November 13, 2006
From the desk of Jane Galt:What would nationalised health care look like here?
Now that the Democrats have won, talk has turned to how we can get a single payer system on the agenda. And critics inevitably say "I don't want a system like England or Canada's", to which the advocates reply "Neither do I--I want a system like [insert favourite country here]", except without the bad stuff, of course.
What I don't hear a lot of people addressing is what sort of system it is feasible for us to get, given the interest groups and institutions we already have. There are some serious constraints that I think would have to be considered by anyone trying to design a national health care package:
1) It cannot provide less, or less rapid, coverage than the typical American policy does now. Over three quarters of Americans are happy as clams with their health care now; to the extent that they support national health care, it is because they fear losing what they have. Nationalisers, therefore, cannot sell a programme by guaranteeing them that they will lose some of what they have now. Horror stories aside, most Americans, despite their copays, have much more lavish coverage than that available elsewhere, with unfettered access to their doctors, semiprivate hospital rooms, expensive machines around every corner, and so forth. In what other country would my eighty-eight year old grandmother have had her hip replaced two weeks after the doctor decided it was time? That two weeks being the period needed for my mother to arrange her schedule so she could take care of Mom. That is the baseline of care, not whatever is currently on offer in France, no matter how fond the French may be of their system. Countries with national systems set them up a long time ago, when the median voter had no insurance at all, so whatever crap the government gave you was an improvement.
2) It cannot substantially lower the wages of medical workers. They all have powerful lobbies, and they vote on their interests. Doctors in Britain may be thrilled to make 60K a year in return for the shot at someday, if they're very lucky, exiting the system for a private hospital. You will not get American physicians to take the same deal; they've already got hefty mortgages and kids in private school. Between the right of exit and the lobbying power of the unions, it will be some time before we can even eat into doctor's pay with inflation; I would expect the pay of lower level medical employees to rise (New York's experience is instructive here).
3) It cannot ration end-of-life care. The AARP is the most powerful lobby in America. Anyone who thinks that a nationalised system will ration all those dollars poured down the drain in the last few months of life is engaging in fantasy--a particularly ludicrous and risible fantasy because we already have nationalised health care for end-of-life care RIGHT NOW and we're spending like eighty shrillion dollars on it.
4) It will not cover immigrants, at least not until they are citizens. That means at least 12 million people will remain uninsured. It also means that emergency room usage will remain high, since that is where illegal immigrants tend to get their health care. Not that this really matters. It doesn't seem to me that emergency room care for routine ailments is actually more expensive to provide than clinical care; it's just that hospitals price it to cover the cost of dead, uninsured trauma patients and so forth. I don't see how a triage nurse, a doctor, and a waiting room are more expensive to provide because they're on the first floor than they would be on the fifth. But perhaps I'm missing something there.
Your thoughts?
Posted by Jane Galt at November 13, 2006 3:31 PM | TrackBack | Technorati inbound links"); ?>I will say I'm reminded of discussions about interventions to stop the genocide in Bosnia in the '90s, where we were told Americans would not stand for a single death in an optional war or occupation.
Not that there isn't something to what you're saying, but often major policy decisions blow right past hypothetical roadblocks.
Posted by: Brittain33 on November 13, 2006 4:14 PMMy comment is going to get buried, but #2 is quite significant. I find it remarkable how much nurses get paid (I'm married to one). Wow.
Posted by: Klug on November 13, 2006 4:39 PM"It will not cover immigrants, at least not until they are citizens."
I assume you meant "It will not cover ILLEGAL immigrants, at least not until they are legal."
I don't think people mind including the green card holder who works in the next office, or for that matter including the green card holder whom they married.
-dk
If you implement a single-payer-system like Canada or England, you will get a FUBAR-system like Canada or England. Every country which did a system like that got the same results: waiting lists, bad care, exploding costs for the public purse and exploding personal costs as people flee for the private sector (the portuguese system is british style and I pay *more* for a dentist than americans do, as in twice as much).
France's system (and most of Europe's) is much closer to the American one than most people realise. It certainly is closer than English one.
Take the US system, add a bit more Medicaid, make enrolment automatic, sparkle some feel-good-propaganda posters all over the country and pouff, that's the French system!
France's system was the result of a compromise between the nationalizers and the free marketeers. Its a mixed system, not single payer. That's why it mostly works.
Posted by: luispedro on November 13, 2006 4:47 PMThese all seem perfectly sensible to me. But here's what I want to know much more: is a single-payer system intrinsically incompatible with any of these objectives? If so, I don't see how.
Why can't we eat into the doctors' premia by forcing open the AMA's system?
We can encourage building of more medical schools and force the AMA to allow more med students from here and abroad to enter med school (by breaking their control of entry). At the moment I can think of few other areas where qualified applicants are still likely to be turned down by all schools (not just top ones). The fact that a substantial fraction of students from elite schools such as MIT, Stanford or Caltech get rejected from all med schools because of low grades indicates we are underinvesting in places for med students.
Your thoughts?
I'm thinkin ...
"we're spending like eighty shrillion dollars"
speech recognition software problems? ;-) Or maybe you didn't realize we already have a perfectly good imaginary number called the "zillion".
Seriously, though. Klug: do you mean remarkably high pay, or remarkably low pay? If low, why do they take those jobs over others? I'll note that most nurses can handle routine primary care just as well as doctors, but the AMA shuts it down, even if that's how they actually run their clinics :-P
Posted by: Person on November 13, 2006 4:56 PMDick King,
To be fair, nurses salaries are on the upswing because demand for nurses is very high. Not too many years ago (late 80s, early 90s maybe. I'm trying to remember all the crap my mom went through as a nurse.), there was a glut of nurses when HMOs decided that they wanted more patients per nurse. A lot of those nurses left the business and the smart women coming into college who wanted to take care of people became doctors. Voila, nursing shortage.
Posted by: Xmas on November 13, 2006 5:03 PMWhy can't we eat into the doctors' premia by forcing open the AMA's system?
Well, it's hard to do quickly because the AMA restricted supply and doctors' premiums end up getting swallowed by the med school tuition in lots of cases. Forcing open the system would screw over young doctors with lots of loans.
Similar to repealing the housing mortgage deduction. Sure, the mortgage deduction ends up doing a lot just to raise the values of homes and the cost of mortgages, and thus on net is fairly questionable (though it does make people buy when otherwise they would rent), but repealing it once it's there ends up ruining people who have recently bought.
Posted by: John Thacker on November 13, 2006 5:21 PMYou're assuming that people who get all their care in the emergency room are going for the same type of care they would go to a primary care physician for. The issue is that preventing a problem is usually much less expensive than treating it, and the poor (including illegal immigrants) get/seek less preventative care. As far as I know, ERs don't offer vaccinations, but they will treat things you should have been vaccinated against
Posted by: Li on November 13, 2006 5:28 PMJohn_Thacker:
Well, it's hard to do quickly because the AMA restricted supply and doctors' premiums end up getting swallowed by the med school tuition in lots of cases. Forcing open the system would screw over young doctors with lots of loans.
Yeah, good point. We should let all of America suffer from unnecessarily expensive health care, so we can save a small subclass of a small subclass of the labor force from having to declare bankruptcy. Next, you're going to try to tell me we should allow the incidence of diabetes to significantly increase due to sugar tariffs so that American sugar and corn farmers don't have to go through the *extreme trauma* of having to switch to a different crop.
Oh, wait ...
Posted by: Person on November 13, 2006 5:40 PMI find it amusing when people just state "lets build more med schools" or let in more students. You all seem to think that many well qualified students just can't get in. Who in hell is going to teach all these new students? We barely have enough people to teach medicine now. Are they going to pass?
In college I took 18 credits each semester. In med school is was 54 credits each semester. It's really really intense. After my first day in med school, I felt like I was 2 weeks behind.
I spent 4 years in med school and then 4 years in my residency before I was able to practice on my own. There is a debate in my specialty (OB/GYN) as to whether we are doing enough procedures in that 4 years or whether we should add another year to training. If we double the number of slots, will all these docs get well trained?
Who is going to want to work all that hard if the pay is slashed, but the liability remains? So if you all think that I should make no more than $100,000 per year. I'll happily do that as long as I don't have to work more than 40 hrs per week, and like everyone else, I'd like my weekends off and no nights. I don't know why all babies can't come between 9am and 5 pm Monday through Friday ( and yes that was firmly with tongue in cheek, but not the 40 hrs per week part)
Posted by: storkdoc on November 13, 2006 6:21 PMPerson: I mean high pay. Don't get me wrong, I think it's great for my little family. But I think that the (relative) high pay of nurses is undoubtedly a huge portion of US health care spending. [Whether or not they're worth it is an entirely different debate.]
Posted by: Klug on November 13, 2006 6:36 PMAs for working nights and weekends, you might try paying a shift premium. Say, 20% for the few people necessary to deal with emergencies. It's also nice to offer flexible schedules for those who actually want to work swing shift and four day weeks.
My favorite job was alternating three and four day weeks of twelve hours each.
But your larger point is right. If you pay less, you get less. Many managers figure that making people work harder somehow magically reduces costs while keeping quality high.
Fear of publicly funded health care is rampant. Canada's system is FUBAR? Canada is damn lucky to have that system in place. The security of having a continuous health care no matter what your employment of income status is a huge benefit, that allows creative people to take risks and pursue alternative careers with one less worry. Sure there are issues, but, believe it or not, the system does continuously evolve. For example, after much hue and cry, wait times are being dealt with in a number of provinces - including Alberta and BC.
As for the wait times example. They are a cost of efficiency. You could drop wait times to zero, but that would necessitate having expensively trained surgeons and surgeries idle for some of the time - unless you could get patients to conveniently get sick on an orderly schedule.
As for the U.S., national health care is an inevitable. While most pundits and politicians don't recognise it yet, the current system is on track to fail - and Jane's interest groups won't be able to do anything about it. Just a matter of time - maybe a decade - maybe two. Put ideology aside, and beome a futurist. Signs I see include i) gradual introduction of "national" health care into public dicussion, ii) gradual withdrawl of employers from health care, iii) gradual decrease in insurance quality.
Posted by: foo on November 13, 2006 6:48 PMIn college I took 18 credits each semester. In med school is was 54 credits each semester. It's really really intense. After my first day in med school, I felt like I was 2 weeks behind.
Are these credits of equal size, in any meaningful sense? I went to a top-ranked college and took about 18-20 credits each semester (engineering curriculum), and find it frankly implausible that medical school somehow manages to be three times as much work as a 60+ hour / week undergraduate program.
Posted by: TJIC on November 13, 2006 7:04 PMwe already have a perfectly good imaginary number called the "zillion".
Personally I thought the implied connotations of "shrillion" was quite clever if intentional; serendipitous if not.
Personally, I don't see how anyone who has ever been to the DMV can be in favour of nationalized anything.
Posted by: bkw on November 13, 2006 7:07 PMThere's one more feature that any nationalized health care system would have to have in the US: Jackpot Justice. The Democratic party will never agree to any health-care reform that doesn't preserve the ability of injured people to sue everyone even remotely involved in their injury.
Posted by: Aric on November 13, 2006 7:21 PMThe health-care system can never be fixed. Nationalized or otherwise. Thats it. End of story. There are just too many people that take advantage of the system.
Posted by: snarkolepsy on November 13, 2006 7:57 PMWhat about some sort of hybrid voucher system? I realize a regular voucher system like those proposed for education wouldn't work because heathcare costs are variable, but could we do some sort of hybrid system, where Medicare actuaries determine how much it will cost to cover someone with a basic level of coverage.
From here on it would work like a standard voucher system. The recipient could use the voucher in the Medicare system or through a private provider. People who wanted better coverage or faster service could then pay the marginal difference between the value of the voucher and the cost of private care.
Aside from vouchers being political poison, is there a reason why something like this couldn't work? Too expensive maybe?
To me the whole root of the problem is that the average person in this country cannot reasonably afford the amount of medical care they would consume in their lifetime. So the first step needs to be looking at how to reasonably control costs. To me the obvious step would be to let experienced nureses train to give preventative care. It simply does not take 4 years of med school and 4 years of residency to perform routine preventative care. We have the best nurses in the world- there is absolutely no good reason why we don't utilize that resource to better effect.
Posted by: Damon on November 13, 2006 8:17 PMI recently saw a patient on dialysis because of renal failure. Her medium expensive Depakote ER cost her $1 a month, Medicaid, in Texas no less, paid the rest; ditto for other meds. Coming to renal failure at greater than 54 in Britain, it is considered you have lived a good British life, it is now time to die of uremia. No dialysis is then offered by the NHS. When you see statistics on health outcomes, you have to consider the contingencies in collecting them. Case in point, infant mortality. In many Western countries, if a baby dies shortly after birth that would be coded as a stillbirth. In the US, you are more likely to get into trouble for not being puncitilious, and so generally it would not, would end up as an infant mortality. Regarding the AMA and medical schools, we have a lot more doctors in this country than we graduate. We have a lot of good foreign medical graduates. Money brings what is in demand to the U.S.
Posted by: michael on November 13, 2006 8:24 PMFoo:
Canada's system, and to a lesser degree England/Europe's systems only "work" (to the marginal extend they do) because the US exists as a safety valve. We heartless greedy Americans pay more-or-less full retail for our drugs so they don't have to. For canada specifically we provide a place for their upper class to avoid the long lines and actually get treatment in a reasonable time frame.
As for your last paragraph, "National Health Care" has been in "public dicussion[sic]" since Kennedy. It's part (a small part) of the reason health care costs have gotten so high. Employers generally *aren't* withdrawling from health care, though they may be passing the costs through more explicitly. Can't say I blame them, after all they're having to pay higher (IRS, OSHA, EEOC) and higher (SOX) compliance costs every year, and profit *has* to come from somewhere.
Which brings me to my *personal* position:
Given the costs of a basic health insurance policy for young/working age individuals, fuck them if they don't have coverage. I looked into out-of-pocket coverage for a dependent (who lives in another state with a maternal grandparent) and was able to get a fairly marginal health policy for about 120 a month. Yeah, if you're working a minimum wage job that's a tough hack.
If you're over 21 and working near minimum wage you really OUGHT to start asking yourself some tough fucking questions. Like "Why am I such a Tard" and "How do I get my damn life together and get a real job". Grocery store clerks make 15 plus an hour, and all that job requires is bathing, timeliness, integrity and marginal physical health.
Now that the *rational* way to handle this is out of the way, the best way to provide some sort of "universal coverage" without bankrupting our country, destroying the pharamceutical industry and ruining, well, health CARE for those productive memebers of society willing to pay for it? (You think this hyperbole? Look at the state of emergency medicine in Califoria.)
Single payer is a singluarly bad idea, it invests too much into one group or organization and provides a focal point for corruption, no room for innovation, and no incentives to increase effiency. Especially when staffed with government job for life types.
As much as it gauls[1] me to say this the French have the right idea in this regards--at least to my understanding of the issue.
You either purchase private health insurance, a performance bond (for those who are rich enough and don't want to pay for insurance), sign a waiver on religious grounds (for those who won't health coverage for religious reasons) or you get taxed 10% (plus something extra for dependents) of your AGI and the state assigns you to a private health insurance provider that has a default basic policy[2] (the government fills in the delta between whatever you're taxed and the "real" cost of the policy).
This does a couple things:
1) It incourages thrift and growth--by (effectively) reducing the tax as a percentage of your wages as you transition the kind of employment that provides for better health coverage it encourages individuals to get better jobs, or to find their own policies as they make enough money to opt into a different plan.
2) It encourages efficiency by apportioning out the Government Insurance Recipients to contracting/any/all health insurance agencies it encourages them to find ways to become more efficient at handling claims and benefits.
3) It gives choice. Choice is good.
4) It may still be a redistributionist horseshit scheme, but it gives a little less power to the government this way.
[1] Yes, that was intentional
[2] Especially a plan that provides cheap preventative health care, sufficient emergency health care, and punitive "doing things stupidly" health care--like using the ER for a PCP.
I work in healthcare and feel that rationing is implicit in any healthcare system. It is necessary because demand is infinite, while supply is limited. In Canada care is rationed by queuing, you may die waiting. In the U.S. it is rationed by ability to pay, you may die trying to figure out how to pay. That being said no one is denied treatment for life threatening illnesses, it is covered somehow, someway. (and yes, I know, there are exceptions.)
An emergency visit is more expensive than a clinic visit. The very uncertainty of volumes and illnesses presented creates higher costs. Also, illness treated tends to be more intense than they are in the clinic setting.
Posted by: J.R. on November 13, 2006 8:27 PMWhy don't we cure old age and major diseases, so none of us die from them? Then the cost of medical care might drop, or might not, but at least everyone would be working (no need to retire if you are fit and in good health regardless of age) and it would be clear that you were getting very positive benefits from your medical care spending (e.g., not dying from old age or disease), and the big spending spurt near the end of life would be gone (perhaps replaced by ongoing costs, but on a known trajectory with clear benefits).
I actually think this will all come to pass, unless we do something to turn off medical research. I'm very concerned about making changes with unpredictable results to a system that is producing the highest rate of medical technology growth of any country on the planet.
Whether you agree with my projection or not (re old age being cured), it is silly to consider that things will continue indefinitely as they are today. In the not-too-distant future, we will have cured cancer, slowed down or eliminated most age-related dementia, etc. These technology changes will have a dramatic effect on well-being and longevity, along with costs and where we end up spending health dollars.
Posted by: Tim Lundeen on November 13, 2006 8:35 PMCanada is damn lucky to have that system in place. The security of having a continuous health care no matter what your employment of income status is a huge benefit, that allows creative people to take risks and pursue alternative careers with one less worry.It's funny that creative people take risks and become entrepreneurs far more so in the US than in Canada. Posted by: Kevin P. on November 13, 2006 8:37 PM
First, I loved this quote: "...we already have nationalised health care for end-of-life care RIGHT NOW and we're spending like eighty shrillion dollars on it."
I never saw "shrillion" before, but, in this circumstance, it is much better than "zillion" or "gazillion."
I agree that there have been no detailed national healthcare plans that address all your concerns. I don't think it is possible to design such a plan.
On the ER issue: ERs are much more expensive to operate than clinics or routine hospital wards. The level of staffing per patient approaches that of intensive care units. ER physicians are paid more than internal medicine or family practice physicians. The nurses tend to be among the most skilled in the hospital (and get paid accordingly). ERs need higher ratios of clerical, transport, housekeeping, and security staff than clinics or hospital wards. The ER gets STAT priority from radiology, cardiology, and laboratory: bumping other patients or specimens adds costs. ERs have lots of monitoring equipment, bedside testing devices, crash carts, intubation setups, oxygen tanks, etc. On a square footage basis, only ICUs and ORs are more costly.
Posted by: Dr. T on November 13, 2006 8:50 PMDamon: The nurse thing happens already, to some extent; I haven't been seen directly by my OB/GYN in 4 years - my annual exams are always done by nurse practitioners, as was the bulk of my prenatal care with my last pregnancy.
Re the French system: I'm no expert but I don't see how their system can be all that efficient. My husband is French. His mother is in late-stage Alzheimers and the state pays for a 5 days a week nurse for her at home (she can't move, communicate, see, anything). All the nurse does is feed her liquids once or twice and maybe help with the bathing. The state covers transporting her *by ambulance* to the dentist for teeth cleaning etc even though she can't chew and is expected to die more or less any minute. The state covers special nurses coming to the house to vaccinate her for flu etc, even though she hasn't been out of the house in years.
Also my husband's grandmother spends 2 weeks at a spa in the south of France every summer - it's considered preventative care.
I'm not saying it's bad to do this stuff, I'm just saying I don't see how this can be considered efficient, or more efficient than Canada, or whatever.
Posted by: BerthaMinerva on November 13, 2006 8:58 PMI agree with other commenters that your constraints are not nearly as absolute as you suggest. I'd put it this way:
(1) It would ideed be diffcult to design a UNIVERSAL health care system which stays within your listed constraints.
(2) What will it take to break down some of those constraints? The system breaking down to one extent or another. Which it will, at some point; it will not be possible, in the long term, for our system, whether universal health care, free market, or some variation of the current system, to continue to meet all of your constraints indefinitelty. When, say, the current system stops providing the current level of care for most people, people will be more willing to accept less. And, of course, the current system is providing less all the time. I'm a bit sceptical of your 3/4 satisfaction figure, but even if you are correct, I can't imagine that still being the case 10 years from now.
(3) In the mean time, enact incremental legislation to provide less comprehensive coverage for the currently un or under insured.
Posted by: Larry M on November 13, 2006 9:02 PMTJIC
I paid my tuition at med school based on the number of credit hours taken, At my school the med school tuition was about 3 times the cost of a full time undergrad, so I think that the university considered the credit hours to be the same.
The first two years of med school are very, very, very intense.
Posted by: storkdoc on November 13, 2006 9:17 PMAnd, of course, the current system is providing less all the time
Evidence, please? Because most of the care I'm receiving wasn't even *possible* a generation ago, and never would have been without the profit motive pushing medical companies to develop new and improved treatments.
Posted by: Dan on November 13, 2006 9:32 PMHad to laugh - almost bought a new keyboard when I read Larry M's argument. Basically, (2) When, say, the current system stops providing the current level of care for most people, people will be more willing to accept less.
Rolling on the floor.
When people get less, they will be willing to settle for even less than that?
Sigh.
This: "a particularly ludicrous and risible fantasy because we already have nationalised health care for end-of-life care RIGHT NOW and we're spending like eighty shrillion dollars on it.", is geniously well-put.
It is, also, a handy mirror--able to reflect the truth of many of the issues that are plaguing our current "Health Care" schema.
Unless something is done about end-of-life care, any reform ideas are just rearranging the deck chairs on the Titanic.
I cannot understand WHY people are so selfish about clinging to the last few weeks of life when, in most such cases, the quality of life is zero.
Billy Oblivion writes
Grocery store clerks make 15 plus an hour, and all that job requires is bathing, timeliness, integrity and marginal physical health.
Some obeservations:
I know a grocery stork clerk. My son. He makes 7-something an hour. No real bennies.
Mrs. Michigander's company had an opening in the mail room. About 8 an hour plus benefits, including medical. Had a ton of applications. A married guy in his 50s took the job.
I think a lot of the problems with the U.S. system can be solved with just a few adjustments. Some of them might be tough to implement but it could be better than trying to dramatically overhaul the entire healthcare system. First, it makes no sense for health insurance to be provided through your employer. I know there is an option to go outside of your employer, but getting insurance through your employer is still the default and most people do it. This seems to limit competition and choice in my opinion, because individuals aren't really choosing their own healthcare--employer-provided insurance is--and so healthcare providers have more scope to overcharge for services and drugs.
More importantly, drugs and medical technology need to be freely traded. If drugs can cost significantly less in Canada and elsewhere than they do here, they cannot be considered to be freely traded. It is because of the limits on reimportation that drug companies can engage in market discrimination, charging less abroad than in the U.S. for the same drug. The only way to solve this problem is to allow for reimportation of drugs and medical technology in general. U.S. consumers cannot continue to subsidize the inefficient healthcare systems in the rest of the world by paying for all of the R&D costs. Drug companies will fight tooth and nail to keep the restrictions on reimportation, because otherwise they would not have a captive market.
If we do go for some sort of universal system, I think it should be very limited in scope and only apply to very basic preventive and diagnostic care. But beyond basic care, all other care would be financed privately through supplemental insurance. This would help address the problem, if there is any, of the underconsumption of preventive care, and in doing so would hopefully help reduce the need for the more expensive crisis care. At the same time, it would keep the incentives for innovation by not touching the advanced care segment of our system.
I agree that the French model sounds good, and might be a good model to use for the portion of our medical system that we plan to apply it to. But again, I think that portion should be very small.
Just a general thought (and it doesn't necessarily contradict the above): as paradoxical as it may seem, it could be possible that a system that encouraged people to consume more healthcare by subsidizing it, if done correctly, could actually reduce TOTAL health care costs to society. Health care is a unique good where one's past consumption permanently affects future demand (kind of like a temporal externality, if such a term exists). Second, unlike other goods, there is a moral imperative to save someone's life and provide critical care even if they can't pay. There is no other good or service where you have a moral need to give it away for free if someone doesn't have money to buy it. Combine these two factors, and you have a situation where once people are unhealthy they make it more expensive for all of us. So you get this paradox where subsidizing basic care can actually reduce costs.
Posted by: Jacob on November 13, 2006 10:44 PMThe tools and care to be healthy are not a right.
To Billy Oblivion's point, I went without coverage for 8 years out of college. Closed many a cut with super glue, stopped doing a number of stupid things on a mountain bike, and busted my butt to get ahead and create a living that would afford health care insurance. After paying private policy rates that felt like a week in a federal prison shower, I dropped out of the race and into an HSA. Populating the account on the front end hurts a little, from savings, but in the end I'm not paying (as much) to drag all the unhealthy idiots in some massive pool of payors with me to the doctors office.
If the federal government takes over the health care system, I guess I'll go back to super glue.
Posted by: Cog on November 13, 2006 10:57 PM"The security of having a continuous health care no matter what your employment of income status is a huge benefit, that allows creative people to take risks and pursue alternative careers with one less worry."
Sure, but that doesn't imply we need government provided health insurance. All we need to accomplish this is to make it easy to buy and keep insurance independent of employers (portability). But lack of portability is something perpetuated by the tax code; imagine - government is part of the problem.
But portability is not impossible even now. I have an HSA and high-ded. insurance. Doesn't matter who I work for - I've got this no matter what.
Posted by: David Andersen on November 13, 2006 11:48 PM"In the U.S. it is rationed by ability to pay, you may die trying to figure out how to pay."
If everyone who was able (most of us) bought low-cost, high-deductible health insurance when they were young and healthy, then made an effort to stay healthy (which most people do not), not only would they have insurance in place when needed for catastrophic medical problems, it wouldn’t be expensive – certainly not as expensive as paying for catastrophic care out of pocket.
To be able to do this at least a few things need to happen:
1. Health insurance needs to be de-coupled from employers.
2. People need to be responsible enough to buy it when young (or required to)
3. People need to try to stay healthy – probably with financial incentives (like the HSA).
The tax code is a disaster, but still I’d rather see government provide tax breaks for healthy behaviors and outcomes than take over the health care system.
Now is not the time for the reasons you listed. Companies are cutting back on coverage, even for well paid employees, and more and more people are uninsured or on medicaid. With in a few years a majority of people will want something reasonable to be done. If something is done now we will end up with a system we can't afford.
Posted by: joan on November 14, 2006 12:56 AMJ.R.: Saying that "in the U.S., [health care] is rationed by the ability to pay" is a nice rhetorical flourish, and it is certainly trivially true. Still, putting it this way obscures some important points.
First, in this sense almost everything is "rationed by the ability to pay". Food. Housing. Vacations. Health care isn't the only good for which demand is unlimited, you know. So, unless you are willing to extend to all these other good whatever alternative rationing system you believe the moral bankruptcy of the market system justifies, please accept that your rhetorical flourish is nothing more than that.
Second, rationing by ability to pay is different from all other rationing systems is a vitally important way: rationing by ability to pay incentivizes the creation of additional supply. Even better, it incentivizes the creation of additonal supply in the most efficient possible way. Rationing by need, age, QUALYs or any other measure won't do that.
Posted by: David Wright on November 14, 2006 1:00 AMAs a matter of practical reality other than some changes at the margin the system we have is the best system that can be had. One commenter suggested what appeared to be the lowering of standards at medical schools. Can anyone seriously believe having less competent doctors is a good idea? Others suggest capping incomes. Right, a guy who has devoted 4 years of college, 4 years of medical school, 4 to 8 years of residency is now going to take a huge income cut and from a shorter career span? Not going to happen. And any attempt to do so and viola! you'll be seeing a lot of very top notch medical centers and hospitals in a luxurious spa setting no more than 4 hours by plane from most of the continental US catering to American medical "tourists". Why is it that those who advocate wage controls on doctors don't advocate the same for themselves? And lets not forget the unions and med malpractice lawyers among others who will not go down without a fight.
As for re importation of drugs from Canada or other countries that is really a populist scam. Drug companies are not charities, when it affects them to much they will either stop shipping overseas more than the local market can consume or pressure those countries to stop the sales or get cut off. The only short term effect would for the US to institute price controls equal to the lowest price for each drug in the Western part of the EU and Canada, Japan and Australia. Those countries will either start paying more and spreading the R&D cost with the US or the pharma industry will stop most of it's R&D. That or we offer them a deal to move all their R&D and manufacturing to the US as well as moving their management here as well and re-incorporating as US companies in exchange for no price controls in our market. At least we will get the export sales revenue and a greater cut of the tax revenue to help pay for the medicaid and medicare consumers.
As long as we continue to think of medical insurance as a pre-paid all you can eat buffet of services when you want or need it what we have is pretty close to the best possible system for the vast majority of the people.
I cannot understand WHY people are so selfish about clinging to the last few weeks of life when, in most such cases, the quality of life is zero.
In many cases, it's not the patients or their familes who are pushing for those last few weeks of life, but the internists who know a good billing opportunity when they see it. The end of life is a great opportunity to put in Swan-Ganz catheters (a reimbursible procedure, even though Swan-Ganz catheters have been shown to reduce life expectancy overall due to the complications they cause), intubate (also reimbursible, even when it's known in advance that the patient will never be extubated), bill for ICU time, etc.
it could be possible that a system that encouraged people to consume more healthcare by subsidizing it, if done correctly, could actually reduce TOTAL health care costs to society
Uh, no. This has been studied, and there are only three medical early interventions / screening / prophylaxis programs that have been demonstrated to be cost effective. Those are prenatal vitamins, well baby care, and childhood immunizations. For every other screening / prophlylactic / early intervention, it is simply cheaper (in a stricly dollars-and-cents way) to wait until the rare few get a disease, and then to treat that disease.
"In many cases, it's not the patients or their familes who are pushing for those last few weeks of life, but the internists who know a good billing opportunity when they see it"
That sounds far-fetched as a common practice. Do you have any evidence of this?
Posted by: David Andersen on November 14, 2006 2:49 AMDo you have any evidence of this?
I don't know of any academic study to prove it, but I am a physician, and trained at U. California Irvine, and UCLA. It was routine, in my training, to see expensive health care for the all-but-dead. I had an SICU patient with end stage HIV, T cell count of approximately 0, bedridden, in the SICU recovering from surgery. I had a patient with extreme pulmonary hypertension and fibrosis, poor cardiac function, perfusion so poor that he was constantly blue, and never quite concious, at a point in his disease at which NO ONE had EVER survived another 6 months, who had an inguinal hernia repair for a reducible hernia. I had a patient who had been in a coma for months, and was soon to die in that coma, who had an aortobifemoral bypass to preserve arterial flow to his legs that he was never going to use. I could go on and on, but I am 100% certain that expensive, pointless care for the near-dead is routine in some medical centers.
storkdoc: "I find it amusing when people just state "lets build more med schools" or let in more students. You all seem to think that many well qualified students just can't get in."
I agree completely. Economists and those who comment on economics blogs do not seem to understand just how difficult it is to be a physician. Extremely high intelligence is just one requiremnt. Medical students - and residents and physicians - must be willing to work long hours. It is not a profession for the genius with merely average motivation.
Economists may not believe you guys are worth the high incomes you guys realize. But the general public does. Your patients want only the most talented and dedicated professionals cutting into their torsos or delivering their babies or selecting the right combination of drugs to solve their medical problem. That physicians continue to rank among the most trusted of all professionals - along with firefighters and nurses - indicates the public is satisfied with what they're getting.
"I am 100% certain that expensive, pointless care for the near-dead is routine in some medical centers."
And why don't the families say "this procedure isn't needed/practical/worthwhile?"
Posted by: David Andersen on November 14, 2006 4:34 AMOpen Border Chairman Martinez to lead GOP?
The GOP base was sent a shock wave by picking a pro-amnesty Mel Martinez as the Republican Party Chairman. It seems clear now, that President Bush will push his open border agenda with the help of Nancy Pelosi lead Congress. Mel Martinez job will be to control GOP Party decent from Congress, with the promise of new Hispanic voters.
Palm Beach Post
Signaling a new direction for the Republican Party, which had heavy losses in the Hispanic community in last week’s elections, Florida Sen. Mel Martinez appeared ready Monday to become the party’s new general chairman while retaining his Senate seat.
Martinez thrust himself into the contentious debate over immigration, helping craft the Senate version of a comprehensive immigration bill that would offer a route to eventual citizenship for longtime illegal residents while requiring others to leave the U.S.
Michele Waslin, director of immigration policy at the National Council of La Raza, is hopeful Martinez and his GOP allies will make the right moves.
Is the GOP selling-out the Base with pushing an open border agenda? Does anyone think that the GOP lost the election due to the immigration issue?
storkdoc and JohnDewey:
One, nurses do most of the work anyway, and they're perfectly qualified despite having less training. In fact, they're more careful about wearing masks, washing hands, and so forth, because they're not as arrogant as the doctors.
Two, I personally know plenty of very smart, hard-working people that applied to medical school, and it basically seems to be a lottery. So it's not limited on the intake.
Three, medical schools are incredibly inefficient. Making students cram for tests to learn material they won't need to know that they'll forget most of by the time they graduate and the rest of a couple years later is stupid. Here's an idea - let's teach people what they actually need to know, and send patients to people who know what they need, and not irrelevant other stuff!
Four, all of this training and screening leaves plenty of doctors who give prescriptions that anyone with google and a half decent knowledge of biochemistry could improve on, and all the complicated procedures leave plenty of mistakes.
Then, there's the whole issue of pharmaceuticals. One, the FDA is incredibly inefficient. As bad as the patent office. And the companies whining about "ooh, if we can't overcharge you for X we won't have enough money to charge you for government research, buy startups who actually do real research so we can market their stuff to you and overcharge for it, and copy existing drugs and try to convince you they're better!" is making me SICK. Would international bounties for drugs, development funded by capital markets, and the FDA sticking to an advisory and recall roll, be better? Sadly, despite the stupidity of investors around technology, and the ignorance of basic medicine of most people, it would.
Posted by: bhauth on November 14, 2006 7:05 AMDoctors in Britain may be thrilled to make 60K a year in return
They make more like £200K, so around $400K USD at current exchange rates.
Posted by: Daveon on November 14, 2006 8:09 AMBrian Engler,
I'm with you on the idea of vouchers. This is a welfare problem - not a healthcare problem. And the simplest and most efficient way to provide welfare is to issue vouchers on the basis of need.
Posted by: Randy on November 14, 2006 8:20 AMAccording to the NHS, their GPs make £50,000 to £76,000--and up to £120,000 if they go independant! The conversion that American expats make on salary is that it takes the same amount in pounds to maintain your standard of living in England that you were paid in dollars in the US; the exchange rate doesn't capture it, as Britons consume very few imports from America, other than television and movies.
I don't think this would satisfy American doctors very well.
Posted by: Jane Galt on November 14, 2006 8:23 AMBnauth said "nurses do most of the work anyway, and they're perfectly qualified despite having less training."
Well I don't know where to start. But I'll have to assume that you mean in the hospital. Nurses give the drugs, do the vital signs and have to fetch ice and all other things that less qualified people could do. As to whether they can diagnose well, well some can but most don't.
I am not sure how they would replace me in the office. I'm the one who talks to and examines the patient. I'm the one who makes the diagnosis and gives the options to the patient.
My wife is a BSN and her basic science knowledge and knowledge of diseases was at one time very limited. Often she would ask why I would perform a certain test because she didn't know how diseases could present, and how some minor illnesses like chronic vaginal yeast infections could indicate some more serious.
She is now a BSN, MS but still lacks the experience of residency, but she now has a better grasp of medicine. So she has had 6 years to learn.
In my neck of the woods most RN's are 2 year graduates and I wouldn't want them to diagnose antything.
Also, "because they're not as arrogant as the doctors." This unfortunately is all too true.
"Three, medical schools are incredibly inefficient. Making students cram for tests to learn material they won't need to know that they'll forget most of by the time they graduate and the rest of a couple years later is stupid. Here's an idea - let's teach people what they actually need to know,..." So what do we leave out? A surgeon needs to learn different things than an internist, but most people don't make their speciality decision until the 3rd year, after they rotate on the various specialties. That is when I made my decision. So first year was anatomy, physiology, biochemisty, histology, psychiatry, neurosciences,embryology...hmmm what should go???
Lastly, "and all the complicated procedures leave plenty of mistakes." Everyone has complications because there is no perfect doctor or surgeon, so therefore we should let less well trained people do these things? Makes no sense to me, but I'm just a simple country OB/GYN
Posted by: storkdoc on November 14, 2006 8:48 AMWhat it will do is dry up RDT&E monies. If you can't touch personnel dollars, and can't touch either procurement or O&M, you ahve to get the bucks out of somebody. It will come out of R&D.
A single-payer health system will make the American medical community into a technological backwater that relies on the government and on foreign countries for all of its research dollars.
Posted by: .cnI redruM on November 14, 2006 9:09 AMstorkdoc,
Is there a forest decimation problem in your area?
Posted by: Mark E Hoffer on November 14, 2006 9:17 AMstorkdoc:
Sure, doctors should diagnose patients - when they have a problem that it takes a specialist to diagnose. The fact is, that's often a small percentage of the time. 95% of the stuff you see you can probably cover with a flowchart on the wall. Giving options to the patient, I'm not sure why doctors > nurses there, unless you're talking about an aura of authority.
Second, nowadays half the stuff you learned in med school is obsolete, and now there's google. Doctors are finding things with google nowadays, as we've heard lately, and nurses can do that too.
What do we leave out of med school? Well, first, stick to diagnostic technique and forget about complex names of obscure ailments. Real medicine isn't like House. Not looking up ailments and drugs you don't deal with all the time means PEOPLE DIE, great memory or not. Second, how about not REQUIRING the rotations through everything, and if people want to pay hundreds of thousands for the privilege of years of insane hours to see what they prefer - if you can tell under those conditions - then I guess they can!
As for the complicated procedures ... the point is, first, the training doesn't matter as much as you think - being careful matters as much - and second, half these procedures are based on obsolete historical things and superstition. Even things as new, IIRC, as drug coated stents which proved unhelpful.
Posted by: bhauth on November 14, 2006 9:56 AMEconomists may not believe you guys are worth the high incomes you guys realize. But the general public does. Your patients want only the most talented and dedicated professionals cutting into their torsos or delivering their babies or selecting the right combination of drugs to solve their medical problem. That physicians continue to rank among the most trusted of all professionals - along with firefighters and nurses - indicates the public is satisfied with what they're getting.
And yet this attitude makes a simple economist like me think that cutting doctors' salaries 30% to 50% would hardly reduce the supply at all.
Posted by: AT on November 14, 2006 10:19 AMStorkdoc, if it isn't too personal, could you give us an estimate of your insurance costs? The OB/GYN's that I am familiar with shell out some eye-popping money for liability insurance.
My point was made by someone up the thread, but bears making again: if something bad happens in a delivery, no matter what the cause, Storkdoc gets sued, the nurses in the room get sued, any anesthetic types get sued, people walking by in the hallway get sued...and I wager that Canada, Britain, France, etc. don't have that particular bit of overhead on their health care systems.
But I don't recall medical tort reform being any part of Hillarycare (and yeah, I did read some of it). The US health care system isn't perfect. It may not be optimal. But it has evolved since WW II in fits and starts. Tampering with it wholesale seems likely to have unintended consequences...
Posted by: ellipsis on November 14, 2006 10:29 AM"...this attitude makes a simple economist like me think that cutting doctors' salaries 30% to 50% would hardly reduce the supply at all."
AT, speaking the Truth is a rare gift, please continue giving.
This is obvisouly anecdotal, but I have to believe that cutting salaries 30-50% in any profession will significantly reduce supply. You can take an example of someone like my father, he is an anesthiologist in Massachusetts.
He is 56 years old, has a great record with no history of malpractice and makes around $180 K per year. He has about $20 K per year in malpractice insurance (I think).
$180K - $20K = $160K Net
If you were to cut his pay by 50%, he would be making
$90K - $20K = $70K Net
For a job that requires very long hours and a lot of stress, especially given that he has invested well, this is not very attractive. The other thing every doctor fears is malpractice, and $70K annually, for a potential wipeout of all your assets is not attractive.
I imagine he would probably take early retirement and find some much less stressful and time-consuming job.
Also anecdotally, I know of quite a few other doctors in similar life circumstances to my father who I have to believe would also consider retiring rather than such a dramatic reduction in pay.
I have to believe that for folks who are talented and bright, such a dramatic fall in future income will push them into other fields where they can make a lot more money.
Posted by: lannychiu on November 14, 2006 10:35 AMAnd speaking of Hillarycare, which just happens to be one of the more recent single-payer proposals, nobody has yet pointed out the following fact: socialized health care proposals in the US don't just pop up out of a vacuum, they are created by people who have a broader agenda. The broader agenda often includes controlling people, for their own good of course, in interesting ways. "National health care" proposals seem to wander down odd byways, unless one recalls the Progressives of 100 years ago, who just knew that banning the sale of alcohol would get all those unwashed, working-class men to quit getting drunk & beating up their families, and start going to libraries where they would read Jane Austen novels and improve their minds. Do I exaggerate? Only slightly, and it is worth bearing in mind when the modern equivalent of the Progressives come bearing "free" health care, with only a few strings attached here and there.
Using the medical system to modify behavior, for our own good of course, may not be high on the agenda to be sure, but it will be there. Count on it, it will be there...and may have unintended consequencs, as Prohibition did.
Posted by: ellipsis on November 14, 2006 10:41 AM2. People need to be responsible enough to buy it when young (or required to)
Reinventing Medicare? Just another redistributionist scheme to steal money from the productive for the post-productive.
storkdoc: "I find it amusing when people just state "lets build more med schools" or let in more students. You all seem to think that many well qualified students just can't get in."
I agree completely. Economists and those who comment on economics blogs do not seem to understand just how difficult it is to be a physician. Extremely high intelligence is just one requiremnt. Medical students - and residents and physicians - must be willing to work long hours. It is not a profession for the genius with merely average motivation.
Actually, extremely high intelliegence is not a requirement, I saw a breakdown of average IQs by professions, physicians were only about 110 on average, college professors were about 135.
As for working long hours - I think this shows greed and selfishness not dedication to patients. No one can work as many hours as interns are required to without the QUALITY of their work taking a nosedive. I can stay up and active for forty hours (by experience, I could undoubtedly stay up longer if necessary) but even I could tell I was slower and less alert after 15 hours.
2. People need to be responsible enough to buy it when young (or required to)
Reinventing Medicare? Just another redistributionist scheme to steal money from the productive for the post-productive.
storkdoc: "I find it amusing when people just state "lets build more med schools" or let in more students. You all seem to think that many well qualified students just can't get in."
I agree completely. Economists and those who comment on economics blogs do not seem to understand just how difficult it is to be a physician. Extremely high intelligence is just one requiremnt. Medical students - and residents and physicians - must be willing to work long hours. It is not a profession for the genius with merely average motivation.
Actually, extremely high intelliegence is not a requirement, I saw a breakdown of average IQs by professions, physicians were only about 110 on average, college professors were about 135.
As for working long hours - I think this shows greed and selfishness not dedication to patients. No one can work as many hours as interns are required to without the QUALITY of their work taking a nosedive. I can stay up and active for forty hours (by experience, I could undoubtedly stay up longer if necessary) but even I could tell I was slower and less alert after 15 hours.
Mark
No I do all of it digitally now so I don't kill too many trees :-)
Bhauth....I carry around my tungston c with all sorts of medical stuff on it. I use it all the time to make sure that I give the appropriate drug at the correct dosage (Thank you Epocrates) I use uptodate.com all the time to help me with my medical decision making.
But personally, I don't want to go to someone who is just following a protocol on the wall. I have NP's and CNM's who miss stuff all the time because they only followed the protocol. Protocols are great but they have limitations.
Being careful is great, I am. I still have complications. Again if you do procedures on enough patients no matter how careful you are, you will have complications because no one is perfect and no one's anatomy is exactly the same as everyone else.
Not requiring rotations through everything may be a problem. Believe it or not despite being an OB/GYN I use my internal medicine knowledge, my pediatric knowledge and especially my psych knowledge every day. I wish I had had s derm rotation, as patiets as me about their skin rashes all the time.
And AT if you cut my salary in half and I still had to do what I do now.... work 80 hrs per week with nights and weekends and have high liability, I'd quit. I love what I do but it wouldn't be worth it.
Posted by: storkdoc on November 14, 2006 10:44 AMAnd why don't the families say "this procedure isn't needed/practical/worthwhile?"
Good question. I myself have seen a number of causes for this. Most egregious are the cases in which the doctors simply don't tell the family that they are going to do somthing. For example, I had an elderly female patient who had an advance directive that forbade intubation. One night, she developed respiratory distress ... and she was intubated. Her husband didn't find out about it until the next morning, at which point the attending refused to extubate her (reasoning that she was already intubated, and the advance directive didn't say anything about extubation).
In other cases, families are simply misled / lied to. The family of that patient with advanced pulmonary fibrosis never, I am certain, was clearly told that the surgical procedure was simply a hernia repair. All information to and from that family was strictly controlled by the hospital, which was easy in that case since the family spoke only arabic. To the best of my ability to tell, all they knew was that there was going to be an operation, and I suppose the rest was left up to their wishful thinking.
Well, that's two reasons, and two cases off the top of my head.
I have to believe that for folks who are talented and bright, such a dramatic fall in future income will push them into other fields where they can make a lot more money.
Or to put it in economic terms, wage caps would be a disincentive for anyone to remain in that field & likely reduce the number of new entrants as well, assuming other fields (such as Wall Street, finance, etc.) had no wage caps. Gosh, did we just discover something new? Should I get on the phone to Stockholm?
Posted by: ellipsis on November 14, 2006 10:49 AM"Shrillion" is a big number which is always stated in a shrill voice. I like it.
Posted by: anonymous on November 14, 2006 10:53 AM"Who is going to want to work all that hard if the pay is slashed, but the liability remains?"
The liability does not remain.
Incompetent doctors have their license revoked, competent doctors who make errors are not punished. Patients never receive punitive damages. Since medical care is already free, there are no awards to provide for it. There is no need for malpractice suits, or consequently, insurance. In addition, this also eliminates the cost of overzealous defensive medicine.
This will require adjustments. Healthcare inefficiency is probably the fastest growing large industry in our economy.
Posted by: Njorl on November 14, 2006 10:56 AMA few notes about Canada:
1) current waiting list at the Montreal General Hospital for hip replacements: on the list for 3-6 months: 74 patients, 6-9 months: 52, 9 months or more: 44;
2) if you have connections, or are willing to pay people off, you can jump ahead of other people waiting for medical treatment. Plus, the wealthy can just pop down to the states for treatment. So the poor and unconnected are at a disadvantage;
3) doctors and nurses are unionized, and periodically go on strike;
4) political considerations dominate which hospitals get money, and where hospitals are built (or closed);
5) dental care, eye care, and prescription drugs are not paid for by the government. Most high-end white collar workers have private plans to cover this;
6) to reduce costs, the government restricts the number of medical students. To get doctors to practice in rural areas, they severely reduce the salary a new doctor can earn in a city;
7) there are substantial shortages of specialists;
8) new drugs & treatments developed (and paid for) in the US have the effect of reducing the cost of medical care in Canada;
9) think doctors are annoyed in the US about having to deal with HMOs? Wait until they have to argue with government bureaucrats...
The result of all this? Not much. Life expectancy in Canada is higher than in the US, and most of the important stuff gets taken care of eventually. I think the US is paying about 14% of GDP on health care, and Canada is paying 7%.
No one pushing socialized medicine in the US should be under the illusion that the same quality will be maintained. But it is a powerful political issue (people love the idea: no responsibility, no choice), and would save a lot of money in the US.
http://news.bbc.co.uk/1/hi/uk_politics/4920692.stm
This caused something of a fuss when it went public, and while it doesn't cover all doctors, it does show that the money is there for some of them, in spades in fact.
Obviously it also depends on the comparison, specialist surgeons make more than general surgeons and gps and so forth, so its hard to quote an average, but I don't hear too many doctor's complaining these days about their wedge.
Of course, the other data point is that until recently they'd have had a completely free training too.
Posted by: Daveon on November 14, 2006 11:00 AMNjorl,
So if I understand you correctly you would;
1) Have some system to determine who and who is not an incompetent doctor run through the government
2) Essentially destroying the field of medical malpractice
As someone married to a lawyer, #2 actually doesn't bother me that much. But I find it inconcievable that #1 could actually be implemented
Posted by: lannychiu on November 14, 2006 11:01 AMOr to put it in economic terms, wage caps would be a disincentive for anyone to remain in that field & likely reduce the number of new entrants as well, assuming other fields (such as Wall Street, finance, etc.) had no wage caps. Gosh, did we just discover something new? Should I get on the phone to Stockholm?
I'm not arguing otherwise. Just saying that emphasizing how brilliant/hard-working/beloved doctors are makes me think that there's a large non-monetary component of compensation, i.e. "prestige," that draws many people in. Enough that people would do it for free? Outside of some Park Avenue families, no. Enough that it marginally hurts doctors' ability to extract higher wages? Probably.
Posted by: AT on November 14, 2006 11:02 AMIf you reduce the amount of money you pay doctors, you'll have to improve their working conditions, otherwise the quality of people choosing to be doctors will be reduced.
Posted by: xxx on November 14, 2006 11:11 AMI wrote:
Or to put it in economic terms, wage caps would be a disincentive for anyone to remain in that field & likely reduce the number of new entrants as well, assuming other fields (such as Wall Street, finance, etc.) had no wage caps. Gosh, did we just discover something new? Should I get on the phone to Stockholm?
AT replied
I'm not arguing otherwise. Just saying that emphasizing how brilliant/hard-working/beloved doctors are makes me think that there's a large non-monetary component of compensation, i.e. "prestige," that draws many people in. Enough that people would do it for free? Outside of some Park Avenue families, no. Enough that it marginally hurts doctors' ability to extract higher wages? Probably.
Maybe I'm missing your point, but you don't seem to be grasping the effect of wage caps. Here's another example:
There seems to be a lot of prestige associated with being a Wall Street finance type. If wages for that field were capped at, oh, $100,000/yr with no chance for stock options & big risk of being sued for bad decisions, do you think that there would still be an adequete supply of them? Or would the best and brightest go into something else? Again, maybe I'm missing your point.
"Life expectancy in Canada is higher than in the US,"
Which may have far more to do with behavior, genetics, and climate than the health care system.
Posted by: David Andersen on November 14, 2006 11:14 AMmalpractice ins $110K
I have had one settlement for under 10k
Posted by: storkdoc on November 14, 2006 11:15 AM"Njorl,
So if I understand you correctly you would;
1) Have some system to determine who and who is not an incompetent doctor run through the government"
Lannychiu,
The government already does this. While the government may not directly make determinations of who is a licensed Dr. and who is not, they do make laws restricting who may practice medicine (though there are grey areas of "healers" who stop short of practicing medicine). They restrict it to licensed doctors. It defers in the licensing of those doctors, and in the revocations of such licenses to other organizations, but it is the government's power nonetheless. Such a situation could continue in a universal health care environment. All that would change is the potential outcomes of medical malpractice. Instead of lawsuits and competency hearings, there would be only competency hearings.
Posted by: Njorl on November 14, 2006 11:15 AMBrian Engler and Randy. I'm also intrigued by the idea of a voucher system. Except, I would piggyback the voucher system on the current health insurance system, like this:
Instead of having individual businesses purchase health insurance for their employees, levy a standard payroll tax similar to the Medicare and Social security tax that would work out to roughly 10% (compared with around 14% for SSI & Medicare). The payroll tax would apply to businesses of all sizes and would address the unpredictablity of health insurance costs that businesses have been struggling with, not to mention releive the businesses of the headache of dealing with insurance benefits for their employees.
Each individual would receive a voucher which they would then use to purchase insurance from the insurance industry. Insurance companies would compete to offer customized slates of coverage to earn your voucher (which they would then redeem from the goverment at some inflation-adjusted standard rate). Individuals would be able to make a personal choice about which coverage they want (this would be a major improvement over the current system where employers are usually the ones buying insurance rather than individuals--unless you're lucky enough to work for a company that offers a variety of options). That individual choice would force greater competition in the health insurance business.
Finally, companies wishing to attract workers with better benefits woudl be free to supplement the vouchers by purchasing additional coverage.
Now, there are some problems that one runs in to with this approach... first, should there be a minimum slate of services/coverage that are required by law to be granted for one voucher? Without some basic minimum, the vouchers might end up being either worthless, or susceptible to scamming insurance companies. But if you do require a minimum slate of coverage, how do you decide what those minimums are?
I'm also intrigued about the possiblity of mixing in some sort of mandatory health savings accounts in to the mix to give individuals some incentive to not over-use health services. Say, for example, the voucher coverage would come with a standard annual $2000 deductible. But then you could have a portion of an individual's paycheck go in to a health savings account to that would be used to cover costs below that deductible. Accounts would rollover unused funds to the next year, so that by older age one could build up a decent amount of savings. Low income people who can save enough in their account based on a standard withholding (say 2%) would qualify for a tax credit in to their account.
I think that some combination of these two approaches would address a lot of the issues we have now, and alienate almost none of the existing stakeholders, while still getting universal coverage.
Someone... tell me where I'm wrong on this, I've been trying to figure it out.
Posted by: Ham Boardman on November 14, 2006 11:17 AMMaybe I'm missing your point, but you don't seem to be grasping the effect of wage caps.
Don't know where you got the wage caps idea. Wasn't mine. Mine was the facetious comment that supply would still be high at 50%-70% of current wages. I think the prestige component is greater than in any other field in the country. I guess the answer to your question depends on whether you think the prestige of Wall Street finance types exists independently of their compensation.
FYI, do you know which large Wall Street bank makes a point of paying less than market to its junior bankers?
It would be interesting to see how much the med school applicant pool size correlates with economic conditions. Is it inversely correlated as much as the law school pool is?
Posted by: AT on November 14, 2006 11:27 AM"Life expectancy in Canada is higher than in the US,"Which may have far more to do with behavior, genetics, and climate than the health care system.
Immigration policy and geography both play a factor as well. Canada tends to be a bit more selective about who they let in than the United States and also has the added advantage of not sharing a border with a third world country that acts as a conduit for illegal immigration from other third world countries.
Posted by: Thorley Winston on November 14, 2006 11:35 AMIf a man transfer from a horrible hospital to a better one, he has to reconduct all the exams, and the documentation from the previous would even mislead to the wrong diagnosis.The issue here is who will take the additional cost.
Then there are three possible approach in the system:
1. the supervisory agency only cares about the funding sponsorship to the patients
2. no transfer of the patients
3. a nationalised hospital like VA
With regards to the cost mentioned,which one would be the optimal ?
Posted by: sally on November 14, 2006 11:37 AMOne follow up note on my comment above... one possible problem might be that the numbers don't add up. I certainly don't know for sure. But my gut tells me that it might work out. High-risk high-cost individuals who would be brought in to the system under the voucher plan ought to be pretty much offset by a combination of 1) the fact that a sizable chunk of the uninsured are relatively young, low-risk individuals...those in their 20s who choose to go without insurance because the cost doesn't seem reasonalbe; and 2) reduced abuse of emergency room care and increased incentives for the insurance companies to offer lower-cost preventitive care.
Also, if you combine this approach with immigration reform that provides a path to legalization for undocumented immigrants and a guest worker program, then you bring another chunk of relatively young and low-risk people in to the system, thereby diversifying the risk pool and offseting the higher cost individuals who would be getting coverage that they don't have.
Posted by: Ham Boardman on November 14, 2006 11:38 AM"I think the prestige component is greater than in any other field in the country...
The income is part of the prestige.
Posted by: David Andersen on November 14, 2006 11:46 AM"Which may have far more to do with behavior, genetics, and climate than the health care system."
"Immigration policy and geography both play a factor as well. Canada tends to be a bit more selective about who they let in than the United States and also has the added advantage of not sharing a border with a third world country that acts as a conduit for illegal immigration from other third world countries."
My point exactly: within a certain reasonable quality range, the quality of doctors & hospitals does not affect overall life expectancy all that much. It can for specific individuals of course, but once you have clean water, basic childbirth care, antibiotics, & communicable diseases under control, the medical system (beyond the basics) does not really add that much to overall average life span.
Posted by: xxx on November 14, 2006 11:49 AMI always enjoy the notion that "Country X has socialized medicine and greater average lifespan than the US, therefore socialized medicine will do the same for the US". If anyone ever writes a new edition of the great book How to Lie with Statistics it should include that argument.
Comparing a data set of 30 million with a small variance against a set of 300 million with a larger variance, and declaring that one and only one factor causes the variance, when a multitude of factors clearly exist, is just too much fun.
Yet socialized medicine proponents do that all the time. They compare Sweden, which for centuries was basically a giant extended family, to the US and assume that somehow all the social/cultural/dietary/hygene variables are the same. It's almost as though there's an agenda that is fact-proof...
Posted by: ellipsis on November 14, 2006 12:01 PM
AT clears things up and asks:
FYI, do you know which large Wall Street bank makes a point of paying less than market to its junior bankers?
Can't say that I do, nope.
It would be interesting to see how much the med school applicant pool size correlates with economic conditions. Is it inversely correlated as much as the law school pool is?
Politics is also a factor. Hillarycare & some of the other Clinton proposals may have had an effect on both med and law school applications, for example.
"the medical system (beyond the basics) does not really add that much to overall average life span."
I suspect, however, that it does for the small populations (realtive to the entire pop) of people afflicted with diseases that can be stopped or slowed with advanced medical care. For example, it is estimated (http://www.cancer.org/downloads/stt/CAFF06EsCsMcLd.pdf) that in 2006, about 213,000 women will be diagnosed with breast cancer. Prolonging their life (only .07% of the population) will have no measurable effect on overall life expectancy, but greatly enhances their own.
Posted by: David Andersen on November 14, 2006 12:04 PMbhauth: "One, nurses do most of the work anyway, and they're perfectly qualified despite having less training."
That's defintely not true in the Operating Room. All medical professionals - surgeons, nurses, and anesthetists - have demanding but unique jobs.
My wife is one of the best nurses. Not only is she very bright - top 1% - but she's professional to the extreme. I know this because nursing educators always try to get their students into her operating room. J. is a BS RN. She studies every year in order to remain certified for the OR.
Even a nurse as talented and dedicated as my wife knows she cannot perform the work of a physician. She just doesn't have the many years of training. Just as important, she must be a generalist to function efficiently. She cannot have the specialized knowledge that comes from fulltime experience in cardiology or internal medicine or oncology or any other of the specialties.
It is true that Nurse Practitioners and Nurse Anesthetists can do some tasks performed by physicians. But the marketplace apparently doesn't value those jobs enough that salaries attract the talented nurses such as my wife.
Posted by: JohnDewey on November 14, 2006 12:08 PM"There is no other good or service where you have a moral need to give it away for free if someone doesn't have money to buy it."
Many people consider food such a good.
We have a wierd mix of agricultural subsidies and food stamps, but by and large food creation and distribution is not single-payer.
-dk
I know that anecdotes are not data, but this one made a big impression on me.
I was in Canada on a business trip a year or two ago, and met a fellow who only had stumps of a couple of fingers on his right hand. Later, I asked someone what had happened. As best I can recall, his answer went something like this:
"He owns a small farm, that he operates on the side. One day he got his hand caught in a piece of machinery, and it was mangled. The fingers could have been saved, but... well, you know what our medical system is like here. By the time he got treatment, it was too late."
Yes, he actually said, "...you know what our medical system is like here." What amazed me was his degree of resignation. I don't know if the Canadians accept this system because they think the benefits are worth it, or because they have just become so accustomed to it.
Posted by: olefins on November 14, 2006 12:10 PMI'm not sure my basic argument is sinking in, so let me see if I can clarify it: the US socialization of its healthcare system will not appreciably change average lifespan, for better or for worse.
In the presence of decent public health measures and a reasonable Western-style medical system, there is nothing much more that doctors & hospitals can do to increase (or decrease) overall life expectancy. This is of course not true for every individual, but the persons pushing socialized healthcare are not interested in the individual.
There is no way the US will be able to avoid socialized healthcare in the long term, because the idea is far too popular.
Are you really considering handing over your medical system to the sort of people who protected New Orleans from the hurricane? At least the British NHS was founded in a generation when people took their responsibilities seriously. It's under the baby-boomer Blair that it's falling to bits. You'd really entrust your system to Blair's chums such as W and the Clintons? How very courageous, as Sir Humphrey would have said.
Posted by: dearieme on November 14, 2006 12:11 PM"the US socialization of its healthcare system will not appreciably change average lifespan, for better or for worse."
But it could easily reduce quality of life if we have to live with discomforts and pain longer due to increased wait times or no care at all (like the guy with the mangled fingers a few comments above).
Posted by: David Andersen on November 14, 2006 12:17 PMxxx writes:
My point exactly: within a certain reasonable quality range, the quality of doctors & hospitals does not affect overall life expectancy all that much. It can for specific individuals of course, but once you have clean water, basic childbirth care, antibiotics, & communicable diseases under control, the medical system (beyond the basics) does not really add that much to overall average life span.
The biggest killers in the US aside from car accidents seems to be circulatory issues and cancer. Diabetes can be described as accelerated aging as far as the circulatory system (and kidneys) are concerned. "Adult onset" diabetes is now known as "Type II" because so many teenagers and even children suffer from it. Reducing the incidence would have a positive effect on mean lifespan in the US.
Now here's the question: what would socialized medicine do, that the current system cannot do, to reduce the incidence of diabetes?
The exercise can be repeated for any number of ailments....being grossly fat seems to correlate with increased probability of cancer, for example. Socialized medicine proponents ought to be able to explain how their system would be better than the current one in concrete terms, not just handwaving "it will control costs better" ways. That smacks of the standard Republican solution for budget problems, "reduce waste and fraud".
Posted by: ellipsis on November 14, 2006 12:19 PMBored Ham man: The problem with your scenario is that if they bought insurance privately older workers would have to pay much more in premiums than they do now. Older people have so much political clout they could sink your otherwise sterling idea.
The answer to Jane's question is that if universal health care is passed it will be promised as just as good as the current system. Money will be saved through reduced paperwork and no TV drug commercials. Those who point out how much this will cost will be ignored. When the bill comes due the government will start to squeeze doctors, old people, and drug companies. Care will erode over years which will make it more palatable.
storkdoc: "Not requiring rotations through everything may be a problem. Believe it or not despite being an OB/GYN I use my internal medicine knowledge, my pediatric knowledge and especially my psych knowledge every day. I wish I had had s derm rotation, as patiets as me about their skin rashes all the time."
If the patients knew exactly which physician they needed to see, perhaps some specialties would not need all training. As I see it, though, primary care physicians must determine which specialists should see a patient for further care. How could they perform that function unless they've been exposed to all specialties?
I think even specialists need general knowledge, so they can discover other problems when working on one. My brother-in-law, a tragic victim of an auto accident this year, had so many problems that priorities for treatment had to be decided. I don't see how three specialists could have reached agreement had they not understood each other's work.
Posted by: JohnDewey on November 14, 2006 12:23 PM
Politics is also a factor. Hillarycare & some of the other Clinton proposals may have had an effect on both med and law school applications, for example.
Possible. The Economist-style eyeball statistical analysis shows that the applicant pool increased significantly in quality while the size of the pool was decreasing and then leveled off when the pool started growing again, suggesting that there is a large subgroup that is highly-qualified and not very sensitive to changing opportunities in other fields. If it were the top and not the bottom that were leaving for other fields, we would not expect to see quality increase. For what little it's worth.
Posted by: AT on November 14, 2006 12:24 PMAll this talk of lifespan reminds me of an amusing thing I read not long ago, something said to be surprisingly accurate for men (it doesn't really work for women):
Stand up straight and look down. If you cannot see your toes, your risk of premature death is significantly increased.
xxx: "the quality of doctors & hospitals does not affect overall life expectancy all that much. It can for specific individuals of course, but once you have clean water, basic childbirth care, antibiotics, & communicable diseases under control, the medical system (beyond the basics) does not really add that much to overall average life span."
The U.S. had clean water, childbirth care, antibiotics, and control of communicable diseases fifty years ago. And yet the average lifespan continues to increase. To what do you attribute this significant increase that occurred over my lifetime? Some may be due to reduction in smoking, but lifespans increased dramatically for non-smokers as well. (If you're 55 like me, a lifespan increase from 67 years to 79 years is dramatic. A 30-year-old may not yet appreciate the extra 12 years, but we seniors certainly do.)
Someone way up the thread pointed out what some are calling the "longevity dividend", and that's worth dragging in to the thread again. There are drugs and procedures in the research pipeline, or in the case of Alteon's "ALT-711" in actual drug trials, that will actually work to reverse certain damage & extend mean lifespan. (Extending maximum lifespan is trickier). This is research, and it's done by those evil, grasping, capitalist drug companies, i.e. Big Pharma in the expectation of making money. Shut down any hope for profits, and the pipeline of new drugs & techniques will get a lot smaller.
It is annoying to me that just at a time when there is a real chance to extend healthy lifespan, as opposed to frail lifespan, we have to go back to arguing about just how much of a beating doctors & medical researchers should have to take, in order to improve things...
Posted by: ellipsis on November 14, 2006 12:39 PMAll this talk of lifespan reminds me of an amusing thing I read not long ago, something said to be surprisingly accurate for men (it doesn't really work for women):
Stand up straight and look down. If you cannot see your toes, your risk of premature death is significantly increased.
I can see my toes, but not as clearly as I used to be able to. Time to go to the gym...
Posted by: ellipsis on November 14, 2006 12:42 PMAll this talk of lifespan reminds me of an amusing thing I read not long ago, something said to be surprisingly accurate for men (it doesn't really work for women):
Stand up straight and look down. If you cannot see your toes, your risk of premature death is significantly increased.
One question: is that "can't see your toes" with, or without, glasses? That's going to make a difference for some people...now, I can see my toes, but not as much of them as a while back. Time to go to the gym.
Posted by: ellipsis on November 14, 2006 12:43 PMJohn Dewey: "The U.S. had clean water, childbirth care, antibiotics, and control of communicable diseases fifty years ago. And yet the average lifespan continues to increase. To what do you attribute this significant increase that occurred over my lifetime? Some may be due to reduction in smoking, but lifespans increased dramatically for non-smokers as well. (If you're 55 like me, a lifespan increase from 67 years to 79 years is dramatic. A 30-year-old may not yet appreciate the extra 12 years, but we seniors certainly do.)"
If it is for you or a loved one, an extra day is appreciated. I'd say that some of the increase is from better medicine, but most would be from:
- better motor vehicle safety
- better workplace safety
- better, more comprehensive vaccinations
- less tobacco use
- better food safety
- better jobs (working in a coal mine or steel mill is harder on you than an office job)
- more widely dispersed, due to wealth, "clean water, childbirth care, antibiotics, and control of communicable diseases"
sourcreamus, I think you're right about older people, but we have that problem already... which is why the Medicare system was created... because no insurance company in its right mind would sell a policy to a senior at anything resembling a affordable price. Everyone over 65 (or whatever Medicare age is) is already in the system, as it were, and could continue to be under the voucher system I propose. The aim of the voucher system would be to bring in the chunk of 35-45 million Americans who are not covered by existing insurance, Medicare or Medicaid (and by not being covered, that also means they're not paying in to the system).
> At my school the med school tuition was about 3 times the cost of a full time undergrad, so I think that the university considered the credit hours to be the same.
Umm, no. The university charged you three times as much because you'll pay three times as much. The cost of providing that year of education may have been higher as well.
These factors have nothing to do with how much work you did.
> Each individual would receive a voucher which they would then use to purchase insurance from the insurance industry.
Which some would sell (or otherwise arrange for someone else to receive the care) and then show up at the emergency room demanding care.
"the US socialization of its healthcare system will not appreciably change average lifespan, for better or for worse."
Maybe, maybe not. I don't care.
Modern medicine does a lot for people that doesn't save their lives. Of the eight or nine middle-aged people with whom I fence or climb or run on a regular basis, four of them have had injuries that have needed a substantial repair, and they got the work done as soon as medically possible [for example, you need to wait a month for an ACL reconstruction to let the inflammation subside even if there are surgeons waiting around with nothing to do]. I myself have benefited from a cortosone shot for fencing elbow -- not a major deal, but it did involve seeing an orthopedist.
Contrast that with Canada. On a vacation I took a while back, I took a train ride to BC [from California], and one of the other passengers walked with a decided limp. He told me his story ... he didn't know what was wrong but it had been over a year. He went to his GP with the injury ... who sent him to an orthopedist [seven month waiting time TO GET TO THE SPECIALIST'S OFFICE]. The orthopedist wants to see an MRI, which requires a six month waiting time in Vancouver, and he was going to get his MRI soon after he gets back. I'd hate to see what the wait will be if he needs arthoscopic surgery if they even have the tools.
However, he won't die, even if the problem is never taken care of.
-dk
3) It cannot ration end-of-life care.
I've checked. Within 117 years every person who ever recieved medical care has died anyway. We don't save lives we prolong them. End of life measures are often affronts to human dignity and mercy.
The numbers are inexorable, Just as we all must die we must ration end-of-life measures. The problem ultimately devolves to a moral decision. My grandmother in her late 70s had a knee replacement. She eventually wore it out in the subsequent 20 years . What constitutes end-of-life is the gray area providers fear to tread.
Posted by: Robert Coté on November 14, 2006 2:49 PMI'm not advocating socialized medicine. The only advantage I can see is lower costs, but I don't think that is worth the reduced quality & government intrusion. People should plan ahead, get private insurance, and I do not believe it is the place of the government to insure away all risk of anything bad ever happening to you.
That said, the movement towards socialized medicine in the US is unfortunately unstoppable.
"I find it amusing when people just state "lets build more med schools" or let in more students. You all seem to think that many well qualified students just can't get in. Who in hell is going to teach all these new students? We barely have enough people to teach medicine now. Are they going to pass?"
Many qualified students are not getting in. I recall a quote from the head of the UCSD medical school in which the ratio of accepted to qualified was on the order of 1:3. Turning away qualified students has only worsened with the nonsensical "diversity" and "affirmative action (aka institutionalized racism)" programs in which students with exemplary academic credentials are turned away in favor of those with differing skin tones with poorer academic records.
There are two actions that would aid in allowing new schools to be opened. The first is the decoupling of medical schools from large academic research institutions. The rationale for this coupling is tenuous at best. Medical students are suppoed to be learning the established tenets of their field. Those interested in research work should get a PhD or enroll in an MD/PhD program but should not be taking up the limited slots that the medical profession allows for those interested in becoming clinicians. Also, foreign trained students at research powerhouses such as "Tijuana Tech" or "Guadalajara Institute for Technology" (sarcasm intended) need only pass the boards and complete a residency in order to practice domestically. The fact that many students trained at these foreign "research powerhouses" are able to pass the boards and competently perform their residency requirements does not the support the domestic coupling. The second action would be to allow for profit medical schools. The supply of both basic science PhDs and clinical science MDs would increase as the demand (and compensation) for their services would increase with additional training facilities. A third and somewhat novel option would be to fund the opening of hundreds of training centers south of the border and thus bypass the AMA and CME obstruction completely. Training costs would be dramatically lowered and the market could be flooded with thousends of new providers.
"In college I took 18 credits each semester. In med school is was 54 credits each semester. It's really really intense. After my first day in med school, I felt like I was 2 weeks behind."
Granted that medical school is difficult (particularly the first two years of basic science courses) but let us no kid ourselves. Medical school courses for medical students are graded on a pass/fail/honors system. An "A" average is required to get into medical school but a "C" average is required to get out.
"I spent 4 years in med school and then 4 years in my residency before I was able to practice on my own. There is a debate in my specialty (OB/GYN) as to whether we are doing enough procedures in that 4 years or whether we should add another year to training. If we double the number of slots, will all these docs get well trained?"
Yes they would. The supply of training facilities and trainers would follow the demand for their services. You do bring up an interesting point (tangentially) and that is are existing providers given the joke that continuing medical education is, sufficiently assessed for competency for new procedures or should some actual additional training be required...
"Who is going to want to work all that hard if the pay is slashed, but the liability remains? So if you all think that I should make no more than $100,000 per year. I'll happily do that as long as I don't have to work more than 40 hrs per week, and like everyone else, I'd like my weekends off and no nights. I don't know why all babies can't come between 9am and 5 pm Monday through Friday ( and yes that was firmly with tongue in cheek, but not the 40 hrs per week part)"
It may not be the current crop of providers but a shift in the physician compensation paradigm need not be passed on to the next generation of providers. Let's face the facts here. The ratio of physicians to demand for healthcare services (the majority of which are granted to the allopathic and osteopathic community via legislative feat) is so skewed in favor of the providers that even the most bottom of the barrel social promotion idiot medical school graduate can easily command a good six figure after expense compensation package. For the most part physician compensation is based on restricted supply and little else. I expect the same level of competency from my auto mechanic when he is fixing my C5 such that the car does not malfunction and kill me while I am driving it as I would from my cardiothoracic surgeon performing a quaduple bypass. The difference is that I can easily go to one of hundreds of local mechanics in order to have my car serviced but only have the choice of a few dozen cardiothoracic surgeons.
Posted by: Criminallopath on November 14, 2006 3:00 PM3) It cannot ration end-of-life care.
Robert Cote' wrote:
I've checked. Within 117 years every person who ever recieved medical care has died anyway.
Except for that woman in France who made it to over 120...a number that was flat out impossible 100 years ago, when living past 50 was doing prett good.
We don't save lives we prolong them.
Exactly. Vaccinating for polio merely prolongs life, too...
End of life measures are often affronts to human dignity and mercy.
Er...
The numbers are inexorable, Just as we all must die we must ration end-of-life measures. The problem ultimately devolves to a moral decision. My grandmother in her late 70s had a knee replacement. She eventually wore it out in the subsequent 20 years . What constitutes end-of-life is the gray area providers fear to tread.
A relative of mine had a hip job done when in her 70's. It didn't prolong her life very much, but made the last 20 years of life a whole lot more pleasant. Was that "end of life" care?
I just watched part of the White House lawn chat by the three automakers. They're claiming that health costs are making it tough for them to compete. I dunno, lowering the price of a Chevy by $1,400 won't make me any more prone to buy one...
Of course the Big 3 automakers health care issues have to do with nice contracts they signed in the 1980's. Now they want to get out of those contracts. Hey, I bet some of the folks that took Greenspan's advice & bought a big house with an ARM would like to get out of their contract, too. Y'think they'll be invited to the White House any time soon?
Posted by: ellipsis on November 14, 2006 3:09 PMCriminal
You sound so much more reasonable over here than at Kevin's place
Posted by: storkdoc on November 14, 2006 3:19 PMStorkdoc:
The problem with Kevin's place (and no offense directed at Kevin) is that every other posting can be summarized as "woe is the profession, we are being savaged by the ATLA." The mere suggestion of a duplicitous standard regarding physicians and trial lawyers and the inerhent similarity of the junk science of clinical causation in PI cases and clinical causation in the John Edwards type med mal cases seems to raise the hackles of some of the other posters on Kevin's site. Unfortunately, I find myself going round and round with the same posters on this issue over there and the debate can become a bit heated at times. In any event, change is coming down the pipe - perhaps even Hillarycare revisited. I have yet to see any of the politicians suggest evaluating the supply side of the equation but perhaps I will be pleasantly surprised. For the record, I am not for the artificial limitation of compensation rates for providers, but I am also not for the artificial raising of the same rates or for keeping them at the current levels based upon supply side restrictions.
Posted by: Criminallopath on November 14, 2006 3:27 PMMichael,
I recently saw a patient on dialysis because of renal failure. Her medium expensive Depakote ER cost her $1 a month, Medicaid, in Texas no less, paid the rest; ditto for other meds. Coming to renal failure at greater than 54 in Britain, it is considered you have lived a good British life, it is now time to die of uremia. No dialysis is then offered by the NHS.
I'm not sure you intended it but this is not a comparison of private health markets to nationalized ones but rather a comparision of two types of nationalized markets. The first is poor people in Texas (under Medicaid) and the second was a regular person in the UK. Overall the US spends more on healthcare per person than the UK so it is not at all surprising to know that the typical UK person gets less healthcare than the typical US.
David
Sure, but that doesn't imply we need government provided health insurance. All we need to accomplish this is to make it easy to buy and keep insurance independent of employers (portability). But lack of portability is something perpetuated by the tax code; imagine - government is part of the problem.
Actually you would need the gov't if the goal was continuous coverage. Yes you could spit out a bunch of tax credits for people who buy their own insurance but that would do little to address:
1. Those unemployed or who suffer income disruptions.
2. The bargaining ability employers have with insurance companies. Those that are profiled as likely to become sick are lumped in with the healthy letting everyone be covered.
David Anderson
If everyone who was able (most of us) bought low-cost, high-deductible health insurance when they were young and healthy, then made an