in the decision process and will reduce the utilization of expensive care that has only a marginal health benefit. This will cause a systemic drop in utilization, not a "one time drop" as A suggests.
"But the availability is determined by non-economical (that is political, bureaucratic, or a mix thereof) mechanisms."
When I say "available," I mean that there is a course of treatment already in existence that would benefit the patient and everything needed to provide that treatment is physically present. All that has to happen is the patient showing up and getting the treatment. In those cases, the patient should not be denied treatment for any reason. If you start subjecting the patient to economic analyses before you provide care, you're almost by definition going to deny care to some patients even though it is otherwise available to them; and to me that is just immoral and unethical. I don't want any other consideration to stand in the way of my doctor providing me the treatment he recommends and that I approve receiving.
So yes, absolutely I would pin that slogan to the banner. Why shouldn't I?
All that has to happen is the patient showing up and getting the treatment.
And free ponies for everyone? Sorry for the snark, but your protestations to the contrary, this is incredibly naive. Under what proposed health care system does everyone needing medical attention just show up and immediately get everything that he or she might need, including treatments to prevent a 1 in a million risk from materializing? We live in a world of limited resources. Given those limits, there need to be mechanisms to decide who gets how much of what. I agree with what I imagine to be your implicit argument: that being lucky enough to have been born rich shouldn't necessarily be what determines whether you should get treatment. However, in the absence of that decision mechanism, another one must be put in place. Universal health care does not mean everyone gets everything they need all of the time. If it did, it would not be nearly as contentious of a political issue.
"Under what proposed health care system does everyone needing medical attention just show up and immediately get everything that he or she might need, including treatments to prevent a 1 in a million risk from materializing?"
I don't think you understood what I was saying. The question you posed was, "what solution to America's health care problem doesn't involve economic analysis?" My answer was, the system that doesn't stand between my doctor and myself when he has the ability to provide me a service and I am willing to receive it. Right now, insurance companies stand between my doctor and me and dictate what services I can receive.
If my doctor has everything he needs to provide me a service, and I want to receive that service, I should receive it. That's the health care system I want us to have.
"I agree with what I imagine to be your implicit argument: that being lucky enough to have been born rich shouldn't necessarily be what determines whether you should get treatment. However, in the absence of that decision mechanism, another one must be put in place. Universal health care does not mean everyone gets everything they need all of the time."
That's one aspect of my implicit argument. The other one is the one I detailed above. I was not arguing that universal health care coverage guarantees everyone everything they need all of the time; many people need a cure for AIDS, and they're not going to get it simply by our instituting universal health care. But to the extent that treatments ARE available, those who need and want them should get them. To the extent that testing for diseases is available, those who want to be tested should be tested. There should not be an insurance company or other middleman dictating who does and who does not get treatment or testing. Ability to pay should not dictate that either, nor should one be forced into indentured servitude. Universal coverage paid for by the government (and by extension all citizens as taxpayers) would seem to me to be the best way of accomplishing this.
liberalrob:
How does having the government (i.e., you and me) pay for health care remove the need for economic analysis? Admittedly, it ceases to be a microeconomic analysis, but it definitely remains at the macro level. Which health care delivery systems have an infinite budget and an unlimited numbers of qualified personal? Or for that matter, can you name any good that is provided at no cost that doesn't have shortages?
What are the negative consequences that you would imagine from your proposal?
You may be right. I may not understand you. But how else was I meant to understand your riposte "Unless you're that lucky one in a million"? Something is always going to stand between you and the ideal level of health care you imagine receiving. That something is called scarcity. You may not like the way the current system manages scarcity. But what you are arguing seems to imply that changing the system will eliminate scarcity. It will not because it cannot.
To put it another way, I don't think you know what you mean when you talk about treatment being "available." There are all kinds of treatments that are "available" insofar as someone thought them up, someone manufactured the drugs and/or equipment involved, someone knows how to diagnose the problem that they solve, and someone knows how to administer the treatment itself. All of these someones, all of these drugs, and all of the equipment involved are scarce resources. Under what system is this entire arsenal going to be at the disposal of every person that might -- just might -- be that one person in a million with the rare stomach cancer?
I know it sounds heartless to suggest that this person, unless they are very rich, is unlikely to even have their problem diagnosed, let alone treated, under ANY health system you or anyone else is likely o think of. But just because it's heartless, doesn't mean it isn't true.
It seems to me that some commenters have unrealistic notions of medical malpractice suits. Person, it is not the case that
"Doctors do not know which cases will win (since it ain't a function of the merit of the case)." If anything, physicians win far more than they should, since the decks are stacked against the malpractice plaintiff. It is one of the only areas of tort law where the plaintiff can't get to trial without a high-price expert witness who will testify that the action or non-action of the physician fell below the standard of care. Those experts are particularly hard to come by, since many professional medical groups ostracize any physician who will testify in favor of a patient (in even the most eggregious case). And, since the attorney will generally have to pay the cost of the expert (tens of thousands of dollars or more) if the doctor wins, most attorneys take a very hard look before taking a med mal case. It's not an area of law for ambulance chasers.
I am aware of all those studies talking about how many procedures are ordered just to avoid liability. I wonder if those studies offset those costs against the costs avoided by medical malpractice liability, such as the reduction in bad outcomes, and the reduction in medical expenses and societal costs resulting from early detection of cancers and other illnesses that would otherwise be missed.
In response to the statement "And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer."
You missed the point. Most diagnostic tests are capable of having side effects and some of these can be lethal. Because of this risk benefit analysis is an important part of deciding what diagnostic tests to run..
liberalrob you said
liberalrob said
When I first saw you make this statement on some of the early comment threads I thought you were a troll trying to make liberals look bad..
Without infinite resources economic analysis has to be done. Decisions on where to put hospitals, what facilities to put in the hospitals, and what services the hospital will provide are all examples of economic analysis being used when dealing with peoples lives.
.
A good economic analysis helps optimizie health care delivery and improves peoples health.
I am a salaried hospitalist, so I don´t have a positive incentive to order tests, but several times a day I say to myself: "well, I´m nearly certain that the test I´m considering will come back negative, but if the patient turns out to have the disease and I don´t order it, I´m at risk for being sued." Nearly everyone thinks like that, so ordering tests with marginal utility sort of becomes the standard of care. It also seems that half my patients these days have family members that work in the health care system, or they work in it themselves, and they tend to push for every test that´s feasible.
Being sued, even if the plaintiff doesn´t have a case and you´re covered by malpractice insurance in any event, is so traumatic that any incentive to avoid dubious tests would have to be substantial to affect doctors´ decisions.
Sophie Brown: "I wonder..."
Unfortunately it is no longer enough to simply win a malpractice suit in order to avoid the negative economic consequences of the malpractice tort system. 8-10 years ago if a doctor was sued her malpractice insurance rates would go up only if a case was lost. That is not the case now; simply receiving a letter stating that a case will be filed now causes the doctor to be "rated', increasing her malpractice insurance rates even if the case is not settled and never goes to trial. Add on top of this the unmeasureable emotional strain that these suits produce and it is quite easy to see why such great pains are taken to avoid them.
There has never been a single study that so much as implies that the malpractice tort system is responsible for better health outcomes, let alone one that proves this conjecture. Likewise, there has never been a study that in any way shows that the malpractice tort system reduces medical expenses or has in any way influenced the timing of cancer detection. Ever. Because it doesn't.
Bad outcomes occur because of bad disease; unfortunately the plaintiff's bar will try a case with a bad outcome simply because they have a sympathetic plaintiff regardless of whether or not any medical misadventure occurred. A bad outcome is not an indication of medical malpractice; sometimes it really is no one's fault. Our system of malpractice tort is one of punishment and punishment alone. If we were truly interested in improving health outcomes and reducing errors that result in injury and death we would do whatever it took to promote the "no-fault" reporting of errors so that root cause anlayses could be undertaken in order to prevent future errors. I believe that it is Sweden that has successfully implemented such a system with the expected positive results.
Malpractice tort reform doesn't let doctors off the hook for results--true malpractice, while rare, occurs and should be punished. But the economic impact of our capricious system of punishment and the attitudes about bad outcomes that you imply produce the crushing effect of defensive medicine at a cost of 15-25% of our $2 Trillion health care economy. There's a lotta vigorish in $500 Billion, eh?
Bingo,
What world are you living in?
Doctors and hospitals make mistakes all the time. I know many people who have been malpracticed by doctors, in my lawyer life and even among people I meet every day. Most don't sue.
It in not the case that plaintiffs attorneys will try cases just because they have a sympathetic plaintiff. As I explained, you need a physician willing to testify on your behalf.
I don't think you are correct about the rating system. I have litigated cases involving the rating system, and I've also represented a number of insurance companies for doctors I don't think a letter is enough. Also, a letter will only be sent if a plaintiff has a doctor and experts in the wings, which in most cases is exceptional.
I am pretty sure that the threat of liability influences behavior -- a number of commentators have stated as much.
What you're saying is the conventional right wing wisdom of med mal, and as someone with a great deal of experience on all sides of the issue, it just doesn't jibe with reality.
Ms. Brown:
1) A mistake does not equal malpractice
2) A bad outcome is not de facto evidence of malpractice
3) It is astonishing how easy it is to obtain a letter from a doctor stating that the standard of care was not met in a case.
4) The reality on the ground is that a letter results in an increase in premium; this is a change that occurred some 8 or so years ago
5) We agree that the "threat of liability" changes behavior. It promotes the practice of defensive medicine wherein physicians order medical care for the expressed intent to avoid a lawsuit, or in the event that a lawsuit is launched to avoid losing the suit.
6) Plaintiff's attornies will bring a relatively weak case to trial if they have a sympathetic plaintiff who has suffered an injury in the course of medical treatment if they think they can win, regardless of the strength of the malpractice claim. Ask a successful one.
7) "Malpractice" is a noun.
8) We apparantly do not have a shared subset of experiences.
I am a practicing physician; I am actively involved in ongoing efforts to effect a rational change in the financing of health care in the U.S.; I serve as an expert witness in malpractice torts in my area of medical expertise; I advise attornies on both sides of the malpractice bar on stategy in trial; I consult for medical practices on a number of issues, among them the implementation of practice protocols and procedures that maximize the efficacy of patient care while both providing an extraordinary office experience and minimizing exposure to risk. What I am saying comes from the distilled experience of 21 years in medicine and business, experience that I have garnered living in the real world.
Ms. Brown, internet boards are not unlike dark, smoky local bars. One should be aware that the person across the bar with whom you wish to escalate a discussion to something less pleasant ("what world are you living in?") may be an experienced, credentialled black belt, not simply some poseur spouting something he read somewhere.
sophie_brown: "Doctors do not know which cases will win (since it ain't a function of the merit of the case)." If anything, physicians win far more than they should, since the decks are stacked against the malpractice plaintiff.
No, it's not. Just because someone has to find an expert witness, doesn't mean the deck is stacked in favor of doctors. Remember: juries are presented with an extremely sympathetic victim. You, as a female, should understand how emotionally appealing this can be, and it should be no surprise that a jury will want to award money even if the doctor did everything right, simply to "give the victim a little something", and heck, it's just a big evil insurance company that will be paying anyway.
The jury has virtually no medical knowledge, finds the process boring, feels sympathetic to victim, and votes based on who can best dumb down the facts and make a John-Edwards-like appeal to their hearts. They do not get any bonus points for making the effort to understand the science. Doctors are now overperforming Caesarian sections because some jury somewhere thought some lawyer's closing speech was inspiring.
Why on earth would you believe that such a jury is more accurate than a medical journal?
Numerous OBGYNs have had to close down because of rising costs. This is supposed to accurately reflect the imprecision of the practice in general?
Yes, my claim that jury malpractice verdicts are unrelated to merit is completely justified.
I wonder if those studies offset those costs against the costs avoided by medical malpractice liability,
Strawman. Like bingo said, no one is opposing the idea that those who commit malpractice should pay damages. The question is whether the existing process accurately awards damages. It does not: juries do not possess the information to accurately judge. As mentioned before, their incentives are skewed and medical knowledge is weak. On top of that, courts prohibit insurers, patients, and doctors, from negotiating in advance what the award limits will be, because the courts will not honor such agreements. So there is no existing record of how much each kind of wrong warrants in compensation, making jury awards have a wide spread, increasing risk, and driving up insurance costs.
"And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer."
Unless you're that lucky one in a million.
I'll keep saying it. Economic analysis should not be used when dealing with people's lives.
First, Megan's statement had nothing to do with "economic analysis." She was talking about medical risk. Doing extra tests is not risk-free. Each test carries a small risk. So you'll catch that one patient's cancer and save his life -- but also kill one other patient through an unnecessary procedure.
Second, the statement about "economic analysis" makes no sense. Until you invent the magic health care tree that one can pluck an unlimited number of doctors and hospitals -- and since we're dreaming, ponies too -- from, we have limited resources, which means we must make choices. Whether we're dealing with "people's lives" or with luxury yachts.
liberalrob: the risks of general anesthesia include death. The death rate is somewhere in the neighborhood of 5 in a million. Less severe complications are more common. Medical procedures almost always have risks.
"And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer."
May?
Risk of death or unwelcome sequelae from general anaesthesia is A HELL OF A LOT higher than 1 per million.
My brother is a surgeon. liberalrob and sophie, A WHOLE LOT of what he does or doesn't do in his practice is modified by malpractice risk and fear of being sued.
And you better hope you are never in the southern half of Illinois and get brain trauma in an accident. Virtually all the neurosurgeons have packed up and left. Thanks, John Edwards!
"Decisions on where to put hospitals, what facilities to put in the hospitals, and what services the hospital will provide are all examples of economic analysis being used when dealing with peoples lives."
I wasn't talking about that kind of economic analysis. I was talking about the analysis that said "this test only really has value for one in a million people, so it's not worth subsidizing for anyone." So if you're one of those one in a million, sucks to be you.
In Megan's case, wasn't it better to definitively know that it was just boring acid reflux, than to just hope and pray that it wasn't a one-in-a-million killer that probably would have been too late to do anything about by the time it got bad enough? I know with general anesthesia involved it changes the risk profile. I'm saying that that choice should be up to the patient and their doctor, not some insurance company.
"When I first saw you make this statement on some of the early comment threads I thought you were a troll trying to make liberals look bad."
Anyone who takes up a contrary position online is now automatically a troll until proven otherwise. It's just the way things are. No offense taken.
"What are the negative consequences that you would imagine from your proposal?"
I'm supposed to argue against my own proposal? I thought that was YOUR job, SG.
"I don't think you know what you mean when you talk about treatment being "available." All of these someones, all of these drugs, and all of the equipment involved are scarce resources. Under what system is this entire arsenal going to be at the disposal of every person that might -- just might -- be that one person in a million with the rare stomach cancer?"
That's not the point. The point is, to not preemptively deny something that is otherwise able to be provided. What I mean by "available" (and yes I do in fact know what I meant, thank you) is everything needed to provide the service is right there, ready to roll. All the doctor has to do is say "make it so" and it happens. Except what happens today is, the insurance company comes in and says, no, you can't give that test to Megan, because it's unlikely to be of any use to someone with her age and health profile. That, in my opinion, is a travesty. I absolutely do think it is heartless, and needlessly so. "Scarcity" is not a part of my analysis; there is no scarcity in my scenario, all components are present. All there is is mulish devotion to the insurance company's bottom line, the "market" deciding that it's better to take a chance, spin the roulette wheel with Megan's life, than shell out for a test that might save her life if she just happened to be the lucky one.
So I think it's better to take "the market" out of the picture completely. I don't want "the market" deciding whether I live or die. Or whether Megan lives or dies.
Um, the fantasy world proposed by your "scenerio" does sound nice. Good luck with that. The rest of us, meanwhile, are talking about the real world and trying to figure out whether or not some form of government-subsidized and government-run universal healthcare system would work better than what we have now. If you are foolish enough to think replacing insurance company bureaucrats with government bureaucrats will eliminate scarcity and the attending need to make difficult and unpleasant decisions about the allocation of resources, then you clearly have nothing to contribute to the discussion.
Look, this is not a question of liberal v. conservative. I am a liberal, I think the current system sucks, and I am in favor of universal healthcare. But the difference between you and I is that I actually know which problems universal healthcare would address. You clearly don't. Unless you pay out of your own pocket, there will ALWAYS be someone standing between you and your health care provider making decisions for you. The reason for this is that health services cost money, and someone needs to pay for it, and that someone also needs to decide what is and isn't worth paying for. There are absolutely not proposals on the table from any party that would eliminate this arrangement, because there cannot be. By failing to acknowledge this very simple fact, you are making our cause look silly and irrelevant.
liberalrob:
It's nobody's job to argue with you. I'm suggesting that there's gain to be had from critically analysis of your own proposals.
Do you imagine that anything approaching the complexity of a national health care delivery system can be created without some negative outcomes? Don't just think about the positives, what are those negative outcomes, how can they be avoided, how do they compare to the negative outcomes of other proposals. Otherwise you're just engaged in magical thinking.
Read matt_c for similiar take.
Rob: I don't know why I keep getting drawn back to this conversation, but I'm going to help you answer SG's question: In your scenerio, where the treatment is "available" or "able to be provided" or "ready to roll" or whatever you want to call it, you seem to be forgetting that the doctor needs to be paid. Who pays the doctor? Where does the money come from? Is it unlimited? If not, what do we do about the fact that there are only limited amounts of money available? If you try to honestly answer these questions, you will inevitably be confronted bythe problems implied by scarcity, problems that demand economic analysis. When resources are scarce, tough decisions have to be made. Just because you don't like it doesn't mean it isn't true. Socializing medicine does not eliminate this problem. The doctors still have to be paid, and there is still only a limited amount of money in the pool.
By all means, try to keep "the market" out of it (or, more realistically, limit its influence). But you can't keep "money" out of it, unless you are planning on holding those doctors at gunpoint. And as long as money is involved, you would be a fool to keep "economic analysis" out of it.
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