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."
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?
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.
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.
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.
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 to say that every human being should be provided with ample attention from doctors, at the government's expense if necessary, is akin to campaigning for a universal supply of platinum bars.
I get that the speaker isn't necessarily speaking as though socialized medicine is the only answer, but he seems to implicitly acknowledge that the government is the only one who will pay doctors to care for poor people. Even if you don't oppose such a thing on political grounds, the money just plain isn't there. I can't really suggest a solution except to keep science and technology marching along and hope that medicine eventually starts getting cheaper when the remedies we invent finally start outpacing the diseases we discover.
Re:Interesting... (Score:3, Insightful)
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. Healthcare expenses are only going up. A lot of what we call the Bush deficit, the Obama deficits (and the Clinton surplus) is actually due to circumstances beyond the control of the president. People are retiring, and the government has promised to take care of them. Now they are cashing in on those promises, and it remains to be seen how good they are.
Re:Standard profit meme (Score:3, Insightful)
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.
Re:Navel gazing (Score:1, Insightful)
Our health care expenditure is higher because we have better care. The problem is it's not available to everyone, only the middle class and up get the best care, and it's very expensive because of our insurance system.
Perhaps, you've been sold a pig in a poke? Did you even check the bag?
It's expensive because sick people will pay lots of money to live. It's just capitalism to an extreme.
The US has a healthy belief in the strong survive and the weak perish.
You let wars and bailouts deplete your ecomony but scream if money is put into healthcare where it's needed.
I hate to bring it out but no, your system is in shambles.
Get your facts straight.
Re: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.
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, and that's really a significant contributor to the problem? Because I'd like to see a citation for that.
I'd believe with your idea, there would be fewer of them, but if we're only talking about 1% of the problem, then let's not bother.
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.
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.
Comment removed (Score:5, Insightful)
Re:Is there a meme for this? (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].
Re:Buffet style insurance. (Score:2, Insightful)
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 politicians who want to be reelected, this is a major problem, they give out entitlements like the money comes out of a money well. Money was taken from taxes, from social security, then wars came so it was no longer enough, more and more was borrowed, all while the manufacturing was outsorced, the 'service economy' grew, all of which means that the trade imbalances grew and ability to pay back the debts diminished.
When the big one hits, UK will no longer be able to provide its services, at least not for the money that is paid by the government for these services right now. I expect UK and US to behave in the same way, by printing cash/bonds and eventually to see the value of their money to diminish into nothingness.
Re:Interesting... (Score:3, Insightful)
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?
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:also: more doctors, less pay, more compassion. (Score:4, Insightful)
Simply put, health and viability are not necissarily correlated with cosmetic appeal.
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:I've always really liked that idea (Score:5, Insightful)
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.
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: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?
Re:Interesting... (Score:3, Insightful)
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 flop houses.
Re:How many different service lines? (Score:2, Insightful)
Car mechanics have a job with similar complexity to what doctors face.
Ehmm, no, they don't. Unless you own a car that *must* have the engine running at all times, even when you're trying to replace the fuel lines.
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?
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:we'll do it, sort of... (Score:1, Insightful)
Are Americans completely incapable of distinguishing between "government run" and "publically owned"?
Why don't you read up a little bit about all the European countries and the quality of their "shitty government care".
Your healthcare companies make enormous PROFITS. What that means is they take in all the money, then they pay all their staff, all their doctors, all their legions of lawyers etc, and THEN they still have millions and millions of dollars left over which they give to the investors! They regularly lay people off just so they'll have enough money left over to give to them!
That is why your healthcare is the most expensive in the world despite being among the worst in the west; you have to pay for your care and you have to pay the investors as well.
A publically owned company makes exactly zero profit, so it is as cheap as can possibly be.
The NHS, for example, is owned by the people of Britain, not by a small group of billionaires.
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:Again: trolling or uninformed. (Score:2, Insightful)
So basically your argument is "They are lying!".
Good job, loser.
Re:Again: trolling or uninformed. (Score:5, Insightful)
Re:Cutting bailout and wars would almost cover it (Score:1, Insightful)
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.
Okay, where in the Constitution did you see anything allowing the funding of a permanent national military? I recall seeing that militias can be raised, but control must remain with individual states, and that clause about a limit of two years of funding for any money appropriated to raising and supporting an army.
Seriously, the Constitution is about as anti-superpower as you can get. Remember it was written by a bunch of people who didn't trust their government. Perhaps our military is a good example of how much governments have changed since 1776, as now people feel government exists only to defend and serve the people.
Re:Again: trolling or uninformed. (Score:1, Insightful)
The point is not which is "better." The point is that Cuba has managed to establish a health care system with VERY limited resources that we are actually comparing to what is by far the best funded, most expensive, and most technologically advanced health care system in the world. With all their limitations, to even be comparing them to our system indicates that we likely could learn a lot from it if we could just get over this black-and-white ideology of "well, they're socialist and poor, so their whole system must be awful with nothing it can teach us."
Re:also: more doctors, less pay, more compassion. (Score:3, Insightful)
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 the world.
So yes, Cuban healthcare is cheap. I don't see what we are supposed to learn from this, though, since it's a consequence of economics rather than some sort of enlightened government policy.
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]
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".
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:Again: trolling or uninformed. (Score:2, Insightful)
You pay hundreds of times more for your healthcare which is only marginally better, at best, than that which is available to anyone in Cuba.
You can't just go by dollar costs here. Cubans pay in other ways as well, which is why they keep turning up on our shores in makeshift rafts trying to get out of Cuba.
Re:also: more doctors, less pay, more compassion. (Score:2, Insightful)
You say there's no optimal command style solution to health care...
The trouble with applying market economics to health care like this is that markets achieve maximum efficiency through consumers acting as -rational- actors seeking to maximize value. When it comes to health care, people are not terribly rational and not terribly good as assigning value.
Sometimes, it's a matter of information. (Turns out, there might be something in that decade of schooling for doctors.) Sometimes, it's a matter of emotion... I mean, what wouldn't you pay to save your life? What about your arm? Or your vision? (I'd pay damn near anything... I'm just glad I live somewhere where I won't be paying personally.)
Re:I've always really liked that idea (Score:3, Insightful)
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.
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 communism? do you have to be a communist to understand or oppose communism?
no: clearly communism is stupid, as it destroys society by removing any impulse to actually try and work. LIKEWISE, libertarianism removes the impulse to have any public good. libertarianism is simply social darwinism: humanity as craven selfish competing indivuduals with no rules, nothing to punish them for bad behavior, without the slightest concern for anyone else. a society of sociopaths
libertarianism is the mirror image of communism: the fanatical triumph of selfishness over altruism. much like communism is the fanatical triumph of altruism over selfishness. the truth is BOTH communism and libertarianism are dangerous destructive follies at either end of a spectrum. the ONLY true way to run a society is a MIX: socialism with capitalist engines, or capitalism with socialist safety nets
the MODERATE path is the only path that makes sense, because humans are a paradoxical mix of the selfish and the altruistic, and any ideology that addresses only one side of human nature fails to rule human beings, by not adequately reflecting who and what they are
we need GOVERNMENT, period. not BIG government. we're not idiots, we don't defend government blindly: government has problems, we need to FIX it. its an ongoing maintenance function that never ends
but libertarians want to THROW GOVERNMENT AWAY, to destroy it down to a cauterized ineffective nub. which is incredibly stupid. libertarians want this country to be like haiti or somalia, where there are a few ultrarich, legions of poor, abuses on every street corner, and the power vacuum of no government filled by mafias and corporations. libertarians may not actually say this is what they want, but this is the end result of their philosophy, whether they realize it or not
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:"ostensibly qualified" is fuzzy (Score:1, Insightful)
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.
They're called nurse practitioners and physician's assistants.
Re:How many different service lines? (Score:3, Insightful)
Even change a head gasket on a running engine? That's what doctors occasionally have to do.
Re:Profit driven (Score:1, Insightful)
There is no industry in the world with 13,600 different service lines to deliver. ...
But there is an industry that has more than 50,000 different product lines to deliver--grocery stores. They could not possibly determine the needs of each individual and deliver the groceries from behind the counter. Self-serve stores work because determining the needs has been put in the hands of the customers. They are free to roam and see what is available, and compare prices. We need to distribute the task of keeping prices down to the people most likely to be able to understand the individual's requirements and values.
I bet we could bring costs down if there were a way for patients to know the expected price in advance and compare suppliers, rather than going to the nearest facility and getting a monster surprise bill months later, after the insurance company decides what part they will pay of the price that was inflated because there was insurance.
For example, my last blood test cost me less out of pocket from Amazon* (without insurance) than the one before did from the local lab when my insurance was supposed to pay 90%. How could the local lab charge more than 10 times as much? And why couldn't I be allowed to know that in advance?
* And no, not an inferior test. Real test, real lab, mail it in, reliable timely results.
Re:"ostensibly qualified" is fuzzy (Score:2, Insightful)
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.
They are called Physician Assistants (or in some cases Nurse Practitioners) and are fairly common.
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.
Re:And what about poor people with a handicap (Score:1, Insightful)
No it doesn't. It tells them to get an explicit subsidy instead of trying to use insurance, since in the end, insurance isn't going to pay. If you have a chronic condition -- i.e. predictable expenses -- then you don't just need insurance. Instead, assuming you can't afford that expense, you need help.
Conflating the ideas of insurance and health care is what caused the problems a lot of people have been having. People make an insurance claim against their insurance company and it gets denied because of a pre-existing condition, and suddenly they're totally fucked, because they were relying on insurance for something that it is unable to handle: health care.
Slashdot car analogy: your car budget includes maintenance and insurance, not just insurance. If you have a shitty car (e.g. Jaguar) you deal with the fact that your maintenance is going to be higher, plan for it, and it gets taken care of. OTOH, if you only pay your insurance premiums and don't ever get an oil change or tire rotation, you will be fucked. Everyone understands that, and yet our whole country is doing that with our bodies. So we end up having a policy that doesn't get the bills paid, and then people (especially the poor people you claim you're defending) get fucked.
Re:And what about poor people with a handicap (Score:3, Insightful)
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. While many countries have lower absolute costs per-procedure than the US, they suffer the same growth curve problems.
Fundamentally we need a better way to align the cost of care with its value to the patient. We don't have a good way to do that right now. Both our current socialized and privatized models suffer from a command-and-control approach in which a small number of bureaucrats attempt to determine the value of each treatment for everyone in their insurance pool, regardless of whether some people would think it's worth the cost to them or not.
We have seen in history command-and-control economies fail every time at determining value and allocating goods to those who need them. We've seen it failing again in modern health care, as costs run out of control and there is nowhere in the system an incentive to be cost-effective. This means we don't get the quality of care we could, and it costs more than it could.
If you want a good read on the subject, check out this [nationalaffairs.com].
Re:And what about poor people with a handicap (Score:3, Insightful)
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 minimal expectation of food and housing, and the other things they need for a decent life, *then* we might think about allowing hard workers and skilled workers some perks.