Best paragraph I've read all year:
Government-dominated health systems, insofar as they work well (a number of them do), succeed simply by lowering costs. Health care has a murky relationship to human health, pharmaceuticals and broken limbs aside. A version of the single-payer system, as might be adopted in the United States, would not lower costs. We would be raising taxes and lowering medical innovation to give poor people a good deal more financial security and a slight bit more health; that is the relevant trade-off.
This is part of the year's best blog post, so you should go read the whole thing.
And what is his evidence of this? Maybe Ezra Klein can talk some sense into the both of you.
I don't agree that this is the case. I certainly don't think that we would be giving the poor "slightly better health." (What is with the love of argument through assertion?) But even if it was, I don't care. As I have said before, the need for universal healthcare comes from moral imperative. I don't care how much it costs, or how it affects the economy, or how it changes the cycle of health innovation. It is an obscenity for people living in the most powerful country in the history of the world to go without health care, and it is our responsibility, in my opinion, to fix that. Everything else is detail.
I don't care how much it costs, or how it affects the economy, or how it changes the cycle of health innovation.
You cannot possibly mean this literally; if the effects were large enough, your moral imperative argument would collapse. You must mean "it will not affect costs, the economy, or innovation enough for me to care."
"A version of the single-payer system, as might be adopted in the United States, would not lower costs. "
I disagree. While it might be true in the short run, where standards of care will just be adopted from those currently existing, that will not persist.
What you must keep in mind, is that there is currently no informed entity in private health care that has an incentive to introduce standards of care that keep costs down. Neither providers, insurers or customers fit the bill.
Customers are not informed. They are not equipped to evaluate the economic merits of standards of care.
Providers want to sell as much as they can. Their incentive is limited to providing care competitively. They have incentive to provide as much as they can, though, whether it is warranted or not.
Insurers have incentive to keep their own costs down, but not industry wide costs. They bargain for the lowest price on services that are covered, and fight to deny costs that are not considered standard, but that is all. They do not fight to prevent inefficient methods from being adopted industry-wide. If their competitors have to pay too, it doesn't matter to them. Those costs merely make insurance more necessary, and are a wash.
A single payer system could be made that had an incentive to keep industry-wide costs down. It creates a government agency to do what people have lost the capacity to do - intelligently evaluate the economic value of medical procedures.
Yes, this is going to be rationing. The government will tell people "No" to what they think (possibly correctly) are life-saving procedures. We get that now anyway. The difference is that now it is not done in anything resembling a rational nor cost effective basis.
I'm not contending that the government is all wise, and will do the job better than private industry. I'm saying that there is no private industry doing this very necessary job.
Freddie, thank you for imposing your moral judgements on us. Since you like this idea so much, there are some evangelical christians who have some things they feel the government must force YOU to work on.
Gracias...!
MM: Best paragraph I've read all year
TC: Gracias...!
Don't get too excited yet, Tyler, the year's only 4 days old... ;)
Njorl, Tyler wasn't talking about some ideal system, he was talking about a "single-payer system, as might be adopted in the United States." So basically this means something like Medicare for all. Medicare, as you may have noticed, hasn't been that successful in keeping costs down.
Njorl, the big problem with your logic is that you can't sue government (at least with any hope of success). What is says, goes. It's mighty hard to sue insurers now, too... and they are sufficiently big to enjoy the effective monopoly... perhaps we should revoke these privileges rather than concentrate them?
What people seem to forget is that the poor currently get almost EXACTLY the same healthcare as the rich.
If the poor are truly poor then they get Medicaid or MediCal (California) or TennCare (Tennessee), etc. and essentially have insurance.
If for some reason they don't qualify for that then they get charity care from most hospitals.
I work as a healthcare consultant and EVERY hospital I've ever worked at has a sliding scale discount that ends at more then double the poverty level. Anything below twice the poverty level (in some cases 4 times) is written off completely.
If the poor are sick, they go to the ER and get care for free. This system obviously has significant flaws but no one can argue that the poor don't get adequete medical care. What is MUCH murkier is the poor's ability to get the drugs they need for non-life threatening conditions. Under a government sponsored healthcare system do we really expect the government to buy drugs for everyone with a non-life threatening condition either?
Assertion!!! Easier than analysis!!!
'Njorl, Tyler wasn't talking about some ideal system, he was talking about a "single-payer system, as might be adopted in the United States." So basically this means something like Medicare for all. Medicare, as you may have noticed, hasn't been that successful in keeping costs down.' - Posted by ed
"Single payer" means there are not other payers.
Medicare and medicaid can't keep industry wide costs down. They have done a great job with the costs that they can control, but they can't significantly differ from the rest of the health care industry. If they do not live by the standards of care set by the industry as a whole, they will not find providers willing to take their patients.
"Njorl, the big problem with your logic is that you can't sue government (at least with any hope of success). What is says, goes. It's mighty hard to sue insurers now, too... and they are sufficiently big to enjoy the effective monopoly... perhaps we should revoke these privileges rather than concentrate them?"-Posted by ...Max...
The effects of lawsuits on medical care are negligible. Suing isn't getting you a liver, not before you die. And you do have the right to petition your government for the redress of grievances. You have elected representitives in government. If you assume that they don't work for you, then assuming that a court will work for you is foolish.
Reducing inefficient measures, and thereby costs, freeing up more resources, would have a non-negligible effect on care.
Here's your analysis:
A farmhand making minimum wage or less suffers a massive heart attack and goes to the Emergency Room. He receives state of the art medical care and fully recovers. Cost of care for the farmhand= $0.00
A wealthy business person with health insurance suffers exactly the same heart attack and goes to the same Emergency Room. He receives exactly the same course of treatment and fully recovers. Cost of care for the business person= Whatever their insurance deductible is for Inpatient care.
They receive EXACTLY the same level of care. Arguably the wealthy person is paying for the farmhand's care as their deductible (as has everyone elses with insurance) has gone up to offset the increased hospitals charges to offset the free care they are providing the poor.
I'm not arguing that the existing system is perfect (far from it really) but I think it is errant to suggest that the poor are not receiving the same care as the wealthy. When you look at reality we already have universal healthcare... it's just not mandated.
Njorl,
"Single payer" means there are not other payers.
Then there's no such thing as "single payer" health care anywhere in the world. As the term is used in health policy discussions, it obviously doesn't mean literally "only one payer."
Medicare and medicaid can't keep industry wide costs down.
But they could keep their own costs down by imposing greater rationing and restrictions on the health care services they cover. They don't do that because it is not politically feasible. And that's the point. "Medical For All" would cost much more than the single-payer systems in other countries because Americans demand a much higher level of coverage. They want shiny new hospitals and private rooms. They want doctors and nurses with very extensive education and training. They want access to the latest pharmaceuticals and diagnostic tests and surgeries. These things cost a lot of money.
From Njorl in regards to Medicare today,
Why is this? Why can't Medicare simply declare, by fiat, that it is controlling the prices it pays (it already does this, by the way). Your explanation is that providers won't take Medicare patients today because they have other patients willing to pay more- a competitition for resources. What makes you think that single-payer will improve the situation for Medicare?
Freddie wrote: As I have said before, the need for universal healthcare comes from moral imperative. I don't care how much it costs, or how it affects the economy, or how it changes the cycle of health innovation.
In that case, I'll see your Moral Imperative, and raise you a Law of Unintended Consequences.
The effects of lawsuits on medical care are negligible.
That's not the prevailing meme. It'll take much more than a single phrase to convince me.
And you do have the right to petition your government for the redress of grievances.
A threat of lawsuit may look weak to a private insurer, but surely a threat of petition is as nothing to a bureaucrat? And yes, I am talking about threats because of the context: conflicting interests. Nothing anyone can say will convince me that any government agency or bureaucrat has my welfare on its list of priorities -- same as any corporation, btw. So let's talk leverage, not good intentions.
the poor currently get almost EXACTLY the same healthcare as the rich. - K9
This, obviously, is completely false, as a look at people's teeth in Tennessee will tell you.
Why can't Medicare simply declare, by fiat, that it is controlling the prices it pays - Yancey
Because it is prohibited from doing so by law, on drug prices. On other prices, the reason is, as Njorl says, that providers will refuse to accept Medicare payments if they go too low. Medicare has such a huge pool of subscribers that it can dictate lower prices than private insurers, but not so big that it can drive the bargain too hard. And the other incentives in the private system combine to drive prices higher, limiting Medicare's ability to achieve bargains. Single-payer obviously eliminates the problem of private industry driving prices higher; this is self-explanatory.
I had some slight reservoir of doubt about whether America would succeed in getting universal health care in the next administration, while I was in Vietnam. I've been back in the US for a week now, and that doubt has vanished. My freelancer friends are paying over $20,000 a year for health insurance for one parent and child. The American private/employer-sponsored model has failed. The argument is over. I'm sure libertarians can find some other interesting issues to talk about, but on this one, you're through.
"Medical For All" would cost much more than the single-payer systems in other countries because Americans demand a much higher level of coverage. They want shiny new hospitals and private rooms. - mixner
Please try to refrain from stating things which are the opposite of the truth. Compare hospital rooms in France and the United States, and the length of stay by people who are covered in both countries.
From Tyler Cowen's post:
3. Government-dominated health systems, insofar as they work well (a number of them do), succeed simply by lowering costs. Health care has a murky relationship to human health, pharmaceuticals and broken limbs aside. A version of the single-payer system, as might be adopted in the United States, would not lower costs.
Huh? Other government-dominated health systems lower costs, but for some reason the US will be incapable of doing so? Are we really such pathetic incompetents in comparison to the French, the Germans, the Dutch, the Canadians, the Japanese....?
K9 writes: "If the poor are sick, they go to the ER and get care for free."
>>>
I work in Fire/EMS on an ambulance, and can attest to this. However, let's not pretend that this is in any way whatsoever some kind of acceptable situation, either in terms of who pays for health care and public health in general. This is for the following reasons:
1) the more write-offs a hospital makes, the more that paying customers end up paying
2) ER visits are exorbitantly expensive compared to regular doctor visits, and taxpayers end up taking care of the bills for those on public assistance.
3) tying up Advanced Life Support ambulances because some deadbeat needs to go to the ER for her farking hangnail is not just a waste of resources, it removes advanced life support from other residents of the districts those ambulances support, requiring ambulances from much farther away to respond instead. Seconds count.
Max:
"[quote]The effects of lawsuits on medical care are negligible.[/quote]
That's not the prevailing meme. It'll take much more than a single phrase to convince me.
"
>>>>
So, you are willing to accept the partisan memes of "think" thanks and campaigns, but it'll take more than just a "single phrase" to convince you? I bet you also liked those chain emails that accuse John Edwards of causing the flu shot shortage, or the ones that conflate the overrall costs of lawsuits with the costs of "frivolous" malpractice cases....
I'm sure libertarians can find some other interesting issues to talk about, but on this one, you're through.
Guess it was due; it's been 12 years since the last time we were through.
Gaack. 16 years since the last time we were through. After the first few times being through, you start to lose track.
brooksfoe,
Because it is prohibited from doing so by law, on drug prices. On other prices, the reason is, as Njorl says, that providers will refuse to accept Medicare payments if they go too low. Medicare has such a huge pool of subscribers that it can dictate lower prices than private insurers, but not so big that it can drive the bargain too hard. And the other incentives in the private system combine to drive prices higher, limiting Medicare's ability to achieve bargains. Single-payer obviously eliminates the problem of private industry driving prices higher; this is self-explanatory.
Much confusion here. What do you mean by "private industry?" Private funding of health care? Private delivery? Both? Something else? And how does "private industry" (of whatever kind you are referring to) drive prices higher? And are you proposing to eliminate this "private industry" altogether, or merely reduce its share relative to "public" industry? If the latter, by how much? As you may know, even in most countries with "single payer" health care systems, much of the funding is still private, and almost all of the delivery is private. But "single payer" health care in the U.S. is a paleoliberal fantasy that you need to let go of once and for all. Even the Democrats reject it.
I had some slight reservoir of doubt about whether America would succeed in getting universal health care in the next administration, while I was in Vietnam. I've been back in the US for a week now, and that doubt has vanished. My freelancer friends are paying over $20,000 a year for health insurance for one parent and child.
Then they need to shop around.
The American private/employer-sponsored model has failed. The argument is over.
Yeah, that must be why Hillary, Obama and Edwards health care reform proposals all preserve this "failure." It must be why the role of private health care funding and delivery is growing in the archetypal "single payer" health care systems of Britain and Canada.
brooksfoe,
Please try to refrain from stating things which are the opposite of the truth.
Pot, kettle.
Compare hospital rooms in France and the United States, and the length of stay by people who are covered in both countries.
I have.
Other government-dominated health systems lower costs, but for some reason the US will be incapable of doing so?
That's right. Government-dominated health care systems lower costs by rationing and denying care to patients and paying lower wages to health care workers. If you seriously believe that the U.S. could provide health insurance (or "coverage") for the 45 million currently uninsured without reducing the level of coverage to the currently insured and at the same time spend less, I'd love to see your proposal for achieving this wildly implausible goal.
My freelancer friends are paying over $20,000 a year for health insurance for one parent and child.
Then your friends are either paying more than they have to, or are exceptionally expensive to insure because of some pre-existing condition you've chosen not to disclose to us.
brooksfoe-
Are we really such pathetic incompetents in comparison to the French, the Germans, the Dutch, the Canadians, the Japanese....?
Lets say a drug costs $100,000,000 to develop. It costs $1 to make a dose of that drug. A country like Canada can mandate a price of $2 per dose, but without some country willing to pay $50/dose you don't have continued medical innovation.
Of course, personally, I avoid most pharmaceuticals like the plague. But assuming some are worthwhile...
Either way, I'd prefer to get naturopathic care for everything except broken bones, cancer, and organ transplants and I'd rather not pay for my health care twice.
You see, that's what I don't get. I have a hard time believing that the only reason there is innovation in medicine is because pharmaceutical companies can use patents to overcharge desperate patients. It takes a special kind of belief in the power of pure greed to add value to the world. I'm not against greed per se, but, it takes specific arrangements for the will-to-profit to result in anything other than the sale of snake oil, and those arrangements are anemic at best in the modern medical industry. If Tyler Cowen thinks that some hypothetical government health care system can reduce medical costs, but doesn't think single payer will do it-well, what will? It's quite possible that something like universal health care is coming down the pipe, for good or ill. Instead of all the talk of the unimportance of the plight of poor people in the face of some vague, nefarious threat to the collective wellbeing of society that has become the hallmark of contemporary economist rhetoric (we could help the poor, but if we do... DOOOOOMMMMMM!!!!), Mr. Cowen would do better to look at best-case scenarios, and ply that trade of his coming up with policy arrangements that will help mitigate the economic impact he believes such a program is likely to have.
"As I have said before, the need for universal healthcare comes from moral imperative."-Freddie
I wonder if I'm the only one who is amazed by the self-righteousness on evidence here. Leftists often just assume that they have some special insight into moral truth that the rest of us mere mortals somehow lack. Meanwhile they thoughtlessly brush aside our own concerns about personal liberty or stifled innovation (though these are equally moral concerns).
Sorry Freddie, but you have to make an argument. Declaring "Socialized medicine is a moral imperative" just doesn't cut it.
If you seriously believe that the U.S. could provide health insurance (or "coverage") for the 45 million currently uninsured without reducing the level of coverage to the currently insured and at the same time spend less, I'd love to see your proposal for achieving this wildly implausible goal. - mixner
You know perfectly well that administrative costs at private health insurers are over 20% of total costs, while administrative costs at Medicare are under 2% and at Medicaid are around 5%. (Medicaid has higher administrative costs in large part because of all the work it needs to do to determine whether or not people are eligible, which would disappear under single-payer and largely under an Edwards-style plan.) At the simplest level of math, 16% of Americans are currently uninsured; administrative savings in the range of 15%+ would cover them. But in fact, it's more complicated than that: the "uninsured" Americans' health costs are currently either being paid out of pocket, which means they are much higher than they would be if paid by insurers, or are not being paid by the patients, and are then factored into the costs charged to all other patients, which raises the costs of everyone else's health care and their premiums. So in fact, the total amount of health expenditures being paid by insurers will rise much less than 16% when those 16% of Americans are covered, because much of it is in effect already being paid by insurers, through passed-on costs in the current totally insane and screwed-up system.
If you have been paying attention at all to the health care debate, then you already know this, which is why I find it baffling that you continue to plug away with the same old ridiculous arguments.
The suggestion that people I know need to "shop around" for cheaper care is ludicrous. Done any shopping lately for gasoline under $2 a gallon? You should shop around some more!
As for Ryan W.: the fastest growing expense in the US pharmaceuticals industry is for advertising. The US is the only advanced economy that allows drug manufacturers to advertise directly to customers.
The US is the only advanced economy that allows drug manufacturers to advertise directly to customers.-brooksfoe
Yes, isn't it terrible when companies try to provide information to potential customers about their products. How dreadful. Let's ban all advertising.
"As I have said before, the need for universal healthcare comes from moral imperative."-Freddie
"I wonder if I'm the only one who is amazed by the self-righteousness on evidence here. Leftists often just assume that they have some special insight into moral truth that the rest of us mere mortals somehow lack. Meanwhile they thoughtlessly brush aside our own concerns about personal liberty or stifled innovation (though these are equally moral concerns).
Sorry Freddie, but you have to make an argument. Declaring "Socialized medicine is a moral imperative" just doesn't cut it."
What are you talking about? Everyone knows what Freddie means when he says that. There are poor people with cancer who are going to die because they can't afford treatment, and people who experience excruciating pain because of illness they can't get help with. He thinks that's not acceptable in a country that could arrange for treatment if policies were in place designed to ensure its provision. Last time I checked, this was America, richest nation in the world (okay, I admit, I never really checked).
You, Mr. "Socialized Medicine," have a much harder argument to make-you have to explain why it's totally okay for us to ignore these people. Either implicitly or explicitly, that's what all arguments against universal health care boil down to.
gerontion,
I have no objection to government subsidies for those who cannot afford medical care. Indeed I think it's a good idea. Medicaid might need some reform, but it shouldn't be scrapped.
I do, however, object to a government take-over of the medical system. Tyler Cowen was talking about "government-dominated health systems," and so was I.
If Freddie is saying nothing more than that we need some government subusidies for the poor, then I agree with him. But if, as leftists are wont to do, he is using the misfortunes of a small portion of the population as a pretext for a nationalization of the entire health care industry, then he and I do not agree.
Subisidies for people who are truly in need are fine. Government control of health care is not, for reasons Mixner has ably explained above.
I see that economist Tom Sowell is also on to this bait and switch tactic:
Thus there is good reason to provide a subsidy to the poor but no good reason to nationalize whole industries. If there are some people who can't get enough food, does it make more sense to give those people food stamps or to nationalize all farms and supermarkets? The answer is clear, I think.
Megan, honey, it's only the fourth of January.
The whole medical system isn't going to get brought to government heel by any of the proposed health care plans. There might be legislation that influences pharmaceuticals, for good or ill (I imagine for good). Employer based insurance will get phased out, which I think even libertarians can't bristle over, since it's a weird arrangement to begin with. What will get nationalized is merely the insurance industry, which doesn't seem to benefit people much from being private to begin with. There are good arguments and a lot of data that support the idea that a market-based insurance system is actually less efficient than a government run insurance system would be. Legislation is reversible. I think, for the amount of good that could be achieved its worth experimenting with.
A picture says a thousand words:
http://ucatlas.ucsc.edu/health/spend/cost_longlife75.gif
Personally I think having a single-payer system would open up innovation in this country - a big reason why people don't change jobs is because of medical insurance - either because they can't afford to lose it, or because they are worried about being denied medical coverage on a new plan because of a pre-existing condition.
Think of all the people that would be more willing to join smaller companies if their insurance was guaranteed and portable.
Insurance companies are clearly useless members in the healthcare chain - they provide no value and will, as all corporations do, seek to maximize wealth for their shareholders. They claim to bring down costs, but all I've seen is cost rising at greater than 8% a year, while the CEO of these companies make a ton of dough.
So, let's lose them from the Healthcare chain, let's toss out that stupid law that prevents the US government from negotiating with Pharma companies. While we're at it, let's put some incentives (I have no idea how to do this) to have pharma companies not create substandard me-too products and have them actually focus on innovation. The dirty secret in the pharma business is that they spend far more, at this point, on marketing than on R&D.
50% of all bankruptcies in the US happen because of a healthcare issue. A country as rich as ours should have no issue providing healthcare to all our citizens - let's just cut $100b from support for the military industrial complex. It is all a question of priorities of a society - and ours is apparently more concerned with war than our own internal citizens.
dmwr...
While we're at it we should have the US governement declare to all the grocers what we should pay for food... after all we all need food too right?
I disagree 100% with your assertion that a single payer system would up innovation. Right now many of the best and brightest people go into Medicine due in part to the high pay as a doctor, drug researcher, biomedical engineer, etc. Under a single payer system these people would likely loose the incentive of higher pay as we would need to "control costs" or bankrupt the whole country. As these people choose other careers (finance, business, etc.) we will have lost all of our future innovators.
Dean Moriarty @ January 4, 2008 8:49 PM
I agree that the poor receiving care through the ER is not the best solution (and probably leads to increases in the cost of care across the whole system) but as it stands now isn't this already a progressive form of universal care? The wealthy, employed and insured pay for the care of the poorest (however indirectly).
While we're at it we should have the US governement declare to all the grocers what we should pay for food... after all we all need food too right?
I disagree 100% with your assertion that a single payer system would up innovation. Right now many of the best and brightest people go into Medicine due in part to the high pay as a doctor
Classic argument - the difference is that insurance is a very different market. Insurance thrives on reducing benefits to increase profits. We also have true competition in the food market - as a grocery I can set my prices, but as a consumer, I can shop at a wide variety of grocery stores. The same is not true for insurance. And a grocery generally doesn't deny me the right to shop at the store - whereas with insurance, I can be refused. My point is just this: healthcare isn't like other markets. The cost of a old person shopping at the market is roughly the same as a young one. And from a moral point-of-view, treating healthcare like any other market is problematic - because the market outcome will not necessarily be a positive (as we have seen here in the US).
Also - innovation was probably the wrong phrase to use on my part - what I meant was that by providing healthcare, we would gain a huge benefit in taking that worry away from small and large companies. Why can't we compete with Japan on cars? There are many reasons - but one big reason is that the cost of healthcare has to be factored into the car. Japan provides workers with healthcare, and, as a result, it is one less cost given to Toyota. Given that corporations are externalizing engines, I think they would welcome nationalized healthcare so they can get out of the business. In fact, I know this - because Walmart is one of the big backers of a single-payer system.
The other part of your argument - that people will be less likely to join the medical field - is also problematic. More and more people are not joining the medical field because (1) they can't make the money that past generations made and (2) because the insurance companies force pricing and incentives on them that benefit the insurance company rather than the patient. As a result, many people are choosing not to be doctors anymore. Add to it the high cost of medical school and malpractice insurance (a different issue) and the business of being a doctor isn't nearly as compelling as it once was.
As for drug researchers and other people involved in fundamental research, nothing in changing the basics of the healthcare provider system would likely affect them - NIH would still exist, and I am not arguing that pharma companies should be price controlled - rather, that the US Government should be allowed to negotiate on price with them.
I agree that insurance is a closed market and needs to be opened up to anyone independent of which state you live in. My reference was more toward drug companies and dictating what we will pay them (which as I reread your post you didn't imply... my mistake). Obviously the issue from the insurance companies perspective is that their risk pool needs to be wide enough so that they aren't stuck with a bunch of overly sick people.
As far as innovation: "The other part of your argument - that people will be less likely to join the medical field - is also problematic. More and more people are not joining the medical field because..." This will only get much worse under universal healthcare.
As someone working in the healthcare field now (non-clinical) as soon as a universal healthcare type plan is passed I will be working to open "private hospitals" that take "private insurance" that provide significantly better care then the publically supported hospitals. Do you want your mom to wait for months to have a 4 slice CT scan done on her brain to see if she has a tumor or would you prefer a same day appointment on our 256 slice scanner so that physicians can much more accurately determine what is wrong with her?
There are essntially two arguments being made on this thread for socialized medicine (in one form or another).
The problem is that this argument is invalid. The conclusion doesn't follow from the premise. And to date, no one has supplied the missing premise(s) in this enthymeme that would make it a sound argument.
The second argument I won't bother to put in the form of a syllogism:
But the problem here is that there is no evidence for this. Yes, of course, price controls can artificially reduce health care expenditures, but they impose other hidden costs that can be enormous--like long waits for hip replacements and even heart surgeries. Moreover, government run industries are notoriously inefficient becuase bureaucrats have little incentive to control costs and improve quality. This is especially true when the bureaucrats have unions.
dmwr, Freddie, gerontoin and brooksfoe also seem to be telling us:
Perhaps they'll forgive us if we do not share their enthusiasm for this.
This will only get much worse under universal healthcare.
Based on what? Has there been a massive drop-off in doctors in countries where they have universal healthcare? I think the answer here is pretty clear - there is no correlation, probably because people go into the medical profession for a wide variety of reasons other than just money. And, of course, we could overcome this by simply paying doctors very well under a universal plan. There are around 700k of doctors in the US, about 500k actively practicing - strikes me that if we took $100b from the military industrial complex we would have no trouble paying them an excellent wage.
As someone working in the healthcare field now (non-clinical) as soon as a universal healthcare type plan is passed I will be working to open "private hospitals" that take "private insurance" that provide significantly better care then the publically supported hospitals. Do you want your mom to wait for months to have a 4 slice CT scan done on her brain to see if she has a tumor or would you prefer a same day appointment on our 256 slice scanner so that physicians can much more accurately determine what is wrong with her?
Well, I think you're jumping the gun on declaring what you would do under universal healthcare - you might want to work for a public hospital because it reduces the amount of time you spend on useless paperwork and managing your patients against the insurance providers.
The second part of your statement is the common argument - that universal healthcare will lead to healthcare rationing. I have seen zero evidence to support this - if you have some, I'd love to see it. My step-father is a doctor in England, as is most of my family - they have never had to wait to get healthcare. This includes MRIs and other relatively technology-driven procedures. Until I see some compelling evidence that this is a huge problem, I put this argument into the category of a scare tactic.
This also presupposes that we don't have healthcare rationing in the US - which, of course, we do. When my father was diagnosed with a disease here in the US, he was in the hospital for 1 day before they sent him home. He was not properly diagnosed, and was rushed to get him out of the hospital. When the disease reappeared on a trip to Germany, he was in the hospital for 6 days in Berlin while they ran a wide of tests that allowed them to get a good handle on his condition.
Another recent personal example: a friend of mine had an operation, and when he woke up, he was disoriented and confused - he actually had to be restrained. He also did not have feeling in his legs. The hospital unbelievably sent him home with wife. Clearly this was not appropriate.
The bottom line is that hospital stays here in the US are shorter and under pressure to send people home early, and more expensive on a daily basis than their European counterpart.
Only in the US could we have a hospital accused of patient dumping (as happened in Los Angeles recently).
The second argument I won't bother to put in the form of a syllogism:
2)"A socialist medical system would be more efficient."-This is brooksfoe's argument
But the problem here is that there is no evidence for this.
Uh, no evidence for this? If efficiency of a medical system can be judged by cost and outcomes, then the US is approaching dead last. Where's the evidence that a somewhat market-based system is more efficient? Certainly if we look, again, at costs and outcomes here in the US the answer to that is clearly no.
"The government can do for health care what it has done for education."
Just because the government doesn't do a good job with one sector, doesn't mean, logically, that they can't do a good job with another. Your argument could be stated as:
"The government does a bad job with education, therefore it will do a bad job with healthcare."
Take the NIH - it does a great job of encouraging innovation in research. Many of the drugs that companies claim to have innovated have come from NIH grants. And why aren't we saying the same thing about the military? Do we think they do a poor job?
Again - the argument is made that "the market will provide" when all evidence has pointed to the opposite. And no viable alternative is offered.
"If efficiency of a medical system can be judged by cost and outcomes, then the US is approaching dead last."
it's a common error to suppose that, because the United States has less government control than Canada and the UK, it represents a free market system. It's clear that isn't the case, though, since something approaching half of all medical spending here comes from the government. Add to that enormous expenditure the indrect control the government exerts through regulation and it beomes clear that we too have "a government dominated system."
The question, then, is whether to move in the direction of more government control (when that has failed in the past) or to liberalize, relying more on markets. Noone is proposing total laiseez-faire, but there are market friendly changes we could make that would improve things. Allowing consumers to purchase health insurance across state lines, for instance, would certainly lower premiums
Incidentally, no country has a health care system that I consider a model, but Switzerland might be the least bad. They have relied more on markets than their neighbors and, if average life-span is any measure, the Swiss are pretty healthy.
it's a common error to suppose that, because the United States has less government control than Canada and the UK, it represents a free market system. It's clear that isn't the case, though, since something approaching half of all medical spending here comes from the government. Add to that enormous expenditure the indrect control the government exerts through regulation and it beomes clear that we too have "a government dominated system."
So here's the question: why have our medical costs been growing at a rate 2 - 3x what other nations have been growing? Why is our healthcare so expensive? It's clearly not that doctors are being paid so much more. It's clearly not just lawsuits and insurance that doctors must carry. Simply put - I would love to hear someone explain the incredible rate of change in our healthcare vs. the rest of the world.
The answer may be in the free market, but it can't include the insurance companies - they provide nothing. They do nothing. They do not control costs, and they make our system overly complicated. Having insurance companies that seek to make a profit basically automatically puts them at odds with getting the best healthcare. There are exceptions: it makes sense, for instance, for an insurance company to encourage someone to stop smoking. But there are also strong incentives to provide the minimal care possible. This is the inherit problem with healthcare insurance being a for-profit business.
Incidentally, no country has a health care system that I consider a model, but Switzerland might be the least bad. They have relied more on markets than their neighbors and, if average life-span is any measure, the Swiss are pretty healthy.
And their costs are much less.
Just because the government doesn't do a good job with one sector, doesn't mean, logically, that they can't do a good job with another.
dmwr: Moreover, there's a big difference between public education in the United States and most single payer healthcare systems. In the former, the government owns and operates the facilities (schools). In the later, the government mostly confines its role to bill paying. The main exception to this is Britain, which, while managing to deliver healthcare relatively inexpensively by rich world standards, also manages to deliver some fairly poor results. The more common single payer model -- whereby the government acts like a big insurance company guaranteeing access and universality, but leaves the provisioning of healthcare to private sector actors -- seems to work pretty well.
But "single payer" health care in the U.S. is a paleoliberal fantasy that you need to let go of once and for all. Even the Democrats reject it.
Mixner: The big three Democratic candidates all have proposals that would allow people to buy Medicare-style coverage directly from the government. I think it's highly likely one of these three will become president, and this president will have a majority in both houses of Congress. I'm not saying it's inevitable, but such a provision sure looks like single payer through the back door, unless you think private sector insurers would be able to compete with Uncle Sam for the premium dollars of middle class Americans. Long term, I doubt they can.
You know perfectly well that administrative costs at private health insurers are over 20% of total costs, while administrative costs at Medicare are under 2% and at Medicaid are around 5%. (Medicaid has higher administrative costs in large part because of all the work it needs to do to determine whether or not people are eligible, which would disappear under single-payer and largely under an Edwards-style plan.)
And you ought to know that Medicare/caid administrative costs don't reflect the treasury costs of tax collection (i.e., payment to cover the services rendered, which are a part of private insurance administrative costs), and other cost savings are achieved by setting fairly rigid but often arcane limits on what is covered, when, and for how much, sticking it into documentation, and then letting the providers work out the paper chase -- in other words, shifting the cost burden of this administrative work onto the hospitals and physicians' offices.
If you have been paying attention at all to the health care debate, then you already know this, which is why I find it baffling that you continue to plug away with the same old ridiculous arguments.
I see your bloody feet and several shell casings lying around. Was that wise?
The suggestion that people I know need to "shop around" for cheaper care is ludicrous. Done any shopping lately for gasoline under $2 a gallon? You should shop around some more!
If you're hanging around in east coast states, then maybe you've encountered the failure of government insurance regulations, specifically state regulations that place stifling limits on insurer ability to offer insrance and differentiate between risk. If so, welcome to the failure of government-meddled healthcare, and learn lessons accordingly. The last time I heard my self-employed aunt and uncle comment on healthcare costs, they were paying something like $14k/year for a family of four.
So, yeah, your friends are getting ripped off. Whether that's their fault, or the fault of the state government they live under, is an exercise for you to determine.
If you're hanging around in east coast states, then maybe you've encountered the failure of government insurance regulations, specifically state regulations that place stifling limits on insurer ability to offer insrance and differentiate between risk.
You mean like in Florida where the insurance companies don't provide flood insurance any more?
Differentiated risk - let's call this what this is - a way for insurance companies to only insure people that are the most healthy and therefore the most profitable. And, conversely, a way to charge the most or flatly deny coverage (as is most often the case) for anyone with a pre-existing condition.
In short - you might be right that government regulations are keeping prices fairly checked - but that is an effort to avoid the common cherry picking affect that happens when you don't have those regulations in affect.
dmwr: That is exactly the opposite of true. If a person is more risky then the insurance company has to charge more to make it profitable. Differential pricing makes all customers profitable (on average).
If prices are restircted then insurers will avoid bad risks. So with free insurence markets people get expensive insurance or no insurance, their choice. With controls they get no insurance, no choice. Now some people can't afford the expensive insurance, but some form of welfare is the right way to fix this, not messing with the price system.
One general result in economics is that price controls are a bad idea, always and everywhere. If there are exceptions, they are unlikely to appear in a policy setting, or be correctly identified if they do.
brooksfoe,
You know perfectly well that administrative costs at private health insurers are over 20% of total costs, wile administrative costs at Medicare are under 2% and at Medicaid are around 5%.
This nonsense, yet again. Medicare's administrative costs are relatively low (though you appear to have invented your figures above out of thin air) because it spends so little on oversight and vetting of claims and services. This leads to massive waste and overconsumption. That's one reason why Medicare spends huge amounts of money to achieve little medical benefit. That's one reason why Medicare is going bankrupt. Tyler Cowen discusses the problem here, for example.
Mixner: The big three Democratic candidates all have proposals that would allow people to buy Medicare-style coverage directly from the government.
Jasper: Giving individuals the option of buying their health insurance from the government instead of from a private insurer, or obtaining it from a private insurer through their employer, is not "single payer" health care. It isn't anything remotely like "single payer" health care.
... unless you think private sector insurers would be able to compete with Uncle Sam for the premium dollars of middle class Americans. Long term, I doubt they can.
Really? And what is the basis for that doubt? Private enterprise does a better job than the government at providing virtually all consumer goods and services, including insurance services. Do please explain why we should expect the government to do a better job at providing health insurance when it does a worse job at providing virtually everything else. Are you also proposing a government takeover of the rest of our economy, too?
brooksfoe,
The suggestion that people I know need to "shop around" for cheaper care is ludicrous.
No, it isn't. What's absurd is your suggestion that health care insurance for an adult and child costs around $20,000/year. All you need to do is spend a few minutes online researching health insurance prices to see the absurdity of that claim. Try going to Cigna's or United Healthcare's websites. It's obvious you're just making numbers up out of thin air.
If your friends really are paying $20,000/year, they must either have very, very unusual medical circumstances, or they are total suckers.
You mean like in Florida where the insurance companies don't provide flood insurance any more?
And why would they? If people choose to live or continue living in a low-lying area surrounded by lots of water after the potential for widespread flood catastrophe has been repeatedly demonstrated, who in their right mind would sell and guarantee a policy to insure against that risk? Would you?
Differentiated risk - let's call this what this is - a way for insurance companies to only insure people that are the most healthy and therefore the most profitable. And, conversely, a way to charge the most or flatly deny coverage (as is most often the case) for anyone with a pre-existing condition.
This statement can mostly be reduced to a single image of a whiny, overprivileged teen throwing a temper tantrum while shouting, "life isn't fair!"
Look, this is the real world. Different people represent different risks based on factors as diverse as health history, demographics, and personal habits. If insurers are denied the ability to differentiate risk, then the basis for the existence of an insurance market vanishes, and instead what you are demanding is an unconditional indemnity service.
Surprise, surprise, unconditional indemnity is extraorinarily expensive -- and that's probably why brooksfoe can testify to having friends who pay $20k/year for a two-person family. They aren't necessarily paying for their own actual health risks; more likely, they're paying for the higher risks of others that the insurance companies are no longer allowed to differentiate against.
dmwr,
So here's the question: why have our medical costs been growing at a rate 2 - 3x what other nations have been growing?
They haven't. Your premise is false.
Why is our healthcare so expensive?
Short answer: because we're so rich and demand such high-quality health care services.
It's clearly not that doctors are being paid so much more.
On the contrary, our higher labor costs are a big part of it. U.S. doctors make two to three times as much as their Canadian and European counterparts. Other U.S. health care professionals--nurses, pharmacists, medical researchers, etc.--are also much better paid than their counterparts in other countries. Good luck trying to persuade the medical community to take a huge cut in their incomes. There's already a serious shortage of nurses in the U.S.
The answer may be in the free market, but it can't include the insurance companies - they provide nothing. They do nothing.
Ah, right. Insurance is "nothing." Your comments are getting more and more absurd.
But there are also strong incentives to provide the minimal care possible.
No, the incentive is to provide the mix of care and price that best satisfies the market. An insurer who provides "the minimal care possible" is likely to lose business to his competitors unless the price he charges is correspondingly minimal and there is a demand for that minimal level of service. The reality is that all major insurers provide a range of products that provide widely varying levels of care with widely varying prices. Some people only want, or can only afford, minimal care for minimal cost, while others want much more comprehensive care for higher cost. Some policies have high deductibles and co-pays, and others have low deductibles and co-pays. There is much variation, reflecting variation in demand, income and tolerance for risk among the population.
So, Mixner, you claimed that you've checked out French hospital rooms, so it should be a snap to fire up the old links and post them here, or the files you've downloaded, right? So let's see this research you've done.
Mixner is doing a good job of educating others here as to the nature of a market system. I just thought I'd add to his answer above.
An essential part of the problem can be seen with simple supply and demand diagrams. The government since the end of World War II has been subsidizing healthcare expenditures heavily. That essentially shifts the demand curve out.
But, ceteris paribus a rapid increase in demand will bring a sharp rise in price. Now, the favorite solution on the left is to impose price controls. But as every economist knows, price controls bring shortages and rationing--as seen in Canada and the UK.
So the irony here is that the problem has been created by too much government interference in the health care market--and dmwr and others are prosposing to fix it with still more government interference.
Some of us would rather go in the opposite direction: toward more freedom and more competition to increase quality and bring down price. It's a shame so many so-called "liberals" are so quick to surrender their liberty for the dubious benefits of a bureaucratic system when free market solutions are waiting to be tried.
Thomas Jefferson must be turning in his grave.
Scent,
Sure I will, just as soon as brooksfoe presents his links. Pot, kettle, and all that.
I didn't ask brooksfoe. I asked you. And it's pretty obvious that you don't have them and you didn't check (otherwise that would have been a pretty refutation of the original assertion.) Why should I believe someone who lies so easily if they think it will help make their point?
Same thing as with Mixner: where's your evidence? I's sure you wouldn't lie about having it, right? I'm sure that you wouldn't say something just because you thought it helped the cause, that in fact, you've actually done the research, and that you've got links, cites, etc.
Right?
Oh - nothing from Cato of course. Or Heritage. Or the AEI, NRO, etc. Because you and I both know that if you post from there, . . . you lose.
SOV,
I don't know much about the French system, but it's pretty easy to find out about the long waiting times for surgery in Canada. Look here, for example:
Cardiac Surgery, BC Wait Times
It's pretty clear from the evidence that Canada has acheived "cost savings" in large part through price controls and that these controls have created shortages and rationing. So the median wait time for heart surgery in British Columbia is 10 weeks. Is that what you want for the United States?
Scent,
I didn't ask brooksfoe. I asked you.
You asked me about a comment I made in response to brooksfoe's claim about comparisons between French and U.S. hospitals. Why aren't you asking brooksfoe for links to substantiate his prior claim? Or any of his other claims?
Why should I believe someone who lies so easily if they think it will help make their point?
Why should take you seriously when you have such an obvious double standard regarding the substantiation of factual claims?
I don't know much about the French system
The most pertinent fact about the French health care system is that it is headed for bankruptcy, like Medicare in the U.S. The French public health insurance fund is chronically in huge deficit. The French health system is unsustainable without substantial increases in taxes, substantial cuts in services, or both.
Why is our healthcare so expensive?
Short answer: because we're so rich and demand such high-quality health care service.
We spend 15% of our GDP on healthcare. The median for OECD countries is 9% (reference: http://www.oecd.org/dataoecd/46/2/38980580.pdf).
Notice, as well, that we have our private companies spend more on healthcare than any other country - a serious competitive disadvantage.
Yet we have worse outcomes, higher obesity, shorter lifespan. If the "market" was really working - then we would have correspondingly better outcomes. Is this the sign of an efficient market? I would say not.
Ah, right. Insurance is "nothing." Your comments are getting more and more absurd.
Explain their function - explain how they benefit the consumer. Explain how they are anything other than a functionless middle tier. Name one person that likes their insurance company and thinks they're great. Getting more absurd? I'd just like you to provide detail on the benefit of the insurance companies. Have they lowered costs? Clearly not. Have they improved outcomes? Clearly not.
On the contrary, our higher labor costs are a big part of it. U.S. doctors make two to three times as much as their Canadian and European counterparts. Other U.S. health care professionals--nurses, pharmacists, medical researchers, etc.--are also much better paid than their counterparts in other countries. Good luck trying to persuade the medical community to take a huge cut in their incomes. There's already a serious shortage of nurses in the U.S.
Already addressed this - fine - keep their pay and just reduce our military expenditure to keep the rates up. By reducing the insurance companies to nothing, you'll also gain back some money to pass directly to physicians.
But, ceteris paribus a rapid increase in demand will bring a sharp rise in price. Now, the favorite solution on the left is to impose price controls. But as every economist knows, price controls bring shortages and rationing--as seen in Canada and the UK.
Again - I'll call for some data that points to rationing - I've seen zero hard evidence for it. Anybody got a paper on it?
So the irony here is that the problem has been created by too much government interference in the health care market--and dmwr and others are prosposing to fix it with still more government interference.
So let's review - their's been a sharp rise in demand, so cost has gone up. Ok - yet in Europe, where the median age is old than that of the US, they haven't seen costs increase despite an aging population.
How was this problem created by too much government interference? When Nixon allowed the creation of the HMOs such as Kaiser? And how exactly has government interference raised our healthcare costs? What is an example?
Some of us would rather go in the opposite direction: toward more freedom and more competition to increase quality and bring down price. It's a shame so many so-called "liberals" are so quick to surrender their liberty for the dubious benefits of a bureaucratic system when free market solutions are waiting to be tried.
What's really a shame is that so many libertarians and conservatives are willing to throw away their rights to corporations which do not have any requirement to service the best interests of the citizens of this country. Free markets work very well in many cases, but even Milton Friedman would say that markets can create outcomes which are not ideal. We are scared of the term socialism, yet we embrace it when it comes to the military - no one argues that we should be applying free market thinking to servicing our soldiers in the field.
Why are we so afraid to look around the world at what is working elsewhere?
I asked you because I am pretty good at sniffing out people who lie. I wasn't sure, so I asked first. I'm still not 100% sure . . but I'm at 90% plus right now.
Chuckle. The lack of logic would be amusing were it not so appalling. Say for the sake of argument that I do have a double standard(I'm not saying I do, but let's assume so.) How does my double standard in any way change the fact that you have been shown to be a liar? Do arsonists, murderers, embezzelers get a break because of the 'he did it too' defense? I think not.
No, whatever anyone may think or suspect of me, this changes not the fact that you are a liar. I just hope the self-declared libertarians posting here now show that they really are principled and condemns your swinish hide.
What does this have to do with Mixner providing evidence for his claim? If I'm going to have a discussion with someone, part of my minimal standards are that they not be such stone liars. Do you disagree? I refuse to talk to people about some issue if, every time I bring up some point, they 'refute' it by bald-faced lying.
Are your standards different?
dmwr,
We spend 15% of our GDP on healthcare. The median for OECD countries is 9% (reference: http://www.oecd.org/dataoecd/46/2/38980580.pdf).
Right, we spend a lot more. As I said, the basic reason for this is that we are so rich and that we demand such high quality care. In general, the richer a country gets, the higher share of its wealth it spends on health care, and the higher level of care its citizens will demand.
Notice, as well, that we have our private companies spend more on healthcare than any other country - a serious competitive disadvantage.
How is this a competitive disadvantage?
Yet we have worse outcomes, higher obesity, shorter lifespan.
Aggregate health-related statistics like life expectancy are essentially meaningless as measures of the quality or performance of a nation's health care system. It's like trying to judge the fuel efficiency of a car by looking only at its tires. There are so many other factors that have a much greater effect on aggregate measures of health--patterns of diet and exercise, smoking rates, violent crime rates, motor vehicle accident rates, pollution levels, etc., that using these stats to evaluate health care systems is meaningless.
Explain their function - explain how they benefit the consumer.
In the same way that any other kind of insurance benefits the consumer. They protect people from certain kinds of financial risk.
Already addressed this - fine - keep their pay and just reduce our military expenditure to keep the rates up.
Huh? So you're not in fact proposing to reduce our high medical care labor costs. You're apparently proposing to increase those costs, and pay for them with cuts in military expenditure. Is that it? I thought you wanted to cut our health care spending, not raise it. Your conflicting comments are very confusing.
Again - I'll call for some data that points to rationing - I've seen zero hard evidence for it. Anybody got a paper on it?
There is abundant evidence of rationing of health care in Britain and Canada. See, for example, Statistics Canada's most recent report on waiting times.
In 2005, the Supreme Court of Canada struck down the laws that banned private health care in Quebec as a violation of the Canadian Charter of Rights and Freedoms. Forcing people to rely on the government single-payer system causes people to suffer serious harm, and in some cases to die, because they are denied health care services.
Scent,
I asked you because I am pretty good at sniffing out people who lie.
I'd say you're utterly hopeless at it.
Again, why aren't you asking brooksfoe to provide links to substantiate his claims?
You're obviously not interested in the truth. If you were, you'd demand substantiation of factual claims regardless of their source. The only evidence you're interested in is evidence that would confirm your prejudices.
And why would they? If people choose to live or continue living in a low-lying area surrounded by lots of water after the potential for widespread flood catastrophe has been repeatedly demonstrated, who in their right mind would sell and guarantee a policy to insure against that risk? Would you?
No I actually agree with you on this - but my point is that healthcare issues usually aren't a choice like buying a house in a flood area. A person can elect to buy a house in a particular area - but a person cannot determine when they will be sick or how they will be sick. This is the essential reason I would argue that healthcare insurance shouldn't be in the hands of for-profit companies.
This statement can mostly be reduced to a single image of a whiny, overprivileged teen throwing a temper tantrum while shouting, "life isn't fair!"
Uh, it's a bit more complex than that. Try saying that to an older couple which loses everything as a result of a serious illness that gives them a $200k medical bill. Here's an interesting stat that I mentioned before: 50% of the people declaring bankruptcy are doing so because of a healthcare issue. Now, of that 50%, 75% of those people had health insurance. Meaning that the insurance companies reached the end of the line and people were forced to make very difficult decisions. Saying it is a whiny teenager is to ignore the real human cost.
Look, this is the real world. Different people represent different risks based on factors as diverse as health history, demographics, and personal habits. If insurers are denied the ability to differentiate risk, then the basis for the existence of an insurance market vanishes, and instead what you are demanding is an unconditional indemnity service.
Yes - that's exactly my point - insurance will naturally progress to the point where only those of the lowest risk will be able to get it. That is the nature of trying to run a for-profit insurance industry.
But if we are serious about helping our citizens - which I am - then clearly you can't have a for-profit insurance industry because they won't help the people that need it.
What, a liar who claims he doesn't lie, but provides no evidence to the contrary? What are the odds?
Another jaw-dropping bit of anti-logic. If you think that 'I'm on brooksfoes's side', then why am I asking you for evidence that would, if it existed, _disconfirm_ my prejudices? It's one or the other, can't be both.
And I'll repeat: I didn't ask because I was interested either way; I asked because it looked as if you flat-out lied, just to score points. I didn't know for sure, which is why I asked instead of making an outright accusation.
But at this point, I'm totally comfortable with it. By all means, do continue to post; it's quite enlightening that those who are on _your_ side don't see fit to condemn your lying eyes.
And all of you 'libertarians' who are busy not kicking this guys teeth in for making you look bad? I'm saddened. Not surprised, but definitely saddened.
Should Megan adopt a policy for kicking known liars off this site?
How is this a competitive disadvantage?
Take a look at the healthcare costs that must be absorbed by US car manufactures relative to their Japanese counterparts. Pension liability is certainly another issue, but taking the healthcare costs off of private companies would allow them to focus on what is core to them - making a product - and get out of the healthcare business.
Let's also add the impact to small companies - the life-blood of America. When you're considering hiring an employee, you must factor in those costs in addition to every other cost. Now imagine freeing up that money.
Aggregate health-related statistics like life expectancy are essentially meaningless as measures of the quality or performance of a nation's health care system. It's like trying to judge the fuel efficiency of a car by looking only at its tires. There are so many other factors that have a much greater effect on aggregate measures of health--patterns of diet and exercise, smoking rates, violent crime rates, motor vehicle accident rates, pollution levels, etc., that using these stats to evaluate health care systems is meaningless.
I respectfully disagree - but I invite you to give me some examples for how we should measure healthcare. Access? Child mortality? Over to you.
In the same way that any other kind of insurance benefits the consumer. They protect people from certain kinds of financial risk.
Yes, that is the general definition of insurance. But it is pretty clear they don't protect people from financial risk.
Huh? So you're not in fact proposing to reduce our high medical care labor costs. You're apparently proposing to increase those costs, and pay for them with cuts in military expenditure. Is that it? I thought you wanted to cut our health care spending, not raise it. Your conflicting comments are very confusing.
I never proposed to cut healthcare costs - I proposed that we should provide healthcare to all citizens of America - similar to what every other OECD country in the world does. What I did propose is that we'd get some efficiency from getting rid of the healthcare insurance companies.
There is abundant evidence of rationing of health care in Britain and Canada. See, for example, Statistics Canada's most recent report on waiting times.
Yes, I've read those reports - but here's the important point - there is generally zero wait time for an emergency procedure. And all the countries are working to reduce the times for non-emergency procedures. Does this mean bad things don't happen? Of course not - but we should also remember the number of people in this country that die because of issues with the insurance companies. You will never be totally rid of such issues whether you have a private insurance approach or a public one.
dmwr,
No I actually agree with you on this - but my point is that healthcare issues usually aren't a choice like buying a house in a flood area. A person can elect to buy a house in a particular area - but a person cannot determine when they will be sick or how they will be sick. This is the essential reason I would argue that healthcare insurance shouldn't be in the hands of for-profit companies.
There are obviously many serious risks to a person's financial security besides poor health. You may total your car in a crash. Your house may burn down. You may be the victim of major theft. Your spouse and breadwinner may die or abandon you. You may become disabled and unable to work. Your investments may lose money. And so on and so forth. Are you proposing to eliminate for-profit private insurance against all these other risks, too, and replacement it with a mandatory, single-payer, non-profit government-run system?
Here's an interesting stat that I mentioned before: 50% of the people declaring bankruptcy are doing so because of a healthcare issue.
No they're not.
Now, of that 50%, 75% of those people had health insurance. Meaning that the insurance companies reached the end of the line and people were forced to make very difficult decisions.
People who are seriously ill will be forced to make very difficult decisions whether their health care is funded publicly or privately. Are you seriously under the impression that "single payer" health care systems have unlimited resources and will pay for any and every medical service that a person may want or benefit from? If so, you seriously mistaken. The limits on coverage under any serious government-funded health care system are likely to be at least as strict as those imposed by private insurers. Private insurers in America pay for all sorts of tests, drugs and surgeries that are simply not available under the single-payer health care systems in Canada and Britain, because those governments deem the tests or treatments to be too expensive.
Scent,
Stop lying and applying double standards, and I might be able to take you seriously.
"So let's review - their's been a sharp rise in demand, so cost has gone up. Ok - yet in Europe, where the median age is old than that of the US, they haven't seen costs increase despite an aging population."-dmwr
Yes, in the US heavy government spending has increased demand and pushed up prices. The UK and Canada (the systems I'm most familiar with) have held costs down essentially through price controls. And the result has been rationing.
"Again - I'll call for some data that points to rationing - I've seen zero hard evidence for it. Anybody got a paper on it?"-dmwr
I gave a link above showing long waiting times for surgery in British Columbia. Mixner gave another link. It would not be hard to find more, so it's just obvious that there's rationing going on in Canada.
"Free markets work very well in many cases, but even Milton Friedman would say that markets can create outcomes which are not ideal."-dmwr
Yes, and Milton Frieman was quite certain that the big problem in the health care market is excessive government interference, through extensive subsidies and regulations. As he once put it, "We have a Soviet system and get Soviet results." Anyone who wants to learn more about Friedman's excellent health care proposals can find them here:
http://www.hoover.org/publications/digest/3459466.html
I'm content to leave the field. As far as I'm concerned, the socialists have been routed. They are now reduced to mere insults or to repeating arguments that have been refuted many times.
Here's an interesting stat that I mentioned before: 50% of the people declaring bankruptcy are doing so because of a healthcare issue.
No they're not.
What's your source? Mine is the Harvard School Law Professor Elizabeth Warren based on her studies.
People who are seriously ill will be forced to make very difficult decisions whether their health care is funded publicly or privately. Are you seriously under the impression that "single payer" health care systems have unlimited resources and will pay for any and every medical service that a person may want or benefit from?
No - I don't think that's the case. Difficult decisions will always have to be made whether it is the government making the decision or private insurance companies. My proposal isn't to solve all the ills any system - my proposal is to provide access to health insurance for all Americans.
Private insurers in America pay for all sorts of tests, drugs and surgeries that are simply not available under the single-payer health care systems in Canada and Britain, because those governments deem the tests or treatments to be too expensive
You'd have to provide some backup to this claim - in England in particular - as I mentioned earlier, my step-father in a physician and in a highly specialized area (neurology) - and his patients have access to every test they have here in America.
Ah, Mixner is at the flinging feces stage I see. You've accused me of lying: what was my lie and what is your evidence? You've accused me of having a double-standard. Where I have I shown it?
No, you're just a two-bit liar who is not to be taken seriously. More significant is your function as the proverbial canary in a coal mine. Not one of the heroic personal-responsibility types has said, hey, this Mixner fellah is bad news.
I'm curiuos, rwe. The 'Socialists' being routed as you say is all well and good. But those doing the routing better not be flat-out lying.
Why don't you condemn people like Mixner? You've got to know they're only hurting your side.
dmwr,
Take a look at the healthcare costs that must be absorbed by US car manufactures relative to their Japanese counterparts.
Japanese car companies that employ American workers in U.S. factories are subject to the same health care environment as U.S. companies. American car companies are losing ground because of bad management and bad union contracts, not health care. American industry in general is among the most competitive in the world. American workers are among the hightest-paid in the world. The American standard of living is among the highest in the world.
I respectfully disagree
Then you're simply wrong. This isn't even a controversial issue. Public health researchers have long known that the kind of social, cultural and environmental factors I mentioned have a much greater impact on aggregate morbidity and mortality statistics than health care services. Smoking alone causes over 20 times as many premature deaths among Americans as inadequate health insurance. Poor diet and lack of exercise, another 20 times as many. Motor vehicle crashes, about twice as many. And so on and so forth.
- but I invite you to give me some examples for how we should measure healthcare.
A comprehensive comparison of health care system quality or performance would require measures of its effectiveness at the prevention, diagnosis and treatment of all major areas of disease and disorder. You can't say "higher average life expectancy = better health care system." It's idiotic.
Yes, that is the general definition of insurance. But it is pretty clear they don't protect people from financial risk.
Huh? So if you crash your car and your insurance company pays to fix or replace it, that's not protection from financial risk? If your house burns down, and your insurance company pays to build a new one, that's not protection from financial risk? If you need heart surgery and your insurance company pays for it, that's not protection from financial risk? As I said, your claims are getting increasingly silly.
I never proposed to cut healthcare costs
You cited our higher health care costs as if you think this is a bad thing.
- I proposed that we should provide healthcare to all citizens of America - similar to what every other OECD country in the world does. What I did propose is that we'd get some efficiency from getting rid of the healthcare insurance companies.
So, again, why aren't you proposing to scrap all private, for-profit insurance, not just private health insurance, if you think the government is better at providing insurance than private companies?
Yes, I've read those reports - but here's the important point - there is generally zero wait time for an emergency procedure.
This isn't true, either. As the Supreme Court of Canada found in the Chaoulli case, Canadians sometimes die while they're waiting for treatment. And emergency care is obviously not the only kind of health care anyway.
And all the countries are working to reduce the times for non-emergency procedures. Does this mean bad things don't happen? Of course not - but we should also remember the number of people in this country that die because of issues with the insurance companies. You will never be totally rid of such issues whether you have a private insurance approach or a public one.
Right. But I've never seen any remotely serious evidence that single-payer systems do a better job of satisfying the need and demand for health care services that private, for-profit systems. Rationing and waiting lists are not minor inconveniences in the British and Canadian health care systems, they are huge, chronic problems that cause an enormous amount of human suffering and misery. I might take proponents of single-payer health care reform more seriously if they showed any sign of a willingless to acsknowledge this problem and consider it seriously in evaluating the pros and cons of different health care policies. Instead, they tend to deny it, ignore it, or dismiss it as a quibble.
Scent,
You've accused me of lying: what was my lie and what is your evidence?
Sorry, but you accused me of lying first. What was my lie and where is your evidence? Pot, kettle, remember?
You've accused me of having a double-standard. Where I have I shown it?
I already told you. You demand links from me but not brooksfoe. That's a double standard.
Oh, and btw, I tend to believe folks like dmwr, because I can find confirmation - and quite easily too. For the bankruptcy figures, all I did was google on 'percentage of bankruptcy from health care issues'. This led me directly to sites like this one:
http://www.healthpolitics.org/program_transcript5qs.asp?p=insolvency2
Wherein you find quotes like this:
And there's literally dozens of sites there that say essentially the same thing. Here's another:
http://www.msnbc.msn.com/id/6895896/
The bottom line is, if you make an assertion, especially one you've 'researched' like Mixner says he has, you better be real sure you can back it up with cites, statistics, links, etc.
What's your source? Mine is the Harvard School Law Professor Elizabeth Warren based on her studies.
The Himmelstein medical-bankruptcy study published in Health Affairs, for example. And you appear to have misunderstood Warren. She didn't claim that "50% of the people declaring bankruptcy are doing so because of a healthcare issue." She claimed only that health care expenses are one factor (not the only factor, or even the biggest factor) in about 50% of bankruptcies. She made no claim that the bankruptcies would not have occurred in the absence of the health care expenses.
In fact, most of the costs arising from a lengthy period of serious illness are not direct medical costs that are covered by insurance, but indirect and uncovered costs. "Universal health care" won't pay your mortgage or your car payment if you are too sick to work. It won't pay for childcare for your kids while you're in the hospital or getting treatment. It won't pay for all sorts of out-of-pocket and uncovered expenses caused by your illness. At best, "universal health care" might modestly reduce the financial insecurity of a minority of Americans.
Scent,
Do you even read your own links? Neither of them supports the claim of dmwr's you're trying to defend. In fact, your first link explicitly contradicts his claim, giving a figure of only 28% of bankruptcies "specifically caused" by illness or injury. And even that number is highly dubious because it is based on self-reports rather than an objective analysis of actual bankruptcy filings.
Chuckle. This is too easy. Originally, brooksfoe said this:
And you replied:
At which point I asked you for your research, your cites, links, references, etc. You've refused to give them, not even so much as a google search line. So I conclude that you're lying. And, we all know, if you had those figures, you wouldn't have wasted any time posting them . . . as shown by the fact that you have posted other links.
Uh, no, I don't suspect brooksfoe has been lying. So I'm not asking him for evidence. What he is saying is in accord with what I've found, for example, from that socialist rage, The Economist:
And other people have said the same thing, that what you've 'found' in your 'research' is simply not what they've seen. So yes, you do need to put up cites when people ask - and you did make the original assertion, so the burden of proof is upon you. Refusing to do so raises the suspicion of confabulation. Accusing other people of partisan motives and using that as a justification for not backing up your assertions when requested (Anyone remember SNL's executive spokesperson for the smoking industry's scetch) just hardens the suspicion into certainty.
Chuckle. So all those people who declared bankruptcy, they would have declared it anyway even if there were no health care issues? Looking back at what dmwr, I also see that you're trying to put your own personal spin on what was said.
Now. You say you've got evidence that says otherwise. Put up or shut up.
ScentofViolots,
The bankruptcy stories all link back to Warren's paper. The problem with her study is that she set the bar unreasonably low for a health-care related bankruptcy. A Northwestern University followup determined that the data only justified a figure of 17%.
http://www.kellogg.northwestern.edu/research/chime/papers/myth_vs_fact.pdf
I agree with you that the US does a terrible job of providing healthcare to its poorest citizens. We clearly need to fix Medicaid, but I'm unconvinced that there is a moral case to be made beyond that. When discussing S-CHIP, Medicare, and the other programs for the middle class, it becomes a question of costs and benefits.
You and I disagree on how to achieve the best tradeoff between costs and benefits, but I think we can agree that there are reasonable arguments on both sides (Not that I hear the reasonable ones very often, but I'm sure they must exist).
Scent,
At which point I asked you for your research, your cites, links, references, etc. You've refused to give them, not even so much as a google search line. So I conclude that you're lying.
No, you asserted that I lied. You haven't shown that I lied. Since I didn't lie, this is terribly surprising.
Uh, no, I don't suspect brooksfoe has been lying.
Uh, no, what you "suspect" is irrelevant. The fact that you demand links from one contributor but not the other is an obvious double standard. As I said, you don't care about the truth. You only care about trying to confirm your prejudices. Any facts or evidence that conflict with your prejudices and that might lead you to reconsider your view is intolerable to you.
What he is saying is in accord with what I've found, for example, from that socialist rage, The Economist:
Nice try. What a shame you neglected to mention this statement from the same article:
As I said, the French health care system is a fiscal train wreck in progress. It is unsustainable. Already, the government has made some cuts, and has increased the share of costs paid by the patients, but it's not nearly enough. Without radical reform, the French health care system cannot survive.
Scent,
Chuckle. So all those people who declared bankruptcy, they would have declared it anyway even if there were no health care issues?
Chortle. No, not "all" of them, but probably most of them. In most bankruptcy cases where illness is a factor, other kinds of debt also contribute to the bankruptcy. Moreover, debt due to medical bills is only a fraction of total illness-related debt. Most of that debt arises from other effects of the illness--such as loss of income from the inability to work--that would not be covered even if we had "universal health care." This is why "universal health care" is not likely to do much to reduce the risk of bankruptcy, or even to reduce the risk of illness-related bankruptcy.
See the Dranove and Millenson study cited by heedless for further details.
Heedless, you and I may be closer than you think. I am not taking sides per se, you see; I am simply noting that one individual in particular is, to all appearances, flat-out lying.
Can we agree that people who lie, lie frequently and glibly are doing a terrible disservice to others who are arguing the same proposition, as well as behaving abusively towards people who are actually making an effort as opposed to pulling 'facts' out of nowhere?
My position, if I may be said to have one, is that much more needs to be done with prophylactic medicine. It not being the most profitable kind of practice, there is probably room for the government.
Further, I run 27 miles a week, walk at least that far over the same time period, watch what I eat, take my meds, schedule regular checkups with my doctor, where a seatbelt, etc. This is all in the name of prevention, mind you, and it has worked very well so far, despite a certain family history. Not that I've enjoyed it. So I fail to see why I should fork over money for people who smoke, don't exercise, drink and eat to excess, etc, except in the sense that I have no alternative otherwise, so I might as well go with the cheapest one. Which in this case probably means some sort of government intervention.
Riiight. So where's this evidence you say you have?
No, actually, the article I'm quoting from is here:
http://www.eriposte.com/health/other/healthcare_US.htm
In which it also says:
Gee, conflating funding issues with cost? Whadda surprise.
So why don't you cite your own 'research'? Could it be because you haven't actually, you know, done any? That you're parasitically relying on the links of others? Nah. Couldn't be.
The Himmelstein medical-bankruptcy study published in Health Affairs, for example. And you appear to have misunderstood Warren. She didn't claim that "50% of the people declaring bankruptcy are doing so because of a healthcare issue." She claimed only that health care expenses are one factor (not the only factor, or even the biggest factor) in about 50% of bankruptcies. She made no claim that the bankruptcies would not have occurred in the absence of the health care expenses.
I stand corrected - sorry for the misuse of the data.
Other points will have to be addressed tomorrow - off to dinner!
Gee, conflating funding issues with cost? Whadda surprise.
I didn't "conflate" anything. I pointed out that The French health care system is near bankruptcy. It's been running deficits continuously for 22 years. It cannot survive without radical reform. That means higher costs to patients, or reduced services, or both. Proponents of the French health care system invariably ignore the fact that it is simply unsustainable.
Really? It's unsustainable eh? Even thought the link I gave said precisely the opposite, that even if taxes were increased, the French system would still end up costing less than half of ours per person. And you have - once again - given no cites, no evidence of research.
Which brings me back to my original point - what I have seen agrees with brooksfoe, and disagrees with your bald assertion. That's why I posted my cite, and I'm not going to let you divert the topic away from your dishonesty. You claimed that the U.S. system had to cost more because it was better, and cited 'shiny new hospitals' and 'single unit rooms'. I posted a cite that says otherwise(and, I repeat, why I didn't think brooksfoe was in error or lying), and you have yet to post any research that backs your assertion up. And I am _quite_ sure that you haven't done any. You just lied because it was convenient and because you thought you could get away with it.
Detestable.
Scent,
Really? It's unsustainable eh?
Yes, really. Yes, it's unsustainable.
Even thought the link I gave said precisely the opposite,
The link you provided didn't say any such thing. Not that a link to a blog post constitutes any kind of serious reference, anyway. The French government's own commission on the state of its health care system concluded that the system would collapse within 15 years without fundamental reform.
Which brings me back to my original point - what I have seen agrees with brooksfoe,
Do please produce your evidence substantiating brooksfoe's factual claims. Not something that sorta, kinda sounds a bit like what brooksfoe said, but his actual claims. Since you apparently don't even read your own sources, and even cite references that explicitly contradict the assertions you cite them to support, it's not likely you have anything remotely resembling evidence.
You claimed that the U.S. system had to cost more because it was better, and cited 'shiny new hospitals' and 'single unit rooms'.
Now you're even making up quotes and attrbuting them to me. There's no end to your dishonesty.
Scent,
even if taxes were increased, the French system would still end up costing less than half of ours per person.
Yet another false claim. According to OECD data, France already spends more than half what we spend per person on health care.
And it can't even sustain that level of spending without significant tax increases or significant increases in uncovered costs to patients, neither of which is politically realistic.
The idea that the French health care system represents some kind of realistic, responsible alternative to the U.S. system is laughable.
SOV,
see:
"An essential part of the problem can be seen with simple supply and demand diagrams. The government since the end of World War II has been subsidizing healthcare expenditures heavily. That essentially shifts the demand curve out.
But, ceteris paribus, a rapid increase in demand will bring a sharp rise in price. Now, the favorite solution on the left is to impose price controls. But as every economist knows, price controls bring shortages and rationing--as seen in Canada and the UK.
So the irony here is that the problem has been created by too much government interference in the health care market--and dmwr and others are prosposing to fix it with still more government interference.
Some of us would rather go in the opposite direction: toward more freedom and more competition to increase quality and bring down price. It's a shame so many so-called "liberals" are so quick to surrender their liberty for the dubious benefits of a bureaucratic system when free market solutions are waiting to be tried.
"The God who gave us life, gave us liberty at the same time."-Jefferson 1774
"I would rather be exposed to the inconveniencies attending too much liberty than to those attending too small a degree of it."-Jefferson 1791
Thomas Jefferson must be turning in his grave.
Posted by rwe | January 5, 2008 3:53 PM
we need less gov't interference, less taxation to fund it, and more choice.."It's a shame so many so-called "liberals" are so quick to surrender their liberty for the dubious benefits of a bureaucratic system when free market solutions are waiting to be tried."
Yeah, 'raising taxes' is 'fundamental reform'. _You_ don't get to define words, bud. Further:
Riiiight. Who said this:
Do you even pay attention to what you write? Now, I quite plainly stated that you said that the American system of single-payer health care for all would cost more because they demand shiny new hospitals and private rooms. I quoted you. Your move. Or is this where you go with semantics, where you say "but I also said higher level of services, and you didn't say that".
Go ahead. And while you're at it, produce your evidence. For a change.
If you don't, I'm signing off, because, quite frankly, you ain't worth any more of my time.
I think I've more than amply demonstrated that you will say whatever you think suits the circumstances, damn the truth, damn research. And I will quite cheerfully point this out on further threads.
I don't know much about the French system, but it's pretty easy to find out about the long waiting times for surgery in Canada. Look here, for example...
rwe: Americans without insurance -- something that's not possible by law in Canada -- may wait indefinitely for surgery unless they can pay out of pocket. Not many uninsured Americans can.
The most pertinent fact about the French health care system is that it is headed for bankruptcy, like Medicare in the U.S.
Mixner: Highly unlikely. Allowing people to go without medical insurance is not politically feasible in France. It's not politically feasible in the United States, either, when it comes to old people.
Scent,
Yeah, 'raising taxes' is 'fundamental reform'.
No it isn't. The problems with the French health care system identified by the commission were not simply its grossly inadequate funding, but fundamental structural and managerial problems, producing gross waste and abuse.
But do get back to us when the French people have voted to raise their taxes sufficiently to stop their health care system from going bankrupt. The commission issued its report 3 years ago, and they still haven't done it. Nor does it seem remotely likely that they will in the foreseeable future. It was all Sarkozy could do to enact modest, and totally inadequate, increases in patient fees and co-pays. There isn't the remotest sign that the political will exists in France to make the huge sacrifices necessary to rescue its health care system from fiscal oblivion.
Jasper,
Americans without insurance -- something that's not possible by law in Canada -- may wait indefinitely for surgery unless they can pay out of pocket.
Anyone in any country "may" wait indefinitely for a surgery. The important questions have to do not with what is merely possible under various policies, but in how different policies actually work in practise to satisfy the needs and demands of the population. Different policies have different kinds of strength and weakness. American health care policy tends to stress choice and excellence, whereas Canadian/European policy tends to stress equality and uniformity.
Highly unlikely.
It's not merely likely. It's undeniable fact. The French health system has been in deficit every year since 1985, and there's no sign that it will become solvent in the foreseeable future. It is indeed "headed for bankruptcy."
Allowing people to go without medical insurance is not politically feasible in France.
Neither are the massive tax increases or massive user fee increases necessary to sustain current levels of service. The most likely scenario is that in the future the French will end up paying more and more for less and less. They simply cannot continue the way they've been going for the past generation without bankrupting the government.
Ah, I see that Mixner still can't seem to come up with any of the 'research' he has claimed to have done, and that now, ending fraud and abuse is considered a fundamental reform. Ooooookay.
For those who actually want to have a discussion rather than rattle off talking points: It's been claimed that one of the reasons for drastically rising health care costs is the cost of new procedures, which makes a certain sense. What is not looked at so much in these discussions is how those costs are distributed over the course of a life:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1361028
A few quotes:
"Per capita lifetime expenditure is $316,600, a third higher for females ($361,200) than males ($268,700). Two-fifths of this difference owes to women's longer life expectancy. Nearly one-third of lifetime expenditures is incurred during middle age, and nearly half during the senior years. For survivors to age 85, more than one-third of their lifetime expenditures will accrue in their remaining years."
and:
"The distribution of health care costs is strongly age dependent, a phenomenon that takes on increasing relevance as the baby boom generation ages. After the first year of life, health care costs are lowest for children, rise slowly throughout adult life, and increase exponentially after age 50 (Meerding et al. 1998). Bradford and Max (1996) determined that annual costs for the elderly are approximately four to five times those of people in their early teens. Personal health expenditure also rises sharply with age within the Medicare population. The oldest group (85+) consumes three times as much health care per person as those 65–74, and twice as much as those 75–84 (Fuchs 1998). Nursing home and short-stay hospital use also increases with age, especially for older adults (Liang et al. 1996)."
I don't see how this can get any better, in fact, only worse as medical technology advances. It might be possible in the future to keep a ninety-year-old alive indefinitely on 'liver machine', for example, but such a hypothetical machine could easily cost tens or hundreds of thousands of dollars a day.
So there's got to be rationing, but I would suggest some sort age-related rationing. A four-year-old suffering from leukemia? By all means, spend the money. The ninety-year-old suffering from liver failure? Sorry, Mom.
That's one of the reasons I like to push preventative medicine, btw. I don't have a cite handy, but there are lots of studies that show that taking care of yourself now, at the cost of a few dollars a day, will save thousands and thousands of dollars at the far end.
Would having age-related cut-offs be feasible? Or is this some sort of nutty sf scenario?
Here is a recent (November 07) Canadian Medical Association Journal article on the "hard choices" facing the French over their health care system. Quote:
That's one of the reasons I like to push preventative medicine, btw.
A nation's "health care system" plays only a small role in preventing illness and premature death. Therefore, investing large sums of money in "preventative medicine" would be highly wasteful. The best investments for reducing illness and premature death are investments in public health measures, such as anti-smoking measures, healthy diet and execise measures, anti-drug-use measures, and so on. Paying for more people to go to a doctor so he can tell them to do what they already know they should do (quit smoking, eat more vegetables, join a gym) would be an incredibly wasteful use of limited resources.
This is one reason why the obsessive focus of liberals on "coverage" or "access" to health care is so misplaced. Cutting the rate of smoking in half via higher tobacco taxes, greater restrictions on advertising and sales, harsher penalties for violating smoking bans, etc, would do far more to improve the health of the nation than giving health care "coverage" to everyone.
Public health measures like anti-smoking campaigns _is_ preventative medicine. Dumbass. On top of being tagged as a known liar. Why don't you do somewhere else where you can bloviate about 'liberals'? The grownups here are trying to have a serious discussion.
"Would having age-related cut-offs be feasible? Or is this some sort of nutty sf scenario?"
isn't Oregon handling their 'health care' scene along these lines?
"This is one reason why the obsessive focus of liberals on "coverage" or "access" to health care is so misplaced. Cutting the rate of smoking in half via higher tobacco taxes, greater restrictions on advertising and sales, harsher penalties for violating smoking bans, etc, would do far more to improve the health of the nation than giving health care "coverage" to everyone."
X2
Paying for more people to go to a doctor so he can tell them to do what they already know they should do (quit smoking, eat more vegetables, join a gym) would be an incredibly wasteful use of limited resources.
Basically every time I go to a doctor, it's because I or my kids have a bad spell of illness which might or might not require medication or more intensive treatment, and I need a professional to assess that. For instance, my son stepped on a sea urchin and is limping. Will it go away, or does it require an operation to remove a fragment? My daughter has a hacking cough. Will it go away, or does it require antibiotics? The doctor's visit costs $80 a pop. At that price, I or someone who earns less than me will skip some of those visits, running the risk that the foot will become infected and require serious surgery or, god forbid, amputation; that the cough will develop into pneumonia; etc. At that level, obviously, the insurance will start to pay for the thousands of dollars in treatment required, where they wouldn't have paid for the $80 doctor's visit that could have prevented it.
In fact, my insurance has a deductible of 0, so I visit the doctor every time it doesn't seem like too much of a pain in the ass. I don't go in every time my daughter has a cough - who needs that? I go in when she's hacking up something green or yellow for several weeks. Hence, no pneumonia so far.
Studies show that people in the US visit doctors less often for necessary treatments than people in Australia, which has universal government-provided health care. (And a thriving economy, btw.)
We need to shift our health system towards incentivizing doctors to keep patients healthy. Nothing in the fee for service system provides a fiscal incentive to keep patients healthy.
we need less gov't interference, less taxation to fund it, and more choice. - MEH
If you live in the US and have employer-provided health insurance, you have no choice. You have to take the plan your employer offers, and you can only go to the doctors who accept your plan. In the Netherlands or France, you can go to any doctor you want.
The employer-sponsored private insurance system restricts customer choice. Single payer insurance, or systems where the government mandates that all doctors must accept all insurers, offers customers choice.
"employer-provided health insurance" started, in the US, as a tax-dodge.
"employer-sponsored private insurance system restricts customer choice" no question.
"Single payer insurance, or systems where the government mandates that all doctors must accept all insurers, offers customers choice." at what cost?
If we could unbuckle the Medical-Industrial Complex from the teat of Gov't, we'd see costs drop..Lasix eye surgery, since most of the expenditure for it is born by the patient, is probably the best example..
Mixner: Americans demand a much higher level of coverage. They want shiny new hospitals and private rooms.
Me: Compare hospital rooms in France and the United States, and the length of stay by people who are covered in both countries.
Mixner: I have.
Then, Mixner, you found out you were wrong. The average length of hospital stay in the US and France was identical in 2002. (http://www.health.gov.au/internet/wcms/publishing.nsf/Content/C7AC35AC391AF8EACA25718D00813967/$File/chapter7-sect12-chart64.html) More to the overall point, the US's length of hospital stay, 5.7 days, was far below the OECD average of 7.3 days - much shorter than the Netherlands, Germany, etc. Apparently US customers are not demanding to stay in hospitals more than people in these countries, which have health expenditures around half as high as ours yet produce better health outcomes. This citation from the International Journal of Health Services may also be apposite:
"Patients with comparable medical conditions were studied; U.S. patients stayed in the hospital for 8.8 days on average, Japanese patients for 25.0 days. The average total charge of hospitalization was 2.3 times higher in the United States than in Japan."
http://baywood.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,9,10;journal,37,149;linkingpublicationresults,1:300313,1
To the quality of hospital rooms in different countries, our experiences have apparently been different. The hospitals my wife and friends have stayed in in the Netherlands have been aesthetically far superior to the ones my grandparents experienced in suburban New Jersey, and are equalled only by newer wings in a Manhattan hospital where a friend works. Again, cost of care in the Netherlands is half that in the US.
Same thing as with Mixner: where's your evidence? I's sure you wouldn't lie about having it, right? I'm sure that you wouldn't say something just because you thought it helped the cause, that in fact, you've actually done the research, and that you've got links, cites, etc. Right?
You must spend the majority of your time tutoring boys in the 5-8yo age group; nowhere else in civilized dialog does one find such a persistent and abusive misapplication of "Oh yeah?/Prove it!/You're lying!/No, you're the liar!" etc.
In any case, your pretense of having fallen off yesterday's turnip truck and smack into this debate isn't going to work this time; your previous efforts to fertilize this website are well-known to any of the regular visistors. Want proof? Forget links; let's start with just this thread:
"lie" (SOV, 4:33pm)
"shown to be a liar" (SOV, 4:53pm)
"stone liars" (SOV, 4:56pm)
"a liar who claims he doesn't lie...lying eyes...known liars" (SOV, 5:30pm)
"two bit liar" (SOV, 5:55pm)
"flat out lying" (SOV, 5:59pm)
"conclude you're lying" (SOV, 6:47pm)
"flat-out lying...lie, lie frequently and glibly" (SOV, 7:20pm)
"you just lied" (SOV, 7:46pm)
"tagged as a known liar" (SOV, 9:31pm)
This doesn't even begin to cover insinuations of dishonesty, open insults, and a wide variety of car-bomb styled character assassinations contained in your posts, just in this thread. So here's my first and only offer to you: let me know which fine state institutions you are presently confined to, and I'll send you a nice card twice a year.
I agree, this is an awesome paragraph. I printed it and put it on my wall.
I only have time for one comment today...
Huh? So if you crash your car and your insurance company pays to fix or replace it, that's not protection from financial risk? If your house burns down, and your insurance company pays to build a new one, that's not protection from financial risk? If you need heart surgery and your insurance company pays for it, that's not protection from financial risk? As I said, your claims are getting increasingly silly.
I continue to have the same problem with medical insurance in particular. Here's my issue: if you let the insurance companies price according to risk, there will be a segment, particularly with health care insurance where the costs are so extreme, where they will not provide coverage. This will be particularly true for people with a pre-existing condition - where turn-downs happen all the time.
So my question is this: what do we do with those people? What do we do with the 50 year old woman diagnosed with breast cancer, now in remission, when she can't get coverage and then she has a reoccurance?
Looks like Brooksfoe's 10:20pm comment about the excellence of French hospital care compared to the US has left Mixner without a rejoinder. Nice way to call B.S., Brooksfoe!
Should that figure change with age? A fifty-year-old (have to check that stylebook) with breast cancer still has many familial responsibilities, people who depend on her, etc. She might even be a parent without having had the chance of being of grandparent . . . and grandparents can be good people to have around. Iow, her illness and death could have a severe economic as well as emotional impact on those closest to her.
Otoh, a woman aged 85 probably already requires more help than she gives, and in all probability, is more of an economic liability than an asset to her family.
I don't mean to be cold. But I do suggest that one not only has to evaluate risk, but reward, the same as in any other gamble. Would I risk a dollar on a 10-to-1 shot on a $50 lottery prize if economic gain is my only objective? I would hope not? Would a wager $100 at 100-to-1 odds that I would win $100 million? Certainly.
But this can very quickly become a very complicated argument. I would add one caveat though: in any form of rationing in the context of a national health program, personal wealth should not be a determinant in who gets how much of what medical resources(of course, we wouldn't deny, say, a liver, to someone merely because they happened to be rich, famous, or powerful.)
Happy, I don't think this is a matter of socking it to the other guy because he's 'on the other side'. And it is most certainly not a matter of rejoicing that the wicked have been smited. This is about maintaining minimum standards. This is about following the rules of discussion, of basic debate and rhetoric. And it is my personal opinion that we all have a responsibility to police these sites to make sure those rules are followed. Allowing people who one strongly suspects of making stuff up just to win a few few points get away without documenting their research degrades all of our efforts.
My take, btw, probably comes from the fact that I am a teacher. One of my duties which I really deplore is to make sure my kids do their homework. I can't tell you how many times I've handed back homework only to have some slacker ask with a look of wide-eyed innocence why he didn't get his back. Well, son, probably because you didn't turn it in. At which point some of these gonifs will threaten to call their parents, as well as demand that I prove that they haven't submitted their assigment. Infuriating.
And some of them will try this up to three times over a sixteen week semester where homework is submitted weekly!
SOV,
Here are a few links on Oregon's Medicaid program..they went through many of the typesof Q's you are alluding to..
http://www.amazon.com/phrase/Oregon's-Medicaid/ref=cap_bod_1
http://www.cmaj.ca/cgi/content/full/164/11/1583
"...an Oregon state representative introduced legislation to restore Medicaid funding for bone marrow transplants. However, the bill was opposed by John Kitzhaber, a former emergency medicine physician and then president of the state senate who later became Oregon's governor. Kitzhaber noted that in Oregon, as in all other US states, substantial segments of the population were uninsured and lacked coverage for even the most basic medical services. Kitzhaber contended that, in this context, it made little sense for the state to pay for costly services, such as transplants, that would benefit relatively few Medicaid recipients. He argued that, although Oregon could not conceivably afford to pay for every medical care service for every person, it could expand insurance to cover all the uninsured while controlling expenditures if it was willing to ration care.2
In 1989, the Oregon legislature enacted a health reform bill sponsored by Kitzhaber that aimed to extend insurance coverage to all Oregonians. The bill contained 2 major provisions: a mandate for private employers to provide their workers with health insurance and an expansion of the state Medicaid program to cover all people in the state below the federal poverty line. At the time, Medicaid covered only 42% of low-income Americans, and other states had been tightening eligibility requirements in response to growing program expenditures, thus adding to the already substantial ranks of the uninsured in the United States. In contrast, Oregon pursued a "pincer strategy" of expanding both public and private sources of medical insurance to produce a system of universal coverage. Oregon's employer mandate, which was beset by business opposition and hampered by the election of a conservative Republican legislative majority in 1994, never received the federal waiver necessary for its implementation. Consequently, Oregon's aim of achieving universal coverage, which is something that no US state has yet attained, was not met. Yet the state's Medicaid reforms, after considerable national debate, were approved by the Clinton administration, and the OHP began operation in 1994."
"OHP began operation in 1994."
Scent,
Public health measures like anti-smoking campaigns _is_ preventative medicine. Dumbass.
No, anti-smoking campaigns are not "medicine" of any kind. Moron. The vast majority of public policies influencing the health and lifespan of national populations have nothing to do with "medicine" or the services provided by a nation's "health care system."
brooksfoe,
Studies show that people in the US visit doctors less often for necessary treatments than people in Australia, which has universal government-provided health care. (And a thriving economy, btw.)
Studies show that there is very little relationship between health insurance or health care "coverage" and health. The landmark Rand Health Insurance Experiment found little difference in health "outcomes" between individuals with high-quality insurance who consumed lots of health care resources, and groups with low-quality insurance who consumed much less health care resources. In the aggregate, most of the services provided by a nation's "health care system" just don't make much difference to the health of its population. The primary determinants of the health of national populations, as I have explained, are social, cultural and environmental factors such as patterns of diet and exercise, rates of smoking, alcohol consumption and drug use, accident and crime rates, pollution and safety standards, and so on.
The Institute of Medicine estimates that around 19,000 Americans die prematurely each year as a result of inadequate health insurance. More than 400,000 die from the effects of smoking. Another 400,000 die from the effects of poor diet and lack of exercise. Around 36,000 die from motor vehicle accidents. Around 18,000 die from use of illicit drugs. And so on and so forth. It is clear that lack of health insurance is a very minor contributor to illness and premature death in the United States. Other factors have a much, much greater effect.
The evidence is overwhelming that "universal health care" would do little to improve the health of the U.S. population or to increase its average lifespan. In order to significantly improve these things we need to get people to change their behavior, not pay for them to have more and more expensive and wasteful high-tech tests and drugs and surgeries.
The kind of health care interventions that do make a difference are the cheap, basic ones that have been around for decades and that are already available on a universal or near-universal basis--vaccines and antibiotics.
dmwr,
I continue to have the same problem with medical insurance in particular. Here's my issue: if you let the insurance companies price according to risk, there will be a segment, particularly with health care insurance where the costs are so extreme, where they will not provide coverage. This will be particularly true for people with a pre-existing condition - where turn-downs happen all the time. So my question is this: what do we do with those people?
We handle these people in a variety of ways. First, we limit the ability of insurers to exclude people on the basis of pre-existing conditions. Second, we provide free or heavily subsidized health care for uninsured persons. Third, we provide government insurance programs, such as the federal Medicaid and SCHIP programs, and a large number of state and local programs.
What do we do with the 50 year old woman diagnosed with breast cancer, now in remission, when she can't get coverage and then she has a reoccurance?
Provide her with treatment under the federal Breast and Cervical Cancer Prevention and Treatment Act, for example.
You either believe health care is a right, something that you should be guaranteed as a citizen of one of the most prosperous, technologically and philosophically advanced nations on the planet; or you believe that health care should be apportioned by the free market, in which case there are winners who get care and losers who do not (because inevitably that's what happens in the free market).
That's what this debate boils down to.
brooksfoe,
I'm not sure what point you think you're making about hospital stays. Your unstated assumption seems to be "longer hospital stay = better health care." I have no idea why you think this. Obviously, a shorter hospital stay may indicate superior health care (faster diagnosis, treatment and recovery, less-invasive surgical procedures, lower rate of surgical complications, more sophisticated outpatient care, etc).
This may be the place where all the non-libertarians conclude that I'm out of my mind, but SOV's comment that the smoking ban is a public health measure scares the hell out of me.
This is one of the biggest problems with any sort of government provided healthcare (at least from my perspective). When the government is paying for your visits to the doctor, it suddenly has a compelling interest in forcing you to stay healthy. I don't know about the rest of you, but I had my fill of government mandated behavior while applying for my driver's licence. I'd rather they didn't turn the same cheerful, can-do attitude to directing my exercise regimen.
"You either believe health care is a right, something that you should be guaranteed as a citizen of one of the most prosperous..."
-liberalrob
lr, try a little reality in your diet..
""...recently wrote a synopsis of the review of the consolidated fiscal 2007 financial statement of the United States which was recently released, and notes that, "For the 11th year in a row, Comptroller General David Walker, the Nation's Chief Auditor, stated that the GAO [Government Accountability Office] could not give an opinion on the government's financial statement."
Mr Walker's actual statement was, "Because of the federal government's inability to demonstrate the reliability of significant portions of the US government's accompanying accrual basis consolidated financial statements for fiscal years 2007 and 2006, principally resulting from certain material weaknesses, and other limitations on the scope of our work, described in this report, we are unable to, and we do not, express an opinion on such financial statements.""
That's what this debate boils down to.
No, it really doesn't. "Health care is a right" is the kind of vacuous slogan chanted by liberals to make themselves feel good, but it means virtually nothing in terms of concrete policy. How much health care do people have a right to? An unlimited amount? If you've had two rounds of expensive chemotherapy, and your cancer still hasn't gone away, do you have a "right" to a third round? A fourth? Do you have a "right" to all the latest drugs and tests, no matter how expensive and how small their marginal benefit? Does an 80-year-old man have a "right" to a $200,000 heart operation that will likely extend his life by only a few months? Do illegal immigrants have the same "right" as lawfully-resident Americans, or only a lesser right? What about people in other countries? Do they also have this "right?"
Resources are limited. Responsibilities are limited. So where do you draw the line? Describe clearly what level of "health care" you think people have a "right" to, and why, and which groups of people this "right" applies to, and then we might have a basis for a meaningful discussion.
Why is it conservatives think deficits are just fine and dandy and don't matter one bit when they arise from cutting taxes or funding wars, but when they arise from providing healthcare suddenly they are about to bring about the collapse of civilization?
MEH:
So are you saying we're NOT one of the most prosperous, wealthy countries on the planet? Are we in fact a Third World nation now, and therefore cannot afford to guarantee health care to all citizens? Perhaps if we're so badly off financially, we should stop giving tax breaks to the wealthy, reduce subsidies for corporations and revisit our spending priorities.
Mixner:
Sigh, we've gone over this a dozen times before. My conception of "single payer" is your doctor recommends a course of treatment, and if you agree you want it, the government pays for it. That's it, end of story. If you want to introduce all sorts of restrictions or "guidelines" on what a doctor can recommend and what the government will pay for, we can have that debate but let's be clear: you want to restrict the health care choices of people who need it. I want to expand them and extend them to all citizens.
Are they citizens? I distinctly remember saying "citizens" up there in my post...yep, there it is alright. That said, I'm sure we can come up with some minimal, humanitarian provision of health care to even illegal immigrants. We're certainly able to rationalize the expense of building costly Berlin-Wall-style barriers on our borders.
We seem to have plenty of resources to finance foreign adventures in nation-building. We have the resources to finance the world's largest "defense" operation. But oh no, bring up health care and suddenly we're too poor to do anything? Gotta be fiscally responsible, you know. Good grief.
No, we won't, because you're just going to deny the legitimacy of anything I argue; after all, I'm a "vacuous slogan"-spouting liberal who really just wants to make myself feel good. What's your definition of "describe clearly," and do I have any reasonable expectation of meeting it? I have stated my position very clearly in many other threads on this site; I'm pretty sure you've read them. In any case, I'm sure you would invent some justification for belittling anything I say, as rwe and others have done in the past. For example, I am not a health professional; therefore since I am not a medical doctor I am not qualified to speak intelligently on health care (or for that matter, any subject whatsoever).
They don't.
Why do liberals want to emulate a health care system that has been in deficit every year for the past 22 years and that its own government predicts will collapse within 15 years unless it is radically reformed?
liberalrob,
My conception of "single payer" is your doctor recommends a course of treatment, and if you agree you want it, the government pays for it.
Utterly absurd. We cannot possibly afford to pay for any and every test, drug or surgery a doctor is willing to recommend. No health care system in the world does that. No health care system possibly could do it. Your policy ideas aren't just misguided, they're economically ludicrous.
Here's an idea. Let's pay for everyone to get an MRI scan once a month. This would dramatically increase our rate of early detection of cancer, which would likely lead to a dramatic decrease in cancer mortality. Let's see: $2,000 per scan, times 12 months in a year, times 300,000,000 Americans. So we can do this for a mere $7.2 trillion a year! Since money is no object to you, I assume you think this is a great idea.
Why do liberals want to emulate a health care system that has been in deficit every year for the past 22 years and that its own government predicts will collapse within 15 years unless it is radically reformed?
If you're referring to France, because it gives superb health outcomes more cheaply and humanely than our own.
"we should stop giving tax breaks to the wealthy, reduce subsidies for corporations and revisit our spending priorities."-lr
actually, we Should give tax breaks to more members of our Society. We are, hardly, under-taxed. And, yes, we should reduce incentive distorting(all) subsidies of any stripe, to any entity, and, for sure, revisit our spending priorities, with an eye toward reducing them, dramatically, over time.
"We seem to have plenty of resources to finance foreign adventures in nation-building."-lr
This, above, is, Cardinally, a bad idea that sows little, but ill will.
"We have the resources to finance the world's largest "defense" operation."-lr
Is another debatable proposition, and, most likely, is untrue. Seems we'd be better off putting, even, the DoD on a fiscal diet.
lr,
It's truly amazing to run into so many who think that being ~U$D55 Trillion in the hole is a sign of 'prosperity'..
Jasper,
If you're referring to France, because it gives superb health outcomes more cheaply and humanely than our own.
First, you have offered no evidence that the French health care system produces "superb health outcomes." And please don't give me the nonsense about average life expectancy and infant mortality rate. Those numbers are not "outcomes" of the health care system, but outcomes of a huge set of socioeconomic and environmental influences, from dietary patterns to drug use to accident rates, of which health care is just a small part. The idea that you can judge the quality of a nation's health care system by looking at aggregate health indicators like average life expectancy is like the idea that you can judge the quality of a car's tires by looking at its top speed. It's meaningless.
An example of a statistic that does represent an "outcome" of the health care system is cancer survival rates. And U.S. cancer survival rates are significantly better than those of Europe, including France. If you get cancer, you are significantly more likely to survive if you live in America than if you live in Europe.
But more importantly, it doesn't matter how good the "outcomes" of the French health care system are, because the system is, in the words of the French government commission, "on the verge of collapse." It's going bankrupt. It has spent more money than it takes in every year for 22 years, and the debt is getting bigger and bigger. You can't keep spending money you don't have. Unless there are substantial cuts in services, or substantial increases in taxes or fees paid by French citizens, or both, the French health care system will collapse. They're obviously not going to let it collapse, so a reduction in quality and/or an increase in taxes and fees is inevitable.
May all those of you who think the present system is just dandy a) lose your health insurance b) develop a "prior condition", and c) try to get future health insurance. After my last several years dealing with the idiocies of the US insurance maze, I'm seriously thinking of moving back to Japan or the U.K.--both places where I lived sufficiently many years, by the way.
Wasn't there a little bit in the Constitution about "the common welfare"? Too bad libertarians and conservatives always forget this clause.
Let's take some of that money that we're so willing to spash around on missiles, wars, and the entire rest of the military budget and use it to fund a good medical system for Americans, ok? I'd much rather my taxes went to fund a decent, good, predictable National Health System rather than all the military junk that doesn't seem to be doing us any good anyway.
May all those of you who think the present system is just dandy a) lose your health insurance b) develop a "prior condition", and c) try to get future health insurance.
I don't think the present system is "just dandy," but I do think it's better than single-payer or any other kind of dramatically different system would be.
But to throw your charming ball back at you: May you move to Britain or Canada or France, develop a medical condition, and then get put on a waiting list to receive treatment at some undetermined future date. May you be denied a drug or test or surgery you need for your condition because the government deems it to be too expensive.
"May you be denied a drug or test or surgery you need for your condition because the government deems it to be too expensive."
Yes, because medical expenses are never a problem for people in the United States, where everyone is super rich.
MEH said:
"employer-provided health insurance" started, in the US, as a tax-dodge.
Actually, employer provided health insurance started, in the US, as a price controls dodge during World War II. Companies waqnted to compete for scarce labor and couldn't offer more money but the labor board did allow fringe benefits.
It would be ironic if we replace one long-term unintended consequence of a government intervention in the marketplace with another intervention.
-dk
No it isn't. I'm quite serious.
Really? And you know that how? Or do you simply "know" it?
Time to reclaim America's role as a world leader.
Yeah, nobody could exceed the speed of sound, either. And the speed of light is a constant.
No, they're not. Over to you. This promises to be a very meaningful discussion indeed.
Would it really? Is there a large, reputable organization of medical professionals advocating this? Is there a body of peer-reviewed research showing that monthly MRIs are required for effectual early detection of cancer?
Or are you just constructing another in a long, long line of strawmen to knock down because what you really object to is "your money" going to pay for other people's health care?
Why does an MRI scan cost $2000? Why doesn't it cost $20? Why isn't it free, after the cost of purchasing the equipment is fully amortized?
Are you saying we need to give MRIs to newborns (which is how you arrive at the 300,000,000 figure)? Is that really necessary? Or in fact is it more likely that an annual or even biannual scan might be sufficient, and only starting at (say) age 40 for people with high risk factors? Isn't it more likely to cost in the millions than in the billions? Can we build a few less useless fighter planes in exchange for meaningful health care?
In your pathetic zeal to construct an absurd case with which to reject single-payer health care, you casually throw rationality to the winds. How sad.
1) the same argument can be made vis a vis the United States Postal Service. We have made a decision as a society that having universal postal service is preferable to having a "free market" in postal service where some areas of the country would have poor or no service due to it being economically non-viable. Instead we do from time to time re-examine the Postal Service and reform it; and miraculously the service has still not collapsed. Why can we not make the same decision as a society to provide health care to all citizens regardless of ability to pay?
2) your underlying false assumption is that the "radical reforms" required to sustain the French system will not occur. As Yoda said, "so certain are you." Somehow I doubt the French will allow their system to collapse. I predict they will find a way to sustain it, as we will find a way to provide full Social Security benefits after 2041.
Really? So if I go to the Indianapolis 500 where the top speeds are over 200 MPH, I can't determine that they are using higher-quality tires than those on my 1929 Model A? It's just as possible that an Indy car will be rolling 40k-rated passenger radials with 50k on them as brand-new racing slicks?
In fact, you CAN make some judgments about the quality of a car's tires by looking at its top speed, if you actually measure performance over time. And you CAN make judgments on the quality of a national health care system based on "outcomes" and "aggregate indicators," if that's the criteria you use to define a successful health care system.
So, Mixner, how do YOU evaluate the quality of a nation's health care system? The size of the CEOs' year-end bonus checks?
But don't you see, that would give the green light for the Islamofascist hordes to pour over our borders, kill us all in our beds, convert us to Islam and put us under Sharia law; Osama's navy would be launching nuclear missiles at us within hours; and the Chinese would invade and conquer us and make us all learn Chinese, and the Russians would invade us and make us all learn Russian and worship Stalin, and the Mexicans would invade us overtly and reannex the southwest, declare Aztlan and make everyone learn Spanish; those of us who weren't killed in our beds, glowing with radiation and praying to Mecca in Mandarin Chinese, at any rate.
We're like the survivalist in Highlander: "I got a trunkful of M-16s, hand grenades, and ammo out the a$$; and I ain't safe! I can't protect myself!"
Re: And U.S. cancer survival rates are significantly better than those of Europe, including France. If you get cancer, you are significantly more likely to survive if you live in America than if you live in Europe.
This is incorrect. Americans tend to be diagnosed sooner with certain cancers (e.g., prostate), thus giving them longer survival periods until the disease runs it course.
Re: You can't keep spending money you don't have.
I asked this question above but with no reply: if deficits are a source of ruin, how to explain the odd survival of the entire US government for decades of deficit spending.
Now here's a further question: most people who lack health insurance in the USA are young and healthy. Why would it break us to provide them with that coverage and in turn require a reasonable contribution based on income? Seems to me that most such people would then be net payors into the system, albeit only by rather small amounts since they are also people of modest means.
Somebody should teach Tyler some English. Stat. Some of his points cannot be read without a pain in the belly, esp. the end of #1.
And if Megan his post is the best of the year, that boulder you see falling is the respect I used to have for Megan's opinion.
Liberalrob, I don't think of health care as some sort of right. It is, however, a commodity that is generally agreed that almost everybody needs. The question is, how does one deliver it? Through, roughly speaking, some sort of private market, or through the aegis of the government in any of it's various incarnations?
My political/economic philosophy, what little there is of it, is to try market or quasi-market solutions first, admitting the role of government only if the outcomes seem less than optimal. A sort of minimize the damage consideration, if you will.
And I think in this particular instance, using reasonable, generally agreed-upon metrics, the health care industry has failed rather spectacularly to deliver optimal outcomes. Also, there seems to be an excellent causal mechanism that adequately explains this failure, an explanation, furthermore, that pretty much precludes any self-imposed reformation. Finally, there are other models that have actually been implemented in other countries that seem to confirm this appraisal.
Iow, I look at health care reform not as an entitlement, but as a correction to a fundamental market failure. To return to your post:
I think it's not a matter of 'rights', but as a conflict between those who think (or say they think) the so-called 'free market' solution is always the best solution, and those who don't.
I imagine the same people arguing for free markets in this discussion, those who are willing to throw any facts or arguments against some sort of national health care regardless of whether they are true are not, are precisely the ones who would have argued in 1906 against the Wiley act, that 'The Jungle' was a nasty piece of sensationalism, that the meat packing industry would 'voluntarily' come up with their own standards of hygiene and quality that would be far superior to anything the government could enforce.
Uh-huh.
They will always be with us.
Well, I'm definitely not a libertarian any more, and I don't much like it. Mandating seat-belts, yes. Those who don't wear seat-belts are people who are engaging in pointless, selfish behavior that I have to subsidize. In contrast, I don't have to put up with smoking in a bar or restaurant if I don't want to; I can simply leave. And I don't think that it can be plausibly argued that my rights or even my choices are significantly infringed upon.
I say this as a former 2-packs-a-day smoker, btw. My physician - in a way that was non-preventative medicine of course - heavily leaned on me to quit when I was forty. He pointed out that if I'm asking him about the efficacy of chromium picolinate, something under contention at the time (according to the best data, it's been found to be about as effective as homeopathic medicine for non-diabetics), I would be far better served to modify my habits in a way that had known positive results.
I would also make clear that I think smokers shouldn't expect to have various smoking-related health-issues treated on my dime, btw. Nor people who eat poorly, or refuse to exercise.
JonF,
This is incorrect. Americans tend to be diagnosed sooner with certain cancers (e.g., prostate), thus giving them longer survival periods until the disease runs it course.
No, it is not incorrect. I don't know what your reference to cancer "running its course" is supposed to mean. Cancer is not a head cold, you know. It doesn't just spontaneously go away by itself, except in rare cases. Left untreated, cancer usually gets progressively worse until it kills the patient.
America's higher cancer survival rates apply to cancer overall, not just to prostate cancer, and are not simply a matter of earlier diagnosis. The U.S. is better at both diagnosis and treatment than Europe, although the better treatment is in part a consequence of the better diagnosis (the earlier cancer is detected, the greater the chance of treating it effectively).
According to the most recent study, the five-year cancer survival rate for women is 63% in the U.S., vs. only 56% in the EU. And for men, the U.S. does even better. 66% for the U.S., vs. only 47% in the EU. Cancer survival rates are especially low in the UK (53% for women, 45% for men).
liberalrob,
In fact, you CAN make some judgments about the quality of a car's tires by looking at its top speed, if you actually measure performance over time. And you CAN make judgments on the quality of a national health care system based on "outcomes" and "aggregate indicators," if that's the criteria you use to define a successful health care system.
More nonsense. The vehicle's top speed tells you nothing about the quality of its tires, because there are so many other factors that affect its top speed (size, weight, engine power, transmission efficiency, aerodynamics, etc.). Obviously, one vehicle may have much worse tires than another and yet still have a higher top speed, because it has a more powerful engine, better aerodynamics, etc.)
And in the same way, looking at a nation's average life expectancy or infant mortality rate tells you nothing about the quality of its health care system, because there are so many other factors that affect these statistics, from diet to climate to pollution levels.
And yet this "longer life expectancy = better health care system" nonsense is repeated endlessly by proponents of health care reform.
I think neither the metrics nor the "optimal" outcomes are generally agreed-upon, which is why there is so much hot debate.
I have to agree with Mixner that aggregate statistics about the health of French people - without any good idea on the correlation of such statistics to the French health care system, which I suspect is pretty low - don't help much at all. There are just too many other cultural & lifestyle factors involved to get such an easy answer. Just because the Autobahn works for Germany, will it work here? I doubt it, just due to the cultural differences alone.
I (and a lot of others) have seen enough government waste to be convinced that yes, that route should be the route of last resort, in ALL cases.
For some though, like liberalrob, it seems like the issue is one of "rights," costs-be-damned. I don't think this gets you very far - there are just too many problems with this logic. The morality issue seems to break down when you begin compelling people to pay for your care. Isn't it more "moral" for you to spend all of your resources on your care before compelling others to do so?
And yes, my version of the constitution says "promote the general welfare", as opposed to "provide for the common defense". I suspect they used different words for a reason.
It also seems a bit naive to suggest that moving to a government-controlled system will not have adverse effects on costs, demand, and incentives. It does everywhere else. Ever heard of the $600 toilet seat, received "service" at the DMV or IRS? And you think your HMO is bad? Doctors will have the final say in what care is given? Um, if insurance companies have the ability & incentive to control the care in our current system then how does the gov't not have the same incentive with even more control? Sure, we may as a society choose to go the gov't route in spite of these effects for lots of reasons, but let's at least be intellectualy honest in our debate and acknowledge that they DO exist so we can rationally consider them.
SOV doesn't want personal wealth to determine how health care is rationed, but at least he recognizes that some form of rationing will have to take place. I agree. I don't think the US taxpayer has the stomach to front 100% of everyone else's heath care needs. So how do we ration it? What is the best and/or moral choice? Age? Is that fair & moral? Why not money, which can be also given to a needy person by others (family, charity), borrowed, etc? It just allows more choices.
Well that pretty much covers America. Guess subsidized care is out, then.
liberalrob,
Why does an MRI scan cost $2000? Why doesn't it cost $20?
Is this a serious question? Because MRI machines are very expensive pieces of medical technology. You really didn't know that?
Why isn't it free, after the cost of purchasing the equipment is fully amortized?
Because, obviously, it costs money to operate and maintain the machine. Operating costs for an MRI scanner run about $10,000 per month (liquid helium and superconducting magnets aren't exactly common household objects, you know), require skilled technicians to operate, and skilled medical personnel to interpret scans. And, equally obviously, the capital costs of the machine (around $2 million) must be amortized across its operational lifetime, so each scan must pay for some fraction of that $2 million. In fact, the $2,000 per scan figure I gave is a low estimate. I was trying to treat your ridiculous idea charitably.
But this is just an example. The point, which you seem to have completely missed, is that your proposal to have the government pay for every test, every drug, every surgery a doctor recommends to a patient is utterly absurd. It is economically impossible. Without some kind of cost-control mechanism, there's nothing to limit consumption and the system would immediately go bankrupt.
But the fact that you seem to think this "pay for anything a doctor recommends" idea is a serious proposal just shows how utterly clueless you are about the whole issue of health care reform, not to mention elementary economics.
I note that you neatly avoid answering my question:
Mixner, how do YOU evaluate the quality of a nation's health care system?
As far as your "more nonsense" claim, you're just blowing smoke in an attempt to obscure your flawed analogy. Yes, it's true that many factors can affect a vehicle's top speed; but all those factors are negated if the tires fail, which they will if they are not of a certain quality. That quality can be measured and prescribed in order for the vehicle to meet a claimed performance standard. So, by knowing the maximum performance permitted by various tires, you in fact CAN make a determination of the quality of tires on a car that is certified to meet a particular performance standard (because that standard could only be certified if the tires met a known minimum quality). Therefore, you are wrong.
Since you are put off by claims of "longer life expectancy = better health care system," I'm sure you will be gratified to learn that life expectancy alone has NEVER (to my knowledge) been the sole criterion on which health care systems are rated (and for myself, I certainly would insist on the consideration many other factors). Another straw man disposed of.
We handle these people in a variety of ways. First, we limit the ability of insurers to exclude people on the basis of pre-existing conditions. Second, we provide free or heavily subsidized health care for uninsured persons. Third, we provide government insurance programs, such as the federal Medicaid and SCHIP programs, and a large number of state and local programs.
It seems to me that many insurers would simply get out of the business if they are unable to deny people on the basis of pre-existing conditions - but this is a leap. It would also be a huge leap to see our government actually pass such a law given the political contributions they see from the insurance lobby.
The other more "human" point I would make is this: when people are going through a medical crisis on the level of cancer, the last thing you want to make them do is have to figure out the how and who of health care coverage. A single-payer setup, of any kind I would guess, would probably offer a lot less jumping between different agencies (private to fed, fed to state, etc.).
I don't think the US taxpayer has the stomach to front 100% of everyone else's heath care needs. So how do we ration it? What is the best and/or moral choice? Age? Is that fair & moral? Why not money, which can be also given to a needy person by others (family, charity), borrowed, etc? It just allows more choices.
This is a bit tongue-in-cheek but I had to laugh:
www.cheneycare.org
"If he were anyone else, he'd probably be dead.
Unlike the average American, the president, vice president and members of Congress all enjoy government-financed healthcare with few restrictions or prohibitive fees. They are never turned away for pre-existing conditions or denied care for what an insurance company labels "experimental treatments."
And why are they that expensive? Have we done everything we can to determine that in fact they HAVE to be as expensive as they are? Do you just accept at face value the sticker MSRP on that Escalade at the Cadillac dealership? Are you not aware that there is a "dealer cost" that represents the true cost of that Escalade, and dealerships routinely jack that MSRP way up above that to maximize their profits? Are you that naive about how things get priced in this country?
No you weren't. You were (and are) doing everything in your power to construct a ridiculous scenario which you could then sneeringly dismiss. Come on.
Fear, fear, fear. You have no basis for any of this. You simply declare that it can't be done, because you can conceive of a tremendously unlikely scenario (100% utilization of any and all resources available). Is that really what would happen? Is your MRI-a-month example even remotely likely to occur?
What was that I read back up there about you wanting to have a clear description of what level of health care I think people have a right to and why, and then having the basis of a meaningful discussion? This is your idea of a meaningful discussion?
liberalrob,
I note that you neatly avoid answering my question: Mixner, how do YOU evaluate the quality of a nation's health care system?
I don't evaluate the quality of a nation's health care system. The premise of your question is false. You're the one advocating reform, not me. It's up to you to show that your favored alternative is superior. As I said in an earlier post:
I have never seen a study that makes a comprehensive comparison of this kind. I doubt we have enough data to do it yet. But the data I have seen--such as the data on cancer survival rates I described earlier--suggests that the quality and performance of the U.S. health care system compares favorably to those of other nations. This isn't surprising, considering that we spend a lot more.
Yes, it's true that many factors can affect a vehicle's top speed; but all those factors are negated if the tires fail, which they will if they are not of a certain quality.
This is utterly irrelevant. You're trying to evaluate the tire (health care system) by looking at top speed (average life expectancy), remember? Even if the top speed is zero, the tire may be fine. Some other crucial component of the vehicle may have failed instead. The point, which you still seem unable to grasp, is that aggregate health indicators tell us NOTHING about the quality of the health care system. A nation may have the best health care system in the world and still have only an average life expectancy, because of all the other factors that influence the lifespan of its population. Costa Rica has a life expectancy almost the same as that of the U.S. Does this mean Costa Rican's health care system is as good as America's? No, of course it doesn't. Costa Rica is a poor country, spends only 5% as much per capita on health care as the U.S., and has only half as many doctors per capita. So why do Costa Ricans live as long as Americans despite having a lousy health care system? Answer: They have a much better diet, get much more exercise, and have a much lower smoking rate.
Since you are put off by claims of "longer life expectancy = better health care system,"
I'm not "put off" by the claim. I'm telling you it's utterly nonsensical, for the reasons I have explained.
dmwr,
It seems to me that many insurers would simply get out of the business if they are unable to deny people on the basis of pre-existing conditions - but this is a leap.
Insurers have some ability to exclude people with pre-existing conditions, but that ability is limited by laws like HIPAA. It's not the simple either-or you seem to think it is. My point is that just because someone has a pre-existing condition, that doesn't mean he is unable to obtain affordable private insurance. In some cases that will be true, but not all. The laws and policies in this area are more complex and nuanced than you seem to think.
And as I said, people who are unable to obtain affordable private insurance may qualify for public insurance through a state or federal program, or can obtain free or heavily subsidized health care from a large network of publicly and privately funded clinics and health care programs. "No private health insurance" does not mean "No health insurance." And "No health insurance" does not mean "No health care."
Is there a good case for expanding public programs that provide health insurance or health care services to the uninsured and indigent? I think there probably is. But that's very different from saying we need to radically reform our entire health care system.
I suspect there is a certain pathology at work here; I suspect this guy honestly doesn't know that you can't get away with just making stuff up.
From that terribly liberal site, cato:
http://www.cato.org/pub_display.php?pub_id=8304
Here's the money quote:
By an odd coincidence, I happen to have a little second-hand information about the subject. MRI machines are expensive because a) few companies manufacture them, so there is relatively little competition, and b) this is due primarily to the fact that the imaging algorithms are proprietary. At least that was how it was explained to me by a math buddy who was working at a startup to develop a new algorithm that wouldn't be some sort of legal infringement.
Would it hurt these idealogues to at least try to research a position before making such confident and flat pronouncements? We've had quite enough of the Robert Heinlein school of debate, thank you very much.
Sigh. 'Generally agreed-upon' does not mean that libertarian/conservative types necessarily agree with. It's 'generally agreed-upon' that the theory of evolution is the best explanation - by far - that we have for the diversity of types of life we have on this planet and it's relatedness. By the usual 'generally agreed-upon' metrics. The fact that you have - what? - four out of six Republican candiates for the presidency obliged to say that they don't believe in evolution doesn't change that fact.
Now, if you disagree with the metric, tell us why, and what you would replace it with, and why your replacement is superior to the original. Please try to rise above the usual sloppiness of your tribe; do you, for example, _really_ think life expectancy is a bad metric, or do you simply think that not enough factors that influence this statistic are being taken into account, that, to name one subclass, sedentary overweight smokers in both populations who don't die violently have the same life expectancies? And that the difference in the size in the relative populations is not taken into account when calculating the overall figure? That would certainly be a valid objection . . . but you would have to show that this is what actually happens. Not speculate that this may be the source of the difference.
And in the same way, looking at a nation's average life expectancy or infant mortality rate tells you nothing about the quality of its health care system.
Mixner: What an absurd claim. The fact that health indicators aren't explained solely by the effectiveness of a nation's healthcare system obviously doesn't mean there is no relation whatsoever.
So why do Costa Ricans live as long as Americans despite having a lousy health care system? Answer: They have a much better diet, get much more exercise, and have a much lower smoking rate.
Another absurd claim. Costa Rica has been widely praised for having built an extraordinarily effective, comprehensive universal healthcare system. As Greg Connolly of the Global Health Council notes:
source: http://www.cehat.org/rthc/paper5.htm
All human beings become ill, or suffer injury. Abstaining from tobacco and eating well can't possibly be the sole explanations for the health of Costa Ricans.
I sense a 'God of the Gaps' style strategy coming from these Defenders of the Faith. Time was, the absence of transitional forms used to be considered a valid objection to the theory of evolution. However, with the maturation of the theory, more and more of these forms were found. The gap between A and B was bridged by C. But then the Creationists demanded the transitional form between A and C, and when D was found, the transitional form between A and D (as well as the multiplied intermediates.) The objection, once considered honest and reasoned, is now viewed askance as the last refuge of a scoundrel. No, given the vagaries of time and the spottiness of the chances of preservation, particularly with respect to the older forms, it is dead certain that many, in fact, most of the 'transitional forms' will never be found. Particularly since finding one generates the possibilities of two more. To insist that evolution 'fails' because it cannot produce them is to turn the burden of proof inside out.
It's like that with the life expectancy argument. To say that the statistics are skewed because, to name an instance, of the way newborns are counted from country to country is a valid objection. And indeed we find that this effect can be corrected for, or at least establish an upper bound on how much it affects the totals. Not surprisingly, this difference in counting comes nowhere near addressing the discrepency.
Fine, say the critics, but how do you know that X doesn't also distort the figures? Or Y or Z or . . . It quickly becomes apparent that this is a mugs game. It is quite easy to pose an objection, easier to declare with infuriating mock imparitiality that you're 'not convinced'. It is much harder to answer those objections, much harder to research, dig through data bases, etc.
So at some point, the burden of proof goes the other way, in fact, that point was reached long ago. If people want to claim that it is 'life style choices' that affect outcomes, it is up to them to show it, not up to other people to chase after spectres and nail them down. They are perfectly free to posit that the blame lies with differing rates of diversity. But it is up to them to show this is the case, not on others to show that it isn't.
And like their Tru believer counterparts, the Creationists, they have failed spectacularly in this respect. Their strength has always been in criticizing the opposing sides evidence, just as their weakness has always been in producing any of their own.
I would also add that their cause, contrary to internal belief, is hindered - that's hindered - not helped by having a cadre of drones who care nothing about personal credibility and who have zero problems with making things up on the spur of the moment with no regard to objective truth. Of course, that applies only if your seeking new converts. If all you want to do is solidify the base . . .
Wow, SoV. Bad day at work?
Sigh. 'Generally agreed-upon' does not mean that libertarian/conservative types necessarily agree with.
Of course not. I'm just saying that everyone's perceptions & definitions of the "problem" (moral, constitutional, fiscal, practical) vary enough that often posters are not arguing over the same thing while thinking that they are. And when that happens it leads to a lot of frustration on everyone's side.
Now, if you disagree with the metric, tell us why
I don't agree OR disagree. I simply question those who prop it up on a pedestal as "proof" without mention of how it actually correlates in the real world. If you have a statisic, how well does it correlate? Am I wrong to ask if I don't have the answer myself already and/or suspect it might be low?
do you, for example, _really_ think life expectancy is a bad metric
I don't know. I _suspect_ that it is, and have given a few logical and obvious reasons why it might be. No one has said "yes, that's a good point but it is corrected for." Instead we spin off into a discussion about how fast your tires can go and wrong everyone else is.
...[do you think] sedentary overweight smokers in both populations who don't die violently have the same life expectancies? And that the difference in the size in the relative populations is not taken into account when calculating the overall figure?
Yes, I think that we have a larger "unhealthy" population/culture and that this plays a much larger role in LE than the health care system. Since I have no real proof of this, shall I just remain silent and not ask if it has been considered? Has it, and I just missed it?
or do you simply think that not enough factors that influence this statistic are being taken into account
Yes yes yes. At least in the arguments on this board.
Speaking for myself, I am not asserting that the statisics are skewed, which is why I was careful to use the words "I suspect" for clarification. Or maybe it was just infuriating mock imparitiality. But I am skeptical of them, which was one of the first things I learned to be about statistics.
It is much harder to answer those objections, much harder to research, dig through data bases, etc...So at some point, the burden of proof goes the other way, in fact, that point was reached long ago. If people want to claim that it is 'life style choices' that affect outcomes, it is up to them to show it
Very true. And I am not making any assertions precisely because I have not done the research myself. But then can I not make contributions? Sometimes, when working on a hard or time-consuming problem, you can at least bracket the solution without knowing the exact answer just by using some logic or asking the right questions. I don't have to solve the entire problem myself to see that some answers don't look very good.
Of course, I could also be wrong. And if so, I'm sure you will tell me.
In relation to the discussion about better metrics, the following paper attempts to do a more systematic study of outcomes for Canada and US. One of the things the paper highlights is the difficulty in doing such an analysis.
The paper highlights that US has better outcomes in many categories (hip replacement and cataracts) and Canada has better outcomes in other categories (renal failure). It also suggests that, if they were able to look at outcomes by income level, there would be a significant difference - but also points out that this is difficult to achieve with the US data because many of the people who fall into that category are probably not reporting, whereas in Canada they would be.
Near the end of the paper, it writes:
Despite the limitations of the available studies, some robust conclusions are possible from our systematic review. These results are incompatible with the hypothesis that American patients receive consistently better care than Canadians. Americans are not, therefore, getting value for money; the 89% higher per-capita expenditures on health care in the United States does not buy superior outcomes for the sick.
Canadian health care has many well-publicized limitations. Nevertheless, it produces health benefits similar, or perhaps superior, to those of the US health system, but at a much lower cost. Canada’s single-payer system for physician and hospital care yields large administrative efficiencies in comparison with the American multi-payer model. Not-for-profit hospital funding results in appreciably lower payments to third-party payers in comparison to for-profit hospitals while achieving lower mortality rates. Policy debates and decisions regarding the direction of health care in both Canada and the United States should consider the results of our systematic review: Canada’s single-payer system, which relies on not-for-profit delivery, achieves health outcomes that are at least equal to those in the United States at two-thirds the cost.
I look forward to comments on the paper, found here at:
http://www.openmedicine.ca/article/viewArticle/8/1
dmwr,
This is an interesting read...thanks for the link. Selected quotes/comments/questions:
Admission of limitations in health care system affecting health, +1 for credibility. "...the health care system is a major determinant of outcomes..." How major? 75%? 50%? 25%?
[sarcasm] No! You cannot admit this! Guards! Take them away...[/sarcasm]
Admission of existence of limitations in Canadian system, +1 for credibility.
Based on the study, I would have to agree.
Again, large section of the study devoted to limitations of data. +5 for credibility.
Uncertainty? They can't prove it? Shhh...don't tell SoV.
The first sentence I think is well-supported by their study. The comments on value, however, are not:
They don't provide data or a reference of any sort for that statement. Even if I assume it to be true, it doesn't say what costs are considered.
For example, it may be that the US spends a lot more than Canada on elective/cosmetic procedures & related care. This would be likely to show up as increased expense, but not in any meaningful "outcomes" study. So to really compare apples to apples, those types of medical expenses should either be excluded or shown to be insignificant.
[note to SoV: I am not asserting that they aren't, I'm simply declaring my uncertainty]
Likewise, there may be expensive procedures that are done in the US that are not done in Canada. If this is the case, and there is no corresponding increase in outcome, the we are wasting money.
The authors of this study seem to do a great job when it comes to comparing the outcomes - which is after all what the study is really about - but then they include a conclusion about something (cost) which they have not studied...? If there is to be a meaningful comparison, shouldn't they consider only the relative costs of the things they limited the study to?
Overall, this study is very convincing that we don't have to take a step back to the stone ages in medical care if we move to a more Canada-like system. Personally, though, there are still other questions out there to consider as well: Cost? Innovation? Rationing?
Re: Since you are put off by claims of "longer life expectancy = better health care system,"
Oddly enough, he uses a claim of better life expectancy for cancer patients as a claim for better healthcare. Anybody se a contradiction here?
Re: It seems to me that many insurers would simply get out of the business if they are unable to deny people on the basis of pre-existing conditions
Nope, not at all, bacuse most insurance policies are written for groups not individuals, hence the costs for any individual is simply amortized across the whole group. And the bigger the group (assuming it is random in respect to health conditions) the better the amortization effect. Community rating makes a huge amount of sense and it's the rule not the exception already, however one must find a way to keep the membership of the community random.
Re: It's up to you to show that your favored alternative is superior.
Easily done then. Everyone has coverage, no one is denied treatment because of personal financial issues. No one goes broke because of health problems. what's not to like?
Jasper,
The fact that health indicators aren't explained solely by the effectiveness of a nation's healthcare system obviously doesn't mean there is no relation whatsoever.
You're not listening. There is a relation between life expectancy and health care. Just as there is a relation between the quality of a car's tires and its top speed. But the relation is weak. It is swamped by other factors (diet, exercise, smoking, crime, etc.). Therefore, you cannot draw any meaningful conclusions about health care quality from average life expectancy. It's really not a difficult point to understand.
Costa Rica has been widely praised for having built an extraordinarily effective, comprehensive universal healthcare system.
Nonsense. The quote you provide says nothing whatsoever about the quality of Costa Rica's health care system in comparison to that of the United States and other wealthy nations. As I said, Costa Rica spends only 5% per capita of what the U.S. spends. It has only half as many doctors per capita. It cannot afford to do much more than this because it is a poor country. The reason Costa Ricans live almost as long as Americans has nothing to do with its health care system and everything to do with the fact that Costa Ricans live a much healthier lifestyle than Americans (much healthier diet, much more exercise, much less smoking). Numerous studies have confirmed that behavioral and environmental influences on health and longevity swamp the effects of health care services.
Scent,
So at some point, the burden of proof goes the other way, in fact, that point was reached long ago.
No, Scent, the burden is most definitely on those who attribute differences in average life expectancy between nations to differences in the quality of their health care systems to produce evidence supporting that claim. In order to do that, they would need to control for all the other differences between nations that influence average life expectancy. An obvious example is smoking. Smoking is the leading preventable cause of premature death in the industrialized democracies. Even a small difference in the rate of smoking between two such nations can easily account for small differences in their average life expectancy. And the smoking rate is just one of a myriad of factors influencing the average lifespan of a nation's population.
If you think you have such an analysis that controls for smoking and all the other factors that affect life expectancy, in order to isolate the effects of health care on that statistic, please produce it. Of course, since no such analysis exists, it's going to be rather hard for you to do this....
Mixner:
I (and others) have done so at length. The fact that you refuse to accept my arguments, while annoying, is ultimately irrelevant. I've said all I think I need to say to convince you. Anything more is going to be wasted effort. Time to move on.
JonF,
Oddly enough, he uses a claim of better life expectancy for cancer patients as a claim for better healthcare. Anybody se a contradiction here?
Do please explain the contradiction you see. Cancer survival rates are a direct "outcome" of the quality of cancer diagnosis and treatment by a nation's health care system. Average life expectancy is not. Average life expectancy is the "outcome" of a huge constellation of socioeconomic and environmental factors, of which health care services are just a tiny component. Try to understand the difference. It's not that hard.
Everyone has coverage, no one is denied treatment because of personal financial issues. No one goes broke because of health problems. what's not to like?
Er, the fact that your proposal is impossible? Do please explain how you propose to ensure that no one is denied treatment because of personal financial issues. Do please explain how you propose to ensure that no one goes broke because of health problems. No health care system in the world does those things. Not Britain's, not Canada's, not France's. None of them. You are living in a fantasy world, like liberalrob and SOV.
They don't provide data or a reference of any sort for that statement. Even if I assume it to be true, it doesn't say what costs are considered.
I'm pretty sure that this has been well covered by the OECD study (I'll have to take a look) - bottom line is that it is clear our healthcare is more expensive than other countries. I don't think anyone is really disputing this. I don't think they could possibly be taking into account elective surgeries such as plastic surgery because they wouldn't be covered. In most cases, the data seems to be coming from the government - so, SCHIP, Medicare, etc. But again, you might have a point - see if you can find any data on the issue.
Overall, this study is very convincing that we don't have to take a step back to the stone ages in medical care if we move to a more Canada-like system. Personally, though, there are still other questions out there to consider as well: Cost? Innovation? Rationing?
I think the cost side is pretty clear - a single-payer option would reduce the complexity of the system and lower administrative costs. This is what was seen in Taiwan when they moved to a single-payer system (actually modeled on Medicare). As for innovation - if the innovation we currently have is not leading to better outcomes, then it is an unnecessary spend.
Rationing is another issue - but I think it is a mistake to think that we are not rationed here in the US - all I'm saying is that both systems require some form of rationing. The question, in my mind, is how that rationing is performed. Mixner has made the argument that physicians and patients can't be put in charge of that. I would argue that the last person I want in charge of my rationing is a for-profit company with strong incentives to deny claims. But that is my opinion.
My opinion is informed by my step-father, a physician in the UK who has long argued that physicians need to be put in charge of these decisions in consultation with the patient. He has viewed this as a large issue with the NHS for a while (along with underfunding). Obviously there is room for abuse - as with any system - but I would argue that at least the physician should have the ability to argue for the care of their patient in a non-conflicted manner. Asking patients to make all the decisions doesn't seem like the way to go - if only because the patient does not necessarily have the knowledge or training to make the "right" (whatever that term really means here) decision.
Here's another interesting paper by the OECD on the whole issue:
http://www.olis.oecd.org/olis/2003doc.nsf/LinkTo/NT00000EAE/$FILE/JT00140050.PDF
Once again, I look forward to comments.
liberalrob,
I (and others) have done so at length.I (and others) have done so at length.
Oh yes, your "at length" demonstration consists of asserting that the government should, and could afford to, pay for any and every treatment a doctor recommends to a patient, with no limits on the cost or consumption of health care services other than the self-restraint of doctors and patients. It's laughable. It's beyond laughable.
Mixner, it's quite apparent to all that you quite casually just make stuff up and have no compunction about lying to make a point. Please go away.
dmwr,
I think the cost side is pretty clear - a single-payer option would reduce the complexity of the system and lower administrative costs.
The skeptic in me says when have you ever known the government to reduce complexity OR lower administrative costs? But I guess that if in fact it would do so then that would be a measure of just how bad things are now...
As for innovation - if the innovation we currently have is not leading to better outcomes, then it is an unnecessary spend.
Agreed. My concern is spoiling the incentive for innovation, and wondering if some of the discrepancy in cost between the US and other countries/systems is due to us funding innovation that then is spread elsewhere and artificially improving their "outcome ratio."
both systems require some form of rationing. The question, in my mind, is how that rationing is performed. Mixner has made the argument that physicians and patients can't be put in charge of that. I would argue that the last person I want in charge of my rationing is a for-profit company with strong incentives to deny claims.
For me, a non-profit company (gov't) with strong incentives to deny claims (or increase taxes to not deny them) is a solid #2 on that list.
physicians need to be put in charge of these decisions in consultation with the patient
Agree 101%. But those who are paying ultimately call the shots, no? Currently, that is the insurance industry. If the gov't is paying, does it not shift to them? This is probably my next biggest "gripe," in that it seems to me we would just be making a replacement of one bad parent for another, more monopolistic one.
Thanks for the input. I'll check out the OECD paper but I have to run to a meeting...duty calls.
The skeptic in me says when have you ever known the government to reduce complexity OR lower administrative costs? But I guess that if in fact it would do so then that would be a measure of just how bad things are now...
Yeah, I understand that impulse - all I would say is the Medicare has much lower admin costs than private insurers (I don't have a reference, I'm sorry). I think the way Hillary wanted to implement it would have created an enormously complex system - I'm arguing for taking the private insurers out of the mix.
Agree 101%. But those who are paying ultimately call the shots, no? Currently, that is the insurance industry. If the gov't is paying, does it not shift to them? This is probably my next biggest "gripe," in that it seems to me we would just be making a replacement of one bad parent for another, more monopolistic one.
I think that's a realistic concern - but by taking the profit aspect out of it, at least, in my opinion, we would not be trying to drive health choices based on stock prices. As for how doctors and the government would work - that is, determining when a cost or procedure is in or out of bounds - there would clearly have to be a framework in place including methods for escalating/protesting issues. Medicare (excluding Medicare+Choice) seems to have a decent framework already in place that could perhaps be extended.
dmwr,
The paper highlights that US has better outcomes in many categories (hip replacement and cataracts) and Canada has better outcomes in other categories (renal failure).
Actually, the abstract states that renal failure is the only condition for which the authors found results that consistently favored Canada.
But there are more serious problems with the study you cite. It's actually a meta-study of older epidemiological studies. Among the problems are the age of the data (most of the data it cites is around twenty years old; some is more than thirty years old), the geographical scope of the data (e.g., individual cities rather than the entire nation) and its definitions of "better" results (better only for certain groups of patients rather than patients as a whole). The authors also have a political agenda, which probably influenced their selection of studies to try and favor Canada. David Himmelstein is co-founder of Physicians for a National Health Program, a political lobbying organization promoting single-payer health care.
The authors conclusions are also contradicted by newer and more comprehensive data. On cancer survival rates, using the most recent statistics reported in the Lancet Oncology and Canadian Cancer Statistics 2007, we find that while cancer survival rates for Canadian women are almost as good as for American women (62% 5-year survival rate for Canadian women vs. 62.9% for American women), cancer survival rates for American men are substantially higher than for Canadian men (66.3% for American men, vs. only 58% for Canadian men). Given these findings, it seems likely that respect to cancer at least, Americans are getting better health care than Canadians.
And by the way, the results for the U.S. include both insured and uninsured patients.
dmwr wrote:
"by taking the profit aspect out of it, at least, in my opinion, we would not be trying to drive health choices based on stock prices."
But that's not the only effect. Removing the profit motive would also be removing much of the incentive to develop new procedures, drugs and technology. Sure, if we removed the profit motive all that advanced health care wouldn't cost as much, but that's because it wouldn't exist.
I've worked on medical devices. The European market simply did not support the investment; the American market did. As I age, I'm hopeful for ever greater advances in health care. Removing the profit motive will cause that to grind to a halt.
I don't deny that the current health care system has problems that need to be addressed, but I'm very wary of going too far in addressing them. My gut feel is that removing the profit motive entirely (single payer) would over time be an increase net human suffering because of undeveloped treatments and a decrease in quantity and/or quality of health care providers.
But there are more serious problems with the study you cite. It's actually a meta-study of older epidemiological studies. Among the problems are the age of the data (most of the data it cites is around twenty years old;
Agreed - I'm just looking for any report that covers anything beyond cancer survival. I think you're right that the study has problems, but I don't think it can be completely dismissed.
Given these findings, it seems likely that respect to cancer at least, Americans are getting better health care than Canadians.
Yes, that seems like good data - although the cost of the US solution is substantially more than the Canadian solution and they manage to cover all their citizens.
So I took it one step further - Political Calculations doesn't break out the individual Cancer survival rates for the Canadian data:
Cancer Type/US/Canada/Comment
Stomach/25/27
Colorectal/65.5/61
Lung/15.7/18
Soft-tissue/15.7/na/Canadian data doesn't break out Soft-tissue
Skin/92.3/93/Categorized as Melanoma in Canadian data
Breast/90.1/86
Cervix/65.8/72
Uterine/82.3/86
Prostate/99.3/92
Testicular/95.4/96
Kidney/62.6/67
Thyroid/93.5/97
Hodgkin's/80.6/86
Non-Hodgkin's Lymphoma/62/61
Acute Myeloid Leukemia/13.9/47/Canadian data doesn't break out Acute vs. Chronic
Chronic Myeloid Leukemia/36/na/Canadian data doesn't break out Acute vs. Chronic
Two numbers jump out at me: Breast cancer and Colorectal cancer - only because there have been very active campaigns to screen for these in the US.
But what is interesting here is that the numbers are very comparable - in some cases the Canadian data is better, others, the US better.
Of course, the data is very clear for Europe vs. the US. I do wonder if there are other factors at work here beyond care - most people attribute the advantage of the US being in early detection of cancer via more active screening.
As Political Calculations put in another, earlier post on the subject quoting Center for Science in the Public Interest's Merrill Goozner (http://politicalcalculations.blogspot.com/2007/09/surviving-cancer-us-vs-europe.html):
"A cancer epidemiologist would probably explain the data this way: In the U.S., we conduct far more tests, which turn up many more cancers. That in turn leads to higher survival rates because we wind up treating some cancers at an earlier stage. It probably even saves some lives that otherwise would have been lost to the disease.
But there's a downside to all those tests. They have relatively high false positive rates. In other words, they turn up minor cancers that may never have progressed to full-blown neoplasms. Yet, they are treated anyway since determining which ones will progress is impossible at that early stage."
So there may well be a sociologic aspect to this as well - Americans may be more likely to be screened because individuals and doctors are more concerned about it. Particularly interesting is the difference in men vs. women.
When you look at the confidence levels:
Gender | Europe | US
All men | 46.8-47.8 | 66.0-66.6
All women | 55.3-56.2 | 62.6-63.2
Women in Europe are much closer to the standard of care in the US - interesting.
Finally, France seems to have been left out of many of the calculations - so that's a big hole in the data.
Question for you: where did you see that the US data included both insured and uninsured patients? I can't see any reference this and I can't download the Eurocare-4 document.
But that's not the only effect. Removing the profit motive would also be removing much of the incentive to develop new procedures, drugs and technology. Sure, if we removed the profit motive all that advanced health care wouldn't cost as much, but that's because it wouldn't exist.
Remember that a large amount of new pharma and medical device innovations come with support from our federal government - with the NIH providing a large amount of dollars for the basic research that most companies can't/won't take on.
Interesting article on the subject:
http://www.nytimes.com/library/national/science/health/042300hth-drugs.html
In other words, the idea that innovation happens because only independent companies can make it happen is false - innovation can come from them, or it can come from our federal dollars.
dmwr,
That article (or is it an editorial?) doesn't actually contradict me. I agree that federal dollars are useful in subsidizing basic science, but as the article mentions, the basic science didn't produce a drug, it produced 'an unpolished diamond". Polishing the diamond into a safe and effective product took more work. That work (and the associated risk) is currently being done by companies with a profit motive.
Now sure, that work could be done under a government contract, but I don't see any reason to think that would make it more efficient or productive. Given the speculative nature of drug development, it would be an area rife with opportunities for fraud and corruption. Plus, a government contract wouldn't remove the profit motive anyways. Look at military contracting for how this would tend to work. There's good national security reasons to tolerate the inefficiencies of the military development and procurement process for the military, but making health care advances go through the same process seems like...a bad idea.
Do you really believe that the government would create health care advances as quickly and cheaply (yes, cheaply: see LASIK) as a competitive private sector?
Sorry - I should have been clearer - I'm not arguing that the work should be done under government contract - private industry should be involved to produce the polished diamond. But the idea that innovation will suffer is what I was seeking to counter.
dmwr,
But if, as you have proposed, profit is to be removed from the equation, private industry will cease to get involved. There will be no more diamond polishers. That's the rub (pun intended).
dmwr,
Yes, that seems like good data - although the cost of the US solution is substantially more than the Canadian solution and they manage to cover all their citizens.
As I said, the results for the U.S. cover all Americans, both insured and uninsured. It may be that even uninsured Americans considered separately still have a higher cancer survival rate than Canadians.
Two numbers jump out at me: Breast cancer and Colorectal cancer - only because there have been very active campaigns to screen for these in the US. But what is interesting here is that the numbers are very comparable - in some cases the Canadian data is better, others, the US better.
But the U.S. is much better overall, at least for men. Comparing counts of the number of cancer types for which each country has better results isn't terribly meaningful, because some types of cancer are much more common and much more serious than others. A higher survival rate for common cancer types is much more significant than a higher survival rate for rare cancer types. Breast, colorectal and prostate cancer--the categories in which the U.S. is significantly better--are among the most common types of cancer.
As I said, the results for the U.S. cover all Americans, both insured and uninsured. It may be that even uninsured Americans considered separately still have a higher cancer survival rate than Canadians.
Yes I read your last comment - my question was this: where does it say that? I don't see any notes that point to that.
A higher survival rate for common cancer types is much more significant than a higher survival rate for rare cancer types. Breast, colorectal and prostate cancer--the categories in which the U.S. is significantly better--are among the most common types of cancer.
Agreed - and this data is old - it stops, I believe, in 1999. One has to believe that it has actually improved due to pushing screening further.
But if, as you have proposed, profit is to be removed from the equation, private industry will cease to get involved. There will be no more diamond polishers. That's the rub (pun intended).
Respectfully, I disagree - the pharma industry spends a lot more on marketing than it does on R&D in this country. I used to work in pharma marketing and I can tell you that they spend way more figuring out how to milk the current crop of drugs than developing new ones. The reason is rather simple - they've gotten to the point where most main drug categories (the blockbusters) have been taken, and many of those drugs will be coming off patent in the next 5-10 years. Developing new drugs that have novel pathways and approaches takes years and they focus much more on the short term picture.
The other smaller drug categories don't have nearly the payoff, but they've constructed a sales and marketing channel that requires blockbuster drugs. At one point, Pfizer had 8 reps calling on each doctor. We've seen them already begin their downsizing as they are forced to address smaller, more limited markets. In this, the smaller drug (particularly biotech companies) are picking up the mantel - and they do actual research, usually on top of some NIH-back research as a starting point.
In short, I don't think the innovation is going to go away - I think these large pharma companies will instead be forced rationalize their marketing and sales channels. We've already seen this at Pfizer and Aventis - they didn't cut R&D - they cut sales reps.
dmwr, quoting one Merrill Goozner:
But there's a downside to all those tests. They have relatively high false positive rates. In other words, they turn up minor cancers that may never have progressed to full-blown neoplasms. Yet, they are treated anyway since determining which ones will progress is impossible at that early stage.
Perhaps Merril Goozner thinks that if you have early-stage cancer, it's better not to know and to go untreated because maybe, if you're lucky, the cancer won't progress and end up killing you or causing you serious harm. I can't imagine most doctors would agree with him.
The poor performance of European health care systems at diagnosing and treating cancer is also discussed in this Medscape article: Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States. The author of the analysis described in the article, Arduino Verdecchia, of the National Center for Epidemiology, Health Surveillance, and Promotion in Rome, attributes the higher survival rates to the better organization and policies of the health care systems, better training and skills of health care professionals, and greater investment in diagnostic and treatment facilities. These are all direct consequences of our greater spending.
dmwr,
I don't see how the scenario you're describing follows from your proposal. What you describe is the rational actions of a company seeking to preserve or increase it's profit margin in the face of declining revenues. But your proposal is to eliminate profit entirely. Presumably the government pays fixed cost? There are lots of other places for capital to go that would have much better risk/return profiles. You can't improve that much by reducing costs when the return is arbitrarily fixed at a low rate.
My biomedical (but not pharmecutical) experience was different. It was a flat-out statement that we would not get continued funding if all we had was the European market (our product had CE mark, but there was a delay in getting FDA approval). The European returns could not support the venture capital investment model; the company would close.
To be clear, I don't think medical advances would completely halt. I do think they would slow greatly. I don't want that to happen.
dmwr,
Yes I read your last comment - my question was this: where does it say that?
In the Lancet Oncology survey from which the cancer data is taken. The paper is not available online, but you can find a summary of its findings here
Agreed - and this data is old - it stops, I believe, in 1999.
Where are you getting that date from? The Lancet Oncology survey title specifically states the period as 2000-2002. This is the most recent period for which comprehensve data is available. While it would be nice to have even more up-to-date figures, this data is obviously much more relevant to contemporary health care system comparisons than the data cited in the Himmelstein study you referenced earlier, most of which is around 20 years old.
One has to believe that it has actually improved due to pushing screening further.
I'm not sure why you think "one has" to believe that, but yes, the better performance of the U.S. health care system is in part a result of more aggressive screening for cancer. That allows it to be detected earlier and improves the chances of successful treatment. The U.S. is better at both diagnosis and treatment of cancer, and the better treatment is in part a consequence of the earlier diagnosis.
I don't see how the scenario you're describing follows from your proposal. What you describe is the rational actions of a company seeking to preserve or increase it's profit margin in the face of declining revenues. But your proposal is to eliminate profit entirely. Presumably the government pays fixed cost?
It's the usual assumption in the scenario that negotiating with the government means working for no profit. Certainly the military has shown that to be false. Look at Halliburton's stock - they have no suffered from working with the government.
Where are you getting that date from? The Lancet Oncology survey title specifically states the period as 2000-2002.
From the Canadian study from 2007.
http://www.cancer.ca/vgn/images/portal/cit_86751114/36/15/1816216925cw_2007stats_en.pdf
Look at page 66 - study runs from 1996-1998
I'm not sure why you think "one has" to believe that, but yes, the better performance of the U.S. health care system is in part a result of more aggressive screening for cancer. That allows it to be detected earlier and improves the chances of successful treatment. The U.S. is better at both diagnosis and treatment of cancer, and the better treatment is in part a consequence of the earlier diagnosis.
Because that is the general trend in the developed world. I'm not disagreeing with you - I'm just saying that these rates are from outcomes 1998 - we'll obviously have to wait for the data to come out in a few years on the more recent data. My guess is that it will show improvement but it is what it is!
The absence of France from the Lancet survey is an issue - I'll have to find the reference but I understand their outcomes for cancer with women is better than the US - but I know you'll want the data. I'll have to see if I can find it.
dmwr,
I'm confused. Are you proposing health care follow the military development and procurement model (a well-known example of efficiency there) or not?
Expecting a military development and procurement process to health care to be quicker or cheaper than the private sector seems like wishful thinking. What leads you to believe that this will accomplish your goals? Do Haliburton's contracts reflect where you'd like to see the pharmecutical industry go?
I also note that transferring responsibility for innovation away from the private sector and to the government might mean letting Mike "I don't believe in evolution and AIDS patients should be quarantined" Huckabee in charge of deciding which treatments get pursued and which ones don't. Are you sure you want to go down this road?
Expecting a military development and procurement process to health care to be quicker or cheaper than the private sector seems like wishful thinking. What leads you to believe that this will accomplish your goals? Do Haliburton's contracts reflect where you'd like to see the pharmecutical industry go?
No - my point is that people argue that pharma companies won't make any money dealing with the government - I don't think this is true and other areas of the government that involve the private sector do very well.
I also note that transferring responsibility for innovation away from the private sector and to the government might mean letting Mike "I don't believe in evolution and AIDS patients should be quarantined" Huckabee in charge of deciding which treatments get pursued and which ones don't. Are you sure you want to go down this road?
I'm not arguing to transfer responsibility. I'm arguing that negotiating with the government does not end with unprofitable companies. I think the private sector should continue to develop products and the government should stay out of it.
Your unstated assumption seems to be "longer hospital stay = better health care." - Mixner
No. I am simply responding to your claim that Euro- or Japanese-style universal health insurance systems will fail to produce savings in the US because American patients will demand to stay in nice shiny hospitals. As the statistics show, Americans do not currently demand to stay in hospitals as much as European patients do; in fact we stay in hospitals less than the rest of the OECD does. And yet for some reason our health care costs twice as much as theirs. As to the quality of the hospitals, I have never seen any evidence that American hospitals are "nicer" than European or Japanese ones; my own experience is the opposite.
I did not say anything about whether longer hospital stays produce better care. You are confused. However, it seems obvious that longer hospital stays should cost more. And yet, despite having shorter hospital stays, US health care costs more than the rest of the OECD - almost twice as much.
That is because the US health care system sucks, and theirs are better.
As for this:
The evidence is overwhelming that "universal health care" would do little to improve the health of the U.S. population or to increase its average lifespan. - Mixner
New study: US last among industrialized nations in "amenable mortality"
-- http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=640980
dmwr,
From the Canadian study from 2007.
http://www.cancer.ca/vgn/images/portal/cit_86751114/36/15/1816216925cw_2007stats_en.pdf
Look at page 66 - study runs from 1996-1998
But where are you getting your U.S. data from?
dmwr,
If the government is paying on a cost-plus basis, that won't justify speculative development on new technologies, areas where there's a significant risk of failure. Capital will flow to areas where the returns are not capped at low levels.
I suppose the government could reimburse at a high enough rate to encourage continued investment in medical advances, but then you won't realize any cost savings. In fact, you most assuredly would have increased costs.
Alternatively, the government could fund the actual development of new technology, but that's the military model. I don't think anyone believes that would be cheaper and more effective. I'm not sure, but I think you're against that too.
Single-payer is fine if you want everyone to have access to the health care of today. It doesn't work well if you want access to the health care of tomorrow.
BTW, if the problem is that some people lack access to health care and you're willing to forgo future advancements to improve access, would you find it acceptable for universal care to be somewhat behind the leading edge of the technological curve? Say universal coverage is limited to those drugs/diagnostic equipment/etc that's fallen out of patent protection, and you have to pay privately for anything beyond that? I think it's essentially the same tradeoff (universal coverage implies a limited access to medical advances), but it doesn't put a big damper on continuing innovation.
Like I've said previously, I readily acknowledge that the current US health care system is strikingly less than ideal, but the fact that it spurs advances that other health care systems don't is not a property to be discarded lightly.
brooksfoe,
No. I am simply responding to your claim that Euro- or Japanese-style universal health insurance systems will fail to produce savings in the US because American patients will demand to stay in nice shiny hospitals.
Huh? If "universal health insurance systems" tend to produce longer hospital stays, then hospital costs are likely to increase if the U.S. adopts such a system. Where are the savings?
That is because the US health care system sucks, and theirs are better.
Simply uttering this assertion over and over again won't make it any less false. If you think it's true, you have to present evidence in support of that claim--facts and figures on the actual performance and quality of U.S. health care. You haven't done that.
brooksfoe,
New study: US last among industrialized nations in "amenable mortality"
Another nonsequitur. Like average life expectancy, the "amenable mortality" rate doesn't tell us anything whatsoever about the quality of a nation's health care system, because it is determined by so many other factors in addition to the quality of health care services. If the rate of smoking in country A is 100% higher than the rate of smoking in country B, the "amenable mortality" rate from smoking in country A will be higher than in country B even if the health care system of country A is 99% better at preventing smokers from dying than the health care system of country B.
You seem don't seem to get this fundamental point. Health care has only a very small effect on aggregate rates of morbidity and mortality. You cannot draw any meaningful conclusions about differences in the quality of health care simply by comparing aggregate mortality data of national populations. You need data that actually measures the outcome of health care system services, such as cancer survival rates. This data strongly suggests that the U.S. health care system is the best in the world.
But where are you getting your U.S. data from?
I'm comparing it vs. the data from Lancet study (http://politicalcalculations.blogspot.com/2007/10/closer-look-at-cancer-survival-rates.html). So the years are not compatible - (1994 -1998 vs. 2000-2002). I'd love to have more recent data to compare on the Canadian side.
I must say that I'm amused with these types demanding more and more stringent proof for assertions regarding life expectancy while conveniently offering none of their own. It's a 'life-style' thing: Europeans just have a healthier lifestyle. At least, that's the claim. Really? Prove it. Don't expect me to assume it. For example, look at the relative rates of smoking:
http://www.usatoday.com/news/world/2003-12-24-europe-smoke_x.htm
wherein we have the digestible little statistic:
A smoking rate half again as high as the U.S. smoking rate is 'a healthier life-style'? Do tell.
Oh, here's another cite for that one:
http://www.chestjournal.org/cgi/content/full/117/5_suppl_2/354S
No, it seems to me that this is just another claim that is made without reference to any real scholarship; but it's truthiness is quite high among the Elect. "Well, them Euros are so poor that of course they're healthier, what with all that walking and all the unprocessed food their poverty consigns them to."
So how about it? Why don't these free market types actually produce evidence that the European lifestyle actually leads to 'healthier' populations?
Well first, your starting premise is flawed; polishing the 'diamond in the rough', as you would have it, is really a fraction of the developmental costs. I don't know how small a fraction, but I would be very surprised if it was as much as twenty percent, and I wouldn't be surprised at all if it was a low five.
Nor does (universal coverage implies a limited access to medical advances). Huh? What's to prevent someone from spending additional money on the physician and treatment of their choice? Why would you assume universal coverage would be a ceiling and not a floor? That makes no sense.
Finally, addressing your point without conceding the assumptions: This goes to basic numeracy. In fact, Megan had a recent post on this one, where she pointed out that raising the fleet automobile average mpg from 20 to 30 saved more gasoline than raising mpg from 50 to 100. Sure, cutting edge tech is nice, and laudable, and should always have money thrown at its development, but since we're talking about basic accounting procedures, what we want is more bang for the buck
SOV,
If you have any data to support your guess as to R&D as percentage of bringing out a new medical technology, I'd be interested in seeing it. Again, my non-pharmecutical experience was exactly the opposite. R&D was huge (as a startup basically 100%, since admin and overhead only existed to support R&D), and the basic (grant funded) science was a tiny fraction (< 5%) of the research costs. Sure, once you get to a marketable product then sales and marketing represent ever larger portions of the budget, but that's because the R&D costs are fixed (and sunk) at that point whereas sales and marketing costs remain ongoing.
Nor does (universal coverage implies a limited access to medical advances). Huh? What's to prevent someone from spending additional money on the physician and treatment of their choice? Why would you assume universal coverage would be a ceiling and not a floor? That makes no sense.
Universal coverage means different things, but my response was in the context of dmwr's original point, which was that profit needed to be removed from the health care system. I took that to mean (among other things) that providers couldn't work outside the system to increase their profits. In that case, universal coverage would in fact be a ceiling.
I agree that universal coverage need not imply a ceiling but the Canadian style system does, and it's what I took dmwr to be advocating, which is what prompted my question. Does he want a ceiling or is a floor acceptable? I'm not opposed to a floor, but I am to a ceiling.
what we want is more bang for the buck
Well I partially disagree and that's the crux of my point. Bang for the buck is good, but it's not the only factor. Developing new technology involves risk. To increase bang/buck you can squeeze on what you pay for health care (there's only so much inefficiencies in the system), but the new technology risk doesn't change so increasing bang/buck will also means changing the risk/reward ratio. Changing that ratio will cause (some) capital that's now going to pharmecutical/biomedical/genomic R&D to be diverted to different, more economically productive uses.
So no, I don't simply want to get more bang/buck today. I also want to continue to produce even better stuff tomorrow. Any health care policy will have to perform a balancing act between these two priorities. The European health care systems have been able to avoid much of this tradeoff by free-riding on the US health care system to continue to provide the incentives. But if we follow the European model, there's no one left.
So how about it? Why don't these free market types actually produce evidence that the European lifestyle actually leads to 'healthier' populations?
Comparison to Other Nations
http://www.unitedhealthfoundation.org/ahr2007/comparisons.html
Money quote:
Note that the diseases listed have a large lifestyle (exercise, diet, BMI, etc) correlation.
U.S. health costs may be highest due to weight
http://www.msnbc.msn.com/id/21101876/
Money quote:
The study that they refer to is Differences In Disease Prevalence As A Source Of The U.S.-European Health Care Spending Gap
http://content.healthaffairs.org/cgi/content/full/26/6/w678?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=thorpe&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
You apparently need to donate $12.95 for 24-hr access to it. Since I'm a cheapskate, I haven't read it.
Also, the WHO has some interesting data:
http://www.who.int/bmi/index.jsp
If you take a look at Country comparison - BMI Obese Adults (%)
USA is #6, at 32.2%
Most other EU countries score around 15-16%
Also DES Oils, Fats, Sugars (calories/day)
USA is #1, 1462
Most other EU countries, 1100-ish
Best I can do while at work and with limited time. But it's a start.
ScentofViolets,
I must say that I'm amused with these types demanding more and more stringent proof for assertions regarding life expectancy while conveniently offering none of their own. It's a 'life-style' thing: Europeans just have a healthier lifestyle. At least, that's the claim. Really? Prove it.
No said has made that claim. The claim is that differences in "lifestyle" between nations are one of the factors that cause differences in average life expectancy. It is up to those who are claiming that differences in average life expectancy between nations are caused by differences in their health care systems, rather than by differences in "lifestyle" or some other variable or combination of variables (diet, exercise, smoking, alcohol consumption, drug use, crime rates, accident rates, pollution levels, climate, etc., etc.) to prove their assertion. They haven't done that. They haven't come up with even shred of evidence in support of their claim.
There is abundant evidence that Americans tend to lead "unhealthy" lifestyles. The typical U.S. diet is high in fats and sugars and low in grains and vegetables. This is associated with high rates of heart disease and cancer, two of the leading causes of premature death, as well as other serious diseases like diabetes and hypertension. The rate of car ownership in the U.S. is very high, and U.S. land-use policies discourage walking and mass transit. This means Americans don't get much exercise. That also contributes to poor health and premature death. The U.S. also has abnormally high rates of drug use and violent crime. And so on. Unless and until you control for all these other influences on morbidity and mortality, you cannot possibly make any meaningful claims about a causal relationship between average life expectancy and health care. It's ludicrous.
ScentofViolets,
Huh? What's to prevent someone from spending additional money on the physician and treatment of their choice?
The fact that they can't afford to, thanks in part to the high taxes they have to pay for their nation's "universal health care" system. There may also be legal or regulatory barriers to the purchase of health care services outside the government-run system, as in Canada and Britain, for example. If Canadians and Britons and other subjects of "universal health care" had the means and the opportunity to "spend additional money on the physician and treatment of their choice," their health care systems wouldn't be plagued by widespread shortages and waiting lists for consultations, tests and treatments. As the Canadian Supreme Court put it: Access to a waiting list is not access to health care.
Sigh. Mixner, we've already established that you lie quite casually and make stuff up without doing the most cursory research. Please go away. Barring that, just don't respond to me any more.
Scent,
You haven't "established" anything, and I'll continue to rebut your false, irrelevant and misleading assertions as I see fit.
Riiiiight. Like you 'checked up' on the fact that Americans want 'shiny new hospitals and private rooms', like your 'facts' about how much MRI's cost, and what drives that cost etc.
I know this is hard for you to believe, but there are some people who are actually interested in the truth, not defending some side or ideology. There are even people who really, honestly, think that making stuff up just to support a position is reprehensible, and not just good tactics.
If it makes you feel better, I'll even expand on this: I've established to my own personal satisfaction that you lie casually and make stuff up out of the blue. What other people may think is up to them.
Takeflight, I think you need to make a better connection than that. For example, from your quote:
Doesn't seem to square with my statistic, which shows that Europeans smoke more (and this is certainly my experience), in fact, at rates half-again as high. I'm guessing that the kicker is the 'former smoker' part; if you tried cigarettes in high school or jr. high, and perhaps even bought a pack or two, you're counted as 'former smoker'
Here's another table:
http://www.kidon.com/smoke/percentages.htm
Which confirms that the United States has a _lower_ incidence of smoking.
I also note that the claims for deaths related to obesity have been vastly exaggerated:
http://www.consumerfreedom.com/news_detail.cfm/headline/3509
http://www.consumerfreedom.com/news_detail.cfm/headline/2744
So, no, it doesn't look like there's much evidence so far for the 'unhealthier' life style (in fact, there's evidence that being a little overweight as measured by the BMI is actually healthy in some respects.)
Scent,
Like you 'checked up' on the fact that Americans want 'shiny new hospitals and private rooms', like your 'facts' about how much MRI's cost, and what drives that cost etc.
That's right.
Doesn't seem to square with my statistic, which shows that Europeans smoke more (and this is certainly my experience), in fact, at rates half-again as high.
On the contrary, the two statistics are entirely consistent. Nation A may obviously have a higher fraction of "former or current" smokers than nation B even if it does not have a higher fraction of current smokers. The fraction of the population who are "former or current" smokers obviously depends on smoking rates in the past, as well as on the current smoking rate.
So, no, it doesn't look like there's much evidence so far for the 'unhealthier' life style(in fact, there's evidence that being a little overweight as measured by the BMI is actually healthy in some respects.)
You're wrong about this, too. There is overwhelming evidence of a link between being overweight or obese and greater health problems, including premature death. Read the links in TakeFlight's post. A recent study did find a slightly reduced risk of mortality for mildly overweight individuals (but not for obese ones), but that study is controversial, inconsistent with a large body of earlier research, and did not find a reduced risk of non-fatal health problems.
Here's the abstract of the Health Affairs study TakeFlight references in his previous post:
The conclusion is clear: The U.S. spends more money on health care than European nations in part because Americans tend to be sicker than Europeans.
Another recent study that reached the same conclusion with respect to a comparison of Americans and Britons is described in this New York Times piece. The lead author of the study explicitly rejected the claim that the health differences between the two nations can be attributed to differences in their health care systems, suggesting instead that the cause is differences in "the circumstances in which people live."
No, don't have any hard data for the pharmeceutical industry; that's why I indicated whether or not I would be surprised. What I am doing is specifically referencing something else you wrote, namely this:
You seem to want to advocate that those dollars for 'basic research' don't count as part of the R&D costs. Why not? You need that research before you even have a diamond, polished or otherwise. Let's look at something I'm more familiar with, the transistor:
http://en.wikipedia.org/wiki/History_of_transistor
It's an OK synopsis, but it neglects certain details, like how the process to grow germanium crystals was actually developed at Purdue university, or the fact that Bell Labs was essentially a research university embedded in a corporation (and now, sadly, defunct - it 'didn't make a profit.) Or the fact that Bell Labs didn't earn any money from their research, no, that went to folks like RCA who, to use your words 'polished an uncut diamond'.
Do you really mean to say that you don't think those research costs, the costs from developing the actual transistor itself, the costs of developing the ancillary technology such as growing germanium crystals of the necessary purity, the costs of figuring out the really fundamental stuff, quantum mechanics, solid state physics, et al should be counted as 'real' R&D costs? Or that if they are counted, that they are considerably smaller than what other companies put in to bring the product to market?
If you really think either of those things, then there's no point in continuing this conversation. If you're reasonably connected to the real world, reasonably sane, then how can you possibly justify your view of the heroic entrepreneur?
Pharma companies spend approximately 2-1 on marketing vs. R&D. This data comes from a new study:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050001
Remember that most pharma spend goes to marketing to physicians (DTC is growing, but still a smaller portion of total spend). In 2002, when I was still in the industry, it was estimated that drug companies were spending $20b a year in the US to market just to doctors (this new study puts that number higher). That's $20b to market to around 700k physicians. More realistically, there are approximately 150,000 physicians who "matter" to the pharma companies (large script writers) - most of the spend goes there.
There are a number of issues related to drug development that iscausing the increase in spend:
- FDA requiring that a new product beat a placebo rather than beating the best-in-class products already developed. This creates incentives for pharma companies to create me-too products and combination products that they can market heavily.
- The fact that, by some estimates, up to 96% of all first and second line therapies have already been developed. Many of these will be coming off-patent in the coming years. Pharma companies have built huge sales and marketing channels to support blockbuster drugs, but they are now finding that new drugs are for increasingly smaller ailments and populations. This breaks their existing model.
The pharma companies have responded as you would think they would - they have been cutting sales staff. At one point, in NYC, Pfizer had 8 individual sales reps calling on one doctor. In recent years, we're starting to see the larger pharma companies start to rationalize their sales channel and cut reps. But they have not cut R&D, and they are focused on acquisitions since it is the smaller (particularly biotech) companies where the real product development is happening.
Takeflight, I think you need to make a better connection than that
Are you offering to fund my research? ;)
Doesn't seem to square with my statistic, which shows that Europeans smoke more (and this is certainly my experience), [....] and perhaps even bought a pack or two, you're counted as 'former smoker'
I don't know where they draw the line. I would like to see that particular study. I agree that my own observations in Europe lead me to think that Europeans smoke more. However, there may be a lot of people in the US who smoked for years, then quit. I read somewhere (no citations, sorry) that the effects of smoking are cumulative and that, even though you should quit, quitting doesn't roll back the clock on the increased risk of adverse effects. So it may be a valid factor to survey.
In any event, for lack of better data at this point, I will concede that the smoking lifestyle factor likely is a wash although I reserve the right to cross-examine the witness later.
You links on obesity, though, are pretty thin.
Both address the claims made by a single study:
None of these, even if false, really refute the point that obesity is a huge factor in health. Are you claiming that since life expectancy is actually better than David Ludwig's forecasts, obesity isn't really bad? I think if you're making such a claim, you'll find yourself swimming upstream against a lot of medical professionals ("scientific consensus", anyone?).
Having said that, there is evidence that overall physical fitness is a better indicator for health risk than simple "obesity." I concede that some (likely very few) obese people are actually "healthy" in the terms we're discussing here. I would like to find more data on overall fitness of US & EU.
You're right, there is some doubt, but not enough to dismiss the case yet.
dmwr,
It sure seems like we're seeing more consumer-targeted (TV) advertising even for prescription products as well.
we're starting to see the larger pharma companies start to rationalize their sales channel and cut reps. But they have not cut R&D
But in the end, isn't it no sales income = no R&D outflow? I don't know that just because there's some excess waste to trim in sales that R&D will remain unaffected.
But in the end, isn't it no sales income = no R&D outflow? I don't know that just because there's some excess waste to trim in sales that R&D will remain unaffected.
Well, let's look at it this way: if a pharma company's patent on a product goes away, they see sales go down as generic companies take over. If the company has all their products go generic at the same time (or a substantial portion of total revenue), then they might cut all areas of the company. This is a rational market decision.
The fact that the company has had all of their products go generic, and that they don't have any further, substantial products either indicates that they weren't spending enough on R&D, or that they spent money on R&D that didn't pan out - either because the product was not effective (even against placebo), failed in reaching it's primary end-point, or that the market for such a product is too small relative to the cost to put that product into the pharma company's sale and marketing engine.
This is, more or less, what happened to Pfizer. Now they also had one of the largest sales and marketing organizations in the pharma business. Their reaction: reduce sales, reduce marketing, increase marketing spend for DTC for products still under patent, cut marketing spend for products no longer protected by patents, increase R&D and acquisition activity, and finally, offload smaller products that do not meet the revenue of the sales and marketing channel to smaller companies.
Given that Pfizer tended to focus on products that matched their sales and marketing channel/revenue needs, they put their R&D efforts into those areas - which is what the FDA has encouraged. So they have reaped what they sowed.
SOV,
Sigh. if you would take the time to actually read what I wrote before flinging insults, you would see that I was speaking of my personal biomedical startup experience. Anecdotes may be of limited utility, but not zero.
I'll retell my anecdote for your benefit. I worked for a biomedical startup that had a product on the market in Europe but not yet in the US and there was an issue in the US clinical trial when we were needing additional funding. It was stated that having a product available in the European market but not the US market would not receive funding. The return from the European market was insufficient to get continued funding. I don't know how generally applicable this experience is, but I don't have any reason to believe it's an outlier, venture funding models are pretty generic.
Also, I haven't dispute the necessity of basic research, but there can (but not must) be a large gap between the basic research and an actual product. Sometimes this gap can (but again, not must) be measured in years and orders of magnitudes of dollars. The startup I worked for was an existence proof. In the health field this gap is even larger and riskier than most fields; going from a peer reviewed paper to FDA market approval is not a trivial process. Currently this gap gets filled by private industry. If you suck all the profit out of the system, you're reducing the incentives for private industry to fill this role. Now things could continue on as before but with lower returns, but it seems far more likely that (some) capital will be diverted into other places.
Also, be careful to compare apples with apples. The large pharma companies are not the entire health care industry, and as dmwr points out, their model is different than the small companies. They're attacking problems that can fit their sales & marketing channels, but a lot of the interesting work (for drugs as well as biotech) is being done at small, often venture funded, companies.
For a different example outside of pharma, look at Medtronic. Their business model involves letting startups prove out the technology and absorb that risk. Once the technology is shown as viable, they then acquire the company and add it to their sales/distribution channel. They do continuing R&D, so their R&D budget is not zero, but they're (largely) not responsible for new technology, they're doing refinements on existing stuff. The new, truly exciting work happens off of their books, and that's the work that I fear will cease to be funded.
I see this same pattern in a lot of technology fields. Federal grants provide the basic research, venture funding makes it marketable, large public companies acquire and add sales and marketing. If all you look at is the big public companies budgets, you don't get the larger picture. Sure, the big companies are doing more sales & marketing than R&D, but that's their position in the food chain, it's their value-add. I'm sure it's not the only model that would work but measured by pace of innovation, it's one that is working. Before we look at just the large companies and say, "there's too much profit there, we can cut costs", remember that they are part of a larger ecosystem. You couldn't eliminate an apex predator without causing a massive disruption, these large companies are filling an analogous role. They can (and perhaps should) be hunted, but driving them extinct might not provide the best outcome.
I worked for a biomedical startup that had a product on the market in Europe but not yet in the US and there was an issue in the US clinical trial when we were needing additional funding. It was stated that having a product available in the European market but not the US market would not receive funding.
Agreed - but your assumption there is that if you bargain with the government, you will not receive a fair price. I've seen no proof of this in any drug or medical device category. Perhaps it was as much about the size of the market as well as the ability to gain fair pricing?
Before we look at just the large companies and say, "there's too much profit there, we can cut costs", remember that they are part of a larger ecosystem. You couldn't eliminate an apex predator without causing a massive disruption, these large companies are filling an analogous role. They can (and perhaps should) be hunted, but driving them extinct might not provide the best outcome.
Agreed - but if we are saying that private insurance and the current healthcare value chain should stay around (which is central to your argument about innovation), then the government should have the ability to bargain for price, just as PPOs and HMOs do either directly or via the formulary. From what I've been researching, drug pricing has definitely increased as a result of the new Medicare drug benefit (maybe someone else has some better data) - and this provision was obviously written by the pharma lobby.
Agreed - but your assumption there is that if you bargain with the government, you will not receive a fair price. I've seen no proof of this in any drug or medical device category. Perhaps it was as much about the size of the market as well as the ability to gain fair pricing?
Actually, it wasn't so much the size of the market as the nature of it. The product was not life-saving, it improved quality-of-life. The European system funding is more triage based, so quality-of-life gets less budget.
And to be clear, it's not that the reimbursements were "unfair". It's that the return didn't meet the risk-adjusted requirements of the venture model. One of the interesting (and non-obvious to me) risks was that future budgets would reduce the number of implantations allowed. Even if each implant had a reasonable reimbursement, if they became too heavily rationed, the company would see insufficient revenue.
In Europe, the size of the market is largely not defined by the number of people afflicted, it's more defined by the political process. There's some correlation between the two, but not a direct one. Note that this means that there's a lot of political lobbying required to get your product a line item in the health care budget. This is another hidden cost, plus it's one I find to be fairly unsavory.
[B]ut if we are saying that private insurance and the current healthcare value chain should stay around (which is central to your argument about innovation)
Well, not exactly. My argument is that a single payer system that uses its monopsony position to minimize costs will harm innovation. I have not argued for preserving the current healthcare value chain as is.
From what I've been researching, drug pricing has definitely increased as a result of the new Medicare drug benefit (maybe someone else has some better data) - and this provision was obviously written by the pharma lobby.
I've read (I believe here) that the Medicare drug law has a provision that the government has to get the best price offered to any customer. Since the government is a big enough customer, I believe the pharmas have (rationally) raised the prices that some big customers were getting in order to have the lowest price be higher when selling to the government.
But whether or not this was the pharma lobby at work or simply an unintended consequence of a rational statute, I don't know. I could believe either.
Takeflight, no, smoking damage is not cumulative, thank God (over the years, I've puffed through a quarter of a million cigarettes, a conservative estimate):
http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33568
The obesity issue is a somewhat different; I know people who could in no way shape or form be considered flabby, people whose percentage of body fat was low enough that you could see their sculpted abs. People whose BMI was was 27 or greater, putting them into the 'overweight' category. Here's one link:
http://www.obesityfocused.com/articles/about-obesity/definition-of-obesity.php
Note that I'm not saying that being overweight is health-neutral, I'm saying that the true figures of morbidity for obesity is somewhat lower than what is commonly thought. Here's another article:
http://www.consumerfreedom.com/article_detail.cfm?article=165
And a few choice quotes:
and:
So if the true figures are 1/10 of what has been reported (this seems to be a reasonable presumption), that is, 40K rather than 400K deaths per year directly associated with obesity, then that condition would have a correspondingly smaller effect on life expectancy.
Let's look at another 'lifestyle' choice - alcohol. There it seems to be a wash, here's a graphic:
http://www.who.int/substance_abuse/facts/alcohol/en/index.html
Which is not terribly surprising actually, given that most of us are largely descended from European stock.
What other 'lifestyle' choices did you have in mind that affect longevity? Because from here it looks as if the United States population looks at least as healthy as those in Europe insofar as basic lifestyle is concerned. Which is, anecdotally, not surprising - there seems to be an undertone, a buzz about the Continents superior Way Of Life, but I sure haven't seen it. Oh, I'll concede an unquantifiable cultural/historical superiority, but let's face it - rural is rural wherever you go. You think the coastals look down on small town USA? That's just about what you hear from the 'elites' in Germany, Italy, Spain, etc.
Here's some references for how the bill was bought for by the drug lobby:
http://www.washingtonpost.com/wp-dyn/content/article/2007/01/11/AR2007011102081.html
"The industry worked closely with the Republican Congress to shape the Medicare prescription drug program, which included a provision barring the government from negotiating with the pharmaceutical industry for lower prices. In the three-year run-up to passage, industry lobbyists poured more than $6 million into both Republican and Democratic campaign coffers, dispatched an army of more than 800 lobbyists to Capitol Hill and quietly funded seniors organizations and patient advocacy groups that opposed Democratic alternatives."
http://www.cbsnews.com/stories/2007/03/29/60minutes/main2625305.shtml
"The unorthodox roll call on one of the most expensive bills ever placed before the House of Representatives began in the middle of the night, long after most people in Washington had switched off C-SPAN and gone to sleep.
The only witnesses were congressional staffers, hundreds of lobbyists, and U.S. representatives, like Dan Burton, R-Ind., and Walter Jones, R-N.C.
"The pharmaceutical lobbyists wrote the bill," says Jones. "The bill was over 1,000 pages. And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning," remembers Jones."
dmwr,
If all medical funding was done through the political process, do you think the lobbying activities you reference would go down or up?
If all medical funding was done through the political process, do you think the lobbying activities you reference would go down or up?
If you mean going to a single payer model, it would dry up because the medical insurance lobby would be dead or severely disabled. Who would be there to pay?
But the lobby would fight tooth and nail to not have that happen. Given the nature of political lobbying in this country, I therefore give a chance of a single-payer system about zero chance of passing.
If you mean lobbying to get medications on formulary, I expect the same amount of lobbying that currently happens with HMOs, PPOs as well as VA, and Medicare. So probably status quote.
Be hard for the pharma industry to increase the spend - by one count they had 1000 lobbyist in Washington during the height of the Medicare rip-off, uh, I mean bill.
If you mean medical funding for medical research - as I've said repeatedly - I'm not for that! :)
But maybe you meant something else?
According to your links, it wasn't health insurance companies that lobbied Congress, it was primarily the drug companies. Even in single payer, the drug companies will continue to exist but in single payer the only customer they can sell to is Congress. Do you think they will have incentive to lobby more or less?
My startup felt the need to hire a lobbyist. That's how you get your new treatment into the budget. New treatments are budgetarily problematic because they don't have an established track record (bang/buck is unknown), so you want a friendly government representative to add funding for your pilot program. BTW, it helps if the hospital running the pilot program is represented by the health system's committee chair.
That's what happens under single-payer systems. These sort of decisions (what hospital runs the pilot program, etc.) cease to be medical or even economic decisions, and instead become political. We see this all over the place in military contracting. What leads you to believe health care would be immune? They weren't with the Medicare law. If Congress becomes the entire system, every health industry is going to have a massive incentive to do exactly what pharma did with the Medicare prescription act. Belly up to the bar and make sure they get their share.
I apologize unconditionally. I am sharp, even derisive, with some people, but only because they don't play by the rules. You seem to be sincerely interested in a discussion, and playing by the rules, so I have no cause to insult you. However, could you tell me what you construed as insulting? I certainly didn't intend to be, and looking over what I wrote, I don't see where I was. If you tell me, I can avoid this in the future.
Well sure, but I fail to see your point. Isn't this what will always happen, regardless of the model?
Well, yes. But two points: many companies in dealing with the government - and doing R&D have profited quite handsomely. I don't see how a universal health care model automatically negates profit, in fact, imho, that would be a reason not to implement that particular model. Secondly, when you talk about 'R&D', you have to say what you mean, be more specific, than to simply talk about 'diamonds in the rough'. That's why I chose the development of the transistor as my example. To my mind, talking about RCA's research & development costs for introducing transistor radios (to mark my age, I owned in my youth a radio that, embossed on the casing, proudly claimed to be an All Transistor Radio!) to the market really should count as part of the costs the actual development of the transistor. To say that transistorized appliances wouldn't have appeared without the profit motive, that there would have been no R&D is to miss the much larger share of costs that went on without this particular incentive.
And to get back to the point, if the R&D work done by the pharmaceutical houses is like replacing tubes with transistors, then talking about the profit motive seems somewhat nonsensical. If, otoh, you're thinking of, oh, wait, here's a good example: The 2007 Nobel prize was awarded for the discovery of giant magnetoresistance. I won't go into details, but suffice it to say it was basic research of the type I wouldn't expect a private enterprise to be able to do. Then private companies ran with it (some with government funding) and put the effect to practical use in the data storage field. As an example:
http://www.research.ibm.com/research/gmr.html
Now, as I was saying, if you think the relationship between publicly-funded pure research and the product released by the big pharmaceutical houses is like the research and development of magnetoresistance, then I'd say you definitely have a point. But I've seen no evidence of this, in fact, a lot of evidence that the basic model is more like the transistor example. If you've got anything to show that this is not the case, I'd sure like to see it.
Again, I'd have to see the specifics upon which you base this assertion. Did you have any examples in mind that are representative of this smaller company you are describing?
See, I don't like the Medtronic model. In fact, it seems predatory. But why would you think universal health care would obviate this independent research? Government has a long history of paying for this kind of thing.
And it's precisely those companies that seem to be responsible for the huge markup in pricing. Why can't the government step in assume this role of distribution? Then the innovative research will still get done - and handsomely paid for - but the overall cost to the consumer will go down. Isn't this to be considered a good thing?
In fact, I fail to see why you think the big companies who follow this pattern of behavior you describe is to be considered a good thing at all; it seems, as you say, to be quite literally predatoy. Most definitely not a good thing.
What was your product? I think the details are important. See, I'm not much of a theory guy on these sorts of issues; I think they need to be taken on a case-by-case basis. The theories that I think apply tend to be descriptive rather than prescriptive, and the only reason I'm for a different model of health care is because the one we're using now seems to be demonstrably suboptimal.
Again, this seems to be an objection rooted in theory. In practice, this happens with all health care systems. Including ours.
According to your links, it wasn't health insurance companies that lobbied Congress, it was primarily the drug companies. Even in single payer, the drug companies will continue to exist but in single payer the only customer they can sell to is Congress. Do you think they will have incentive to lobby more or less?
These sort of decisions (what hospital runs the pilot program, etc.) cease to be medical or even economic decisions, and instead become political.
We see this all over the place in military contracting. What leads you to believe health care would be immune? They weren't with the Medicare law. If Congress becomes the entire system, every health industry is going to have a massive incentive to do exactly what pharma did with the Medicare prescription act. Belly up to the bar and make sure they get their share.
Uh, this is already the way our government works.
I think you're confusing lobbying governmental organizations and Congress. Congress doeesn't "own" a single payer system - they'd setup the organization. Then pharma companies would lobby that organization to have their drugs put on formulary. This would likely follow a standardized process - similar to the way the FDA requires pharma's to submit applications for new drugs. Presumably the new drug/device would be evaluated vs. similar drugs or the drug currently in use and a decision would be made.
Would this process become political? It is always somewhat political, but the FDA isn't often viewed as being political - they're more often viewed as being science-driven. As is the NIH. Fact is, if you have scientists working it, it will probably be pretty good - I think the NIH and FDA do a pretty good job in terms of both setting up grants for research and in the drug approval process.
Congress, with it's ability (limited at the moment) to pass laws, would remain a lobbying target for the pharma industry, and may or may not remain a lobbying target for the medical insurance industry. But who knows? Maybe they amp up their lobbying. Maybe they blow away like a tumbleweed. Really, it is impossible to know.
My startup felt the need to hire a lobbyist. That's how you get your new treatment into the budget.
Budget for what? Medicare? Fine - I don't see an issue with this. I'm fine hiring someone to get your product in front of the right people - if it flies from both a scientific and cost/benefit analysis, great, if not, then maybe the product shouldn't be on the forumulary. This is all really no different than what companies do with HMOs and PPOs by the way. The FDA used to tag products with a basic high-medium-low rating in terms of the benefit - I wish they'd return to that - that's another way the pharma lobby has flexed their muscle.
See, I don't like the Medtronic model. In fact, it seems predatory. But why would you think universal health care would obviate this independent research? Government has a long history of paying for this kind of thing.
It's a good point - maybe big pharma will be the record labels and blow away. Yeah, right! :)
This seems to be your central thesis. I agree that the degree to which the various health care models influence innovation, or it's lack thereof, is a valid concern. But what makes you think that a single payer system would be worse than what we have now? What specific examples, what specific mechanisms, other than some vague appeal to economic theory or prejudice? I know for a fact that to some extent, innovation is deliberately stifled right now, the way affairs currently stand. For example, milking the patent lifespan of a particular drug even though there are more efficacious drugs that could be released to the market that have been discovered in the interim, in fact, patenting those drugs at the first sign a competitor has come up with something similar just to block their entry into the market. Or making minor alterations in a drug to re-invoke the patent barrier and prevent the sale of generic alternatives.
no, smoking damage is not cumulative
But the data on your link shows that the negative effects are not completely neutralized, even after 15 years, except for risk of coronary heart disease.
I actually read that other consumerfreedom article before but didn't comment on it because I think it's mostly irrelevant. This is starting to sound somewhat like a shell game. They're saying obesity itself isn't the cause, but that it is the lifestyle factors of obese people - "physical inactivity, low fitness levels, poor diet, risky weight loss practices, weight fluctuation, use of weight loss drugs", etc. Okay, sounds like my original argument to me: lifestyle. And it seems that this just confirms that obesity is a good indicator of health, even if it is not - in itself - the actual cause of the problems. What am I missing?
So if the true figures are 1/10 of what has been reported (this seems to be a reasonable presumption), that is, 40K rather than 400K deaths per year
The way I read it, it's not 1/10 but 1/10 less:
What other 'lifestyle' choices did you have in mind that affect longevity?
Well, I could go with physical inactivity, low fitness levels, poor diet, risky weight loss practices, weight fluctuation, use of weight loss drugs...or
http://www.medscape.com/viewarticle/507156_2
http://www.euractiv.com/en/health/lifestyle-health/article-154425
Though I admit it sure would be nice to find a big, smoking-gun comparison survey of US vs EU instead of having to do all this CSI style investigation.
BTW, and off-topic, I love this quote from the consumerfreedom article:
"Our estimates may be biased toward higher numbers due to confounding by unknown variables."
I think I'm going to add that to all my outgoing e-mails....
This seems puzzling:
and this:
What officials from what organization did your your startup lobby? You seem to think that these people are going to put the arm on some congressman, but I would think that there would be an agency, like the FDA or the CDC, who would be in charge of these sorts line items. So isn't this kind of what happens already?
Or are you talking about something else?
"Our estimates may be biased toward higher numbers due to confounding by unknown variables."
That is the best line I've heard in a while - definitely going in my signature from now on. :)
I agree that the degree to which the various health care models influence innovation, or it's lack thereof, is a valid concern. But what makes you think that a single payer system would be worse than what we have now?
Ahh...perhaps some common ground?
What specific examples, what specific mechanisms, other than some vague appeal to economic theory or prejudice?
My personal experience wherein the European health care systems reimbursements would not justify continued funding whereas the US health care system did. It's an existence proof of my thesis. How generalizable it is, I can't say but I've worked at enough (non-health care) venture-funded places to suspect it's not too far off the mark.
On the flip side, I point to the military development procurement process as an example of a single payer system that produces innovation but at a shockingly slow pace for an astoundingly high price. NASA also appears to fit this bill.
I feel comfortable in saying that under a single payer system, we can have low prices or we can have innovation, but we are unlikely to have both. Besides, you're the one making the argument for change. The burden's on you to prove that the single payer system wouldn't harm innovation.
Yes, there's a markup in our current system. It's chasing that markup (also known as profit) that attracts venture funding. Are the margins too high? Good question, I can't say. In large part, your answer to that probably depends on whether you need health care now or not. If you're sick now, you want the best care you can get today as cheaply as possible. If you're healthy, you want as much money chasing new treatments as possible so when you do require care you maximize your outcome.
All I've been saying is that any health care reform needs to balance these two. This thread has largely about how we could get care today more cheaply and I agree we could do that. My basic point is that there's a hidden cost to reducing today's bottom line; minimizing costs today will chase away dollars working on tomorrow's cures. I don't think that simply squeezing today's costs as hard as possible will minimize net human suffering over time.
And again, I'm not claiming that our current system is optimal either. I'm just saying that to minimize net human suffering is a different (and harder) problem than just asking how many people can we cure today for X% of GDP. That's the only question that single payer advocates seem to be interested in, but it's not the only relevant one. And being currently healthy but aging at the rate of 1 year/year, I'm very interested in encouraging future advances.
And again, I'm not claiming that our current system is optimal either. I'm just saying that to minimize net human suffering is a different (and harder) problem than just asking how many people can we cure today for X% of GDP. That's the only question that single payer advocates seem to be interested in, but it's not the only relevant one. And being currently healthy but aging at the rate of 1 year/year, I'm very interested in encouraging future advances.
I think people interested in single-payer systems are interested in one issue: how can we supply healthcare to every US citizen. The answer to this by critics - fair I might add - is how can we pay for it. The answer from the single payer advocate is that our administrative costs are too high because of the multi-payer model. And so on.
I actually think there is an easy solution for the pharma companies if they were thinking ahead of the curve. It's best stated by Uwe Reinhardt in Frontline interview on the subject (this is prior to the Medicare drug act being passed):
"Frontline: From a public relations point of view, the drug companies have really been in the crosshairs, attacked from many, many sides. Does it matter that they are as unpopular as they are? Can they weather this, or do they have to really pay attention to their image?
Reinhardt: Industries can weather such storms, but it's very expensive and the impression lingers. It goes into the folklore. It saddens me, in a way, how that industry has allowed itself to become the scapegoat for all kinds of problems in health spending that's really not their fault. They could have been more proactive.
For instance, that industry should have worried about having a lot of poor elderly without insurance having to pay double the price for drugs that everyone else pays. You know, that sort of situation really violates the sense of fairness among Americans. That should never have been allowed to happen. They should have done something. Maybe a card that such elderly get, that says you pay no more than the average insurance company pays in this state, something where the drug industry would have sort of made a gesture. But they didn't.
And so I think when they get in trouble, as they might in the next five years, there'll be relatively little sympathy for them. And in a way, I don't think it's good, because whom do we look to, to get rid of SARS? It's not surgeons. It's the drug industry. So you know, you don't really want to hurt that industry."
http://www.pbs.org/wgbh/pages/frontline/shows/other/interviews/reinhardt.html
Begging your pardon, but that is most definitely not specific. You mentioned 'implants' and I've already asked for clarification but have yet to receive it. I'll ask again: what were these 'implants' that that were considered as you say 'quality of life' items rather than something more needful?
If you're talking about some sort of drug delivery system, say an insulin feed, then I'd be sympathetic, but I'd still want to hear more details about it's cost relative to providing simple shots. If we're talking about a tenfold increase in cost, then I don't think you can criticise this sort of rationing.
If, otoh, your talking about something cosmetic when you're alluding to 'quality of life', if, God forbid, you're talking about something like breast implants, then pardon me while I quietly choke a bit, before replying no, that is most definitely not a valid example.
Please tell me that's not what your venture startup was trying to sell.
SOV:
I'm still under NDA, so I can't go into details about cost/benefit and the like, but it wasn't cosmetic - it was auditory. Think cochlear implant.
Oh, and to be clear, deafness/hearing impairment are often considered as quality of life issues. For example, most insurance companies don't cover hearing aids.
But this doesn't support your argument at all then; it's demonstrably more expensive than the alternatives, and I don't see how you can claim any sort of technological innovation of the sort you say will be stifled. Cochlear implants have both a) been around for some time, and b) are controversial everywhere. Finally, c) to the extent they are approved here in the U.S., guess which authority approved them? None other than that stodgy old body of government impediment, the FDA:
http://www.fda.gov/cdrh/cochlear/Approved.html
Oh, and something I didn't address from an earlier post of yours:
The military procurement process suffers, not because of politics per se, but because there is no objective scientific criteria to rate purchases. So it's very easy for various people to come with 'reasons' for doing what they were going to do anyway. Sound familiar :-( Otoh, rating the effectiveness of a new drug, or procedure or treatment can be done in a very scientific manor, in fact, there are already scientists and scientific bodies employed by the government for just this purpose. If there's any complaints about 'politicization', it's complaints from the departments themselves about the insertion of the adiministration's cronies and their distortion of this evaluative process.
So I don't think you can point to the military procurement system as an example of how the system would work in practice.
I wrote "Think cochlear implant", not "cochlear implant". It was a different technology with a different set of tradeoffs. It could treat some patients more effectively the cochlear implants, especially people whose hearing loss isn't as profound (higher fidelity, no retraining necessary). My point was that it's not breast implants, it's a Class III active medical device.
And the utility of this particular application is almost irrelevant. Not every new technology will become the standard of care, but that doesn't mean that the current standard of care is optimal. Your argument seems to be that if a new technology isn't immediately more cost-effective than the old, it shouldn't be funded. How long did it take transistors to be more cost-effective than vaccuum tubes? How agressively would it have been developed if there was only one potential customer who was unwilling to buy until it was better and cheaper than tubes?
You're also neglecting that medicine is not one-size-fits-all. I think it's a good thing that we have multiple therapies for the same disorder. Ever had to change meds to avoid a side-effect? Often what works for one person doesn't work for another, or the cases differ in relevant ways.
And for the record, my argument is not that single payer health care would necessarily work like the military procurement system, it's that the military is an example of a single payer system and innovation is slow and expensive relative to the private sector. My secondary point with the military is that even basic procurement is a heavily lobbied activity. Nor do I buy your assertion that there's no objective scientific procedures behind military procurement. They call it mil-spec for a reason. Everything the military purchases is very well spec'd.
They call it mil-spec for a reason. Everything the military purchases is very well spec'd.
Yes but it doesn't seem required to actually work - ala B2 bomber or the Patriot missile. The comparison isn't valid - having a spec for something is not the same as having medical or scientific proof that it works. That is the clinical trial process. There isn't an equivalent in the military world because they will often continue on in projects even though they don't work. The reason for this is that there is generally a sunk cost for the military during development. This isn't the case with pharmaceutical or medical devices - they either work or they don't work. If they don't work, the company goes back to the drawing board. In the military world, if you fail, they generally give you more money on top of the money they've already given you to go make it work.
No, I don't have an argument. I asked you for a specific example to support your theory. You gave me your 'personal experience', which I assume is this hearing device. With all due respect, I repeat, that is not an example that supports your theory, for the reasons I outlined above.
If you want to support your theory with examples, your example must involve some innovation that holds, if not the promise, at least the distinct possibility of a superior outcome, with the dimensions of superiority explicitly stated - is it cheaper, for example, or can it be used to treat what were previously untreatable cases.
As to your questions about transistors, you might be surprised at what you find. As I indicated, they were not developed within the framework of your private enterpise model. And it was obvious from the outset what potential advantages they had over vacuum tubes. When I say 'potential', btw, I mean that there were excellent theoretical arguments for believing this. I don't use 'potential' in the sense that there was a vaguely expressed possibility that they _might_ turn out to be superior to vacuum tubes in terms of power consumption, weight, reliability, ruggedness, switching speeds, etc.
SOV:
You proved nothing, you've simply been contrary, and in a way that doesn't even make sense. While acknowledging that my example is short of detail due to legal reasons, it is an innovation. It's being developed by private funding with the expectation of superior return compensating for the inherent new technology risks (that it doesn't prove to be better, that it doesn't gain market acceptance, that some currently unknown reason is uncovered that makes it infeasible, etc.) One health care market supports the continued development, another one doesn't. It's exactly an example of my thesis.
The expectation of superior returns is what encourages private capital to be invested to pursue these innovations. There has to be, as you put it, "excellent theoretical arguments for believing [potential advantagesof the innovation]" That's why we received private funding in the first place. Have you ever received VC funding? You have to pretty explicit about how your product is going to be marketable, which means you have to convincingly demonstrate where you're going to better than the competition. (And more convincing than with a military contract, I'd argue. The VC's are putting their own money at risk, not the taxpayers.)
Now, perhaps this is out at the margin where the societal cost of lost innovation is out-weighed by the cost savings seen from monopsony pricing. Fair enough, that line exists somewhere and perhaps this has crossed it. But it's still an existence proof of the US health care system supporting more innovation than the European health care system.
And frankly, my point seems so obvious I can't believe it's being argued. You're the one arguing for the change - let's get single payer so we can squeeze profit out of the system to deliver more health care/dollar. You prove to me that reducing the profit margins won't cause a decrease in investment. Give a real, concrete example of an industry where the margins have declined and that's resulted in no change (or even better - increases) in investment in that industry. As the one proposing the change, the burden of proof is on you to justify your proposal.
brooksfoe - re "My freelancer friends are paying over $20,000 a year for health insurance for one parent and child."
Very unlikely. If it was once case it might be a situation where the person was paying a high cost to provide insurance coverage (well really more of a medicinal payment plan than true insurance but "insurance is the commonly used term even when you really aren't insuring against / pooling risk). But mulitple people? Insurance rarely costs that much.
Maybe in New York. Costs are extraordinarily higher there, but even in New York it seems really unlikely. And the costs in New York State are pushed higher by state regulation. It would be simpler and more direct to repeal some of that regulation than put in place a national insurance scheme.
See
http://siliconinvestor.advfn.com/readmsg.aspx?msgid=23852911
http://siliconinvestor.advfn.com/readmsg.aspx?msgid=23852970
http://siliconinvestor.advfn.com/readmsg.aspx?msgid=23853115
brooksfoe - re: You know perfectly well that administrative costs at private health insurers are over 20% of total costs, while administrative costs at Medicare are under 2% and at Medicaid are around 5%.
I know perfectly well that this is false, or at best misleading.
Even the officially reported administrative costs for the government programs are more than 2% (more like 3% or a bit more), and the costs don't include costs for services or activities that are outsourced, and for costs born by other parts of the federal government, and costs imposed on third parties. Meanwhile over 20% is too high of figure for the private companies. For example taxes paid are not administrative costs. And profits aren't administrative costs either (and even if you include them your figures are still too high).
http://www.manhattan-institute.org/html/mpr_05.htm
http://siliconinvestor.advfn.com/readmsg.aspx?msgid=24138146
dmwr - Re: "Japan provides workers with healthcare, and, as a result, it is one less cost given to Toyota."
The cost is still there. If its paid for by the government than it comes from taxes. Toyota pays taxes, as do its customers and employees. If the employees pay more Toyota has to increase the amount it pays for labor. If the potential customers pay the cost, than they are less likely to buy a Toyota, or buy a 2nd one, or be willing to pay as much for one.
Now Japan has lower health care costs, so the total cost is less, but making the government assume the burden doesn't mean that it goes away. The government gets it funds from the private sector.
Why are Japan's costs lower? Well for one thing they apparently have a healthier diet. They also tend to pay doctors less, and pay less for prescription medicines. They have fewer medical lawsuits and lower average payment on the ones they have.
Shifting to a government insurance system won't necessarily give us any of those advantages in terms of lowered costs.
The most likely advantage, is lower drug prices, but this isn't certain, and if it does happen there would be a cost. Japan, Europe, Canada, etc. can to an extent free ride on American consumers who pay for new drug development. If the Americans stop paying who will?
Tim - my argument isn't to make healthcare cheaper (read earlier posts) - my argument is to increase coverage for all Americans. I would propose to do this by reducing our military spend. My argument about Japan is that if we did it here in the US, we would gain a benefit - people would feel more free to change work, and companies would get out of an area they shouldn't be in - healthcare. This is why Walmart supports such a plan.
As a side note, I think we would see cost savings by reducing the size of the healthcare chain, and could reduce the cost of drugs by allowing the government to negotiate with the drug makers.
As for costs - I would just say that I'd rather have my taxes pay for healthcare than for a huge military. We could easily pay for healthcare for all - we just choose, as a country to not to.
dmwr,
Correct my numbers if they're mistaken, but I believe the military is ~5% of GDP and health care is 15%. If this is correct, even if the the military budget was reduced to zero, it would only provide 1/3 of today's health care spending, let alone provide health care to 1/6th more people. Simply cutting the military budget won't get you where you want to go.
I agree with you that health insurance shouldn't be tied to the employer, but that doesn't mean that everyone should get it from the government either.
Depends what you count in the military budget - best estimate I've seen, which includes the wars, is a total defense spend of $717b. Medicare cost, for 40m people, is $330b or so - these are also the most expensive people to insure (they are old). Total including Medicad and SCHIP is around $516b.
The Bush Medicare act, which made it impossible for the government to negotiate with the drug companies, is estimated to cost around $400b. So, if we took, say, $200b from the military (take the $100b from wars), we'd probably be able to cover a large portion of the uninsured. Add the ability for the government to negotiate drug prices and you take down the medication bill. All back of the envelope (I'm at work).
Sources:
http://www.cbpp.org/4-10-07tax2.htm
http://www.thebudgetgraph.com/site/index.php?main_page=product_info&products_id=1
(only covers discretionary budget)
dmwr - I don't think a decrease in our military budget would be wise at this time. Of course at some point we will be pulling out of Iraq (or at least greatly reducing our forces there and the tempo of their operations). However I'd rather use that money to cut the deficit or cut taxes than to start a new program.
In any case universal government paid health care for all would cost far more than any reasonably likely cut in the military budget, in fact it would cost much more than the entire military budget. Even with no changes Medicare by itself will pass the military in coming years, and that's just for the elderly. Covering everyone would be even more expensive.
dmwr - My comment in response to your 1/16/08 3:15 PM comment has been held for approval. Probably because it contained 4 links.
The gist of it is that not only is military spending much lower than health care spending, but that as a percentage of GDP military spending has been trending down (with a recent counter move against the trend, which isn't large enough and hasn't been long enough to amount to a break from the trend), while health care spending has been trending up. Military spending used to be much higher than health care spending, now its the other way around. So counting on savings in military spending to fund health care for everyone just isn't a good idea. It isn't even if you assume that military spending should go down and that federal government health care spending should go up. There just isn't enough dollars in the military budget.
Frankly Tim, that's the age-old argument, yet every other developed country in the world can do it. So rather than just saying no, let's figure out how to do it. I've suggested several ways that we can save in healthcare costs. Here's another - pay for physician training so that we can have physicians with lower initial salaries and no debt.
Before we figure out how to do it, we have to figure out if doing it would be a good idea.
Here's another - pay for physician training so that we can have physicians with lower initial salaries and no debt.
Paying for physician training makes it possible to have physicians with lower salaries but it hardly guarantees it will happen.
Also if the salaries are lower only by about the amount we pay for the training, than we aren't really lowering costs, just changing how we pay them.