July 1, 2007
From the desk of Jane Galt:Okay, so what's the plan?
Matthew Yglesias snarks at CNN:
CNN's SiCKO analysis concludes:
As Americans continue to spend $2 trillion a year on health care, everyone agrees on one point: Things need to change, and it will take more than a movie to figure out how to get there.Yes, it will. We could, for example, read the earlier sections of the article. For example:
The United States spends more than 15 percent of its GDP on health care -- no other nation even comes close to that number. France spends about 11 percent, and Canadians spend 10 percent.France . . . Canada . . . cheap . . . but does their health care suck? Well:
Like Moore, we also found that more money does not equal better care. Both the French and Canadian systems rank in the Top 10 of the world's best health-care systems, according to the World Health Organization. The United States comes in at No. 37. The rankings are based on general health of the population, access, patient satisfaction and how the care's paid for.So, okay, it's not that hard to figure out. France and Canada both have two difference systems of health care delivery both of which are cheaper than the US system and both of which are more effective. What's more, these aren't obscure countries. Lots of people have heard of France. Lots of people have heard of Canada. How hard is it for them to just write the words "Michael Moore is right; American health care would be improved if we adopted French methods instead"?
Forget, for the nonce, the pro's and con's of doing this; don't ask whether longevity statistics might be affected by factors other than the healthcare system. (Many of which, to be fair, Mr Yglesias probably also wants to change; but then you have to ask whether we shouldn't focus on doing those things, rather than mucking around with health care financing.) Just look at our spending patterns.
In the United States, government at its various levels now accounts for roughly 45% of health care spending. (And by "now", I mean 2004, the latest year for which OECD data are available. In 2004, of course, the government provided little prescription drug coverage. Remember that fact; it will become important later.) The United States spends about 15.3% of total GDP on healthcare. That means, for those following along at home, that government spending on health care consumes about 7.7% of GDP.
Canada spends 9.9% of GDP on healthcare. France spends 10.5% of GDP. What is the magic route by which we are going to cover all the people not currently covered by government insurance for 2.2-2.8% of GDP?
Even as we walk through the fairyland of perfectly executed policy programmes, there are some magical byways that the Ogres of Reality have blocked off:
- We will not save massive amounts of money on prescription drugs--because in 2004, the year from which those figures date, the government didn't spend that much money on prescription drugs. So cutting the prescription drug bill will not help you reduce that 7.7% very much--which still leaves you with a paltry 2.5% of GDP to spend on the remaining 2/3rds of the population that currently enjoys health insurance.
- We will not "save money" by adding younger, healthier people to the government's insurance pool. We may lower the average cost of caring for them, but sticking the nation's 18 year olds onto the Medicare rolls will not lower one iota the amount it costs to replace Grandma's hip. Putting 18-year-olds into the insurance pool is a slightly nicer way of slapping them with a gigantic tax on their earnings in order to cover the old and six; it does not actually make the care any cheaper.
- We will not get huge savings from preventative care. Medicare, Medicaid, and the VA already have whatever incentives they are going to have to provide preventative care. They are still costing us 7.7% of GDP.
- We will not garner immense cost-reductions from administrative costs. Medicare, Medicaid and the VA already have European-style administrative costs.
- We will not realise fantastic cost benefits from bulk-buying. If you want French-style health care (this being the current favourite model of most progressives I talk to), that means that hospitals and doctors are private entities; they do most non-pharmaceutical purchases in healthcare. The centralised model enjoyed by Britain and Canada does provide such cost advantages, but it has severe drawbacks, which is why most progressives I talk to say "that's not what we want". Moreover, I find it exceptionally politically unlikely that any American system would ever operate along British/Canadian lines.
Now, I can think of several ways to reduce that spending. But they all have one of two problems: either they could (and should) be done right now; or they are not currently being done because they are politically inconceivable. For example, I could mandate electronic medical records at doctors offices. That might save money. (Might not, of course, but why not try?) But Medicare could do this right now, by the simple expedient of demanding that doctors keep records for Medicare patients using a system that complies with some sort of information standard. If you think that we could save money this way, don't wait for single-payer--go out there and do this right now! Then you can show everyone how awesome government payments systems are.
Aside from that, however, most of my ideas are simple, elegant, and doomed to die an agonising death in committee--like bringing back open wards, slashing the salaries of doctors and nurses, or denying expensive treatments to the elderly, disabled, and other severely ill people. If Matt has better ones for trimming down that 7.7% to a level where we might feasibly cover 200 million other people with what remains from France's spending, I am very interested to hear it.
Otherwise, it seems fair to say that, well, we still need to figure out how to get there.
Posted by Jane Galt at July 1, 2007 9:36 AM | TrackBack | Technorati inbound linksI think "The Old and Six" would be a great name for a pub!
What's the main object of a health care system ? To trim down costs or to provide good care ?
The US spends more on health care than, say, Canada, because it's people are rich, and have money to spend, and wish to buy every concievable treatement, even if it's expensive and of dubious medical value. And they are perfectely entiteled to it.
The comparison of health care spending as a percentage of GDP is meaningless, unless considered in the context of another 1000 variables.
Of course, drug costs could be reduced (but such reductions would not reduce the amount government spent in 2004 since drug costs did not make up much of that number) by adopting France's approach of paying drug companies a "fair price" (a/k/a just above the variable cost of manufacture) for their products. Of course, that would prevent the drug companies from recouping the costs associated with developing new drugs -- stopping innovation.
The same approach could be used to save money in other areas. Think of how much money could be saved if hospitals and doctors were able to pay a "fair price" for new surgical equipment, diagnostic tools, and other health care products? Sure, that would slow the advances in health care to a trickle, but is that really so bad? Today's care is much better than it's ever been. What's so wrong with freezing the standard of care at today's level? After all, if the research is never done, we'll never know how many lives could have been saved or meaningfully improved by such a penurious approach.
I don't think the incentives for preventative care are as solid as you say (outside of the VA). Medicaid (which, as I recall, is really 50 state-level programs at this point) doesn't know when someone will join or leave their rolls because of a interstate move or a change in their financial circumstances. And I would guess that, medically, the most fertile ground preventative care that would save Medicare money would be in the 50 (or 55)-65 population where you could slow the progress of expensive diseases. But I've never heard Medicare doing that sort of prevention - I'd guess that might be because they can't legally provide services before someone is old enough.
The more I think about "fair pricing" the more I like it. Just think about how much cheaper it would be to buy and own an iPhone if we just mandated that Apple and AT&T would price things closer to variable cost. No, Apple wouldn't have produced the iPhone if that was the pricing structure that was in place. Why should that matter (any more than it should matter whether a drug company would have engaged in years of research if such costs could not be recouped)? I want my iPhone at a "fair price"!
Controlling America's runway health care costs is NOT difficult. Reduce the huge amounts being spent on heroic but completely futile attempts at keeping dying people alive for a few weeks or even days longer, when the chances of long-term survival and the quality of life are both zero. Preventative medicine, currently all but ignored, should be a major focus, as should medical research.
Canada's 9.9% GDP spending actually consists of roughly 7% GDP government and 3% GDP private spending (paid by patient or employer provided supplemental insurance).
So, the % of GDP spent by US government on healthcare is not even more than the % spent by Canadian government. I'm not sure how Canadian government manages that but some of that certainly comes at the cost of quality. (Living in Canada, I know people who have had 8-hour emergency room waits because of hospitals being understaffed.)
Megan,
That was a very good analysis of the situation.
The universal care advocates are utterly convinced that overhead explains almost all of the extra GDP points that America pays for healthcare outside of pharmaceuticals. This is where they expect to get most of the extra funds to cover everyone not covered by insurance today. However, they ignore the overhead costs of the government programs and they ignore what private practice spends on overhead dealing with the government programs. They blithely assume that all of this overhead disappears once you get rid of insurance companies since they assume that none of the overhead serves a purpose.
On the preventative care aspect, I, also, am a skeptic as to the efficacy with regards to costs. Earlier treatment may save lives, but I doubt that costs will actually be lower, and are just as likely to be higher. And, in any case, you still can't force people to go to the doctor, and you still can't really do much to keep them from overeating, smoking, doing drugs, or driving like maniacs. What prevention is really good at, we already do much of it, such as vacinations, good sanitation, or good engineering such as protection in automobiles.
If I were a dictator, I could lower healthcare spending really easily by denying any life prolonging care to anyone over the age of 75, just providing pain relief and antibiotics. However, this is not likely to be popular.
Awwww, yyyeah. I love health care debates.
I have a RN wife. While we would be affected by "slashing the salaries of doctors and nurses", it occasionally appears to me that nurse salaries seem to be a bit of a golden goose for those who are in the system. Herb Stein's dictum looms.
As for physicians, slashing their salaries would seem to me to lower the median quality of new physicians significantly. Med schools seem to consistently get the best, brightest and most ambitious of colleges; being a physician of any sort appears to be the best road to upper middle class affluence. FWIW, though, it would have the salutary effect of reducing the number of pre-meds at universities. Organic chemistry would only be taken by God's people, not point-grubbers. (a joke.)
In France, a doctor isn't an especially well-paid professional. It's good for French standards, but not impressive (less than 100k in the median, once converted to US dollars).
The median starting salary of a doctor in the US is higher than the median salary of a doctor in France.
A simple way to reduce this issue is to ease the importation of foreign doctors and allow more medical schools to operate. Of course, this is politically impossible.
I have a question for those who are interested:
Peter and Yancey have both suggested suspending care in old age to a certain degree. While essentially breaking the Medicare promise to today's elderly is politically impossible, there's gotta be a generation of folks who know that their care will not be paid for by the gov't/society.
What is the maximum age of people now who should "know better" and for whom future Medicare promises should be broken? I'd say 50. What do others think?
Great idea Peter. I love it. Now I want you to tell me exactly how much a year of life is worth. Then tell me exactly what chance of success you define as "heroic" or "futile" 10% cure, 10% chance at an extra 1 year. 1% chance of seeing your daughter graduate college next month? Some formula using cost per QUALY (quality adjusted life year)? It's been tried in Oregon and Tennessee and fails because people start suing for coverage under the ADA. Does it matter if the patient with a 1% chance of survival is 20 or 80 years old (watch your answer, age discrimination laws you know)? The fact is that predictive models for survival and quality of life are extremely poor. For example our ICU has a 4% higher than predicted survival using APACHE II methodology. That is 4 out of 100 people that the state of the art predictive model says should die make it out of our ICU alive. Should we turn them off b/c the computer says so?
Now even if you're so sure of yourself that you think you can come up with the "right" answers to all of the above, try to get your ideas passed in the US. Remember that the legal system forced Fairfax hospital to keep an anencephalic baby alive at all costs (literally) http://en.wikipedia.org/wiki/Baby_K And remember the Schiavo debacle.
Now try to get them passed when they mostly would effect one of the best organized voting blocks extant -- the AARP. Remember 80 year olds aren't interested in prevention, too late.
I write this from the perspective of someone who truly believes that we flog people WAY to long in the ICU. I regularly do things to people that I would not let happen to my family or myself because the family wants us to "do everything". But it's not my choice nor do I want it to be.
I hope Matt gets prostate cancer, and I hope he goes to France or Canada to have it treated.
He'll change his tune quite quickly.
BladeDoc,
I don't want to leave the impression that I am advocating the forced suspension of treatment, only that it is the one of the only ways to actually dramatically reduce medical costs. I certainly would never force that made decision on someone else, but coercing the decision and simply refusing to pay for the extra care are two different things. The hard truth is that you get to make decisions when you are the one who has to pay. If someone else has to pay, your autonomy is already limited.
I agree with you, some of the medical care inflicted on the dying by their loved ones is something I would not wish for my worst enemy.
"being a physician of any sort appears to be the best road to upper middle class affluence"
While doctors do pretty well, the aggravation and expense involved in becoming one are way beyond other less glamorous methods (sales, for example) of attaining that level of wealth. Go to med school because you want to be a doctor, not because you want to be rich.
An issue I never see discussed in this debate is the constitutional one - maybe a legal scholar here can educate me on this one, but I think an attempt by the government to prohibit a citizen from obtaining FDA approved medical treatment they were willing to pay for themselves would get laughed out of court. Thus, I think nationalizing our healthcare industry would almost instantaneously create a parallel private healthcare sector exclusively for those wealthy enough to buy into it, and that the "high end" of the business would migrate into that system immediately. I'm not sure that would be much different from what we have now, other than the new system would probably have a higher wealth threshold for entry.
I don't know how we can have a respectable political argument without bringing global warming in. For example, in the summer of 2003, France lost 15,000+ of its elderly to heat related deaths. Perversely, we would expect that this lowered the long-term costs of these patients! So unless we do something about global warming now, we can expect the French health care system to become increasingly more efficient.
J: While I agree with you that passion for medicine should drive medical school applications, it's worth noting that being a physician offers not only high pay, but high status. It's extraordinarily attractive to an ambitious young person in a way that engineering or public service can't compete with.
In addition, the average salary of an MD is high. In sales, it seems to me that while some salaries are comfortably high, while most salaries are average at best.
Ah, J, but you do miss one point: medicine is a field in which being good at studying and taking tests will get you just about everything. Every medical school class has a few people who have the personality of a potted plant. They make quite a bit more money in medicine than they would almost anywhere else.
Furthermore, although you and I know there are a lot of easier ways to make good money, I'm a doctor because my parents didn't know them. Medicine has been the ticket to the top of the middle class for a whole lot of smart children from poor backgrounds.
More on topic, as Yancey said, preventive care isn't going to do much. Largely, you save money in health care by not doing things, and there isn't a big groundswell of public desire for less of anything, even when cost savings could be significant. Doctors' salaries can still be cut, but the nurses' already have been - and lo, we have a nationwide nursing shortage. Seems people don't want to work that hard for $30k and poor benefits.
As far as denying goes, I'm with BladeDoc - it's a great concept, but when it gets down to it you have families saying they want heroic measures taken, and no politician wants to be the one to tell them they can't have them unless they pony up. (And we do keep people going too long in the ICU. Terrible, really, when you think about it. Folks, talk to your families now - your parents/kids/siblings shouldn't have to live the rest of their life wondering if they did the right thing when they turned the ventilator off.)
While I agree with much of your analysis regarding state run health care I think you're ignoring a huge problem.
The free market just isn't cutting it anymore.
We could spend weeks and months and years arguing over why this is, from the US paying for innovation that ends up being used by other countries to tort law to hospital mismanagement, but the real problem is, the current situation is bad, and getting worse and is presently unsustainable.
So I'm going to bring up and idea that no one here will like (because it involves government regulation and I know Meg's audience), why don't we start with farcing a 10% cap on insurance company profits. Anything above that 10% gets refunded back to the consumer. I'd love to hear about the flaws in that idea.
While my respect for Matt waned when I realized that he wasn't perceptive enough to get the joke behind The Offsprings "Why don't you get a job?", I definitely don't hope he gets Prostate cancer. That seems wildly out of proportion to his "crime" of being a naive young man who still believes that big government is a good thing.
In any case, y'all are arguing the wrong point. As long as everyone accepts the WHO analysis that the US ranks 37th in "health care quality", statists will continue to insist that a centralized, government controlled health care system is better.
Why is the US ranked 37th? Is this ranking reasonable and fair? Did WHO cherry pick to find data points that support their pro-big government bias? I know, at least on infant mortality, that the US practice of "alive at birth" instead of "alive after 24 hours" causes our infant mortality rate to appear wildly worse than other civilized countries, even though its simply a byproduct of how much we value our babies. That's almost certainly one of the factors. What are the other factors in the WHO analysis? How much of their analysis is subjective vs. objective? What about innovation and heroic end-of-life measures - where does the US rank on those axes? Are they included in the analysis?
Blade Doc -
The Europeans seem to have figured out how and when to say "enough's enough," when it comes to prolonging the lives of the dying, and they're hardly a bunch of heartless barbarians.
What's really ironic is that Europeans are better able to accept death even though death is a bigger deal to them. America has a much higher percentage of Christians - who have no reason to fear death, as it means spending eternity with Jesus - than the often atheistic Europeans, to whom death means oblivion. Yet they can deal with it, and we can't. Go figure.
Kate - you do know that Blue Cross is a non-profit - right?
And Kate, 10% of what, revenue?
I'd be very surprised if any insurance company had profits in excess of 10% of revenue.
For example Cigna had Premiums and fees and other revenue of $15,123,000,000 and net income of $1,155,000,000 there "profit" was %7.6 of revenue.
Kate - did you even look to see what the rates of return for health insures was?
Kate wrote: why don't we start with farcing a 10% cap on insurance company profits.
Hey, you called it a joke, not us.
PEROT: We got the most expensive health care system in the world; it ranks behind 15 other nations when we come to life expectancy, and 22 other nations when we come to infant mortality. So we don't have the best.
Pretty simple, folks -- if you're paying more and you don't have the best, if all else fails go copy the people who have the best who spend less, right?
You know, if we could get everyone in the country access to health care at the same cost we pay now, isn't that still a win? It'd be nice if universal health care cost less than the mess we've got now, but I don't see why it should be a requirement.
(I note that I don't have the knowledge to check the factual assumptions the post is based on. I'd be surprised if there were really no administrative savings/preventive care savings to be realized.)
So I'm going to bring up and idea that no one here will like (because it involves government regulation and I know Meg's audience), why don't we start with farcing a 10% cap on insurance company profits. Anything above that 10% gets refunded back to the consumer. I'd love to hear about the flaws in that idea.
I see a dozen Enrons in the making.
Remember, only fools and money are soon parted. For anyone else, it requires a lot time and expense in the enforcement aspect.
Look, I don't have a problem with people making a profit from insurance. Hell, I better not, I work for an insurance company. I'm simply saying that I think we can all agree that health insurance has been going up at a dramatic rate. Some of that is because of increased medical costs and some of it is not. I am certainly not an expert in this field.
But I do want to point out that Blue Cross/Blue Shield is NOT a non-profit. It is a consotium of 38 seperate insurance companies all operated under francise agreements. Some of them are non-profits. Some are not. And all are required to pay Federal taxes (as opposed to true non-profits).
The only thing "simple" about this, Mike J., is maybe you. Read jb's comment. The WHO numbers are based on apples and oranges comparisons. In addition to directly contrasting numbers based on crucially different definitions of things like infant mortality, the WHO also puts its finger on the scale explicitly to favor countries with entirely state-run medical/health care establishments. Statism earns extra points. This is pure ideology. The WHO rankings are a joke.
I've lived and worked in Europe and I've been without medical insurance coverage in this country from time to time. There are problems with the current U.S. system, but nationalizing it isn't a solution. Having experienced health care delivery in three European countries, plus the U.S., I vote for the U.S. status quo over anything the Europeans do.
At the end of the day, the main difference is that the state-run health systems in Europe and Canada all ration care in ways Americans would find unacceptable. We both invent most medical technology and also try to apply it to every possible recipient. That's expensive, but it's not, by any means, obviously wasteful.
Health care is like any other good produced by humans: universally available, technically advanced and of high quality, cheap - pick any two. No amount of leftist hocus-pocus will get you all three.
Megan,
A quick math check: 45% of 15.3% is 6.8%, not 7.7%, right?
Probably doesn't affect your larger point, but still....
This is awesome... -ly hilarious.
Canadian health care isn't cash based, it's rationed on personal connections and time. If you know the right people, you get amazing level sof care for no immediate out-of-pocket cost (it hits you at tax time and lower economic growth). If you can wait long enough, you get your procedure, but the wait is horrendous (years for hip replacements... we save money by waiting for the patient to die in horrendous pain, whee!). Also, doctors get paid very little - about $400k before expenses like secretaries, insurance, offices... Net is about $150-200 then hit with 50% tax rate, so the government gets most of it back...
Jane's idea of reducing expenses by bringing back open wards is insanely misguided. Since we have unionised maintenance staff and don't have the free labour of nuns, open wards would cost more money and kill more people than the current system. Jane remembered this in her past mention of "Martha Stewart on meth levels of cleaning", and it applies here. Unless of course the goal is to kill 80%+ of the patients with resistant TB and MRSA.
As to medicine being the ticket to UMC life... I guess it all depends on where you come from, as was mentioned above. Sales and business are the only real routes to this, the professions all being fairly low reward, though low risk, for the people involved. The best doctor, lawyer, accountant, or consultant, could have much greater success running their own businesses (see Craig Venter) than working in their profession, and this is true all the way down the line. Senior partners at a top 5 AmLaw firm are making a few million, when their equivalents in corporate and entrepreneurial life are making 10-100 times that and will have 10-10,000 times the net-worth (99.999th percentile to 99.999th percentile). They do have better status with your mother or prospective mother-in-law at entry levels, but that's about it in terms of status advantages.
The only thing "simple" about this, Mike J., is maybe you.
Don't insult me, insult Ross Perot. I was just quoting him.
Anyway, don't believe everything that some random guy on the internet says. If it turned out that infant mortality rates were uniformly defined as deaths before age 1, would you change your mind? If it turned out that, in an apples-to-apples comparison Sweden and Japan had half the infant mortality rate of the U.S., would you change your mind? Singapore has a relatively private health care system and much better infant mortality numbers than the U.S. Are you willing to believe that?
Dick -
I love what you said on leftist hocus-pocus.
However, I have some right-wing hocus-pocus as a response :)
If we let the free-market run its course, the advanced techniques that are now expensive and available only to a select few will become universally available at low costs.
However, the process of getting there is very painful as we see people suffering from curable diseases, and this agony puts us under pressure to alter the free-market fundamentals that will make us happiest in the long run.
Easy for me to say as a healthy young man :(
The rankings are based on general health of the population, access, patient satisfaction and how the care's paid for.
I have a hard time taking the rankings seriously when two of the factors are whether its socialized medicine and how well the patient liked their free care.
I would love to see how the rankings turn out when they are based on access, outcomes and waiting period alone.
Every industrial country but ours has universal health coverage, and they're all democracies. If their health systems are so bad and ours is so good, why don't they switch over to our system? Why didn't Mrs. Thatcher, for example, abolish the National Health? When Jane explains this, I'll pay more attention to her ideas.
Every industrial country but ours has universal health coverage, and they're all democracies. If their health systems are so bad and ours is so good, why don't they switch over to our system? Why didn't Mrs. Thatcher, for example, abolish the National Health? When Jane explains this, I'll pay more attention to her ideas.
USA Today had a front page article about 10 days ago about an increase in the death rate in New Orleans post Katrina (attributed to fewer 'high paid' doctors); the article 'exposed' the fact that the death rate was higher than the offical statistics, perhaps not as accurate also post Katrina, based on newspaper obituaries. Possibly what we need to do to improve our health statitics relative to the rest of the world is to export our vital statistics bureaucracy. Due me a favor though. If you want to reduce health care costs in the US, due away with JCHO, the Joint Committee on Hospital Organizations, formerly JCAH, the "A" for Accrediting. They're the group that did away with open wards, have led in the VA system, to Potemkin treatment plans on psychiatric outpatients, you could't give an agent to alleviate flashbacks for instance you had to say how much you would alleviate it in how much time and how you would measure that - a Potemkin like fantasy.
Anyway, don't believe everything that some random guy on the internet says. If it turned out that infant mortality rates were uniformly defined as deaths before age 1, would you change your mind? If it turned out that, in an apples-to-apples comparison Sweden and Japan had half the infant mortality rate of the U.S., would you change your mind? Singapore has a relatively private health care system and much better infant mortality numbers than the U.S. Are you willing to believe that?
Except that it’s not uniform because the United States unlike most other countries includes stillborns (about 45% of our overall infant mortality numbers according to March of Dimes) in its infant mortality statistics and most countries don’t count them because to them “deaths before age 1” doesn’t include children who die before they were born only those who die with a year after being born.
Surprised not to see a mention of malpractice insurance rates. Caps on awards would cut costs.
Caps on govt benefits are potentially feasible, but the implementation would be somewhat contentious. Still, they already exist in terms of denying experimental (expensive) treatments under Medicare, but there would seem to be a number beyond which it is just not worth it.
There seems to be a fundamental expectation that all people should pay the same insurance rates, regardless of risk factors, behavior etc.
Finally, there will eventually need to be more general acceptance of the fact that all treatments will not be available to all patients. This is already the case, but most policy is debated as if it shouldn't be.
The overall feeling that tax dollars are infinite and every tragedy that can be solved by pulling out the national credit card poisons this debate. The question "how can this happen in the richest country in the world?" is symptomatic of this dangerous thinking.
I was just asking Mr. Eagleson whether he was willing to be responsive to the facts. I wasn't asking him what the facts are.
In any case, I think you're mistaken about why people have doubted the comparability of infant mortality rate numbers and about their actual comparability. Let me know what you think of this.
But now I'm curious about whether you're willing to be responsive to the data (whatsoever they may be) as well. If you were convinced that, in apples-to-apples comparison, all Western European, the richer Asian states, and Canada do better in a half dozen metrics that you picked in advance, even though they spent less per capita and are less wealthy per capita, would that make you change your mind about anything?
re: "we still need to figure out how to get there"
ron wyden has a plan,
http://www.ft.com/cms/s/e76a290a-c758-11db-8078-000b5df10621.html
"Mr Wyden’s bill is 166 pages against Hillary Clinton’s 1,364. Instead of trying to flatten the opposition as the Clintons did, Mr Wyden is courting Republicans. He recently got five of the most conservative men in the Senate to co-sign a letter to Mr Bush endorsing the principles of universal coverage and cost containment.
"Under Mr Wyden’s plan, American employers would no longer provide health coverage, as they have since the second world war. Instead, they would convert the current cost of coverage into additional salary. Individuals would use this money to meet the requirement that they be insured. Buying coverage directly would encourage consumers to use healthcare more efficiently. Getting rid of the employer tax deduction, which costs $200bn a year, would free funds to cover those who are not poor enough to qualify for Medicaid but not wealthy enough to afford insurance. The Lewin Group, an independent consulting firm, recently estimated that Mr Wyden’s plan would reduce national spending on healthcare by $1,500bn over the next 10 years and save the government money through greater administrative efficiency and competition."
for more details see http://wyden.senate.gov/
In any case, I think you're mistaken about why people have doubted the comparability of infant mortality rate numbers and about their actual comparability. Let me know what you think of this.
You mean other than the fact that the numbers on the homemade graphs don’t appear to actually match the numbers on the source documents that the blogger linked to? I generally dont think very much of that sort thing.
I used to remember the #s but no longer. I want to know the stats in all of those countries to know if the US is the only one with such a lopsided distribution of care- that is 8% of the population spends ~30% of the costs; 50% of the pop spends ~95% of the costs.
So the way that that state healthcare operates is by triage and rationing - much the same way that HMOs operate; whilst there wont be a man in a cubicle negotiating with your doctor on what care you will be given, there are commitees that decide nationally what treatments are approved.
In the UK or France or Australia, a basic level of care is guaranteed to everyone, but you wont necessarily get the latest or most expensive treatments. If you want a better deal, then additional insurance can usually be purchased.
Having a basic universal level of coverage is an improtant thing that binds society. It says that we all belong to one nation, and if we falter or suffer, someone will be there to help us.
Its interesting; I lived in the US for 10 years, and now in the UK for 6 months. The general attitude here is that noone should be denied health because of their bank balance. Its seen as a fairness issue - something the counterbalances class divisions. In the US, class division is a concept that is denied, and so nothing can be done to address it.
In the US, class division is a concept that is denied, and so nothing can be done to address it.
Or, perhaps in the United States, the preferred solution to class divison is individual opportunity (i.e., in lieu of a collectivist nanny state). Pretty sure that something to that effect was stated a few times in our founding documents.
So, if your goal is to "recognize" and "solve" class divisions via proactive government interventions, you probably best stay over there -- because that one's not going to catch on as fast back here.
The way I understand it, some other outgrowths of British attitudes toward government-as-cure-all have been a complete ban on firearms, a generally hostile attitude toward self-defense, and government-run Nanny Cameras heavily interspersed throughout metropolitan areas. I doubt you'll find many of those becoming rabidly popular around these parts, either.
Megan, an absolute excellent synopsis of the many-headed hydra of health care. Thank you for a fairly complete and balanced presentation to use as a springboard for these many comments.
If there is a system that's broken or getting there, health care is pretty close. 15 years ago a friend in Washington state had a wife who worked at a local hospital. As they were leaving the area to move on to another job, he said that his wife told him she found out the hospital was routinely double-billing for all Medicair and government programs, "because there was no one auditing" and they felt they could (and did) get away with it.
By the way, we were pretty close to the Canadian border, and way back then they were coming down to purchase care they couldn't get in Canada.
There are some really cold-hearted types here, Yancey and Peter in particular. What goes round comes round, and they'd best hope that the dictum doesn't apply to them.
"If it turned out that, in an apples-to-apples comparison Sweden and Japan had half the infant mortality rate of the U.S., would you change your mind?"
I think that it is extremely difficult to make apple-to-apples comparisons between different countries with respect to health care statistics.
For example, I'm certain that infant mortality rates are strongly correlated with the ages of mothers. Are the rates of teenage pregnancies similar in the United States, Japan and Sweden? I'm also sure that infant mortality rates are strongly correlated with substance abuse by pregnant women. Are these rate constant across borders?
I'm sure that obesity rates have a major effect on health care costs. The United States has high health care costs and high obesity rates. I saw the correlation between these in effect awhile back when a morbidly obese woman at my work tripped and caused severe damage to her knee as she fell. She incurred major medical costs in addition to missing work for several weeks. Same accident to me would not have resulted in any injury or lost time at work.
Here's an idea I've been kicking around (don't know if it would reduce costs). Make employer-provided insurance taxable as income and give employees an option of getting a raise rather than insurance. Implement a Negative Income Tax, BUT, all payouts from the NIT go into a tax-free Health Savings Account that can be used only for non-elective medical procedures, prescription drug purchases and medical insurance.
This gives the citizens ownership of their own health care because, even though they can't use the money in their HSA to finance a house or car or whatnot, it's still *their* money, and they can will it to their heirs (who can cash it out and pay taxes on it, or roll it over into their own HSAs and NOT pay taxes on it).
Once you've done the above, eliminate all forms of government-financed medical assistance. Probably there are other things that could be done in regards to streamlining overhead, mandating industry standards in insurance claims forms and record-keeping and suchlike, but I don't know anything about those aspects of it all.
There are some really cold-hearted types here, Yancey and Peter in particular. What goes round comes round, and they'd best hope that the dictum doesn't apply to them.
Duuuude, there is nothing "cold-hearted" in recognizing that life has its limits. Spending vast amounts of money on prolonging the lives of dying people, when their quality of life is zero, is about as far from compassion as you can get. Does the thought of rotting away in a nursing home in diapers, hopelessly senile, sound attractive to you?
Falkoyn,
So, it is cold-hearted to point out that most of the expenses we are wasting is devoted to the extreme elderly and dying? Would you rather we ignore this fact? If we are going to socialize medicine, then a cost-benefit analysis to society will have to be instituted since you cannot have everything, as Dick Eagleson so elegantly pointed out.
But tell me, who is really cold-hearted? I am not the one advocating we lower healthcare expenditures in the United States. Are you?
First, anyone who believe you can get the health-care that the USA has for cheaper is dreaming in Technicolor. What universal health-care systems like Canada provide is a *somewhat* lesser health care for *vastly* less money. Unless your goal is to substantially lower health-care spending at the cost of somewhat lowering health-care outcomes, a universal health-care system has nothing to offer you. Rationing is the only way to cut costs, and that's what a universal system allows you to do with the least amount pain. (Not 'no' pain, 'least' pain...)
Note: Comparing GDP costs percentage costs of health-care makes no sense. Should Rwanda have similar health-care to the USA if it spends a similar amount of GDP? One should be comparing $/patient covered to see what actual health care costs are like. This makes the US system even more expensive in comparison, especially if you average its costs among those who can actually get health-care.
As a Canadian that is very happy with our health care system, it should be recognized that Canada does have several advantages when implementing universal health-care that the USA does not.
- Because the system is universal, the appearance of choice is removed. When a doctor says "nothing can be done", it tends to be understood and believed, substantially lowering the emotional cost of cutting off care.
- The USA provides a viable 'second tier'. This means that very wealthy people can spend more on health care (removing their incentive to change the current system), but it's out-of-reach enough for the vast majority that (1) few compare care and (2) Canadians choose to keep the system reasonably well founded.
In conclusion, I'd say that American level health costs are frankly impossible for the rest of the planet. We're just not rich enough. So, countries like Canada and France have got Corolla level health care at Corolla level prices, and the USA has Lexus level health care and Lexus level prices. If all you care about is transportation, then the Lexus costs a lot more for a little more. But if someone is threatening to trade in your Lexus for a Corolla? Ouch.
I'm still scratching my head to determine how folks ignore the fact that where there is no third party payment for medical procedures there is a consistent trend toward lower prices and higher quality.
No one gets LASIK or boob jobs paid for by their insurance or Medicaid or Medicare, at most you can save money tax-free through your Flexible Spending Account. Why would cosmetic procedures be any different from anything else? Why does the free market work so well for those services, and yet we don't trust it to handle run-of-the-mill illnesses?
And best yet, we wouldn't have to worry about some imbuing government with the power to determine who lives and who dies. People can decide for themselves that spending $1,000 a day to prolong Dad's life 2 weeks just isn't worth it.
By toying with these quasi-socialistic approaches to health care we give further creedence to the absurd and dangerous notion of positive rights. We must avoid this at all costs if we really want this crazy experiment with liberty called the United States to last much longer.
I'm confused. When did "Progressive" start meaning "Socialist"? Can we not call a spade a spade any more? Is that our problem?
There is currently no free market in medicine. Just because the government isn't running things doesn't mean the market is running wild. It is a heavily regulated industry that bases most of its pricing off of Medicare prices.
As has been mentioned, one of the real costs of American healthcare is end of life treatment. The fact is that in many countries, people are allowed to die because the government stops providing care at a certain age. If you look at the numbers (somewhere north of 20% of total healthcare dollars) for end of life costs, the U.S. could save over 3% of GDP (.2 X 15.3%). If they add in making access to care more difficult for older people, you're probably very close to French levels of spending.
Jane, the post is good because it gets to the heart of the matter: in order to reduce medical costs, we need to reduce medical care. That's should be the crux of the debate, because if we have universal care, service will be cut. We don't need a gigantic new system, we just need the government to refuse to pay, and to make it legal for insurance companies to refuse to pay. Then we will have the European system.
There are some really cold-hearted types here, Yancey and Peter in particular. What goes round comes round, and they'd best hope that the dictum doesn't apply to them.
I believe what Yancey said is that (1) most of our healthcare costs arise from life-extension treatments with very small returns and (2) it is not sensible to be infinitely warm-hearted with other people's money.
That's not "cold-hearted"; it is fact and common sense. The problem is that we presently have a system that is not necessarily bound by either facts or sense, and has sufficient access to other people's money to drive itself into cycles that are beyond sustainable.
I'm returning to a post I made earlier. If health care is so bad in Canada, France, Italy, Germany, the UK, etc., why don't the voters in these countries elect governments that pledge to abolish "socialized medicine"? Are the voters there stupid? Is that Megan's premise? Or is she going to argue that Canada, France, etc. are dictatorships? I await her answer with baited breath.
BladeDoc: Drop the indignation. Cost/life decisions are inevitable. We could conceivably spend all of GDP on keeping one 120-year-old alive. Somewhere you have to draw the line. Don't pretend you're superior because you place it somewhere else.
Don't pretend you're superior because you place it somewhere else.
You're missing the point of that post. It isn't that he (or she) places the line in a different place. It's that everyone draws the line in a different place. That's what makes a "one size fits all" policy problematic, both politically and ethically.
Progressives believe in making people do the right thing through the police power of government. Socialists believe in government control of major industries for the good of the people. Where is the inconsistency? It certainly follows that the solutions that progressives pose are socialistic.
The effort of the Left to rename themselves every few years to escape the negative connotations that earlier names accumulated is well-known to anyone who has read at least a few pages of Orwell.
Stan-
You wonder why other countries don't follow our lead. It's simple, they are nations that have long and proud traditions of collectivism. They believe in the power of the state to create utopia. They believe that a right is anything that makes your life easier.
The US is profoundly different because we are a country of individualists. We have a Constitution that has enshrined Natural Rights as the basis of our liberty, in contrast to the Positivists of Europe. The Canadians, having never really split from Britain, do not have the same disgust for European trends that we do.
If health care is so bad in [the US],why don't the voters [here] elect governments that pledge to [establish] "socialized medicine"?
There. Much better.
Seriously, their societies may have different values or priorities, or they may just suffer from inertia, like all polities. I see no reason to do X merely because other countries do X, any more than they should do what we do just because we do it.
Put another way, American voters should get to decide American policies. I should not be ruled by what people in other countries choose.
With respect to the end of life care issue, I think it would be helpful if living wills and advance healthcare directives were a requirement of insurance. As it stands now, only about 25%-30% of the population has executed a living will, and, when it's needed, it often can't be found by anyone and does not become part of the chart. If one has a living will that calls for nothing heroic as the end of life nears, doctors and hospitals should, at the very least, be required to honor the patient's wishes. If they don't, they shouldn't be paid for any services that the patient didn't want. For those who want everything possible done to keep them alive as long as possible, they should be charged a higher insurance premium. I wonder how much of our higher healthcare costs are due to our much more aggressive and intensive interventions at or near the end of life.
Also, keep in mind that any universal healthcare system in the US would have to deal with all of the social issues we still face, like race issues, geographic distances of a vast scale (i know they have some of that in Canada, too, but I'd imagine the homogeneity of their population outside of cities and nature of rural living makes this less of a concern), as well as a movement of "Right to Lifers" who, besides opposing abortion on moral grounds (a position which I hold with qualified exceptions) also believe that old people should be dragged along forever and ever until there's just literally no way to keep the often mindless body alive. I'm not advocating euthanasia, as cost-effective as it would be, but rather saying that some of these "life-saving" drugs and procedures, while they may keep gramma with us for just that little bit longer is it a) going to make gramma any happier, or in any less pain, and b) would it really be fair to the taxpayers in this hypothetical universal healthcare system to have to treat these old people when they themselves and their families would choose not to?
Thus a lot of the other arguments against socialized medicine come into play...
Perhaps a solution to this would be a "dementia test." If we established criteria for when a person is mentally "gone" (i.e. neurological tissue blockage/breakdown levels, cognition, etc) and then ceased extreme and expensive medical care to prolong life after that point, then the age issue might be taken care of. I liked one earlier commenter's idea of "giving antibiotics and pain-killers only." That would in all likelihood drastically reduce the whole issue; Medicare was designed when people would regularly die at ages like 60 and 65, and these were considered old ages and not tragic. Without automatically dooming everyone to die at these ages, it seems like reducing the frequency of expensive treatments in universal healthcare provision (although this might descend into classism... there would only be "ancient" rich people) for those who could not supplement it after a certain age, level of mental decline, or long-term viability of treatment with their own money might be another solution.
As for me, I'm just glad to be going on Tricare soon. I have never had health insurance because my parents zealotry against QualChoice's funding of elective abortions has left me with a host of easily treatable congenital problems that we couldn't afford to treat without any kind of insurance, but that would greatly enhance my quality of life. Sometimes even those who have healthcare insurance available choose not to use it for other reasons... maybe consider that variable... the "fundy factor" in America that definitely doesn't exist in Japan or most of Europe.
"What is the magic route by which we are going to cover all the people not currently covered by government insurance for 2.2-2.8% of GDP?"
No magic is needed. The 7.7% the government spends is almost all on the elderly. The rest of the population is very cheap to care for.
Medicare and the portion of medicaid spent on the elderly come out to about 5.8% of GDP. The rest of medicaid costs about $1800/yr for each person. For 200 million people not currently covered by the government, that's about 3.0% of GDP. That brings us to 10.7% of GDP for the whole country. (5.8% for seniors, 1.9% current non-senior medicaid, 3.0% the rest). Administrative savings for the bulk of providers who no longer need to retain any capacity for dealing with private insurers, who could be pressured to pass those savings on to the government, might even get it down to 10.5%.
BTW, the government does pay almost 1% of GDP for prescription medicine.
The single biggest reason that the US health system is more expensive than anyone else's is that the US is the only country in the world to pay doctors what they're worth. Incedentally, the US is also the only country in the world not to have severe doctor shortages.
The second biggest reason that the US health care system is the most expensive is that the US is one of the few countries that doesn't try to destroy the pharmaceutical industry by capping prices at a low level, with no concern as to whether or not that will earn back their R+D costs. This terrible, cost-increasing practice means that the US is the sole reason why the world gets 90% of the new drugs it gets - without the US policy being the way it is(or some similar-sized nation opening itself uop in the same way), most new drugs would be unprofitable and their development would cease.
#3 on the list of reasons is that the US contains a higher proportion of litigious bastards than anywhere else, and that legal/malpractice costs go up accordingly. I offer no defence of this practice - this part of the system needs to be changed.
And take the WHO numbers with a grain of salt - when one of the characteristics that goes into the rankings is "how the care's paid for", it seems like an excuse to bludgeon the US.
Mmmmm . . . try again. The rest of Medicaid is spent on an unusually healthy population: young women and small children. It isn't treating any of the expensive ailments of middle age, from diabetes to cancer.
Then there are the 40 million uninsured you've promised to care for . . .
#3 on the list of reasons is that the US contains a higher proportion of litigious bastards than anywhere else, and that legal/malpractice costs go up accordingly. I offer no defence of this practice - this part of the system needs to be changed.
While I favor tort reform (going to a loser-pays system) I don’t think that it is a significant cost-driver for health care costs. IIRC the amount of awards has been pretty flat although the costs of litigation (which aren’t part of the awards) may have increased and there are certainly costs in the form of defensive medicine although one doctor’s “defensive medicine” might be another doctor’s “quality of care.” There is also the legitimate claim by opponents of tort reform that we have too many people who are injured due to medical errors and many who don’t get anything because it is difficult to prove a malpractice case.
What I do think would be an improvement would be going to a system of electronic health records whereby each patient/consumer would be able to get an electronic copy of their medical records including treatment and billing similar to the system the Veterans Administration moved to in the 1990’s. The VA found that the system pretty much paid for itself by reducing the number of duplicate tests and they’re a useful tool in preventing many medical errors (and thereby many patient injuries and lawsuits) such as adverse reactions to medications, misdiagnosis, etc. Also it has some serious potential for stopping health care fraud which eats up at least 3% of all health care costs.
Moreover for those of us that favor a free-market or consumer-driven style of health care reform, EHT’s allow patients to bring their medical history with them and may have the potential for allowing patients/consumers to shop around for health insurance the say we can shop around for automobile insurance.
"Mmmmm . . . try again. The rest of Medicaid is spent on an unusually healthy population: young women and small children. It isn't treating any of the expensive ailments of middle age, from diabetes to cancer. "
You don't know much about medicaid.
It covers natural parents, but also foster parents and many adoptive parents who are not so young. It covers any household with less than $2000 in assets (though those have restricted benefits). It also covers 9 million people eligible for SSI who have life-long chronic, dibilitating conditions, which alone skews the covered population to "less healthy" than the rest of the non-senior population. It isn't just young mothers and children.
"Then there are the 40 million uninsured you've promised to care for . . . "
They are included in my calculation. They also include some of the cheapest elements in society to insure. Many are uninsured by choice. Those are healthy, young people with no prospects of pregnancy. While they may like insurance, they opt out by choice, not need.
Njorl,
Sounds like you are advocating Medicaid for all.
Do you think Medicaid partially free-rides on private healthcare dollars, or do you think the relationship goes in the other direction? The same question applies to Medicare.
Here's an idea, before we go ahead and nationalize the remaining 50% of healthcare dollars that come from private sources in the U.S., let's try to actually have de-regulated, market based medicine.
1) No tax deduction difference for health insurance payed for by an employer versus an individual or non-employer group.
2) Removal of legislative mandates and regulation for specific coverage for health insurance
3) Removal of 50 state micro-markets all regulated differently
Foster parents? Foster children, yes. But foster parents have to prove that they are meeting their own financial needs before they can have foster children; AFAIK that would by definition disqualify them from Medicaid's means test. I could be wrong, but none of the foster parents I've ever known have gotten Medicaid for the parents (they almost always get it for the kids) unless they're a special circumstance, like a close relative allowed to foster the kid. Perhaps their social workers were incompetent.
And AFAIK, the OASDI are in the "old people" basket, no?
And AFAIK, the OASDI are in the "old people" basket, no?
Yes however both the disabled and the elderly make up a disproportionate share of Medicaid expenditures:
Underlying today's debate is the critical question of how Medicaid can survive as it shifts from funding medical care for the young poor to providing custodial care for the elderly and disabled. Already, Medicaid's seniors claim 26% of the program's budget -- $48 billion in 2003 -- even though they make up just 9% of enrollees. The disabled -- including the mentally ill and those suffering from debilitating chronic diseases or developmental disabilities -- represent 16% of the rolls but take 43% of Medicaid's funds, almost $80 billion in 2003.Medicaid already pays more than 60% of the nation's total tab for nursing homes, vs. just 5% paid by Medicare, the government's medical insurance plan for the elderly. As more seniors join the program, costs will rise more rapidly. Care for seniors and the disabled averages more than $12,000 annually per person, while caring for a child or young adult costs less than $2,000. And as the 40 million baby boomers age, their growing demand for nursing care threatens to crush Medicaid's original mission of serving impoverished mothers and youngsters.
Source
http://www.globalaging.org/elderrights/us/2005/newface.htm
So based on this it looks like in 2003, 25% of Medicaid’s enrollees account for nearly 70% of their costs. However it’s also possible that the elderly are also part of the disabled population in Medicaid so it could be that it’s as low as 16% consuming 43% of the costs (making the generous assumption that all seniors on Medicaid are also part of the disabled) which is still pretty high.
"Njorl,
Sounds like you are advocating Medicaid for all.
Do you think Medicaid partially free-rides on private healthcare dollars, or do you think the relationship goes in the other direction? The same question applies to Medicare."
I don't know about advocating...
I am explaining that it is feasible to provide. Personally, I'd spend a bit more to get more than medicaid.
I don't think there is necessarily free riding one way or another. I think there is gross inefficiency in private health care provision because the ultimate customer has little grasp of what they are paying and what they are buying.
Medicaid does so much better because the customer is not the patient. It is the government. The government, at least in this case, bargains hard.
You may think that private insurers would do the same thing, even more efficiently because they are allowed to have greedy motives. They don't. While each individual insurerer wants to minimize costs, the insurance industry as a whole wants to maximize them. The more health care costs, the more necessary, and valuable (and profitable)insurers become.
Because there is so much more money chasing medical services than there should be, the strong and shrewd customer (government) can demand a huge bargain.
I think our current system is as bad as it gets. People either need their government representing them to get the best price they can, or they need to feel the sting of the real costs they are paying. As it is, we have anesthetizing leeches sucking our blood.
"And AFAIK, the OASDI are in the "old people" basket, no?"
Not from what I saw. It was labelled child, adult, and 65 and over. SSI is by definition, not OASDI. It is specifically people not over 65.
Njorl,
So you think insurance companies like spending money on things that subtract from profit? Where is your evidence for this assertion?
I see no reason to believe the government cares more about how much it spends on healthcare on behalf of its users than health insurance companies care about the spending on its users. In fact, as you mentioned then discarded as an argument, I would believe they have more incentive to control costs because it would increase their profits. It might be that they do a poorer job of controlling costs, but that may be due to the fact that the state of the law prevents them from exercising all options, options that are open to the government programs, such as flat denial of coverage for certain items. Almost every complaint I have read about private insurance companies involves the denial of payments for care. It is hard to square this with the assertion that insurance companies like to drive up costs because it benefits them.
I see no reason to believe the government cares more about how much it spends on healthcare on behalf of its users than health insurance companies care about the spending on its users. In fact, as you mentioned then discarded as an argument, I would believe they have more incentive to control costs because it would increase their profits. It might be that they do a poorer job of controlling costs, but that may be due to the fact that the state of the law prevents them from exercising all options, options that are open to the government programs, such as flat denial of coverage for certain items. Almost every complaint I have read about private insurance companies involves the denial of payments for care. It is hard to square this with the assertion that insurance companies like to drive up costs because it benefits them.
I also have a tough time believing that an individual insurance company is willing to forgo higher profits for itself for the good of some mythical insurance cartel. From what I’ve seen from talking with people in health insurance companies and benefits administrators at a number of local companies, the focus seems to be on encouraging preventive care and moving towards a pay for performance system in order to try to control health care costs. I also don’t buy the idea that making health care more expensive is good for health insurance companies because while it may enable them (or drive them) to increase premiums, it also means that more people cannot afford health insurance which means fewer customers (read: employers) are able to afford premiums.
Also I don’t see any benefit to an insurance company in having to pay for routine medical expenses because they’re too expensive for people to afford on their own. Seems to me they’d be better off if routine expenses like checkups were so affordable that people were able to pay (and did so) on their own rather than make them so expensive that their customers forgo them and end up with a more expensive illness that the insurance company ends up paying for.
The single biggest reason that the US health system is more expensive than anyone else's is that the US is the only country in the world to pay doctors what they're worth. Incedentally, the US is also the only country in the world not to have severe doctor shortages.
The second biggest reason that the US health care system is the most expensive is that the US is one of the few countries that doesn't try to destroy the pharmaceutical industry by capping prices at a low level, with no concern as to whether or not that will earn back their R+D costs. This terrible, cost-increasing practice means that the US is the sole reason why the world gets 90% of the new drugs it gets - without the US policy being the way it is(or some similar-sized nation opening itself uop in the same way), most new drugs would be unprofitable and their development would cease.
#3 on the list of reasons is that the US contains a higher proportion of litigious bastards than anywhere else, and that legal/malpractice costs go up accordingly. I offer no defence of this practice - this part of the system needs to be changed.
And take the WHO numbers with a grain of salt - when one of the characteristics that goes into the rankings is "how the care's paid for", it seems like an excuse to bludgeon the US.
Don't insult me, insult Ross Perot. I was just quoting him.
Roger, wilco, Mike. Ross Perot is as full of beans on this matter as he is on many others too numerous to list here.
Anyway, don't believe everything that some random guy on the internet says. If it turned out that infant mortality rates were uniformly defined as deaths before age 1, would you change your mind?
Not necessarily. There are things other than the nature of a nation's healthcare system that contribute to infant mortality numbers, even applying this supposedly "neutral" definition of the term. If there are real such cross-national differences, there is no reason to suppose that changing just the healthcare delivery infrastructure will necessarily improve matters.
If it turned out that, in an apples-to-apples comparison Sweden and Japan had half the infant mortality rate of the U.S., would you change your mind?
If it turned out that under laissez-faire capitalism every poor child got new shoes and a horsey would you change your mind about the superior efficacy of government entitlement programs?
The infant mortality rates of Sweden and Japan are not half those of the U.S. and aren't even in that neighborhood.
How about we stick to reasonably verifiable facts and leave the wishing up to those poor solipsists who think reality is "socially constructed."
Singapore has a relatively private health care system and much better infant mortality numbers than the U.S. Are you willing to believe that?
Singapore's reported infant mortality numbers are certainly very low, but I don't think the degree of privateness of their healthcare system is very highly correlated with this circumstance. Singapore is a city-state. It has no rural areas remote from big-city medical facilities and no large urban underclass populations living high-risk lifestyles. In fact Singapore also has a quite draconian approach to policing its citizens's lifestyles in most respects. Are you willing to put up with Singaporean levels of government lifestyle coercion to boost American infant mortality figures? I'm not.
I was just asking Mr. Eagleson whether he was willing to be responsive to the facts. I wasn't asking him what the facts are.
I'm always responsive to facts. To wishes and baseless hypotheticals, not so much.
In any case, I think you're mistaken about why people have doubted the comparability of infant mortality rate numbers and about their actual comparability. Let me know what you think of this.
I think the same thing about it I thought some years ago when I first researched this issue. The U.S. has a modestly higher overall infant mortality level than the advanced Asian and European countries. Changing the normative definition of "infant mortality" by amalgamating figures for all deaths below age 1 probably does provide a better basis for trans-national comparison than just what most countries report as "infant mortality" per se.
The modestly higher U.S. number, however, hides one extremely salient fact - infant mortality in the U.S. is quite bimodal. For all but chronic underclass groups, infant mortality here is essentially the same or even a bit better than in the countries to which we are usually invidiously compared. Within these U.S. underclass subpopulations - urban blacks, some Hispanics and many reservation Indians - infant mortality is much worse.
Unfortunately for the thesis of single-payer healthcare advocates, nearly all of the people in the bad infant mortality sub-groups already get all of their medical care from government. While an opponent of single-payer healthcare, even I don't claim that there is a causative relationship here. These people are seriously screwed up for all sorts of reasons having nothing to do with the mode of their healthcare delivery.
Meanwhile, the large majority of ordinary U.S. citizens, who enjoy infant mortality numbers comparable to the supposed medical care paradises of France, Canada, etc., get most of their medical care via employer- or self-provided insurance.
To reiterate: The reasons why U.S. chronic underclass populations are the way they are - including their infant mortality rates - are complex and numerous, but the mode of medical care delivery is, I believe, not centrally decisive in any aspect of their relative dysfunction. As these folks already rely heavily on government for their healthcare provision, it's hardly obvious that forcing the rest of the U.S. into an all statist medical delivery mode will have any siginificant effect on these current problem populations, good or bad.
And moving the rest of the country - which is doing just fine with the status quo - to an all-government, single-payer system is unlikely to produce any improvement either, at least in the area of infant mortality rates.
But now I'm curious about whether you're willing to be responsive to the data (whatsoever they may be) as well. If you were convinced that, in apples-to-apples comparison, all Western European, the richer Asian states, and Canada do better in a half dozen metrics that you picked in advance, even though they spent less per capita and are less wealthy per capita, would that make you change your mind about anything?
I'm always responsive to data. What I am not responsive to are attempts to take single national statistics with complex components and causes as stand-ins for the "quality" or "efficiency" of alternative healthcare delivery modes when no evidence is presented to support the notion that it is said delivery mode that is causative of whatever differences exist.
There may be an intellectually respectable case to be made for single-payer healthcare delivery. But contrasting the infant mortality statistics of the U.S. with those of other countries which have such healthcare systems - but also have populations that vary hugely from that of the U.S. in terms of size, ethnic diversity, age distribution, birthrate, etc. - is not it.
Thorley Winston - checkups are actually quite affordable, even if you pay full price. If the thought of paying $100 for a measured professional opinion bothers you, call around and find someone who's willing to bargain. I suspect you would find quite a few family physicians who would happily take $50 cash on the spot for a visit.
The infant mortality rates of Sweden and Japan are not half those of the U.S. and aren't even in that neighborhood.
Where are you getting your numbers from? Compare them with these. (And be grateful that you don't live in Angola.)
An idea I had regarding tort reform was that we could allow reverse insurance. The idea is that people could sell some or all of their right to sue to a third party and use the money to offset the cost of a procedure. It would partially indemnify the doctor from the patient's perspective, but without the moral hazard, since the doctor would still be liable for a screw up. Something like a cap on, or elimination of, pain and suffering awards could actually be embedded in a regular insurance policy with lower premiums (the third party buying out part of your tort rights is your regular medical insurance provider).
An essay here.
Healthcare costs are wwaaayyyyy too costly! Slipping on the green eyeshade gives you a perspective that only those true bean counters can possibly admire...
First of all, the only truly healthy group are those under 29 years old. In the 30's you are seeing incredible numbers of old-age symptoms in our overfat, overfed bunch of youngsters. Also, still believing they are armor-plated, they often have extremely poor health habits (put down the KFC, stub out that cig, get yer butt off the couch and out the door!!).
The best thing we can do is to only provide free or subsidized healthcare to those 29 years of age and younger. This would absolutely save billions of dollars, and provide it only on that group that is most at risk (children - all for the children) and are least expensive to pay for. As part of the moving into the middle-age category of 30-70, you would require these folks to get educated on healthy lifestyles, and get the equivalent of a Master's degree in it so they can make themselves healthier as they age and get creaky.
Frankly, as many people as there are in the world right now, we could do with a few billion less. So, if anyone of 30 were in an accident or had an illness, there should not be any medicine expended upon them beyond the use of acetylsalicylic acid. What the hell, if they can't stay healthy on their own, let the worms, at least, enjoy the organic matter.
Poof! Now there isn't very much of a problem with the cost of healthcare.
As I commented over at Simberg's in his pointer noting employer provided insurance as a big problem:
"It's the second biggest cause of healthcare/insurance problems, after the fact that Medicare exists and the government de facto controls how much gets paid for what and artificially changes - well, eliminates - the market.
Oh wait! The government ALSO caused employer provided health coverage to exist!
Ah, the great tag team of Roosevelt and Johnson; what would we do without them?"
Government is the problem. It's probably too entrenched to change that, sadly, which makes going the rest of the way to complete government provision of healthcare a logical if horrifying reaction. Yet not that much of a stretch, since they already control things through Medicare. Not to mention promoting heroic and expensive end of life expenditures for keeping grandpa alive and miserable One More Day.
Ah, the good old French health care system.
I, like Mr. Yglesias, long for the days when we in the United States can lose 15,000 elderly people to a heat wave without putting a significant financial strain on our health care system.
Serously, how does a country lose three times as many people to heat stroke as this country lost to 9/11 and Katrina put together and still get to stand on a pedestal as a paragon of health care virtue?
"Njorl,
So you think insurance companies like spending money on things that subtract from profit? Where is your evidence for this assertion? "
Yancey,
You completely missed the point of what I argued. Individual Insurance companies work to keep their own costs down. Insurance industry organizations, like AHIP, work to keep prices as high as possible.
Yes, this raises the cost of insurance so that many can't afford it. AHIP then lobbies for tax credits so that poorer people can purchase private insurance! It's even better than a protection racket. The mob never lobbies for tax credits so that shop owners can afford higher extortion payments.
No matter how much you spend, you can't buy immortality. We're all going to die. No one gets out of this life alive.
Back in the old days, people weren't shipped off to discrete locations to pass on. They died at home or near home. Death was among us. It was natural. Today, we treat it as unnatural. We desperately seek any means at any expense to keep it at bay. And everyone else is expected to pay that price.
People used to die of 'old age'. No one dies of 'old age' anymore. It goes back to treating death as unnatural. 'Old age' isn't natural. At least by today's standards. Everyone dies of something. It's all for the statistics which in turn are for funding. Death is a big pie chart. Decrease the 'cause' of death in one category, it increases in another. Which becomes the basis for demand for attention, funding, and fear mongering.
"#3 on the list of reasons is that the US contains a higher proportion of litigious bastards than anywhere else, and that legal/malpractice costs go up accordingly. I offer no defence of this practice - this part of the system needs to be changed. "
This is a non-issue as far as total costs are concerned. Malpractice suits, settlements and litigation comprise less than 1% of medical costs. The issue is hyped beyond reason.
But, if it bothers you, keep this in mind; a universal system would eliminate malpractice insurance.
Driving down medical costs is easy. It's simple supply and demand. Increase the supply, while holding demand constant (a neat trick if you can do it), and the price will drop.
How many of you know that the Clinton administration actually paid medical schools NOT to train new doctors because the politically powerful AMA feared a "doctor glut" (google those words for more information) would put a crimp in their member's earning power?
Njorl,
I understood your argument, I am just saying that it makes no sense unless most of the extra expenses in healthcare go to profits of insurance companies, but no insurance company in the world makes the 30% profit margin that would cover the extra amount of GDP that US is said to waste on healthcare. No insurance company comes close. Cigna had a profit margin of 6.7% last year and it is one of the most profitable in the nation.
Here's my warning from the UK.
I dislike the NHS because it:
A) Nationalises people.
b) Rations treatment on beurocratic whim.
c) Incentivises poor health choices.
d) Is funded by punishing success.
e) Has no working feedback mechanism.
f) Provides poor service.
g) Provides further wedges for a state to remove choices.
h) Is staff focused not customer focussed.
i) Is "one size fits none".
j) Has no pressure to improve.
k) Sees patients as a cost, rather than a customer.
l) Crowds out better providers.
m) Protects bad staff.
n) Obscures poor performance.
o) Is top-down not bottom up.
p) Is all or nothing/ Take it or leave it.
q) Deters innovation.
r) Subsidises and thus lowers the quality of immigration.
s) Incentives ill people to migrate to the UK.
t) Has a fixed pot of cash that does responds too slowly to changing demographic health.
u) Centralises staff away from communities.
Socialism kills, and the NHS is the most distilled form of socialism.
As a plea to Americans, don't sacrifice your system because you have lost confidence in your own abilities.
The issue is simple,but politically imporssible. Until people have the personal incentive not to use expensive health care, pay for expensive drugs or have the last operation for their parent health care costs will run out of control.
Most of the arguments above involve top-down planning to take the decision away from individuals and give to someone else.
How many people have the ability to use spend health care dollars for a plan that balances cost/benefit, including the option on NO health-care insurance, Most employees dont, most government health-care recipients dont.
I don't think we have a health care problem, we have a health-care financing problem, where everyone want to pass off costs of their health-care to someone eles.
If over-market salaries, pensions, benefits, leave time, tenure and non-existent productivity standards of many present government employees is any indication, Government will be even less able than Private insurers to control the largest percentage of budget in any health care plan --- medical care workers increasing compensation and latitude to give themselves a form of pay raise by minimizing their productivity. Government controlled/funded health care will simply extend the chaos and triage of the ER to the rest of health care services. Substantially full coverage medical plans of Unions and Government employees currently guarantee price increases thru over-utilization and guarantee ever-increasing base funding to the med industry. Huge, ever increasing and guaranteed base funding supports continuous price increases, price increases that can then be made pay-it-or-leave-it to under/non insureds. Require co-pay of a significant portion of each medical service and demand/prices of medical care will go down. The individual's pocket book, not government or private insurers will provide triage.
Reminds me of an old quip by Milton Friedman:
[Someone]: The Swedish are much more successful than Americans.
Milton Friedman: Why yes, and Swedes in the United States are much more successful than most Americans as well.
>
No it's not "hyped beyond reason", because you're not taking into account all the millions of dollars wasted because of "defensive medicine", unnecessary tests and consultations with doctors that are ordered soley to protect the ordering physician from being sued for malpractice. That's one big problem that would pretty much go away with medical malpractice reform and it neeeds to be done on a national level so that each individual state doesn't have to spend the next 20 years trying to combat the plaintiffs lawyers attempts to block such legislation.
On top of that, fixing the system in the US is relatively easy. Open up the insurance market so people from one state can buy insurance from carriers in another state, which would drive the cost of health insurance down. Right now one can't do this. Remove the deductability of insurance premiums from businesses so they stop providing insurance, and make health insurance premiums tax deductable for individuals buying the plans. All of these things would shift things towards individuals buying their own plans, shopping around for what they can afford and need, and result in premiums falling.
Sorry, I was speaking about the comment that the medical malpractice crisis is overhyped. It plainly is not.
Every industrial country but ours has universal health coverage, and they're all democracies. If their health systems are so bad and ours is so good, why don't they switch over to our system? Why didn't Mrs. Thatcher, for example, abolish the National Health?
Have you ever seen the politicos voluntarily relinquish any power they have attained?
It might be funny to subject ours to the complaints everyone makes to health insurance companies. They thought the "Comprehensive Immigration Bill" caused their phones to light up!
A note about taxing profitability. Underwriting profits (premiums - claim reserves)are negligible and often negative. Investment profits make insurance companies successful. Currently our government is prohibited from mucking up nearly everyones pension accounts by "playing the market." Taxes which take away the cushion the insurance companies utilize to attempt to stabilize rates being taken away will result in rating increases to cover the cyclic trends on strictly an underwriting basis.
We pay more because we get more, and those that pay also pay for the uninsureds' free care at every emergency room. I'm personally acquainted with people that have decided not to contribute $20 a month on an employer provided health care plan that would have given them $15 office visits and $10 prescriptions because they would prefer to go to the emergency room and not pay anything.
When we bring all the self-chosen uninsured in the system and force them through taxes to support it, do you think they will still avoid going to a doctor unless they actually need to? Or will you consider that utilization and thus costs of this new expensive "right" will climb dramatically? Medical care and availability rate of growth will slow, but by the time it stops and starts to decline, the current crop of America's only distinctly criminal class will have retired.
Remove the deductability of insurance premiums from businesses so they stop providing insurance, and make health insurance premiums tax deductable for individuals buying the plans.
This isn't clear. Are you suggesting that a health plan provided by an employer shouldn't be deductible on the employer's taxes, or on the employee's?
Either way, you're introducing a bizarre anomoly into the tax code. Pretty much everything your company gives you is deductible to them as a cost of hiring you; assuming you want to exempt health care from this, you're proposing to further complicate the tax code is an odd way. Making the opposite assumption, wouldn't it be strange for Employee A to be taxed on the price of health insurance paid for by an employer, but for Employee B to take a deduction for buying his own plan? And wouldn't that deprive many employees of the benefits of a group plan?
Of course, there are plenty of people who could afford to take health insurance but don't, as RRRoark has pointed out, and their numbers would probably grow if more people had to go to the trouble of shopping around rather than just checking a box on an employer's election form.
As I said in the first comment, separating health insurance from employment is a good idea, but not trivial to achieve, so far as I can tell.
'How many of you know that the Clinton administration actually paid medical schools NOT to train new doctors because the politically powerful AMA feared a "doctor glut" (google those words for more information) would put a crimp in their member's earning power?'
Bull.
A bipartisan effort (Republican congress and Democratic president) passed legislation that ended a set of subsidies for med schools. At the same time, subsidies to teaching hospitals were increased*. It was a matter of spending the money more intelligently. Med school enrollments were not being encouraged significantly by the subsidies while teaching hospitals were having funding difficulties. The "doctor glut" was a matter of too many doctors coming out of med school with inadequate means to further their education, not a case of too many doctors.
Still, if Clinton did it, it must be part of his plot to destroy humanity.
Easy answer, work visas for foreign doctors.
"Open up the insurance market so people from one state can buy insurance from carriers in another state."
You mean... nationalize healthcare! :)
There are an incredible amount of tests that could be dispensed with if doctors were not paranoid about being sued. The standard of care says go get an MRI because a significant number of doctors (maybe 30%) can't reliably diagnose without it. You have 20 years experience and you already know what the MRI is going to show. But if you omit that MRI and a bad outcome happens, that missing MRI from the chart is going to be a nail in your professional coffin. Expert after expert will testify that having the MRI was the standard. You're sunk then so why save some insurance company some money by risking your livelihood?
I do think that we're going to EMR/e-prescribing because there were incentives for it in the Medicare part D bill. In a few years, bill submission via paper is going to command lower reimbursement than electronic submission. New practices are going to all go EMR and the old guys will either go out of business via retirement or bite the bullet.
"slashing the salaries of doctors"
How, by government mandate, I thought you would allow the market place to set the rate. Even the libertarian seems to want his health care for free. Anyone whose labor is controlled in this manor is the victim of slavery.
Everyone assumes that physicians make a lot of money. Examine the case of a new physician, true story, who has just signed a 3 year contract for $300,000 plus per for his 1st job. Impressive? Let's apply a little reality, after undergraduate degree(3years), medical school(4years),surgical residency(5years), vascular fellowship(2years) for a total of 14 years this is not a fantastic reward on the investment. This is only the time factor, the dollar cost is usually about $200,000.
Do the math on life time after tax earnings, compare physicians to other professions and there is not that great a differential.
As a physician, English working in Canada and spending time in the US, I have some knowledge of medicine and the different health care systems. I am impressed by how clueless both you and most of the people who discuss this topic are.
PS. As a physician I don't care if I am loved but I deserve respect and every discussion of health care treats us as if we are a commodity. Beware because the medical community is not happy.
Has anyone taken a look at ranks of med schools and healthcare training? What does the future supply of doctors and service workers look like?
Lot's of graduates ran from the job market collapse in 2000 to law school and med school. I think this was common for several years following. Seems like there are lots of people training to become nurses and assistants.
How, by government mandate, I thought you would allow the market place to set the rate.
It's not hard to see how "not restricting supply severely" anymore, would do anything but reduce salaries.
Even the libertarian seems to want his health care for free.
No, it seems libertarians are the only ones who don't want that.
Anyone whose labor is controlled in this manor is the victim of slavery.
I think anyone whos labor is "controlled" in any "manor" is a slave. Now, if you meant "manner" on the other hand ... :-P
I don't know who coined the phrase, "The perceived value of anything that is free is nothing," but it certainly applies to government-funded health care. I work in a medicaid-funded, public clinic, and one problem that I see often is the abuse of emergency services as primary care. And this is in a population that is frequently living proof of the co-morbidity of poverty, poor health choices, substance abuse, obesity, diabetes, etc. (and a number of childhood disorders related to lifestyle choices and substance abuse of the parents, but that is a whole 'nother issue).
By contrast, my employer's health plan gives me a financial incentive, through a very low copay with no deductible, to go to primary care for anything that I can. I also get a stiff consequence, in the form of a pretty large deductible, if I choose to go to the ER in the middle of the night because I have a sore throat or a twisted ankle instead of waiting until morning to see my PCP. I get generic meds for practically nothing, but pay out the nose for non-generics that have a generic equivalent (we split the difference on those that don't). Our insurance company creates these incentives on purpose to encourage me to make good health care choices that keep their, and my, costs down. The problem I have with any government system that gives it away totally free is that there is no incentive to make good health care choices. No one should have to choose between eating and getting medical attention, but I certainly see a LOT of abuse of the system simply because there is no reason to care about the actual cost of the service.
As for regulation, less is ALWAYS more. Doctors and hospitals are so burdened with regulations and risk-management measures that they are often not free to innovate. The American way is to use our creativity to do things better, faster, and cheaper than our competitors, and the devil take hind-most. However, the entire medical industry is trapped in this swamp of bureaucracy that stifles their ability to do things efficiently and cheaply. I've read several ideas here like "we should mandate that they go to electronic records", or "we should mandate [enter your suggestion here]". Mandates are NEVER the answer. Free markets and competition work better than anything yet invented, but they have to be freed to do so. My dental plan only pays the "usual and customary", (which is a euphemism for "about half of what it really costs.") Hence, I shop around for a dentist who's sliding fee scale or regular fees are closest to that amount. I can walk across the street to a dentist that will bill me WAY over that amount because he is convenient and has millions of dollars worth of the latest decor and equipment, or I can drive 30 minutes to a more modest facility and get good care with almost no out-of-pocket expense. Hmmmm; which do you think I will choose? What if medicaid recipients got those same choices? Instead of telling them "you will go to this provider" like we have now, they got "we pay this much, take it and go where ever you like and pay the difference." Some might make different health care choices that benefit not only themselves, but everyone who uses the services or pays taxes. We might just see private-not-for-profit clinics spring up that take ONLY what medicaid pays, and get private grants to assist in their operation! The current system rewards providers to toe the line and simply bill what medicaid establishes as the norm, rather than having a reason, or even the climate in which, to offer consumers a financial incentive to choose them over their more expensive competitors. You don't see many health clinics with strings of banners and balloons out front advertising a special on annual physicals or well-child checks do you? But, drive down the part of town where all the car lots and furniture stores do business, and you'd think it was mardigras every day of the year.
Healthy choices also have to come into play. Some of us inherit genetic traits for cancer, diabetes, high blood pressure, high cholesterol, mental illness, etc. that we cannot help, but we still have a responsibility to take the best care of ourselves that we can to minimize the cost of health care. Some kind of incentive, like the low cost for young single people, the non-smoker discount, etc. should be devised. Many people just make horrible dietary and lifestyle choices that make keeping them healthy or even alive frightfully expensive. I don't see how the taxpayers should assume the burden for paying for their care. I shrink from putting limitations on care, but this is an area where I can certainly see doing it. Self-inflicted illnesses should only receive maintenance therapy, medication management, or, in extreme circumstances, palliative care. I'm sorry, but this is another area where the current medicaid system rewards bad choices for both consumers and providers.
I need to grip about public health clinics here for a minute too. The local private clinic (which takes medicaid by the way) has one PA, a part-time supervising physician, one nurse, and a minimum-wage receptionist. They work 6 days a week, and see about 50 to 60 clients a day. The public health clinic in the same town has 7 nurses, two office staff, and executive director, and a program director (because they run some many government mandated programs). They have clinic hours three days a week, and see about 5 people a day, some of whom are just coming in for condoms or needles (for which I am thankful!) The rest of the time, the directors are in meetings and trainings all over the region, and the nurses seem to spend about a day in training for every day of work. This kind of absurdity is part of why our current government-funded health care is such a large percent of GDP. I agree that the public health services provide an essential safety net to communities, but jeez louise! If the county put out an RFP for all of the services that this agency does, I'd bet that the local clinic could do it with the addition of a couple of nurses and a working/supervisor nurse practitioner, and the tax payers would save a BUNDLE. This is a perfect example of how the US government (or probably any government for that matter) would do health care. The less the government has to do with this industry the better. I am not a big fan of Ron Wyden's plan, but the brilliance of it is that it puts the money into the consumer's hands to make their own privately provided decision with. Rather than create or enlarge any government institution to oversee health care, I would much rather see them just create a group plan with which to purchase private insurance, and let the insurance companies(who, trust me, KNOW how to run this kind of business efficiently. That is how and WHY they make a profit!) compete for the contracts.
Finally, people who can afford expensive services should be able to receive them; that is a large part of what funds the demand for medical innovation in this country, which contributes more than any other nation to medical technology and pharmaceutical research. But, people who cannot afford them should not be herded into them out of some kind of "fairness doctrine". Public health care should not mean "free and unlimited" health care. It should mean basic health maintenance with incentives to make good health and financial choices.
40-some percent of all our health-care spending is for people who are in their last half year or so of life. You could bring us, instantly, into line with the cheapest countries by a vigorous policy of ... well, you know ...