Is it fair to worry that the Democrats included an end-of-life counseling provision in the health care bill because they're planning to push Grannie off the ice floe as soon as they can get naional health care passed? No, and yes. No, because I don't believe that they want to bamboozle people into ending their lives before they should. It's quite clear from what Obama has been saying that he thinks there is a great deal of unnecessary care, particularly late in peoples' lives, that makes them worse off, or at least, no better off.
But though the implication that the Democrats are heartless technocrats is thoroughly wrong, I think the worry underlying it is legitimate. First of all, Obama has made a number of missteps that paint a worrying picture of what he thinks an "unnecessary procedure" is. Or at least worrying for seniors and other important voting blocks. It is actually entirely true that if you're focused on cutting costs, you would never install a pacemaker in a 99 year old woman. The number of quality-adjusted-life-years you could expect to get out of that procedure is not high. Meanwhile, she's very likely to die on the table, wasting thousands of dollars and the last days of her life. If Obama is serious about bending the cost curve, he will create some sort of agency that will say no. And it's no good saying, as you do to under-65's, that this rationing will only apply to bonus care for people who currently lack insurance. Cutting costs means taking options away from seniors. You may think that they would be better off without those options. But they clearly don't.
The other reason I think the worries are legitimate is that as the government is on the hook for more medical costs, its incentives change. The fact is, it wouldn't be hard to manipulate a significant number of sick people into forgoing a lot of expensive care. The Obama administration's point, which is well taken, is that it's problematic to give doctors financial incentives to bias their advice towards treatment. The problem is, it's also problematic to give them, or their employers, incentives to bias their advice towards undertreatment. Every compensation scheme on the table does one or the other. And I think Americans are inherently more comfortable with a bias towards proaction than inaction, even if the latter is cheaper and more restful.
Insurance companies already have those undertreatment incentives, but it's hard to act on them. Right now, people know that their insurance companies would love to provide self-serving "end of life" counseling that would encourage sick people not to waste so much valuable money. But they are limited by, first, competition--an insurance company that tried to do this too blatantly would suffer horrible publicity and ultimately lose business--and second, the threat of lawsuits and/or regulation.
People aren't trusting the free market as much as they're trusting various institutional arrangements, some within the market and some outside of it, to protect them from the perverse incentives of any insurance company. Once the government has the perverse institutional incentives, the institutional checks are fewer, more ponderous, and worst of all, often create huge new problems. The institutional checks we have accumulated have now so encrusted the government that it's ever-harder to make changes, or for that matter, to get anything done. As my father is fond of pointing out, adding federal money to a project now adds an average of five years time-to-completion while the project managers jump through various procedural hoops.
Medicare basically free rides on this; Medicare reimbursements are tied to, and broadly reflect, the private reimbursement system. (Yes, I know there are a lot of crazy exceptions--Medicare reimbursement policy is an enigma wrapped in a puzzle placed inside a labyrinth and shrink-wrapped with red tape. But what Medicare pays for and what private insurance sector pays for are not, in toto, wildly different.) If the public sector atrophies, the scope for manipulation broadens, because the information about what's available outside the public sector shrinks. Nor is this just crazy speculation. I actually think it's pretty reasonable when conservatives worry that the Dutch attitudes towards euthanasia are influenced by the burden old people and severely disabled children put on the public purse. I don't see how they could fail to be.
So I don't think it's crazy that Rasmussen is reporting that 51% of people now trust their insurance companies more than the government to handle their health care. In fact, I expect that number to go up. This is not, as some libertarians would have it, because the free market is Teh Awesome, while the government is Teh Suck. It's because the two institutions are, on this particular question, balancing each other. In doing so, they are creating cost inflation. But they're preventing something that many people legitimately believe is worse.
Copyright © 2010 by The Atlantic Monthly Group. All rights reserved.
I actually think it's pretty reasonable when conservatives worry that the Dutch attitudes towards euthanasia are influenced by the burden old people and severely disabled children put on the public purse.
Indeed.
Self-styled liberals and progressives have very versatile and fluid notions of what's moral. When that's coupled with their arrogance about the correctness of their ideas and the morality of their own posturings, it's easy to see how euthanasia could obtain currency - despite their protestations now.
Protestations? The protestations are that there is an effective opposition to their ideas. Obama openly said that an older woman should get a pill rather than a treatment.
Derek
I actually think it's pretty reasonable when conservatives worry that the Dutch attitudes towards euthanasia are influenced by the burden old people and severely disabled children put on the public purse.
It's already happened. The state of Oregon has a state medical program, the Oregon Health Plan. Last year, the Oregon Health Plan denied a woman coverage a form of chemotherapy. The letter denying coverage went on to say that "physician aid in dying" (i.e. assisted suicide) would be covered under the Oregon Health Plan.
Earl Blumenauer, a Democratic congressman from Oregon, is a supporter of Oregon's assisted suicide law, and is responsible for inserting the end-of-life counseling provision into the health care bill. Why would people think that such "end-of-life counseling" is not innocuous - perhaps not in this iteration of the bill, but a few years down the line.
Three notes on the Oregon case:
1. Please note that the Oregon Health Plan is only available to people who DO NOT already have group health insurance and can't obtain / can't afford regular individual plans. If not for the OHP -- i.e., in most states -- the woman would not have been covered at at all.
Certainly she would have gotten acute care in an ER as the cancer got bad, but she certainly wasn't going to walk into an ER and walk out with $4,000 worth of chemo every month.
I'm curious what you think would have happened to the woman in another state where she was simply uninsured? Please, tell us.
2. Are you arguing that all private insurance in the country would cover a new cancer drug at $4,000/mo which has a
3. The mention of assisted suicide was a pretty brief mention in a much larger discussion of the palliative care that would be covered. I.e., it was made clear that they'd cover all the pain relieving comfort care she wanted, hospice care, whatever, but that one of the options under palliative care was assisted suicide. Horrible PR to mention it at all, but the letter in question certainly wasn't pushing it.
Not sure what happened, should have been:
2. Are you arguing that all private insurance in the country would cover a new cancer drug at $4,000/mo which has a less than 5% five year surivival likelihood? Just trying a Lexis or Google News search and see if you can find an article of the form, "Insurance Company Denies Cancer Treatment". More precisely, count how many dozens you find. Really nothing diferent here.
Oh I see; it's just for the poor. That's OK then.
STATEMENTS OF INTENT FOR THE APRIL 1, 2009 PRIORITIZED LIST OF HEALTH SERVICES COMFORT/PALLIATIVE CARE
It is the intent of the Commission that comfort/palliative care treatments for patients with an illness with less than 5% expected 5 year survival be a covered service. Comfort/palliative care includes the provision of services or items that give comfort to and/or relieve symptoms for such patients. There is no intent to limit comfort/palliative care services according to the expected length of life (e.g., six months) for such patients, except as specified by Oregon Administrative Rules.
It is the intent of the Commission to not cover diagnostic or curative care for the primary illness or care focused on active treatment of the primary illness which are intended to prolong life or alter disease progression for patients with less than 5% expected 5 year survival.
Examples of comfort/palliative care include:
1) Medication for symptom control and/or pain relief;
...
5) Services under ORS 127.800-127.897 (Oregon Death with Dignity Act), to include but not be limited to the attending physician visits, consulting physician confirmation, mental health evaluation and counseling, and prescription medications.
Earl Blumenauer, a Democratic congressman from Oregon, is a supporter of Oregon's assisted suicide law, and is responsible for inserting the end-of-life counseling provision into the health care bill.
And that "Death Panel" has been championed by Republican Senator Johnny Isakson of Georgia. A big time wing-nut.
Euthanasia is just one of dozens, perhaps hundreds, of procedures that are ethically tricky. We're seeing these in Public Health already (should all 13 year old girls receive the HPV vaccine?)
One of the key benefits of offering people choice in health insurance is that you also offer them choice in health care. If you don't want grandma to be "death counseled" at 65, pick a plan that uses "all means available" regardless of her age.
And then pay for it.
Pay for it?
Are you crazy?
I want someone ELSE to pay for it - Health care is a RIGHT, damnit.
Sorry. What was I thinking?
I WANT IT ALL, I WANT IT FREE, AND DON'T BOTHER ME ABOUT ALL OF THAT PHONEY "WRECKING THE ECONOMY" CRAP.
Y'er all capitalist swine...
Or dumping a live-born baby in a closet until it dies.
Our current president, BTW, is on the record as saying this should not be illegal because if it were, it would be a burden.
"But they are limited by, first, competition--an insurance company that tried to do this too blatantly would suffer horrible publicity and ultimately lose business--and second, the threat of lawsuits and/or regulation.
People aren't trusting the free market as much as they're trusting various institutional arrangements, some within the market and some outside of it, to protect them from the perverse incentives of any insurance company. Once the government has the perverse institutional incentives, the institutional checks are fewer, more ponderous, and worst of all, often create huge new problems."
This all is only true if the government is the sole player. No one is arguing for single-payer here. Any government-provided coverage will still be in competition with private plans.
"The other reason I think the worries are legitimate is that as the government is on the hook for more medical costs, its incentives change. The fact is, it wouldn't be hard to manipulate a significant number of sick people into forgoing a lot of expensive care."
Compare to the status quo. Again, the people who might be subject to these pressure are not those who already have great plans. Instead, they are the ones with little to no coverage. And it still looks like an improvement for them.
My concerns with the public option is that:
1. I don't see how it will be walled off from the treasury or politics. It might set up to be independent, but whatever lobbyist give-aways don't get into the initial creation of the plan will surely get tweaked in over time.
2. I believe every state has different demands on health insurance providers. Will the public option have variants for each state? If not, that is a money-saver right there that will make private plans unable to compete.
This all is only true if the government is the sole player. No one is arguing for single-payer here. Any government-provided coverage will still be in competition with private plans.
Except that Obama is on the record as arguing for a single payer system, as are several of his advisers. They all acknowledge that it won't happen all at once, but they know that, over time, the public system will squeeze out private insurers in almost all cases. It's easy - they government will simply implement regulations requiring that all "private" health plans include so many features that they will become uneconomical - even if they don't shut down immediately, they will not be able to add new members to their pools, which is essentially a death sentence for a plan. As the remaining private plans become more and more unaffordable for employers to due mandates and other regulation, the government plan will be waiting in the wings.
http://www.youtube.com/watch?v=zZ-6ebku3_E
http://www.youtube.com/watch?v=p-bY92mcOdk
Or they could price the public option at something ridiculously low, claiming to make it "affordable". Unlike private insurance, it does not need to show profit, or break even. It can be subsidized by taxes or debt. Price it low enough, and private insurance cannot compete.
If private insurance cannot compete with a public option in price, features, service or some other metric (better end of life care?) then explain to me why private insurance should exist.
Gotta agree with my man sloth on that one.
But wasn't the private plan supposed to be revenue neutral, existing on it's own premiums? Or have they dropped that farce?
Sloth: If public options can do everything you claim, than there is no reason for private insurance.
However, if you simply write down a very low price by hiding the true costs, than this is really not the case anymore.
Sloth,
FTFY...
Also, more directly, the 'public' option can by law make the private insurers uncompetitive - mandate higher coverage minimums and not private the plan to be revenue neutral (subsidize it through taxes/debt). Acting like this is simple market competition makes you look either naive, unserious or intentionally deceptive.
(replying to Sloth @12:30 here as comments only nest finitely)
"Price", narrowly conceived (i.e.: what the consumer pays), is something of a straw man. "Cost" is really what we need to consider when we compare market and government options.
@Ken That would be unfair competition, I agree, and we would need to see detailed accounting for the public option, but we'd need that in any case. I'm not thinking that any public option is going to get away with running at a higher cost basis than any private option for any extended period of time; look at the scrutiny that a tiny clause about optional end-of-life counseling is getting. And I don't think that even the most rabid lib is going to have any luck trying to support such a state of affairs, if they'd even want to.
The problem would seem to be very similar to that faced by medicare+choice today.
(@Sloth 12:57) We already have Medicare/caid, but even if you were given a week to chew on it, could you work out what the "real" cost per persson is of the Medicare/caid plan options, including the proportion of administrative overhead that the program shifts onto the healthcare providers and the proportion of fiduciary responsibilities that are covered by the IRS and US Treasury?
The private insurers probably won't share much of this data for competitive reasons, but you can be quite certain they know what it is, as they have for-profit business enterprises to run. And if government magically determines that the cost of Plan X will be Y, and Y is less than the real net cost of providing Plan X, who runs out of resources first and exits the market: Government, or the private company?
To add to what Sloth is saying here:
I can tell you that as a supporter of healthcare reform and the public option, creating a system in which a public option competes fairly with private insurance is the critical criterion for my support. If in fact, at some point in the future, the public option ends up being subsidized by the federal government at below-market rates or competes in a blatantly unfair way with private insurance through regulation, I will then oppose it.
Furthermore, I don't think it's naive or foolish to believe that there will be enough people like me out there to keep the program honest. People just sort of repeat the old line, "Once you start a government program, you can never get rid of it," but as I get older and gain experience that argument seems less and less true. Overall, I've grown more confident over the years that our system of government is better able to correct its own mistakes than most voters assume it is, especially in areas of life-or-death.
If private insurance cannot compete with a public option in price, features, service or some other metric (better end of life care?) then explain to me why private insurance should exist.
If the public option wins on price and service, the private option will compete on features, i.e. covering procedures that the public option won't cover.
Cf. Medicare supplemental insurance in today's market...
Troy: How many government programs that exist on any sort of scale ever go away? Sure, wartime procurement, building something prior to a big event, some random program nobody has ever heard of, those can go away. But healthcare?
@aMouseforallSeasons
True enough, but a lot of the "hidden" costs (i.e., no billing - IRS does it for free as part of what they do), I think is a good thing. An efficiency.
If the public option sets rates as to what it can or will pay, you will have hospitals and doctors refusing to accept it. They do that today. That's a competitive advantage for private plans.
If the public option *can* negotiate lower rates, those rates must be available to all insurers.
Sloth, no politician or bureaucrat need to hide the costs of the program. Regulation simply needs to be drawn up in such a way as to not keep track of those costs.
You say that you will oppose this program if it becomes subsidized, but how would you ever know? Likely a report will come from some private think tank, that will be argued and debated about.
Show me a single gov't program that keeps a true tab on its costs, instead of doing some very generalized calculations after the fact.
Keeping track of costs is hard. Gov't programs don't need to do this, they just have to keep track of funding. The question is rarely "Is this worth doing?", but rather "Do we have enough to do this?". And why would such programs go to the trouble of keeping track of their costs? Its not their money they are spending, and its not them that receives the benefits.
Let me illustrate the point. Assuming you do not live alone, try to calculate the cost of a single member of your household. How much actual utilities they are using? How do you divide up the cost of living space? Which paid for services would not be necessary if that person was not there? Which opportunities are lost? What is that cost? Which opportunities are gained?
The numbers get fuzzy pretty quick, and I doubt anyone could arrive at an answer with a high degree of confidence. So instead most would say, my household cost X, there are five people living in it, and cost per person is X/5.
And this is just a simple household. Now imagine a program covering hundreds of millions, controlling multiple trillion dollars a year with the ability to influence both prices and the value of currency. Why would you expect anymore accuracy in accounting?
@Ken, let's try this way. Can I, as a businessperson, give you a breakdown of what my costs are, by department, including shared costs such as office space, heat, electric, healthcare, admin, etc? Yes, I can. Pretty easily. We do it all the time.
I reiterate, some of those costs which are "shared" amount to efficiencies for the public option. IRS for billing, for example. Others amount to inefficiencies - lousy employment contracts. That's all part of the overall package - if the public option works out to less efficient, tough for it. If private industry cannot manage to compete with the government, too bad for it. The NOAA is federally funded - accuweather competes nicely. NASA is federally funded, SpaceX is after that. We have massively subsidized public transportation in my city, most people drive cars. These people somehow believe they can compete with a massive federal bureaucracy, I think the private insurance industry can too.
But if they can't, too bad for them.
Well said! HT
(@Sloth 3:14) Fine points, but I have yet to be convinced that Medicare Borg won't be structured in such a way, especially by future generations of politicians seeking to expand services to special interest groups, to increasingly crowd out the private insurance market while eating ever larger bites out of the federal budget.
You cite cars versus busses. Fine; but the only thing necessary to shut people out of their cars without exericising absolute fiat is to make private vehicle registrations onerous and expensive to obtain, add a hefty gas tax besides, and then then make the permitting and egress processes for private road development so difficult as to be infeasible. Add some budget line items for increased policing to ensure compliance, and voila, no cars on the road. Enjoy your busride, sorry if the guy next to you is incontinent today.
The political repurcussions would be so devestating that no politician, not even in his greenest moment, suggests such a thing (Gray Davis came the closest, and look what that got him). With healthcare, however, there is a lot about the present system that is a giant black box to the average person, leaving plenty of room for additional regulatory takings and overreach that will pass below scrutiny. Each successive "failure" in the private market brought on by this fiddling will justify additional expansion of the federal system. In fact this kind of fiddling has played a non-trivial role in explaining why we are having this debate at all. What prevents more of the same once the government has outright control? So far as this bill appears to be structured, nothing at all.
It is a yellow brick road to an NHS even if the present proposal doesn't set up such a thing.
@aMouseforallSeasons
You have a lot more faith in the efficiency of the government than I do.
As for the great all-swallowing borg, arguably it would have swallowed all private transportation if it wanted to - it didn't, so either it didn't want to or it couldn't. I tend to think both.
There is also the counter example of the armed forces moving to increasingly outsource key components of itself. Security and logistics, for example. Very un-borgish.
Insurance companies already have those undertreatment incentives, but it's hard to act on them. Right now, people know that their insurance companies would love to provide self-serving "end of life" counseling that would encourage sick people not to waste so much valuable money. But they are limited by, first, competition--an insurance company that tried to do this too blatantly would suffer horrible publicity and ultimately lose business--and second, the threat of lawsuits and/or regulation.
Wow--in all the hundreds of posts and comments I've read about the issues surrounding health care in recent weeks, this is first one that asserts that insurance companies are currently unable to act on their financial incentives to restrict treatment.
This flies in the face of real-world experience--unless you choose to believe that all the many, many stories people have been telling in countless venues, including Andrew Sullivan's blog, about being denied coverage by their insurance companies are just fabrications.
I'll simply add that my wife, a nurse practitioner, has spent countless hours in recent years battling insurance companies to get essential coverage for her patients. (All-too-typical example: A clincally depressed patient who is cut off from psychiatric care by an insurance company agent who says, "Well, she hasn't threatened to commit suicide in the last 24 hours, has she?") As a result, my wife is now one of the many health-care professionals I've spoken to who ardently supports health-insurance reform and is only worried that it won't go far enough.
I'll all for reform, but remember that they aren't just trying to "reform" it, they are trying to bend the cost curve downwards...i.e. reduce the cost of healthcare and the rate of growth of that cost.
To do so, someone is going to need to get reduced care in some form. Cutting inefficiencies out of the system is a one-time cost savings measure (unless you think inefficiencies are growing by 5-10% of all healthcare costs per year).
Maybe the depressed patient gets told "your depression isn't severe enough, please conduct diet and exercise unless breakdown occurs"....
I know that's a ridiculous sentiment, but it's pretty similar to what's happening now: why would we expect that under a reformed, lower-cost healthcare system that your wife's patient would suddenly receive treatment?
Joe
Obviously we can and should debate the details of reform. But the point of my comments is that we need to start the discussion with reality--not with Megan's fantasy that the current system is one in which private health insurers are prevented from denying coverage by competition and their fear of bad publicity.
Karl,
Read more carefully. She's talking about the specific instance of fear of repercussion (public sentiment, reduced enrollment, loss of revenue) for counseling older (and presumably sicker) people to forego expensive end-of-life treatments that, when they work, add little quality time to the person's life.
She's not talking about ordinary, everyday denials of service, which we both know they're good at.
Thomasblair, if Megan is only writing about the narrower case you describe, why did she preface the lines I quoted earlier with the following paragraph:
The other reason I think the worries are legitimate is that as the government is on the hook for more medical costs, its incentives change. The fact is, it wouldn't be hard to manipulate a significant number of sick people into forgoing a lot of expensive care. The Obama administration's point, which is well taken, is that it's problematic to give doctors financial incentives to bias their advice towards treatment. The problem is, it's also problematic to give them, or their employers, incentives to bias their advice towards undertreatment. Every compensation scheme on the table does one or the other. And I think Americans are inherently more comfortable with a bias towards proaction than inaction, even if the latter is cheaper and more restful.
This paragraph clearly broadens the discussion to the general issue of how "compensation schemes" inevitably contain a bias toward either treatment or undertreatment. Megan then says that insurance companies today are restrained from acting on their bias toward undertreatment--and that is the point I am contesting.
Nice straw man. Megan never said that insurance companies are prevented from denying coverage for fear of bad publicity. She said that the potential for lawsuits and lost business resulting from bad publicity dis-incentivizes insurance companies from denying coverage. I've litigated several bad faith insurance claims and and they are a very real threat to insurance companies and their bottom lines. You have infinitely more recourse against an insurance company than you do the federal government. You can't sue Medicare for bad faith denial of coverage and you won't be able to sue the government's "public option" plan.
Also, why do liberals like to talk about insurance companies' denial of coverage when the main argument presented in favor of Obamacare is that we currently spend too much money on needless procedures and Obama has given us his dissertation about taking a pain killer instead of having surgery. Everyone knows that a government run plan would never deny care to someone who needed it. I am not aware of anyone who is proposing that we ignore the hard cases. Opponents of Obamacare just don't want to throw the baby out with the bathwater. The 47 million uninsured figure is misleading at best. We have somehwere between 10-20 million working poor (out of 300 million) who make too much money to qualify for government aid but make too little to afford private insurance. Let's devise a policy to take care of the 3%-6% (in addition to making health nsurance portable etc.) who truly can't afford health insurance instead of imposing a policy that will adversely affect 97% of Americans. As they say in the legal profession, hard cases make bad law. Liberals always scoff when Obamacare opponents reference the horrible anecdotes from socialized systems but they love to pretend that the anecdotal horror stories in the US are the norm. They aren't.
If our system is horrible because of these denial-of-coverage horror stories yet denial of coverage occurs in socialized systems as well, why should we switch to Obamacare? Especially in light of our higher cure rates compared to the rest of the Western world for all kinds of diseases? What Democrats are proposing is to let the rationing decisions be made by the federal government. Come to think of it, what happened to the abortion rights argument that we should keep your laws off my body and that health decisions should be between an individual and his/her doctor?
"... but it's hard to act on them. ..."
does not equal
"... are currently unable to act ...".
Oh, so Megan's point is that insurance companies CAN in fact "act on" their undertreatment incentives by denying coverage, but that "it's hard" for them to do so? That's an interesting distinction. I wonder wherein their difficulty lies? Is it hard for them to hire people to tell doctors and hospitals "No, coverage is denied"? They don't seem to be having much trouble doing it.
The point is, of course they do when they can, but not nearly so much as they would like to because of bad PR and competition. The government scheme won't really have to worry about bad PR, competition or, I would assume, law suits, so it will be far more free to do what it wants.
I have dealt with enough US Insurance companies that I have found them to be difficult, obtuse, faceless bureaucracies. that said, compared to the British Columbia ministry of health, they are frickin' Santa Clauses.
I see a lot of people asserting that anything the government gets involved in is automatically bad. My experience doesn't support that. I've found some government offices very annoying, others quite efficient. (And, if anything, I generally find federal offices much better than state offices, like the dreaded DMV.) It's the same as with private enterprise--some corporations are well run, others are horrible to deal with. (For example, see this post from Kevin Drum.)
If government incentives regarding medical care are so terrible, why is VA care generally regarded as quite good? Why are seniors angrily demanding that their Medicare be left untouched? Again, facts just don't bear out the contention that private enterprise inevitably provides better service than government.
Karl Weber,
Libertarians believe government is bad. The glass is always half empty, and some poor, lazy, uneducated rat's gonna steal what's left in the glass.
Libertarians are incapable of appreciating the benefits of any government. Despite the road they drive on, the internet they surf, the medical care they get as seniors, the research that's at the basis of that medical care, the are constitutionally unable to see a good because it's theft of their money.
They also view themselves as responsible, moral, and upright, and totally ignore the ways they suck of the system the abhor.
the internet they surf
Drop this one already, will you? The part of the Internet financed by the government has been dwarfed by private investment by orders of magnitude.
Karl,
Zic is a 'reform' zealot- she's so blinded by her obsesssion she's lost the ability to think rationally (saying MM's father's job makes MM a hypocrite) or behave politely (see above). She's not worth engaging, since she operates on the level of a spoiled 6 year old.
Since the vast majority of seniors are currently covered by medicare, I'm wondering why we think that end of life coverage will change in any meaningful way under obamacare.
Putting aside, of course, the point that there may or may not be a public option, but there is no plan out there which elmininates the existing set of insurers.
This is in reply to zic:
Zic, you do realize, of course, that the Seniors on Medicare have spent their entire working lives paying premiums for this care and continue to pay premiums while receiving benefits. These Seniors also don't really have a choice - at 65, everyone moves to Medicare for coverage. Those that can afford it (the vast majority, as I understand it) also pay premiums to private insurance companies for extended coverage to help pay for those things Medicare doesn't cover.
My in-laws would be a good example of someone having paid dearly for the coverage they now receive. As small business owners, they paid (and continue to pay, as they are still employed) not only the employee portion of mandatory Medicare taxes, but the employer's portion as well. They also pay the employer's cost (100%) of the company sponsored insurance, which acts as a supplemental for them. My husband and I, as part owners of the company, are in the same boat they have been in. Hopefully, by the time we reach 65, what we will have spent over 40 years paying for will still be there for our benefit. However, given the unfunded liabilities Medicare currently runds, I doubt that will be the case.
Replying to ...Max due to limitation on indents,
While after invention investment is of course important, equally as important is the investment in a technology no entrepreneur sees as useful at the time of initial development. That is a useful role of government and academia and why DARPA continues to deserve credit for the invention of the internet.
No private enterprise would have ever sponsored Maxwell's work because it had no foreseeable payoff, yet it laid the foundation for modern society. Nor was any private investor willing to sponsor the fundamental research which went into developing the internet. That's where the rub comes in. Most libertarians don't value DARPA or the government money spent there at all, but gladly take the benefits that evolved only because of DARPA's sponsorship of ideas so out in left field as to be miles beyond the stadium (and without the potential to realize profits within the useful time frame of a business, why would any rational private enterprise sponsor such researh, ever though there are benefits to be realized 30 years or more after invention.)
Karl: "If government incentives regarding medical care are so terrible, why is VA care generally regarded as quite good? Why are seniors angrily demanding that their Medicare be left untouched?"
This would be a good point if either group actually paid the cost of the care that they receive as they went. The question is not whether the government can provide services of value. It can. The question is not whether it can give those services away for free to select groups while coercing payment from the population at large (or, in the case of VA care, free riding on other sectors), so that the select groups will fight to keep their free services. Of course the government can do this as well.
The question is how well the government can provide services when in fair competition (or especially when not in competition at all) with the private sector.
If the government plan is revenue neutral, more power to it. If not, I hope its scope is extremely limited (just enough to prevent people from using emergency rooms, which is the current unfunded mandate.)
In reply to TimesCurrent:
I dunno who those "most" libertarians are -- this libertarian thinks DARPA is definitely one of the few worthwhile, though not perfect, government agencies. The larger point still stands: the fact that current Internet is loosely based on protocols conceived under the ARPAnet umbrella is of only academic interest at this point. That technology already felt lackluster at the time of its wide adoption (let's say 1994) and the reasons for it winning over proprietary (CompuServe, AOL, SprintNet) and open (FidoNet) competition are manifold but we'd certainly have an equivalent of the Internet by now even if it wasn't based on IP packet transport and HTTP content delivery...
Times: Regarding your theory that no private entity sponsors basic research, I suggest you look up Bell Labs - home of, among other things, the transistor and the laser.
You actually believe what's written on Andrew Sullivan's blog?
Barnum was right, I guess.
The Iranian revolution is about to start in T-minus...
And Sarah Palin just had ET's baby!
Well, when one of Andrew's readers writes in detail about his/her personal experience with our dysfunctional health care system, yes, I tend to believe it. Especially since I've heard dozens of similar stories from people I know. Or would you prefer to believe that, in our current system, everyone who needs health care has perfect access to it all the time? Does that strike you as more plausible?
You know perfectly well that I wasn't referring to anything Andrew has written about Sarah Palin.
The death panels stuff is deliberate lies being spread to scare people.
Why do you feel a need to justify it?
So maybe the same thing could be accomplished a different way.
When the budget is planned, allocate enough resources for X procedures of a certain type, evenly spaced through the budget period. People needing the treatment would get it on first come first served basis.
Have the budget deciders isolated from any data that would indicate any short falls, have them influenced by priorities from lawmakers.
Then if you die before getting treatment, well, that's life.
Is that antiseptic enough for you?
Derek
No, that is the Canadian system. Also, if there are more preemies born than your budget allowed, you don't add more beds, you send them to Buffalo.
How about a middle aged (44) woman who needs a hip replacement, but has to wait for over 2 years? This is not some octogenarian who will die before the shine is off the new hip - this is a person in the prime of life who should be active and healthy but instead become sedentary, and pretty much a pain-pill addict, which if course adds more health costs down the road. This is not a hypothetical story - this was my high school French teacher.
"The death panels stuff is deliberate lies being spread to scare people. Why do you feel a need to justify it?"
I am getting a kick out of the angst and gnashing of teeth by liberals who are now getting a dose of their own medicine (pardon the pun). For decades they charged up the third rail of politics (Social Security) by scaring Grandma and Grandpa whenever the Republicans wanted to reform the program. Modest proposals in 1994 to restrict the growth in Medicare were akin to medical deprivation and crimes against humanity. Just like slowing growth in the school lunch program was snatching food out of the mouth of babes.
I have no sympathy for you. This is the acid swamp you created.
On what basis are you calling me a liar?
Lies may be fine for you, but I'm agin 'em.
My point was broader than just you Downpuppy, unless you also condemned Newt Gingrich for trying to put the brakes on Medicare spending in the mid-90s.
http://www.timeswatch.org/articles/2009/20090108141248.aspx
Again, the people who might be subject to these pressure are not those who already have great plans. Instead, they are the ones with little to no coverage. And it still looks like an improvement for them
You are presumably not one of these people, but merely presume to speak for them.
The uninsured are perhaps the less-educated, perhaps non-English speakers etc.
But it's nevertheless strange to see statists and union members telling usthat these uninsured will be much happier when the system is changed.
When it comes to health care, in particular the significant intervention kind of health care, the cheaper outcome for the insurance company or for the government is for you to do with less treatment (or no treatment) and muddle through or die. The difference, of course, is that you can sue the insurance company. You can't sue the government.
Where I think Megan is wrong is that much will change once the government shoulders a substantially larger portion of the cost of health care. Its incentives might change, but it probably won't be able to act on them. The bureacracy will want to "bend the cost curve", but the politicians won't let it. No, I do not think Congress will EVER allow MediPAC or any other independent board set reimbursement rates, etc. In other words, the costs will continue to soar. That was the big mistake in Obama's strategy--if he was ever really serious about reining in costs, he had to take the cost-cutting out of the political process by basically mandating that part of the legislation himself. Instead, he left it to Congress.
Megan -
This brings up a point that I question frequently: Is life expectancy data accurate?
If we spend some hugely disproportionate amount of money on end-of-life care, then we should be seeing some benefit out of it.
Now, I understand that maybe the benefit is hard to quantify. Maybe it's quality of life. Maybe it's pain management. Maybe it's simply providing bed-bound subjects with an automatically adjusting bed that prevents bed sores from forming.
But my (personal) instinct tells me that SOME of this care is life-extending. Maybe it's a surgery or treatment with a low chance of success....none of the less, that low chance of success should be extending a certain portion of the populations life.
My point is: If we spend a disproportionate amount of money on end-of-life, low-chance-of-success treatments, then we should be seeing an extension to that person's life expectancy and/or quality of life.
So either:
1. that's not currently quantified,
2. or we have another source of mortality that is dragging down our life expectancy
3. or it truly is producing no improvement in people's lives (I find that hard to believe due to the shear quantity of money being spent)
4. Or the life expectancy statistics are not wholly accurate
I'm thinking it's a mixture of 1,2, and 4.
Much like we talk about (in these comments) how the newest, latest and greatest innovations are very expensive and we tend to buy them moreso in this country (inflating cost), I also think that we are actually gaining something in our treatment of end-of-life subjects....which is either not being accurately quantified, not being quantified, or is mixed in with another subset of data that is muddying the waters.
You can call this bias on my part if you want, it's just my gut.
Joe
P.s. How much do we spend on nursing home care/hospice care compared to other countries where people tend to be cared for by family/die at home?
I sometimes wonder if the extra end of life expenses isn't just partly the "keys are in the last place that I look" fallacy. That is to say that treatment is often one procedure followed by another until one works. When a procedure is successful you stop earlier which means less expense and the patient doesn't get counted as end of life. End of life patients are those where you've exhausted your possible solutions.
TreeJoe-
I agree your first point is probably important. Which leads to another conclusion-that quality of life care would suffer more under a system determined to cut costs, because its less "measurable." The cold hard math may say someone gains an insignificant life extension, but what if without the treatment the remain bedridden? Unless the system can quantify this, the incentive will be to not give them the treatment.
I would guess point two is partly driven by accidental death. Especially if it disproportionately hit younger people, this would drag the average down.
BTW, I'm with our hostess. Rationing is unlikely, at least if it involves politically powerful groups and diseases. People hating HMOs, so they'd probably hate the government doing the same thing.
That's simply not true. In the early 1980's it might have been the case. But by the late '80's, quality of life metrics were an important part of the biostatistics of any trial.
What quality of life metrics are used? The problem is that quality of life metrics are inherently more subjective than just measuring additional years of life. This is a problem because people are different. For example, when it comes to prosthetic legs, a 75 year old diabetic may be content with a low cost prosthetic that allows him to continuing to get around his house without a wheelchair. A 25 year old war veteran may want a high tech leg that allows him to run marathons. Do we give them both the low cost leg because keeping them out of a wheelchair is enough quality of life improvement? Do we give the 25 year old the high tech leg and the 75 year old the low cost leg? What if the 75 year old isn't a diabetic who's in poor health, but a pretty fit senior who lost the leg in a car accident? Should he get the less functional leg simply because of his age? This is a complex question that I don't think any quality of life metric can really capture.
The death panels stuff is deliberate lies being spread to scare people.
Why do you feel a need to justify it?
Because Partner/Hubby Suderman makes a living astroturfing, and that kind of stuff is what it takes to get people off the TV, and show up atthe protests.
Any administration that includes David Axelrod should just STFU when it comes to claims of astroturfing. Hell, how do you think Obama won the Dem primary?
My fiance makes a living writing for Reason magazine.
Hell, the "Death Panel" amendment was offered by a Republican(Johnny Isakson of Georgia). Why Democrats aren't pointing that out, I don't know.
Look at the intellectual forebears of the people crafting this legislation, and how easily morality was pushed aside for the 'common good.' The ends always justify the means for these folks.
And you're going to trust them with your health care?
Which side is lying again?
The one making up the euthanasia crap, pretending the grandfater clause forbids new insurance, inventing "Death Panels" etc, right?
So they're the ones to trust! their lies are so stupid they,...
Gaah. Give me the black pill.
I believe they prefer to be called "African American" pills. Your gross racial insensitivity has been noted and may result in a kegger at the White House.
I'll slam a 40. Steel Reserve - none of that watery slop.
I mean, they still idolize Sanger and the eugenicists who advocated aborting black babies for the good of society.
Do you actually believe that "they" are proposing eugenics measures, or are you just lying?
If you believe it, what's the evidence?
Pretty much anyone before the last 40 years or so(and that number is probably generous) held some beliefs that would be considered shocking and offensive today. That's equally true of the historical figures you admire as it is of the ones you despise. Is Churchill any less great a leader because he advocated terror bombing with chemical weaponry to put down a rebellion? Is Jefferson any less important a fighter for human rights because he owned slaves? The Declaration of Independence was written by a hypocrite, but that doesn't make it any less valid. Similarly, Planned Parenthood was started for some pretty vile reasons, but the modern-day institution cannot reasonably be tarred with the same brush.
Here is what I just dont get:
when the "reforms" in the system are described with a goal of "bending the cost curve down", accompanied by criticism of the current fee for service arrangement, isnt Obama just describing the HMO concept administired by the government?
As I recall -- people HATED the HMO experience. They hated having to run the gauntlet of the primary care physician who had an incentive to minimize the amount of treatment you received. There were lots of stories about HMOs denying treatement,etc,etc.
So wouldnt a government run plan have to make the same tough decisions that private HMOs do? With private profit margins around 10% max -- either the government plan could cut the costs on a one time basis 10% and deny the same treatments, or allow 10% more treatments but not bend the cost curve.
To the extent that healthcare moves toward single payer, it becomes a zero-sum game. Americans are NOT good at zero sum games.
Imagine the fight over, say, affirmative action if the direct result of such policies was not that you denied a promotion at the Fire Department, but that your kid wouldn't receive a life saving transplant.
That happens now, of course, but people blame the system or insurance companies or whatnot - not each other. They don't look at their neighbor's kid getting therapy for autism and say - those resources could used to save my kid. I don't care if that never happens elsewhere - that's what will happen here.
Two years ago, my mom's partner became ill while visiting Alaska. Trip to hospital, to discover he had pancreatic cancer.
Emergency flight back home. Trip to hospital, same tests repeated to diagnose pancreatic cancer. Trip to larger hospital, same tests again repeated to diagnose pancreatic cancer.
Guess what? He died of pancreatic cancer; it was not treatable. Now there are treatments for pancreatic cancer, but they said he couldn't have them because they would not work on his type of cancer.
Now if he had been among the 8% of people with treatable pancreatic cancer, at 72 should he have been treated? He was otherwise healthy and strong. I'm pretty sure he would have, and would still get treated under a reformed system.
But Medicare paid for three CT scans in the course of a few weeks. One would have sufficed. And Medicare paid for two biopsies of his pancreas, again, where one would have sufficed.
But Medicare did not pay his doctor for the time spent explaining options once it was apparent that there the cancer couldn't be treated.
But there is another side to this that's equally important. My father died of prostate cancer, diagnosed when he was just 58. He survived another 10 years. His treatments were hellish enough that he did have a living will; he clearly learned what he didn't want. At the was still incubated and put on life support, with it falling on my step-mother and I to tell them to pull the breathing tube. His living will was ignored, though it was on file in the hospital and his wife had a copy of it with her and told everyone to follow it.
I suspect that if doctors were actually paid for their time talking about end-of-life care, they might give it more credence and respect when it comes time to implement that care.
Are you really complaining that doctors are trying too hard to help their patients? I understand the complaint against ignoring someone's will, but complaining that a doctor wanted a second look in the hopes of finding some information that may have saved that persons life?
Jesus, Ken, we already knew his life wasn't "savable." There was no new information to find; he had cancer all through his body, a broken shoulder that couldn't be fixed because of the cancer in it, a stent that has been in place for four years and was constantly infected, an untreatable staph infection.
But Medicare did pay out tens of thousands to the doctor and hospital for the time between he was incubated and died.
I see, well since you have complete faith in your medical expertise, why didn't you roll the guy right out of the hospital? They can't run all those tests on him against his will. Could've just stayed in Alaska.
Place yourself in the physicians shoes. A patient comes in from some hospital in BFE. Chart says that he is untreatable, based on their admitted inferior diagnosis. You can do one of two things:
A. See if your superior facility offers an option that the remote hospital is lacking.
B. Write the patient off as not savable.
In my experience, doctors worry about treating patients first, and paying for it second. This is why the keep billing depts, so they can concentrate on what they are good at, treating patients.
Let me bring in another, personal, example. Someone I know, a severe diabetic, finds out that she is pregnant, due to carelessness. She has no interest what so ever in being a mother. Also, it is extremely unlikely that her body can handle pregnancy. Being that a miscarriage is virtually inevitable in very short order, she chooses not to have an abortion (I have no doubt whatsoever that she would have chosen one otherwise).
But she sees a doctor on a regular basis, and informs him that she is pregnant. The doctor immediately moves to try everything he can think off to make the pregnancy a successful one. Why? Because that is his job, to treat people. His job is not to deny them care, to make ethical decisions for them, or to make sure that medicare/medicaid is sustainable. You don't go to a doctor if you do not want to be treated, anymore than you take your car to a mechanic if you want it junked.
Give it up, Ken. I gave two examples. Don't twist them to squirm your way out.
In the second, my father with prostate cancer, he was incubated at the cancer-center that had been treating him for ten years, was told not to incubate by the patients wife, and living will was on file.
I'm quite sure the incubation was a mistake; done by someone looking at a dying patient, act now, question later.
And that's the point I was trying to make, instilling a culture where the minute or so needed to ask the question, "Does this patient have a living will, and does it allow extreme life-saving measures?" is part of the protocol.
And I completely agree that ignoring someones will is wrong.
However in the first example there was no will, and you are trying to blame doctors for trying, unsuccessfully, to do their job.
No, I didn't blame doctors. I gave an example of waste in the system that drives up costs needlessly.
There's no reason CT scans had to be repeated three times over the course of three weeks; it happened because of the difficulty of getting records from medical facility to another. And were the test an uncomfortable, invasive one. . .
One other point, Ken. Because Doctors oversee medical care, when we talk about any problems, it's going to seem like they're doing something wrong, when that's not likely to be the case.
Doctors are going to need a thick skin in this discussion. Were we talking about education, teachers would have the same problem. Same for finance and bankers. Addressing the problems of a system doesn't mean the individuals are evil, that's actually a straw-man argument to avoid the discussion of the problems.
No zic, you are not blaming the doctors, you are simply shrinking away from personal responsibility.
Right now, every person has an option for those last chance procedures. Believe it or not, some people choose to forgo chemotherapy for cancers when there is a low chance of success.
Your example could've not gotten treated if he so chose. Trying to accommodate his wishes and treat him is not an inefficiency of the system.
You propose that some person, far removed, with little information regarding specific details, make the decision as to high risk treatments, leaving all the people with any stake in the situation with not choice. How is that an improvement?
zic, first off, I'm very sorry for your loss. My question: How would a government healthcare option prevented the three CT scans? I agree that there is inefficiency in the # of scans, but the current government plan, Medicare, has nothing in place to prevent that. My other question to the government option proponents on this thread is why not reform Medicare first?
Preventing duplicate procedures and a public option are only tangental, not directly related. Reforming health care so that it won't bankrupt our nation requires several means several things; better, more effective sharing of information (digitized medical records), better medical culture (comparative effectiveness studies,) and insuring those under or uninsured now, which is where a public option is important.
As far as reforming medicare; teabaggers aren't exactly calling for reform, are they? It's politically impossible to reform medicare alone.
It's politically impossible to make just about any good reforms to the system. That doesn't mean that you should make it worse just to see it change.
Isn't everybody busy looking in the wrong direction with this fear that government care will restrict end of life interventions? Isn't it far more likely that it is preventative care and early detection that will become restricted. It seems to me that it is very unpopular to restrict end of life interventions and government tends to be very bad and sustaining unpopular actions in order to get better results.
Take my (Canadian) health care system. Though we do have some issues with waiting lines which results in care delivery issues (but arguably our waiting lines are on average no worse than the American average) where our system is clearly far worse than the American system is in early detection: eg. Cancer screenings and colonoscopies.
It seems to me it is much easier for a politician to remove a screening, which is no fun to get, than to risk the fall out of not delivering some surgery. At least it is easier for a politician to make this sort of choice than it is for an insurance company analyst.
It is in no way arguable that Canadian wait times are no worse than American. The simplest look at the statistics will reveal gargantuan differences - frequently an order of magnitude.
I find this discussion astonishing. You people seem to actually be discussing whether it is good government policy to allow your neighbors to bankrupt you and your country to save themselves, their child or their mother.
Now almost everyone is in favor of saving all these people and giving them the longest most healthy and fulfilling lives possible but the catch is the cost.
The quality and duration of peoples lives are impacted by money already and it is impossible to legislate this fact away. In a finite universe of healthcare resources supply and demand will always dictate that some people are more 'equal' than others but is it wrong to want to make people more equal and to try to keep healthcare from bankrupting everyone in some sort of logical way?
If you want effective government healthcare policy it can't be based on emotions and YOUR mother or YOUR child because none of us is very logical or pragmatic, on a personal level, when it comes to these type issues.
It is pretty obvious that insurance and human nature are incompatible when it comes to containing costs. If I pay my premiums I want ALL the healthcare I can get...especially when it comes to MY child. Since we can't legislate away human nature it seems inescapable that we need to legislate away insurance companies over time. As we transition toward a single payer system we will nlso need to adopt sound policies for rationing finite resources that don't have exceptions for MY child or YOURS.
We don't live in a fairy tale world where we can have everything we want. Hopefully we have enough adults in this country capable of understanding the real choices and the real costs. If not, be prepared to have reality thrust this understanding upon us in the coming decades.
If you want effective government healthcare policy
Some of us don't want a government healthcare policy. Or, granting it is inevitable, want as little of it as possible.
We don't live in a fairy tale world where we can have everything we want
Yep. And there's a feedback mechanism to control this already. It's called money.
The reality is that something needs to be done to manage healthcare costs and resources more efficiently. The current system is unsustainable. Government bureaucrats don't have a very good track record in most areas in which we've allowed them to inrude in our lives but absent some sort of government intervention how do we as a country address this issue before it implodes under its own weight?
Would some sort of cost controls imposed on insurance companies/healthcare cooperatives work? Say each person could only be charged a set percentage of their income for baseline healthcare and that any care beyond that would be optional and provided at market rates to individuals so inclined? This way, at least for baseline coverage, we would make sure healthcare was available for everyone and that the government's only role is to set the price and the rules of coverage for this basic level of care.
To simply say that 'money' already controls costs doesn't address the fact that in the coming decades healthcare will bankrupt us as individuals and as country unless something is changed. While bankruptcy will ultimately 'control' costs this seems to be a pretty extreme way to address the issue.
the government's only role is to set the price and the rules of coverage for this basic level of care
Whoa. Government setting the price is rich. It did so well setting the gasoline prices back in the seventies.
How about "the government's only role is to manage a pool for those who cannot get insurance elsewhere"? Kinda like it does with liability automobile insurance, at state level?
Tell that to the town hall protesters.
From what I can tell based on their questions, on their handouts, and on the TV commercials I see, the big source of anger is the fear that Obama will do something to limit what Medicare pays for. Yes, that Medicare, the huge government program.
If the biggest conservative objection to Obama's plan is that it might slow down the rate of increase in government spending on Medicare, then I guess we really have compassionate conservatism now....
The proposal to pay doctors for "end of life" counselling is a joke. Here's why: a few years ago new Medicare enrollees were offered a "welcome to medicare" physical. In the past, Medicare did not cover routine checkups, so over 65 patients would often try to game the system by having their physicians game the system by performing a routine exam and submitting the bill to Medicare under a disease-specific diagnostic code. I am a family physician, and believe me, everyone tried it. When the "Welcome to Medicare" physicals were announced, the feds sent us physicians a long, conviluted set of instructions about what had to be done, what had to be documented and so forth, and the penalty for not doinf exactly as the government ordered was to have the payment claim denied. Never mind what the patient or physician wanted; it was all about the government. I suspect the "counselling sessions" will come with all sorts of conditions and produce little revenue for the physician. And they will be carried out while the counselee is relatively healthy. My experience tells me it's very easy for a person to talk about end of life care in the abstract; much harder when your spouse or parent has a life threatening infection, let's say, from which they might recover. Of course, if they don't recover they spiral down the drain in a way that costs everyone dearly, and not just in terms of money.Chances are the results of the sessions will not be binding on anyone. I can tell you right now that every patient being admitted to a hospital today is asked if he/she has an advanced directive. Medicare rules already require that.It doesn't make anybody DNR/DNI and there is no committee of ghouls going around harvesting organs or anything. The thing that I dislike MOST about government sponsored health insurance is that it has, for the last 40 years produced absurdly inflated "prices" which are only charged to the uninsured. Commercial carriers and Medicare/Medicaid all demand and get sharply discounted rates which in the case of payments to individual physicians in primary care (I am being selective here)do not pay for the cost of the service. That's why a lot of physicians are not seeing new Medicare patients. They are tired of losing money every time one comes into the office.
The problem is, it's also problematic to give them, or their employers, incentives to bias their advice towards undertreatment. Every compensation scheme on the table does one or the other. And I think Americans are inherently more comfortable with a bias towards proaction than inaction, even if the latter is cheaper and more restful.
This point addresses the elephant in the room: the rising cost of healthcare insurance is a byproduct of insatiable American consumerism.
We aren't in fiscal destitution because we use paper medical records, or because we don't have comparative effectiveness data. We face soaring deficits because we collectively believe in (and electorally support) the entitlement culture: the guarantee of a life past 80-years (90?), with retirement at 50, regardless of how much it costs and how much we will bankrupt the next generation.
We believe in shedding off our elderly to nursing homes and assisted living facilities, all paid for by inflationary federal government Ponzi schemes. We believe in mandating standard-of-care treatment for every disease state, for every living human being, no matter how much of a physical/fiscal strain this puts on our medical infrastructure and community. We elect and pay politicians to come up with new ways to redistribute money they don't have to people who shouldn't have it, then worship them for their genius and pragmatism.
At no point is anyone willing to look in the mirror and say: "What am I doing to make my life cheaper?" Instead, we buy the fairytale notion that a room full of bureaucrats with election coffers to fill and cronies to placate will write an law making our debt all just magically disappear. Does anyone honestly believe that universal healthcare was a concept born out a need to stave off fiscal crisis?
Call me when you hear somebody state what needs to said: in order for healthcare costs to go down, we all have to live with dying.
Too much "we" in here, as usual. I don't recognize myself in this "we".
As Sullivan points out: most Americans do not want people dying in the streets and If you have guaranteed emergency room care for the uninsured at public expense, you have already effectively socialized medicine.
Interesting. Do you have any empirical data to support this statement? Or are you just making a prediction based upon some sort of theory, albeit making it in a nonstandard way, without numbers attached?
My own suspicion is that health insurance - especially at later ages - tends to be a consumer good like electricity or gas, as opposed to steak or peanut butter, i.e., the demand is rather inelastic, and becomes more so the older one gets. Thus, even with bad PR and competition thrown into the mix, the number of customers won't decline by all that much. Presumably, having access to better data and highly paid specialists, insurance companies are already near their optimum pricing strategies, so their behaviour right now can probably be assumed to be close to optimal for profit mazimization . . . and if this isn't the case, I'd certainly be interested in why, and why aren't they acting upon that information.
Note, btw, that this is not accusing these companies of being 'evil', merely acting amorally (as God intended) to maximize value for shareholders.
My own suspicion is that health insurance - especially at later ages - tends to be a consumer good like electricity or gas, as opposed to steak or peanut butter, i.e., the demand is rather inelastic, and becomes more so the older one gets
Demand may be inelastic, but the issue with healthcare price inflation is that supply is even more inelastic.
I don't know the numbers off-hand - I would love to see them - but I bet the number of hospitals, primary care physicians, and walk-in clinics as a % of the population has leveled off, or even decreased, as the population itself has increased exponentially, combined with an increasing life-expentancy.
That is to say: we have no way of meeting the current demands with the appropriate supply. Just like a commodity of fixed-quantity, you in essence have a bubble.
Obama has not made much effort to conceal the fact that his health plan is simply a foot in the door that will enable a more aggressive government takeover of health care later. As such, it is completely reasonable for people to wonder what else it might be a foot in the door for.
In this case, he wants end of life counseling paid for in a bill sold as a cost cutting measure. He says it will not direct people towards one decision or another. Maybe right now it won't. But it's nearly inevitable that sooner or later some pressure will be applied. What's the big deal? After all, people already have these end of life options. In fact, the death with dignity folks fought hard for years to get these rights recognized. Some people will exercise them, some people won't. As is their right.
The big deal is what happens to people who don't have strong opinions one way or the other. It says something about us as a society when we encourage them to pick a side, regardless of which side we push. The death with dignity people simply want the right out there. The government, at least sometimes, will encourage people to exercise it.
There's no need for this "counseling" to be in the bill at all. It serves no medical purpose and you don't need experts to decide the point at which your life is no longer worth living (frankly, I can't even imagine what, exactly, the "experts" might be expert in), you only need your family and loved ones.
Downpuppy: Death Panel = Scary Lie
Derek: Allocate FIFO: Remainder die
There will be rationing of medications,
due to lack of funds.
There will be allocation of procedures,
due to lack of doctors.
I do not want the State doing the triage;
They have too much arbitrary power over
our lives already; They must not gain any
more say in how we live or when we die.
I know FIFO. (Also LIFO, replacement cost, LCM & 263A Uniform Capitalization.) Nothing at all to do with health insurance.
Health insurance, for older Americans means Medicare or the VA. Both have been just fine for years, and are still doing much better than the private part of the health insurance system. You're piling nonsense on top of the lies.
Just why do you think that the VA provides great care? In my experience, it doesn't even come close to what a private hospital provides. (1) Most of the doctors don't speak idiomatic understandable English. (2) Rooms for the most part are not air conditioned. (3) Nurses are in short supply. (4) They are full of bureaucratic red tape.
Now you might say that this is true of all big city medical centers, and you would have a point, but it is not at all true of regional hospitals in flyover country. (I'm in flyover country even though living in a Blue State.)
The last thing in the world I would want is to be cared for in a VA hospital.
The VA got its act together in the mid-1990s. Since then, they've shown that solid, centralized organization is key to improving care & cutting cost.
http://www.washingtonmonthly.com/features/2005/0501.longman.html
Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.
It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals
This observation may or may not be accurate. But note that if what you're looking for is the greatest possible life extension . . . other countries do better with less. Please, enough with the canards about differential definitions of live births, or attrition due to violence; just look at the WHO life tables for any given age and see which countries have the highest life expectancies at any given age. For example, in Canada, those aged 70-74 can expect on average to live another 15.9 years. In the U.S.? The 70-74 crowd lives only another 15.2 years. That's another eight months of life, and life which is purchased more cheaply to boot.
SoV,
Are those adjust for heterogeneity of the populace, the lifestyle issues (weight, activity, smoking) and gender?
If not, 8 months is noise and you know it. Still trying to pass of invalid data as evidence? I thought we went through this with your red/blue income data that wasn't adjusted for COL....
That's what I thought... please refrain from passing off bogus data in the future, we all know you have trouble with statistics but just be more careful.
This observation may or may not be accurate. But note that if what you're looking for is the greatest possible life extension . . . other countries do better with less.
Not with their crappy socialist medical systems they don't. They just drink a lot of green tea and red wine.
For example, in Canada, those aged 70-74 can expect on average to live another 15.9 years. In the U.S.? The 70-74 crowd lives only another 15.2 years.
In addition to not being attributable to medical care, as has been pointed out ad nauseam those differences are very small and the statistics are not counted the same way in different countries, so an extra 1-2% of LE is meaningless.
My wife and I used to take our dog down to a couple local nursing homes on Saturday mornings. One time, a very aged lady, wheelchair-bound, had a bunch of balloons and other cheerful knick-knacks in her room. She explained that she had turned 100 the day before.
My wife and I made the routine, patronizing comments about what a wonderful life accomplishment that was. She snapped back: "Forget about that, sonny! I'm planning on making it to 110!"
It seems to me that, by hook or by crook, a large part of health care efficiencies are based on the idea that centenarians will do the rest of us a favor and just die. After all, we 30-somethings believe, who would want to live like that?
Walk a mile in a man's shoes. Roll a mile in a woman's wheelchair.
This is going to get way worse than people realize.
As long as she has decent quality of life, and her mind is not in full blown dementia then she shouldn't go before Obama's death panel. But if she's starting to say wacky things, then Soylent Green time.
When I read this comment on the RSS reader, I thought you were talking about Palin.
I'm not sure if this comment is meant approvingly or disparagingly...
"an insurance company that tried to do this too blatantly would suffer horrible publicity and ultimately lose business"
Do people in the US really, really have their choice of company? Or are most people stuck with the one their company decided was the cheapest?
Its true that most employers will have a limited set of choices in the cafeteria plan during open enrollment. But turn the argument around: would any health insurer risk being left out of the cafeteria list at a coveted local company?
How many health insurance horror stories involve group plans at large corporations or other large buyers of insurance, e.g. universities, etc? Not many, right? Seems like the insurers have an extra motive to play nice, not to incur the wrath of BigCo's HR department.
Petel,
I wish it were true that BigCo's HR department is under pressure from management to make sure that the company's employees get first-rate medical care. Actually, the pressure they are under is to get insurance costs down.
When the bids come in from various insurance companies to handle next year's company contract, do you really believe that the vice president of HR is going to choose the winning bid based primarily on customer service rather than cost? When the CEO goes to the HR vice president and asks why he/she didn't choose the cheapest contract, do you really think "Because it's more important to make sure our employees are treated as well as possible" is going to be an acceptable answer?
Point taken. In fairness, comparing costs in health insurance plans is a little like comparing costs of mattresses. Not sure whether a company like Anthem would ever present a policy that didn't have some cost-benefit angle that they would play up to the HR department.
Also, its not that customer service in the abstract is a motivation for these big insurers. Its more like none of them want a series of angry employee letters (of vignettes such as those immortalized in a movie like Sicko) crossing the CEO's radar screen.
"When the bids come in from various insurance companies to handle next year's company contract, do you really believe that the vice president of HR is going to choose the winning bid based primarily on customer service rather than cost?"
having participated in this process at three different companies, I can tell you that quality was on equal footing as price in the selection process.
Why? Because upper management participates in the same plan. No VP of HR wants to deal with all their peers being angry with their and their family's health plan. No HR department wants to deal with complaints from the employee population.
(replying to market karma)
Not always. Top management in many companies have those gold-plated cadillac plans as part of their perks.
zic,
cite?
I also think that's an ERISA violation.
Limited set often means "one".
I know my spouse has had a choice of one and only one plan from her last several employers (law firms, non-profits, and a local government). Lots of employers offer a choice of only one, or at best, a PPO and HMO option from the same carrier.
At the macro level, in a number of states, Blue Cross / Blue Shield controls as much as 80% of the market. Those are mostly smaller states, but even in NC BC/BS has 75% of the private market.
And you can thank the government for quasi-monopolies....
Possibly, PeteL, but in any event, the medical profession appears to be up against hard limits in terms of human life span. The only way to increase it at this point is science-fictional.
My own thought is that this being 21st Century America, the future, iow, maybe some enterprising folks will be able to make a buck off cryonics, now that there are increasing numbers of people who really do want to - by hook or by crook - make to 110, or 120 or . . .
ObSF - "Why Call Them Back From Heaven?" by Simak. In the future, the trust that oversees the financial instruments put in their care by the Sleepers comes to dominate politics and society(Compound interest being what it is and all that.) A trust that wonders to whose possible interest would it be to wake the Sleepers, even if revivification becomes possible, and cures for all the manifold diseases are found.
ScentofViolets writes: in any event, the medical profession appears to be up against hard limits in terms of human life span. The only way to increase it at this point is science-fictional.
SoV, I don't agree. If you limited government health care to drugs and procedures invented prior to 1990, I think you could see a lot of cost containment, but people wouldn't stand for it -- they think that the innovation in the last couple decades has been substantial.
I suppose you could argue that medical history is one of continuing innovation until just now, but really, how would you know?
Possibly, PeteL, but in any event,
And this is why I hate your practice of replying to the OP instead of to the person whose comment you're actually trying to address. PeteL has made three comments above, and you reply to him generically. It makes it impossible to actually follow the conversation and see what point you're trying to make.
There is a safety issue in health care that is never discussed in the "Heavenly American Health Care" propaganda circles.
The older folk are more at risk to the dangers in this system that kills hundreds of thousands of people each year, however, it is not discriminatory, and maims people of all ages, races, genders, and creeds.
Doctors deal with life-or-death decisions on hundreds of millions of patients a year. Doctors are human. Thus, some proportion of the time they'll screw up, and when they do it'll sometimes kill people. This is about as meaningful a statement as counting up people killed by truckers in traffic accidents and then calling long-haul a murder industry.
Once the government has the perverse institutional incentives, the institutional checks are fewer, more ponderous, and worst of all, often create huge new problems.
This kind of fishy un-American dissent has no place in a civilized debate. I'm reporting you to the White House.
It is actually entirely true that if you're focused on cutting costs, you would never install a pacemaker in a 99 year old woman
And 99-year-olds are getting more healthy and more numerous over time. This is going to be a bigger and bigger problem going forward, as we learn more about cell senescence and how to delay or prevent it. It also may bring down costs, as we learn more about how to prevent age-related disease.
It's imperative we don't further cripple market-driven medical innovation. Given the rate of advances in nanotech, AI, and genetics, functional immortality could well be achieved this century. 100 years ago, antibiotics, laparoscopic surgery, and gene therapy were the stuff of science fiction; what could the free market develop by 2109?
These guys are attacking the aging problem pretty seriously.
It's interesting that all of these mechanisms have been known for decades. I remember Niven's book A World Out of Time that I read as a kid contained an immortality machine that would remove intracellular aggregates.
That's a great book
There is quite another matter of controlling costs that has not been addressed here yet: salaries for healthcare workers - doctors, nurses, and administrators.
Single payer would essentially create gigantic new public employee unions. Anybody want to use examples from our current public employee experience to argue that cost of medical services will go down and that quality will go up?
And don't forget, paying for tests, drugs, medical devices, etc. = funds that can't be spent on union members salaries/pensions.
So perhaps those 99 year olds will get lots of labor-intensive medical care and even operations, but maybe not for pacemakers ...
So will my pacemakers continue to be replaced once I'm 99? I'm on my 4th unit now because the batteries are sealed within the unit and wear out over time. I was in my late 40's when I had my first one installed.
Replacement is a simple procedure: because the unit is only subcutaneous, the skin is sliced open, lead(s) unscrewed from the old unit, new unit attached to lead(s), and skin sewed or stapled shut. One week later, staples are removed.
Now, there might be more involved with a 99 year old, due primarily to the condition of the skin, but my original implantation was done while I was conscious, under valium and a local anesthetic.
Soylent Green is old people.
Just say no to Obama's death panels!
Right now, people know that their insurance companies would love to provide self-serving "end of life" counseling that would encourage sick people not to waste so much valuable money. But they are limited by, first, competition--an insurance company that tried to do this too blatantly would suffer horrible publicity and ultimately lose business--and second, the threat of lawsuits and/or regulation.
All too typically, Megan, you don't know what you are talking about.
Nothing prevents insurance companies today from offering such counseling as a covered benefit. My group insurance does that today, and I expect that the same is true for many others.
Nor is your "self-serving" characterization an accurate description. In my experience, many people have a strong desire to die at home rather than in a hospital. This is a legitimate issue of medical care preferences, and one that requires planning.
You misunderstand. I wasn't saying that no insurance companies offer end-of-life counseling. I'm saying you don't hear a lot about insurance companies offering end-of-life care instead of chemo to someone with Stage 3 breast cancer.
@ Downpuppy: You're piling nonsense on top of the lies.
You wish. So do I. What I am doing is adjusting two
variables of the predictive equation further than you:
Economy down, TPTB panic point up. Pass the trip point,
and the State will use a monopoly on health care as a
political weapon. Of course they will make enemies;
They will also make friends.
Anicipated accusation of paranoia accepted, IF you will
admit that you see a world in which it has happened
_there_, but it can't happen here.
It's been well-known and generally accepted for decades, possibly the better part of a century, that while average lifespan is increasing, maximum lifespan is not. My comment is in reference to the centenarian who is hoping to make it to 110; while that has been demonstrated as a possibility, living to 125 has not. This doesn't seem to have much to do with medical technology, at least, not so far. Any thought that it does is at this point, I repeat, science-fictional.
@ SoV: life extension SF
Is right at the transition point from
scientific question to (bio) engineering
development, depending on which theory
of death turns out to be correct:
1) The human body is a machine; It wears out,
breaks down, and dies; Nothing can be done.
2) The human body is a cell in a 4-D selfish genome,
optimized for survival _of_the_genome_ by death of
the individual, to promote genetic diversity;
Individuals gets sapient, break code, live forever.
The experiment has been underway for some years;
Replacement of critical biochemicals which decline
with age; Update at 11. :)
And other than a couple small countries, all those records are people who have died in the last quarter-century. I'd say that the maximum is going up too.
Typically incoherent post and response, Megan.
Insurance companies provide coverage, they do not provide health-care services, including counseling. You say they would love to provide end-of-life counseling today, but are limited. In fact, there is no such limitation on covered benefits.
I don't know what makes you think that end-of-life counseling is necessarily about cutting costs; it's about information, and patients making affirmative decisions about their care and the end of their lives. Medical professionals with ethical obligations provide the counseling. It should be straightforward to find a counselor with no financial interest in your care, if you want.
You suggest that the government will restrict what is covered under medicare. That is of course quite possible (and I would think you would support it given your concerns about exploding deficits) but you have failed to connect this to the end-of-life counseling issue.
As to what you hear about, I can't speak for you, but in fact insurance companies do provide hospice care as well as chemo, and plenty of breast-cancer and other patients choose the former and eschew the latter at the end.
You are completely misreading what I wrote, and then blaming me. Since you're the only one having this misunderstanding, it's probably not me.
No one is preventing them from providing a counseling service that presents information in such a way as to suggest that the patient end it all (and in fact many insurance companies do have various sorts of counselors working directly for them--just ask anyone with a chronic disease.) Yet they don't provide that kind of biased service. Why? Because it would look terrible. Congress would hold hearings, the media would have a field day, etc.
On the other hand, if the government does it, how do you even know you're being steered? The steerers may not know themselves. They just know they have a budget problem . . .
The point is, on issues like this, it's often better to have a lot of competing interests in the system than one "aligned" set of incentives.
MM is correct:
"SPRINGFIELD, Ore. - Barbara Wagner has one wish - for more time.
"I'm not ready, I'm not ready to die," the Springfield woman said. "I've got things I'd still like to do."
Her doctor offered hope in the new chemotherapy drug Tarceva, but the Oregon Health Plan sent her a letter telling her the cancer treatment was not approved.
Instead, the letter said, the plan would pay for comfort care, including "physician aid in dying," better known as assisted suicide."
http://www.katu.com/news/26119539.html
If that had been a private insurer, you'd have heard about this about million times by now. But it was a state agency, and I'll bet most of you are reading about it here for the first time.
Sigh. What you mean is that it's been pointed out ad nauseum that you're making a God of the Gaps type of argument, and that no amount differential studies will ever satisfy you; you'll always be free to point out that x, y, and z weren't controlled for no matter how thorough and exhaustive any such studies are.
That's why - it's been pointed out ad nauseum - the burden of proof is on you to show that the differences in life expectancy are due to something else besides the medical care system. So, where's your evidence ;-)
Additionally - and I am genuinely curious here - what do you mean by the fact that the statistics are counted differently in different countries? How does that change the outcome in the figures I gave? As I said, I really am curious on this point, because what you said doesn't seem to make any sense at all.
SoV,
You present stats that are not at all adjusted for the factors I mentions, have not been proven to be related to medical care and still only show 1% increase in life expectancy... You then claim the burden is on us to disprove your bad stats... please!
I would expect someone with your background in mathematics to have a better sense of basic argumentation logic.
That's quite a strong null hypothesis.
What this will result in, one way or another, is that a huge mess will be temporarily averted in favor of a thousand smaller ones.
This is all very interesting. However, I need to go cram for my first "end of life counselling session".
Anybody read "Nudge"? That's what this is. Lots of people avoid or just don't think about the topic of end-of-life care. By nudging them to consider the topic, advocates are confident that some % > what we see today will opt for less than aggressive care. Thus costs decline. No coercion necessary (at least not at the moment.) Nudge nudge. Not sure about the wink wink part. Overall, I'm OK with nudging, as long as the nudge isn't in an evil direction. This doesn't seem to be. And if it becomes "push push", then I switch sides.
You are conflating two distinct issues:
(1) whether an insurance plan covers what might be regarded as standard treatment; and
(2) whether an insurance plan will arrange its coverage of end-of-life counseling to push you towards not availing yourself of covered treatment.
The case you link to appears to be clear example of the former, a straightforward issue of what treatments are covered. Indeed, it actually is an excellent example of why our current system needs reform; the woman cannot afford insurance that would provide the drugs she might benefit from while fighting a life-threatening disease.
sorry, last post was directed to Relyt post of 5:55 pm
Wow. What's the point of this navel gazing? Have you ever read your own policy? If you had you would notice that there are a number of provisions which allow the insurance company to decide what treatment is reasonable and effective. Hundreds, thousands of critically ill people denied care under these provisiong ALL THE TIME. You posit that insurance companies would get bad PR if they encouraged people to make end of life decisions. In fact, your speculation is wrong: Insurance companies routinely make profit driven decisions that effectively end patients' lives, and they don't get any bad PR (in fact, people like you who claim to be educated and knowledgable enough to render opinions on the subject know nothing about it).
So why is your PR postulation wrong? Could be a number of reasons. First, patients battling life threatening illnesses don't have the time or energy to generate bad PR. Second, that insurance policy you haven't read also contains provisions requiring arbitration of claims, sometimes with confidentiality provisions, so even if you have the energy to challenge the insurance company you'll never see the inside of a courtroom. Finally the insurance industry PR machine is HUGE. This is not at all a level playing field. If you have any doubt, just consider the fact that we are actually discussing government sponsored death panels. On the virtual pages of the Atlantic no less. My poor mom, who suffered a lengthy painful and dehumanizing battle with colon cancer (and who would certainly have benefited from end of life counseling) must be turning over in her grav at how far this venerable institution has fallen.
First, there is already rationing and denial of care which is leading to premature deaths, estimated at 18,000 a year.
Second, the insurance companies already deny care (personal experience) because it is not cost effective. Megan most people don't choose their insurance companies. Their employers do and the employers want the ones that promise them they will cost the least. You presume information is freely available, but except for anecdotes individuals have little ability to find out which insurance company will rescind its coverage or not. The business plan of these companies work by collecting premiums from healthy people (and if you are healthy, why would you not be satisfied with your plan) and cut off the sick and expensive.
Finally, the crew initiating this firestorm over Medicare and Medicaid death panels will, if they ever regain power, move once again to emasculate these programs so that care will be rationed by price and those who can afford it. If you are poor or even middle class and old you forego care and die while the rich get the best care that money can buy.