Health care

Kemp shocks me by pushing a project near and dear to my heart--switching America's government provided insurance to catastrophic income insurance, rather than the current screwed up system. My proposal is that the government should pick up the tab after you've expended 15% of your annual income.

Goolsbee responds by saying that consumer driven health care helps you on the price side, but then you get less on the preventative care side. This is fair. But something that isn't emphasized enough is that a lot of preventative care can be iatrogenic. Drugs and treatments have side effects; people die on operating tables. There are some diseases where preventative care has overwhelmingly clear benefits--diabetes management, for example. But diabetes patients spend enough on insulin and needles to quickly pop a catastrophic cap--at least, if they're poor enough to need the money, they do. And compliance is a far, far, far, far, far bigger problem with diabetes than cost. People don't eat too much and ignore their insulin because they can't afford a doctor's visit; they do so because dieting and injecting yourself with insulin is extremely unpleasant.

Indeed, it's possible that consumer driven care would improve preventative care for some conditions--if you have to pay $1,000 for an emergency room visit when you get slack on your asthma management, you might get a lot more motivated.

More broadly, I'm suspicious that a shift towards preventative care is going to save tons of either lives or money. I don't object to it, exactly. But I think its advocates make far too many claims for its grandeur.

Comments

Don't know about live, but I think it's been shown that spending on preventive care doesn't save money. Partly, perhaps, because the longer people live, the more illnesses they get. Smoking reduces health-care costs (by about $10,000 a person, lifetime, last I looked); it would seem to follow that things that enhance health would tend to cost money, in the end.

Posted by Alan Gunn | July 4, 2008 4:28 PM

Don't know about lives, but I think it's been shown that spending on preventive care doesn't save money. Partly, perhaps, because the longer people live, the more illnesses they get. Smoking reduces health-care costs (by about $10,000 a person, lifetime, last I looked); it would seem to follow that things that enhance health would tend to cost money, in the end.

Posted by Alan Gunn | July 4, 2008 4:28 PM

Amen Megan! So much of the real 'preventative care' has nothing whatsoever to do with doctors. Eating better. Exercising. Having the time to exercise. Etc. Anything that essentially compels people to spend more money on doctors against their will would have the effect of reducing those resources which could go towards the real 'preventative care.'

Posted by Ryan W. | July 4, 2008 5:00 PM

Much of preventive care is unproven and/or politicized.

For example, annual screening mammography performed on normal risk women from ages 40-49 provides a survival benefit of less than 0.1% over the entire 10 year period. Not annually, but for an entire decade. On the other hand, during this 10 yr period, 50% of women will need follow up studies or biopsies.

This is a huge amount of money poorly spent. The return is awful in terms of public health policy investment.

But, breast cancer is the most politically correct disease in America, and the special interests involved with their lobbying power are not about to allow anything short of everything available done for breast cancer detection/treatment.

Prostate cancer is relatively neglected in terms of education, screening etc. as far as policy goes, yet the incidence, survival, etc. is quite similar.

And I practice breast cancer surgery for a living.

Posted by A breast surgeon. | July 4, 2008 5:13 PM

Much of preventive care is unproven and/or politicized.

For example, annual screening mammography performed on normal risk women from ages 40-49 provides a survival benefit of less than 0.1% over the entire 10 year period. Not annually, but for an entire decade. On the other hand, during this 10 yr period, 50% of women will need follow up studies or biopsies.

This is a huge amount of money poorly spent. The return is awful in terms of public health policy investment.

But, breast cancer is the most politically correct disease in America, and the special interests involved with their lobbying power are not about to allow anything short of everything available done for breast cancer detection/treatment.

Prostate cancer is relatively neglected in terms of education, screening etc. as far as policy goes, yet the incidence, survival, etc. is quite similar.

And I practice breast cancer surgery for a living.

Posted by A breast surgeon. | July 4, 2008 5:13 PM

"Don't know about live, but I think it's been shown that spending on preventive care doesn't save money. Partly, perhaps, because the longer people live, the more illnesses they get. Smoking reduces health-care costs (by about $10,000 a person, lifetime, last I looked); it would seem to follow that things that enhance health would tend to cost money, in the end. "

So your point is that by enhancing health and prolonging life you're expending more money than you otherwise would have if you had just had the sense to DIE when its convenient.

I do mean to layer that on. Preventative care or medical costs in general aren't there for your financial happiness. The reason you see a doctor for a colonoscopy isn't for the roto-rooter experience, its so he can identify a potentially lethal, if not them seriously debilitating illness. Preventative care while by no means a panacea, is effective in getting an individual a better quality of life for a longer period of time.

On a side note if you ever look at what old medicinal treatments. Galen, Hippocrates, etc. they all recommend much the same for preventative care. Country air, brisk walks, cleanliness, maintaining the balancing Humours. And as stated earlier in the thread that basic advice has not changed. "Diet and Exercise," while every health nut friends mantra, is just the plain old common sense truthiness lost in a culture that has a Triple Whopper.

Posted by ben | July 4, 2008 5:53 PM

Goodness, me. If I keep this terrible Grammar up Ockham might get mad again.

Posted by ben | July 4, 2008 5:55 PM

I'm not sure how this works into the equation, but my wife has been diagnosed (after 15+ years of misdiagnosis) with celiac disease. The only way to manage this is with a gluten-free diet - there is no magic bullet. In Europe the diagnosis rate is much much higher than here in the US, yet there is nothing in our respective DNAs to indicate a real difference. There are probably thousands of celiacs walking around the US who don't know it, and so exacerbate their symptoms even more, leading to higher expenditures at doctor's offices and hospitals.

I don't know if this means that government-run healthcare has more of an incentive to diagnose diseases that can only be managed or not, but I would like to hear a reasonable explanation for the discrepancy.

Posted by celiacspouse | July 4, 2008 6:01 PM

I can't tell you why. I don't think anybody could, determining discrepancies in patient diagnosis is tricky. I doubt the causes are incentive related however. My best guess would be that doctors notice it more in Europe because it is diagnosed more in Europe. So they look for it. Whereas in the states they're looking for Cancer, joint problems, etc. Diagnosticians typically are anything but "HOUSE". Truth be told sir I suspect you had to go through a great many doctors. They all tried, but they couldn't see it. I hope all goes as best it can.

Posted by ben | July 4, 2008 6:13 PM

I can think of three major problems with the "pay up to 15% of your income on health care" plan:

(1) It wouldn't really address most of the unnecessary health care costs in the system today - since most of these are for high needs, complex patients, who would regularly be over the cap anyway.

(2) It would create some perverse incentives, of the sort we already see with other means tested programs. For instance, married couples would have a strong incentive to get bogus divorces if one spouse was diagnosed with a serious illness - so that the other spouse's income would be exempt from the 15% calculation.

(3) More fundamentally, it seems unjust. What this plan would mean is that if you are diagnosed with a serious chronic illness (multiple sclerosis, diabetes, Parkinsons, etc.) you would face what would effectively be a 15% "illness tax" for the rest of your life. Over the long term this would have an incredibly pernicious impact on somebody already facing a harder life than usual in other respects.

Posted by Greg | July 4, 2008 7:40 PM

Robin Hanson has a number of articles about the questionable value of preventative healthcare, and healthcare in general (because of bad side effects, treatments can often be worse than the disease)

http://www.overcomingbias.com/medicine/index.html

Preventative healthcare is mentally frustrating. On the one hand, we've all been trained to be proactive - 'an ounce of prevention is worth a pound of cure', etc. And people generally remember the times where they were proactive, and it worked out - something bad was avoided, something good was gained.

They seldom remember the times when they were proactive with no meaningful effect.

Posted by jb | July 4, 2008 7:42 PM

For example, annual screening mammography performed on normal risk women from ages 40-49 provides a survival benefit of less than 0.1% over the entire 10 year period. Not annually, but for an entire decade. On the other hand, during this 10 yr period, 50% of women will need follow up studies or biopsies.

Do you have a citation for these data? Just within my circle of friends I know of a woman diagnosed with a fairly advanced cancer at age fifty who had no signs of it on a mammogram performed at age 47. I dearly wish she had been examined annually, as does she, as do her doctors.

Posted by Art Deco | July 4, 2008 7:42 PM

Yeah, actually, AFAIK it's Britain, not "europe" that's best with celiac disease, and I have no idea why that's so. No one else does either. America does a bunch of chronic diseases than other people, and other people do some better than us--Britain is tops in celiac and diabetes, for example, while we rock high blood pressure and heart disease.

I think it's more plausibly attributed to medical culture than to financial incentives. Doctors who don't look for celiac disease train other doctors, who don't look for celiac disease, who train other doctors . . .

Posted by Megan McArdle | July 4, 2008 7:43 PM

Ben wrote:

"So your point is that by enhancing health and prolonging life you're expending more money than you otherwise would have if you had just had the sense to DIE when its convenient.

I do mean to layer that on. Preventative care or medical costs in general aren't there for your financial happiness."

True. So what? The question was whether added spending on preventive care will save lives and/or reduce costs. My answer to the first is "I don't know." To the second, "no." Do you disagree? Are we supposed to pretend that preventive care reduces costs because it's a good thing (if it is)?

Posted by Alan Gunn | July 4, 2008 9:11 PM

ben,

Preventative care while by no means a panacea, is effective in getting an individual a better quality of life for a longer period of time.

I'm sure it can be. But that's not terribly relevant to whether it's a cost-effective way of improving health and longevity. The evidence I have seen strongly suggests that a focus on preventative medicine would likely produce only small benefits, and would be very expensive. The money and effort would probably produce much larger improvements in health and longevity if they were applied to promoting healthier lifestyles (less smoking, better diet, more exercise, etc.) than to preventative medicine (tests, drugs, etc.).

Posted by Mixner | July 4, 2008 9:25 PM

They seldom remember the times when they were proactive with no meaningful effect.

Right, this is why people keep buying extended warranties. They remember the one time something broke and the warranty saved them $X, while forgetting the $2X they've paid in premiums for stuff that didn't break.

What this plan would mean is that if you are diagnosed with a serious chronic illness (multiple sclerosis, diabetes, Parkinsons, etc.) you would face what would effectively be a 15% "illness tax" for the rest of your life.

On the one hand it's unfair that you got a chronic illness. On the other hand, you'd be getting medical treatment whose value far exceeds what you're paying, with taxpayers picking up the rest of the tab; seems a reasonable compromise to me. "Free health care for everyone" just isn't going to happen for a number of good reasons.

Posted by Brian | July 4, 2008 9:36 PM

True. So what? The question was whether added spending on preventive care will save lives and/or reduce costs. My answer to the first is "I don't know." To the second, "no." Do you disagree? Are we supposed to pretend that preventive care reduces costs because it's a good thing (if it is)?

Posted by Alan Gunn

Is this some sort of trick where being contrary makes one right? This post makes zero sense. The correct comparison is between, say, $200 spent now rather than $200,000 spent later to achieve the same outcome.

The depressingly common experience we have with contrarians, btw, is that they so often contradict themselves: If 'preventative medicine' doesn't 'save lives' - whatever that means - then it's nonsensical to speak of extra any costs incurred from people living longer.

Posted by ScentOfViolets | July 4, 2008 10:44 PM

SoV,

The comment was in reference to preventative medicine saving money! The argument is that preventative care for condition A can lead to a longer life and more expensive health care when you are older. This was the reason the smoking example was brought up, by dying sooner your lifelong total medical expenses tend to be lower.

It most likely will save lives, or at least extend them, though the question of whether it will reduce costs is not solved, AFAIK.

Posted by Skullberg | July 5, 2008 12:00 AM

SOV,

Is this some sort of trick where being contrary makes one right? This post makes zero sense. The correct comparison is between, say, $200 spent now rather than $200,000 spent later to achieve the same outcome.

No it isn't. The correct comparison is the total costs of preventative medicine versus the total benefits. If you know that spending $200 on preventative medicine now will save $200,000 later then obviously it's a good deal. But you probably don't know that. More commonly, preventative medicine would involve giving lots of people expensive tests for a disease or disorder to find just a few who test positive. Or giving lots of people expensive prophylactic drugs that would benefit only a few. The evidence strongly indicates that unhealthy lifestyles are a much larger contributor to poor health and premature death among Americans than inadequate access to health care.

The kinds of preventative medicine that clearly are likely to be cost-effective--e.g., mass vaccination against common infectious diseases--are already very widespread. To the extent that people don't receive these health care services, it's more likely because they simply choose not to (out of an irrational fear that vaccines cause autism, for example) than because they don't have access to the service.

Posted by Mixner | July 5, 2008 12:49 AM

The preventative health care legislation that would make a serious improvement is a big tax rebate based on your body fat content and cholesterol score.

It would also be regressive as anything.

(One based on fresh vegetable and fruit intake would also help, but is basically unenforceable, even in North Korea.)

Posted by doctorpat | July 5, 2008 4:20 AM

Alan-

While Violet is a tad more uncouth about it he is correct. If you catch a polyp in a colonoscopy before it becomes prostate cancer. You've just saved a lot of money. And improved your quality of life. Mammograms are the same way. Cancer as a whole seems to be the main focus of preventative medicine because its treatments require the most invasive procedures. Heart disease and diabetes can be prevented, or are preventable through (parrot call) "diet and exercise."

I guess the point I'm trying to make is the statistics on this are always going to be skewed. The guy who has prostate cancer won't fess up to any kind of preventative measures he could have initiated. No doctor, at that stage, could make the call if it was preventable or not. Whereas the guy who catches it early and has it treated only to LIVE longer, better, only to come down with diabetes.

Above all else folks, use personal judgment. If you haven't had a physical since high school sports and you're in your late 30's early 40's maybe you should think about it.

Posted by ben | July 5, 2008 5:50 AM

The breast surgeon may have better references but this is a good place to start screening guideline for women age 40-49 with the important 'graph being

Recommendation 2: Clinicians should inform women 40 to 49 years of age about the potential benefits and harms of screening mammography.

Screening mammography for women 40 to 49 years of age is associated with both benefits and potential harms. The most important benefit of screening mammography every 1 to 2 years in women 40 to 49 years of age is a potential decrease in breast cancer mortality. A recent meta-analysis estimated the relative reduction in the breast cancer mortality rate to be 15% after 14 years of follow-up (relative risk, 0.85 [95% credible interval, 0.73 to 0.99]). An additional large randomized clinical trial of screening mammography in women 40 to 49 years of age found a similar decrease in the risk for death due to breast cancer, although the decrease did not reach statistical significance (relative risk, 0.83 [95% confidence interval, 0.66 to 1.04]). Potential risks of mammography include false-positive results, diagnosis and treatment for cancer that would not have become clinically evident during the patient's lifetime, radiation exposure, false reassurance, and procedure-associated pain. False-positive mammography can lead to increased anxiety and to feelings of increased susceptibility to breast cancer, but most studies found that anxiety resolved quickly after the evaluation.

Now just reading that quickly you might say that screening for women 40-49 is clearly indicated -- it says so, right? But what it actually said is the big study referenced did NOT show improved survival -- it wasn't statistically significant. But being a medical system that is biased toward intervention we pushed a trend toward significance to make a positive recommendation whereas in Europe they do not recommend it.

In short the risks and benefits are very unclear. For a more lay treatment see this ABC news story.

Posted by BladeDoc | July 5, 2008 7:43 AM

"If you catch a polyp in a colonoscopy before it becomes prostate cancer. You've just saved a lot of money."

Yes, but only if the person whose life you've saved never develops any other illness. Whether spending on preventive care reduces overall costs is a question of fact. I've never seen a serious argument that it does. A single example proves nothing.

Posted by Alan Gunn | July 5, 2008 7:52 AM

"If you catch a polyp in a colonoscopy before it becomes prostate cancer. You've just saved a lot of money."

Yes, but only if the person whose life you've saved never develops any other illness. Whether spending on preventive care reduces overall costs is a question of fact. I've never seen a serious argument that it does.

!?!?!?! Scenario A: you get a long gash in your lower leg at a construction site. You immediately stop work, get the wound cleaned, smear it with a topical antibiotic, and seal it up with a bandage. Total cost, less than a dollar, not counting time off from work. Scenario B: you get a long gash in your arm at a construction site. Playing the tough guy, you take off your tee shirt to swab off the blood, and keep doing so for the next half-hour until the blood stops flowing. At the end of the day you take a shower, making sure you take an extra few swipes with the soap bar on your arm. Over the course of a week, that shallow gash becomes puffy and your arm stiffens up. You develop a fever, and the boss finally sends you to the emergency room when he looks at your arm and sees some significant (and smelly) drainage. You're prescribed a week of bed rest and some serious antibiotics, as well as two additional visits to change the dressing and to drain the abscess. Total cost: $1,800.

Given the specificity of the events, I trust that no one will be surprised when I say that this actually happened. Was the preventative route cheaper? Yes. Was the prudent man's life prolonged? Well, to the best of my knowledge, both guys are both alive and in their fifties. But I think it's safe to bet that the answer is no.

This rather explodes the notion that preventative care prolongs life, does it not? I suppose it's possible to argue that it does, in the sense that it was either preventative care or no care at all, that it was either wear your seatbelt and live, vs not wearing your seatbelt and being DOA. Or that it was diet and exercise for your diabetes vs no shots or doctor's visits at all. But then you're not arguing that preventative care saves lives and is more expensive; you're arguing that preventative care vs no care at all saves lives and is more expensive.

Is that what you're really saying?

Posted by ScentOfViolets | July 5, 2008 10:21 AM

What this plan would mean is that if you are diagnosed with a serious chronic illness (multiple sclerosis, diabetes, Parkinsons, etc.) you would face what would effectively be a 15% "illness tax" for the rest of your life.

How is spending money on goods and services that you need and consume, personally and directly, a "tax", again?

Posted by R C Dean | July 5, 2008 10:25 AM

Alan-

? Are you saying that preventative care is a good or bad idea? To me medicinal care is about value, like I value my teeth so I take care of them. I value them enough to pay money for someone else to clean them more thoroughly than I can.

It sounds to me like your trying to make a financial argument out of something that doesn't rely solely on financial values. Yes, if I protect myself by spending $390 at a gym (don't really know gym costs so insert whatever number you pay) which helps me with diabetes, heart disease, joints (or can cause joint problems if I don't know what I'm doing) I could be overpaying for the service, or I could have a genetic predisposition to heart disease negating any positive effects of going to the gym, I may even have success maintaining my body in better shape. But then I get cancer, was the gym membership worth it? Preventing one disease to contract another? Is that the argument?

If so I'd say thats pretty foolish. Its like saying I'm going to die therefore I might as well get it over with. Or Life hurts a lot, why try to have fun. Yeah its not economically sound, but the alternatives are in no way superior. I mean I value my health well enough to take precautionary steps now (a physical recently) and in the far future (consultations, colonoscopy, x-rays)

Posted by ben | July 5, 2008 11:21 AM

RC: you just don't understand liberal accounting.

Increasing the budget of a federal government department by less than they asked for is a "budget cut".
"Restoring" tax cuts is not a tax increase.
And making you pay for something the liberals think you're entitled to get for free is a "tax".

Posted by markm | July 5, 2008 11:21 AM

Sigh. I have no idea what you mean by the other two items, but the middle one is certainly true, as you just admitted with the word 'cuts'. Yes, the taxes some people will pay will go up. Of course. But that is not a 'tax increase', any more than having to pay more taxes when your salary increases is a 'tax increase'.

I'm guessing that markm is also one of those people who think that Clinton saddled us with 'the biggest tax increase in history'. No, that would be Ronald Reagan. What's that you say? That closing tax loopholes is not a 'tax increase'?

Isn't that being a little inconsistent? Even using your own definitions?

Posted by ScentOfViolets | July 5, 2008 11:29 AM

How is spending money on goods and services that you need and consume, personally and directly, a "tax", again?

Obviously it's not literally a tax. However, it is tax like in the sense that you don't have any meaningful choice about whether to pay it or not.

I'm not hung up on the terminology. My basic point was this: I think when someone gets a serious chronic illness, largely through bad luck and no fault of their own, I think society should largely bear the costs of treating that individual. That could be through a public program or through insurance.

Obviously I realize there's significant variation in how much getting a chronic illness is bad luck, and how much it is the result of the patient's actions. Some chronic illnesses are almost entirely luck (multiple sclerosis, Parkinsons, schizophrenia, etc.) some are largely luck, but have a significant behavioral component (diabetes, some kinds of cancer), and a few are primarily behavioral (AIDS). Nonetheless, even in the most extreme case - say someone who gets AIDS through genuinely reckless behavior, I don't really think that person deserves to be punished by having to pay 15% of his or her income for the next sixty years - severely diminishing that person's ability for economic advancement, etc.

Posted by Greg | July 5, 2008 11:33 AM

There are two basic kinds of preventative care:

1. What you do yourself. That includes exercise, diet, and properly treating a minor cut. These are unquestionably effective in extending your life and giving you a healthier life. Sometimes they also dramatically save health care costs (SOV, thanks for the example of the untreated cut).

2. What doctors can do, e.g.a colonoscopy. These may or may not be effective at giving you a longer and healthier life, but they increase health costs overall. Everyone dies of something, and nowadays anything that doesn't kill you instantly will receive very expensive treatment, so the most preventative care services can do financially is to shift the cost of your final fatal disease to later - while adding the cost of preventive care and of treating anything that care uncovers.

Of course, when people talk about government subsidies for preventive care, they're talking about type 2. You can build bike and walking trails, but you can't make couch potatos use them.

Posted by markm | July 5, 2008 11:36 AM

markm,

Sorry, but that's BS. Regular dental care is preventative. Vaccines are preventative. Eye exams have preventative elements. In other words, not every preventative measure is on par with a colonoscopy nor is it something you do for yourself. But I guess those common procedures don't fit the narrative.

And the "Everyone dies of something. . ." Well, duh. We can welcome back childhood diseases so we can all take our chances with the big, bad world around us and give conservatives that ideological afterglow that they seem to crave so much.

Get diagnosed with leukemia, find the nearest bridge. Save a bundle (you, your family and even the government) 'cause you're gonna croak anyway. And the annual blood test (oooo, preventative) that caught the leukemia at an early stage that allowed further (very expensive) life-saving care? Could have been skipped, saved the money on the blood test, saved the money on the interferon, saved the money on all the rest of it, less of course the funeral costs for someone's sister dead at 41.

I heard your same crap from my doctrinaire brother-in-law before my sister was diagnosed. Strangely quiet in the nine years since.

The story is, of course, one anecdote and to your fellow marchers therefore proof of nothing. But it's also far from unusual and, thankfully, positive if not easy so far.

Oh, and sorry for my liberal accounting. Funeral expenses don't count since we all have to pay them sooner or later.

Posted by Rofe | July 5, 2008 12:38 PM

Some considerations.

Kaiser segmented its member base into six cohorts--three profitable, from those who participate actively with their care including preventive care to those who simply never see a doctor, and three unprofitable, from those with chronic conditions to those who avoid seeking care until things go acute. They made little progress educating the problem segments. There is little motivation to modify behavior when costs are negligible.

Medicine is subject, like all things, to Pareto's curve. Indeed, 80 percent of the benefit of medicine is provided by a quarter of the practices. You get in an accident, you want trauma care. More than half of medicine provides little or no real benefit (apart from reassurance). A significant chunk of medicine leaves patients worse off than not having sought care. Why, then, subsidize all of medicine?

Medicine has arrogated gatekeeper powers unto itself. You have to spend $75 on an office visit just so you can go spend $75 on the pills you already know you need. In most other countries, you walk down to the pharmacy and buy the pills without a prescription and for substantially less.

The powers that be in medicine themselves largely want socialization. In my experience this is because medicine has overwhelmingly become a hidebound, jealous, bureaucratic, anti-competitive, innovation-wary, information-hoarding monopoly. Nothing would help medicine like opening it up to regular competitive business practices. Doc in the boxes at Walmarts will do more to improve our nation's health care than any plan politicians are cooking up.

Posted by Charlie | July 5, 2008 2:12 PM

The merits of tests for specific diseases are fairly easily calculable, and for the most part the current recommendations for screenings are efficient. If they're not, they can be revised. And if you're really risk-averse, you can shell out your own money for whatever tests you want.

But the trend in evaluating the value of annual physicals - what most people mean by "preventative care" - is toward the view that they hold little value for people who aren't manifesting symptoms. Your primary care doctor isn't going to find anything subclinical by asking you basic questions and looking in your ears. Any national health program that forces even more healthy people into an inefficient preventative care system is a waste of resources.

Posted by AK | July 5, 2008 2:15 PM

Why doesn't the Congress use its Commerce Clause power to:

1) Wipe out insurance regulations from the 50 states which dictate the substance and financial terms of the contracts that health insurance companies enter into with groups and individuals, and,

2) Allow national insurance companies to sell insurance to residents of any state?

The result would be fairly cheap catastrophic health insurance across the country. I.e. For a $10,000 deductible, an individual could get affordable health insurance with virtually no lifetime limit (sometime literally no limit, sometimes a 1 or 2 million limit.) This cannot be done today because of:

a) State regulations that dictate Cadillac coverage, e.g., mental health, chiropractor visits, etc. Sounds great, but the practical result is that the non-well-off are priced out of the market, and are left without insurance.

b) Local regulations, such as in NY, which actually prohibit the selling of high-deductible catastrophic health insurance to individuals.

c) The balkanization of insurance into 50 different jurisdictions governed by 50 different regulatory regimes creates smaller risk pools and therefor higher-costing health insurance.

A $10,000 deductible might not seem like a bargain, but the point it means a family is covered in cases of cancer or any other serious illness. Even a poor family can survive a 10K debt - it's a handleable hardship - and doctors and hospitals will treat a person with catastrophic insurance, knowing that their risk is limited and that voluntary and/or governmental aid can take up the slack.

Posted by Brian | July 5, 2008 2:37 PM

Around and around we go.

The question on the table is this: does additional preventative medicine cost society as whole more resources or less? Now some people, like Alan Gunn, clearly understand the question, while others seem to be missing it. It is a question of accounting. To illustrate the question, lets use an actual hypothetical- colonscopies.

(1) Let us assume there are 1,000,000 Americans age 40 at this moment.
(2) Let us suppose that each of these people is given a colonoscopy every 5 years and spends $4000 (2008 dollars) each on such procedures until they reach age 80.

This gives a total expenditure of $4 billion dollars. Did this cost more resources or less than the scenario where no one got colonoscopies?

To answer this question requires the input of a lot of data points. First, what would have been the cost of treating colon problems in the absence of universal colonoscopies? Second, what was the cost of treating these people for colon problems identified by the colonoscopies. If the difference between the 1st and the 2nd of these is greater than or equal to $4 billion 2008 dollars, then, to a first level of colon accounting, the colonoscopies were a cost saver.

Unfortunately, the accounting doesn't end at that point. One must also account for the future medical costs incurred on behalf of those who survived because of the colonoscopies. If you end up treating them at age 68 for dementia, then you have a cost that would not have been there otherwise. One must also account for the additional product from those who survived longer because of colonoscopies. If someone survived at age 45 that would not have done so otherwise, then his contribution to net wealth after that point is a plus for universal colonoscopies. In addition, there are a lot of other considerations to account for that I have not listed.

These are not easy calculations to make, but they are open to empirical analysis. It is not enough to say that a $200 procedure today saves $200,000 tomorrow. In the above hypothetical, everyone gets a colonoscopy, but not every one will get colon cancer. Indeed, only a fraction will ever get the disease, with or without the preventative procedure. It's overall cost effectiveness requires deeper analysis.

Posted by Yancey Ward | July 5, 2008 2:53 PM

"No, that would be Ronald Reagan."

No, that would be the Democrat-controlled Congress at the time. Now on to the topic.

Didn't we hear all of the praises of so-called preventative care when Clinton gave us HMOs and "managed care"? And it seems that about a month after we got all these glorious HMOs and managed care plans, the horror stories started rolling in.

We'd save a great deal of money if we went back to health insurance, instead of this supermarket discount card plan we have now -- and if people didn't run to the doctor everytime they scraped a knee, instead of spraying bactine on it and getting on with their lives. Insurance is for emergencies, not regular visits. Somebody has to pay the difference every time you plop down that card with your $15 co-pay.

Go back to blue cross wit $1000 or $1500 deductible, and go to the doctor only when you need to go to the doctor.

Posted by rightwingprof | July 5, 2008 3:32 PM

In response to ArtDeco and blade doc.

Blade references the correct study indirectly with the link to ABC. I believe the study was in the Annals of Internal Medicine. Blade also makes the correct point that although there was a difference, it was not statistically significant. Therefore, that means there was no difference.

Art, I am sorry for your friend and for the frustration and heartache that all of you must feel. But her case makes the point. It is not well understood by patients and practitioners alike, but breast cancer is typically diagnosed 10 years after the malignancy began.

That's right. If you have an abnormal mammogram today that shows a cancer, that cancer began 9-10 years earlier, maybe earlier if the cancer is big and can be felt.

Additionally, the cancer has the ability to spread many years before it is discovered. Specifically, the disease can often spread long before the cancer can be detected.

The problems with mammography for low risk women in their forties are these: the breasts are very dense since the women still have ovarian function (for the most part), and the incidence of breast cancer is relatively lower in the forties than at older ages. Additionally, we find relatively more aggressive cancers in younger women, implying that their average survival will be worse at the time of diagnosis than will be post menopausal women.

So, unfortunately, your dear friend actually proves the point. She most assuredly had breast cancer when her MMG was normal, and when she was diagnosed, her cancer was more aggressive. Therefore, it is hard to make the case that more frequent, if any, mammography would have made a difference.

Our dollars should be spent on finding breast cancer preventatives rather than early screening.

And, the public should be educated as to realistic expectations for treatment outcomes with breast cancer.

Posted by A breast surgeon. | July 5, 2008 5:00 PM

Also,

Let's be very clear about another point.

Removing a polyp at the time of colonoscopy DOES NOT prevent PROSTATE cancer.

Colon cancer comes from colon polyps.

Prostate cancer starts in the prostate, not the colon. They are entirely separate organs and different cancers.

Posted by A breast surgeon. | July 5, 2008 5:07 PM

Surgeon-
Forgive me for not elaborating.

Now Yancey and Alan,

"does additional preventative medicine cost society as whole more resources or less?"

What does it cost society as a whole? How is preventative care, or indeed care period relevant to a whole society, directly? Any effect would be indirect; transfered from the individual to society. Ok lets take your example 41 year old man catches the polyp early lives to be 68 develops dimensia. The difference is he got 27 years without having a variety of seriously invasive treatments, that would alter his quality of life, and may have killed him. The value of that is not in any $ signs. Also lets assume he worked and continued to add value, spend, grow the market. Lets say his kids got to have a father boss them around when they're teenagers. Keeping them off the street or suffering depression related to his death. Or his wife had to put up with him, maybe a divorce. Or maybe he was a workaholic jerk, that had no family and everyone hated him. I don't know how much is a year of your life worth? What you seem to be talking about is the cost associated, flat out ignoring, not even acknowledgin,g that there are other incentivs, and value in your quaint mathematical model that are unaccounted for. If you wanted to address the issue in this manner you should've made perfectly clear what you mean to exclude. The monetary costs of extended life should be the title of the strain of thought you've embarked upon. The decisions your addressing ultimately come out to more than monetary value.

As to how the US government ought move on this issue. Still working it out, but preventative care is in there. I do agree that some procedures are overkill. But still prevention can and will save you some pain (that goes for everyone, it may only be a cavity in you entire life, but for most it will be a few things, hopefully none as big as cancer).

Posted by ben | July 5, 2008 5:57 PM

Giving people all-state access to catastrophic care insurance would be the best thing that could be done for health care in this country. I was quite happy with my $8000 deductible policy, then the great state of California, in its infinite wisdom, began to stack on health insurance mandates. Now my deductible is only $2000, but my premiums have tripled. Gee, thanks!
Too many people feel their health care should be "free." Insulating people from health care costs leads to grotesque distortions in the market. For example, if you're just coughing up a $15 co-pay on your meds, why would you even bother to even ask the doc if you need the latest, well-advertised "wonder drug" rather than the generic that works just as well? (In my case, I was paying a $35 co-pay for a med whose only advantage--as I discovered with personal research--over the generic was you only had to take it once a day rather than twice. Actual retail cost of the new med: $375/month. Cost of the generic: $15/month. Who would voluntarily pay that much for a simple extended release formula?) And studies in Canada have shown a mere $5 out-of-pocket co-pay for office and emergency room visits slashed the abuse of those services.

Posted by Manji | July 5, 2008 6:28 PM

Hmmmm.

You want a healthier America?

Then we need a wealthier America.

That's the simple difference. If you've got plenty of money then being, or staying, healthy isn't a problem. But if you're having trouble paying the heating bill and having to choose between medication and food, then staying healthy is a problem.

The simple fact is that we need to work on our economy. We need to draw in the poorest *Americans* into the economy. We need to evict illegal aliens, and the insane variety of diseases they're bringing in. We need to control immigration to match the workforce to the work.

Posted by memomachine | July 5, 2008 6:38 PM

Re: What this plan would mean is that if you are diagnosed with a serious chronic illness (multiple sclerosis, diabetes, Parkinsons, etc.) you would face what would effectively be a 15% "illness tax" for the rest of your life. Over the long term this would have an incredibly pernicious impact on somebody already facing a harder life than usual in other respects.

Agree with you on this. Though it could be dealt with by stipulating that expenses arising from chronic illnessdes would be subject to the 15% once only, and thereafter would be paid 100% for the rest of the person's life.

Re: The result would be fairly cheap catastrophic health insurance across the country. I

Catastrophic health coverage is expensive and will remain expensive because the costs associated with it are very high-- and also because a very large fraction of us will eventually suffer a catastrophic illness.

Posted by JonF | July 5, 2008 6:46 PM

(2) It would create some perverse incentives, of the sort we already see with other means tested programs. For instance, married couples would have a strong incentive to get bogus divorces if one spouse was diagnosed with a serious illness - so that the other spouse's income would be exempt from the 15% calculation.

First of all, that already happens. There are families, right now, who have met their lifetime benefits and/or maxed out their catastrophic care cap in their private insurance that choose for one partner or the other (often the person that makes more) to quit working in order to meet the income limits for federal or state benefits like Medicare disability or Medicaid.

Particularly, couples with children with catastrophic illnesses or conditions. So, in reality, we already have a system that is half of what Megan proposes. The issue today is that it takes a productive worker out of the work force along with his or her income from the economy.

Is that a good trade off?

Posted by Kat-missouri | July 5, 2008 7:12 PM

Ben,

I am only addressing the assertion that more preventative care lowers costs. This is an accounting question- a question of dollars.

This issue arises in the debate about universal coverage, and the assertion is made repeatedly without support. I was just pointing out the things you have to account for when determining if a particular preventative screen actually lowers costs or not. Many on this thread seem to only want to see the issue from the point of view of the guy who found his cancer early and had it treated cheaply and successfully, but a complete accounting must delve deeper to actually prove or disprove the assertion.

Posted by Yancey Ward | July 5, 2008 7:41 PM

very large fraction of us will eventually suffer a catastrophic illness.

Which percentage/fraction is that? 10%? Mind you, that is 30 million people, but, in the scheme of things, that isn't a significant fraction of the population really.

Catastrophic health insurance costs money because it is costly care and because, frankly, not that many people actually buy it as a separate policy. We spend most of our money on all inclusive health insurance that covers doctors visits and medications for basic health care.

Posted by Kat-Missouri | July 5, 2008 7:56 PM

Yancey-

I suspect its not the guy that necessarily caught it early. Its the guy that caught it early enough to prevent death or life-altering events in relation to medical care, and the value of that. Preventative care is not a lottery.

Pick a procedure some are better than others, a dental exam and cleaning seems effective, a blood work-up that can diagnose 2 extremely rare diseases not so much. And as to it lowering costs, there is a point at which preventative medicine becomes ridiculous. However, what your talking about is procedure specific. Dental exams, physicals, colonoscopy, a chest x-ray, these are considered preventative, and the cost of these procedures has come down, actually I should say has failed to rise commensurate to the rise in medical costs.

A few basic procedures can save money. Because it isn't the accrued costs of doctor visits that can financially destroy you. It is the "I have cancer $350,000 cost" that will ruin your finances, not the yearly mammogram.

Posted by ben | July 5, 2008 9:06 PM

This is an interesting thread. And much of this discussion confirms what I have observe over many years of practicing surgery.

The blunt truth is this: we actually know very little about what really works in medicine. The public believes that there are very clear proven guidelines that offer obvious paths to good health and disease prevention. That is simply not the case.

There is very little, if any, evidence that disease management programs impact disease. There are actually very few preventative measures that have been proven to work. And those that are proven today may ultimately prove to have been worthless next week.

As to whether "preventive medicine" saves money, I encourage everyone to be very careful applying logic to human disease. I am not the sharpest tool in the shed, but over a couple of decades of surgery, I have been continually amazed at how what seems so obviously appropriate today is so clearly wrong tomorrow.

We know so very little. Only arrogance leads us to believe that we have a real handle on what works and what doesn't.

Apparently, some of the things we do work. Our average longevity continues to improve. I believe it is now 78. Back during my residency, we thought a 65 y.o. male who had a heart attack was a horrible surgical risk. I operate on 80 and 90 year olds now with some regularity.

My big fear is that politics will determine what is appropriate health care. Demagoguery at the hest of special interests will determine the standard of care. Billions will be spent, medicine will be choreographed, and we will all become patients of a socialized system.

(We are not far from that even now. Look at the incredulity of those who insist our earth is burning up, despite obvious scientific evidence to the contrary. Imagine for a moment that the same sentiment governs your health. Oh my.......)

So, one day when you are absolutely certain about colon cancer screening or treatment of your cholesterol, remember this: in the late 18th century, the brightest minds in medicine were absolutely certain that the standard of care for most medical disease was blood letting. (In fact, George Washington died of anemia induced by blood letting, not by the disease that was being treated.)

When in doubt, go slow. Don't insist on many absolute truths in medicine. You may be surprised.

Posted by A breast surgeon. | July 5, 2008 10:26 PM

One oft overlooked aspect of preventative care are the health and monetary costs of false positives. All surgery carries risk, even a biopsy for a breast cancer that doesn't actually exist.

(Remarkably, there is very little evidence that mammograms save lives and some evidence that they increase the risk of breast cancer.)

Simply reducing smoking, increasing vaccinations, improving public sanitation and improved nutrition have done more to improve the health of all people than ANYTHING medicine has otherwise done.

Posted by Joe | July 6, 2008 2:36 AM

Re: Which percentage/fraction is that? 10

No, a far higher a fraction than that. A majority of us are going to suffer high-cost, chronic illnesses before we die and those illnesses will be why we die. Some minor fraction of the populatioon dies in car accidents and from other sudden traumas, including acts of violence, and a much smaller fraction will keel over from an unexpected heart attack or massive strike and thereby shuffle off this mortal coil cheaply. But most of us are going to become expensive patients during the last months or years of our life, dying by slow inches and running up the tab well into the hundred thousands.
It isn't ordinary doctor visits that are running up healthcare bills. Those are fairly cheap. It's those last six months of life bills. Remember the maxim (more or less true): 20% of the population, at any point, causes 80% of the healthcare spending. My point is that most of us will someday be in that 20%.

Posted by JonF | July 6, 2008 8:37 AM

As I have traversed life through the 30s and now the early 40s, I have witnessed quite a number of family, friends, friends of friends, and colleagues that have died of "old age", and with increasing frequency. Few of those died unexpectedly- without warning. Almost all spent significant time and money being treated for the actual illnesses that claimed their lives such as cancer, heart disease, lung disease, and strokes. Dying is getting to be quite expensive. There is a growing disconnect between what we expect to be spent to keep us and our loved ones alive, and what we actually are prepared to pay for ourselves.

Posted by Yancey Ward | July 6, 2008 1:10 PM

Megan said "And compliance is a far, far, far, far, far bigger problem with diabetes than cost. People don't eat too much and ignore their insulin because they can't afford a doctor's visit; they do so because dieting and injecting yourself with insulin is extremely unpleasant."

Speaking as one who's been doing exactly that for the last fifteen years, the diet is a bit of a pain, but the insulin is pretty trivial, aside from having a bit more "stuff" to carry when away from home. It isn't really painful. The issue is that it is trying to adjust a wristwatch with a twenty pound hammer.

Insulin pump therapy is closer to normal insulin action, and when the government gets around to approving closed loop control for the pumps, then blood sugar control for diabetics should approach that of the rest of the population. But insurers don't want to cover the pumps.....

Posted by bbeeman | July 6, 2008 6:42 PM

Truth be told sir I suspect you had to go through a great many doctors.

Actually, my wife went to a good hospital in Orange County, CA, that has a Women's Wellness Center and was diagnosed there. Her insurance, by the way, refused to cover the cost. That's our healthcare system for you.

And yes, previous diagnoses by her doctor focused on joint pain, thyroid (which had to get taken care of since she was so far down the celiac road), autoimmune disease, etc. Agreed that diagnostics are difficult in any field, but my impression of doctors is they basically match up symptom "A" with Pharmaceutical "B" and send you on your way.

There is definitely something to Megan's post about doctors training other doctors, but your point that its better diagnosed in Europe (or Britain) because there are more diagnoses sounds circular to me. That may be the case now, but was not always the case, so what changed? We'll probably never be able to answer that one, but the fact remains that American Med Schools rarely teach their students about celiac.

Oh yeah, and it really bugs me that her health insurance (not a "cheap" HMO, by the way, but the gold-plated PPO available through her government employer), considered her visit to the wellness center as "Alternative" medicine and would not cover the cost. This is precisely the problem with the American system: employers and employees pay enormous premiums to the insurance industry, and they refuse to cover medical services.

Thank you for the encouraging thoughts, however. So far so good.

Posted by celiacspouse | July 7, 2008 1:03 PM