What US Health Care Needs 584
Medical doctor and writer Atul Gawande gave the commencement address recently at Stanford's School of Medicine. In it he lays out very precisely and in a nonpartisan way what is wrong with the institution of medical care in the US — why it is both so expensive and so ineffective at delivering quality care uniformly across the board. "Half a century ago, medicine was neither costly nor effective. Since then, however, science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we're struggling. There is no industry in the world with 13,600 different service lines to deliver. ... And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem — far and away — is the soaring and seemingly unstoppable cost of health care. ... Like politics, all medicine is local. Medicine requires the successful function of systems — of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively. ... This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do."
also: more doctors, less pay, more compassion. (Score:5, Informative)
If I want to give my patients the best care possible ... This will take science. It will take art. It will take innovation. It will take ambition.
...it will also take the AMA not artificially restricting the number of new doctors. More than half of ostensibly qualified applicants every year are turned away. In the 1800s there were 400+ medical schools in the united states. By the early twentieth century there were less than eighty. The fewer doctors we have, the more each doctor is paid. The AMA carefully guards doctor salaries. This practice can be seen over and over (and resistance to influx of doctors willing to work for cheap) in country after country (the film Salud covers this well).
/. has a typical signal-to-noise comment ratio... for those who want to doubt my claims above, calling them propaganda, etc, they are backed up by reputable sources. Paul Farmer, for instance, has written extensively about Cuba [and also happens to be the UN Envoy to Haiti and runs Harvard's School of Social Medicine at their Medical School, so he tends to be considered a reputable source] and almost never has a bad thing to say about their healthcare attitudes or outcomes. The list goes on.)
Furthermore, we need to eliminate the debt load for student doctors. You can't expect doctors to work for lower salaries (as I propose above) when they are graduating with hundred of thousands in debt. Basically we need way more medical schools (or slots in existing schools) and we need to lower their cost in exchange for a willingness to work for less money. This has the benefit of more doctors and lower cost, as well as shifting the pool of applicants to those who want to be DOCTORS and not just those who want to make MONEY or play GOLF all the time (and so on).
Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction (read: less than 1/20th) as much per person on healthcare. They achieve these same outcomes using finnicky x-ray machines from the 1980s and out of date textbooks. They do this by having the greatest doctor-to-patient ratio of any nation, and by focusing on preventative medicine. But that's evil socialism. Insert dramatic music here. At any given time more than a third of Cuban doctors are voluntarily serving abroad (often in Africa) doing global health work. More than a third. What percentage of American doctors voluntarily serve in Africa? And they have a 98% retention rate, so any claim that this service is to "escape Cuba" is pretty well dispelled. (and just to go on the offensive for a sec, since I don't generally reply to those who reply to me, unless they actually make good points, since as you know
Re:also: more doctors, less pay, more compassion. (Score:4, Funny)
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No. That isn't until 2012.
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No. That isn't until 2012.
In other words, the year that every first post will be informative. It's a sign of the end times.
Re:also: more doctors, less pay, more compassion. (Score:5, Funny)
Last time I checked the next doomsday is Jan 19th 2038.
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The other thing that should be mentioned is that health care in the U.S. excels in one area and by relation another. Medicine excels at trauma medicine. It is at the point where even deaths from gunshot wounds are declining. The relation is in diagnostic technology.
Re:also: more doctors, less pay, more compassion. (Score:5, Interesting)
More than half of ostensibly qualified applicants every year are turned away.
One of the prime reasons I didn't go into medicine was the cost. Chose the I.T. field instead.
In retrospect, I wish I went into medicine. Instead of competing with a glut of "educated" "certified" "trained" personnel in IT, I'd have a "guaranteed" job as a Dr.
What fraction of people go into C.S., learn how to design compilers, databases, OS kernels, clusters, large scale BGP networks, etc, and then get stuck on the helpdesk, or if not underemployed, unemployed due to outsourcing?
On the other hand, it seems that approximately 100% of doctors whom learn how to suture wounds, on the job, believe it or not, actually get to suture wounds?
The level of underemployment in IT is so extreme, that there is a whole comic industry of making fun of the "peter principle" folks above them in management, the humor being that IT folks are so strongly underemployed that the concept of a "peter principle" line of work is hilarious to them. On the other hand, it seems like doctors actually get to do, what they trained to do, which must be pretty nice.
Re:also: more doctors, less pay, more compassion. (Score:5, Interesting)
As a side note, addressing the GP/FP doctors in the US have a bit of a control freak nature. Not only are there not enough of them, they seem to have issue with delegation. Recent pharmacy grads are exceptionally good at prescribing and much better at diagnosis than their predecessors. Yet doctors are still slow to utilize them as specialists. This lack of respect for other disciplines in medicine is causing many issues as well. (There are states that do allow pharmacists to prescribe and are getting closer, but we are a long way from reducing the burden).
Re:also: more doctors, less pay, more compassion. (Score:5, Insightful)
The thing is, that you don't actually have to go as far, politically, from the USA to see a working health care system. Before Margret Thatcher's management reforms crippled it, there used to be one in the UK and to a large extent there still is one in Scotland. The key element is to understand that money is a terrible motivator in health care.
There are always many many treatments and tests possible. For any given patient, most of those tests will either do more harm than good or be unjustifiable financially (costs 100,000, has a 1 in a million chance of helping you). The doctor has to be trustworthy to say "no, it's not worth it". That means that you have to believe that a) he has nothing to gain from not giving the treatment and b) he really has to have nothing to gain from giving the treatment c) he has to be competent and well enough trained to make that judgement.
Unfortunately, as soon as we have insurance companies, financial administrators and ignorant courts involved this breaks down. The insurance means that the doctor is doing the treatment for profit, so the more he gives, the more a non-involved third party pays. The financial administrators (e.g. in UK state care) mean the opposite. Now the patient knows the doctor is under pressure to not deliver treatment and will not leave until they get it (even if they don't need the treatment). The courts mean that the doctor can get away with killing hundreds of people with extra CAT scans, but if he misses one brain tumor by not doing one he goes bankrupt.
We need to take the direct money out of front line medicine, or at least pay it much more cleverly. For example, if you pay doctors by results (percent patients cured) they will only work on easy cases. Almost any such system I can think of can be gamed.
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We need to take the direct money out of front line medicine, or at least pay it much more cleverly. For example, if you pay doctors by results (percent patients cured) they will only work on easy cases. Almost any such system I can think of can be gamed.
Which is yet another reason to dump the entire concept of prepaid medicine to begin with. Sure, keep true insurance around for catastrophic events, but otherwise let each person decide how to spend their own money on their own regular health care. If you want to subsidize the poor, give them vouchers and let them spend their own vouchers on their own health care the best way they see fit. The idea being that since there is pretty much no optimal 'command-and-control' style solution, you might as well put
I've always really liked that idea (Score:5, Insightful)
For just about everything else in life, insurance is just that: Ensuring that in the event something happens, you are covered. It is a risk transfer for certain situations. For example I carry insurance on my house. In the event it burned down, or everything was stolen or the like, I could not afford to replace it all. My cash reserves are insufficient and, indeed, I have to have a mortgage to own the place. So, in an emergency, the insurance company will cover my loss. However, it is only in an emergency. They do not cover regular maintenance and upkeep of the house. Even in terms of qualifying emergencies, like theft, there's a $500 deductible. So if someone breaks in and steals a couple speakers, I'm paying for that myself, but if they steal everything the insurance company will pay.
It is all about transferring risk. I take care of the high risk, low cost stuff, they assume the low risk, high cost stuff. It is a certainty I'll have to repair things, the risk of something breaking down is as high as it can be, more or less. But the cost is low, I can afford it. The risk of my place burning down is quite low, but the cost is high, too high, so I transfer that risk. Doesn't cost a lot, since it is low risk. Likewise, my insurance company does the same thing. They cover individual incidents. However for large things, like disasters, they have their own reinsurer. That company only deals with extremely rare stuff, the risk of it happening is minimal, but the costs are astronomical.
But for health insurance, that's all turned around. It covers EVERYTHING. I pay, at most, $10 for anything. Insurance pays the rest. Doctors visits, tests, hospital, etc. I only bear the cost if it is extremely cheap, like a generic drug. Otherwise they pick it up. However they also pick up high cost stuff. If I have a major accident and require intensive care, they pick all that up. They are liable for ALL risks to my health.
Is it then any wonder that it costs more per month than my home insurance does per year?
I really thing a medical savings account kind of plan is the right idea. You save money to pay for normal things. In the event of something catastrophic, no problem, your insurance is there to pay any and all costs.
However finding that is hard. They started offering one at work... And it wasn't worth it. My premiums stayed the same, my employer had to put in just as much money, and my personal financial risk increases. How he hell is that useful? It should cost my employer much less, but it doesn't.
Re:I've always really liked that idea (Score:5, Insightful)
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The reason why healthcare insurance policies are counterintuitive to other insurances is to foster preventive care
Disagree. Very few people avoid preventative care in other insured areas. If I don't replace my sparking electrical wiring, the insurance co will buy me a new house when it burns down. Its a pain in the ass to crawl around on the ground and check my car tire pressure, and if I don't the insurance will buy me a new car when I flip it on the highway. I just don't see this happening.
Personally, I always thought paying for health care via real estate taxes was the fairest, rather than income. I live six bl
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I really thing a medical savings account kind of plan is the right idea.
If it can be rescued from the companies, it would be great. It should be something that I can go and open at any bank, transfer money into whenever I want, and have no "use it or lose it" rush to waste money in December (or if I get laid off). The banks could use the interest they'd normally pay on the savings accounts to administer them (not that much administration should be necessary beyond reporting how much money was taken out.
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But for health insurance, that's all turned around. It covers EVERYTHING.
There's a reason for this: it's socialized healthcare.
Sorry, you might be thinking I'm stupid right now. It's a bunch of private companies, right? How can that be socialized healthcare?
Here's the deal: As you've noted, health insurance doesn't work like insurance. Insurance is when you pay into a system, but only receive a payout in the likelihood that something unexpected happens. If the unexpected happens, you get compensation, but most people pay in more than they'll ever get out. It only works if
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There is another part of the problem. If you had insurance, not only would you not have to pay $32k, but neither would the insurance company. The insurance company would probably end up paying $4-5k for the procedure and you would probably pay $500. Doctor's bill ridiculous amounts, and then the insurance companies adjudicate it down.
This is the "elephant in the corner" that is usually missed in American discussions of medical pricing. With almost any other commercial "product", you can easily price shop,
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This is the "elephant in the corner" that is usually missed in American discussions of medical pricing. With almost any other commercial "product", you can easily price shop, and people do. But with most American medicine, the medical system does something to you, and then writes down a number, and that's the price you have to pay. You can't learn the price beforehand,
I'd say that the pricing transparency problem is precisely because of the current insurance system. It sure wasn't that way 40 years ago before the insurance industry was so prevalent. That's one of the goals of having people be responsible for the majority of the payments of cash or vouchers themselves - the more skin they have in the game the more incentive they have to get the best value for the money. My expectation is that if we went (back) to a system where people have personal responsibility for t
And what about poor people with a handicap (Score:3, Insightful)
Your suggestions tells poor people who happen to have a handicap or chronic condition to get stuffed.
You sir fail at humanity. Congrats, you can now enroll in US politics.
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In an discussion of US health care problems the first step is to admit that the problem has been solved, in many different ways, in many places.
So don't:
Re:And what about poor people with a handicap (Score:4, Insightful)
Your points are fair, with a small caveat on the last one. It might be possible that something that works well in annother country will not work well here.
For example public transportation systems that work well elsewhere don't work as well here. We simply have too many people living in low population density areas. In all areas for public transportation to be convenient enough for people to use, there must be many stops. However, each stop cost money, and in low population density areas it may not be possible to recoup the costs if you have many stops, so they have fewer if there is a public transportation system in place at all. That explains a fair bit of the lack of good public transit in the US. There are other reasons though, such as a culture where owning a car is viewed as pretty important, even by those who really have no need for one. That helps explain why even in many cities the public transit is often not particularly good (although it is definitely far better than the public transit outside the cities), and the lack of good intercity public transit.
By similar mechanisms it is just as possible that some of the solutions used elsewhere will not work. That is of course not to say that no solution will work for the United States, but not all the systems that work elsewhere will necessarily work here. I would certainly agree that anybody who wants to argue that a specific system that works elsewhere will not work here should be ready to provide argument as to why that would be the case.
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In an discussion of US health care problems the first step is to admit that the problem has been solved, in many different ways, in many places.
I guess that depends on what you think "the problem" is. If you think "the problem" is guaranteeing everyone a minimum level of care, maybe that's true. But if you see the exploding costs of medicine as the problem, both because it's made high-quality care unaffordable for many now, and because it's making it unaffordable for everyone in the long term, then the problem has NOT been solved.
Nations around the world, whether government-run or privately insured, are suffering from the same exploding costs. Wh
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Why should poor people get worse care? Why should rich people get better care? If society has the resources for $300 worth of care and 20 people, giving the rich guy $230 worth of treatment which covers emergencies, regular care, and elective surgery while the other 19 only get emergency and occasional regular care - that's not a just system.
The carrot and stick in economic logic is best laid-out *after* the basics for a reasonable life are laid, not before. When everyone has adequate health care, some mini
Comment removed (Score:5, Insightful)
Health care is a problem for society as a whole. (Score:4, Informative)
And those people end up paying more in the long run? I don't have a problem with that. Unless of course you ask me to foot the bill for their lack of maintenance.
...which is the point. Providing a reasonable standard of health care to all individuals in a society provides huge benefits to the functioning, productivity, and quality of life of the society as a whole, and as a society we're going to face significant costs for 'lack of maintenance' or 'bad luck' or any other given issue that leads to serious health difficulties for an individual who lacks the means to pay. The assumption that we can reduce the costs to society as a whole by letting individuals get substandard care is false even from a purely economic perspective, backed up by a great deal of epidemiological and social science research.
So, ideally, we need a rational healthcare system which decouples healthcare decisions from monetary incentives and relies on healthcare providers to make reasonable decisions about treatment that maximize the overall benefit to society.
This was effectively SOP for the health care industry in the USA until relatively recently. I have half a dozen MDs in my family near/past retirement age, and they have stated that the expectation in the field of medicine was that between 10% and 30% of patients would simply be unable to pay for treatment, and that providing a reasonable standard of treatment for them regardless was simply the cost of doing business.
Coming out of medical school today with hundreds of thousands of dollars in debt and with the range/cost of treatments skyrocketing, medical students today don't have this option. This has also contributed to a legion of other perverse economic incentives, such as clinics which make money from the tests they recommend, and the transitive nature of health care coverage has given insurance companies solid financial reasons to deny coverage to the greatest degree possible, so the greatest amount of the cost is distributed elsewhere. The prime motivator for the increase in health care costs isn't the cost of the treatments available, it's coupling treatment decisions with monetary incentives that are inherent in the structure of our current system.
Health care can best be envisioned as a public utility. It's in our own interest to structure it in a way that provides the best quality of care available at a price we can pay.
So, SOMEONE has to determine which treatments are actually beneficial and cost-effective for patients. The best group to do this is medical professionals who get a steady paycheck and are judged on the quality of the health outcomes of their patients.
This means SOMEONE has to provide the steady paycheck, as well as provide metrics on the quality of work done, enforce professional standards, and generally keep a lid on things. Any structure capable of doing that society-wide is going to end up being functionally equivalent to a government. Attempting to do it on a smaller scale leads to massive structural inefficiencies as other health-care entities that are running for profit do their best to chuck 'unprofitable' patients/treatments out of their coverage areas and 'cherry-pick' profitable individuals.
Any plan that significantly disagrees with these core ideas is likely to be based on political posturing or willful ignorance... which is precisely the problem we're running into.
Re:also: more doctors, less pay, more compassion. (Score:5, Insightful)
I'm haemophilic - where am I supposed to get the cash for my treatment?
The free market is survival-of-the-fittest, healthcare is preservation-of-the-weakest; I don't find it that suprising that they don't get on.
The best solution is a publically owned industry like here in the UK, with much, much smaller private insurers who can stay light on their feet and plug gaps in the service when they appear.
This system is way cheaper, higher quality *and* it's fairer.
If there is a profit motive, doctors will ignore people who are really ill as it won't be worth curing them.
In the UK we are committed to provide healthcare for everyone until they are healthy, hence it is massively in the doctors and the governments interest to keep people healthy and out of the hospital; so they don't have to pay for their care.
If everyone suddenly got healthy in the UK, we would save a tonne of money - if they suddenly got healthy in the US your economy would collapse. You need people regularly paying the deductibles.
Re:also: more doctors, less pay, more compassion. (Score:4, Insightful)
I'm a life form - where am I supposed to get the cash for food?
Food stamps. Soup kitchens.
I'm a mammal - where am I supposed to get the cash to heat my home?
You go to the shelter, where they provide the heat for free.
Or you live in public housing, and get free utility allowances.
This can go on and on.
No, not really. Society pays for as much of Maslow's pyramid as it can afford. Usually most of the lower rows: food, shelter, health. Policemen, firemen, libraries and schools would probably fall under your "on and on."
Re:also: more doctors, less pay, more compassion. (Score:4, Insightful)
That's a great idea unless you're chronic ill
Ok, now justify the expense.
His lungs stopped working so we put him on a respirator. Then his heart stropped beating so we put him on a pace maker. Then his liver stopped working so we give him regular dialysis. Then his digestive system gave out so we now feed him intravenously.
When does it end, and who is to judge?
Re:also: more doctors, less pay, more compassion. (Score:4, Informative)
Yeah, so if you want to have teeth as lovely as late 20th century brits, follow their lead!
There's a formula for good teeth. It goes something like this:
Calcium + Phosphate + Vitamin D + (misc other vitamins minerals) -> normal teeth
If a child's diet doesn't have enough nutrients, bone structures will not develop properly. Good teeth come from good nutrition and sunlight (Vitamin D), NOT nationality.
See Gerard Judd's work [healingtee...urally.com], Dr. Weston A Price's work, [westonaprice.org] etc
Re:also: more doctors, less pay, more compassion. (Score:4, Insightful)
Simply put, health and viability are not necissarily correlated with cosmetic appeal.
"ostensibly qualified" is fuzzy (Score:3, Interesting)
Who is to say where the cut-off line should be?
You could put that line almost anywhere without being unreasonable. I think we can agree that it's unreasonable to have 99.999% of the applicants on one side of the line or the other, but beyond that? What about taking only the best 10%, or only the best 90%, would one of those be OK with you?
It seems the AMA decided that the lower 50% are unfit. OK. Well, would you want one of those doctors instead of one in the top 50%? The top 50% is dangerous enough.
Re:"ostensibly qualified" is fuzzy (Score:5, Interesting)
Doesn't that depend on what your ailment actually is? If you've got the flu, a doctor in the bottom 20% is good enough, while if you've got brain cancer, then you'll want a doctor in the top 10% or better. You could have a system, let's call it "triage", where someone qualified could decide what kind of doctor you need...
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That's an appealing theory. The problem is that there are serious conditions which masquerade as common ailments, and require a great doctor to catch (such as Cushing's). The more mediocre doctors we have, the more misdiagnosis we will have. You seem to suggest better doctors closely oversee lesser doctors, but that will either become an exercise in rubber stamping or a horrible bureaucracy (the former tends to fail and become regulated into the latter). How do you suggest dealing with misdiagnosis?
I ag
Let's ask the AMA (Score:5, Informative)
Some quotes from the AMA themselves [ama-assn.org]:
"Not a single allopathic medical school opened its doors during the 1980s and 1990s
I think we can agree that it's unreasonable to have 99.999% of the applicants on one side of the line or the other, but beyond that? What about taking only the best 10%, or only the best 90%, would one of those be OK with you?
How about 98% rejection rate? From the AMA article above: "Many private medical schools have 5,000 or more applicants for a class of 100 students."
Again, I hope it comes across, I know something about this issue. I said "ostensibly qualified" and "more than half" in my OP because I didn't want to get into a big debate about the exact percentage of people who apply and are grossly underqualified and rejected versus the legit applicants who are rejected, but basically the former is not happening, since you need to take the MCATs (not easy) and complete the equivalent of a degree in Molecular Biology simply to even apply to med-school (and currently to be competitive you need hundreds of hours of volunteer work, professional medical experience such as EMT work, and even then it is often a crapshoot, I know many qualified applicants who have been rejected more than one year in a row).
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It seems the AMA decided that the lower 50% are unfit. OK. Well, would you want one of those doctors instead of one in the top 50%? The top 50% is dangerous enough.
That's largely a false dilemma. At this point, for millions of Americans, the choice is between the lower 50% and no doctor at all.
Re:"ostensibly qualified" is fuzzy (Score:4, Funny)
I've thought for a long time that maybe there was a place for someone who's more than a nurse but less than a doctor. But the politics of that industry gives politics a bad name. It'd be the demarcation dispute to end them all.
He writes out a paper saying, in big bold (but still unreadable) letters, "Absolutely do not, under any circumstances, give this person Viagra"?
Profit driven (Score:2)
Insurance companies, hospitals, and even individual doctors are profit driven.
While it is certainly no crime to make a dollar, that dollar shouldn't be THE_MOTIVATING_FACTOR in health care.
If/when every doctor, every hospital, and every insurance agent actively seeks to provide the best REASONABLE care possible, at the lowest REASONABLE cost possible, then we will have gone a long way toward solving our health care problems. Ambulance chasing lawyers need to be reigned in as well. An accident in which a p
Re:Profit driven (Score:5, Insightful)
It seems to me that you have chosen to misinterpret my words. You'll note that I didn't ask or demand that ANYONE work for free. All I ask is that the profit motive not be the determining factor in health care considerations.
As for myself - I can't work for free, anymore than any other man or woman in the world. I MUST feed myself and my family, and all the rest of the stuff that goes with being a responsible adult.
But, personally, my career, my day to day decisions are NOT all profit driven. I COULD HAVE had any number of careers. Instead, I have chosen to work where I enjoy working, all of my life. When the job starts to suck, I go find another job. I walked away from the best paying job that I've ever had, because the boss thought that he "owned" me, and started becoming abusive. He simply could not imaging that anyone in this part of the world could walk away from more than 20 dollars an hour, a company vehicle, paid insurance, along with some other perks. I walked. Unlike so many Americans, I don't worship that Almight Dollar, to the exclusion of all other considerations.
Again - I don't ask that anyone work for free. All I ask is that people recognize that sometimes that dollar isn't the most important thing.
While I was in business, I put a roof on a house for an old lady, only charging her for the materials. I took a loss on that job, because I knew that she couldn't afford the work. I spent two days working on her house, and paid a helper out of my own pocket, because no one should have to put pots and kettles around the house to catch water from a leaking roof. Most especially, an aging woman in poor health. I did a few other jobs at discounts for people who needed a helping hand, but that one particular job, I actually took a loss.
If I can do such a thing, I expect that a doctor can do as much, now and then.
Profit. How much profit do you take with you when you leave this world, anyway?
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Cuban healthcare costs 1/20th of American healthcare for similar outcomes? That's... not really suprising.
Most of the cost of health care is the cost of labour. Health care is very labour intensive, as I am sure you know. In the West, labour is expensive. In the third world, it is cheap. The cost of living is lower, the average salary is lower, and therefore the cost of labour needed to provide healthcare is also lower. But the healthcare itself can be just as good. There are excellent hospitals throughout
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>>>Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction
False. The second part is true but the first is false, because Cuba's government hospitals often don't treat people at all. Since those persons are left to die, they never become part of the system and don't appear in the statistic. Plus given the type of government (totalitarian) it wouldn't surprise me to learn unfavorable stats are removed by the government. (Se
Mod Troll. (Score:5, Informative)
Cuba has a dog and pony show.
I already warned you in my original post not to trot this shit out, because I'm not some idiot who happens to have seen a Michael Moore film and now thinks Cuba is a utopia. Instead I'll choose to believe the guy who runs Harvard Medical School's Social Medicine program (see: end of my original post), Jim Kim MD (former Prof of Medicine and Chair of Global Health for Harvard Medical School, now president of Dartmouth), and the World Health Organization, amongst many other credible sources.
Because I am busy and you make no effort to substantiate your claims, I'm just going to paste a chunk from Tracy Kidder's (Pulitzer Prize winner) biography of Dr Farmer, where Farmer talks to Kidder about dispelling myths about Cuba (and then after that some of Farmer's own writings)...
"For me to admire Cuban medicine is a given," Farmer said. It was a poor country, and made that way at least in part by the United States' long embargo, yet when the Soviet Union had dissolved and Cuba had lost both its patron and most of its foreign trade, the regime had listened to the warnings of its epidemiologists and had actually increased expenditures on public health. By American standards Cuban doctors lacked equipment, and even by Cuban standards they were poorly paid, but they were generally well-trained, and Cuba had more of them per capita than any other country in the world-more than twice as many as the United States. Everyone, it appeared, had access to their services, and to procedures like open heart surgery. Indeed, according to a study by WHO, Cuba had the world's most equitably distributed medicine. Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries. About five hundred Cuban doctors worked gratis in Haiti now-not very effectively, because they lacked equipment, but even as a gesture it meant a lot to Farmer.
One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.
He had studied the world's ideologies. The Marxist analysis, which liberation theology borrowed, seemed to him undeniably accurate. How could anyone say that no war among socioeconomic classes existed, or that suffering wasn't a "social creation," especially now, when humanity had developed a grand array of tools to alleviate suffering. And he was more interested in denouncing the faults of the capitalist world than in cataloging the failures of socialism. "We should all be criticizing the excesses of the powerful, if we can demonstrate so readily that these excesses hurt the poor and vulnerable." But years ago he'd concluded that Marxism wouldn't answer the questions posed by the suffering he encountered in Haiti. And he had quarrels with the Marxists he'd read: "What I don't like about Marxist literature is what I don't like about academic pursuits-and isn't that what Marxism is, now? In general, the arrogance, the petty infighting, the dishonesty, the desire for self-promotion, the orthodoxy. I can't stand the orthodoxy, and I'll bet that's one reason that science did not flourish in the former Soviet Union."
He distrusted all ideologies, including his own, at least a little. "It's an ology, after all," he had written to me about liberation theology. "And all ologies fail us at some point. At a point, I suspect, not very far from where the Haitian poor live out their dangerous lives." 'Where might it fail? He told me, "If one pushes this ology to its logical conclusion, then God is to be found in the struggle against injustice. But if the odds are so p
Again: trolling or uninformed. (Score:5, Interesting)
ACing this since you posted as AC above (where I replied as AC and refuted your infant mortality claim).
First, if you have any background in health you know the different between determinants and indicators. You can cherry pick whatever indicators you think will militate best in your favor. And when they don't militate the way you'd like (say: infant mortality) you will claim they are "cheating" by offering abortions or by using a marginally different method.
Allow us to get into the technicals of the method they use. Using your OWN LINK's info, the US method includes less than 1.3% extra babies, of whom 50% may die (less than this but we'll round up. So instead of 6.0 per 1000 for Cuba and 7.2 for the US The US actually has (.5*1.3%) better stats. So 7.1532 instead of 7.2. Wow, who cares. Furthermore, even if we ignore all of this and say that US IS BEST EVER for infant mortality, Cuba still trumps several other "first world" countries that have way more GDP/PPP and use the SAME method of measurement as Cuba. So their indicator holds.
Furthermore, this is ONE indicator. Life expectancy is another important indicator, and one you can't explain your way out of so easily, especially if Cuba has such a horrible medical system the fact that they live approximately (but not quite) as long as Estadounidenses again speaks to their health outcomes. Or their abilities at reanimating their dead.
You cherry pick breast cancer survival, which is a pretty random and focused statistic. I don't think you want to get into the "focused indicator game" with me to prove which country has better health outcomes. How many people does breast cancer kill in the US? Instead of arguing if Cuba wins or loses here, I'll just let you have it. Now how may people do GUNSHOTS kill here? How many in Cuba? Drug overdoses? Car crashes? You will lose the focused indicator game. Most resident doctors in Havana's hospitals have never seen a gunshot wound. Or a drug overdose.
And when we dig deeper into indicators, and I mean overall indicators, not narrower ones that are likely to show more bias, things get interesting. US life expectancy is one thing, but the distribution of life expectancy tells us a whole lot more. Which is to say that black men who live in Harlem have a shorter life span than the average Bangladeshi. So yea, if your last name is Buffet or Rockafeller you're gonna live maybe even 10 years longer than the average Cuban (if you're really lucky), but for the million of marginalized minorities in the United States, you'll probably live 10 years less. See: Hans Rosling's work.
Lastly you are either an idiot (i don't think so) or disingenuous to characterize experts who literally write WORLD HEALTH policy as "enchanted foreigners." If you or I went to Cuba and came back with a glowing review, we might fairly be viewed as "enchanted." When the world's foremost health equity experts have glowing reviews it is ignorant and dismissive to call them "enchanted." I cited people who run the top medical schools in the world. You cited a Philip Morris funded web site. Game, set, match.
Re:Again: trolling or uninformed. (Score:5, Insightful)
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Cuba has a dog and pony show. Shit for the vast majority of the population, and high quality care for VIPs and foreigners.
Do you have any data or empirical evidence to back this up?
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Re: (Score:3, Informative)
Nonsense. You're focusing on a small part of the overall discrepancy. That plus about 10 other factors are why the US is artificially high in infant mortality, especially in regards to quality of health care available.
OK, how about this one [findarticles.com] then? That got enough facts and numbers for you?
What would be interesting would be survival rates for all births by country. Every single child than emits from between a woman's legs would be counted, every thousand. And from that thousand the number that live to 5
AC for AC. (Score:2, Interesting)
OP here. Infant mortality rates? Yeah, there are two ways to measure them. Yeah, Cuba uses a marginally different one that makes their stat slightly better. And they "cheat" by having widely available abortions. When it comes to their life expectancy do they "cheat" by reanimating their dead? Because we also have life expectancy on parity with them, despite the fact that they have a per capita income of something like 1/5 of ours (off the top of my head) and according to you "dog and pony show" medica
Interesting... (Score:5, Insightful)
One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem -- far and away -- is the soaring and seemingly unstoppable cost of health care.
I'll admit that my concept of our spending is probably skewed by intentionally misleading infographics and such, but this doesn't seem to jive with anything I've ever seen. Can someone explain how this is true, or point to something that does?
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Note: The proportion of GDP devoted to health care has grown from 5% in 1962 to 16% today. Rising health-care costs appear to have suppressed wages, as firms seek to make up for the expense. America spends 53% more per head than the next most profligate country and almost two-and-a-half times the rich-country average..
There is a systemic problem in the US that is well document: that of wrong incentives in the system
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Re:Interesting... (Score:4, Informative)
It's called Medicare. It's a large percentage of federal spending right now, and it's projected to exceed 100% of all federal spending by about 2020, baring any changes.
If you don't know this, it's simply because you aren't informed at all. Experts have been sounding the alarm bells for at least a decade, loudly and repeatedly. It seemed to be the top topic just a handful of years ago, when ballooning medical costs were the largest problem facing the general public, just a while before the economy started to fail completely, and more immediate concerns became paramount.
Obama, Clinton, and McCain talked about it all through their presidential primaries and campaigns, in no uncertain terms. It was a major issues discussed endlessly in the house and senate for about a year as Obama tried to push health care reform through. I have no idea how you could be ignorant of this fact, if you pay attention to national/world events at all.
http://blogs.abcnews.com/theworldnewser/2009/12/president-obama-federal-government-will-go-bankrupt-if-health-care-costs-are-not-reigned-in.html [abcnews.com]
Re:Interesting... (Score:5, Informative)
Of course I've heard all the clamor over Medicare. Medicare represents $491 billion. DOD's annual budget alone is something like $1 trillion. I believe we've spent over a $1 trillion on the wars in Afghanistan and Iraq. Iirc the bailout ran into many trillions of $'s (certainly correct me if I'm wrong, some more inflammatory sources seem to put it at $24 trillion). Not to say that Medicare isn't a serious problem, but this doesn't seem to answer this question of our war and bailout costs being a fraction of what medicare costs us. No?
Sounds like the earlier posters overall estimation of all healthcare costs as a percentage of GDP was more likely what he was talking about.
Re:Interesting... (Score:5, Informative)
Where the heck are you getting your numbers? $24 trillion would be something like 1.6 times the total US GDP, how would it even be physically possible to spend that much?
Per the official US Budget DoD section, the total amount including supplemental spending hasn't exceeded $666 million. (see here: http://www.gpoaccess.gov/usbudget/fy10/pdf/budget/defense.pdf [gpoaccess.gov])
Wikipedia's got a pie chart showing general expenditures for 2009, demonstrating that total defense spending was 23% of the budget, whereas Medicare and Medicaid are barely less at 19% of the budget (here: http://en.wikipedia.org/wiki/File:U.S._Federal_Spending_-_FY_2007.png [wikipedia.org])
But the big problem, as noted, is not today's spending, but what happens in the future. Wikipedia's got a great graph for that, too: http://en.wikipedia.org/wiki/File:Medicare_%26_Social_Security_Deficits_Chart.png [wikipedia.org]
Re: (Score:2, Interesting)
Here's how you fix it:
1.) You re-tool Medicare to widen its coverage, in preparation for what will actually save it:
2.) You open Medicare to everyone. Until 65, Medicare is a buy-in system. You will actually have to pay for it. Just like you pay for an insurance policy. Actuarially-sound price scales are created, with sliding scales derived from them for income sensitive pricing. Basically Medicare becomes an option on the "Exchanges" that will be up and running beginning in 2014.
And how will this fix Medic
Re:Interesting... (Score:4, Interesting)
This is pretty much what happens right now in Australia.
All income taxpayers pay the Medicare levy. A large payment base means there's enough in the nation-wide pool to cover pensioners, unemployed, etc who can't afford to pay-in.
Private health insurers then come in and make a killing on gap insurance and covering things Australian Medicare doesn't - like dental.
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that's the reason why we didn't have robust public option for Healthcare, because Obama and the congress are bitches of the megacorporations. beyond hot-button issues, the core problem of either republican or democratic party is that they serve the Oligarchs, not the people. This is why the bailout proceeded against the wishes of the majority (started under Bush, continued under Obama who is just another Bush).
The solution is to throw the bums out, and not to replace them with more bums from the same two
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Yes, unfortunately we DO need to put a price on life. This attitude of "Do whatever you can, whatever it takes, no matter how little good it does," doesn't work. We have some extremely expensive procedures these days, and can dump a lot of money in to the last few months of a person's life and make little difference. Unless we want to become a nation where healthcare is more or less what we do, we need to start thinking about economics.
Now this doesn't mean saying "A person is worth $300,000, once that much
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Public health for all, private if you want it, gov health bureaucracy.
Take your chances with either system, free or some $ gap, good dr, bad dr.
But nobody has to stress, working, not working, young
Or you can go private and pay for them.
The US seems to have stuck in an extra layer of private health bureaucracy.
The gov to pay for a safety net, public health ect and th
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The Iraq/Afghanistan war has only cost a little over a trillion dollars over the last decade, and that amount presumably will drop in the future. The stimulus also cost around a trillion dollars, but it was mostly a one time expense.
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The Iraq/Afghanistan war has only cost a little over a trillion dollars over the last decade, and that amount presumably will drop in the future.
Which is why we'll have to go find a couple more wars to start. Don't you just love the military-industrial complex?
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If you think that a world war will never happen again you are fooling yourself. Do you really think the Chinese would hesitate for a moment if the American military vanished over night?
It is also one of the few federal expenses that the Constitution actually even permits.
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war spending != defense spending.
There aren't many nuclear submarines deployed in Afghanistan.
Buffet style insurance. (Score:3, Insightful)
Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.
I'm not saying this is the entire problem, but it's a huge part of it. If you don't see the costs of your health care, you won't wisely use it. It's the same problem plaguing college tuition costs. "Oh, it's free money - either I'm getting a loan (free money!) or someone else is paying for it!". Yeah, until schools notice this and start charging $25k a year to attend because nobody cares - it's "free money".
My solution is a high deductible plan. If you can't afford it, the government picks it up for you. You pay the first $5k of your health costs out of pocket, the HDHP kicks in afterwords. If you're too poor for that, then they have government clinics for you.
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Based on the cost of private health care here in Australia I reckon I would be better off investing the money and paying for health care in cash.
(in 99.9% of cases anyway).
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Re:Buffet style insurance. (Score:5, Interesting)
Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.
Which is why in the UK, where everyone can use the health service for free and is insured automatically by the government provides better health care cheaper?
Doesn't sound like you've sorted that out right.
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If you thought that Greece has problems, just wait until you find out how much debt UK has to other nations and what their trade imbalance is.
It seems nobody is paying attention to HOW things are funded anymore, bankers give out loans to companies and to governments without understanding the first thing about the ability of the debtors to pay this money back.
Imagine what will happen to all of the entitlements once nobody wants to bankroll it any longer.
UK government, like all other governments consists of p
Re: (Score:3, Insightful)
Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.
While that would -sound- like a convincing idea, I see no evidence of that being the case. From personal experience, I don't decide to schedule myself, fill out the forms, disrupt my schedule, and then take the MRI for my sore throat, and I wouldn't even if it were absolutely free, no questions asked. A buffet of food, yeah, I'll take extra because I like eating food. Extra medical procedures? Who wants more of those? Are you telling me that people pointlessly waste other's money and their own time, an
Buffet Kevorkian style. (Score:2)
Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.
So what is the cost of a human life?
Standard profit meme (Score:3, Insightful)
2. Throw barrels off cliff.
3. Pick working system like that from Australia or Canada.
4. Copy it.
5. Don't let the rebulocrats change anything.
6. Profit.
I'm serious, even if you choose to keep private health your premiums will go down as they now have to compete with the lowest cost alternative (public health), which is net profit for you. Another boon will be increased service from private health funds as public health sets the minimum standard for care.
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All the private practice you want with a free system for all "citizens" if/when needed.
This would expose the union free, interchangeable, disposable workforce and not be allowed to pass.
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Too bad the Dem's in the US want this brilliant idea to micromanage every single freaking point of the healthcare system. Sorry but systems like socialized insurance in Canada, are wholly incompatible with the Dem view of how it should be done. Only the feds know the right way to do it. To point out the obvious, in Canada, the feds do nothing to the healthcare system unless it's run federally aka reservations and government(RCMP/Mil/etc). It's all in the hands of the provinces.
The republicans have the r
A universal supply of expensive services (Score:2, Insightful)
Half a century ago, medicine was neither costly nor effective. [...] Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive.
This is the problem in a nutshell. The notion that leads people to call for universal health care is intuitively moral: that every human being deserves the best medical care possible, even if they can't pay for it. It seems cruel to deny that. But medical care is some of the most expensive labor in the world. And justly so: pharmaceutical patent abuse aside, doctors and nurses deserve to be paid a bundle for how long they have to study to get certified and for what a general pain in the ass their job is. So
we'll do it, sort of... (Score:2)
You're right that the money isn't there, but we can still promise the care. We don't have the stomach for death committees or official rationing. We will refuse to accept the problem.
Of course, the waiting lists will grow as required to ration out the supply. Everybody gets healthcare, except the people who die while waiting for treatment.
Maybe you can bribe your way to the front of the list, make friends with a senator, or claim to be part of some disadvantaged group that needs special treatment. The black
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Your post has quite a bit right and I hate to pick nits, but you conflate two different things and they are very very different.
[..] every human being deserves the best medical care possible [...] every human being should be provided with ample attention from doctors
We can certainly afford to provide pain relief and basic medical care for every member of humanity. "the best medical care possible" is a completely different thing. There is always one "the best heart surgeon in the world" and he will never be able to see everyone. Hopefully he gives access to people with difficult and interesting cases, but in the end money or pot luck may n
OK, time for another rant (Score:5, Interesting)
1. Uniform billing codes and realtime price-lists so that we know we're not getting ripped off. California's chargemaster publication requirement is a step in the right direction, but it needs to be updated more quickly, and rural hospital exemptions are BS. If you can run a hospital, you can update your billing DB no matter where you are.
2. No anti-trust exemptions. This is so fundamental it's mindblowing.
3. Nationwide competition.
4. No more buyer's clubs. If the doctor and/or hospital is *licensed* then the insurance must pay out. You get to keep your doctor no matter what. Any company that wants to keep having a buyer's club can do that; but you can't be compelled to purchase into a club, only real insurance.
5. Real insurance means you can't lose your life savings due to a percentage payment or a cutoff. After all, you can't actually insure health. Only genes and behavior can do that. When we talk about health insurance, we're really talking about medical bankruptcy insurance, and the current system fails to do that. In order to be considered a real insurance plan, you have to prevent medical bankruptcy. That means, for example, you can lose no more than 10% of your net worth or income in any calendar year. That way, you could be severly ill for 5 years, on chemo, and emerge with roughly 60% of your life savings intact instead of nothing.
6. Stop torturing doctors. No, really. Many people won't even consider med school because it's torture. Maybe we need to put some doctors through boot camp. Maybe it's important for brain surgeons; but I can't imagine this system is really doing much to increase the number of competent family doctors.
7. Malpractice/tort reform. Duh! If a doctor is so incompetent that we're better off taking him out of the profession then let's do that. Requiring all the other doctors to pay out as if they're that bad is insane. Multimillion $ payouts won't bring back your relative. License revokation, however, will prevent it from happening to somebody else. Note, this is tricky since it's possible for competent people to make mistakes. You actually need to make sure that the number of mistakes is statisticly significant. Otherwise, nobody will want to risk becoming a doctor (see point 6). Statistics is a bizarre thing. There's actually an expected number of botched operations; but the odds of a single doctor botching 10 operations in a row are probably low enough so you can safely conclude that doc needs to lose his license.
8. Everybody self-pays and submits claims. That's right. You run healthcare like a normal business. I know it's hard to believe, but it really is just like buying a loaf of bread. Fire the beurocrats. No biggy. They'll get free health care while they look for a real job.
9. No paper work until the patient is well. No signing anything under diress.
10. You can put a pharmacy in the hospital. Quit making sick people drive to get meds.
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After all, you can't actually insure health. Only genes and behavior can do that.
I think you're confusing insure with ensure. The way you seem to define insure, fire insurance would be a payment you make to prevent fires from happening, and flood insurance would somehow prevent floods.
defective medical philosophy (Score:2, Interesting)
science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures.
It's too bad that Western medicine doesn't have a comprehensive guiding philosophy. Imagine if they taught principles like these in M.D. schools:
Is there a meme for this? (Score:3, Interesting)
Re: (Score:3, Insightful)
/.tivism? Slashtivism? This is the first time I've seen the editors directly come out on the side of a political issue in the form an article on the main page.
If this is the first time you've seen it on /., why would you name it after /.?
Also, I suggest you look up meme [wikipedia.org].
How many different service lines? (Score:5, Insightful)
Dr. Gawande suggests the "13,600 different service lines [doctors] deliver" is an issue in health care costs. I put forth these comments:
* How many services are listed in the manual which guides the number of hours an auto mechanic is allowed to charge for a repair, e.g., replace spark plugs: 0.75 hours. How many items are in this book?
* How many different services does a software engineer deliver over a year's time?
I suggest the problem is related to control over charges. Car mechanics have a job with similar complexity to what doctors face. Software engineers often face a problem much more complex. (How many "surgeries" require several weeks to solve a single-line bug?)
The control of health care "service" in the US is in the hands of the AMA and the bureaucracies created around hospitals and other facilities. If they were willing to reduce their profit margins (assuming we can eliminate the defaults they see because of uninsured/under-insured patients), we could see significant reductions in general health-care costs.
This is just a thought...
-Todd
Re: (Score:3, Insightful)
Even change a head gasket on a running engine? That's what doctors occasionally have to do.
The Health Care Problem in a Nutshell (Score:5, Insightful)
2) Effective heath care
3) Obscene corporate profits from health care
As long as corporations control our government, number 3 is not optional.
Re:The Health Care Problem in a Nutshell (Score:5, Insightful)
Please define " Obscene corporate profits ".
Any revenue by any middlemen whom add no medical value, or exist solely to subtract medical value, from patient care?
If they're not profitable they'll either raise costs or go out of business, so he really means "obscene corporations"
Maybe he means obscene as in culturally unacceptable, obscene like kiddie pr0n or eating household pets for dinner or working in the medical insurance racket, not obscene as in "they make more money than I think they should".
yes they have found a way (Score:3, Interesting)
they profit from the taking of organs, be damned about the ethics or the consequences
the reason that there is no legal market for human organs is the the fact that the poor will sell their kidneys. there is a belief in human dignity, i don't know if you share it, and anyone ethical does not believe that poverty should be a gateway to permanent degradation of health, of loss of dignity. being poor does not mean you have no human dignity
of course, people will still sell their kidneys, on the black market. the
The real solution (Score:3, Interesting)
The article is interesting in stressing the need for a more systematic approach to medicine in the hope of providing both better care and lower costs. That will improve things but it does not solve the fundamental problem.
The fundamental problem is the inherent improper design of biological systems which results in aging. As organisms age components fail and need treatment, repair or replacement. As the fraction of the population which requires these therapies increases costs will increase. Period. There are only two ways to solve this. Agree that because the biological systems are failing and will eventually lead to death we should reduce the level of care provided to these failing systems. Or redesign the systems so that they are more resistant to aging -- i.e. eliminate aging. If one eliminates aging one eliminates a significant fraction of the anticipated increases in the costs of health care.
Now as is usually the case the devil is in the details. What causes aging? Largely the inherently poor design of the system, e.g. energy production methods (the electron transport chain in the mitochondria) which produces free radicals which in turn damage the DNA producing point mutations and/or DNA double strand breaks the repair of which cumulatively corrupts the genetic program of each and every cell in the body until one ends up with either cancer or "aging" [1]. From a programmer's perspective each and every program in the trillions of cells in an adult human's body is becoming corrupted and will eventually fail. We have replacement capacity for some of those programs through our stem cells but those programs become corrupted as well. Until we have the ability to replace or repair the declining genetic programs we will not solve the increasing costs of health care.
Note that one can replace the programs in bulk (organ transplants) and there is an X prize pending for growing replacement organs from ones own stem cells. There are also a number of companies, e.g. Regenexx, BioHeart, etc. working on legitimate autologous stem cell therapies. There are also companies like 23andMe, Navigenics, etc. making personalized medicine available to the masses (so one can known what ones own genetic weaknesses are). And eventually if molecular nanotechnology develops quickly enough and we get real nanorobots like "chromallocytes" the repair of the cumulative DNA damage in each and every cell may become feasible (at low cost without the need for an operating room and a team of surgeons to perform a large organ replacement proceedure).
But until one starts seeing more people point out that the lack of clothes on the emperor (that the real problem is gradual genome corruption and "aging") and the need for a real "industry" to deal with it *and* the political problem that if you solve aging (so people live indefinitely [2]) then one is also going to have to touch the "third rail" of politics (social security entitlements) if one is going to avoid bankrupting nations [3] then speeches such as the one cited will miss the critical issues.
1. This isn't the only way the system is mis-designed. One could argue that the use of free radicals and inflammation by the immune system is questionable. On the one hand it may help to fight bacteria or viruses when one is wounded or otherwise exposed to them but at the same time the same processes probably contribute to heart disease. But heart disease can largely be dealt with through proper diet and exercise, and if necessary relatively inexpensive drugs, the same cannot be said for cancer and aging.
2. Indefinite lifespans are not "immortal" lifespans. Fatal accidents still have a non-zero probability.
3. All of the news debates about medical care costs, national debt, etc. (largely promoted by right wing politicians, new "Tea parties", etc. IMO) *all* ignore the probability that these perspectives largely disappear in light of molecular nanotechnology. People largely don't need Medicare if their genomes were better engineered to last indefinit
A Possible Solution (Score:3, Interesting)
After thinking about things for a bit, here's a simple statement of the health care "problem" - from a bias of being familiar only with the US system. I've also got a proposal that could address many of the issues while meeting most of the goals of a health care system.
As introduction, the marks of a "good" system might be: treatment at any given level is available to all independent of individual wealth (equality of care), there is enough care at a given quality to support the needs at that level (availability of service), there is an emphasis on preventive care, and cost to individuals is proportional to amount of service utilized (fairness of cost). These are pretty much the main arguments of the day - people want to get (good) care for everyone but it is not economically or socially responsible to have everyone pay the same amount personally to get massively different benefit.
My solution would be along the lines of requiring everyone to pay some baseline amount for insurance. This would be a small amount so everyone could afford it. Note that I would not exempt anyone from this small payment. But: If individuals go in for at least the basic regular checkups and basic preventive care, they would receive rebates that would offset this minimal fee. However, if you need more service than that, you must pay increasing amounts depending on the level of service needed.
So this is something like the Taguchi loss function - if society as a whole has zero health care that's a big loss so should have a cost (the "minimum fee"). But if people have basic care to prevent communicable disease, basic checkups, etc. the total cost to society is lower - this is why rebates are offered. But then there are major illnesses and the like, which increase cost to society - so those should carry larger costs.
Admittedly there are details that are probably important, but the major idea is sound - it encourages both minimal levels of treatment and preventive care but also (fairly) puts higher costs on those who need greater amount of care. This "greater cost" should probably be on some kind of relative scale; chronic illnesses with treatments should have not have debilitating payments (think of future value of work). Probably something like cost is inversely proportional to amount of time remaining to the average lifespan or something. Or so that "chronic" treatments are just a small amount per month, but a major illness at age 68 would cost more than the same illness at age 28 or 38. The costs should really be structured to reflect the cost/benefit to society rather than simply spreading high costs for a few to a small amount of people (in other words, avoid the "car payment" situation where yes, the monthly payments are lower but the total cost is higher. This is the sad economic effect of the current health care system; individual payments may be lower but the total cost to society is higher.)
To summarize:
1. Minimum fee required by all.
2. Rebates for routine checkups and basic preventive care that would fully offset the minimum fee.
3. Additional fees for any additional treatment beyond preventive/basic care ("basic" here things like non-STD communicable diseases or non-lifestyle-related injuries) to discourage unnecessary treatment and overly-risky behavior (e.g., X-games participants would pay for injuries or take out additional "occupational/hobby injury" insurance) but structured in a way to not financially crush people who need it.
4. Provide some mechanism to reduce facility costs - property tax breaks or something. After all, we provide public libraries but not public clinics?
5. Reduction in certification requirements for basic health services to increase the available health care providers to help with supply side. Things like nurse practitioners are a step in the right direction.
I'm sure there are other minutiae, but this framework should address many of the personal-cost-side issues related to health care.
Re:Link to the address transcript here (Score:4, Informative)
HERE it is...
http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html#ixzz0rEyC8iDU [newyorker.com]
Re: (Score:2)
Also, the "But the fantastic thing is: This is what you get to do" part sounds to me like a lovely way to say "We old geezers couldn't figure it out. You young ones are our only hope, and you better not f*ck up"
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Expected lifespans should show if a population had access to health care over their life or not.
"external influences" is what, alcohol, war, pollution?
Most of that would average out as most of the developed world is not that drunk 24/7, at real war or living under toxic smog.
Re:government out of economy (Score:5, Insightful)
I have yet to hear a single empirically sound argument against public health care. No amount of ideology can contradict two very basic, and very important, statistics: percentage of GDP spent on health care and life expectancy. If the government was really driving up the cost of health care then you would expect to see the former be much higher than the US, but in fact it is the opposite. Also, if the health care was really as bad as a lot of people on the right make it out to be, you would see average life expectancy to be lower than that of the United States but it is in fact higher.
Re:government out of economy (Score:5, Insightful)
To add further empirical fuel to my argument, look at which economies in the G7 are recovering the fastest, Japan, Canada, and Australia. What do those three have in common that other countries do not? They all have public healthcare systems WITHOUT a lot of the other bullshit that comes attached with hiring and firing workers that the Europeans have. Despite their surging currencies(the loonie, ozzie dollar and yen are all really strong right now) it is STILL cheaper to hire workers(esp. for small businesses) in these countries than it is in the US. The healthcare system in the US is hurting international competitiveness and thus costing a massive # of jobs.
If you want to refute me please actually use real, verifiable evidence and don't repeat your last rebuttal where you think you win an argument just by using the word "socialism".
Re:government out of economy (Score:4, Informative)
Infant mortality rates: the US ranks an embarassing 33rd according to the UN, 46th according to the CIA [webmd.com]
US also ranks pretty shittily in heart attack rates too [nationmaster.com]
Do I really need to go on pointing out what a farce the supposed "superior" US healthcare system is?
Re:government out of economy (Score:5, Insightful)
In US 50 years ago a family of 4 could have actual health insurance (covering of up to $50,000 of expenses, which was enough for everything) for a year for $25 dollars (payment for an entire year!) with a $500 deductible.
Basic problem is the government giving out public funding for any sort of endeavor. This leads to very rapid price increases. Before Nixon, a day in a hospital could cost $100, today it could cost up to 100 times that much. Obviously this has nothing to do with inflation. Costs to treat cancer could go as high as up to 20,000 dollars before then, now it could easily reach between 500,000 to a cool million.
Another ranting Rand-ite with no actual understanding of the problem.
Look, idiot, 50 years ago, virtually every hospital was run on a not-for-profit basis. Because there were no shareholders to have to provide quarter-over-quarter profits to - and essentially no MBAs to pander to them - nearly every dollar spent on hospitalization went to actual medical care. Likewise, medical insurance was MUCH less paperwork-intensive, which meant that overhead costs for medical billing were a whole lot lower than they are today. And finally (and utterly crucially), medical technology was barely getting started in 1960: no MRIs, no monoclonal antibodies, no gamma knives, no transplants. In fact, the only real high-tech devices were "iron lungs", developed to keep polio victims alive. If you got cancer then, surgery and whole-body radiation were pretty much the only options. Cisplatin-based chemotherapy didn't become commonplace until the 70's. So, no high-tech drugs and devices meant that treatment costs were quite modest by today's standards - and so were survival rates. It's a pretty straightforward tradeoff.
Free-market fanatics like you want to make government spending the culprit for all financial ills, because that makes understanding the world so much simpler for you. The problem is that your underlying assumptions are simply wrong, so your worldview is full of shit. The fact is that medical costs are out of control in this country not because of Medicare/Medicaid spending, but because of proliferating treatment costs and the rise of the for-profit medical insurance economy (whose overhead costs run ~30% - as opposed to Medicare/Medicaid, whose overhead is ~1.5%).
Oh, and Medicare/Medicaid wouldn't be facing the deficit problem that's looming, if Congress had had the sack to increase Medicare premiums and payroll taxes by a relatively tiny percent 25 years ago, when the impending problem first became apparent. Or, to put it in terms your tiny mind will reject: the problem isn't government spending, it's the government's cowardly unwillingness to raise taxes to levels sufficient to fund its spending mandates that's the problem.
I'm not surprised I have to explain this to you, because you're obviously too blinded by your free-market dogma to grasp the actual causes of the medical economic bubble we're experiencing in this country.
Re:government out of economy (Score:5, Interesting)
How do you answer the point that many other developed countries have much more government involvement in healthcare, and yet pay less for better healthcare?
In France, for example, public healthcare is available to all, but they pay only only 3/5 as much as the US as a proportion of GDP and are considered to have the best healthcare system in the world by the WHO.
The British NHS, which at the time of the WHO's report cost only half as much as the French system in terms of GDP, was placed 18th; a fair few countries behind France, but still 19 places ahead of the US. To reiterate: the NHS, which is entirely Government funded, costs only just over a quarter of the US system and yet has better results.
Developed countries with socialized or partly socialized healthcare systems topped the list, while the US, coming far closer to your vision of non-Governmental healthcare, was beaten by powerhouses like Costa Rica, Columbia, Morocco, and the UAE.
Projection (Score:4, Insightful)
You think he's wrong despite what he says. I suspect strongly that you haven't even read it deeply.
Once the government guarantees that it will pay, the incentives to keep prices at what the market can bear disappear.
If that is true, then why is health care so much cheaper everywhere else in the world - where the government really does guarantee to pay?
Government provides a gigantic moral hazard, you are looking at it and completely not seeing it.
What an awesome argument! Way to go brains! Did it ever occur to you that what you think you can "see" is just the play of neurones? It's not actually real.
If the government is such a huge moral hazard, then perhaps you should go live some place without a government - say like Somalia. No government there. Just pure economics. Paradise!
You buy civilisation with taxes,and that must be administered by government. Far from being a moral hazard, the collective spending and government administration is the basis of a functioning economy. It really is a question of what qualifies as efficient and worthwhile.
If private industry cannot do better than a government institution, then why prop up an inefficient private solution? That is precisely why we have public fire fighters.
Or is that a big moral hazard as well??
No wonder you immediately start with an ad-hominem, you have no intelligence to do otherwise.
Psychologists call that projection [wikipedia.org]
did you ever stop to think (Score:3, Insightful)
that those who oppose the idiocy of libertarianism are not "lovers of big government" as you say? why, why would we love big government? who would anyone? what is the motivation?
"oh, i am a sworn protector of bloated government bureaucracy, it is my burning passion" pffft
NO ONE loves big government. but we oppose libertarianism BECAUSE BE UNDERSTAND IT BETTER THAN LIBERTARIANS: it is clearly a road to hell
if you say "how could you understand libertarianism better than libertarians", well: do you understnad
Re:No, what US Health Care Needs (Score:5, Insightful)
So if you eat too much/drink occasionally/smoke/use a cellphone in SF or any number of other things that are bad for your health you don't get cover? So I decide to go bungee jumping and you spend ten years eating burgers 3 times a day. I don't deserve medical cover if something happens, but you do?
I have a friend who is a podiatrist. He has patients who have ignored their conditions, to the extent that the necrotizing faciitis they have has eaten a hole clean through the centre of their foot (you could see 3 metatarsals). This patient is an idiot for not going to the doctor earlier when something could have been done, do they get care? What about people who don't get the vaccines or smear tests or prostate exams they are supposed to. All conscious decisions, all of them idiotic. Should they too be denied care? I'd bet that the people that make those kinds of idiotic decisions cost an order of magnitude more than the people who get hurt doing extreme sports that you seem to have a problem with. Or is it just that you don't like other people having fun whilst you're in your sterile bubble of healthiness?
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