surreal and more surreal

[kenberg]

In any discussion such as this we can ask:

Better for me, the speaker/writer?

Better for the more needy among us?

Conforming to our general ideological outlook?

 

When it comes to getting the proper treatment for a serious medical problem, we all give ourselves (ourselves includes our family as well as literally ourselves) high priority. I don't mean that we don't care about other people, hopefully we do. But in discussing any approach to reforming medical care in this coutry, a person might ask all three of the above questions, and the answers might not be the same.

[Winstonm]

This is rather distressing to read.

...it’s hard to design any political system strong enough to withstand a party as ideologically radical and epistemically closed as the contemporary GOP. (Its proximate casus belli—forestalling the onset of universal health insurance—is alien to every other major conservative party in the industrialized world.) The tea-party insurgents turn out to be right that the Obama era has seen a fundamental challenge to the constitutional order of American government. They were wrong about who was waging it.

[blackshoe]

"The Constitutional order" has been dying for a century. This "fundamental challenge" is nothing new.

[mike777]

In any discussion such as this we can ask:

Better for me, the speaker/writer?

Better for the more needy among us?

Conforming to our general ideological outlook?

 

When it comes to getting the proper treatment for a serious medical problem, we all give ourselves (ourselves includes our family as well as literally ourselves) high priority. I don't mean that we don't care about other people, hopefully we do. But in discussing any approach to reforming medical care in this coutry, a person might ask all three of the above questions, and the answers might not be the same.

 

 

Yes, as we have often mentioned here....the last 6 months of life consume something close to 50%? of our lifelong medical costs.

 

A discussion most of us don't want.

 

I repeat my oft point....really super cheap scans of our body in many forms help....but no one wants that. It scales.

[Trinidad]

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

Sorry, I must have misunderstood. When you simply stated that government run health care systems can't work, I thought that you would be open for examples where they do work. My mistake.

 

Of course, I understand that you want good health care for you yourself and that you are not interested in the question whether the Vikings have a good health care system. But then stop saying that government run health care systems can't work, if you really mean that this particular government run health care system can't work for you.

 

Rik

[mike777]

Sureal.....all of this is

 

Trin..would you be so kind as define heath care system. As I understand it is a very very wide definition.

 

So wide that words such as single payer mean nothing or everything

-------------------

 

 

Example: Canada is single payer....Canada is NOT single payer

 

fwiw I understand UK and Canada is not single payer if that means one and only one single payer.

 

From what I understand (limited) there are more many more than one payer in the entire health care system. IN fact Canada does not have anything close to one and only one payer of health care.

 

-------------

 

 

One example...I understand in Canada there are many many payers of health care ..so many that the system of one payer would fold in a second if forbid.

[billw55]

To those in favor of socialized health care, and especially Trinidad: I think the main reason many Americans oppose this is simpler: we don't trust the government. Can you blame us? Look at the legacy of incompetence, waste, and corruption .. and now you want control of the healthcare system? I think it is quite normal to be wary.

 

The other side of the coin, of course, is that the free market is also corrupt. Incompetence and waste, however, are more often punished, by financial losses up to and including going out of business. Whereas government has no accountability for these failures - they just add debt or raise taxes, and go on their merry way.

 

I'm not saying I am against universal healthcare, just that I understand the concerns. It is a complex and difficult issue.

[kenberg]

A single payer system sounds good to me, as long as I'm not the single payer. Maybe Warren Buffett is up for the job. OK, OK, it's a serious topic, but I couldn't resist.

 

We are not going to switch to a free market approach to medical care. Even if I am not exactly sure what it would be, we are not going to do it. Similarly, I don't really understand single payer, but we are not going to do that either. The options before the House are to fund the ACA or... well, I'm not sure that there are other options. But they hope to destroy it, so we can talk about it. The ACA is intended to replace a rather incomprehensible system that evolved randomly over the years. Every year, during open enrollment, I get booklets of 100+ pages explaining, if explaining is the right word, my various options. There are, or at least there used to be, days set aside where you could go in and wander from booth to booth to get further explanations, usually from people who saw their job as trying to sell you something. Explanations were vague. I have Medicare together with supplemental coverage. It works quite well, so I pretty much ignore any opportunity to improve matters. As near as I can tell, as the ACA goes into effect I don't actually have to do anything, and little will change. Maybe I pay more. It's ok, I regard my health coverage as a bargain. It took some doing, but I am happy with the docs i now have and the costs are manageable.

 

So what's happening? Some people that I did not vote for and would not vote for have gained enough leverage to make a pretty fair mess of things. From time to time, crazies get way too much influence in this country. There was the Student Non-Violence Coordinating Committee (or, as it later became known, the Non-Student Violence Coordinating Committee). There was the John Birch Society. And now we have the Tea Party wackos. The country will come to its senses sooner or later, but sooner is far preferable.

[y66]

Guest post from Krugman:

 

The federal government is shut down, we’re about to hit the debt ceiling (with disastrous economic consequences), and no resolution is in sight. How did this happen?

 

The main answer, which only the most pathologically “balanced” reporting can deny, is the radicalization of the Republican Party. As Thomas Mann and Norman Ornstein put it last year in their book, “It’s Even Worse Than It Looks,” the G.O.P. has become “an insurgent outlier — ideologically extreme; contemptuous of the inherited social and economic policy regime; scornful of compromise; unpersuaded by conventional understanding of facts, evidence and science; and dismissive of the legitimacy of its political opposition.”

 

But there’s one more important piece of the story. Conservative leaders are indeed ideologically extreme, but they’re also deeply incompetent. So much so, in fact, that the Dunning-Kruger effect — the truly incompetent can’t even recognize their own incompetence — reigns supreme.

 

To see what I’m talking about, consider the report in Sunday’s Times about the origins of the current crisis. Early this year, it turns out, some of the usual suspects — the Koch brothers, the political arm of the Heritage Foundation and others — plotted strategy in the wake of Republican electoral defeat. Did they talk about rethinking ideas that voters had soundly rejected? No, they talked extortion, insisting that the threat of a shutdown would induce President Obama to abandon health reform.

 

This was crazy talk. After all, health reform is Mr. Obama’s signature domestic achievement. You’d have to be completely clueless to believe that he could be bullied into giving up his entire legacy by a defeated, unpopular G.O.P. — as opposed to responding, as he has, by making resistance to blackmail an issue of principle. But the possibility that their strategy might backfire doesn’t seem to have occurred to the would-be extortionists.

 

Even more remarkable, in its way, was the response of House Republican leaders, who didn’t tell the activists they were being foolish. All they did was urge that the extortion attempt be made over the debt ceiling rather than a government shutdown. And as recently as last week Eric Cantor, the majority leader, was in effect assuring his colleagues that the president will, in fact, give in to blackmail. As far as anyone can tell, Republican leaders are just beginning to suspect that Mr. Obama really means what he has been saying all along.

Unpersuaded by conventional understanding of facts, evidence and science? Qu'est-ce que c'est mes amis du forum?

[barmar]

We are not going to switch to a free market approach to medical care.

I'm confused. Isn't that what we've had prior to Obamacare?

 

And it demonstrably has not worked very well. It's fine for people who have good jobs that provide health insurance, and for rich people who can afford to pay for their own health care. But huge numbers of people are forced to choose between putting food on the table and getting health care.

 

AFAIK, Obamacare does not remove anyone's freedom of choice in selecting health care providers. For people who previously couldn't afford health care at all, their options may be limited, but at least they now have options.

 

BTW, be very careful in citing poll of numbers of people for and against the ACA. Many of the "against" votes are from people who are in favor of the general idea, but disagree with the specific implementation. For instance, some want a single-payer system, which the GOP forced Obama to remove from his proposal.

[y66]

The current budget brinkmanship is just the latest development in a well-financed, broad-based assault on the health law, Mr. Obama’s signature legislative initiative. Groups like Tea Party Patriots, Americans for Prosperity and FreedomWorks are all immersed in the fight, as is Club for Growth, a business-backed nonprofit organization. Some, like Generation Opportunity and Young Americans for Liberty, both aimed at young adults, are upstarts. Heritage Action is new, too, founded in 2010 to advance the policy prescriptions of its sister group, the Heritage Foundation.

 

The billionaire Koch brothers, Charles and David, have been deeply involved with financing the overall effort. A group linked to the Kochs, Freedom Partners Chamber of Commerce, disbursed more than $200 million last year to nonprofit organizations involved in the fight. Included was $5 million to Generation Opportunity, which created a buzz last month with an Internet advertisement showing a menacing Uncle Sam figure popping up between a woman’s legs during a gynecological exam.

 

The groups have also sought to pressure vulnerable Republican members of Congress with scorecards keeping track of their health care votes; have burned faux “Obamacare cards” on college campuses; and have distributed scripts for phone calls to Congressional offices, sample letters to editors and Twitter and Facebook offerings for followers to present as their own.

 

"]More

 

This is what happens when billionaires do not play bridge.

[y66]

I'm confused. Isn't that what we've had prior to Obamacare?

 

What we have now is Big Med which Atul Gawande describes thusly:

 

Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They’ve decided to become employees, and health systems have become chains.

[barmar]

What we have now is Big Med which Atul Gawande describes thusly:

That's not a contradiction. Doctors are joining conglomerates, but it's in the context of a free market system. The economics of health care make it favorable for them to do so. But the government isn't forcing them to do it.

[y66]

That's not a contradiction. Doctors are joining conglomerates, but it's in the context of a free market system. The economics of health care make it favorable for them to do so. But the government isn't forcing them to do it.

Agreed. Less free and less market-like does not mean not a free market.

[blackshoe]

Free markets are not regulated. Regulated markets are not free.

[ArtK78]

Free markets are not regulated. Regulated markets are not free.

The world is not so black-and-white. The U.S. economy is, for all intents and purposes, a free market economy. And many aspects of that economy are subject to regulation. Does that make them less free? Certainly. But does that make them not free at all? Absolutely not.

[y66]

On a less surreal note and somewhat related to the health care part of this conversation:

 

Jim Yong Kim and Atul Gawande are getting together Wednesday afternoon to discuss what it takes to drive organizational change and improve health care delivery systems:

 

http://live.worldbank.org/conversation-president-jim-kim-dr-atul-gawande

 

These 2 guys really are changing the world.

[y66]

From moveon.org via Krugman:

 

Twenty-four new surveys in GOP-held House districts, commissioned by MoveOn.org and conducted in the wake of the government shutdown, make clear that Republicans could easily lose control of the House if the next election were held today. The surveys challenge conventional wisdom that gerrymandering has put the House out of reach for Democrats and indicate the shutdown has significant electoral implications.

[mikeh]

To those in favor of socialized health care, and especially Trinidad: I think the main reason many Americans oppose this is simpler: we don't trust the government. Can you blame us? Look at the legacy of incompetence, waste, and corruption .. and now you want control of the healthcare system? I think it is quite normal to be wary.

 

The other side of the coin, of course, is that the free market is also corrupt. Incompetence and waste, however, are more often punished, by financial losses up to and including going out of business. Whereas government has no accountability for these failures - they just add debt or raise taxes, and go on their merry way.

 

I'm not saying I am against universal healthcare, just that I understand the concerns. It is a complex and difficult issue.

 

While I can empathize with a distrust of government, and a fear that government controlled health care will waste billions of dollars and often be mismanaged, where you and I part company is with respect to the notion that private enterprise does a better job.

 

Private enterprise does a 'different' job, but I think one can seriously argue that it is not, in fact, a 'better' one.

 

It matters how we define 'better'.

 

If I had a bad cancer...a difficult one that needed extremely sophisticated care and vast resources spent on it, I'd come to the States, provided that I could afford it. I don't think there is any doubt but that for the absolute best in individual care, the US system delivers it.

 

But: the vast, vast majority of health care issues do not require that level of care.

 

Consider this: my wife had a heart condition, a very common, rarely fatal, but inconvenient condition, treatable by a process known as oblation. There was a 1 year wait list due to budgetary constraints in our government funded health care system, so I checked US hospitals.

 

The Cleveland Clinic offered to do the day surgery (with an option of an overnight stay, limited to one night, if complications arose) for $125,000.

 

As it happened, the government awarded more money to the programme here and my wife got her operation within 3 months. The cost to the taxpayer: $6,500.

 

Now, under what sane system would Cleveland Clinic charge 125,000 for a procedure that we got here at a cost, to the system, of 6,500 and to us, 7.50 for parking?

 

Which system was 'better'? Btw, the clinic here has a success rate for the procedure that is amongst the highest in the world, and as good as that boasted by the Cleveland Clinic.

 

Other examples abound. I had a client who had a whiplash: a straightforward injury with completely predictable treatments and outcomes. I have handled many hundreds of such cases.

 

She happened to spend half her time in Florida and half in British Columbia. When she went to her GP in Florida, complaining of her sore neck and mild headache (a completely normal problem for which the universal treatment is physiotherapy, analgesics and anti-inflammatories), he had her undergo a MRI, in a machine he had in his clinic...a machine that, at the time, cost over a million dollars and required a trained technician to operate.

 

This was utter nonsense. It made absolutely zero difference to the treatment protocols or the outcomes, but I am sure that her US insurer wrote a big cheque.

 

Another aspect where private enterprise wastes money is in the competition for business, often fueled as much by making the hospital resemble a high end hotel as it is by advertising. Does anyone really think that running television ads is either cheap or good for patient care?

 

Then of course there is the profit motive. I don't see much difference, in terms of patient outcome, if 20% of the budget is wasted due to government mismanagement or if 20% is paid out to shareholders and senior management, the latter getting bonuses. As for the invisible hand of the market rewarding winners and punishing losers, I suggest you read something about behavioural economics...the invisible hand only operates efficiently in a rational market, and humans are not rational consumers.

 

Few of us are able to adequately inform ourselves of the relative merits of those who compete for our business, whether we be buying a car or cancer treatment. Look at the number of people driving big SUV's in North America as one example. Look at the tea party members riding their medi-care scooters to protest socialized medicine as another.

 

Note that in this discussion of 'better' I have not even referenced the staggering economic cost of dealing with the uninsured in the US.

 

Many of these people live with debilitating conditions that are amenable to preventative and maintenance programs, or that could be detected early, and either cured or managed with early detection, but the only care they can access is emergency care once the problem becomes profoundly debilitating. This makes it difficult for these people to participate in the economy (tho many of them are so deprived educationally and socially in the unequal US economy that they may never have had a chance anyway....the US is amongst the most socio-economically rigid societies in the Western world, contrary to the mythical 'American Dream' propaganda that it sells to its populace).

 

That is a true cost to society, that is measurable, albeit with wide margins of error, and ignores what to most non-US westerners is a profound moral point: all members of a wealthy society ought to be afforded reasonable health care. It is indeed a weird paradox: the most loudly 'Christian' nation in the developed world affords the worst treatment to the poor of any developed country, and has amongst the worst ratings in all measures of public health, general education, and levels of happiness.

 

Universal health care wouldn't solve all of these problems, and would bring others in addition, but the experience of many hundreds of millions of Europeans, Canadians and others suggests it might go a long way to legitimizing what most of us non-americans see as an irritating claim to 'exceptionalism'. Lest I be accused of anti-Americanism, let me hasten to add that from my readings in history, not to mention an English Public School education that, in terms of learning history, was a lesson in nostalgia for the then-recently lost empire, it is completely normal for the population of any temporarily dominant nation to ascribe their nation's success to their exceptionalism. Measured in centuries, such exceptionalism eventually regresses to the mean....as the US is slowly realizing as it looks at China and as China will no doubt eventually learn in turn.

[billw55]

Mike, you make some great points. For clarity, I did not say that the private/market system is better overall, only that it might be better at controlling wasteful spending. Of course against that, they want profits, big ones.

 

As for the $125,000 vs $6500, yes that is absurd. I think what you would find in our private system, is that your insurer would actually pay much closer to the $6500 than the $125,000. As far as I can tell it is some kind of voodoo bookkeeping game: hospitals/providers give enormously, comically inflated "list" prices. Then the insurers only pay a small fraction of that. I can only assume that the providers use the difference as some kind of "loss" in their accounting. Or perhaps they are just saying: we don't want out-of-pocket business. Either way, nobody ever actually pays those joke prices.

 

Yeah, ads are waste. Redundant administrations are waste. Profits are waste in a sense, because those dollars provide no care. Maybe a government system will be better. I am willing to try it. My biggest concern is that, even if the government system fails, there will be no way back out of it. Government programs rarely go away.

[blackshoe]

Profits are waste in a sense, because those dollars provide no care.

Depends on where those profits go, doesn't it? If they go to improved infrastructure (more beds, more doctors, more nurses, new equipment, etc.) then they do provide care.

[kenberg]

The ercent posts of mikeh and billw are both of great interest to me. I have some work to do so i will comment only briefly for now.

 

The $125,000 op. First, I am glad to hear that it worked out. Also, it reminds me of something I said earlier about how if medicare was not going to pay for something, I would. But of course not everyone is in a position to say such a thing. And Bill is right, that the posted prices are often totally unreal. my favorite was some procedure, I forge what it was, that Medicare said it would not pay for but also said that it seemed as if I didn't realize it wouldn't pay for so I didn't have to pay for it either and the doc could just go whistle for his money. It didn't put it exactly that way, of course.

 

Mike says: "Few of us are able to adequately inform ourselves of the relative merits of those who compete for our business, whether we be buying a car or cancer treatment.". You got that right. Double and re-double. And tthen it has to be properly implemented. Some years back when health insurance was first becoming widely used, I had something where I first had to pay, then I supposedly got money back. No matter which form I filled out, I would get a letter explainging that it was the wrong form. I would then send in a different form and I would get a letter back saying that it was now too late to file. So I switched to an HMO. Different doc every time I went in. When one of them asked me if I remembered what my form had on it because she couldn't find their copy, I moved on to something else.

 

Well, I hope we get this right. but I do value the option of saying "Buzz off, you clowns, I want what I want and I'll pay for it".

[billw55]

Depends on where those profits go, doesn't it? If they go to improved infrastructure (more beds, more doctors, more nurses, new equipment, etc.) then they do provide care.

Well, in that case they show on the balance sheet as expenses. By "profits" I mean strictly those dollars which leave the organization for enrichment of the owners/stockholders. Hospitals are very good at keeping the money in - they can't have too much profit, and still maintain their non-profit tax status. So the successful ones keep building and expanding, which can indeed be good for care. Insurers are a different animal however. Those (large) profits provide little towards care.

[ArtK78]

Well, I hope we get this right. but I do value the option of saying "Buzz off, you clowns, I want what I want and I'll pay for it".

That is all well and good, but the vast majority of the people cannot afford that option.

 

Oh, wait. I forgot. The Republicans don't represent the vast majority of the people (except for the wall street people, the oil people, the banking people, the insurance people, etc.).

[Winstonm]

Depends on where those profits go, doesn't it? If they go to improved infrastructure (more beds, more doctors, more nurses, new equipment, etc.) then they do provide care.

 

Let me tell you a true story from my time working as an RN at St. John's in Tulsa. I asked a cardiologist what significance a certain blood test had on cardiology. He answered that the test had allowed him to buy a 100-foot yacht instead of the 60-foot one he had his eye on.

 

He was not kidding.