surreal and more surreal

[mike777]

Actually, I think you're both right. Answering Mike's question is part of answering FM's.

 

 

fwiw I think people forget for some reason.

 

 

governments in usa are thrown out all the time...common.

 

 

But I think the comments that it leads to confusion...true....and ok

 

 

Usa style=debate/confusion/anger/etc. Not easy

[akwoo]

I don't care so much if we are a strong nation economically. We are rich enough, and we would be rich enough if we only had half our GDP.

 

I want us to be a virtuous nation, and any religion will tell us that part of virtue is providing generously for the needy (which of course includes the sick).

 

Some people might think that welfare is a relatively novel idea. It isn't. The poorhouse and other expenditures for poor relief was a significant part of the budget of every town in colonial America. And the poorhouses were taken down in the 19th century because they were felt to be inhumane ways of providing poor relief, not because states and municipalities thought they could legitimately drop the expenditure. Tax burdens back then were high too; they just happened to be in the form of property taxes rather than income taxes, which made sense since most income came from agriculture.

[mike777]

I don't care so much if we are a strong nation economically. We are rich enough, and we would be rich enough if we only had half our GDP.

 

I want us to be a virtuous nation, and any religion will tell us that part of virtue is providing generously for the needy (which of course includes the sick).

 

Some people might think that welfare is a relatively novel idea. It isn't. The poorhouse and other expenditures for poor relief was a significant part of the budget of every town in colonial America. And the poorhouses were taken down in the 19th century because they were felt to be inhumane ways of providing poor relief, not because states and municipalities thought they could legitimately drop the expenditure. Tax burdens back then were high too; they just happened to be in the form of property taxes rather than income taxes, which made sense since most income came from agriculture.

 

 

so? at this point you say nothing.

[kenberg]

I don't care so much if we are a strong nation economically. We are rich enough, and we would be rich enough if we only had half our GDP.

 

I want us to be a virtuous nation, and any religion will tell us that part of virtue is providing generously for the needy (which of course includes the sick).

 

I care a great deal about whether we are economically strong. Of course I acknowledged in an earlier post that I hold some conservative ideas, but I seriously doubt that this view is held only by conservatives. Some conservatives in fact seem more devoted to ideological purity than to economic or other strength. At any rate, I greatly favor economic strength.

 

As far as helping those in need of help, I see this as greatly intertwined with economic strength. First, and again I think I am not at all alone here, I find it to be a lot easier to be generous when I have some spare cash around. But further, effectively helping people can increase our economic strength. It is true that in some cases the disadvantaged will never be able to contribute much or anything to society. They are entitled to assistance too. But many more can become productive but need a little help in getting there. It's in our best interests to help them, and in fact it is in both our interests and their interests that this help be done effectively. There is room for disagreement, an open mind, and negotiation over the best approach.

 

It wouldn't surprise me if you agree with a lot of this, I don't want to take your statement about not caring about economic strength too literally.

[kenberg]

"What is the role of government?"

 

 

At the risk of egocentrism, let me quote myself on recent events.

I have in fact been surprised by the variety of small ways this has come up.

At the Y today I was chatting with a guy who has a small plane. He was supposed to file some paperwork with the FAA. The office in question was closed. I came home to work on a report for the National Science Foundation. FastLane, their website, is down. Yesterday there was an incident near the capitol requiring police. The police are working but their pay, at least for some, will not be coming for a while. These items are not exactly paralyzing the nation but it's three items in 24 hours. My understanding is that Congress is getting an earful. I recommend that they listen.

 

 

Let's look at these.

 

FAA filings. Overly intrusive big government? I can't say exactly what had to be filed. I take my car, even whenit is running perfectly, in for a mandatory exhaust check-up to hold down pollution. I suppose the FAA filing, while probably not about pollution, has something to do with public safety. We are opposed to this?

 

Cops responding to a mentally deranged driver attempting to crash through barriers at teh White House. I prefer having the police handle this rather than private citizens, and I would like to see them be paid w/o having to wait for the check or beg for the check.

 

My filing with the NSF. Ok, perhaps you object to the NSF funding mathematics and science. This goes back a ways. I was 18 when the Russians launched Sputnik and this led to a substantial increase in government funding for science. I had an NSF fellowship in grad school, I was also supported by grants, both in grad school and afterwards. But really it precedes even this. At the time of Sputnik I was attending a state university (the University of Minnesota) which was generously supported by the tax payers of Minnesota. And by federal grants. We object to this, do we? My father finished eighth grade, my mother had a little high school, I have a Ph.D. Government support of education had something to do with that.

 

As an adopted child, I can say that government "interference" in my life goes back to my birth. I don't mind.

 

It's easy to bitch about the heavy hand of the government. I simply haven't found it to be all that oppressive Less ideology and more practicality in addressing our issues would suit me just fine.

[y66]

From 10/1 Quinnipac poll:

 

American voters oppose 72 - 22 percent Congress shutting down the federal government to block implementation of the Affordable Care Act, or Obamacare, according to a Quinnipiac University national poll released today.

 

Voters also oppose 64 - 27 percent blocking an increase in the nation's debt ceiling as a way to stop Obamacare, the independent Quinnipiac (KWIN-uh-pe-ack) University poll finds.

 

American voters are divided on Obamacare, with 45 percent in favor and 47 percent opposed, but they are opposed 58 - 34 percent to Congress cutting off funding for the health care law to stop its implementation.

 

Republicans support the federal government shutdown by a narrow 49 - 44 percent margin, but opposition is 90 - 6 percent among Democrats and 74 - 19 percent among independent voters.

 

President Barack Obama gets a negative 45 - 49 percent overall job approval rating, compared to his 46 - 48 percent score August 2.

 

American voters disapprove 74 - 17 percent of the job Republicans in Congress are doing, their lowest score ever, and disapprove 60 - 32 percent of the job Democrats are doing.

 

"Americans are certainly not in love with Obamacare, but they reject decisively the claim by Congressional Republicans that it is so bad that it's worth closing down the government to stop it," said Peter A. Brown, assistant director of the Quinnipiac University Polling Institute.

 

"President Barack Obama enters this standoff over the budget with an edge over Congressional Republicans in the voters' eyes."

 

American voters trust President Obama more than Republicans in Congress on a number of issues:

63 - 26 percent on helping low income families;

51 - 38 percent on helping the middle class;

47 - 38 percent on handling health care;

47 - 42 percent on handling the economy.

 

Voters are divided on the federal budget deficit as 43 percent trust Obama and 42 percent trust Republicans. On gun policy, Republicans get 45 percent to Obama's 42 percent.

 

Gridlock in Washington is mainly because Republicans are determined to block any Obama initiative, 55 percent of voters say, while 33 percent blame Obama's lack of skill.

 

In another question, 28 percent of voters blame Republicans for gridlock, while 10 percent blame Democrats and 58 percent blame both equally.

[y66]

Now steaming on NetFlakes ...

 

http://www.slate.com/content/dam/slate/blogs/the_slatest/2013/10/01/shutdown_front_pages_how_today_s_papers_greeted_the_news_of_the_government/1380633347.png.CROP.promovar-mediumlarge.png

[Winstonm]

Exactly! Which is just about identical to their proportion in Congress. So the "gerrymandering" reference really made no sense, since that suggests that they have been somehow given undue influence. Unless you are saying that the folks you disagree with should have been treated via gerrymandering in such a way as to under-represent them.

 

So here is the dynamic from their perspective. They were elected in areas where their views represent the majority of their electorate. They don't believe that the US Government should walk away from its obligations. But they also believe that the US government is spending too much, by taking money out of the pockets of voters AND out of the pockets of people, some yet unborn, in the future. Taxation without representation might once have been tyranny, but today it is just good politics for PROFESSIONAL politicians. Today, the best way to get elected is not to espouse the American Dream, but rather promise (pander) to the broadest electoral base, promising benefits that someone else will pay for.

 

Opium is addictive. OPM (Other People's Money) buys votes.

 

Is not raising the debt ceiling the way to go? You tell me. Sequestering failed to address the biggest underlying problem in government spending (TAXATION - they don't create money, they just take it from the public - hopefully for you OPM), which is the entitlement budget. It also has turned out not to be the horrible problem envisioned. Perhaps it is now time to dig into the major part of the US budget.

 

Beating addiction is painful. Gaining strength is painful - No Pain - No gain.

 

Somebody up-thread said "does any other government have a debt ceiling? I don't think so". Facts are probably better than opinions (thinking). Denmark has a debt ceiling. Effectively the Euro nations did as well, until the weaker ones just ignored it. They are not doing so well right now, and the populace of the countries bailing them out are not happy about it either.

 

The value of the debt ceiling is not important - except that it is written into US law. The error made - politician lawyers are neither mathematicians, nor economists, is that the debt limit should have been some fraction of a macro economic variable such as GDP. But even there, and comparing only to highly developed countries, we are in worse shape than all but Japan (20 years of gloom) and Italy.

http://www.usnews.com/news/articles/2011/01/28/the-10-countries-with-the-most-debt

 

Forget the surreal label. Propose how we can become a strong nation economically, not borrowing nearly our annual production. We aren't a startup!

 

No, our debt is not like a mortgage where we borrow to make a capital purchase, and pay it back ourselves (not our heirs).

 

Perhaps I wasn't clear about gerrymandering - gerrymandering accomplishes a virtual guarantee of a party's victory, but not a faction within the party. This lies at the heart of the current problem - it is the threat of primary challenges from Tea Party members that allows the 18% minority to control the majority of their own party - and that entire situation has been caused by gerrymandering so that there is no true two-party system within many districts.

[Winstonm]

I think the shutdown has woken many to the economic power as well as the political power of our current government.

 

At this point posters do not seem concerned but this kind of stuff will just repeat. When you keep putting more and more economic and political power in just a few hands, this stuff happens. AT times you will be happy it happens, but often you wont. At this point the voters want it.

 

Economic and political power are synonyms for wealth - the Koch Brothers are more representative of "few hands with more political and economic power" than does the government. The "government" is not an entity but a collection of individuals - the only way to strengthen the power of government is by placing more and more power into the Executive Branch, which then reduces the collective aspect of government and places control into one person's hands - oddly, this is a position I have seen you argue in favor of in the past, but now oppose.

[Winstonm]

Exactly! Which is just about identical to their proportion in Congress. So the "gerrymandering" reference really made no sense, since that suggests that they have been somehow given undue influence. Unless you are saying that the folks you disagree with should have been treated via gerrymandering in such a way as to under-represent them.

 

So here is the dynamic from their perspective. They were elected in areas where their views represent the majority of their electorate. They don't believe that the US Government should walk away from its obligations. But they also believe that the US government is spending too much, by taking money out of the pockets of voters AND out of the pockets of people, some yet unborn, in the future. Taxation without representation might once have been tyranny, but today it is just good politics for PROFESSIONAL politicians. Today, the best way to get elected is not to espouse the American Dream, but rather promise (pander) to the broadest electoral base, promising benefits that someone else will pay for.

 

Opium is addictive. OPM (Other People's Money) buys votes.

 

Is not raising the debt ceiling the way to go? You tell me. Sequestering failed to address the biggest underlying problem in government spending (TAXATION - they don't create money, they just take it from the public - hopefully for you OPM), which is the entitlement budget. It also has turned out not to be the horrible problem envisioned. Perhaps it is now time to dig into the major part of the US budget.

 

Beating addiction is painful. Gaining strength is painful - No Pain - No gain.

 

Somebody up-thread said "does any other government have a debt ceiling? I don't think so". Facts are probably better than opinions (thinking). Denmark has a debt ceiling. Effectively the Euro nations did as well, until the weaker ones just ignored it. They are not doing so well right now, and the populace of the countries bailing them out are not happy about it either.

 

The value of the debt ceiling is not important - except that it is written into US law. The error made - politician lawyers are neither mathematicians, nor economists, is that the debt limit should have been some fraction of a macro economic variable such as GDP. But even there, and comparing only to highly developed countries, we are in worse shape than all but Japan (20 years of gloom) and Italy.

http://www.usnews.com/news/articles/2011/01/28/the-10-countries-with-the-most-debt

 

Forget the surreal label. Propose how we can become a strong nation economically, not borrowing nearly our annual production. We aren't a startup!

 

No, our debt is not like a mortgage where we borrow to make a capital purchase, and pay it back ourselves (not our heirs).

 

Your argument fails because your basic assumption is incorrect. National debt is not the same thing as private debt - it is simply not a crisis that must be fixed instantly above all other problems.

 

Second, the government is an elected body that represents all of us - and We, the People, decided long ago that it was a good idea to share the wealth and create a social safeguard for our elderly and ill - Social Security, Medicare, and Medicaid represent the will of the people, not the actions of some government strongman armed robber.

 

And third, the national debt and spending are mainly comprised of 3 roughly equal parts: social security, medicare, and defense. The first two are parts of our social safety nets for our own people - the third - defense - is the only one that is discretionary.

 

I have yet to hear anyone with your belief system challenge the wasteful spending of using the military in an attempted pax Americana and the continued spending on modernizing weapons in order to continue to joust with windmills.

 

WWII is over. The Cold War is over. China cannot afford to attack and would not want to. Our enemies are not nation states. We don't need to spend nearly 20% of our budget providing worldwide military police work using million-dollar RoboCops. A handful of special forces in helicopters gets a lot done for a lot less.

[y66]

As far as I know, there is this "wisdom" in US politics that it is a good idea to have a president from one party and a congressional majority for the other "to keep a political balance".

 

Might it be a good idea to point out now that it also leads to political stalemates, "political hostage taking" and a disfunctional government?

 

Bridge players know (or should know) that a pair will be more succesful playing one bad system than two different good systems. Wouldn't it be better to have a well functioning government that globally reflects your political ideas, even if on details their ideas may be different from yours?

 

Rik

Here's an interesting analysis of this phenomenon by Larry Sabato and Associates at The University Of Virginia Center For Politics:

 

That’s how it goes in American politics and in our two-party system: Success in a presidential election often invites later failure. The tides of victory overwhelm the opposition, but then quickly fade back into the sea. The setbacks for the president’s party during that person’s term can basically be summed up this way: Bad stuff, often having to do with the economy, usually happens during a president’s term, and he and his party are held responsible to some degree; if that stuff is really bad and happens before a president is up for reelection, that president could get the boot; and if the people can’t punish the president for the bad stuff, then they punish his party. That’s an oversimplification, but you get the point.

 

An often-overlooked, frequently steep political price paid by the presidential party is a loss of governors as well as state legislative seats and chambers.*

 

Since World War II, the president’s party has gained a net number of state legislative seats in just one of 17 midterms: George W. Bush’s 2002 midterm. (This election was a rare positive for the president’s party across the board — the exception that proves the rule, given the unique impact of Sept. 11.) The loss of power by the president’s party can be particularly damaging in election years at the start of the decade. For instance, Republicans had total control of 25 out of 50 state legislatures after the 2010 elections, which was their highest mark since 1952. Given that state and federal legislative districts are drawn at the start of a decade to coincide with the U.S. Census, the timing for Republicans was exquisite. They were able to draw favorable districts in many competitive states, like Michigan, North Carolina, Ohio, Pennsylvania and Wisconsin, while Democrats had comparatively fewer places to squeeze redistricting to its fullest (Illinois is really the only notable state where Democratic redistricting greatly aided them in 2012, although the Party of Jackson did benefit from “nonpartisan” redistricting plans in places such as Arizona and California). For reference, there are about 7,400 state legislative seats spread across the 50 states.

 

Again, let’s just imagine what would’ve happened if we hold all else equal in 2008, except that McCain wins instead of Obama. Not only do Democrats probably retain their state legislative power (they held total control of 27 states after 2008), but they also would probably have retained influence over redistricting in at least some of these aforementioned states. Again, Obama’s 2008 victory — and his subsequent rebuke in the 2010 midterm — has had long-term repercussions for Democrats. For example, it is possible that the 2010 election essentially ceded control of the U.S. House to the Republicans up through the year 2022, when the next redistricting takes effect — determined in good part by the outcome of the 2020 contests.

 

Meanwhile, no postwar president left office with more governorships than when he entered office.

 

This is not to suggest that the presidential trophy is some sort of cursed, booby prize, like wearing Sauron’s “One Ring” in Lord of the Rings or being named the drummer of Spinal Tap. The American presidency is immensely powerful, and the person who holds it has wide latitude to craft national policy; ladle out immense portions of patronage and powerful lifetime appointments; and, effectively, start and end wars abroad. But winning the presidency has its downsides, too — if not directly for the person who holds the office, then certainly for his or her party.

 

Now, explain to us again why so many senators, members of the House, governors and state legislators work hard to elect their party’s presidential nominee?

As for why we do this, Philip Converse asserted in his classic analysis of The American Voter 50 years ago that "most voters are remarkably unsophisticated in their thinking." This hasn't changed.

[blackshoe]

No one is old enough to have never experienced government interference in their lives, even if they don't recognize it as such.

 

As Ken points out, the greater our economic strength, the better things are for everybody. As for education, and welfare, and most of the other things government does, the question is whether government or the free market does it better. I suppose one's opinion on that depends on one's goals for the country, and one's beliefs about what works. And please don't raise the straw man of "we tried free markets, they don't work." There has always been government interference with the market in this country, and in every industrialized country. That's what doesn't work.

[kenberg]

This argument that we cannot say the free market works reminds me of a discussion with someone at the opposite end of the political spectrum. In the 60s a friend ran for governor of Minnesota on, I believe, the Socialist Labor Party label. I think he got five or six votes, something like that. Anyway, his argument was that you could not use various failures of the Socialist as any sort of proof anything because "there has never been a truly socialist state". Ok, point taken. He then argued that socialism was a good system because there had never been a war between too socialist states. I thought we might well come to blows (he tooks his politics seriously) when I pointed out that this would be a consequence of his argument that there had never been even one socialist state.

 

My brilliant repartee aside, I generally don't buy into arguments based on perfection or the lack of it. Not for free markets, not for socialism, not for marriage, not for living in sin (as the old expression went), not for nothing.

[blackshoe]

The free market is not perfect — it has flaws like anything else created by humans. But it is, as Churchill said of democracy, better than everything else. As for socialism, Ludwig von Mises wrote a brilliant critique of the system. I recommend it.

[Trinidad]

It's absurd to think that we need to make a global choice between complete free market and complete government control of the economy. Obviously the optimum is lying somewhere in the middle. Some segments of the economy are best left to the free market whereas others are better suited to be handled by a government.

 

To someone looking from the outside it is blatantly obvious that for an optimal economy the USA has too much free market and not too little of it. It is also obvious that the Soviet Union had too little free market and too much government control.

 

The point is that decisions about how much of our life is in the hands of the government is not an economic question. If it would be the USA would have switched to something like the French or Swedish health care system ages ago: The quality is better and the cost (for society as a whole, not just counting for the individual patient) is substantially lower.

 

Instead, the question of what part of our lifes is in the hands of the government is moral-ethical-political:

"True Americans" do not want a government to run health care with tax payers' money. They rather pay for their doctors themselves, even if it means that -on average- they need to pay much more.

 

That is because the "True American" is an optimist. He wants the freedom to bet that he won't need a doctor. It is irrelevant that he will be betting against the odds, just as it is irrelevant that he will be making a bet that he can't afford to lose. In short: it is irrelevant that it is a really stupid bet. He wants the freedom to make a stupid bet.

 

So, it boils down to the, now again, economic question: "How much is the freedom to make a stupid bet allowed to cost?". And as soon as the phrase "cost of freedom" enters a question, for some in the USA the answer is "infinite" since "freedom" is the most precious "economical good" in the eyes of these people... even if it is the freedom to do something really stupid at the expense of other people.

 

Rik

[kenberg]

"True Americans" do not want a government to run health care with tax payers' money. They rather pay for their doctors themselves, even if it means that -on average- they need to pay much more.

 

That is because the "True American" is an optimist. He wants the freedom to bet that he won't need a doctor. It is irrelevant that he will be betting against the odds, just as it is irrelevant that he will be making a bet that he can't afford to lose. In short: it is irrelevant that it is a really stupid bet. He wants the freedom to make a stupid bet.

 

So, it boils down to the, now again, economic question: "How much is the freedom to make a stupid bet allowed to cost?". And as soon as the phrase "cost of freedom" enters a question, for some in the USA the answer is "infinite" since "freedom" is the most precious "economical good" in the eyes of these people... even if it is the freedom to do something really stupid at the expense of other people.

 

Rik

 

It's risky to generalize. Being 74, I am reasoanably confident that I will need to see a doctor from time to time. As in any profession, half of them are in the bottom half of their profession. When push comes to shove, who is in charge? This is the question at the forefront of my concerns.

 

I have had some issues, and it has led to some, let us say, frank discussions with doctors. To give you the flavor, at one point I said something like "I don't have to be right" and the doc chimed in with "That's something I haven't noticed about you". At another point, someone in his office called me about a dispute we were having and congratulated me, sincerely or not I don't know, on beating the system.

 

A family member, for reasons of privacy I will leave it at that, had life threatening problems and very much found it useful to speak up clearly and insist. I would say it saved her life.

 

I have had good doctors and I have had bad doctors. I want to be treated by the good ones. Any system that interferes with my ability to make this choice will not be regarded favorably. It has nothing to do with betting that I will not need a doctor. I am quite sure that I will.

[blackshoe]

Sorry, Rik, but what you consider obviously right I have to say is obviously wrong, on many levels. For one thing, how best to provide health care for a nation may be a political question, but it is also an economic question, and you cannot answer the former without an answer to the latter. For another, it is not obvious that the "optimal" economic system lies somewhere between a free market and socialism. In fact, that assertion has been well refuted (see, inter alia, Ludwig von Mises, Socialism: An Economic and Social Analysis).

 

Ken puts it pragmatically, and he's absolutely right — no one in his right mind wants to delegate, or more to the point have delegated for him, health care decisions to a government bureaucracy.

[kenberg]

As Blackie no doubt guesses, my comments are not intended as being citical of ObamaCare, at least in its current form and as I currently understand it. He and I come at this from different angles.

 

ObamaCare is controversial, few would dispute that. Many have said that the administration has been inept in presenting it to the public, and I think that I agree. A good place to start would be to understand people's concerns about their own medical care. My concerns are the ones I stated, not the ones Rik described. I suspect that quite a few people share my concerns, and if the administration wants to gather support then the real concerns held by real people have to be addressed. There is some distrust out there, and distrust of politicians with grand plans is generally warranted.

 

 

I referred, vaguely, to some of my own physical issues. At one point it came down to an assertion that Medicare would not pay for what appeared to be the best treatment. My position was first that I thought that they were wrong and second I wanted what I needed and if Medicare wouldn't pay for it I would. I got what I wanted, Medicare paid for it. I can tell you that what Medicare would and would not pay for was very difficult to determine. I called them, waited the usual half-hour to get a live human on the line, and got nowhere. She explained that the doctor's office could call for more detailed information but in this case the doctor's office already "knew" the answer, they just knew it incorrectly. Broad statements of what will be covered are easy to find and useless, details are much more difficult to ascertain. Incidentally, the treatment I wanted was the treatment that the doc felt was the best, it wasn't some far out recommendation found by going to weird websites. The question was whether Medicare would pay for it, there was no disagreement with the doc about its appropriateness.

 

I could go on. Over the years it has become very clear that the patient is primarily responsible for his own health and had better be prepared to fight for it. As I understand it, ObamCare would not stop me from doing this effectively but in fact I am not certain. I am, however, very certain that this is my top issue, and I am willing to bet that it is the top issue for many. Someone who wishes to build support for, or for that matter someone who wishes to build support against, ObamaCare would be well-advised to address this very real concern. Bland assurance will not do the trick here.

[blackshoe]

As Blackie no doubt guesses, my comments are not intended as being citical of ObamaCare, at least in its current form and as I currently understand it. He and I come at this from different angles.

Not so very different, I think. When I mentioned government bureaucracies, I wasn't thinking of ObamaCare, in fact I was thinking of the VA and Medicare. IAC I think where I go further than you is in stating that I believe that the free market will do better than bureaucracy in providing health care. I could be wrong about that, but we'll never know, because the free market doesn't stand a chance of being tried in this country today.

[PassedOut]

Over the years it has become very clear that the patient is primarily responsible for his own health and had better be prepared to fight for it.

I could not agree more. In three very important medical situations, two with sons and once with Constance, we had to work hard (and in two cases, fight hard) to get the right care.

 

In the first case, when Nick was young and his asthma medication caused memory loss (a known side-effect), we were insured through an HMO. They refused to pay for the more expensive medication that did not have that side-effect. The young doctor who was treating Nick, caught between pressure from me and from the HMO administration, broke down in tears in front of us. We dropped the HMO then and there and got that fixed.

 

In the second case, Daniel developed kidney stones during his first semester in college. A doctor in that city ran tests that pinpointed a problem with one of his parathyroid glands. The doctor recommended immediate surgery--that he would perform: He just needed our permission. Daniel would be laid up for awhile and would have to abandon his classes for a month.

 

Our response was, "Not so fast, doctor." We consulted with the Mayo Clinic and found that (a) there was no need for immediate surgery, and that (b) there is a minimally invasive technique available at Mayo that reduces the recovery period substantially. We brought Daniel to Rochester on his semester break and the experience was enlighteningly positive for all of us. Since then, Mayo has been our go-to place for any significant medical problem.

 

In the third case, we were traveling (in the US) and Constance needed emergency care. The hospital there came up with a scary diagnosis that seemed quite unlikely, but we knew to get Constance out of there and to Mayo right away. The hospital was wrong about the diagnosis, the Mayo doctors fixed what was wrong, and Constance is fine.

 

I do think there is quite a difference between making sure that folks get the right care (and the ACA does, in fact, address some of those issues) and how the right care is paid for. I would be fine with Medicare excluding some of the very expensive end-of-life measures (such as the ones that Mayo won't provide because the treatments are stupid, but that other hospitals do provide), requiring folks who want that sort of treatment to buy extra insurance. That approach would require very specific rules about what is excluded, of course, but is the way to go.

[y66]

Not so very different, I think. When I mentioned government bureaucracies, I wasn't thinking of ObamaCare, in fact I was thinking of the VA and Medicare. IAC I think where I go further than you is in stating that I believe that the free market will do better than bureaucracy in providing health care. I could be wrong about that, but we'll never know, because the free market doesn't stand a chance of being tried in this country today.

According to Phillip Longman, Minnesota Public Radio and many others, you are indeed wrong about this.

 

Excerpt from The Best Care Anywhere by Longman:

 

By the mid-1990s, the reputation of veterans hospitals had sunk so low that conservatives routinely used their example as a kind of reductio ad absurdum critique of any move toward "socialized medicine." Here, for instance, is Jarret B. Wollstein, a right-wing activist/author, railing against the Clinton health-care plan in 1994: "To see the future of health care in America for you and your children under Clinton's plan," Wollstein warned, "just visit any Veterans Administration hospital. You'll find filthy conditions, shortages of everything, and treatment bordering on barbarism."

 

And so it goes today. If the debate is over health-care reform, it won't be long before some free-market conservative will jump up and say that the sorry shape of the nation's veterans hospitals just proves what happens when government gets into the health-care business. And if he's a true believer, he'll then probably go on to suggest, quoting William Safire and other free marketers, that the government should just shut down the whole miserable system and provide veterans with health-care vouchers.

 

Yet here's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be "significantly better."

 

Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.

 

It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.

 

Not convinced? Consider what vets themselves think. Sure, it's not hard to find vets who complain about difficulties in establishing eligibility. Many are outraged that the Bush administration has decided to deny previously promised health-care benefits to veterans who don't have service-related illnesses or who can't meet a strict means test. Yet these grievances are about access to the system, not about the quality of care received by those who get in. Veterans groups tenaciously defend the VHA and applaud its turnaround. "The quality of care is outstanding," says Peter Gayton, deputy director for veterans affairs and rehabilitation at the American Legion. In the latest independent survey, 81 percent of VHA hospital patients express satisfaction with the care they receive, compared to 77 percent of Medicare and Medicaid patients.

 

Outside experts agree that the VHA has become an industry leader in its safety and quality measures. Dr. Donald M. Berwick, president of the Institute for Health Care Improvement and one of the nation's top health-care quality experts, praises the VHA's information technology as "spectacular." The venerable Institute of Medicine notes that the VHA's "integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation."

 

If this gives you cognitive dissonance, it should. The story of how and why the VHA became the benchmark for quality medicine in the United States suggests that much of what we think we know about health care and medical economics is just wrong

[y66]

I could not agree more. In three very important medical situations, two with sons and once with Constance, we had to work hard (and in two cases, fight hard) to get the right care.

 

In the first case, when Nick was young and his asthma medication caused memory loss (a known side-effect), we were insured through an HMO. They refused to pay for the more expensive medication that did not have that side-effect. The young doctor who was treating Nick, caught between pressure from me and from the HMO administration, broke down in tears in front of us. We dropped the HMO then and there and got that fixed.

 

In the second case, Daniel developed kidney stones during his first semester in college. A doctor in that city ran tests that pinpointed a problem with one of his parathyroid glands. The doctor recommended immediate surgery--that he would perform: He just needed our permission. Daniel would be laid up for awhile and would have to abandon his classes for a month.

 

Our response was, "Not so fast, doctor." We consulted with the Mayo Clinic and found that (a) there was no need for immediate surgery, and that (b) there is a minimally invasive technique available at Mayo that reduces the recovery period substantially. We brought Daniel to Rochester on his semester break and the experience was enlighteningly positive for all of us. Since then, Mayo has been our go-to place for any significant medical problem.

 

In the third case, we were traveling (in the US) and Constance needed emergency care. The hospital there came up with a scary diagnosis that seemed quite unlikely, but we knew to get Constance out of there and to Mayo right away. The hospital was wrong about the diagnosis, the Mayo doctors fixed what was wrong, and Constance is fine.

 

I do think there is quite a difference between making sure that folks get the right care (and the ACA does, in fact, address some of those issues) and how the right care is paid for. I would be fine with Medicare excluding some of the very expensive end-of-life measures (such as the ones that Mayo won't provide because the treatments are stupid, but that other hospitals do provide), requiring folks who want that sort of treatment to buy extra insurance. That approach would require very specific rules about what is excluded, of course, but is the way to go.

 

Posts like this are what make it possible for me to rationalize spending time in the water cooler. So good.

[Trinidad]

Ken puts it pragmatically, and he's absolutely right — no one in his right mind wants to delegate, or more to the point have delegated for him, health care decisions to a government bureaucracy.

What gave you the idea that government bureaucracy makes healthcare decisions -on a personal level, nonetheless- in a government run health care system? Do you really think that accountants, lawyers or computer programs make the medical decisions in Finland, France or Sweden?

 

A good system is based on:

 

1) a reliable system guaranteeing well educated doctors.

2) doctors making the medical decisions, of course in discussions with their patients, where they weight the medical interests of their patients vs the interests of society as a whole. These decisions are (how obvious can it be?) not influenced by any bureaucrats.

3) doctors being able to make these decisions without any financial (or other) consequences for themselves.

 

Many (not all) government run health care systems match these criteria. Practice shows that health care systems based on the free market will not be able to handle the third criterion:

- A doctor will make more money when he "sells" more treatments.

- A doctor is influenced by third parties (pharma, or medical facilities) who make money from treatments.

 

After all, the free market is based on financial incentives. Medicine should not be corrupted by those.

 

Rik

[Trinidad]

I have had good doctors and I have had bad doctors. I want to be treated by the good ones. Any system that interferes with my ability to make this choice will not be regarded favorably. It has nothing to do with betting that I will not need a doctor. I am quite sure that I will.

Ken, I don't give my opinion on the way health care is implemented in Obamacare (simply because I don't know enough about the details). Blackshoe started a discussion about how good the free market handles health care and how bad it is when a central government runs it. I intended to show that there are excellent government run health care systems, medically and economically.

 

Obviously (at least to me) the freedom to chose your doctor has nothing to with whether the free market runs the health care system or whether a central government runs it. It is perfectly possible to have a government run system where you can chose your own doctor. And there are plenty of free market health insurers who don't give you the opportunity to chose your own doctor.

 

Rik

[blackshoe]

Longman's article says that VA health care is better than many people think it is. I'd say he's right about that. The article does not say that a free market can't do even better.

 

I don't care who makes health care decisions in other countries, I care who will make them here.

 

I say again: we don't have a free market (in just about anything, including health care) and are not likely to have one any time soon. So comparing government health care (VA, Medicare, Obamacare, whatever) to our current not-so-free non-government health care market doesn't say anything about how, or how well, a truly free market would work.