Perhaps predictibly, someone showed up in the comments to my post on Medicare and Social Security to argue that liberal analysts have very serious plans to cut Medicare's costs, which is why we need universal coverage, so that we can implement those very serious plans.
I hear this argument quite often, and it's gibberish in a prom dress. Any cost savings you want to wring out of Medicare can be wrung out of Medicare right now: the program is large and powerful enough, and costly enough, that they are worth doing without adding a single new person to the mix. Conversely, if there is some political or institutional barrier which is preventing you from controlling Medicare cost inflation, than that barrier probably is not going away merely because the program covers more people. Indeed, to the extent that seniors themselves are the people blocking change (as they often are), adding more users makes it harder, not easier, to get things done.
I suppose there's some possible argument that only with universal health care can we prevent providers and consumers from realizing there's an alternative they prefer to the status quo . . . but that implies a Canadian style system that outlaws private care, which is not what anyone's proposing, not what anyone's going to get out of the American political system if they do propose it, and not just a little bit disturbingly totalitarian.
Otherwise, people who want to reform Medicare to make it more cost effective should go ahead and propose the changes to Medicare they can get passed. I am not going to buy a pig in a poke on the slim chance that the pig might be able to get me 20% off an echocardiogram.
Copyright © 2010 by The Atlantic Monthly Group. All rights reserved.
Hmm... here's an interesting thought.
Folks are quite fond of pointing out that most other countries spend less and get better health outcomes with their universal health care than we do.
So here's the challenge, we will start seriously considering universal healthcare when the cost per capita for our over 65 cohort in medicare drops to the cost per capita for the over 65 cohort of one of the universal health care countries (Canada, UK, etc).
Until then, you are just whistling dixie about cost containment. If cost containment really is feasible, then we should be able to match cohort for cohort the systems that universal health care advocates would like us to move to.
Personally, I don't think we have a snowballs chance in hell of doing so, because the universal health care countries we are having advocated to us achieve most of their savings by providing less care (please note, less care need not necessarily mean poorer outcomes) and I simply don't see it being politically feasible to provide less care.
Regarding less care - I think it's very feasible to provide less care under universally provided healthcare. It's all a Ponzi Scheme anyway (take from the young to give to the old), but that's how it is now anyway.
Young men and women (20's) should be receiving check-ups once every 3-5 years max, unless there is an existing problem. This should continue until at least 35 or possibly 40, not including obstretics for women when the time comes.
Preventative check-ups with a physician are almost a joke for most people between the age of 20-40. Almost all the needed items can be done by nurses/PAs/etc.
Further, hypertension drugs shouldn't be prescribed for most people under 160/100. Hyperlipidemia drugs should be used less frequently as well for people who aren't severely over or are still young.
The list goes on and on and on.
There is a good model for instituting national health policy run by well-intentioned individuals in a vacuum, compared to our current system.
Unfortunately, rarely does a national policy get run by well-intentioned individuals who don't have political, lobbying, and other influences on their decision-making.
Hypertension drug I've been taking for 10 years or so is dirt cheap though (I always pay less than my minimum Rx copay is). I doubt cutting that off would save anybody much of anything.
It should also be pointed out that the research is pretty good that controlling hypertension pays huge dividends in long term health... currently even as low as 130/90.
FYI... not sure how good this data is, but this article claims that the Canadian systems spends $8,969 per capita for those 65 and older.
By way of contrast, the best data I can find shows that medicare spending per beneficiary was $14,471 in 2005. So why not see if we can cut per benificiary spending for medicare by 40% and then we can talk about universal health care being able to manage cost containment...
Hagbard - I've read alot about those outcomes which supposedly show better lower costs for better outcomes in other countries.
Most of the statistics I've seen seem meaningless. Things like "84% of canadians are satisfied with their healthcare, vs. 53% for the US" (Numbers made up for example).
There are legitimate questions about average lifespan, but there are many, many confounding factors there beyond the receipt of some sort of preventative or lifesaving intervention. So that's not at all a clear cut outcome measurement.
Can you point to a clean-cut health outcome to cost per capita measurement that shows the U.S. is seriously deficient in some manner?
Joe
P.s. Just out of curiosity, does the cost of our healthcare per capita rise at all because most new therapies begin the U.S., and are therefore more expensive here before being approved and spreading to the rest of the world? Our the statistics swayed because we're inventive?
Joe
I apologize if I was less than clear. I was *not* claiming that other universal health care systems were in fact getting better outcomes, or that we would achieve better outcomes with less health care. I was simply noting that less health care is not the same thing as worse health care outcomes.
My own gut feeling is that we do in many many many cases, particularly when you look at things in more granular slices provide better health outcomes (although I should be careful to note I do not have the data to back that gut feeling). I should also point out that my gut feeling matches that I've seen many rational health care economists express that about 50% of our health care provided is either ineffectual or counter productive... we just don't know which half.
It is important when discussing health care cost cutting though to note the distinction between health care provided and health outcomes achieved. They are not the same thing and the relationship between them is quite complex and confusing.
We do know which half is ineffectual (or at least we know which 30% is useless).
If a person would have a procedure performed if it were free, but not if they had to pay for it, then it is probably ineffectual (on average). This was shown by the rand experiment.
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-
in-half/
Let me step back then... I know of now way for a central planner (be they government or insurer) to make that call reliably and inexpensively.
Let's consider the logic of that argument; you are poor, or young and earning ok money but interested in settling down, and so you are told that you should see a doctor who will order tests and probable prescribe drugs for hypertension or something.
You know that this will require you to sacrifice something you consider important in order to pay for this. (And you can find out you should spend the money because you stopped by a free health screening where they check BP.)
You know the odds are you won't suffer immediate adverse health effects if you delay for a year, and each year the added risk is small. And you know that if you suffer a stroke or heat attack, you will get good ER care no matter what, after which you can reset your priorities. Further, you know that if you can't pay for the expensive treatment, they won't take it back.
Why would you sacrifice to get care that doesn't provide immediate or certain benefit and that at best only benefits society which might avoid the bill for your ER and critical care treatment?
If we implemented euthanasia as a standard treatment offering and refused to provide any treatment after an emergency without financial proof of payment, then the cost of not getting seeing a doctor for your hypertension takes on a new dimension.
The data is clear that treating hypertension is cheaper than not treating it in a developed nation like the US for a large group over a long time. The study you cite didn't keep people in the group that paid for their own care over a lifetime. That cost equation isn't true in undeveloped or developing nations because they can't afford the emergency or life saving treatment.
In the CATO model of things, Africans don't use condoms because they consider condoms to be a waste of money and they chose to die because Western AIDS treatment isn't worth the cost. Instead they shower after sex and take herbal medicines because those are better and more cost effective methods for dealing with the AIDS epidemic.
It's worse than that. For instance, child mortality is lower in most socialist countries because doctors in those countries are far more likely to abort problem pregnancies. And since they spend far less on diagnostic medicine, their outcomes data is not especially meaningful in comparison either (undiagnosed illness deaths never make it into their numbers). And then there's the plain old-fashioned bureaucratic number-jiggling governments are prone to anyways.
Health care in the U.S. is almost certainly better than almost anywhere else, even for the uninsured (who have access to Medicaid and etc.). The scary "I couldn't get treated" stories are more than counterbalanced by the rationing and generally poorer care under socialist systems.
I'm calling this complete and utter bullshit. You're free to prove me wrong with a link. Please do.
Yes, U.S. life expectancy is number 38 in the world because the health care here is so much better.
Now, before anyone says "but life expectancy sucks at measuring health care outcomes!", please read my long discussion with Colin on the post "Obama's Magical Mystery Tour of Health Care Savings".
I didn't know that the fact that a higher abortion rate leads to lower child mortality was a disputed fact. Nor that (expensive) problem pregnancies that are treated, sometimes unsuccessfully, in the US and elsewhere are simply aborted in places where healthcare rationing is decided by the cost-benefit analyses of government bureaucrats.
But, since you asked: here's a broad empirical study on Cuban healthcare. The relevant bits:
Also missing from the conventional analysis
of Cuba’s infant mortality reduction is its staggering
abortion rate, which, because of selective termination
of high-risk pregnancies, yields lower infant mortality
rates. Cuba’s abortion rate was 55.0 per 1,000
women in 1985 but declined to 45.6 in 1990 and
22.8 in 1998. When the abortion rate is reported per
100 pregnancies, the significance of these procedures
increases. In 1970, the rate was 24.2; it increased to
49.1 in 1986 and by 1999 had declined to 32.0. Although
the Cuban government has been successful in
reducing the abortion rate through sexual education
and contraception use, it still is among the highest in
Latin America.
In English, this means that about a third of all pregnancies in Cuba are aborted. I don't know enough to get into the debate about what percentage of these are compulsory -- I've heard horror stories -- but when the individual is not the final arbiter on his or her health decisions, these kinds of things are likely to happen occasionally, even if they aren't policy.
Perhaps Cuba isn't the best example, but where I live I do note that prominent mainstream liberals often cite Cuba as a model we should be following. (BTW, I'm not a pro-life nut; I'm thoroughly pro-choice. I just wanted to comment on the fact that, yes, more abortion leads to lower child mortality (some people might even say this is a good thing), and that this fact must be acknowledged when we make comparisons between various national systems.)
Now, before anyone says "but life expectancy sucks at measuring health care outcomes!", please read my long discussion with Colin on the post "Obama's Magical Mystery Tour of Health Care Savings".
It is well understood that life expectancy statistics can be pencil whipped in many ways, including legitimate differences in reporting methodologies, illegitimate differences in reporting methodologies, differences in access to specific types of care as opposed to general access, differences in racial composition, differences in climate, and perhaps most importantly, differences in lifestyle choices.
If you've got evidence that official life expectancy statistics, cited alone, are a meaningful proxy for health care access and/or quality, that evidence needs to swamp the above uncertainty by at least an order of magnitude. If a "long discussion" is required to present the claim, it probably doesn't.
Since for some reason you can't reply 3 posts deep, Grundles your math is all wrong. Even with the highest numbers 55.0 per 1,000 is .055 percent. I don't know how the hell you got one third of all pregnancies are aborted. I have never seen numbers that high, while Cuba does have a higher abortion rate than the US it's only mildly higher per capita than the United States according to the most recent WHO and UNHDR reports.
Ross, that's because it's 55/1000 abortions per woman. Abortions per pregnancy is a different metric.
The data I cite says this: in 1998, the abortion rate measured as abortions/woman was 22.8/1000. But this is not the only way to measure abortion rates, because a lot of women don't get pregnant, especially as contraception is more widely used, as it is in most places nowadays.
The more relevant measure is abortions per 100 actual pregnancies. The data says that this rate, in 1999, was 32. Thats 32 abortions/100 pregnancies, or a pregnancy termination rate of 32%.
This is pretty consistent with what I was told when I visited Cuba in 2005 as a student.
Grundles, the numbers sited include medical abortions and ECPs. Surgical abortions within Cuba are only a few percentage points high per capita compared to the US. Generally pro-life groups like to site Cuban statistics the numbers are so high but you can't directly compare the two because of the ease which ECPs are available compared to the United States.
I am in no way saying Cuba is a model we should follow.
It is. Western Europe has the lowest number of abortions and child mortality rates.
http://www.nytimes.com/2007/10/12/world/12abortion.html
"In Uganda, where abortion is illegal and sex education programs focus only on abstinence, the estimated abortion rate was 54 per 1,000 women in 2003, more than twice the rate in the United States, 21 per 1,000 in that year. The lowest rate, 12 per 1,000, was in Western Europe, with legal abortion and widely available contraception."
So what places are those? TallDave usually includes Western Europe in the category "socialistic countries", especially when discussing health care. You know, there's all those government bureaucrats taking your choice.
But you chose Cuba. Now, your "broad empirical study" is not, I must say, very credible. It was published with no peer review in Spanish, in some foundation magazine called "Nueva Sociedad". So the source is kind of fishy. But I'll accept the numbers. This article has U.S. data:
http://www3.interscience.wiley.com/journal/118571181/abstract
Quote - "In 2000, the latest year for which data are available, there were 21.3 induced abortions per 1000 women aged 15–44 years, down from 27.4 in 1990."
In spite of very high rates in previous in the 80s, in 2000, the last year of both studies, Cuba's abortion rate was 23 per 1000 women. In the United States, also in 2000, the rate was 21.3 . So they are practically the same.
As to abortion per 100 pregnancies:
I can see you were shocked. For the U.S. I could only found an article with data up to 1992.
http://www.foxnews.com/story/0,2933,880,00.html
Quote - "The number of abortions for every 100 live births showed a gradual decline since 1980 (35.9) to 1992 (33.5)"
This statistic is for live births, not pregnancies. But is still means that, in 1992, the number of abortions was 33.5/133.5= 25% of all pregnancies.
I don't know how much this changed from 1992 to 2000, but a fourth of all pregnancies in 1992 is not much less horrifying. What proportion of the abortions in Cuba and the U.S. were motivated by high-risk pregnancies? There are no statistics, either in the Cuba study you shown or the United States. So I continue to disagree that "child mortality is lower in most socialist countries because doctors in those countries are far more likely to abort problem pregnancies", which was TallDave original sentence.
Finally, I have to remind you again that we're talking about Cuba, a poor embargoed dictatorship. When TallDave said "most socialistic countries", I have a very strong feeling that he didn't mean Cuba, North Korea or China. After all, the usual quoted statistic is that infant mortality in the U.S. is very high when compared with other developed countries. The usual suspects are Western European countries, Japan and Australia, which according to TallDave are "socialistic" because they have universal health care. In the same way that France is "socialistic", you know.
a
Really? There are different methodologies for calculating life expectancy? You mean countries have different criteria for when someone is dead?
Or could it be that you're parroting a talking point you heard somewhere?
Yes, me and Colin went through all that. It was a pretty long discussion. Long story short, there are ways to control for the factors you mentioned.
Hmm... What can "at least one order of magnitude" mean in this particular context? Oh, that's right, nothing. Or rather, it means "I'm using expressions without knowing what they mean because I'm trying to disguise the fact that I'm not going to discuss this in good faith".
But I must tell you that, if life expectancy has nothing to do with health care, the U.S. is a pretty dangerous place. The money spent on health care is almost twice what all the other developed nations spend, and the country is number 38.
Nimed, you raise important and difficult questions, especially regarding the fact that Western Europe has lower abortion AND child mortality rates.
I don't want to pretend to have the answers here, but perhaps we can agree on this: access to contraception and sex education leads to fewer abortions and, in turn, fewer high-risk pregnancies and lower child mortality rates.
On a side note, this may be where the positions of non-ideological and non-absolutist pro-choicers and pro-lifers can, perhaps, find some detente: reducing abortions by reducing unwanted and high-risk pregnancies.
Nimed;
I think the big concern, and the big disconnect, is that when people say the health care is better in the US, they are referring to people that have insurance. Using the uninsured as a measure of health care when they don't have access and comparing that number to any system where everyone has access does not, to me, seem an equitable comparison.
Furthermore, I think one of the unarticulated fears is that, if turned over to the government, the quality of the care will suffer. My biggest concern, especially as someone in medical school, would be the government's role in choosing treatment options. I wouldn't want a bureaucrat deciding which drug or treatment is or isn't cost effective for my patient. Also, one huge benefit of doctor's freedom to treat is the ability to use drugs in off label treatments.
And while I have no experience or data about waiting times in countries with universal health care, I definitely know that there aren't nearly enough doctors to implement a system like that right now. Even if the government decided to increase the number of physicians in the country as quickly as possible, that wouldn't begin to happen for at least 8 years.
Finally, reducing physician pay would cause a problem, and most statistics seem to show that physicians are paid less in universal health care systems. Part of the reason people view our health care system so positively is because our medical school is because of the dedication and intelligence our doctors show. Medical students commit a pretty ridiculous amount of time in school, and most realize that the average practice is going to require at least a 50 hour work week. This is after a highly, highly competitive admissions process (tried but couldn't find statistics on this for other countries). Even with tuition covered, I think you'll see a drop in the quality of applicants because students just won't find the time commitment worth it.
Infant mortality is higher in the U.S. because we count a birth with *any* vital signs as a live birth, while most other countries count some number of very short-lived babies as stillbirths.
I'm calling this complete and utter bullshit.
Shrug. It's not surprising socialists react with venom to the idea socialist rationing means expensive babies get the axe. But that's reality. It's ugly but it's rational, and it's what happens when government bureaucrats make life and death healthcare decisions for you.
But the facts are well-established. There is no international standard for infant mortality, and in Western Europe abortions are sometimes done without even telling the parents birth is possible.
http://www.telegraph.co.uk/news/uknews/1566811/Babies-with-minor-disabilities-aborted.html
Not surprisingly, former Communist countries are even worse.
https://bora.uib.no/dspace/bitstream/1956/2224/1/article_stenvoll.pdf
Yes, U.S. life expectancy is number 38 in the world because the health care here is so much better.
That's because the cost-ineffective premium medical care we receive isn't a large component of life expectancy.
TallDave wrote:
Ah, I knew it! I'm a socialist pinko baby killer. So is Western Europe, and, let's face it, the rest of the world. Let me tell you comrade TallDave: not only are expensive babies fun to kill, they are also make a delicious meal.
Grundles, I told you that by "socialistic" TallDave meant Europe, not Cuba. It's the kind of routine imbecility we've come to expect from him.
Hmmm... Do you mean that, because parents aren't notified, those abortions aren't recorded at hospitals or clinics? Those Europeans sure are eccentric!
Of course, the "no international standard" is also bullshit. You can check the World Health Organization definition of live birth here:
"WHO-HFA definition of live birth: Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live-born."
This is the standard used to make international comparisons. To be sure, there are countries that don't adopt this definition. They are enumerated on the page - Estonia, Poland and Czech Republic.
According to WHO:
Infant mortality in the U.S. - 6.3 (per 1000 live births)
Western Europe average - 4.7
Are Europeans more prone to abort fetuses with congenital defects, and this ends up inflating U.S. infant mortality? Possibly. I have no idea. I looked and didn't find any data on this. I suppose you could try to make the case that more religious countries are more prone to carry through high-risk pregnancies. That would be a sensible argument, although it lacks empirical data to support it. But what is truly idiotic is saying the statistics are invalid because you don't like them.
Thanks for the Telegraph article link. I guess that piece of news settles everything in your head. By the way:
Infant mortality
U.S. - 6.3
U.K - 4.8
Abortions per 100 pregnancies
U.S. - 22.6
U.K. - 21.8
What was that sentence, TallDave? "...child mortality is lower in most socialist countries because doctors in those countries are far more likely to abort problem pregnancies."
Hmm...
But the countries mentioned in this study (Russia, Poland and Romania) don't have a Communist regime for nearly 20 years! Most importantly, all 3 of them have both higher child mortality and a higher abortion rate.
Summing up, you have:
- Western European countries who have lower infant mortality and lower rates of abortion than the U.S.;
- former communist countries who have higher infant mortality and higher rates of abortion than the U.S.;
Let's take yet another look at your original sentence:
"...child mortality is lower in most socialist countries because doctors in those countries are far more likely to abort problem pregnancies."
This sentence is beautiful in its complete opposition to reality.
Really? There are different methodologies for calculating life expectancy? You mean countries have different criteria for when someone is dead?
First, regarding how to count infant mortality, there can be. Not necessarily "are", but "can be", and that needs to be either excluded or shown to be an inconsequentially small compared to the scope of the numbers, before the uncertainty is removed.
Second, if a country is going to deliberately misreport a statistic, the incentive is to revise down. Granted, the countries that lead the United States in life expectancy are generally open, Westernized nations, and are probably reporting accurately. So we could look for a common factor in the leading countries, and we might find some sort of universal healthcare. On the other hand, we might also find countries with relatively uniform ethnic populations located in comparatively temperate climates. So which factor is controlling, and have we excluded all others?
Or could it be that you're parroting a talking point you heard somewhere?
Polly want a statistical analysis.
Yes, me and Colin went through all that. It was a pretty long discussion. Long story short, there are ways to control for the factors you mentioned.
"There are ways." That's encouraging, but when you simply point out that the United States is #38, are the cited data actually controlling for those ways, or are they still subject to uncertainty of the types I mentioned?
Hmm... What can "at least one order of magnitude" mean in this particular context? Oh, that's right, nothing. Or rather, it means "I'm using expressions without knowing what they mean because I'm trying to disguise the fact that I'm not going to discuss this in good faith".
So you question your debate opponent's position, then ascribe both stupidity and mallice without even waiting for an explanation. Classy stuff, that.
At any rate, it means that you can't counter uncertainty with more uncertainty. If there are ways to control or eliminate the above uncertainties, they must conclusively remove that uncertainty, not merely generate more debate points.
Anyway, what are they?
But I must tell you that, if life expectancy has nothing to do with health care, the U.S. is a pretty dangerous place. The money spent on health care is almost twice what all the other developed nations spend, and the country is number 38.
The actual spread between the US average and the top of the list is pretty narrow, something like six years. The US average is something like 78 and most of the Western European nations ahead of it are hovering around 80, with a small handful at the top pushing the average all the way up to 84. And said handful is still subject to the uncertainty of whether health care, or ethnic homogenity and favorable climate, has more explanatory power for the outcome.
Nimed,
Hmmm... Do you mean that, because parents aren't notified, those abortions aren't recorded at hospitals or clinics? Those Europeans sure are eccentric!
Leaving aside your insults, you seem to be missing the point. If Country X aborts babies a certain birth defect without telling the parents birth is possible, while Country Y tells parents a difficult birth is possible, this is going to negatively affect the infant mortality rate for Country Y, because those babies are more likely to die.
Of course, the "no international standard" is also bullshit. You can check the World Health Organization definition of live birth here
Again, vehemently and derisively missing the point. OECD was pretty clear as recently as 2007 that the WHO standard is not universally applied. As with Kyoto, there are lots of signatures but few means of enforcement. See links below.
According to WHO numbers we are actually higher in abortions per capita, both medical and surgical, than most European countries with socialist healthcare systems. Only Sweden is statistically tied with us in abortions.
Shall we place a bet on whether we're higher with pregnancies per capita as well? Unless you divide the abortions per capita by the pregnancies per capita, it's a meaningless statistic. This is all irrelevant anyway. The proper way to measure quality of care as regards to pregnant women would be too look at preemie birth/death statistics.
It is only a matter of time before you get the 'economy of scale' argument (because the Medicare scale obviously isn't big enough!) and the 'the magical preventative care offered by universal coverage will greatly reduce the cost of 65+ care' argument. *pulls out stopwatch*.
It is only a matter of time before you get the 'economy of scale' argument (because the Medicare scale obviously isn't big enough!)
We lose money on every patient, but we make it up in volume!
Maybe the reason why they don't make these changes right now is that if they did, and they were effective, it would weaken the argument for a total overhaul of the health care system.
Perhaps all conversation about reforming health care falls apart because it's too big a problem to solve.
But it has smaller components that can more easily be tackled:
Access; currently, too many people are without access, with two causes -- a lack of trained professionals in some fields (GPs and dentists, for example) and lack of ability to pay for health care.
Cost -- as a nation, we're paying more for less, and the distribution of cost is unevenly spread. Further, there seems to be little relationship with what a procedure costs to deliver and what's charged to the patient/insurer.
Risk management -- too much unneeded care to protect doctors from law suits; not enough preventive care to prevent smaller, cheaper problems from becoming bigger problems.
Efficacy -- our free-market system has delivered a host of competing treatments/tests, without sorting out efficacy.
Rationing -- Insurance rations treatment, but poverty and lack of insurance also create forms of rationing. Controlling costs likely means deciding on other methods of limiting or rationing care.
Research -- the cost of developing new technology is expensive; companies risk huge amounts of money for the opportunity to earn huge rewards. There's also substantial public investment in research that frequently results in corporate reward, not public benefit.
Delivery -- there's no good system to ensure best treatments are used in delivering health care.
Records -- medical records, prescription records, and potential abuse of that information is a huge conundrum.
Lifestyle -- any serious debate about controlling costs has to include personal responsibility. Does the smoker get a lung transplant? The alcoholic a new liver? What about passing on the costs of expensive and genetic illness?
Finally, remember when we talk about health care, there are a number of different, if related, industries, including insurance, pharma, providers, etc.
It's true we pay more for less, but that's just an inevitable result of diminishing returns. A country that spends $100 per person on healthcare obviously gets more from that first $100 than the last $100 of a country spending $10,000 per person.
When I cross the border from Canada home to Maine, we inevitably have our car searched for prescription drugs; there's quite a business in getting drugs in Canada and "reimporting" them to the US because they're so much cheaper there then they are here.
It makes me wonder if folks in the US are subsidizing medical care, in the form of higher cost to companies, for the rest of the world.
It makes me wonder if folks in the US are subsidizing medical care, in the form of higher cost to companies, for the rest of the world.
Our Host has blogged on this. When it comes to drugs, yes. The single payer countries free ride on us. They pretty much order Big Pharma to sell them drugs at marginal cost of production + a small markup, where the US pays for the R&D. IIRC, one country threatened to pass laws voiding the patents on some HIV drugs unless this was done.
We are subsidizing the medical care of other countries. Our drug prices are based on "full absorption" pricing -- it covers the costs of research and development, not just the variable costs of making the pills. Other countries "force" our drug companies to sell based on the variable cost of producing the drugs -- leaving the US to pay for 100% (virtually) of new drug development. If, with a single payer government run system, we go to a similar pricing model within the US, new drug development will all but stop.
This is another thing I hear very much without anyone ever asking for credible sources. Do you have any?
Nimed,
The costs of drug discovery/development are pretty enormous while the drugs themselves are pretty damned cheap to actually produce (except for certain biologics). Without monopoloy pricing, the return on investment in drug discovery is going to be negative unless you change/ease the FDA policies in the same stroke. No one is going to spend a half billion dollars discovering and developing a drug that 10 competitors are going bring to market 6 months after you do.
And, if you attempt to control the prices by fiat in the US, you approach more closely that negative ROI point, which serves as a demand/supply function for capital investment in pharma research.
There are no free lunches.
Nimed, again, you ask for sources to (presumably) object to something that is not really a disputable opinion, but a simple observable fact.
75% of new drugs are marketed in the United States first, because of that fundamental concept of human nature that seems to evade the understanding of so many would-be economic planners: incentives.
“The United States has become the country of choice to introduce new prescription drugs to the market due, in large part, to the size of the pharmaceutical market, the positive environment for innovation, and the lack of price controls,” said Tufts CSDD Director Kenneth I Kaitin. “For example, because many countries limit the prices that drug companies can charge for their products, they turn to the U.S.”
So, I doubt that drug development would stop if the US went to a single-payer system, but the laboratory of the real world as it is teaches us that such a system is unlikely to produce the same amount of innovation.
I am not 100% opposed to universalizing health care, as I know it can bring some obvious benefits -- but it's so frustrating and insipid when people act as if there are absolutely no opportunity costs to socialized care. There are pros and cons to each system; what we need to decide is not who are the evil fatcats who hate poor minority children, but which combination of pros and cons are the best for our society given our resources, our cultural expectations, and our demographics.
Now, wait a minute. I was contesting the sentence "if, with a single payer government run system, we go to a similar pricing model within the US, new drug development will all but stop.".
See? New drug development will all but stop. Now you're saying
So, while it is, I agree, predictable that pharmaceutical companies will have less money for research, nobody really knows how much single payer would affect the amount of research. It can also come out of profit margins, or money for publicity and PR. So we agree there's a trade-off, but we don't know its size.
In other words, the advantages of having market forces work in drug discovery are not that great, because you're going to end up with monopoly pricing. So why have solely private research and development of new drugs? Basic research is mostly financed by governments all around the world, and with pretty good results. Why not drug research?
Note that I'm not suggesting ending Pharmaceuticals. But a little competition never hurt anybody, especially if drugs developed with public funds are cheaper than the others.
Nimed,
It isn't a certainty, and likely not even probable, that publicly discovered/developed drugs would be cheaper- someone still has to pay for the research, and the discovery/development part is the really expensive part of the process. Sure, you could have the newest drugs as cheap per pill as generics right from the beginning, but that is ignoring the taxes needed to fund the research.
And I should clarify something- it is only monopoly pricing for a maximum of 10 years in almost every case. Every drug discovered and brought to market before 1995 is now off of patent. Practically every drug covered by a patent today will be available in generic form 10 years from now.
So which is it- do you want to greatly lower the prices of the newest drugs or not? Your last comment seems to be ambiguous on the issue (the part in your last sentence).
Yancey Ward
Ops. My reply is down there.
In other words, the advantages of having market forces work in drug discovery are not that great, because you're going to end up with monopoly pricing.
/facepalm. Sure, why have intellectual property at all?
nobody really knows how much single payer would affect the amount of research.
Great, we don't know how bad it will be, just that it will be bad. Very comforting.
I think to the extent one can make an argument against the current system, it's that it makes more sense for companies to develop expensive drugs for decades of treatment than cheap one-shot cures. An emphasis on "X-Prize" type rewards could probably help quite a bit.
Yeah...I'm not sure that pricing explains the R&D location. Fact is right now all the major insurance companies negotiate prices with the drug companies for new drugs. Unlike the gov't, they don't just take on face whatever the companies want to charge them. It's a weird kind of oligopoly market and I don't think price controls or the lack thereof explains the whole innovation story.
The US is the center of all kinds of innovation. Take a look at a global map of patents by city in the Economist. It's not just drugs. It's whole host of things all made and marketed first in the US. Think Silicon Valley and our university system. If it's all about cost, every company in California would pick up and move to Ireland or Dubai. I'm not sure that untying the gov't hands and allowing it to negotiate would make everyone pack their bags.
On the general debate...
More useful than comparing the US to other countries is comparing US states to each other. Time did a good job of this in a recent survey. The South--where all those whiny don't tax me conservatives live--sucks up way more Medicare dollars per capita than anyplace else. As Orszag likes to point out, regional differences in Medicare spending show the potential for huge savings, especially if we can make preventive care more prevalent (ala universal health care).
Preventable chronic illnesses make up a huge portion of Medicare dollars. A lot of that is bad habits--I'm scared to see what will happen when the first wave of morbidly obese start to retire--but at least some of it is simple stuff that grows out of control because we don't catch it early.
We basically need to flip the pay scale of GPs and specialists.
I have to inject this into all these discussions. Baumol's Cost Disease applies to medicine, in spades, with spades as trump.
as a nation, we're paying more for less
I thought the point was that we're not paying it as a nation though. To the extent that insurance pools socialize the cost, it might well be a bad thing rather than a good thing. If so, getting more of it is not likely to improve the situation.
Why no one is talking about how much we're paying for other things "as a nation"? Wide-screen HDTVs? Lawn care? Twinkies?
More to the point, our employer-based insurance system creates a tremendous drag on employers, particularly small businesses.
The single best reason I see for advocating for a national system is the benefits to employers and the freedom it gives to employees to change jobs without fear of a health-care catastrophe. That said, Im self employed, and have junk insurance that cost nearly $1,000/month and has never paid a dime for my health care. It's just there to insure our home, not our health.
Our employer based system exists primarily because of weird taxation rules, no? Absent that, why wouldn't other types of pools form?
This is not generally believed by most health care economists. Health care is compensation; if employers saved that money on benefits, they'd have to pay it in wages.
Megan, according the the this WH health-care reform report 13 million of the uninsured are employed by small business. That's more than a quarter of the uninsured in this country. And if you were to expand that number to include under-insured, I'm sure it would be substantially bigger.
If health care economists are suggesting this isn't a drag on business, I would be seriously questioning their assumptions.
Particularly when you consider the cut-backs in insurance benefits, the increases in premiums and co-pays, etc, what you're saying health-care economists "generally believe" does not make sense to me. I would wonder what they're basing their assumptions on. Living in a state where more than 90% of workers are employed by small biz, having been told that job-creation happens in small-biz, something smells sickly in the notion.
Even though these are 'more easily tackled' some are going to be very controversial.
Risk management - how to cut down CYA tests without tort reform, capping punitive damages, etc...
Rationing - your idea of what should be covered is probably not the same as mine. How to get people to come to some sort of consensus. Personally, I would love to see some sort of absolutely basic coverage that everyone could get - simple things but nothing catastrophic - as a start, but try selling this politically.
Efficacy - how do you do this without killing experimental treatments?
Lifestyle - I would love to see personal responsibility injected into this, but I doubt that it will ever happen. How do you do this without creating uncertainty - we all do some things that aren't terribly healthy, could coverage be denied when you need it? The examples you cite are actually the easy ones - what about simply being overweight and out of shape, which has huge implications for heart disease and diabetes. People will always come up with excuses as to why it isn't their fault, how they are stigmatized, etc...
Not mentioned is possibly improving the FDA certification process. Companies have a limited amout of time to recoup their investment while they have a patent and still have to face the possibility of lawsuits even though products have been deemed safe and effective.
And I'd add a discussion of the benefits/risks of separating health care insurance from employment as an issue.
Rationing care based on life style choices will never happen in the US. Smoking, obesity, type II diabetes, etc. all impact historically disadvantaged minority groups disproportionately...denying health care to those individuals would be political suicide.
which is why we need universal coverage, so that we can implement those very serious plans.
Translation: we must destroy health care in order to save health care.
The reason why trying to contain costs through Medicare alone is insufficient is that the way to cost control isn't Medicare deciding to pay for X and Y but not Z, it's in changing the structure of the health care delivery system itself. Thre culture of medical practice and patient expectations can't be altered by Medicare alone.
Could you provide examples of what you mean? I really really don't understand your comment and would like to.
Very simple. Without alternatives, doctors are forced to work for the government where they are easy political prey.
If this debate goes on for another couple of months, the nasty will come out of the closet. It's all the doctors fault. Power must be given to 'health economists' to fix things.
Derek
Fee-for service payment and small practices are the most obvious examples. Physicians who work for salary in organized systems whose primary incentive is good outcomes (rather than maximum resource consumption) tend to develop a culture where satisfaction and peer acceptannce is based on something better than demonstrating their omnipotent benificence to patients (otherwise known as doing everything they can think of even when it doesn't do any good.) The Mayo Clinic and Geisinger are pretty good examples of organizations that are already well-suited to operate this way.
it's in changing the structure of the health care delivery system itself
In other words, you don't want single payer -- you want nationalized providers. Thank you for being forthright.
"Figures compiled for the Sunday Express by premature baby charity, Tommy’s, reveal more babies of 12 months and under die in the UK than in nearly all wealthy nations."
"But many specialists blame lack of medical care for the high number of premature baby deaths. They say chronic shortages of NHS staff mean many mothers are not monitored properly.
And they say many premature infants are at risk because staff shortages mean they do not have the recommended level of care. Overstretched NHS resources mean increasing numbers of sick and preterm infants are forced to undergo risky journeys across the country to find a suitable cot.
Beverley Beech, of the Associa-tion for the Improvement of Maternity Services, said: “Mater-nity services have reached crisis levels and we know babies die because of inappropriate care and poor staffing levels in the NHS."
http://www.dailyexpress.co.uk/posts/view/15640
I really hope whatever system we eventually settle on will not look anything like Great Britain's. There are simply too many horror stories coming out of that place. I'd much rather keep the current system than go with socialized medicine, but even if we go that route we can do better than Great Britain (or Canada, for that matter). Germany, for instance, has a far better system.
zic:
The reason that drugs are more expensive in the US than in Canada is that in the US the govt respects the patent that they issued. That's why govt drug buying schemes are usually pretty silly in the US, the idea is to create a monopsony buyer (the govt) to counteract the monopoly seller, the patent holder. Of course they could just get rid of the patent, or shorten it's length, since that's an artificial monopoly, created by the govt.
Canada, and Europe too, generally tells the drug company that they cannot charge what they wish, or, as the phrase goes, they will license a local manufacturer to make whatever the pill is, i.e. they will break the patent. Since the threat is usually credible, the drug company usually will knuckle under. That's why drugs are cheaper in Canada.
If they got rid of patents, which would cause drug prices to crash, well Constitution says patents are for the encouragement of useful Inventions.
One can think of an similar situation if the Canucks put a bunch of copyrighted stuff, like movies or songs on a server and let US citizens 'reimport' them for free, Hollywood would be for massing troops on the border, they're artists, not greedheads like drug companies.
I think that going more towards nurse practitioners would have a huge benefit to the system. We have the greatest nurses in the world and we are not taking advantage of it. For the uninsured who need a normal checkup a Nurse practitioner would have more expertise than the doctors in many countries. For someone with a cough who needs an antibiotic prescription that simply doesn't take a medical degree to solve. For someone with a common rash shouldn't the first stop be to a nurse practitioner instead of taking up the time of a doctor?
Can anyone say "monopsony"?
Personally, I would love to see some sort of absolutely basic coverage that everyone could get - simple things but nothing catastrophic - as a start, but try selling this politically.
I'd prefer the opposite: cover catastrophic stuff but make people pay for the routine stuff.
So, as you say, consensus is difficult.
The problem with this incentive scheme is that it disincentivizes the routine stuff; as a result, you will have more catastrophic stuff. Most of the doctors I know, both conservative and liberal, believe that a greater emphasis on primary care can lower overall costs by fixing problems before they become catastrophic (and expensive).
But the third-payer system incentivizes and produces more specialists than GPs, when there should be far more GPs than, say, gastroenterologists (sp?). On a separate but related not, the John-Edwards/trial-lawyer industry also disincentivizes OB-GYNs, which is a MAJOR disservice to the system.
It also rewards procedures instead of outcomes.
It's supposed to disincentivize overuse of routine stuff. But that does not necessarily mean more catastrophic stuff. It may mean more Internet assisted self-diagnoses and trying the cheap solutions before resorting to the expensive ones but I don't see that as a bad thing.
"[S]elf-diagnoses and trying the cheap solutions" is thought to be responsible for a large fraction of the death toll from swine flu in Mexico. Many people didn't seek serious professional medical care until it was too late.
If "routine" medical care is widely and easily available it's going to be very difficult to change the biases that prompt a lot of people to go to the doctor when they don't really need to.
And is this really a big driver of medical costs? Aren't systems like Canada's criticized because they make routine care highly available at the same time they ration the expensive stuff?
If it's not a big driver of medical costs, then we should have no problems paying for it ourselves. The government doesn't have to do everything. And, looking at the most recent headlines, only 60 people have died in Mexico because of swine flu. That's not a lot. Certainly not significant with respect to universal health care.
I see Jmct already said it.
Our employer based system exists primarily because of weird taxation rules, no? Absent that, why wouldn't other types of pools form?
They would, but changing the tax rules would mean a tax hike for employed Americans with health benefits. So while it might, over the (very) long term, have beneficial effects, the short-term effect is politically negative. "Congratulations, you're paying more taxes in the hopes of gradually changing our social expectations and forming a better equilibrium on health-care costs" is usually not a winner.
which means someone with employer-based insurance is getting a tax break subsidized by small business that can't afford health insurance and the self-employed.
47 million uninsured and counting.
millions and millions more under-insured, subsidizing industry's employee perks.
They would, but changing the tax rules would mean a tax hike for employed Americans with health benefits
Rob, you're missing the obvious solution: make whatever's currently deductible by the corp. also deductible by the individual. No minimums, no cutoffs.
Ah... that would mean falling tax revenues? :-)
Me, I've been for flat tax no deductions for a very long time. If I can't have that, I'll take deductions with as few rules as possible.
If we want lower health care costs, the most effective way to do it would be to abolish all medical insurance, public and private. We will all of a sudden, as if by magic, use less resources when we have to foot our own bills. Good luck getting something like that through congress though.
When someone says universal health care is "totalitarian," they add the "g" to libertarian.
Universal health care without advanced nanotech and AI's to control it is completely totalitarian.
The problem with this incentive scheme is that it disincentivizes the routine stuff; as a result, you will have more catastrophic stuff.
That may or may not be true depending on the degree to which payment is a factor in people's decision to seek routine medical care. Plenty of people don't like doctors even if their free; our choice of payment system doesn't change their outcomes much.
I favor catastrophic coverage over routine coverage because the costs of catastrophic care are going to be socialized whether we like it or not. Poor people--heck, even most middle-class people--can't pay for catastrophic care. They will either not get it, and die, or they will get it, paid for by someone. If you cover routine but not catastrophic, then you inevitably wind up covering both, only the latter in a patchwork and unsystematic way.
"gibberish in a prom dress"
RotFLMAO
Great Phrase!
When someone says universal health care is "totalitarian," they add the "g" to libertarian.
It's a good thing nobody said that, then.
We are subsidizing the medical care of other countries. Our drug prices are based on "full absorption" pricing -- it covers the costs of research and development, not just the variable costs of making the pills. Other countries "force" our drug companies to sell based on the variable cost of producing the drugs -- leaving the US to pay for 100% (virtually) of new drug development. If, with a single payer government run system, we go to a similar pricing model within the US, new drug development will all but stop.
>>
The word "force" does not belong here, in quotes or otherwise. The pharmaceutical companies take the deal they are given, and voluntarily produce drugs at the price point dictated. They can voluntarily abandon the Canadian, Spanish, French, or British markets. It is untrue as suggested above that advanced Western countries take the Indian-Brazilian tack and threaten to break patents and produce the drugs themselves. Even under the various systems of socialized medicine, the pharma companies decide to do business to make a buck, not for their health (pun intended).
My query to you is why are the French, Swiss, and German pharmaceutical industries so robust, when they produce for their home markets first? If superhigh prices in the US are the only boundary between the pharma companies and bankruptcy...
I also wonder that so many folks experience "health care" in the form of a prescription when other things -- lifestyle/nutrition advice, physical therapy, exercise, acupuncture -- can produce better results for less cost.
I need to amend this to say "better results at less cost" in my experience and the experience of many people I know. But I'm not talking about treating cancer, AIDS, etc., -- I'm talking more mundane mental and physical health.
The answer to your query is that they don't really often market at home first. Most new drugs, regardless of the location of the laboratories in which they are developed, are brought to market in the US first, and for a very, very good reason- there is more money to be made here, and patent protection starts ticking away the day you file your applications. If a drug is marketed somewhere else first, it is almost always because the approval process in the US simply took longer.
I also wonder that so many folks experience "health care" in the form of a prescription when other things -- lifestyle/nutrition advice, physical therapy, exercise, acupuncture -- can produce better results for less cost.
That's hardly something to wonder at; everything you cite takes more time, effort, and discomfort than a pill. Compliance is likely to be low (docs can't even get people to take their pills as directed, nevermind radically remake their diets or go to weekly therapy for a year), and patients are likely to be dissatisfied when they relapse after quitting treatment.
I can't imagine that anyone who has health insurance now would permit the government to restrict any of their health care services. I also cannot imagine how health care can be made cheaper, but still kept in the form of a comprehensive largely pre-paid plan without actually restricting services. I also can't imagine universal health care reform not happening this year. What will give?
Ah, yes. The problem of reality and human nature getting in the way of utopia. This is the debate between Plato and Aristotle, updated for the modern era and our healthcare problems.
I, for one, tend to agree with Aristotle (and Edmund Burke): policy should be made with an eye to how people actually behave, not how they SHOULD behave. When was the last time you saw everybody on the freeway traveling at 55mph?
Sorry to threadjack. Just something that ocurred to me.
Sorry, this was in reply to Rob's point immediately above.
Rob, you're missing the obvious solution: make whatever's currently deductible by the corp. also deductible by the individual. No minimums, no cutoffs.
Sure, but that doesn't do anything for the underlying problem, which is the disconnect between consumer and payer. Instead of a choice between cash and employer health plan, which would drive competition and efficient choices by employees, the employed insured now has a choice between employer health plan and non-employer health plan. So workers and employers still have an incentive to go for maximally gold-plated plans as the most tax-efficient. The only thing your proposal accomplishes is the elimination of employer-based risk pooling and the corresponding creation of an adverse selection problem.
I should add that adverse selection has been largely ignored in all these discussions; any move to a non-employment-based system creates a big adverse selection problem which nobody has explained how to solve absent either universal single-payer coverage or the regulatory elimination of actuaries (AKA mandatory universal coverage by private companies). And even if we could start at Year Zero, so that everyone could theoretically jump in and buy health coverage with no pre-existing conditions, not everyone would, resulting in uninsurables as a drain on the system (or dying in the street, according to preference).
I should add that adverse selection has been largely ignored in all these discussions
In my mind it's the main benefit of employer health insurance. The tax benefits are nice, but the safety of a risk pool if I get sick is worth far more. In our company plan, the insurance company must insure and cover pre-existing conditions for any full-time employee. In fact, the only question they ask is "Do you smoke?" Unless we can mimic the risk pooling that employer health insurance provides, then purchasing individual health insurance plans will cause more problems than it solves.
Compliance is likely to be low (docs can't even get people to take their pills as directed, nevermind radically remake their diets or go to weekly therapy for a year), and patients are likely to be dissatisfied when they relapse after quitting treatment.
This conservative rant, blaming the individual, requires the liberal response of including pharma marketing, including sales to docs and direct-marketing via ads to the consumer. Were I reporting the topic, I'd also question the role of medical training.
This conservative rant...
It's not a rant, it's a real problem doctors face: their advice is often ignored. I'm not saying you're wrong on the merits of exercise, or the effects of marketing and medical training, I'm saying that even controlled studies with diligent weekly follow-up have compliance problems, never mind ordinary office visits with no follow-up.
Rob haven't you realized that ANYTHING a liberal doesn't want to hear is a "conservative rant"?
Yancey Ward wrote
Sure, I'm not proposing we ignore taxes as part of the cost. But I think we agree that, the further away market conditions are from perfect competition, the less efficient private companies are. There's nothing magic about private ownership of resources, right? It's the process of competition that keeps you honest (by honest I mean with incentives aligned with consumer interests).
So it may very well be that drug research financed with, say, NIH grants is less wasteful than research conducted by private pharmaceuticals. I don't know if this is true or not, but maybe it's worth a try.
This is a good thing. However:
1- It makes the drugs more expensive in the short run, because the bulk of the costs associated with research must be payed for in less time. This is arguably not a bad system. It's kind of the health care version of paying for the newest technological gadget.
2- The need to have new patents encourages spending money on the development of new drugs that are only marginally better than the previous one, just to get a new patent. Of course, if you're a pharmaceutical company you better sell the notion that the new drug is much better than it actually is. So you'll have to spend something in advertising too. I've heard some rumors that this happens, but not from very credible sources, and I certainly don't know any studies that confirm this.
Honestly, I don't know. That's the thing.
I would like to have a clearer picture on what the trade-off is. This is what's missing, right? If, in a single payer system, you negotiate the price of a drug down $1 from what the price would be under the current system, how much of this dollar money is cut from drug research? How much from the profit margin? How much from PR and advertising? I have no idea.
So maybe we could try and see how government subsidized drug research would fare against current private research.
So it may very well be that drug research financed with, say, NIH grants is less wasteful than research conducted by private pharmaceuticals. I don't know if this is true or not, but maybe it's worth a try.
Socialism has a very poor track record of doing better than the profit motive.
If, in a single payer system, you negotiate the price of a drug down $1 from what the price would be under the current system, how much of this dollar money is cut from drug research? How much from the profit margin? How much from PR and advertising? I have no idea.
That's not how the market works; you can't just magically assign numbers that way after the fact. What you're saying to drug innovators is "OK, you go ahead and spend your billions to develop drugs (the vast majority of which will fail), and then we'll dictate what kind of profit you're allowed to make from the few successes." There's that profit motive again.
You really ought to check out the amazing research funded by NIH. Socialism at its best.
Academic research funded by NIH works very differently from drug-company-funded research. If an NIH-funded academic researcher finds something marketable (potential drug or drug target), they patent it and incorporate a small start-up to bring it to market. The NIH grant funding mechanism is great for giving good scientists a big sandbox to play in, but very poor at structuring the type of trials needed for drug development.
Also NIH funding isn't really socialism--scientists compete for grants and in that sense is one of the few government programs that works as a meritocracy. Scientists that don't produce results lose funding. I've been trying to come up with a way to restructure the Education Dept such that educational systems compete against each other to receive federal funds.
Though if you wanted to make the comparison between meritocracy-based vs bureaucracy-based science, you could compare the output of externally-funded vs internally-funded NIH scientists. (10% NIH budget remains internal for PIs that actually work at the NIH campus in Bethesda; 90% is distributed to external PIs at other academic instutitions. Once tenured, the internal NIH researchers essentially cannot lose funding (they don't compete for grants), while the external PIs can.) A few internal PIs remain at the leading edge of science, but most of the good stuff comes out of external sites.
I know, my husband worked for an NIH-funded research agency for years.
My point was that it funds a lot of research that is than turned into for-profit business; and given the aversion to any sort of socialism many posters here adopt, I just love to point this tidbit out.
but thank you for saying what I'd hoped TallDave might figure out on his own. Because that NIH-funded research often ends up as the intellectual property of major pharma companies who then charge market-absorption rates without ever reimbursing NIH.
Well, but it depends on how you define "reimbursement." The profits the drug companies make are taxed, so presumably the for-profit sector provides some return on the NIH investment, even if it's not direct.
Would that my other business ventures got such a leg-up from the government. . .I'm not complaining. I'm just pointing out that those sacred "intellectual properties" are frequently the result of social investment, for the Libertarians who view any such activity as a taking. They like to remember the patents and reward the investment while denying the importance of public investment -- the benefit to patent and profit.
Medicare really needs to work out a new payment system. There are 7000 or so billing codes for providing services to patients.
http://content.nejm.org/cgi/content/full/360/7/653
One thing that I have never understood here, with the argument that we need universal coverage to fix Medicare, is that right now those who have their insurance pay their medical costs, or (actually) pay for them themselves, massively cross-subsidize Medicare. In other words, Medicare only works right now because of the existence of private insurance.
I was riding on a plane recently and sat next to the CFO of a hospital. I asked him about cross-subsidization, and he indicated that MediCal (or whatever it is called) was paying about 10% of their costs, and Medicare was paying about 25%. His situation may not be typical, but clearly eliminating private insurance would destroy his hospital economically. The usual Medicare payment for services from primary care providers is, if my memory serves me right, somewhere around 50%.
So, what do these people think is going to happen when they start applying the Medicare reimbursement model to everyone else? Who is going to be left to cross-subsidize Medicare, etc.?
Who is going to be left to cross-subsidize Medicare, etc.?
I'm guessing the government will take them over when they fail (they've been doing a lot of that lately) and taxes will be raised to subsidize them. Gradually fewer and fewer employers will offer health insurance. What will ultimately happen is that we'll have the failed public-school model applied to health care: everyone except the rich will get crappy public health care.
Even ignoring your wildly implausible claim that private health insurance will be eliminated for the non-rich in the US, it's simply risible to call our public school model "failed." By most broad measurements, the US has become the wealthiest and most powerful country in history, and the vast majority of the builders of this society were educated by this so-called "failed" model.
I'm not prepared to argue in favor of the superiority of the healthcare outcomes generated by the rich world's various universal health care systems; but at the very least these outcomes are broadly as good as those in evidence in the US. If we were to copy the universal healthcare system of a France or a Germany or an Australia lock stock and barrel, we might not obtain robust improvements in American healthcare outcomes any time soon (I suspect what we'll get instead is modest improvements and a lot of saved money, but whatever). But surely our healthcare won't then become "crappy." Do you really think denizens of top-tier rich world nations -- all of whom besides the Americans enjoy government-guaranteed health insurance -- get care that is "crappy?"
Also, life expectancy is not calculated the same way for different countries.
http://en.wikipedia.org/wiki/Life_expectancy
For starters, it's heavily influenced by infant mortality, for which there is no firm international standard.
http://en.wikipedia.org/wiki/Infant_mortality
Someone called this "complete and utter bullshit" upthread.
This is truly pathetic.
TallDave, let me be clear: you are a dishonest steaming pile of s***. And you just got caught.
I hope the others be patient and pardon me the language. In the quote in TallDave's post, do you see the ellipsis after note [5]? This is the part of the Wikipedia article this moron deliberately skipped:
"...some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country."[5] However, all of the countries named adopted the WHO definition in the late 1980s or early 1990s.[6]
This is the Wikipedia section in question:
http://en.wikipedia.org/wiki/Infant_mortality#Comparing_infant_mortality_rates
He skipped the sentence in bold so he could disingenuously continue to defend the position in his previous comments that "there is no firm international standard" for infant mortality that allows comparisons with Western Europe, which pretty much falls apart because the WHO definition is the one currently adopted by OECD members. Basically, the only doubts that remain about infant mortality statistics in OCDE after you add the sentence he took off are Hong-Kong and Japan.
Clearly, I made a mistake in taking TallDave seriously enough to post a long response to his point above in the thread. Oh well... in the remote chance anybody is still interested in the discussion, it's the post that starts with the string "TallDave wrote:"
That was me, by the way, and rightly so. It seems TallDave doesn't have a sense of shame even when he's sweeping inconvenient facts under the rug. We've had a discussion upthread. Feel free to follow TallDave's completely unsupported theories on abortion and infant mortality.
So sad.
You've got a point about Talldave selectively quoting. I found it frustrating that the source for claims about differences was a USNews report, freely available, and names it's sources in turn but without giving a link. The claim that all those countries adopted the same standard, however, is based on a journal article that I can't access without paying for it, and might not claim what the wikipedia articles says it does. I decided to check WHO information myself.
Although I didn't see any evidence that every country counts live births the same way, I did stumble on a better statistic that avoids the issue. The WHO page includes a Perinatal Mortality which includes all deaths from 22 weeks gestation to 7 days after birth. Given that the UK for instance is better than the US on Infant mortality in 2004, but was worse than us in 2000 with perinatal, there may be something to the issues with how infant mortality is counted. I'm sure it has it's own issues, and the different years for the 2 measures makes it difficult to draw any strong conclusions.
Thanks for the link, that measure would seem to work better. For one thing, it eliminates the scenario in which some countries are less likely than others to abort birth defects (meaning more high-risk births), which would not show up even if all countries faithfully used the WHO standard, which they clearly don't (see below).
Unfortunately, perinatal mortality seems to have problems too.
http://www3.interscience.wiley.com/journal/119025613/abstract?CRETRY=1&SRETRY=0
This one, right? - "The crucial role of definition in perinatal epidemiology," - Social and Preventive Medicine
Yeah, the unavailability also frustrated me. And it has such a promising title on top of it.
Good thinking. Also available was the 2004 perinatal report. It has numbers similar to the 2000 report, so you didn't miss much.
Perinatal estimates brings European countries a bit closer to the U.S., and the U.K even surpassing the U.S. I wonder what's going on over there.
Continental Western Europe, though, remains with lower numbers across the board.
TallDave wrote
http://www3.interscience.wiley.com/journal/119025613/abstract?CRETRY=1&SRETRY=0
Uh... That study you linked states that the maximum shift in estimates that occurred after data adjustment was 17%. The maximum adjusment. The case for non-comparability wears weaker still.
Uh... That study you linked states that the maximum shift in estimates that occurred after data adjustment was 17%. The maximum adjusment. The case for non-comparability wears weaker still.
Again, strange reasoning. As Phlinn points out, the fact the U.S. does so much better in a perinatal comparison strongly supports the notion the U.S. has better care than the infant mortality stats suggest, and that our IM rates are being pushed up by our more stringent reporting.
Secondly, 17% is larger than the gap between the U.S. and nearly all European countries, suggesting that
1) There is no actual significant infant/perinatal mortality gap due to poorer U.S. health care.
2) Because IM weighs heavily on life expectancy, the supposed gap in LE is also smaller than commonly stated.
And there's this:
A review of studies on
underreporting indicates that, while both live births and neonatal deaths may be underreported,
fetal deaths are much more likely to go unreported (29,30). Moreover, the earlier the gestational
age and the lower the birth weight, the less likely it is that birth and death will be reported (29,30).
A number of studies in developed countries show that incomplete reporting of vital events varied between 10% and 30% (33,34,35,36,37).
...
Caution should nevertheless be
exercised when comparing rates across countries, keeping in mind that the data used to calculate
estimates have different sources and levels of accuracy. Some rates have been estimated from
regressions or by applying ratios, while others have merely been adjusted within the WHO underfive
mortality framework for the year 2000.
Country estimates should thus be understood as indicating orders of magnitude rather than precise
figures.
http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
Emphasis added.
So, by the WHO's reporting standards, there is NO DIFFERENCE in perinatal care between the Europe and U.S., since they share the same order of magnitude.
QED.
Sigh. I omitted that sentence because it's irrelevant. The WHO policy goes back decades; the whole point of the USNEWS article is that they aren't following it. This has been proven for Japan, and there's every reason to think it applies in Western Europe as well (see the many links above regarding abortion for birth defects). This is like following a story about murder with a note that murder was made illegal many years ago.
Again, I'm not surprised the socialists get so angry and throw around obscenities. Their position is empirically indefensible.
Of course, you can easily verify this in the OECD documents:
http://www.oecd.org/dataoecd/4/36/40321504.pdf
Some of the international variation in infant and neonatal mortality rates is related to variations in registering practices of premature infants among countries (whether they are reported as live births or fetal deaths). In several countries, such as in the United States, Canada, Japan and the Nordic countries, very premature babies with relatively low odds of survival are registered as live births. This increases mortality rates compared with other countries that register them as fetal deaths instead of live births.
Or you can just play "gotcha!" and call people names.
Nice try. But I'm afraid this is too blatant for you to weasel out of.
TallDave cited a Wikipedia entry that quoted from an U.S. News & World Report claiming that a bunch of Western European countries have different infant mortality criteria from the U.S. - the named ones were Austria, Germany, Switzerland, Belgium and France. Because of this, says the article, "...it's shaky ground to compare U.S. infant mortality with reports from other countries."
The very next next sentence in the Wikipedia article says the infant mortality criteria changed, and all the European countries named "adopted the WHO definition in the late 1980s or early 1990s".
Hence, according to the sentence you left out, the previously different infant mortality criteria are now the same, and the numbers are comparable!
This, people, is the sentence TallDave found irrelevant!
After all of this he dug up an OECD pdf. Only this new source does not repeat the countries mentioned earlier, nor the weight criteria: the new states are now United States, Canada, Japan and the Nordic countries, instead of Austria, Germany, Switzerland, Belgium and France.
Why does TallDave keep bluffing instead of manning up? Well, as I said before, he is a dishonest steaming pile of s***. That may have something to do with it.
Hence, according to the sentence you left out, the previously different infant mortality criteria are now the same, and the numbers are comparable!
Apparently you didn't read the dates. The USNEWS story is from 2006, so changes in the 1980s/1990s could not have subsequently fixed those problems. Furthermore, the OECD link which states that there are different standards being applied is from 2007.
Only this new source does not repeat the countries mentioned earlier, nor the weight criteria: the new states are now United States, Canada, Japan and the Nordic countries, instead of Austria, Germany, Switzerland, Belgium and France.
What an odd argument. Why would you expect separate studies raising separate points about problems with infant mortality comparisons to find those problems with the same countries? And I don't know what to do but laugh at the idea this is somehow my fault (?!).
Why does TallDave keep bluffing instead of manning up? Well, as I said before, he is a dishonest steaming pile of s***. That may have something to do with it.
Again, getting upset and callimg me names does not advance your argument, or reflect well on you. Perhaps a few deep breaths before you post?
This is a re-post of another thread. It's kind of more relevant here. Sorry for the abuse, I'm having parallel discussions.
Jaspel
What? No hijacking? Oh, come on, live a little.
Jaspel
Ahah, so you are going to thread hijack yourself. I knew it.
Jostel
You said it perfectly. It's a classification system, not a disarmament treaty. Unless there's weird off-the-books stuff, like maybe what's happing in Japan, how could you adopt it without following it? It makes no sense. And if there's off-the-books stuff, USNews wouldn't know about it.
But let me give you some context on how all this started:
TallDave
TallDave solves the mistery of high child mortality in the U.S. - the sole reason the U.S. is behind this indicator is that countries with bad socialist doctors abort problem pregnancies. But which countries are those? Well, we can eliminate the former communist countries, like Russia, Poland, etc. They have high rates of abortion, but concomitant rates of infant mortality. He's talking about someone else...
TallDave
I find out in this passage that I'm a venomous socialist, so we may deduce the definition of "socialism" employed is not be very strict. Western Europe countries, of course, fit the definition like a glove.
These two passages sum TallDave's initial theory: infant mortality rates are lower in Western Europe because problem pregnancies are much more frequent, and they are more frequent because "government bureaucrats make life and death decisions for you".
Furthermore, this is just one of the faults of the likes of Austria, France, Italy, Switzerland, Germany, Sweden and other Western European societies. For instance, you can't really rely on their data, not due to different mortality criteria (that was still to come up) but because "undiagnosed illness deaths never make it into their numbers" and they "spend far less in diagnostic data". Oh, and the "plain old-fashioned bureaucratic number-jiggling". These countries are shit-holes!
Naturally. TallDave never provides evidence for these amazing claims. But he insists on one point:
And, as proof, he links to this article. This is an article that reports on abortions performed on fetuses with minor disabilities, not life-threatening conditions: club feet, webbed toes, cleft lips and palates. A Reverend protests against the possibility, not obligation, of performing these abortions after 24 weeks. Naturally, nowhere in the article it is said that abortions are done "without telling the parents birth is possible". There are no government bureaucrats making decisions for you. This remains a figment of TellDave's imagination. Indeed, the theme of the piece is the abuse of the "seriously handicapped" term in The Abortion Act by mothers and doctors to perform late-term pregnancies of children with minor disabilities. If you are shocked by this, you should be shocked with the mothers first, and the doctors who assist them in this second.
This is a recurring topic:
TellDave
What TallDave doesn't tell you is that he dreamed up a Western European country X. I would consider an argument like "religious couples, which are relatively more numerous in the U.S., are more inclined to carry through a pregnancy of a child with birth defects". This sounds more reasonable, although I would still call for evidence.
We now reach the infamous post with the Wikipedia quote, largely discussed in the other thread. About the omission, Phlinn said
And Jaspel says
Thanks guys. I was wondering how transparent this was. Given the record of the particular discussion, is it unfair to attribute bad faith to TallDave's omission? I definitely think so. The irrelevance and date confusion are definitely very unconvincing. TallDave left it out because it was too confusing and I could assume the USNews article was from the 70s? Please.
But I suppose I'll take your advice, Jaspel. It's definitely not fruitful to speculate on commenter's intentions. And I was a bit of a troll.
Now, regarding the comparability of infant mortality rates between the U.S. and Western Europe, both TallDave and Phlinn linked a number of good sources (we are all freaking experts on the subject by now).
Two concepts are useful here:
Infant Mortality Rate = Deaths from birth to up to one year of life per 1000 live births
Perinatal Mortality Rate = Deaths from 22 weeks of gestation up to 1 month of age = fetal mortality + neonatal mortality
First, what do we know about uniformity of criteria on infant mortality in Western Europe and the U.S.?
Wikipedia gives us the 2 conflicting sources already discussed. Unfortunately, one of the sources referenced in the Wikipedia entry, note [6], is not available online (except for the first page). So, in the name of good faith, let's take the USNews article at face value and say there are relevant differences in the measure of infant mortality rate. According to the article, the U.S. has the most lax criteria: all births with any sign of life count as a live birth. Other countries have, in addition to signs of life, either weight, age or length requirements to be considered a live birth. How much these more stringent criteria affect statistics in the first year? We don't know. The more stringent European requirements are quite modest, though: weight of 500 grams (the normal in a new born is 3 kg), or 6 months and 2 weeks of pregnancy, or a length of 30 cm. One must wonder the percentage of babies in the U.S. that are born below these criteria and still show signs of life
Recent data on infant mortality:
http://www.oecd.org/dataoecd/4/36/40321504.pdf
The study has a disclaimer:
"In several countries, such as in the United States, Canada, Japan and the Nordic countries, very premature babies with relatively low odds of survival are registered as live births. This increases mortality rates compared with other countries that register them as fetal deaths instead of live births. "
Let's exclude cheating Japan. Notice that, in the study, the countries with the U.S. mortality criteria still have lower mortality rates than the U.S.. That includes Canada and the Nordic countries. How do you know which are the Nordic countries? You don't. But you know that they aren't Mexico, Turkey or the Slovak Republic, which are the only countries with higher mortality rates than the U.S. So this is a strong clue that stringent IM criteria are probably not at least not completely responsible for the lower mortality rates in Western Europe (besides the Nordic countries are themselves certainly European).
Furthermore, Iceland, the only European Country with the same requirements as the U.S., has less than half the infant mortality rate. USNews looks like an article made to enumerate reasons for the gaps with Western Europe countries, and so they give a bunch of non-medical reasons for the gap with Iceland. They are pretty plausible.
Anyway, comparing infant mortality with all these cautionary facts in mind, we find that U.S. as a mortality rate about 40-50% higher than the average Western European country.
That's it for infant mortality. Phlimm then proposed we use the perinatal mortality rate as a comparison proxy. TallDave linked an article with 1994 data warning that perinatal data among European countries is also not comparable. But, in fact, it is. When comparability adjustments were made, the maximum adjustment was of 17%. The average adjustment was less than 5%. In sum, the different criteria change the final numbers very little.
You can check it here (table 4, indirect adjustment method). Remember these are 1994 numbers, so the absolute values are higher than in the present day. This article serves to establish comparability.
http://www3.interscience.wiley.com/cgi-bin/fulltext/119025613/HTMLSTART
Contrary to infant mortality, there is no source that tells us that the U.S. has a more stringent criteria than Western Europe. So much for that excuse. So what are the values for perinatal mortality?
I'm citing them from here
http://www.who.int/making_pregnancy_safer/documents/9789241596145/en/index.html
deaths per 1000 live births:
U.S. - 7
Western Europe
I'm setting the islands appart for reasons I'll explain latter:
Ireland - 9
U.K. - 8
Continental Western Europe:
Sweden - 5
Switzerland - 5
Spain - 4
Portugal - 5
Norway - 4
Netherlands - 7
Italy - 5
Iceland - 4
Germany - 6
Finland - 4
Denmark - 5
France - 6
Belgium - 5
A couple of observations:
1- the gap with the U.S. is reduced in relation to the infant mortality rate, which is consistent with stricter criteria for this measure in the U.S.
2- the countries that are above the U.S., the U.K and Ireland, are also the ones which were closer to the U.S. on infant mortality. So the 2 measures are coherent. This is also consistent with the low reputation of health services in English-speaking Europe (the U.S. better not choose U.K. model of universal health care)
3- Finally, except for Netherlands, Western Europe maintains lower indices of perinatal mortality than the U.S. across the board.
In sum, natal health care indicators are consistently better in Western Europe, whatever the measure used. Perinatal deaths are about 30% higher in the U.S. Remember that average consistency of perinatal criteria is in average, about 5%
Finally, I'm repeating myself, but let's remember what started the whole discussion in the first place:
TallDave
I have prolonged this discussion because it's not the first time that I hear people state these and other profoundly ignorant statements. I want to stress that only someone who has absolutely no idea of how life is like in Western Europe could paint such a distorted picture.
We get it, you caught TallDave with his pants down. Thanks guys. I was wondering how transparent this was.
No, actually, you just misread the article and embarassed yourself by bringing up your misinterpretation as some evidence of personal malfeasance on my part, while calling me all sorts of names. Your interpretation of the omitted sentence requires some sort of time travel to be involved, as it would mean problems identified in 2006 were fixed in the 1980s and 1990s.
I find out in this passage that I'm a venomous socialist
Given that you've referred to me personally with about a dozen different obscenities, I'd say the evidence is clearly on my side here when I characterize your reaction as "venomous."
So what are the values for perinatal mortality?
And what does the WHO say about comparing those values?
"However, analysing and comparing mortality rates between countries is also fraught with pitfalls, as minor differences or similarities may be the result of real distinctions in mortality levels, or may be due to diverging definitions and reporting systems, sources of data, or levels of accuracy and completeness. ... Country estimates should thus be understood as indicating orders of magnitude rather than precise figures.
So, values in the same order of magnitude can be considered identical, given the known issues with the data. That is to say, there is NO DIFFERENCE, I repeat NO DIFFERENCE, in perinatal mortality between the U.S. and any European country, as they all fall in the same order of magnitude."
http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
So, we can further say that the oft-repeated assertion from socialists that infant mortality and life expectancy (which is heavily based in IM) are better in socialist countries is suspect at best.
Of course, much of the socialist argument collapses if socialized medicine countries do not, in fact, have better IM/LE, and the data clearly do not support them, so the handwaving personal attacks are unsurprising.
The IM/LE comparability problem is a nontrivial point, because the Soros-backed Commonwealth reports actually explicitly make the claim that socialist health care leads to better outcomes based on this data, and lefty policymakers here in the U.S. are citing those reports.
Finally, it's worth noting two of the three "profoundly ignorant" quoted statements by me were supported by multiple links. The other (regarding doctors not notifying parents birth was possible) is (iirc) from a recent survey of Swedish doctors, though I don't have a link. I note this not so much in my defense (debating how awful I am or am not is not particularly interesting even to me, let alone Megan's readers) but as another example of how poorly argued and dependent on personal attacks the socialist position is.
Oops misplaced quote above. s/b
And what does the WHO say about comparing those values?
"However, analysing and comparing mortality rates between countries is also fraught with pitfalls, as minor differences or similarities may be the result of real distinctions in mortality levels, or may be due to diverging definitions and reporting systems, sources of data, or levels of accuracy and completeness. ... Country estimates should thus be understood as indicating orders of magnitude rather than precise figures."
So, values in the same order of magnitude can be considered identical, given the known issues with the data. That is to say, there is NO DIFFERENCE, I repeat NO DIFFERENCE, in perinatal mortality between the U.S. and any European country, as they all fall in the same order of magnitude.
Again with this? You are now, of course, being deliberately idiot, as opposed to your usual naturally idiot. Jaspel answered this nonsense for me, so it's clear these ridiculous attempts to pin an erroneous interpretation on me aren't obviously pretty futile.
Ah, but, you see, there's a difference. You have proved yourself to be a dishonest steaming pile of s*** with selective quoting and omission of inconvenient sentences. I, on the other hand, was "venemous" from message 2. Not that I mind, I see it more as a sign of paranoia. You obviously see socialists everywhere. By the way, "a dozen different obscenities"? You're getting a little hysterical now.
Ah ah, this is the new cop-out. You can't compare anything! The WHO study is only accurate up to an order of magnitude, so there is no discernible difference between the U.S. and Western Europe, even though every single indicator shows 20-40% higher mortalities in the U.S., and perinatal data is pretty consistent with IM data.
But, as is his habit, TallDave omits the inconvenient. Throughout the report you read that underdeveloped and developing nations show severe underreporting and do not have reliable data. These are mainly African and Latin American countries. Many of their figures thus require adjustments and a high number of statistical assumptions. Of course, with all of this, precise comparability suffers.
What does this have to do with comparisons between U.S. and Western European countries on perinatal data? Nothing. Obviously they don't have this problem. The funny thing is, TallDave himself linked a study showing that perinatal measures among European Western countries have been consistent at least since 94, with adjustments showing difference of less than 5% on average.
Notice also that TallDave didn't say a peep about the OECD study he also linked himself, in which all countries with the same criteria as the U.S. in IM show lower infant mortality rates.
Where Don Quixote saw windmills, TallDave sees socialists. And his mission in life is very clear: to desperately convince himself and others that health care is extremely bad outside the U.S., where the socialists are. Well, in some countries it is. In Western European countries it isn't. Western European countries have consistently better statistics in all natal measures, and most of them perform fewer abortions than the U.S.
By the way, even if the Western European countries had only the same results as the U.S., which they don't, the defense of their "socialist health care" would have been accomplished, because their health care systems are by far than the U.S. system is.
Actually, they have very different systems and it's profoundly stupid to lump them together. Switzerland, for instance, has good results with all health insurance companies and hospitals in private hands, and the U.K. has not so good results with everything in the hands of the government. But to clueless TallDave, they are all part of homogeneous socialist Europe. Oh, well...
This is now D. Quixote winning battles against the windmills. On the laughable assertions TallDave thinks he proved, he didn't produce a shred of what you and I call "evidence" in their support. Not a single one. The most he could do was completely misread an article from an U.K paper.
A reminder of what TallDave "proved":
- "child mortality is lower in most socialist countries because doctors in those countries are far more likely to abort problem pregnancies" - notice the causal relationship. No link ever produced.
- "in Western Europe abortions are sometimes done without even telling the parents birth is possible" - TallDave says he lost a link from a survey of Swedish doctors. But, in his original post, he provided the U.K. paper link to support this idiotic assertion. Now he probably re-read the article, saw how completely unfounded his assertion is, and is now changing his story. Nothing new about this.
- "socialist rationing means expensive babies get the axe. But that's reality. It's ugly but it's rational, and it's what happens when government bureaucrats make life and death healthcare decisions for you." - no single link supporting this supposed government bureaucrat decision making.
Again, that I'm even discussing these last 3 sentences is itself telling. Pretty much any citizen from a Western European society would react to them with either outrage or perplexed amusement.
Before I'll consider supporting any national health scheme someone is going to have to show me how the laws of supply and demand don't apply to health care. Sure, demand for some medical products, such as heart transplants or kidney dialysis, may have inelastic demand, but the fact that we will all eventually sicken and die, combined with the fact that none of us wants this to happen to us personally, makes the demand for overall health care to be potentially infinite.
Given potentially infinite demand, exactly how is it possible that reducing the point of purchase price for health care to zero or near zero is not going to cause demand to go up and supply to go down? In other words, how will this not result in shortages of health care?
To borrow one of the left's favorite adjectives, national health care isn't "sustainable."
yours/
peter.
Peter Jackson: I don't think you're accurately describing reality. Most of the analysis I've seen suggests in fact many -- perhaps a significant majority of people -- avoid using the healthcare system. Hospitals, needles, doctors, colonoscopies-- that's some scary shit to a lot of folks. I reckon the vast majority of human beings would rather hang out on the sofa and watch football than see a doctor. It's true that when they finally get sick they're likely to want lots of robust, expensive treatments, but that's already largely the case under the status quo - a status quo that provides even the indigent with necessary treatments for most catastrophic conditions.
Because increasing the percentage of the population possessing robust access to preventative care saves us money; most of those uninsured, after all, will eventually end up having to use that eye-wateringly costly dispensary of health care known as the emergency room. Far cheaper just to pay for them to go the the goludurn doctor's office for a checkup once in a while. The general thrust of your argument would make a a lot more sense were ours a society willing to let poor people die on the street. Fortunately, ours is not a society like that.
So how does the US compare in a meaningful health care metric... you know, actually treating and/or curing diseases or ailments or injuries?
This whole argument is about compassion versus efficiency, with a large dose of central planning and management thrown in, which is why is is certain to cause LOTS of people to complain about it. We want everyone to get the best care possible, at the lowest price, with no waste, fraud, or abuse, but we also want to be able to lobby for our favorite disease/treatment to be covered.
Compassion and efficiency are not compatible in this context, because the uncertainties in medical treatment are too large to deal with. People's individual responses to medical care are uneven, and in many cases, unpredictable, but the planning efforts are based on statistical models of the entire population, without consideration of individuals. This is a LOT like the financial modeling that got us into the current recession, where the modelers did not consider the effects of the tails of the distributions. In medicine, the "tail" of the distribution is often represented by a premature baby, or a cute child, or an otherwise photogenic elderly person surrounded by her grandchildren. How can you be "efficient" when the compassionate point to these examples of a system that does not meet "the needs of the people"?
"How can you be "efficient" when the compassionate point to these examples of a system that does not meet "the needs of the people"?"
You can't. This debate isn't about level of care (ultimately) its about who rations care, the market or the government, because health care is a commodity with infinite demand and limited supply.
If you think the market is doing a bad job just wait. The nice thing about the market is that it is faceless and arbitrary (yes, these are good things). Don't believe me? What bothers you more- a man shot in the street by a stranger, or a man shot in the back by a police officer? It's one thing to be screwed over by the inequalities of the world, another to be screwed over by the government you vote for, pay, and who swear they are trying to help you.
If you think the market is doing a bad job just wait.
We don't have the real market forces because very few people pay for their medical care. If so, there would be far less money spent at the end of life because they either couldn't afford it or their relatives wouldn't mortgage the house to pay for 1 more months of life.
Do you propose of doing away with Medicare completely? Do you propose that people on Medicare can spend an unlimited amount of money on treatments that extend life by weeks? How many liberals are proposing that the government takes over health care completely like the NHS UK, versus a mix of public/private like France has? In France if the government decides not to cover it, you can still pay out of pocket or have private insurance for those cases. I just don't see how you can say a country like France has done away with a health-care market completely.
I actually live in France, but have my healthcare thru a US company, so I am not reimbursed by the French system. However, I have used the French system in the past, and it generally works well, especially when your employer provides a "top-up" policy to cover the things that the French system does not. The French system does provide some things that I do not think would be politically acceptable in the US, such as a week or two(don't remember which) at a spa to take "the cure" each year.
But the focus of my comment is that the political system in the US would not be able to withstand demands from special interests to include all medical care, at heroic levels, for every medical condition. There is a big push right now to include mental health treatments at the same level as physical ailments, and this sort of treatment is a real black hole for money - it can take some people FOREVER to get over their childhood.
The politicians in the US HATE to have to make decisions about "the value of a human life". They try to delegate this decision to the bureaucracy, so that they can then beat up the bureaucrats about the horrible decisions they have made. (Been there, done that) So, how are we going to make "rational efficient decisions" about how much to spend on someone who suffers a catastrophic illness/injury where the outcome is highly uncertain? This is the process that needs to be described, in detail, with examples. Also, how are we going to ensure that this process does not lead to more expensive defensive medicine to avoid lawsuits when the outcomes are not good. I don't see anyone describing these processes in any way that is politically acceptable.
One more real-world example. My mother-in-law fell and broke her ankle 10 months before she died. She was only marginally mobile before she fell, and the doctors all knew that she had other unrelated conditions that were shortly going to be the cause of her demise, but they still spent _$250K_ to fix her ankle, including dialysis treatments when her kidneys failed because someone did not note that she was allergic to penicillin. She herself had signed a living will saying "no heroic efforts", but when push came to shove, she was lucid and agreed to the dialysis treatments.
At what point during this process should someone have made the decision to stop? And who should make that decision? Her daughter? The hospital? Some doctor? Some judge? Any volunteers?
We're not. What we're saying is that creating a French-style healthcare system in Cleveland is not likely to be any easier or successful than creating a French-style brasserie in Cleveland. The laws we pass are nothing more than a cookbook and it takes a lot more than that to make a meal.
First of all I think it is particularly dangerous to compare ourselves to more socialized systems with today's data. Falling off a building is a lot like bunjy jumping for most of the trip down.
We have a huge demographics bomb that is going to go off in the next couple decades that no-one even wants to talk about. Europe is in the same boat and probably worse off (they don't have our levels of immigration). Things may be fairly peachy now, but what happens when the aging population doubles? Those tough decisions stop becoming marginal and start becoming all encompassing.
With the level of taxation and market fixing required to even keep the system afloat under such conditions (and medicare is surely in store for this here if nothing else), I really don't see how the tail that is healthcare doesn't completely wag the dog that is the economy. It may seem like a rather small step towards socialism today, but its writing a blank check for tomorrow. We seem to be doing a lot of that these days.
Just today, in Santa Fe, Obama said two things:
We cannot continue to borrow at the rate that we are, without bankrupting the country.
And, the reason we are borrowing so much is that our healthcare costs are so much higher than the rest of the worlds.
Let's do the math, shall we?
Our health care costs are about $3,500/year per person higher than most of Europe's. That data is from the OECD. Belgium is about $3,000/year, England is about $2,700/year, Norway is $3,800/year. We're about $6,800/year, so let's say that we're about $3,500/year more per person.
There are 300 million people in the USA, most of whom aren't borrowing to pay for their healthcare. Only Medicare and Medicaid need to borrow, but let's say that EVERYONE had to borrow.
If every US citizen had to borrow every penny of the $3,500 in question, that comes to just over $1T/year.
Can someone then explain why Obama is borrowing 2X that?
I know he's a only a lawyer who couldn't get tenure as a professor, and I've never credited him with a lot of brains, but this is 7th grade math (for the non-advanced kids).
And when you realize that we *haven't even started* socializing medicine yet, and that the transition costs will be ghastly, and that they will all have to be borrowed at the current rate of $0.50 for every dollar spent...
Could someone wake Chauncey up, give him some remedial arithmetic, and let him know that the light he sees at the end of the tunnel is most certainly an oncoming train.
I guess we can all look forward to the day when orthopedic surgery is done by a government employee making $20/hr.
Well, here in France the doctors do seem to get paid about$20/hour, or maybe a bit more, but nowhere as much as in the US. A typical doctor visit runs about 15-25 euros, maybe up to mid 30s for a visit to the opthomologist(a doctor, not an optomitrist(sp?)) for an eye exam. Very reasonable prices, they do a good job, and most of them even speak English! And no long waits for an appointment.
In order for health care in the US to cost less, someone needs to start getting paid a LOT less, or we need to stop doing or do less frequently a LOT of the stuff that is done.
Any volunteers for real reductions? No? I am shocked, shocked, that no one wants to offer up their own vital medical procedure as the first one to be cut.
It's almost like people won't choose inferior medical care unless the gov't forces them to.
I suspect the French healthcare system is much worse when it comes to specialist care. Any rationed system is going to have problems finding and funding expensive specialists.
Of course, if you cut down on diagnostics the perceived need for specialists can magically evaporate...
I guess we can all look forward to the day when orthopedic surgery is done by a government employee making $20/hr.
The funny thing is, orthopedic surgery is one area where technological advance has both increased efficancy AND lowered costs at the same time for many procedures. Things like rotator cuff repair are cheaper, faster, more likely to succeed, and have shorter recovery times than they did just 15 years ago.
That is, absent hefty financial rewards for path-breaking innovation, orthopedics today would be both more expensive and less effective.