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Medicine Education Government The Almighty Buck Politics

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."
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What US Health Care Needs

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  • by r00t ( 33219 ) on Monday June 21, 2010 @02:43AM (#32637716) Journal

    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.

  • by Anonymous Coward on Monday June 21, 2010 @02:48AM (#32637734)

    The Movie "The Blob" Supports the Case Against Government Healthcare []

    Okay, this isn't exactly the most serious piece I've ever written, but I think it's interesting and may make a good point. This past Spring, I was sifting through Comcast OnDemand, and found two versions of the movie "The Blob"- the original 1958 version, and the 1988 remake. The 1958 version is an old favorite of mine, so I decided to check out the 1988 version for comparitive purposes. I didn't get very far into the movie- I thought it was awful compared to the original -but I did get far enough into it to notice one crucial difference between the remake and the original.

    In both movies, an old man in the woods is attacked by the Blob, which sticks to his arm, and is then taken to get help by teenagers that find him. In the orignal film, they bring him to the town doctor, who is about to leave town on business. The doctor immediately forgets his previous plans and brings the old man into his office for treatment. The doctor sifts through books, and calls friends to attempt to diagnose the problem with the man's arm. He is clearly dedicated to helping the old man and the idea of payment is never even mentioned.

    In the remake, the teenagers bring the old man to the town hospital, but when they rush him to the front desk, they are greeted by an indifferent secretary who simply asks if the man has health insurance. The two teenagers become very upset and irritated at this point. The old man is eventually led into a room, and apparently forgotten. The doctor is uncaringly sitting at his desk doing paperwork.

    If each movie can be considered a reflection of the time it was produced in, a case may be made against government interference in healthcare. In the 1958 version, the doctor is apparently providing healthcare because he feels that it is his duty to do so, not because he is looking to make lots of money. In the 1988 version, the hospital is clearly only giving healthcare to make money, and it does not deem human well-being important. If one remembers Ron Paul's discussion on healthcare in "The Revolution: A Manifesto," this difference makes perfect sense. Ron Paul writes that when he became a doctor (in the fifties), it was standard for doctors to give free healthcare to those who needed it, but couldn't afford it. He then goes on to say that this benevolence ended when the government increased regulation on the healthcare industry (in the sixties), making free healthcare too expensive to give.

    So there you have it- the same story, with two different scenes (which doesn't really matter to the story, because the Blob does what it does best in both cases). Now, I don't really like it when people make art into things that it's not. But I really do think that each movie is accurately reflecting its own time period, and I think that government interference may be resonating even through the movies we watch. Really though, I just wrote this article for a little fun. Beware of the Blob! [And government :)]

  • by beelsebob ( 529313 ) on Monday June 21, 2010 @02:53AM (#32637754)

    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.

  • by Jah-Wren Ryel ( 80510 ) on Monday June 21, 2010 @02:56AM (#32637772)

    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 the responsibility for the spending back in the hands of the people with the most to lose or benefit.

    FWIW, I practice what I preach - I carry the closest thing I can get to true catastrophic insurance (and have not needed it yet) and pay cash for everything else. When I think a doctor is jerking me around for money (like the time they convinced me to do strep and mono tests despite being asymptomatic just because they could do them in their in-house lab so they were super-profitable) I dump them and move on. On the down side it is getting harder and harder to find doctors who are cash-friendly. Its like they've all just caved to the system and forgotten how to do business the normal way - even though the overhead of dealing with 'insurance' companies can easily equal 50% of the bill.

  • by martin-boundary ( 547041 ) on Monday June 21, 2010 @02:56AM (#32637776)

    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.

    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...

  • by Anonymous Coward on Monday June 21, 2010 @02:56AM (#32637778)

    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.

  • by Anonymous Coward on Monday June 21, 2010 @03:11AM (#32637840)

    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:

    • The body must be properly nourished, and must be able to assimilate nutrients from food and the environment.
    • The body must be able to evacuate waste products from the system. The organs of elimination are the skin, the lungs, the kidneys/bladder, and the large intestine/colon. If any of these systems are compromised, problems will result.
    • The body's structure must support the functionality of the body's organ systems.
    • The activities of mind have a major influence on the body's state.
    • The body has electrical properties which must be balanced for optimal health

    Western medicine plays whac-a-mole [] with the body's symptoms - a pill for high blood pressure, a pill for acid reflux, a pill for high cholesterol, ad infinitum - while health practitioners guided by superior philosophies (there are many) try to distill down to the fundamental reasons for a given body's dysfunction.

    The brand of medicine represented by this commencement address is defective because medical education was hijacked by the Carnegie Foundation (who represented the drug trusts). My favorite articles on this bit of history are 100 Years of Medical Robbery [] and the followup, Real Medical Freedom []. "How The Cost-Plus System Evolved" (pt 1 [], pt 2 [], pt 3 []) is also well-written.

    US Healthcare needs guiding principles: nothing more, nothing less.

  • /.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.
  • Re:Interesting... (Score:2, Interesting)

    by MsGeek ( 162936 ) on Monday June 21, 2010 @03:21AM (#32637888) Homepage Journal

    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 Medicare?
    1.) A flood of young, healthy people ditch their private insurance for this "public option" that provides better value for the money. Medicare has a 5% overhead rate. The private insurers take something like 30 cents out of every dollar paid in premiums for overhead and promotional costs.
    2.) This pool of new, young blood in the Medicare program spreads the risk and re-balances the pool of insured.
    3.) This will not harm private insurers one bit: instead of trying to sell people insurance policies they sell people "MediGap" policies that cover the things Medicare won't. Like gynecological and obstetric care, for can bet this new expanded Medicare will not touch women's health issues...third rail time.

    There, fixed it for you.

    I'll throw in a bonus: I'll fix Social Security too. Did you know there is a ceiling on income taken by FICA? After a certain point, your income is not subject to FICA taxation. You know how to fix Social Security and not have to worry about it for another century? You remove the ceiling and subject all earnings to FICA taxation. Bada bing bada bang Social Security is solvent. You take that money and put it in that lock box Al Gore was going on about in 2000, so that Republican raiders can't get their grubbies on it. Fixed that for you too.

  • by Anonymous Coward on Monday June 21, 2010 @03:31AM (#32637948)

    Let's see...

    Infant mortality rates. OK, first most of the world measures them in different ways. The US measures them more strictly. Oh, and I wonder why Cuba's abortion rates are so high? I'm sure that rampant abortion of non-viable infants has anything to do with it.

    But if all it takes to be convincing is to claim that I am "backed up by reputable sources" and just label anyone who disagrees with me as noise, I guess that's easy enough. []

    But really, all you need is a taste test. Even poor people in the US have access to multimillion dollar equipment and highly trained doctors, expensive medications, etc... Do you really think a little shithole poor country like Cuba has better healthcare? Really? I'm sure Cuba does a good job with what they have, they just don't have, well, jack shit.

  • AC for AC. (Score:2, Interesting)

    by Anonymous Coward on Monday June 21, 2010 @03:54AM (#32638048)

    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" medical care that amounts to utter neglect. So why do they live as long as us?

    Regarding your source:

    1: good job linking a right wing thinktank []. Funded by philip morris and headed by a former coordinator of Bush campaign? I'm SHOCKED that they don't like Michael Moore's film, haha.

    2: i win a prize for calling it... you're a disgruntled Moore hater. Well, so what. Get over it, and start contesting some of the legitimate non-fiction academic literature on Cuba instead of stuff that plays alongside action movies in theaters across the US.

    Even poor people in the US have access to multimillion dollar equipment and highly trained doctors, expensive medications, etc... Do you really think a little shithole poor country like Cuba has better healthcare?

    Tiger Woods is a billionaire. So I'm sure he wear condoms all the time he's banging cocktail waitresses, right? That's about the same sort of stretch in logic you use above.

    SOME poor people have access to multimillion dollar equipment in the US. And for every one of them, there are 20 persons who have health insurance, get cancer, and are dropped by their insurance company or denied coverage (because a commission is paid to reps every time they find a way to deny coverage, and those who don't are fired). The vast majority of American poor are victims of structural violence, are highly marginalized, and have essentially no access to first world medical care.

  • by RightSaidFred99 ( 874576 ) on Monday June 21, 2010 @04:03AM (#32638086)

    No, poor people can go to government clinics. If you're poor, you should get minimum care - that's it. Any other suggestion just proves you fail at maths.

    Let's look at world demographics - who's having the most babies? Poor people. You propose that the rapidly growing population of poor people the world over should get top notch medical care? Are there dragons in this fantasy land you've concocted?

  • Re:Navel gazing (Score:2, Interesting)

    by RightSaidFred99 ( 874576 ) on Monday June 21, 2010 @04:17AM (#32638156)

    Infant mortality is not easy to collect. In the US, any child born living (even marginally) will be put in NICU and every measure taken to ensure they live. This counts _against_ infant mortality. Most countries declare the baby nonviable. Go do some research.

    Expected lifespan is also subject to measurement error or outright lying (small shithole third world countries), but generally is highly impacted by health choices. Obesity, alcoholism, a sedentary lifestyle, stress, etc...

  • by Anonymous Coward on Monday June 21, 2010 @04:23AM (#32638176)

    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.

  • by Anonymous Coward on Monday June 21, 2010 @05:28AM (#32638456)

    This is completely true. I don't know why people on the left keep trying to wheel out this "don't you care about Old Mama Poor not being able to afford her drugs?" shthick; the economic arguments for having publically owned healthcare are stong enough on their own.

    For example, if a pharma company invents a new drug in the US, and goes to the insurers and says "I've got this new drug, it's awesome, it costs $100,000 if you don't buy it, your competitors will and everyone worried about getting cancer will flee to them", then what happens is the pharmas get to dictate prices.

    In the UK, the NHS goes "Oh, that's too bad, we're only paying $20,000 for it". The pharma company HAS TO SELL to the NHS and it's 65 milllion customers so it will accept this much fairer price.

    Of course, it is in the NHS's interest to keep GlaxoSmithKline profitable and inventing drugs, so it won't say it's only paying $10 or whatever, but it means the balance of power is tipped back towards the people and not the megacorps.

  • Re:Interesting... (Score:4, Interesting)

    by Gavin Rogers ( 301715 ) <> on Monday June 21, 2010 @05:36AM (#32638506) Homepage

    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.

  • by Kijori ( 897770 ) <ward.jake@gm[ ].com ['ail' in gap]> on Monday June 21, 2010 @07:47AM (#32639080)

    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.

  • by vlm ( 69642 ) on Monday June 21, 2010 @08:05AM (#32639176)

    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.

  • by Rockoon ( 1252108 ) on Monday June 21, 2010 @08:19AM (#32639244)

    I'm haemophilic - where am I supposed to get the cash for my treatment?

    I'm a life form - where am I supposed to get the cash for food?

    I'm a mammal - where am I supposed to get the cash to heat my home?

    This can go on and on.

    The upshot is that your needs cost a certain amount over a lifetime, X, and you are declaring that society should foot the bill for medical X's that are above average. What are the limits to this value? Can X be a hundred trillion dollars/pounds/euros? Really?

    We are talking about tradeoffs here. Certainly we can save multiple people with the money it costs to keep some individuals alive. Are you sure that you arent one of those people that is actually costing lives because of your treatment needs?

    Still further, we can simply improve the standard of living of some people with that money. Are you saying that no amount of standard of living increase for many people is worth your single life? What about liberty? Is liberty for all worth a dozen lives? ten dozen? thousands?

    For pennies per day we can feed people in 3rd world countries. Your medical costs could literally save thousands of lives if they were diverted to those needy people, right?

    I propose that we end hunger on the planet before we start worrying about giving health care to everyone. The money would be much better spent on that.

  • by vlm ( 69642 ) on Monday June 21, 2010 @08:29AM (#32639318)

    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 blocks from the best neonatal care unit in my county, also had an excellent ER before it was invaded by illegals. I get better medical care, thus should pay more for it than my cousin running the sheep farm whom has a two hour drive to the nearest dumpy clinic. People are already used to the idea that my property tax is a bit higher than my farmer cousin's property tax, so no problem there. Peoples lifetime medical care budgets are spent almost exclusively at the start and end of their lives, and coincidentally, kids and seniors spend most of their time nearby home, coincidentally in the service area of their properties nearby hospital. Currently, my emergency room health care received depends almost solely on where I live when the problem occurs, not on my highly variable income, may as well codify that situation. You can use the same justifications for using real estate taxes to pay for primary education, as you use to pay for medical services, like on average everyone needs it so we may as well have everyone pay for it, we've decided culturally that no education / no medical care is unacceptable, community pride / real estate values / rental rates depend strongly on the services we provide our residents, etc.

  • The real solution (Score:3, Interesting)

    by bradbury ( 33372 ) <Robert.Bradbury@gmail . c om> on Monday June 21, 2010 @08:47AM (#32639486) Homepage

    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)

    by ThosLives ( 686517 ) on Monday June 21, 2010 @09:26AM (#32639870) Journal

    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.

  • 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. there's nothing that can be done if someone is hell bent on ignoring their human dignity

    but that doesn't mean that anyone with ethics is going to accept the fact that some people have no dignity, and that some businessmen recognize no human dignity. accepting these thoughts is a gateway to a hell of social darwinism, where human life and human dignity has no value

    you may have no problem with that, but i do, and plenty others with a belief in human dignity do as well. so, stay in the shadows with your black market with your fellow sociopaths, and understand that just because you convinced someone to degrade their dignity, and you yourself recognize no dignity, does not mean that human dignity does not exist, and that it is not important for most of us

    take solace in the fact that you should do well in business, where sociopathology is rewarded

    as if doing well in business is the ultimate determinant of what is right and wrong. as so many callous ayn rand fools currently believe in this world, unfortunately

  • by Anonymous Coward on Monday June 21, 2010 @10:12AM (#32640406)


    We, a small Canadian company, let our US division deplete from attrition because we could not afford the ridiculous insurance premiums. Our intent was to increase the number of jobs there because there was less travel involved the wages were perhaps slightly less, and we thought perhaps Americans would like to deal with Americans (stupid Canadian cultural sensitivity). The number one reason people left us was because someone was offering a slightly better health care package, and ours was actually pretty good. After the last round of interviews where the first question we were inevitably asked was "... health insurance" the higher ups finally got pissed off and stopped trying to hire there.

    Instead we hired another 6-10 people in Canada and we travel to the US when necessary.

  • by COMON$ ( 806135 ) on Monday June 21, 2010 @10:53AM (#32641092) Journal
    Why do you think my Wife went into Pharmacy? She could have spent tens of thousands of dollars getting a PHD in biology (she already had her Masters and was teaching). Then spend the next 30 years competing for jobs for a crappy salary and moving around the country. Or she could spend the same time, a little more money, and have a guaranteed job. She will probably end up teaching or doing wellness care as she cant stand retail. Even cutting out that sector, her job prospects are WAY better in Pharmacy than they ever would have been in academics.

    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).

  • by coaxial ( 28297 ) on Monday June 21, 2010 @01:04PM (#32643072) Homepage

    Get government out of economy, take government's ability to screw with market prices out of the equation

    Take a step back and listen to your world view and the private insurers' argument for a second.

    1. The government is horribly inefficient, and always will be.
    2. The private sector is intrinsically efficient due to profit motive and competition.
    3. Private insurance can't compete against the government.

    Private insurance can't compete on cost and service against the organization that's bloated and can't find it's own ass with both hands and an electronic ass finding machine? If that's the case, how the fuck can private insurance even exist?

    AFAIC all government behavior that touches economy leads to pyramid scheme being created.

    Luckily for the rest of us, that's simply not true.

  • by nine-times ( 778537 ) <> on Monday June 21, 2010 @01:25PM (#32643302) Homepage

    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 the payout happens in the event of an unlikely disaster.

    Health insurance, on the other hand, pays out expectedly. It pays for our doctors visits every year, and it pays for our medication. As we get older, we all get sicker and sicker and require bigger payouts. And yet, we're still convinced that the system makes sense because we think we get more out of health insurance than we put in.

    Politicians and lobbyists have us convinced (if subconsciously) that health insurance makes our doctors visits and medication cheaper. You pay $20 for your doctor visit instead of $200, so it must be cheaper, right? Think about it much, and you realize that this is economically impossible. The money comes from somewhere. Therefore, the existence of health insurance would mean one of two things: either (a) we're wrong about insurance making things cheaper on an individual level and we're paying more to the insurance company than we would pay to just go to the doctor; or (b) the insurance companies are getting additional money elsewhere.

    For the answer, ask yourself where most of us get our health insurance: our employer. So the reason health insurance is cheaper than paying the doctor directly is that your employer pays a portion of the cost. But why does your employer do that? Why not just pay you that amount extra in your paycheck, and let you decide how to spend it? One of the chief reasons is that employers get a tax break for paying for their employee's health insurance. That's right: federal tax breaks. So now we see the source of the additional money. The federal government is indirectly funding health insurance through tax breaks.

    It's true. Our "private" health insurance industry is set up and funded by the federal government as a way to have socialize health care. We do not have a "free market" for insurance. Our current insurance industry is not an example of "capitalism". If the health insurance industry was subject to normal market forces, it would look a lot more like the renter's insurance market: Very few people would bother to get it, and it would only cover you in cases of unexpected catastrophe. There's no other way that the business model works.

    So yes, we have a socialized healthcare system that consists of giving health insurance companies unbounded subsidies, and this was done on purpose to disperse costs among the taxpayers and increase access to health services. While politicians are trying to phrase the question as, "Do we want to move to a socialist system?" the real question is, "Is our current socialist system working efficiently?"

  • by jc42 ( 318812 ) on Monday June 21, 2010 @01:36PM (#32643446) Homepage Journal

    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, 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, and you can't dispute it afterwards. Well, maybe you can, if you have a few million dollars for the decade or so of court expenses. But for the other 99% of the population, the "customer" has essentially no negotiating power.

    It's easy to see what would happen if other purchases happened this way. Consider the canonical /. auto analogy: You'd take your car into the auto hospital, where the mechanics will tell you what they're doing to the car, and at the end, they'll tell you how much you have to pay. After the car is in their hands, you'd have no further say in what's done to it, or what it costs. They might decide you need a new car, in which case they'll decide what model you should get, and you'll be legally responsible for whatever price the dealer writes on the invoice.

    We have the sense not to allow the auto repair business to work that way. But that's how our medical system works.

    It turns out that the American insurance system does have a function in all this mess: The insurance companies are a (not very good) way for the system's "customers" to build up negotiation strength. An individual can't negotiate with the medical system, but an insurance company can. This is why insured medical aid is cheaper than what uninsured people pay. But this is a "perverse" situation, because the insurance companies aren't motivated to minimize their customers' costs. They are motivated to minimize what the company pays to the medical system, while maximizing what they receive from their insured customers.

    (My wife has worked for some years at a local "non-profit" medical finance agency. She likes to tell people that in reality, nobody in the medical system can actually explain how they come up with their prices. It clearly has little if anything to do with actual costs. But even the system's insiders can't usually figure out how the prices are computed. They "just look it up", and it's turtles all the way down. ;-)

  • by Jah-Wren Ryel ( 80510 ) on Monday June 21, 2010 @05:34PM (#32646398)

    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 the cost of their healthcare we would quickly see standardized price lists - just like we currently see in the market for cosmetic surgery and stuff like lasik where people are generally 100% on the hook for the costs.

"The whole problem with the world is that fools and fanatics are always so certain of themselves, but wiser people so full of doubts." -- Bertrand Russell