Asymmetrical Information

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.

My 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.

"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.

These 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

Dick 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.

Why 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.

You'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

John_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 ...

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?

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)

Person: 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.]

As 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.

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.

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.

we 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.

There'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.

The 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.

What 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.

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. 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.

Foo:
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.

Why 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.

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.

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.

Damon: 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.

I 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.

TJIC

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.

And, 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.

Had 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.

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.

The 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.

"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.

"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.

J.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.

As 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?

Do 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?"

Open 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.

Doctors 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.

Brian 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.

According 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.

Bnauth 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

What 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.

storkdoc,

Is there a forest decimation problem in your area?

storkdoc:

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.

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.

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.

Storkdoc, 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...

"...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.

And 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.

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.

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.

And 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?

"Shrillion" is a big number which is always stated in a shrill voice. I like it.

"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.

A 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.

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

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

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?

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.

If 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.

I 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.

malpractice ins $110K

I have had one settlement for under 10k

"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.

Brian 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.

Maybe 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?

"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.

If 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 ?

One 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.

"I think the prestige component is greater than in any other field in the country...

The income is part of the prestige.

"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.

I 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...

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.

bhauth: "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.

"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.

I'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.

"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).

xxx 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".

Bored 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.

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.

All 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...

All 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...

All 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.

John 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.

I'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.

3) 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?

Criminal

You sound so much more reasonable over here than at Kevin's place

Storkdoc:

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.

Michael,

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 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.

1. Why wouldn't premiums rise as people aged and their risk of illness increased dramatically? Sure as part of a marketing campaign an insurance company could reward those who signed up young and stayed loyal to the company for decades by capping premium increases but at the end of the day an insurance company exists to make a profit and that doesn't happen if you're not charging enough to cover your costs.

2. A voucher type system could accomplish something like this. Everyone would by default be covered with a basic plan. They would be free to supplement it by using their own money to purchase more just as seniors can buy plans that go above and beyond what is covered by Medicare.

David Wright
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.

A quibble, I'd say ability to pay incentivizes DEMAND rather than supply. If I have to pay for my lunch I'd be less inclined to order desert or to order the most expensive dish. If you're paying for my lunch....well :) It's nice to have a boss who doesn't look at your expense report too carefully.

On easing requirements to be a doctor or attacking the FDA:

What about all these third world nations? I'm sure many of them would let just about anyone practice medicine or any pharma company start selling drugs with minimal regulation. Considering the billions that are spent on health care I'm sure if libertarian deregulation was the easy answer a lot would be saved by simply sending patients to overseas clinics. Sure this wouldn't be cost effective for the person who just needs a $10 script for some antibiotics but if you could do a $40,000 operation for $5,000 who cares if you have to toss in $3,500 for airfare and a nice hotel stay?

Boonton writes:
What about all these third world nations? I'm sure many of them would let just about anyone practice medicine or any pharma company start selling drugs with minimal regulation.

Don't confuse "selling" with "manufacturing". I understand that some drugs are sold essentially for nothing in parts of Uganda, for example, because they are donated from the US and Europe. There's still no pharma industry in Uganda, though, despite lack of regulation. Pharma is quite capital intensive, and not likely to be set up in countries where keeping the main roads paved is a major challenge.

Considering the billions that are spent on health care I'm sure if libertarian deregulation was the easy answer a lot would be saved by simply sending patients to overseas clinics. Sure this wouldn't be cost effective for the person who just needs a $10 script for some antibiotics but if you could do a $40,000 operation for $5,000 who cares if you have to toss in $3,500 for airfare and a nice hotel stay?

I have reason to believe this is already in the works. If doctors in India can read X-rays at a lower cost than US doctors, enabling big HMO's to cut costs, then it's not that big a step to send people in need of some routine surgery over there as well. If not India, then one of the windward islands in the Caribbean can import a score or two of doctors from India and set up shop. Given a much different legal structure, and lower overhead for other reasons, it wouldn't be that tough to cream off many routine procedures, even on a cash basis.

It is called medical tourism and the word is (as per the LA Times to the degree that the paper can be trusted) that some Fortune 500 companies are already considering it as an option for non-emergency surgical procedures as a mechanism for the continued provision of healthcare benefits. The reduction in cost is astounding and allowes the company to split the savings with the employee.

When it comes to interpretative radiology there is no resonable rationale beyond protectionism to not allow outsourcing of interpretation of imaging data.

"As a matter of practical reality other than some changes at the margin the system we have is the best system that can be had."

A system where we have lower life expectancy, higher infant mortality, and spend more money and %GDP, seems an odd definition of 'best'. My summary of the data. The UK spends half of what we do and lives longer, and they're at the bottom of the scale for socialized First World countries. US lifestyle differences don't explain the 50% higher infant mortality rate we have. Race doesn't either -- just looking at whites still gives low life expectancy and high infant mortality.

"First, it makes no sense for health insurance to be provided through your employer"

No, it doesn't, but individual insurance doesn't make lots of sense either. The point of insurance is to pool risk, while the goal of a for-profit insurer is to avoid high-risk people or charge them more. This might be justifiable for lifestyle things like smoking or not exercising, but already makes people uncomfortable, and definitely isn't what they want for "oops, you have breast cancer". A national insurance plan can spread the risk over the widest possible pool. And yes, a system which encourages preventive health spending can end up spending less later on.

"People need to be responsible enough to buy it when young (or required to)"

The system would work if only human nature was different! Or we could require them to buy in -- hey, that's one form of socialized medicine...

"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..."

Sweden, Canada, Australia, France, Germany, Italy, the UK, Japan. Tiny countries, and countries half our size. Hot countries and cold countries. Countries with pretty different diet and genetics and countries who are the source population of the US and our next door neighbor. Immigrants? White Americans still compare unfavorably. Lifestyle? Look at infant mortality...

It's almost as though there's an agenda that's fact-proof!

How about the biggest reason of all?

THERE IS NO CONSTITUTIONAL BASIS FOR THE FEDERAL GOVERNMENT TO TAKE OVER AN ENTIRE ECONOMIC SECTOR LIKE THIS

HEALTH CARE IS A PRODUCT NOT A RIGHT

The medical tourism issue-
Sounds great if you nothing goes wrong, because surgeons don't mind taking care of their own problems, someone elses no way. Its a long car ride to India if you are having problems with your total knee. Plus would you rather have someone that is concerned about every move they may because of lawyers or one that never ever has to worry about anything because you can't sue and to follow up you have to ride a plane for 12 hours. Its dangerous as well getting on a plane for 12 hours after a knee replacement, someone is going to die.

The largest barrier for universal healthcare is the insurance companies. United healthcare gives their CEO a bonus of 100 million in one year, what do you think is going to happen if someone tries to implement a universal policy. All of the companies with that much capital will spend into oblivion to prevent that from happening. They would spend hundreds and hundreds of millions of dollars and we all know that is how things get done in Washington. No way will it ever happen.

From my paper on the subject at the Heritage Foundation (shameless plug: "High-Priced Pain: What to Expect from a Single-Payer Health Care")

With a single payer, the US can expect what other countries have seen:

Long waits and reduced quality. In Britain, over 800,000 patients are waiting for hospital care. In Canada, the average wait between a general practitioner referral and a specialty consultation has been over 17 weeks. Beyond queuing for care or services, single-payer sys­tems are often characterized by strict drug for­mularies, limited treatment options, and discrimination by age in the provision of care. Price controls, a routine feature of such sys­tems, also result in reduced drug, technology, and medical device research.

Funding crises. Because individuals remain insulated from the direct costs of health care, as in many third-party payment systems, health care appears to be “free.” As a result, demand expands while government officials devise ways to control costs. The shortest route is by pro­viding fewer products and services through explicit and implicit rationing.

New inequalities. Beyond favoritism in the provision of care for the politically well-con­nected, single-payer health care systems often restrain costs by limiting surgeries for the eld­erly, restricting dialysis, withholding care from very premature infants, reducing the number of intensive care beds, limiting MRI availability, and restricting access to specialists.

Labor strikes and personnel shortages. In 2004, in British Columbia, Canada, a health worker strike resulted in the cancellation of 5,300 surgeries and numerous MRI examinations, CT scans, and lab tests. Canadians have a shortage of physicians, and the recruitment and retention of doctors in Britain has become a chronic problem.

Outdated facilities and medical equipment. Advances in medical technology are often seen in terms of their costs rather than their benefits, and investment is slower. For example, an esti­mated 60 percent of radiological equipment in Canada is technically outdated.

Politicization and lost liberty. Patient auton­omy is curtailed in favor of the judgment of an elite few, who dictate what health care needs and desires ought to be while imposing social controls over activities deemed undesirable or at odds with an expanding definition of “public health.” Over time, government officials will claim a compelling interest in many areas now considered private.

Damien -

"The point of insurance is to pool risk, while the goal of a for-profit insurer is to avoid high-risk people or charge them more."

So insurance companies are not pooling risk with auto and homeowner's insurance? I buy them myself, so I guess not.

Boonton -

Ever heard of saving for a rainy day? Does everyone who's temporarily out of work have no savings or ability to pay for essentials? Or is that just not fair to have to spend your savings for essentials rather than fun stuff?

How is it that we have a competitive market for auto insurance and we buy it individually? Only health insurance has to be purchased by employers? That's silly.

I keep hearing the words "we'll force them", meaning doctors and nurses and health care providers. Who are the "we" and what sorts of actions are you willing to take to make private citizens do your bidding? Sounds like some of you need to work in the health care arena to see what it is that you are talking about. When was the last time you gave a 300 pound woman an enema, and stayed to clean up the mess? Would you like to take over for the health care providers who do some of the dirtiest work and the most important work, only to be told that "we' are going to cut your wages?

"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."

It's funny that creative people take risks and become entrepreneurs far more so in the US than in Canada.

Kevin P.:

BINGO. Here's a name folks might recognize from recent news stories: MICHAEL J. FOX. If Canada's single-payer system is so friggin' wonderful, why are talented Canadians like Fox (who, incidentally, became an American citizen in 2000) pouring across our northern border faster than hot maple syrup out of a bottle? Seems to me that if Canadian care was the best available, Fox would have headed back to the Great White North to get treatment for his Parkinson's. But he didn't, did he?

Hmmm, could it be that Fox and other expat Canadians know something that single-payer advocates on both sides of the border either can't...or WON'T know?

"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..."

Sweden, Canada, Australia, France, Germany, Italy, the UK, Japan. Tiny countries, and countries half our size. Hot countries and cold countries. Countries with pretty different diet and genetics and countries who are the source population of the US and our next door neighbor. Immigrants? White Americans still compare unfavorably. Lifestyle? Look at infant mortality...

Thanks for making my point for me. What percentage of the population of Japan, Italy, the UK come from 3rd world countries, for example?

It's almost as though there's an agenda that's fact-proof!

Yep.

I had my doubts about your argument, Scof, but putting it in all caps persuaded me.

dawg wrote:

The largest barrier for universal healthcare is the insurance companies. United healthcare gives their CEO a bonus of 100 million in one year, what do you think is going to happen if someone tries to implement a universal policy.

You obviously don't recall Hillary's little secret meetings with insurance execs, and how that played out in the actual Hillarycare proposal. Companies are all too willing to go along with government created cartels so long as they get to be part of the club...

Criminalpath you rail against physicians and their salaries, but these payments only make up 9 cents out of every healthcare dollar. Seems your great ideas would be better served looking at the 91 cents.

Ok, Damien, explain to us all how a nationalized health care system would do a better job preventing Type II diabetes than the current system does. Take all the time you need, and use as many electons as you wish.

Hasn't anyone mentioned Oregon, a state on the West Coast of the U.S., north of California, yet?

If not, why not? Seems to me that they've already begun to experience, in real life, some of the questions, and answers, being discussed here.

Say, I wonder what car insurance would look like if it was run along the same lines as health insurance. Let's see, your car insurance would come from your company, some plans would provide free repair of all dents and scratches, minimal copays for oil changes and when you blew the engine because you never checked the oil, you'd get a new engine pretty much gratis.

Great idea!

JG,

btw, is it possible to have the posts #'d, some of these threads get waay long, and, thereby, somewhat difficult to navigate.

Mark E Hoffer wonders:
Hasn't anyone mentioned Oregon, a state on the West Coast of the U.S., north of California, yet?

Where? Someplace way, far, far west of the Hudson river and not part of California? Are you kidding?

I'm a medical student. I am always exhausted. I have no life. I work 14-16 hours a day everday (no weekends off) through my various rotations and studying. When I am not working I constantly worry that I might have screwed up or that I need to be studying. So what is your incentive for me.

PS... All of my friends share the same sentiments. I am not odd in the slightest. Trust me, all those squishy good feelings towards medicine leave pretty quick when you don't have time exercise, see your family, sleep, eat (I study while I eat), etc. You should walk a mile in my shoes before you start judging and deciding what I do and don't deserve.

Oh yeah, My life only gets worse from here because when I start my residency then my home time will also belong to the school/residency program.

I get a hoot seeing all the posts about the AMA restricting the supply of doctors. They WISH they had ANY market power.

More doctors would not decrease health care expenditures and would probably increase them as people with time on theirs hands and bills to pay would go looking for things to do.

Regrettably, Scof, that ship sailed with Wickard v. Filburn in 1942. So long as the courts can envision a non-insane rationale for the regulation of something that's at least arguably related to interstate commerce, it'll be upheld as being within the ambit of Congress' power under the Commerce Clause.

There's got to be more non-citizens in the U.S. than the 12 million undocumented workers.

Uh, from where will all these "qualified" students come who are going to enter medical schools? These "qualified" students simply do not exist. Science and math education at the elementary and secondary levels has been pathetically awful for many years and the US ranks quite low in all international math and science comparisons. Yes, medical schools can always enroll more students, "qualified" or not. Frankly, as things stand now with the current med school students, I suggest to all of my friends that they choose doctors 45-50 and older.

Here's the problems with flooding the market with providers. Costs will go up. Provider payments make up 9% of healthcare expenditures but providers make decisions that end up being responsible for 80% of the healthcare dollar. More providers, more decisions, more tests, more frequent visits, more procedures equals much more money being spent.

Criminallopath: (3 PM comment): Seconded.

JohnDewey (12:23 PM):

I would say that to some extent telling what specialist you need is easy, and the rest of the time, doctors usually don't send you to the right place anyway any better than a flowchart could. Anectodal: It took three doctors (not referring to each other) to diagnose my friend with lymphoma, for example. Said he had asthma.

(12:08 PM): My point was that the nurses can do what the most doctor hours are still spent on, and they can know when to send patients off to someone else.

Storkdoc (10:44 AM): I wasn't saying you don't look things up, I was saying it made half the memorization you do in med school pointless.

Sure, you may need some "non OB GYN" stuff in your job. But that just means it should be part of "OB GYN stuff in med school" if you don't do the rotation. I'd bet that the amount of stuff you need to know in these other areas in your job is a small part of what you're going through in med school, and mostly gets drowned out by stuff you don't need. And some of that will be stuff you're better off, as least if there was less friction in the system, saying "go see Dr Z for this."

Malpractice insurance is a whole other thing too. One thing, looking at short term malpractice insurance price changes, is that insurance costs will go up as bond rates go down, and when a trend starts for increasing malpractice payouts, insurance can get priced assuming that will continue. But policies are often so overpriced and can vary so much by region and specialty in different ways that something must be funny. One thing is that insurance prices may be overly conservative in hard to predict insurance markets - thus leading to a soft form of collusion.

Based on this, insurance rates should actually go down in the future. Basically, medical malpractice insurance is volatile and cyclical. However, insurance prices may be sticky downwards. Government regulation may help here. The extension of physician-owned non-profit insurance companies and getting them into more capital markets may help too.

Lawyers have their share of the blame too. I'm not sure exactly what system would be most fair and efficient for deciding malpractice cases, but I'm sure the current one could be improved.

Then there's the whole issue of, the more you can reduce medication errors and so forth with computers and checks, the less malpractice costs...

In conclusion: EVERY institution and system involved is broken pretty well.

my dog got a full blood workup for about $400. For me that is $2000. A replacement knee/hip for a dog is about $6K. That's what happens when there is NO protection from the state. They are lucky they can't vote.

P.J. O'Rourke said it best. "If you think health care is expensive now, wait until you see what it costs when it's free."

I rail against supply side restrictions and the throttling of even the basest of free market principles when it comes to the American healthcare market. Admittedly, tt is my particular pet peeve. Even more so if we are looking at a future healthcare system that doesn't address the supply side of the equation. By the way, the supply side of the equation also relates directly to the access to care problem.

Bhauth: You are making yourself sound naive with each post.

1. It is stupid to think you are going to know what to search on google if you have never tried to learn about it previously. You will be searching blind. When it relates to medicine I know this very well as it can very hard to get any worthwhile information of the internet if you haven't been exposed to it at a level beyond what the internet offers.
2. You are mad that your friend took three doctors to diagnose them, so you are suggesting that they need less training and less integrated training? What?
3. As much as it would simplify medicine, the lymphatic system, circulatory, organs, CNS, etc. do not work independently. Obviously, you have never been exposed to medical education in the slightest. Yes, even specialists have to understand the body outside there realm of expertise. This is why we need to understand all of medicine and not just chop the body into little pieces.

You lose all credibility when you talk about learning and integrating knowledge less. The human body does not work in a common sense way.

PS --> flow charts kill people because they leave no wiggle room and the person using them doesn't understand why things are the way the are and when you shoulnd't follow it. It is a process that must be learned about. I guess you just have to do it to understand... until then you need to become a little bit less opinionated

Funny, last I have heard, Blair did not use the NHS for his family. I wonder if Hillary will send Bill for his next angiogram to the General Hospital in Washington DC. I will believe them when they will put their life where their mouth is. But maybe it smells too nasty.

Whatever you want to argue about it, I think it's inevitable. Too many interest groups have an interest in getting health care risk off their plate and the government has an inevitable desire to take over stuff. I'd bet that at some point the government will cut a deal with the employers that pay for health care, restricting them to a health care tax that's around what they pay now for the private care and can only "increase with inflation" or somesuch. (Don't forget that just today the big carmakers met with GWB about this.) This money will then funnel through Washington and out to the private health insurance companies whom the government will have hired to administrate the care to us proles. Done and done. Best thing you can do now is try to make as much money as possible so you can afford private care in Central American resort-clinics or whatnot. That's my plan!

A few notes on emergency care. Although this is a crude oversimplification, American hospitals are essentially required under federal law to have emergency rooms. (To be more precise, they're required to have emergency rooms if they've availed themselves of certain federal facility bond programs.) And, under federal law, hospitals cannot turn any person away who presents with an emergent condition--including, incidentally, illegal aliens. (Indeed, federal law provides funding to reimburse hospitals for providing emergency care to illegals.)

Accordingly, hospitals have no choice but to maintain the staff and infrastructure to treat any patient with emergent conditions who comes into the ER. And the cost of treating each patient is not a marginal cost.

All of this means that, as it now stands, patients who are very sick or injured and who go to the ER will be treated--regardless of ability to pay. So that means (as others have pointed out) that a lot of uninsured people who avoid relatively inexpensive primary or preventative care because they cannot afford to pay for it out-of-pocket will come to the ER when they get sick enough--and, if the patient has no assets, the hospitals eat the costs.

One lesson from this is that--despite what the critics of America's health financing system say--the fact that our country has so many uninsured doesn't mean that people aren't getting needed medical services. It just means that those services are often delivered in a highly inefficient, expensive, and, for those uninsured who can pay for ER services, financially crippling manner. But uninsured doesn't equal uncovered.

For what it's worth.

THERE IS NO CONSTITUTIONAL BASIS FOR THE FEDERAL GOVERNMENT TO TAKE OVER AN ENTIRE ECONOMIC SECTOR LIKE THIS

HEALTH CARE IS A PRODUCT NOT A RIGHT

The State totally regulates healthcare.
Why shouldn't they pay for it?
If it is a product why can't I go straight to WalMart and buy one of those $4 prescriptions
without paying some quack $90 every time I need something? If I want the quack's opinion or a procedure why can't I pay the same thing the Government or a regulated insurance company pays him?
In cash without his expensive billing/reimbursement overhead to boot.
If a huge industry like home building can get an edge by hiring foreign workers why can't I encourage a skilled underpaid foreign doctor to move here and treat me at a mutually agreeable price?
If I want health insurance why do I have to pay coverage for mental health addiction pregnancy gynecology chiropractic wellness and all the other crap I have no use for?

If we aren't going to have something resembling a free market in healthcare the Govt should pay for it.

Boonton, Jane's question was, 'What would a nationalised health service look like?' which implies that the US is a Dickensian world in which Tiny Tim doesn't get his operation nor, but for Dickens, a lump of coal but, oh, the heaven of the NHS is just at the horizon; I believe that is Karl Marx at the gate. So you don't need to go to the trouble; we have payment tiers, a mixed system, which, last clue, I think we should continue to finagle with. Damien, I guess the charm of my earlier comment didn't hold you. I have no doubt that an NHS could improve reported statistics. Heck, Sadaam isn't really doing anything right now; maybe we could import him to improve our reported infant mortality. His voting statistics were better than Bush.

Why don't you look at the REALITY of socialized medicine in the USA? I did Indian Health Service for ten years.
Doctors salaries won't be lower? Well, my salary working many hours of overtime in the remote woods of Minnesota was $120thousand, but when I changed to a 40 hour week in a less remote area of Oklahoma, it went down to $80. Now, compare that to salaries in private practice.
There won't be rationing? Tell that to my Oklahoma patients who can't get their knees fixed or have to wait for permission to get "routine" medical care on non threatening problems
Would it relieve the physician shortage? Not really. Those of us who are dedicated to work in hard areas would still go there, and docs seeking Green cards would still go to inner cities and become small town specialists, just as they do today. But you might find city born docs will still refuse to work in, say, Durpee South Dakota, Pawhuska Oklahoma or Burley Idaho. After all, they have kids, and want good schools, sophisticated friends, and happy wives who can shop closer than 200 miles to the mall.
As for rationing of "end of life" care, that is already being done by "ethics" committees and "living wills".
Finally, doctors, who take responsibility and are used to making decisions, are less prone to enjoy working for a system where a bureaucrat tells them what's ok and what's not. The result will be that the best people will retire, or not enter medicine in the first place.

Anericans, and eveybody else, love free "stuff." Eventually, we will vote for a Democratic Congress and President - and they will finish the New Deal. FREE heath care for all - all you want, all you need, when you want it - for free. The "evil" rich people will pay for it. Lalala - it's all so wonderful.

Somebody in the comment strain said it best - When the Europeans got "free" health care, their system was so bad that anything seemed like an improvement.

Our demanding "Baby Boomer" seniors (me included) will not feel quite the same - we want our wonderful, perfect, and comprehensive health care now - FOR FREE - AFTER ALL, WE DESEARVE IT.

Ain't Socialism fun. There is a magic money tree out back to pay for everything. The bottom line, all the Democrats who think they will be getting something for nothing, because they are alive on the planet, ARE NOT GOING TO BE HAPPY AT ALL. I can't wait to see the farce. Enjoy Socialism - let's all be messed up equally.

Criminal
Take your auto mechanic vs cardiothoracic surgeon example and it is very easy to see where the money goes and it is not to the doctor.
Say your C5 needs a new motor, you ran a diagnostic test it costs you 100 bucks
You need heartsurgery an angiogram is going to cost you 2500 bucks
You have your motor replaced the labor costs 1000, the parts 3000 the garage costs you nothing.
You have a bypass surgery surgeons fee is going to be 2000 dollars, the equipment for surgery 2000, the hospital stay and charges 40,000.
Its not the physician's salary that is the issue, it's paying 40 grand for the garage and cherry picker that is.

I have been thinking about this for a while and it seems that this is the right place to orate (or what ever). Several months ago I tried to cut off two fingers on my table saw (pure stupidity). The surgery was day surgery did not stay the night, the hospital bill was just under $6000. When the insurance sent me the invoice the insurance had negotiated the price down to less than $600 a reduction of 90%. I went to the hospital admission office and asked if I did not have insurance what would I have been charged. Their reply was $6000, now I remember that as a teenager in the 50's the people who made less money (my mom, a widow who baby sat, cleaned homes and took in laundry to support us was one of these) was charged less by the Dr. than they charged the people she worked for, seems the system is upside down.
Now my radical solution to this, ban insurance, yep do away with it. then make medical savings accounts available to everyone, most of us have these if we work for the right company, this will make personal responsiblity the key to good health care and keep the cost down. If I want to reduce my health care cost I will try to eat right and watch my weight (reduce heart problems and diabetes etc) I can personlley effect my health care cost. I pay $1200 a month for an ins. policy that would have more than paid for the surgery, if I saved half of that and bought a catastophic policy with the other half and if I take care of my self and make good decisions I would have a bunch of money in a few years and reduce the load on the health care system. Gee it seems simple to me, but then I am a simpelton

I'm an academic physician who runs a fellowship program. Allow me to address the AMA issue:

The AMA does not run medical education in this country.

Repeat. They don't.

Medical schools are accredited by a separate organization (the AAMC), and graduate medical education (residencies) are accredited by another separate organization (the ACGME). The AMA has no formal role, and the AMA does not limit either the number and size of medical schools nor the number and size of residency programs.

Who does? Easy: the government.

The government pays for public medical schools (e.g., Enormous State University College of Medicine), and each state decides how many schools and how big. Private schools are limited mostly by tuition and the size of their connected hospitals.

Medicare reimburses residency programs for training under Part 'A'. This is because a) residents provide care to Medicare beneficiaries and b) Medicare wants to encourage the training of docs who take care of benes. That money is given to hospitals who sponsor residencies and divided accordingly, and currently there is a cap on total payments.

So if you want more American-trained doctors, you nudge your state legislators to fund the public medical schools and nudge the Feds to push up Medicare payments.

How about foreign (er, international) docs? The system that lets them in is rather strict, and we end up skimming the cream of a lot of third world nations (India, Pakistan, Malaysia, etc). This is a source of concern on the liberal side, where it is (I think correctly) argued that we're stealing their best and brightest.

But again: the AMA does not govern medical education in the U.S.

Ham Boardman opines: 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.

Sounds great! Except, that amnesty you're describing will be seen as a giant flashing neon AMNESTY sign around the world, and millions of new illegal aliens will come here to take part in the next amnesty.

And, those same far-left groups that currently support illegal immigration and giveaways to illegal aliens will not sit idly by. They'll go to work to give all possible benefits to as many illegal aliens as possible. For instance, the recently rejected CA attempt at universal healthcare was open to illegal aliens. If we had universal healthcare without immigrants/illegal aliens, expect to hear CardinalMahony whining from the pulpit, expect marches, expect the Bishops to weigh in, expect TeddyKennedy to weigh in, and on and on.

And, bear in mind that helpers of the president that Jane Galt endorsed are reaching out to those far-left groups and giving them legitimacy. So, don't expect much opposition to what those groups would advocate.

There is really only one consideration. Do you want to participate in a giant HMO?

I'm an insurance agent that does small business insurance, today I sold health insurance to a Pediatric group. The HMO option (of which they are in the network of Docs) was immediately dismissed. The much-maligned HMO was, after all, was an invention by government for cost shaving.

Personally I spent a lot of time in the military and I think the HMO option is okay, but very few of the business owners' wives that I have met think so.

There are simply three areas to reduce what we spend on healthcare, reduce costs, reduce services or reduce waste. The third is obviously not something government is capable of, and I'm not too confident of the other two. Palms to be greased, votes to be bought, dontcha know?

That means we pay more with less choice. If you have insurance now, don't believe for a minute that taxing all those uninsureds will spread the risk and reduce your costs, because those that are forced to pay for something they have never valued are going to make absolutely certain they get their money's worth.

I'm an MD working in my own office.I quit a prosperous job a few years ago,and am making very little.That's OK.I can always return.
Now,as to why the single payer won't work.
Unlimited demand for medical services.Actually,it's unlimited now.It will be more than unlimited in the future.
Lifestyle issues.In the past 3 weeks,I've had 3 walk in very sick alcoholics in my life.they suck up tons of hospital dollars.I do a better job with diabetics than anyone I know,but most of my adult onset DM-er's are very overweight.
Lab tests>this is what breaks the bank,not meds.But I have patients wanting an MRI for headaches,that want any "Cancer test" they'v heard on TV,and want every sun lesion sent to path.
By the way,there is no AMA plot to keep down med school numbers.Hell,I,ve never been in the AMA.How do they influence state legislature to not appropriate money,anyway?
Oh,and one last thing.Cigarettes.I have a lot of patiens I've started on Chantix-which is a VERY good med for stopping Americans don't necessarily want it to be free;but they do want someone else to pay

Bill, to quote Reagan's advertiser, 'You are now free to move about the country.' When you get to Laredo just walk over to Nuevo Laredo; a pharmacy there can help you. No 'mentalhealthaddiction...crap' necessary.

Hillary care was based on the Canadian system - with one major exception. she took the worst parts of the canadian system and made it a crime to try to circumvent the problems in which the canadian system was experiencing. For example, buried it the details was the ban on obtaining a mamogram prrior to age 50.

Simply put: We cannot grow health care expenditures by 6% a year and our economy by 3% a year. Rationing is coming, whether public or private.

My personal experience with the English health care system is this:

While running a 105 degree fever, I waited for five hours.I was then treated with wholly inapproprate medications because they happened to be cheap. Medication we consider to be commonplace are treated as gold by the NHS.Do not expect the latest treatments. They are more expensive.

Since there was a mental institution attached to the hospital, the insane patients ranged through the emergency room at will. The place was so terrifyingly bad that after one night in the institution, my family pulled strings. I was taken to a special pediatric ward in London where I was given special care, equal to the best in the United States (although still without the latest medicines). There were 24 of these beds in the NHS, and another 24 cancer beds on the floor below. This for a country with 60 million people! Of course, for the connected, the NHS is great. For the ordinary people, they are completely mal-served.

Remember this: Health care costs serious money. And not everyone will be able to afford this. There will come a point in the not too distant future when the richest country in the world, America, can't afford the bill.

Dawg:

The garage costs are factored in as overhead in the price mark-up for the parts (good luck getting a GM branded part from a GM dealer at Mitchell pricing) and into the labor costs for the mechanic. Not having seen a billing statement for angioplasty in a while, I still find your cost estimate for the surgeon's fees to be a bit of low estimate. I routinely see orthopaedic billing for simple arthroscopic meniscal repairs or minimally invasive lumbar spinal surgery that run into the 10s of thousands of dollars for the primary surgeon for a couple hours worth of work. Throw in the assisting surgeon's fees, the anesthesiologist's fees and you are already paying premium dollar for work at even the hands of a non-board certified middle of road skilled surgeon (all of this prior to adding the hospital or even better the surgery center that is owned by the provider fees). I can easily count in the hundreds (living close to Los Angeles) the number of places that I could go to to get the old C5 serviced with similar quality of care but with vastly differing pricing based on labor charges. Unfortunately, I could not say the same for paying the surgeon's fees for fixing a simple bucket handle medial meniscus tear. Also, my life is just as much in the hands of my mechanic when it comes to competent servicing of the good old piece of cr*p that is my GM product as it is in the hands of a wayward surgeon who accidentally lacerates my popliteal artery.

Personally, I have no problems with good healthcare providers becoming fabulously wealthy at their art. Also, I do not wish to see a healthcare system in which the hard work of well trained providers is pissed away for a pittance from a patient population that expects top notch care for minimal price or that expects other people to pick up the cost of their healthcare.

Dr. White - would you care to expound upon the role of the CME (Council on Medical Education) in setting academic standards and restricting the supply of students?

Hillary car was based on the Canadian system -

Well, maybe so, but it bore a very strong resemblance to the socialized insurance that Italy had put in place back in the early 1920's, by Mussolini, with all the regional committees & whatnot.

she took the worst parts of the canadian system and made it a crime to try to circumvent the problems in which the canadian system was experiencing.

Yes, that's one of the things that scared the daylights out of me, and quite a few other people.

For example, buried in the details was the ban on obtaining a mammogram prior to age 50.

I don't recall that one, although considering the sheer size of the document it's hardly a surprise. I do recall the creation of private docs for rich folks, and the criminalization of trying to get something done outside of the system except for certain special situations/groups. I also recall the myriad committees for setting prices and fees, echoing the roaring success of the Nixon wage and price controls of the early 1970's...

Well, we might as well start with what is known.

Oregon has been hashing out these types Q:'s for awhile now:
http://www.google.com/search?hl=en&q=Oregon+Health+Care+Issues

I didn't have time to read all the comments but I hope they are more informed than this:

"Why can't we eat into the doctors' premia by forcing open the AMA's system?"

There is no AMA system. The AMA is a trade association and has no power other than its lobbying which is fairly weak. It competes with a lot of other lobbies like chiropractors, nurses, physical therapists, etc. All of which are more effective.

"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)."

The AMA has no control of entry. In the 1960s (after I graduated in 1966) the US government, which does have power, unlike the AMA, doubled medical school enrollment. What do you think happened ? Costs went UP !

"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."

This is nonsense. The high turndown rates are due to the fact that applicants apply to 25 schools. About 10% get completely turned down and they go to foreign school where they get inferior educations and come right back and practice.

There are good ideas and bad ideas but these ideas are not among the good ones. You might try reading my book and then think about it. The comment above about the French system was quite good. They are probably the best with the Germans next. Canada made major errors in designing theirs and ruined a good medical system. Australia had an almost ideal system and screwed it up about 1987.

Mark 6:00 pm -
Those figures you see about Canadians getting medical care in the United States can be misleading. Tens of thousands of Canadian retirees spend the winter months in Florida and other warm parts of the United States. Not surprisingly, given their ages, quite a few of them find themselves in need of medical care while in Florida etc. and can't always return to Canada for it.
I don't know if any statistics exist for these "snowbirds" but it certainly must account for a non-insignificant percentage of the Canadians getting medical treatment in the United States.

Criminal
Billing and what you get are two entirely different things. A surgeon will get $845 from a well known insurance company which I can't name in Indiana for a torn bucket handle meniscus. No more and often less or not at all. He doesn't recieve a dime for your postop care because its in the global period. The tens of thousands of dollars is not what is recieved and 90% of it is all fluff. A bill for a MIS spine surgery and an arthroscopy are not even close to the same ballpark. Its like looking at the sticker price on a Bentley and a Buick.

The number of physicians trained has stayed the same since 1993 when the number of residency spots were frozen. Unless there is more funding there will be no more residents.

It seems as though people need to educate themselves on the system before they claim to have the magic bullet to fix the system. :P

Speaking of Med School, I do think that reduced rotations and workload for many specialties would be a benefit. For operating room or trauma bound doctors, a hellish stressful education would likely represent the potentials of their job well. For them, you really do need to know everything and know it right now.

But I see little reason why the rest of the student body should have to spend 4 to 8 years slowly destroying themselves to be a general practitioner, or a OB GYN, or any of the many less stressful areas.

If you did not have "hellish stressful education" you would never finish being educating.

For example, since the invention of the eighty hour rule rumor at my school has it that many general surgeon residents are having to opt for further training (fellowship) because they do not feel they are getting the expertise in more demanding surgeries.

PS... the term general practioner is antiquated. Most everyone now is either Internal medicine or family medicine which is three years post medical school education. These doctors have to be prepared for hard lifestyles as they are the ones left to manage many systemic conditions. Just because all you have ever seen your doctor for is a cold doesn't mean that more complex patients don't exist.

medstudent:

I'm a medical student. I am always exhausted. I have no life. I work 14-16 hours a day everday (no weekends off) through my various rotations and studying. When I am not working I constantly worry that I might have screwed up or that I need to be studying. So what is your incentive for me. . . . You should walk a mile in my shoes before you start judging and deciding what I do and don't deserve.

I'm thinking about price elasticity of supply. Deserve, for better or for worse, has nothing to do with it. May I ask you, why med school and not, for example, law school or banking? Was it primarily financial considerations, or other considerations? What about others in your class?

Everyone needs to get their hands on a copy of The President's Health Security Plan. The edition I have was published in 1993. It is the Clinton Blueprint, Hillary designed it and she wants it back.

I've read this book and if anyone wants a bunch of bureaucrats in Washington, with a convoluted plan like this, managing their health care...that person is not sane. Period. Read the book. It's a train wreck.

I lived with nationalized health care. I watched my ex die a painful death from it. They determined that seeing as he had a relativly rare nerve disorder and was 58 years old he would not "add enough back into the system" to warrant them treating it. If they had treated it when diagnosed he would still be alive because if treated early there is a very good survival rate.

BTW-If he would have ever allowed me to put him on my American health care it all treatments would ahve been covered. He never wanted me to put him on it because he always thought he would get better treatment under his nationalized health care then under American style. It was also something he would use to "bash" me with on those occasions when we would get into the EUro vs. America arguments that we occasionally had. Needless to say, he was not happy that my points about nationalized healh care were proven right.

"Access to a waiting list is not access to health care."
Beverly McClachlan, Chief Justice, Supreme Court of Canada, June, 2005

I suspect tackling the issue in small chunks might be the best approach. Understand what drives costs and address the root causes.
Tort reform would go a long way to easing the burden on the courts and lower insurance premiums for medical professionals. Correspondingly, lower costs would dare I say...trickle down to the patient consumer.

You'll get my bill in the mail...:)

I believe it was a mix of factors that go into making the decision of medicine: autonomy, impact on people's lives, money and prestige (in that order). I think priorities begin to shift though when you have 100K of debt (not joking) and worse you have give up your twenties. I never really believed that I would have to literally give up my twenties to become a doctor, but now I am realizing it is true. My point is when you are 100K in debt, tired, and overworked it changes your goals. I could give a crap about prestige. I love the impact I can have on people's lives, but that doesn't mean that you don't get treated horribly by patients and patient's families. I won't be able to begin paying off my debt until I am 33. That is when my training will stop. I guess if you put all these things together you can see why I think that I should be compensated well. If you drop compensation I can guarantee you no one will want to train until they are 33 if they can do another field that is just as interesting and let's them stop earlier.

I am rambling... sorry if that didn't make sense

Not sure I buy that 3/4 of Americans are happy as clams with their healthcare system. Where did you find this statistic? I found several references to an '04 survey which indicated that over 55% of Americans were not satisfied with their current system.

origin.www.healthscout.com/news/68/522404/main.htm

Also, I question your comment that there are 'oodles' of doctors available to most Americans. HMOs can be very restrictive regarding provider selection. They can also restrict access to high-end equipment. Further, in terminal cases, access to specialized care is often difficult to obtain.

Although I am not a proponent of national health care, I don't think we should overlook problems with our current system.

My thoughts?

Socialized medicine fails *because it is socialized*. If it's partly socialized, it will fail to that extent -- like the current US system, which is essentially semi-socialized medicine, outsourced to private industry. You get the failures inherent to socialized enterprises, but delivered to you with the characteristic efficiency of private enterprise.

How many experiments in other countries (like Canada, from which I hail) and within this country (Tenncare) must fail before you bloddy dimwits get it?

The solution to the health care problem is to restore the free market, not blame it for the sins of the current system.

As a Canadian who's lived in the U.S. for 10 years now, I've experienced both systems as a patient, and given my choice, I'd take the Canadian system. I'm willing to stipulate that, if you're wealthy, the U.S. system works fine. But if you're wealthy, you can make anything work for you. The problem with health care has nothing to do with the rich. It has to do with the poor and middle class.

Kevin Fleming writes: "single-payer sys­tems are often characterized by strict drug for­mularies, limited treatment options, and discrimination by age in the provision of care. Price controls [are] a routine feature of such sys­tems...." Even if we grant that all of that is true, I can't see how it's different than the HMO system used by millions (the majority?) of Americans.

I can't believe that in this entire discussion thread, the term HMO has barely been raised. The U.S. system is absolutely plagued by hordes of middle men (not just the HMOs but staffing agencies, HR departments for corporations, etc.) all adding significantly to the cost of health care. Everyone associated with those middle men is making money off of the inefficiencies of the U.S. system, and that's the real reason single-payer health care reform faces a nearly insurmountable struggle in the U.S.

For-profit organizations exist to maximize their profits; the idea of "care" is irrelevant to such organizations except insofar as care brings in dollars. Is that really the best way to look after citizens' health? When we raise that bogeyman of "line-ups" to get care in Canada, what we're really talking about is the egalitarian nature of treatment there. Argue against long lines if you want, but what you're really arguing for is survival of the richest.

Because I am not wealthy or likely to be so in the future, these are the deciding considerations for me:

-- In Canada, the term "pre-existing condition" has absolutely no relevance to anyone's health care experience.

-- In Canada, the fear of personal bankruptcy doesn't have to be added to the fear of coping with a life-threatening illness.

-- In Canada, the trauma of losing your job isn't compounded by that of losing health care for your family.

-- In Canada, a patient can walk into any hospital anywhere at any time and not worry about whether the hospital itself, or the doctors who will offer treatment, are covered by her particular health care plan.

Do people have to wait for elective surgery in Canada? Yes, they do (whether they have to wait longer than the average U.S. citizen, I can't say). Is that a fair exchange for guaranteed coverage? I'd say it is, particularly since it's not like cancer and heart patients are being refused care. Meanwhile, is anybody willing to argue that health care-induced bankruptcies aren't a real problem in the U.S.?

All those who want government health care?

Join the US military!

If you want an exercise in futility try military health care. The ONLY time it works is in emergencies. Routine care is an exercise in (test of) patience. It can take MONTHS to get a referral to a specialists for an ailment that for the civilian side happens the same day.

There is a reason military members laugh about "Motrin". Cut your arm off? Here's some Motrin.... Compound fracture? Motrin....

medstudent:

Thanks for sharing; that was what I was asking. I agree the priorities change the deeper in you get, although for me (law school) it was more like: possibly doing something interesting, then money, with the latter really taking over as debt approaches $200k.

Here's what I know.

I know monopolies are bad, and government monopolies are the worst. At least when Bill Gates takes over the world, I can find Linux, Mac, and countless minor OS alternatives. When Hillary Clinton does, chances are the only alternative I'll have access to is a fluffy pillow.

I know Americans spend billions if not trillions on medical research and therapy, and that politicians are the sort that can't really be trusted with a dime unless they are the absolute only choice.

I know 'risky' or 'low-value' individuals have been killed, routinely, through negligence or abortion, simply to keep the Canadian single-payer system 'alive'. As we speak, a prenatal test for autism is being developed. The same medical condition that gave Edison, Tesla, and Einstein their singular, directed focus, is now considered a train wreck. By the end of the decade, expect ~90% of autistic children to 'disappear'.

I know Crohn's Disease, a painful condition a friend of mine suffers, would be considered far too expensive to meaningfully treat.

I know I'd prefer to keep my friends.

DJR -

"is anybody willing to argue that health care-induced bankruptcies aren't a real problem in the U.S.?"

If the implication is that nationalized health care is the best and only solution to this problem, think harder.

Hey medstudent, I graduated from med school in 1990 with 105K in debt. During my 4 yr residency when my earnings averaged 26K/yr I had to forebear on my loans and they grew to 160K.

I have spent 320K over the last 12 yrs and managed to finally pay them off this past May. Everyone assumes that because I have a good income I'm rich. But my net worth did not reach postive figures until I had been out of residency for 7 yrs. I guess because I bought a house, my first new car ( a toyota corrolla) and had 2 kids I stayed in debt longer. But because I'm "rich" (top 2% of income earners in the last 7 yrs) everyone loves to tax the hell out of me. I got no break from Bush because of the dreaded AMT. I couldn't deduct my student loan interest because I made too much money. I'm 43 now and finally putting some money in my 401K.

Good luck

Nationalized health care will break down in the U.S. for the same reason it breaks down in Canada and Europe, and for the same reason there are problems with Medicare and Medicaid: Funding for those programs is budgeted on a nationwide scale, and in competetion with other essential programs. When there simply isn't enough government income to fund everything, money has to be cut from budgets. This will ultimately translate to fewer dialysis patients or cardiac surguries and to closing entire floors in hospitals that were full before the closings, because you reduce expenditures in health care by reducing treatments. The budgeteers will not be able to see shortened lives, but only bottom lines.

Worse yet, such decisions will not stop the porkbarrel earmarking corruption. Not even under the Democrats.

I agree that doctors' primary role should be diagnosis, though they tend to be horrid at that when it's anything outside of an obvious physiological ailment. Broken bones? Hernias? Doctors get it right most of the time. The one exception was my sister, who's had back problems and gotten five different diagnoses from five different doctors.

But when it comes to pathology doctors are nothing short of horrid. What's worse, if they can't find a problem their first thought is not "well, I must have missed somthing" but rather "well, there must not be a problem." What incredible arrogance. I just want a good diagnosis. At times, I'd even prefer to talk to the nurse and order the tests I want myself. I'll pay for them. The treatments offered by doctors have been consistantly worse than what I can find for myself on the intenet, sometimes requiring a little trial and error.

No doctor is halfway as concerned about my health as I am, nor halfway as aware of my medical history. I'm not saying this is option is great for everyone. I do have a bit of a biotech background from school. But can't I at least have the option of managing my own care, to the extent I feel I can do it?

It is stupid to think you are going to know what to search on google if you have never tried to learn about it previously.

I've done quite a bit better with this method than with following my doctor's advice. It's stupid to think that people are incapable of doing their own research.

"Life expectancy in Canada is higher than in the US,"

As discussed earlier, how does Canada count babies who die shortly after birth? In the US they'd be infant mortalities. In other countries, they'd be stillborne. It makes a huge difference in life expectancy.

Re: medicine overseas

Plus would you rather have someone that is concerned about every move they may because of lawyers or one that never ever has to worry about anything because you can't sue and to follow up you have to ride a plane for 12 hours.

I would much rather visit a doctor with an excellent reputation who can't be sued than an mediochre doctor in the US who is afraid of lawyers. I'm not going to sue anyone anyways. Fear of lawyers produces CYA behavior, not a better standard of care. What we really need are better methods for determining who the good doctors actually are. I'd also like to see liability waivers which encourage full disclosure and small amounts of proactive compensation rather than one or two litigants winning the "I got hurt" lottery. In other words, if you're up front with patients and give small, standardized amounts of compensation early you should be held immune from later prosecution. (There's somthing similar now, where compensation makes a person immune from later settlement. But many doctors are unwilling to admit guilt if they aren't guarenteed that their compensation will be accepted.)

If it is a product why can't I go straight to WalMart and buy one of those $4 prescriptions
without paying some quack $90 every time I need something? If I want the quack's opinion or a procedure why can't I pay the same thing the Government or a regulated insurance company pays him?

Amen! If healthcare is a product, I shouldn't need someone's permission to purchase it.

rwallis:
Now my radical solution to this, ban insurance, yep do away with it. I don't know. I still think it's better to negotiate with someone before you get hurt rather than afterwards. But if the initial charge is $6000 and the negotiated charge is $600 why can't someone just pay an extra $200 on the spot and hire someone to negotiate for him?

corwin
I do a better job with diabetics than anyone I know

Do you mind me asking what you do? I'm not diabetic but I am looking at glucose intolerance. I run daily when I can, I'm very thin (though I've lost a lot of hair), and I'm careful of what I eat. (High protein. Low trans fats. Lots of vegetables. Low on the refined sugars and oils. Daily ascorbate. )

medstudent :
My point is, you're screwed as it is, and there are cheaper alternatives that are just as good. As far as finding medical information on the internet, well, I've never found it difficult. If I didn't see this thinking so much I'd have a hard time believing you see the stuff you're learning in med school as mostly applicable to practice.

Mike K 9:24 PM:
More than 10% get turned down.

Ryan 10:09 PM:
Diagnosis: Right on. This is what med school should teach.

Negotiation, if you don't have insurance you can negotiate with the hospital yourself.

Ya know, given the incredible discounts (up to 90% for some things) of the rack rate that insurers demand from network providers, a no-pay policy that simply gave the subscriber the network rate would be a godsend to most uninsured.

Example from a recent billing: A blood test costs the uninsured $200. The in-network discounted rate is $30. So far the insurance company has spent nothing. If that's all the policy did, that's still a $170 savings to the insured.

Except to the degree that providers would insist on higher negotiated rates to cover the mythical income they get from uninsured people who either don't pay or don't come in, the cost of this kind of policy is pretty close to zero.

Of course, drug coverage would be harder as the insurance companies spend heavily here, some people need a lot of drugs, but even there a discount rate policy (rather than a co-pay policy) would help.

But nothing says this needs to be single-payer, as it can pretty much relies on the current system.

I was asked previously: Dr. White - would you care to expound upon the role of the CME (Council on Medical Education) in setting academic standards and restricting the supply of students?

Obviously we need academic standards for medical schools, and someone has to set them.

The AAMC (not the Council on Medical Education) has guidelines for the number of medical students; these relate to the individual school's capacity to train the students (number of faculty, teaching hospitals, etc). There have been periodic movements to raise, or lower, the numbers of medical students; currently there is a movement to incrase the numbers of students by about 20% or so in the next few years. We'll see if that does any good.

The Council on Medical Education is part of the AMA; it's a lobbying group and has no formal role in all of this.

Criminallopath:

In your post above, you claim that too many well qualified applicants are turned away from medical schools--and give California schools as an example--and later posit that there are medical students graduating that are academically unfit to be physicians. Which is it, now?

California has a large in-state pool of applicants and few private medical schools (as compared to say New York). Their UC medical schools are among the best in the nation and are relatively well-subsidized with low (relatively, again) tuition rates. As such, they naturally attract disproportionately large numbers of highly qualified applicants both from in California and out of state. It is no surprise that a UC medical school has a high application rate. The same is probably true of U. Washington, Harvard. and Johns Hopkins. That ratio is irrelevant.
Most aspiring medical students apply to many institutions to maximize their chances of getting into a desirable institution, especially the better-qualified students. Unless you can show that these applicants who are unsuccessful at UCSF or UCLA also cannot get in anywhere else, then the rate of acceptance vs rejection at the most competitive schools really doesn't tell you much, except that those schools are popular..

Which leaves me to consider your later comment: that there is still room in the classes of American medical schools for legacy applicants who but for their family connection would not have a place. I would not necessarily dispute this, except there is no social promotion and there marginal applicants still have to pass their courses to graduate. Medical schools are loath to fail students once accepted, and generally try to salvage those who get into academic trouble, but they will not graduate someone they think underqualified. So their energies go into selection.

"Health-Care Rationing
by Neal Conan

Talk of the Nation, September 24, 2003 · The demand for health care is nearly limitless, but funds are finite. How do we decide which patients get expensive treatments and which do not? Some argue that rationing is the fairest way. Host Neal Conan and guests examine the economics and ethics of health-care rationing.

"
http://www.npr.org/templates/story/story.php?storyId=1444391

even on NPR!

and many others:
http://www.google.com/search?hl=en&q=Oregon+Health+Care+Rationing

Imagine.

--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).--

Read Hillary's 1993 health care plan, they were going to lower the # of those going to med school, IIRC.

As to the Canadian plan?

Please, you've lost 20% of your neurosurgeons, mostly to America, and your dog has a better chance at getting and MRI more quickly. - oohhh, if I only had my links in this computer!

Run away from Canada.

---

As to shipping out an employee to India for surgery, read about that a few weeks ago, I think the auto industry was going to do it and the union was furious.

Check out Ozland and New Zealand, too, they both have socialized medicine and it's not working there, either.

And Scotland and their dental plan.

You can't have a one-payor system until you figure out how to handle the excess cost growth in the field.The limitations you cite are real enough but are part of the problem. The delivery system has its own problems now,too.
Many cities in the Northeast,particularly, are overbedded,which is an example of the bloated cost structure in health care. Another example is new technology has come on stream,MRI (not new now,of course) is an example;those machines were to be purchased in a rationing system within each market (SMSA, I believe). Instead,virtually every hospital got one and then had to justify it.Soon enough,there were clinics outside the hospital system which do nothing but MRIs.The process hasn't gotten cheaper although the machines have, there are vastly more procedures ordered.
One step that the government could help with are clinics for preventive care,especially prenatal care. There are other things as well,such as different coverages for different procedures but it all comes back to rationing.Waiting lines aren't all bad.

Dhaut: Your previous posts have been riddled with flaws as to how the healthcare system ACTUALLY works in real world and not in fantasy land. You are right that colds, influenza, etc. can be diagnosed by people who are lesser trained (evidence NPs and PAs). Believe it or not though there are people who are actually sick. A lot of them have very complicated cases presenting multiple problems. This is when flow chart medicine doesn't work in the slightest. You must understand the processes behind the flow chart in order to make sense of what is going on and improvise.

Also, I would like to say that the internet spreads just as much misinformation as good information.

Your theory on medicine is good though. When you are older and have more then just a cold try to do a search then. Funny how google, webmd, etc. isn't that good at cross linking diseases and managing their morbidity.

Although, I don't expect you to know what I am talking about at all because once again I have to point out that you never studied medicine beyond observing your primary care doc give you a Zpak when you got sick last winter...

It seems as though you an inherent lack of respect for a profession that you do not practice. I believe you said that you were an engineer earlier? Well, give me google and the engineering software you guys use and I bet I can do your job just as well if not better than you or at least we can start training engineers at technical schools for one year instead of the standard four years. I mean why should they even go to college?

Ridiculous...

Here's the problem with the nationalized model in a nutshell:

The laws of supply and demand. When one considers that as we age we all get more seriously ill more often and that we will all eventually sicken and die, the potential demand for health care is virtually infinite. Eliminate the price of health care (notice I didn't say cost) at the point of sale and the supply will plummet. This is a given. If one genuinely wanted to make health care more available, this is about the worst way imaginable to go about it. Universal systems around the world get worse every year. The only ones that get better do so by becoming less universal.

Unfortunately, there's no one cause for the galloping costs of medical care in the US; there are instead many reasons, many of which are not obvious due to their technical nature. That being said, here's the Liberal Capitalist perscription:

1. Deregulate the insurance industry at the national level.
2. Allow the purchase of most drugs without perscription.
3. Create a rigorous but open national licensure regime and allow Federal license holders to practice in all fifty states. Don't let the AMA near it.
4. Exempt businesses that insure their workers (notice I didn't say "employees") from all Federal taxation.

And if we really wanted to go all the way and could manage to replace our current tax horror with a Fair Tax system, we could force those who aren't otherwise insured to purchase basic endemnity coverage with a portion of their Federal payout.

yours/
peter.

Via DailyPundit from Breitbart.com:

She also said Democrats would focus on improving the quality and affordability of health care - a touchy matter for the former first lady, who in 1993 led her husband's calamitous attempt to overhaul the nation's health care system. The failure of that effort helped Republicans win control of both the Senate and House the following year.

"Health care is coming back," Clinton warned, adding, "It may be a bad dream for some."

What is everyone's hang up with the AMA! It has no regulatory power at all!!! It is a lobby group that doesn't even represent 40 percent of physicians. Why can't people get it through their heads that the AMA is not some big bad wolf that tries to control the amount of physicians!

You can let patients purchase drugs without a prescription and you will end up with a lot of drug resistance and hypersensitivity reactions. We hear about how drugs are prescribed in the wrong doses each year by physicians resulting in X (was it 100,000, i can't remember) number of deaths on the news, yet you want to let anyone prescribe drugs to themselves... ya... sounds like a good idea

peter jackson,

The "Fair Tax" is just a Trojan Horse to get the IRS embedded on Both the Income and Expediture sides of your "budget".

And, to follow-on the insight of the individual, above, who mentioned that the discussed "single-payer" program will be run by the same peoples that did a helluva job in NO:
http://news.yahoo.com/s/ap/20061114/ap_on_re_us/fema_houses

Note that the 'decision-maker', yet again, goes unnamed. Responsibility lies at the core of both scenarios.

Just to comment on some of the medical side of the discussions:

ER care is INCREDIBLY more expensive, as was pointed out. One additional reason is that there is a higher standard of care expected than in an office setting, i.e. if an ER doc sees someone with cold symptoms, treats them, doesn't get lab and they come back very ill...they could be successfully sued because no lab or xray was ordered.

End of life care...most of the time nowadays, doctors are more often forced to keep people alive by families and fear of lawsuits than any desire to get extra money out of performing surgeries or procedures. That's what I have seen, at any rate. Doctors get hemmed into a corner by families who plead and beg to get Grandma well, though Grandma has had severe Alzheimer's for years.

Many families are realistic..and btw, I am not an advocate for any kind of euthanasia, but there is sometimes a total breakdown of common sense at the end of life, and decisions, understandably in many ways, are based on emotion. It's not easy for the doctors to know what to do...nor is it easy for families to let go oftentimes.

In fact, many of the problems mentioned here relate to the lawsuit environment we are in...and sorry, good docs get sued too, not just the bad ones, and for things out of their control. Yep, there is a lot of CYA medicine going on out there, but until or unless that is addressed in any discussions of nationalized health care...well, the Dems can't have it both ways.

The Dems are heavily supported by litigator attorneys; John Edwards, who is going to end up running for Pres. this time is a classic example, a man who manipulated juries with bad science and stole millions. The Dems can't nationalize health care and control costs if CYA medicine is not addressed.

I agree with Jane's initial set of gotchas. Expectations on both the provider and the consumer side of the desk are set by the current model.

Until the wheels fall off the current system and a significant proportion of the electorate finds themselves uninsured (which for many folks means they're uninsurable unless they're part of a large-employer plan) there'll be little pressure for change.

Obvious:

We're not going to abolish health insurance and put healthcare back on a purely market-driven basis.

Opinion:

We're not in my lifetime going to have a system in which providers are government functionaries e.g. UK NHS.

Point for discussion:

Private insurance with regulation of and constraints on insurers' risk-avoidance behavior - a flavor of 'community rating' e.g. Australia, Ireland, etc.

Is insurance truly 'insurance' if the insurers are allowed to weed out of their insured base anything resembling a risk?

I'm not sure where you get your figures from, Jane, but no qualified doctor in the UK would work for $60K per year.

And some of the figures quoted in the comments are a bit off, too. Headline grabbing figures of 250K (I'm switching to pounds now, but don't have the symbol on this US keyboard) have skewed public perceptions somewhat. In fact, the average British GP (family doctor) earns between 90-100K (pounds), the average hospital doctor slightly less.

Those who are entrpreneurial can earn significantly more (this is where the GP earning 250K story came from - he was almost certainly running one or more large practices with considerable business acument).

In Germany, the dirty little secret is that if you are old and enter a hosiptal, (best case) you are "allowed" to die; (worst case) you are "encouraged." In the UK you die simply because there is not enough health care to go around. In Canada, you just go south of the border. In Germany when they instituted a 10 Euro co-pay for visits to doctor's offices (because "free" health care was bankrupting the country), office visits dropped by 30 percent in within three months. So what kind of universal health care do you want?

If you think that medics in the UK get only $60k per year you are sadly mistaken.

The nationalised healthcare system here is in the grip of the medical unions and doctors are very well paid (way above other European rates) in the UK. The average UK general practitioner (family doctor) makes around £100k per year (around $200k) not to mention a state subsidised guaranteed pension.

Recent figures show that medics are paid on average more than any other profession in the UK - much more. Newly qualified nurses make more than graduate engineers, despite the fact that they are paid during training and the course entry requirements are academically far lower. Like everyone in the NHS, they retire at 60 on generous index-linked pensions, taxpayer subsidised.

Randy: I agree with you that the basic issue is a welfare problem, but like Ham I think the system should provide basic coverage to all workers. Large corporations have plenty of advantages as it is, so I think that normalizing the costs and removing the paperwork burden of providing insurance from small businesses and self-employed individuals would be a good way to help them compete. Providing vouchers to everyone also removes any stigma from the welfare aspect of the system. I'm thinking less of the "school lunch" stigma and more of the type that affects my Midwestern relatives, who are too proud to take any sort of assistance from the government. Or it might not, but I think the idea is worth exploring.

Ham: Your follow up brings up the reason that I suggested a "hybrid" system between vouchers and Medicare. In order to cover high risk (and low risk) individuals fairly, you need to have someone do the actuarial work of estimating how much it's going to cost to cover someone. I suppose you could have insurance company doctors do the exams, but it seems to me that it would be better to have them performed by independent or government sanctioned doctors, just to keep the insurance companies honest.

Plus, by not eliminating Medicare completely you reduce one of the stumbling blocks to any sort of privatization, which is resistance from entrenched government workers. Probably not by much, since they know that the likely alternative is a huge increase in funding, but at least it reduces the "I'm going to lose my job" panic.

I guess my other argument for a hybrid-voucher system is that I don't see the status quo as the most likely alternative. As other commenters have suggested, the most likely alternative is a high regulated (even more so than we have now now) socialized medicine system. I don't like the idea of increasing my tax bill, but I like the idea of increasing the regulation and regimentation of our healthcare system even less. And as a small business owner I definitely like the idea of reducing paperwork and uncertainty.

When it comes to being "uninsurable", there objectively is no such thing. ANYTHING can be insured at a certain price. What makes a person "uninsurable" is that he cannot find any company that will write him the coverage he desires at or below the maximum he would pay for it.

That said, I'd like to see a real market for health insurance where companies have to make plays directly to consumers rather than to employers. My reasoning here is that when I was working part-time and had to purchase my own insurance, I had very few options available, none of which made economic sense for a fit man in his 20s. I contrast this with car insurance, where I had, and still have, more options than I can shake a stick at that are priced competitively.

Note that this is the opposite of single-payer health care, where the incentive structure is skewed even farther away from the interests of the health care consumer.

medstudent - Also, I would like to say that the internet spreads just as much misinformation as good information.

Granted, but here you are, all the same. No? The same could be said of "books" if taken in general. Some books have bad information, or inconsistently good information. Even some doctors have unreliable information. Many websites have unreliable or bad information. But certain sites, like pubmed.org, for those willing to wade through the heaps of jargon, generally give a better, more detailed view of a (properly diagnosed) ailment than the advice of most doctors that I've talked to.

And there's insight that you can get from talking to other patients that you don't get from doctors. A fair portion of doctors seem to get their information almost uncritically from the drug companies.

I find it interesting that you assume I'm an engineer, medstudent, and then use that for an ad hominem attack. I guess it comes down to differing views on current diagnostic effectiveness and the relation of that to training. Since you care so much, I'm a mathematician, though I have also worked in labs and done acturial work.

Jane, I thought at first your post was sort of a serious advocacy of universal health but looking at the conditions you posed it seems tongue in cheek. I'll take you seriously though and just say straight out that universal health care, single payer, etc. won't work, can't work and on and on. The major reason is not that all the conditions you outlined couldn't be met it's that with your conditions or any conditions, the system is financially untenable. The dirtly little secret of the rest of the world's fabulous "health care is a right" is that most populations are aging and there are less replacement workers for the retirees meaning there a less workers to pay the freight via taxes. This sets up the same kind of death spiral we have in Social Security only faster-it wouldn't surprise me if France's system isn't already well into it's final stages of solvency, unlike the US many countries do not have the same adherence to public transparency. In other words, they are lying about how deeply they are being financially impaired by their health care. Further, in additional health care, you will typically marry disability and unemployment in the mix further diminshing the financial capacity. And finally, the sexy, emotional and caring nature of the "sound" of universal health care are simply ridiculous. Many educated and wise people still think it would be "free". The fact is that if you pay $300, 400, 700 or 1,000 to Blue Cross or Aetna now for health insurance and you think that it will suddenly stop with the universaly single payer system you're sadly mistaken. The government will just take $300, 400, 700 or 1,000 out of your paycheck every month-and deliver inherently inferior health care. I could add even more but I'm sure it's clear, I think it horrible idea.

There are two simple rules that must be obeyed:
1. People spend "other people's money" like drunken sailors.
2. Service businesses cannot escape from "Fast, cheap, good, pick two."

Single payer systems deny these rules at our peril, both health and pocketbook. Single payer systems fail because there is no price mechanism to portion out care and help patients determine value (see economist Martin Feldstein).

Single payer systems do not see health care as an individual right, they see it as a group right. As an individual right, medical care is too expensive. That is why there are queues and rationing with single payer systems. The idea that health care is a right was begun in the 1930s as a precursor to government control of health care. In essence, by a bunch of people that have always denied the economic aspects of the choices we make.

A better system would be to protect people from catastrophic costs, encourage better consumer behavior with incentives and have prices play a larger role in health care. Markets work, government control doesn't.

I have reason to believe this is already in the works. If doctors in India can read X-rays at a lower cost than US doctors, enabling big HMO's to cut costs, then it's not that big a step to send people in need of some routine surgery over there as well. If not India, then one of the windward islands in the Caribbean can import a score or two of doctors from India and set up shop. Given a much different legal structure, and lower overhead for other reasons, it wouldn't be that tough to cream off many routine procedures, even on a cash basis.

True there is a small industry behind 'medical tourism'. South Africa is one place known for it. I read a while ago that Iran is huge for cosmetic surgery (not only are nose jobs done cheaply there their plastic surgeons are highly skilled since noses are very important in a veiled culture).

But this sort of thing is on the margins IMO. If the assertions of some libertarians are correct then the medical system of the US is basically over priced by a huge margin due to the monopoly effects regulation then there's a huge windfall to be made for any poor country that would position itself as a medical heaven just as developing countries have done well being banking heavens or gambling heavens.

David Anderson
Ever heard of saving for a rainy day? Does everyone who's temporarily out of work have no savings or ability to pay for essentials? Or is that just not fair to have to spend your savings for essentials rather than fun stuff?

What you are proposing though is that people purchase medical insurance when young and hold it for life in order to lock in good rates. Most people will not be able to do that. You can chalk it up to a character flaw if you wish but economics serves human nature, not the other way around.

How is it that we have a competitive market for auto insurance and we buy it individually? Only health insurance has to be purchased by employers? That's silly.

Actually many employers do purchase life insurance for their employees and when they do the rates are often pretty competitive with what one finds when one tries to buy it on their own. Auto insurance is a bit different because its much more unique to the individual person so trying to form a large group to bargain for auto insurance would be a bit trickier. Why do you think insurance purchased by employers is not a competitive market? Don't you think an insurance company that needlessly raises premiums would lose business to one that kept their premiums as low as possible? Just because there's a tax incentive doesn't mean its free. $100 more spent on insurance is still $100 in lost money.

Also health insurance is really two different things combined into one. One part is like auto or home insurance. It is coverage for an unexpected illness such as the teenager who gets a rare cancer. The other part is more like a 401K, you expect to have a certain amount of increasing medical expenses with age and you expect them to exceed your disposable income at some point.

You can think of a 401K as a type of reverse insurance. You're paying into it because you expect to need it when you get too old to work. If you die before then you've lost just like if you buy auto insurance but never have a car accident that's money down the drain (almost, yes the 401K will be part of your estate but you probably would have choosen to put less in it if you could know you weren't going to make it to 65).

Like it or not we have rejected the idea of just letting people take care of themselves for retirement long ago. Just about everyone now will have something in old age because of Social Security. Beyond that, though, people are responsible for themselves. If you put a lot into your 401K you'll have more than just a monthly check at 65.

The logic seems to follow, then, that there should be a basic single payer system with an option for people to use their own money for private care above and beyond.

michael
Boonton, Jane's question was, 'What would a nationalised health service look like?' which implies that the US is a Dickensian world in which Tiny Tim doesn't get his operation nor, but for Dickens, a lump of coal but, oh, the heaven of the NHS is just at the horizon;

Indeed but as Paul Krugman rightly points out the British spend a lot less overall on healthcare than other developed nations. Essentially, for whatever reason political or cultural, they like to be as cheap on healthcare as they do on toothpaste. So yea you're going to have stories about long waits and denied claims. However even in the UK it isn't illegal to pay for your own healthcare. If the NHS doesn't want to pay for your operation you are free to hire a doctor to do it anyway.

The comparison was made between the UK and a person in Texas on Medicare/Medicaid. Essentially you're just comparing one single payer system that doesn't pay much to one that does. Yea you get more with the one that does. So what? Here's a newsflash, in states that spend more on road construction there tends to be more roads than in ones that spend less!

Boinke
There won't be rationing? Tell that to my Oklahoma patients who can't get their knees fixed or have to wait for permission to get "routine" medical care on non threatening problems...

Have we forgotton the infamous tearjerking story of the little child denied a life saving operation by the big mean HMO?

Joe K
Hillary care was based on the Canadian system - with one major exception. she took the worst parts of the canadian system and made it a crime to try to circumvent the problems in which the canadian system was experiencing. For example, buried it the details was the ban on obtaining a mamogram prrior to age 50.

Actually Hillary's plan was dramatically not the Canadian system. Quite a few liberals criticized it from the left for not simply importing single-payer.

Everyone needs to get their hands on a copy of The President's Health Security Plan. The edition I have was published in 1993. It is the Clinton Blueprint, Hillary designed it and she wants it back.

I seriously doubt that even she wants it back.

BTW-If he would have ever allowed me to put him on my American health care it all treatments would ahve been covered. He never wanted me to put him on it because he always thought he would get better treatment under his nationalized health care then under American style. It was also something he would use to "bash" me with on those occasions when we would get into the EUro vs. America arguments that we occasionally had. Needless to say, he was not happy that my points about nationalized healh care were proven right.

Why didn't you simply pay for the treatment out of pocket?

why should health policies from the feds cover non-American immigrants?

Our big car makers and our pres complain that health care costs make for lousy auto sales in America. But health care, covered by govt in other countries do not need autho companies to cover costs--and thus we have lost our auto industry!

Mark E Hoffer
The Fair Tax bill includes abolishing the income tax and proposes and repealing the 16th amendment.

TennCare was an attempt at HillaryCare. Google it. And don’t tell me that it’s failure was because they weren’t able to force everyone into it. It does demonstrate supply/demand economic principles however

"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."

Some 30 to 50 years after the US has implemented universal healthcare, in some country that retained a market based healthcare system, a Dr. McCoy, after using a tricorder or other medical protocol we cannot now envision, will be reminded that those poor smucks in the US don't know what they're missing.

I'm an experimenting sort of person. So when I hear shouts of acclamation about how wonderful "single-payer" healthcare systems are, or would be in the United States, if only we were wise enough to act like Canada, &c. &c. &c., I look around to see if it's actually been . . . you know . . . tried. And if it has, what have been the results?
You see, for the better part of the last half-century we in the United States have in fact had an extremely large (multi-million patient, where the patients represent a wide swathe of the American population) "single-payer" system. It's been modified in recent years, but for most of 40-plus years its salient features were as follows: (i) unlimited access to full-spectrum care for those eligible, which included employees, spouses of employees, and minor children of employees, (ii) pert-near universal geographic portability, in that those eligible could be sure of coverage no matter where their employer chose to employ them, (iii) zero deductible, zero co-pay, (iv) full prescription coverage, again in unlimited amounts, and (v) full coverage continuing for life for the employee and spouse upon retirement after 20 years. Pretty impressive, huh? And to top it off, those eligible to participate had that wonderful free-market benny: choice, and specifically, the choice to opt out and participate in that nasty ol' pony-up-your-own-money-like-you-mean-it U.S. healthcare system. And it's that ability to choose that makes this such a valuable experiment.
You see, with all those benefits to participation, you'd have to be God's original knuckle-head to opt out . . . if you have the choice to opt out, and to opt out into a system that will cost you measurably more, and IF THE PRODUCT, VIZ. HEALTHCARE, IS IN FACT THE SAME AS BETWEEN SYSTEMS. So if you have significant numbers of people opting out, maybe, just maybe, it's an indication that . . . well . . . maybe the product ain't in fact the same.
The system to which I refer of course is the military healthcare system. It provided all of those benefits. And yet during my tenure in it, and during my father's tenure in it, and during my close friends' tenure in it, no one I knew personally or heard of, officer or enlisted, who could possibly go outside the system failed to do so. A great deal of the time they couldn't because they couldn't pay (yep: couldn't; a master chief petty officer who worked for me and had 27 years in was eligible for food stamps). But the vote-with-the-feet "exit poll" (no pun) was something even Saddam would've been proud of.
But, the gentle reader will quip, this was just the manifestation of that ol' "military culture," and a prospective civilian "single-payer" system not so beholden to "the brass" would be so kind, gentle, and high-quality that my little experiment can be discarded as an outlier. Not so, Grasshopper.
You see, I also have some fairly close (not, thank God, so close as to have been first-hand) experience with a civilian "single payer" system, and one that specifically involved the upper end of that sort of system. More particularly, the quality of healthcare dispensed at a well-regarded university teaching hospital for a problem (nasty kidney infection) that was serious enough to be serious, but not serious enough to be life-threatening, unless left completely untreated (cf. Tsar Alexander III). To shortcut: all the aspects of what I later witnessed in the military healthcare system that have lead countless servicemen outside that free, unlimited, "single-payer" system were exhibited in full during this brush with the modern (c. 1986) German healthcare system.
So much for the experience. Let's take a look at the merely anecdotal. For the past ten or so years I've subscribed to The Economist. Helluva paper. And for the better part of the past ten years the Great Britain section of the paper's been thrashing through what in the world to do with the Gawd-awful NHS, and how to improve the lamentably low standards of care provided inside the system, and how to get more and better care to those who can't afford to go outside the system. And Canada? I just vividy recall some years ago reading one of those treacly how-wonderful-is-Toronto articles in some magazine (forget whether it was Nat'l Geo., or Smithsonian, or whatever). Mind you, this was an Agitprop cheerleading piece the tenor of which was something along the lines of how-unfortunate-are-all-you-roobs-living-in-U.S.-flyover-country-not-to-live-in-beautiful-clean-fun-cheap-well-planned-Toronto. Not the kind of place that you'd expect to see someone putting the idiot stepsister dead center in the family Fourth of July picture, in other words. And yet there it was. A segment on an ambulance, driving around Toronto . . . and driving, and driving . . . with an automobile accident victim in the back, looking for a hospital with an E.R. that could take the case and a bed out in a hallway they could put the patient in when treated. That, folks, is what "single-payer" means.
All this is not said in defense of the American healthcare industry, the avarice of which can be monumental. The expression "Medicare millionaire" did not arise by spontaneous generation. Nor is it said in defense of the insurance industry, which is its own worst enemy in terms of its over-reaching. It certainly is not said in defense of the plaintiff's bar, which as an industry segment probably deserves 90% of the muck hurled at it. But please, please people, do not imagine that inviting the either the federal or the state governments into the examination room is going to make better anything about the healthcare delivery systems in this country that is the least important to the person about whom this discussion supposedly is: the patient. If you take the King's shilling, you will wear his uniform and you will march in his ranks to the tune and cadence he chooses, upon pain of coercive punishment.

Overlooked by most is the fact that America has 3 National Health Care models in use today - Medicare for the elderly and disabled, TRICARE for the military and dependents, and VA Health benefits for low income or disabled veterans. Pick your poison - insurance-style plans paid for with taxes and/or enrollment fees or a national network of medical facilities with rationed care, long lines, and spotty quality of care. No matter how you cut it, the more the government involves itself in the health care system the more the patient gives up in exchange for a "simple" and "inexpensive" system that turns out to be neither.

I think we would have to figure out a way to deal with advertising of drugs. many countries with socialized medicine ban direct-to-consumer advertising of drugs. this makes it easier for the government to not provide a certain drug.

in the US, drug companies could just advertise to the people, thus putting pressure on the government to provide the drug (or to pay a higher price for the drug, since the advertising would strengthen the company's position in negotiations with the government).

i also think we would have to deal with lawsuits, since Americans will still demand the right to sue when they believe something has gone wrong.

Tort reform anyone? Reduce the "shrillions" of dollars paid out in malpractice claims => reduced insurance premiums => reduced costs.

Nurses don't get paid enough IMO. They live in a dog-eat-dog environment (there's a saying in the field - "nurses eat their own"), they have to make life-or-death dosage calculations based on doctors' handwriting, plus deal with bodily excretions that are not only beyond disgusting but also dangerous (ask any nurse you know about cleaning up a patient with C. Diff.).

RRRoark,

That you posit(parrot):
"The Fair Tax bill includes abolishing the income tax and proposes...repealing the 16th amendment."

Only adds to the idea that the "Fair Tax" is simply a Trojan Horse.

see: http://www.fairtaxcalculator.org/

Please, Ignorance is one thing, Duplicity, is quite another.

In your post above, you claim that too many well qualified applicants are turned away from medical schools--and give California schools as an example--and later posit that there are medical students graduating that are academically unfit to be physicians. Which is it, now?

Okulus, you might be confusing my commentary regarding turning away of qualified students vs. needing a C average (pass) in order to graduate from medical school or the lack of a stringent continuting medical education requirement. On the other hand you might be commenting on the use of special set-asides for certain "favored" groups for admissions. I am unsure in that I did not use the verbiage (paraphrased of course) that you are attributing to me.

Most aspiring medical students apply to many institutions to maximize their chances of getting into a desirable institution, especially the better-qualified students. Unless you can show that these applicants who are unsuccessful at UCSF or UCLA also cannot get in anywhere else, then the rate of acceptance vs rejection at the most competitive schools really doesn't tell you much, except that those schools are popular..

Agreed. My comment was only in reference to a quote from the head of the school of medicine (it's been a while and I can can't recall exactly) at UCSD in terms of who they reject. Obviously, rejection at one school does not equal rejection at all schools. On the other hand, the differences between the students accepted and rejected would appear to be marginal at best if 3 "qualifed" students are being rejected at any given institution for every one that is accepted.

Which leaves me to consider your later comment: that there is still room in the classes of American medical schools for legacy applicants who but for their family connection would not have a place. I would not necessarily dispute this, except there is no social promotion and there marginal applicants still have to pass their courses to graduate. Medical schools are loath to fail students once accepted, and generally try to salvage those who get into academic trouble, but they will not graduate someone they think underqualified. So their energies go into selection.

Understood. But it is not just legacy candidates. We are all well aware of the "social engineering" occuring in this country in which academically marginal candidates are allowed entry simply as a matter of social policy while highly accomplished candidates are not. It almost seems criminal for this system to exist given that there are so few slots to go around for medical school admissions.

More than tort reform, in the classical sense, is reform needed for the admissibility of "expert" clinical testimony. Raising the bar to meet the same standards as scientific testimony would not only get rid of the John Edwards type litigation but would also remove the much larger problem of junk science PI cases.

The simplist solution for the US is to allow each State negotiate rates with any Insurance companies that want to sell. If Insurance companies can afford to give a good discount to unions / companies with 300k people why not use that mechanism to force similar discounts for 1 million plus people?

Reducing the costs of ER is most simply achieved by adding walkin patient services. Sort the patients at the door, series problems go to the ER, normal care problems go to walkin services.

You can put out all of the students you want to. It doesn't matter if there are no residency spots. The funding for residency positions was frozen 13 years ago. You will only get more physicians when you also approve much more funding for residency positions.

This may have been already mentioned in the shrillion previous comments, but:

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.

NHS doctors in Britain would be extremely unhappy to make that little money. The bog-standard doctor in the UK is on an average of $190k.

http://news.bbc.co.uk/1/hi/health/4373519.stm

That was sixty thousand *pounds* a year; y'all are reading in a dollar sign where there isn't one.

COuple things:

1) As I said above, you can't convert the salaries at market exchange rate, unless your average British GP lives in the US.

2) The standard expat calculation is 1-for-1

3) The PPP converter is generally roughly 1.5

So average British doctors make, in terms of living standards, somewhere between south of $100,000, up to something less than $150K. That latter figure being what a first year associate at a top law firm earns.

Just to back up medstudent and storkdoc (not that they need it)...

Medical education is not the purview of the AMA. As previously stated, GME is handled by the ACGME and AAMC (and paid for by Medicare Part A), and the construction of medical schools is dealt with largely by state legislatures. More private medical schools could be built, but that would require faculty willing to teach. There's a shortage of academic physicians as it is, building more medical schools will not automatically populate those structures with physicians ready to teach.

With regard to bnauth's assertions about medical training, yes, there are people who can deal with things using a flowchart/algorithm system. It's likely you could go your whole life with one of those people. It's easy to practice medicine when everything is clear-cut and obvious, and when you have virtually unlimited access to medical imaging and laboratory services (all of which cost, BTW). When things go badly is when you need a physician.

I'm a radiologist. I serve the needs of the entire spectrum of patients, of all ages and with virtually all diseases from psych to cancer to URIs. Only by having at least some background in nearly all of those areas am I able to provide a useful report to the referring physicians. While there are probably some improvements to be made in medical education, limiting the scope of medical education to a specific specialty at the beginning of medical education is by no means an improvement. I didn't know until halfway through my clinical rotations what I needed to be doing, had I chosen what I was interested in on Day One of medical school, I would have been sorely disappointed to find myself doing something I despised nine years later. While you are blissfully untainted by formal medical education and no doubt a clever and perceptive person, it doesn't give you much in the way of credibility in criticizing how physicians are created.

I was always told that medical school was the equivalent of 24+ semester hours of other education. Medical school is not an intelligence test, it's an endurance test. It's like drinking from a firehose.

I loved HillaryCare, it scared a sizable portion of my competition away from radiology before ultimately collapsing. The "50/50" distribution of specialist/primary care physicians is nothing more than a politically-salable number.

I don't have a problem with increasing the number of medical school graduates, in part because the gender mix of medical school has introduced far more women into medical education than in generations past. Women become superb physicians, equal to or superior to men in every facet of practice with one exception: length of career. According to the US Department of Health and Human Services:

http://bhpr.hrsa.gov/healthworkforce/reports/criticalcare/cc2.htm

"During the past three decades, the proportion of graduates from U.S. medical schools who are female has risen from 10 percent to about 50 percent. Because work and retirement patterns differ systematically by gender, the increasing proportion of physicians who are female has profound implications for the overall supply of physician services. Female physicians tend to work approximately 15 percent less time in patient care then do their male counterparts after controlling for age and specialty. Female physicians are more likely than their male counterparts to choose non-surgical specialties, spend fewer hours providing patient care, are less likely to work in rural areas, and tend to retire earlier. The COMPACCS data indicate that female physicians practicing as intensivists or pulmonologists worked an average of 300 hours less per year than their male counterparts."

We need more medical schools simply to stay in place with regard to physician supply if this data holds true. Furthermore, many younger male physicians are choosing work fewer hours as well, meaning that one FY2000 graduating physician (of either gender) may not be one FTE compared to a FY1970 graduate.

American Companies do price discriminate by selling for cheaper in Canada. But, if they weren't allowed to, that doesn't mean drug prices would necesasrily be cheaper, it could mean they would sell to Canda at the same rate as they do here. Its like movie theaters selling student tickets, (which alot don't do anymore). The idea is that once you have sunk the costs and have the product ready to go, you make your money by selling at the higher price, the price that makes the product worth providing. The discount prices are to squeeze a little more profit by selling to people who can't afford the higher price. This discount price is above the marginal cost of additional production, but not high enough that it would allow a profit given the average total costs of production. If there was no price discrimination allowed, the higher price might not come down at all, and the lower price could disappear completely. (Of course, this assumes that the drug companies are not engaged in exploiting monopoly power, are not involved in collusive activities, etc.)

"You can let patients purchase drugs without a prescription and you will end up with a lot of drug resistance and hypersensitivity reactions. We hear about how drugs are prescribed in the wrong doses each year by physicians resulting in X (was it 100,000, i can't remember) number of deaths on the news, yet you want to let anyone prescribe drugs to themselves"

People who don't have a clue will go to the doctor as always and get his advice, and they'll do at least as well as they do now. The only difference would be that there wouldn't be an expensive and cumbersome system in place to watch over us and make sure we took his advice, so overall costs would be lower.

People that have already been to the doctor and been advised shouldn't have to go back to the doctor for permission to keep getting the medicine he already told them to keep taking long-term.

People that don't have a clue and are too dumb to go to the doctor will not outbreed the rest of us by quite as big a margin, but the impact will be small. It's not like stupid people have any shortage of ways to kill themselves under the system we have now, anyway.

No-prescription medicine is looking like a much better system than the one we have now.

"What you are proposing though is that people purchase medical insurance when young and hold it for life in order to lock in good rates."

Not necessarily. They can pay smaller rates when the cost of taking care of them is smaller, which leaves them with more money in their pocket, some of which can be saved for later when their costs go up. Combine that with the fact that people tend to make more money as they get older, and it turns out that charging people less in their youth and more as they get older is actually better overall than trying to hold this cost constant and burdening young people just starting out with higher costs.

"Like it or not we have rejected the idea of just letting people take care of themselves for retirement long ago."

Who's "we"? What "we" did was give FDR a lot of latitude to try and keep people from starving, and he slipped in Social Security, the FCC, prescription requirements, and a whole lot of other crap that didn't have jack to do with the Depression while he had the chance when a majority of the people weren't in the mood to argue with him over anything.

If such a system had been proposed anytime after WWII, it would probably have been rejected.

'Tort reform anyone? Reduce the "shrillions" of dollars paid out in malpractice claims => reduced insurance premiums => reduced costs.'

Medical malpractice settlements, legal fees and administration fees are 0.46% of medical industry GDP. Eliminating them would not have a noticeable effect on medical costs in aggregate. These costs are only an issue in specific specialties in specific states. They are local problems that have no noticeable impact on medical costs as a whole.

Of greater impact would be defensive medicine. Just how much is spent merely to avoid lawsuits is not clear. Still, even if 10 times as much is spent on defensive medicine as malprictice, you're only at around 5% of industry GDP total. That isn't a big part of the problem.

(link for data quoted http://www.rwjf.org/publications/synthesis/reports_and_briefs/pdf/no8_primer.pdf )

countrylawyer

You see, for the better part of the last half-century we in the United States have in fact had an extremely large (multi-million patient, where the patients represent a wide swathe of the American population) "single-payer" system. It's been modified in recent years, but for most...

Few things you missed:

1. The military might better be described as 'single payer / single provider'. You don't just walk into any doctor, tell him you're in the military and then he sends the bill to the Pentagon.

2. You should look more at Medicare for an example of a US single payer based system. You go to just about any doctor you want (provided they accept Medicare...most do but there are 'superstar' docs that don't). Medicaid as well would be a single payer example.

3. As I pointed out the UK's 'problem' is mostly the result of a decision to simply not spend much on healthcare. Whatever system you have the fact is unavoidable that more stuff will cost more money.

Jane Galt
So average British doctors make, in terms of living standards, somewhere between south of $100,000, up to something less than $150K. That latter figure being what a first year associate at a top law firm earns.

Hmmmm, then again wouldn't you be inclined to think that the US market overprices lawyers? Perhaps if we had less use of lawyers some smart students would find it more sensible to go to the UK to become doctors rather than lawyers in the US.

Bill, the question about price discrimination comes down to this: why don't drug companies charge BOTH Canada and the U.S. a price that recovers their average total production cost. A fixed startup cost over a larger consumer base results in a lower price. You are assuming that for some reason they can't charge Canada the average total production cost and only the marginal cost, so that the fixed development costs must be covered by U.S. consumers only. I don't think this makes sense. It is not as if Canadian consumers get less utiltity out of the drugs, or somehow have less ability to pay. We're not talking about a third world here.

Second, if it would only result in higher prices in Canada, why are drug companies opposed to reimportation?

Finally, it is certainly hard to say the exact effect that breaking down the trade restrictions between U.S. and other countries would have on drug prices. But there are only two possible effects: either things stay the same because the prices already reflect the equilibrium price level in each country, or the prices change to reach a more optimum equilibrium. (by the way, that could never involve only the prices of Canadian drugs going up without a reduction in U.S. prices, because the only way Canadian prices go up is if Americans are reimporting drugs from Canada).

In principle, since when should we be opposed to free trade? I find it hard to stomach that many of the same people who favor free trade on any other issue are opposed to it on this one. That tells me that the drug companies are shelling out a lot of political contributions to get free-trade advocates to ignore its application to the healthcare industry. It can only help or have no effect...it can't hurt.

Some great comments here, sorry for the earlier drive by CAPS comment. I was just angry 'bout it, the Wickard decision ain't right. Its law, so all I can do is the futile CAPS argument...it just seems so obvious that the founders didn't intend the ICC to be the gaping hole it is.

Health care at its core needs to be the responsibility of families to get. If you get a statist gov't program to replace the role of the family here you will get what we see in Europe.

Well, shadowdoc, let's cut straight to what is apparently the heart of the issue. How do you know that you've done a good job? How do you know that the mistakes you've made are outweighed by clever things you've figured out? How do you know that fewer longer-trained doctors save more people than more less-trained ones and fewer long-trained ones when many people can't get *enough* medical care?

So average British doctors make, in terms of living standards, somewhere between south of $100,000, up to something less than $150K. That latter figure being what a first year associate at a top law firm earns.

But Jane, your 60k figure, while ambiguously expressed, was far too low regardless of currency, and I think this is an American blog, so I translated the £100k average figure using Google, into a dollar value of $189,000.
I think that $189k average is just for the humble GP, who is the type of non-specialised doctor who treats the more common ailments and refers the complex stuff to hospital docs.

So the point is that UK doctors probably wouldnt, as you assert, be that delighted to earn what is just over half the average salary for UK GPs.
I think the point stands, even when up against the retroactive tapdancing to do with the cost of living. :-)

The business model for drug companies is all wrong. They argue the need for patent protection to recover R&D, and look for legal loopholes to extend that protection, delaying the availability of generics which finally come on the market at a fraction of the brand cost. Yet looking at their financial statements, their marketing and administration costs run 33% of sales, and R&D is typically half that.

The drug companies should do research, if that is what they are good at, and the generic companies should make pills, if that is what they are good at. Research funding should be won through competitive bids submitted annually to a government agency, with an award fee made when a drug gets approval to go to market. In this way, the drug companies choose the research initiatives, they are compensated for their work at cost plus a nominal fee, and get paid handsomely if/when the research pays off in product. Risk/reward issues met. The public owns the patent, and contracts with a generic producer to make the pills at a cost the public can afford. Much better than the complex "doughnut hole" Schedule D protocols offered now, which don't help that much and threaten to break Medicare.

Bill, the question about price discrimination comes down to this: why don't drug companies charge BOTH Canada and the U.S. a price that recovers their average total production cost.

Second, if it would only result in higher prices in Canada, why are drug companies opposed to reimportation?

In principle, since when should we be opposed to free trade?

We trade with lots of countries in which the federal government is setting prices. That is to our benefit, not our loss. If Canadians are able to free ride on our R&D, we should be able to free ride on their government-run healthcare system's negotiating power and price-capping.

"Well, shadowdoc, let's cut straight to what is apparently the heart of the issue. How do you know that you've done a good job? How do you know that the mistakes you've made are outweighed by clever things you've figured out? How do you know that fewer longer-trained doctors save more people than more less-trained ones and fewer long-trained ones when many people can't get *enough* medical care?"

I guess by the respective piles of corpses on one side or the other. If you want definintive proof there's nothing like morbidity and mortality. I don't personally know the numbers for M&M of people treated by nurse pracs and poorly-supervised PAs, which would be the control group to test your theory. Controlling for degree of illness would be important, though.

I don't believe, as Jane has said, that we'll convince the American public to participate in the experiment. "USA-NHS" will have to provide more, not less, care to be politically salable. And considering that we already spend more per capita on health care than any other nation in the world, we'll have USA-NHS if the Chinese will pay for it by purchasing even more of our debt. Otherwise it's a no-go.

I wonder whether the disparity of costs experienced in the US (where a small share of people are responsible for disproportionate costs) is reflected elsewhere. I don't have the figures in front of me but I think it's like 1% of the US population... 3 million people, are responsible for somewhere between 1/5th and 1/3rd of our medical costs. I'm not sure whether "socialized medicine" does or doesn't experience similar breakdowns, but via rationing those costs can be controlled. I'm also not too sure what's the difference between denying care to the sickest 1% of Americans because they lack health insurance or because the single payor refuses to pay for it.

-- If Canadians are able to free ride on our R&D, we should be able to free ride on their government-run healthcare system's negotiating power and price-capping.--

Dont' forget our military.

I swear I read that if we made other countries start paying their "fair share" for our drugs, they'd go make them generic, that's 1 reason we pay higher prices.

Via Lucianne:

A man fixed his front tooth with superglue after failing to find an NHS dentist.

Gordon Cook, 55, has used the bizarre "DIY dentistry" technique on a loose crown for the last three years - with each fresh application of glue lasting around two months....

James said, "The simplist solution for the US is to allow each State negotiate rates with any Insurance companies that want to sell. If Insurance companies can afford to give a good discount to unions / companies with 300k people why not use that mechanism to force similar discounts for 1 million plus people?"

The only way they are able to give these "discounts" to large unions and companies is by raising premiums on smaller companies individuals. The insurance companies have to have enough premium coming in the door to cover operating losses and claims, plus maintaining reserves.

The basic principle in operation is that the better underwriters can price risks and balance risks on the books, the more coverage they can offer per dollar of premium. Large group rates make this difficult by limiting the amount of information coming in about each person in the group. This is part of the reason that health insurance costs are rising faster than inflation, since as each of us uses more health care we have a greater impact on the company books.

So, while you're right that, in our current situation with the tax code making employer-paid health care favorable for companies, insurance companies provide a discount to large groups, I would say that people are paying significantly more than they would have to if insurance companies sold directly to individuals, which would enable them to price insurance more accurately and to avoid the effects of adverse selection of risks on their books.

Back to the point of having states buy group rates for everyone, or a good chunk of everyone, you run into the problem of not having anyone left to subsidize those discounts. What happens? Rates go up for everyone.

What needs to happen here is that the one choosing and paying for health insurance has to be the insured himself, not companies or unions or government. Only then will the needs of both insurance companies and insureds be in line. (Also, only then will insurance companies actually be accountable to insureds.)

I lost the central vision in my right eye at the age of 41 due to the British National Health "Service." Was on vacation, had some blurring, went to the emergency room, had an examination and was told nothing was wrong.

Waited too long to get back to the US, and REAL doctors, and discovered that I had bleeding under the retina, with macular scarring.

With an fluorescene dye angiogram, which certainly would have been ordered in the US, the problem could have been found and probably corrected with laser photodynamic therapy.

Of course, they don't offer THAT in the UK either.

No way in hell I will ever support some sort of nationalized health "care."

Bill didn’t say that reimportation would result in higher prices in Canada. What he said was that because drug companies are able to discriminate by selling at the lower government mandates prices in Canada and actually do realize some profit above their marginal costs, this does result in slightly lower prices in the United States than if they didn’t sell in Canada at all.

Look back to your economic model of a monopoly. A monopolist who is able to exercise price discrimination (which is what Canada without reimportation is) does indeed earn more profit. However that does not result in lower prices for anyone. A monopolist prices his product to what the market can bear. A few extra dollars of Canadian profit wouldn't be plowed into lower US prices but into higher returns for the monopolist.

Because it isn’t free trade when the government is setting the prices as it is doing in Canada.

Or is it that a massive purchaser is using their buying power to win concessions from a supplier. Is Wal-Mart controlling prices when they force their suppliers to sell to them for less? I find it ironic that critics stake out this position. By supporting the ban on reimportation you are actually making it easier for Canada to use their single payer position to win lower prices. Without a ban Canda wouldn't be able to have price control over drug prices. It is also ironic that liberals who are friendly towards single-payer regimes would undermine them by supporting reimportation.

Quincy
The only way they are able to give these "discounts" to large unions and companies is by raising premiums on smaller companies individuals. The insurance companies have to have enough premium coming in the door to cover operating losses and claims, plus maintaining reserves.

Say I have an insurance company that writes policies to individuals and small companies. The application has a lot of questions on it so I'm able to get a lot of information and set premiums to vary per the risk of each individual or small group.

Say Honda opens up a plant in the neighborhood and approaches me to write a policy for 10,000 of their employees. Their condition is that the per-employee premium be a flat fee with no variation for individual risk profiles. Either I will set my premium higher enough to cover the medical expenses of those 10,000 new Honda employees or not. If I do then there is no need for me to raise premiums for my original base of individuals & small businesses. If I don't then I should decline Honda's offer. Why would I add customers at a loss?

If it was illegal for a large group like Honda to try to purchase insurance in bulk then yes indeed I would write 10,000 individual policies with premiums tailored to reap as much profit as possible. By purchasing in bulk Honda is costing me that profit but giving me a huge volumne. This is no different than any other economic transaction where bulk purchasing is a factor.

> The drug companies should do research, if that is what they are good at, and the generic companies should make pills, if that is what they are good at.

There's no reason to believe that the generic companies are more efficient producers. They sell for less because they do less - they don't do research and they don't do (as much) marketing. Marketing is (part of) what makes a market big enough for them to be interested.

Remember, marketing actually reduces the per-consumer costs. (It's also what tells the MDs which new drugs are worth prescribing.)

Navigator,

Nothing really prevents the realization of your idea right now. All that is really needed is for the government to offer to buy patent rights to newly approved drugs. Now I wonder why the government doesn't just do this? Would you care to take a guess?

Skipped to the bottom to point out that nurses salaries are not what drives up the cost of health care, but what makes health care possible. Nurses are educated, middle class Americans who, if they work lots of overtime or have senior possitions, can make 60K. Sounds like a governmet worker to me.

And for that matter, I recently was given a quote for a ( less than 2 hour) cash pay surgery. The surgeon's fee was $10,000, the anesthseiologist's fee was $900-- both M.D.s. My point is that cash pay physicians are making much more money than insurance pay physicians (a 2 hour $10,000 surgery, in their dreams) and that there is a wide disparity between specialties and pay. The truth is that most doctors made less than 200K. Not a bad living, but hardly a king's ransom considering their education, liability and lack of pension and benfits.

And, for what it is worth, the AMA is not run by doctors, but by people with political agendas that are not remotely concerned about the wealth and welfare of doctors. I do not think that doctors have a cohesive lobby that would be concerned about their collective fortunes.

Great discussion going on here, very interesting.
Does anyone here have any experience with Swiss health care?
The Swiss don't have nationalized health care but they have never linked it to employment either. It is like auto insurance in most states. Residents are required to purchase health insurance; the government provides a voucher or subsidy to lower income Swiss who couldn't afford to pay the premiums.
Someone mentioned Australia had a great healthcare system until circa 1987.....could someone please explain that?
As an aside since nurses were being discussed earlier I'd like to mention nurse training. My mother is a nurse. She's 55 and in her younger days nursing school was a 3 year program. Beginning in the 2nd year, if not the 1st, student nurses had classes in the morning and in the afternoon they worked the floor, under the supervision of more experienced nurses. This 3 year on the job program has largely been replaced by 4 year university programs or 4 year nursing schools where the nurse receives a Bachelor of Science in Nursing upon completion. My mom is not happy with this. Although the length of schooling has been extended, the time in the classroom has increased and the time a student nurse spends on the floor has decreased. My mother has been hospitalized twice recently due to lymphoma and pneumonia and she feels the 4 year nurses are "book smart but street stupid". Performing a basic task is often done incorrectly or half-a**ed. The less said about the 2 year nurses the junior colleges turn out the better..... Two years is simply too little training.
I think American nursing should return to the 3 year on the job training program instead of the 4 year university style program. Nurses may not have a degree to boast of then but they would have more practical knowledge of nursing.

Boonton said, "This is no different than any other economic transaction where bulk purchasing is a factor.

I'm arguing that it *is* different due to the need of insurers to balance risk. If you're buying computers for 10,000 people, it doesn't matter whether 5% or 65% are diabetic. In health insurance, it can mean a difference in millions of dollars in losses.

Right now, the primary incentive for employers to buy group health insurance is the tax code. Without this incentive, employers would not be nearly as inclined to offer health coverage to employees. I'm arguing that this has to happen to fix the health insurance market.

The problem is that Jane Galt’s first premise is significantly flawed. Even if it were true that 75% of Americans are “happy as clams” about their health care, The Journal of the American Medical Association reported on a study last year demonstrating that Americans (the “beneficiaries” of a “for profit” health care system) are significantly less healthy than the English (those who rely on nationalized health care)--despite the fact that America spends more than twice as much per capita for health care.

No health care system on this planet is perfect, and the British system surely has its share of problems. But can we seriously entertain the idea that Americans have “much more lavish coverage than that available elsewhere” with results like this? The proof is in the pudding. The objection of free-market advocates have been refuted. For all its problems, I’ll take the system which guarantees all citizens access to fundamental health care and promotes significantly better health among its citizens.

**There's no reason to believe that the generic companies are more efficient producers.**
I wouldn't claim they are more efficient, just that they don't have to recover the sunk costs in R&D, which is covered by the patent buyout. The point is the current per-pill charge has no relationship to the cost of making the pill. If the production was turned over to an entity who did not have to recover R&D sunk costs, the retail pill price would be affordable, and the R&D costs would be covered by direct taxpayer subsidy, rather than the convoluted one offered by Medicare Part D (a more efficient subsidy, imho).

That the existing system continues in spite of the consumer burden does seem to indicate the drug companies are happy with the deal they are getting.

Navigator,

There is nothing pharmaceutical companies are doing that stands in the way of your idea. They are happy with the present situation because no one has made them an equivalent offer. Pharmas are perfectly willing to sell patent rights (it happens all the time between companies). If the government bought out rights, it would get a discounted cost since it would also be removing risk.

All it takes is a simple proposal in Congress to authorize the negotiations with the funds to do so. Now, I ask again- why do you suppose Congress hasn't really proposed this?

Derek
Comparing overall health to other countries can't be put entirely on the healthcare system. A large portion of our healthiness is to blame on the people itself not the system. I dare anyone to dismiss the following statement. We are the Fattest country in the world bar none. We are the fattest civilization that has ever lived. That and our affinity for cigarettes contribute a portion to the equation that is never mentioned. An average american compared to a canadian, englishmen, japanese or whatever country you want to is not comparing apples to apples.

Derek, as I am sure has been repeated many times in many places, correlation is not causation. To wit, your statement that:

Americans (the “beneficiaries” of a “for profit” health care system) are significantly less healthy than the English (those who rely on nationalized health care)--despite the fact that America spends more than twice as much per capita for health care.

means little by itself, even if true. Have you considered that the realationship between dollars spent on healthcare and the general health of the population may not be so tightly related? That there could be other factors explaining the variance between two populations?

For example, if one population is prone to induldge in more risky behaviors it is not only likely to result in more negative health outcomes, but also greater spending in an attempt to ameliorate those negative outcomes.

"Right now, the primary incentive for employers to buy group health insurance is the tax code. Without this incentive, employers would not be nearly as inclined to offer health coverage to employees. I'm arguing that this has to happen to fix the health insurance market.

Absolutely.

Yancey,

I'm not sure how to respond to your direct question

**All it takes is a simple proposal in Congress to authorize the negotiations with the funds to do so. Now, I ask again- why do you suppose Congress hasn't really proposed this?**

other to start in on my opinion of Congress, which would be off-topic for this thread.

At best, I'm sure the stakeholders (drug companies, generic manufacturers, insurers, pharmacists, advertisers et al) would seek to enlarge or at least keep their share of their current revenue streams if such legislation were proposed, and I suspect Congress would fold to the special interests. Awhile back, I ran some numbers to see if this approach was economically feasible, and recall concluding it would be less than the current Part D Medicare program projected costs (this is a tough calculation in that you can "assume" your way to the "right" answer).

There are potential industry abuses to this approach (phony R&D initiatives, padded research expenses, etc.), but in my mind they present less of a societal risk than the current system, both scientifically and financially.

I mentioned advertising (someone else also brought that up) in the vein that it is a (unnecessary) cost burden. I recognize the value of marketing a product, but I believe the marketing we do for medications is inappropriate. I don't want my doctor choosing my medication based on a 30 second spot he saw while watching a football game, and I am not going to go against his judgement based on that same spot. Ditto for hospitals.

If this isn't the answer your looking for, enlighten me.

> I mentioned advertising (someone else also brought that up) in the vein that it is a (unnecessary) cost burden.

Why do drug companies voluntarily incur an unnecessary cost?

> I believe the marketing we do for medications is inappropriate.

No one is stopping you from providing drug information in a better way.

What? You don't have any drug information to provide?

> The point is the current per-pill charge has no relationship to the cost of making the pill.

So what? That's hardly unique to drugs.

Heck - it's even true of most professional labor.

Marginal or even production costs aren't necessarily dominant, even if one's belief system or argument requires that they are.

"For all its problems, I’ll take the system which guarantees all citizens access to fundamental health care and promotes significantly better health among its citizens."

Derek -

There is one huge, fantastic thing you're overlooking when you're making that analysis, and part of satisfactory health care is making patients *feel* better so they can live their lives, not just getting numbers right on a chart. In that regard, speaking to family and friends in the UK and who can't afford private hospitals, the system there is a dismal failure.

Personally, I've had two situations in my relatively short and safe life which would have left me permanently crippled had I been forced to use Britain's NHS, both of which were knee injuries that needed to be fixed immediately but were not life-threating. Here, in our already government-burdened health care system, I was in an OR days after both incidents, which preserved my quality of life.

Socialist health care systems don't take into account quality of life, they only take into account the quantifiables, like life expectancy or obesity rates. Why is this so? Because the incentive structure points away from the individual and towards a bureaucracy. Health is more than statistics, and bureaucracies can't deal with that.

Patients need to be in the driver's seat when it comes to their health care, and socialist medicine takes them from being back seat drivers to being stuffed in the trunk. No thanks.

Derek,

I second the argument of Dawg, that lifestyle choices of Americans account for most of the health differences between England and the U.S. I'll offer four more reasons.

Genetics apparently play an important role in life expectancy. African-Americans have slightly shorter lifespans than European-Americans. The higher African-American population of the U.S. accounts for nearly all the difference between life expectancy in the U.S. and the UK.

Rich nations spend more money for everything. U.S. has more money, and so they spend more. The medical care demand curve for the richest nation is bound to be different than that for all other nations.

One example of demand differences is the high proportion of elective surgeries performed in the U.S. Not all elective surgeries show up in statistics. Some surgeries deemed "necessary" by surgeons are actually borderline "elective" ones. (My wife has worked in the OR for 30 years, and I do know what I'm talking about.)

I'm not sure about the UK, but I do know that most European nations do not spend as much as the U.S. on either end-of-life care or on care for high-risk premature births. Whether we should or not is a point to debate.

Another reason for the high U.S. expenditures is the high awards given in questionable malpractice verdicts. Malpractice lawyers have driven up our health costs. Doctors and hospitals are forced to practice defensive medicine, and order more tests than would otherwise be needed.

I'm certainly not offerring the partially socialized U.S. system as a perfect one. But, for the reasons above, I cannot accept arguments that it is less efficient based on outcomes and expenditures.

I'm arguing that it *is* different due to the need of insurers to balance risk. If you're buying computers for 10,000 people, it doesn't matter whether 5% or 65% are diabetic. In health insurance, it can mean a difference in millions of dollars in losses.

True but so what? Insurance companies pay statisticians very good money to make accurate estimates of such things. No matter how 'powerful' the purchaser for 10,000 people is an insurance company will not write a policy if he insists on premiums that do not cover the costs of the care provided and do not permit the company to make a reasonable profit.

Right now, the primary incentive for employers to buy group health insurance is the tax code. Without this incentive, employers would not be nearly as inclined to offer health coverage to employees. I'm arguing that this has to happen to fix the health insurance market.

Why?

Navigator,

All that is needed is to buy out the patent rights to approved drugs. There is no need to compensate for research costs on an ongoing basis. It would be a simple nogotiation-a drug under patent has x years of coverage and the two sides simply bargain for a one time payment for those x years. There is no need for a Rube Goldberg apparatus that you outlined in your original comment.

As for the marketing- it would no longer be needed with the public buying the patent rights, unless we as a society decided some marketing was still necessary.

The reason I believe no such proposal has been made or will be made is that it is going to be far cheaper for the government to simply coerce cheap drugs today by fiat. The unseen consequence, of course, is that this will nearly completely destroy future research.

Andy,

**No one is stopping you from providing drug information in a better way.**

You best stick with the ads, rather then come to me for drug info. (and don't forget to take your Celebrex)

**Marginal or even production costs aren't necessarily dominant, even if one's belief system or argument requires that they are.**

My "belief system" is not the issue. Trying to find a better way to provide medicine at an affordable price, that's all. Charging $5 for a pill that costs 2 cents to make seems like an obstacle toward that goal.

Navigator

Yancey,

**All that is needed is to buy out the patent rights to approved drugs. There is no need to compensate for research costs on an ongoing basis.**

I agree, it would make things simpler. As an ongoing business practice, it probably would work, until Company ABC hit the home run and found the anti-Aids or anti-cancer pill. Price negotiations for the patent might get sticky, if the research was privately funded.

The research model I'm suggesting is similar to the one used today by the Department of Defense (that should generate an enthusiastic round of applause from the folks on this thread) and it seems to work in that it meets corporate and government needs. I don't pretend it couldn't stand some tailoring for the drug issue, and your suggestion might be the right way to go.

Again, all I'm suggesting is a way to encourage research and get drugs to market at an affordable price. I just don't think the current market approach does this very well.

Navigator

I am a foreigner who has lived in the US the past 6 years. I arrived from a country that has universal health care. It has its problems, like long queues. But it is basically free, and you can get any treatment you need. It is also no hassles system.

Now coming to the US I was shocked. The health insurances are so mind boggingly complex! And ridiculously expensive! And over the last 6 years my premium has gone up a lot every year, while the coverage has gone down a lot every year.

I am in the IT sector and my employee pays most of my premiums, but with the latest premiums and coverage I get I am starting to think that I would actually get a better deal with universal health care. Currently, just a single family member needing major surgery and extended stay in hospital would bankrupt us, even with the insurance, because the insurance does not cover even close to 100% of the astronomical costs of medical operations.

Every month I look at my pay stub and wonder - why even bother with health insurance as it won't really help in case of real trouble?

>>No one is stopping you from providing drug information in a better way.**

>You best stick with the ads, rather then come to me for drug info. (and don't forget to take your Celebrex)

Ohh - snark. I note that Navigator didn't tell us why drug companies spend massive amounts of money unnecessarily.

If he's right, his drug company would be so profitable that he could buy out all of the stupid drug companies.

And yet, he's not trying to create that drug company. Why is he so unwilling to do good?

>>Marginal or even production costs aren't necessarily dominant, even if one's belief system or argument requires that they are.

>My "belief system" is not the issue. Trying to find a better way to provide medicine at an affordable price, that's all. Charging $5 for a pill that costs 2 cents to make seems like an obstacle toward that goal.

Like I wrote, marginal costs aren't necessarily dominant, even if they need to be for some one's personal reasons.

canadian life expectancy, average medical cost and infant mortality rates are all better than the US. of all the industrialized nations, the US system is by far the worst. 47 million people have no insurance in here. that's 15% of the population.

that the government still does nothing shows how apathetic it is towards its poor citizens.

It cannot provide less, or less rapid, .. 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.

I know a Frenchwoman academic in the US whose son broke a leg. She has solid US insurance, from a university. She could not get her son's leg set during the weekend. No one in the network would do it, in a major (1 million) metropolitan area.

She was angry. She said that in France it would be done instantly. Please, please, please don't tell us how terrible French health care is compared to the USA. People who have experienced both claim the opposite.

Somebody in the comment strain said it best - When the Europeans got "free" health care, their system was so bad that anything seemed like an improvement.

If this is indeed true, it is just another case of beneficial leapfrogging. There is no broken legacy system to fix so you can afford to attempt to get things right.

I'm an American living in France. I can't bear the thought of going back to the States and finding myself needing medical care. I would probably try to get returned to France if that were possible.

Something i forgot to mention in my previous post:

England's NHS is a dismal failure from almost every point of view and should be cited as an example of how NOT to do single-payer, socialized healthcare.

• Financially, it is a black hole that well-thinking governments pour lots of money into to no noticeable effect.


• Socially, doctors, nurses and other HCP staff are generally exasperated.


• Waiting lists exist. They are long

At least, this is what I hear from the many British expats who come down to the south of France to live.

Using the NHS as a benchmark for comparison of US vs socialized healthcare systems is bad for the discussion.

A nationalized health care system will probably be mandatory in the near future. I'm a retired health care provider and I worked as an orderly way back then and a VP before retirement. I've seen our health care system become more fragile each passing year. Many hospitals lose money each year and those that don't operate on shoestring budgets.

We already have the perfect system in America but because of its old and tarnished reputation, most people simply don't understand that the Veterans Administration system is the largest and most efficient of it's kind ever. I get all my care at VA today. In some instances I may wait a week or a month or even 6 months to see a specialist but those waits are acceptable for chronic care, non-urgent issues.

Urgent issues are cared for on the spot. Physicians are all board certified or eligible. They are paid at levels their civilain colleagues envy when you consider they have no overhead to worry about.

Most important of all, the VA has set standards for outcomes of care in the last decade that all other hospitals in America envy. On analysis, the only really important detail of your health care is how you do after receiving it. The VA system has sicker patients than most of the rest of our society and their patients have better outcomes after treatment. In other words, your chances of survival after a surgery at a VA hospital are measureably better than at its civilian counterpart.

Costs for care are significantly less. Much of this has to do with the lack of multiple layers of hospital administrators who count beans, do marketing and collect salaries in the 7 figure range. VA operates with as few management types as possible, many managers are working physicians...who better to run your health program than a professional?

Lastly, VA has you as a patient for life thus an investment is made in wellness. Preventive care is handed out at VA like nowhere else in the world. From diabetes care to flu shots and blood pressure control, VA long ago recognized that keeping you healthy saves money in the long run. Your local private hospital can only turn a profit if you're very sick. Keeping you well isn't reimbursable so there aren't any free diabetes testings, free hypertensive meds or free cholesterol medicines for you. When you need that well paying bypass is when they want to see you.

You'll still hear horror stories about VA. Not so different than horror stories about any hospital if you listen to a few customers. The facts are this though...excellent care, low costs, well paid staff and the heath care you need, when you need it.

I have a choice, I can use Medicare and private insurance and go to my local private hospital or I can go to VA. My healthcare background, almost 4 decades worth, leads me to make the choice to get my care at VA.

Prufrock,

Really, is it possible to go to an emergency room in this country with a broken leg and not get it set?

Overall, this has been one of the best comment threads on nationalized healthcare that I have read.

I think it is very enlightening to read what most Americans' major complaints about their healthcare are: (1) they are paying too much for too little-and this is getting worse all the time and (2) they don't have healthcare insurance at all. These are the expectations that nationalized healthcare will have to find some way to satisfy, and I fail to see how it can be less expensive while doing so.

Nationalized health care is an idealogical goal of the left in this country and is basically a solution looking for a problem. People love to point out statistics showing that x% of Americans lack health insurance, but do they show how many people are dying because they couldn't get health care? Very, very few because of our collection of Medicare, Medicaid, state-run programs, and rules requiring doctors and hospitals to treat patients.

Compare that to places where they have nationalized their health care, and people die waiting in line for rationed care...

J.A. Prufrock:
I know a Frenchwoman academic in the US whose son broke a leg. She has solid US insurance, from a university. She could not get her son's leg set during the weekend. No one in the network would do it, in a major (1 million) metropolitan area.

You know, I hate to say merely "Bullshit" just because of the awful stench around that, but... that deserves a tentative bullshit, barring further information.

Having said that, I suppose that it's possible that the leg was not set. What, instead was the action taken? And did it stabilize the leg until it could be attended?

Or was this person left without any care until Monday at 8, as you imply?

My wife broke her ankle Thursday afternoon. We took her to a podunk, in the middle of nowhere hospital about 4 PM. By 5:30 she'd been braced, X-rayed, and stabilized. Not cast - because the attending was happy with the stability of the injury, and wanted to wait for a specialist to view the X-rays. The Orthapedic expert indeed did cast her - but she was not left uncared for in the meantime. This, by the way, was essentially without insurance.

She was angry. She said that in France it would be done instantly.

Funny thing, according to the French I know, it's so much better than the US, they wish they were there. Well, not enough to leave the US, but almost! It's so much better! One day! We'll go back! The wine is better! The Cheese - what is THIS you call "Cheese?".

It's peaceful there! France doesn't go around starting wars! Ivory Coast? What's that? Nevermind! There's no crime in France! No disruption! No Bigotry or Racism!

So excuse me if I discount your French academic with her story that doesn't match my experience. (BTW: Had we not been available to come back the next day for the Orthapedic follow up, the ER MD would have cast the break.)

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