Health Care’s Senior Moment

Seniors have recently emerged as an important battleground in the health reform war. Katharine Seelye of the New York Times has a post on the “new generation gap” separating the elderly from the not-so-elderly, and multiple polls have shown that seniors are more resistant to reform, at least when it is phrased broadly. In addition, the nonsense about “death panels” has worried at least some seniors, enough for the AARP to pitch in to try to shoot it down.*

This should seem ironic, given that people over 65 are the one group that has already most benefited from health care reform – only their reform happened in the 1960s, when Medicare was created. But hey, it’s a democracy, and people don’t have to wish for others the benefits they themselves enjoy.

What are the underlying reasons why seniors are more likely to oppose “reform?” The first – leaving aside the self-contradicting notion that health care reform will mean a government takeover of Medicare – is probably fear that Medicare will be negatively affected. Now, there is a grain of a partial truth to this fear. Several of the proposals on the table include paying for health care reform (meaning, paying for the subsidies that poor people will need if we’re going to mandate universal coverage) in part by reducing growth in Medicare spending. One proposal is the Independent Medicare Advisory Committee, which would look for ways to increase efficiency in Medicare, which could include lower reimbursements for procedures that were deemed to be not providing benefits commensurate with their costs.

To its credit, here’s what the AARP** has to say about health care reform and Medicare:

What do the proposals say? It’s true they all seek to save billions from Medicare costs—not by cutting benefits, but by setting up new ways to pay doctors more fairly and to reward providers for quality of care instead of (as now) paying them a fee for each separate service; reducing waste and fraud; and reducing preventable hospital readmissions.

All the proposals would cut the amount of subsidies now paid to Medicare Advantage private health plans, which cost an average of 14 percent more per person than traditional Medicare does. Without subsidies, the private plans could become more efficient, or they could raise premiums, reduce benefits or withdraw from Medicare.

The proposals also add benefits to Medicare­—such as covering more preventive services and narrowing the Part D “doughnut hole.”

More fundamentally, though, the need to reduce growth in Medicare spending stems from the simple fact that otherwise Medicare will blow through the entire Federal budget within the next few decades. Not reducing the Medicare growth rate is not an option. If I were a senior, or expected to be one in the next couple decades, I would very much want health care reform now, because the alternative will be much more draconian cuts to Medicare benefits in the future as the national debt explodes.

And reducing costs is precisely the other thing that seniors care about. According to Seelye, concern about health care costs rises with age. Now this makes sense; even with Medicare, seniors’ out-of-pocket medical expenses are considerably higher than those of younger people, for the simple reason that on average they consume more medical care. But there’s no good way to reduce seniors’ out-of-pocket spending without at the same time reducing Medicare spending because, broadly speaking, those two types of spending are buying the same thing – health care. You can’t have a system where Medicare spends more and more yet seniors spend less and less out of pocket (short of simply reducing seniors’ relative contribution to their health care costs, which would only make the fiscal problem worse).

It’s simply contradictory to oppose reductions in the growth rate of Medicare spending while favoring reductions in your out-of-pocket spending. Of course, there’s nothing that prevents people from holding two logically inconsistent thoughts in their heads at the same time. Uwe Reinhardt had a brilliant column a couple of weeks ago on the stew of inconsistencies that many Americans take for granted when it comes to health care.

Luckily, they elect representatives who can think clearly about these complex issues. Oh, wait, sorry about that.*

* On the other hand, what the hell does Chuck Grassley – one of the six people who think they are writing the health care bill – think he’s doing, saying “We should not have a government plan that will pull the plug on grandma?” As Brad DeLong might say, why oh why does he have a seat at the table?

** As far as I can tell from their website, the AARP is neither for nor against health care reform in general; they say they are working to make sure that health care reform is good for their constituency.

By James Kwak

91 responses to “Health Care’s Senior Moment

  1. The AARP is primarily another member of the K Street Gang. They have developed a very lucrative business selling endorsements for those wishing to market gods and services to AARP members. Check out their publications.
    As for Chuck Grassley having “a seat at the table,” I suppose that may be because the people of Iowa have elected him to the Senate. If Brad wants to get involved, I suggest he follow Al Franken’s example. (Of course, I might be about as comfortable with Brad setting Health Care policy as I am with Grassley setting grain price supports.)

  2. It’s simply contradictory to oppose reductions in the growth rate of Medicare spending while favoring reductions in your out-of-pocket spending.

    It makes perfect sense to me: make young people pay.

    Guess who’s on YOUR death panel?

  3. From the “new generation gap” article: Dennis Boltz, 60, a retired nuclear reactor operator at Three Mile Island, carried a sign reading: “If you need surgery, Obamacare will cut you out.”

    He is excused since his mind was zapped by radiation in 1979.

  4. Hey James,
    I’ve read your pro-socialist health reform rants long enough to know you have no clue what you are talking about. As a physician, I know that there are 6 prongs to this problem, and all are complicit. The first 4 (hospitals, doctors, pharmecutical, and insurance companies) are being raked over the coals by the current administration. Surgeons making $50,00 for a foot amputation? (http://www.facs.org/news/obama081209.html) BS.

    The 2 prongs that aren’t discussed are 1) lawyers and 2) patients. American doctors order 4x MRIs than German doctors. I order MRIs to cover my ass from getting sued. I explain that to patients, but I can’t take a risk without protecting me, my job, and my family. The trial lawyers that state that medical malpractice fees are 0.1% of total medicare care are right – but they’re totally freaking wrong that the threat of malpractice doesn’t dramatically increase the cost of medical care. Similarly, we live in the fattest country in the world. To compare our cost of medical care to freaking Norway is insane. In 1962 13% of Americans were obese. Now, 33% of Americans are obese. If you want to decrease the COST of medical care, you have to incentivize patients and expect more from ourselves.

    By the way, when the hell does just merely HAVING health insurance somehow make someone HEALTHY? If anything, we should be going AWAY from health insurance and paying for healthcare as we need it with a population-based program.

    But don’t ram a “solution” down my throat without addressing the giant elephants in the room. Barry has greatly disappointed me on this. He has received (by far) more money from the health insurance industry and the unions than anyone. Anybody that thinks he’s in it “for the better good” anymore is incredibly naive.
    BN

  5. One can find more rage than reasoning in this comment. Would seem that Brian has really given some thought to all this, but it doesn’t seem to make sense b/c it shoots off in different direction without coherence. I really have tried to read it four times to see if there is something that really hangs together…. Come to think of it, that is the definition of a “rant”. Brian, if you have a point to make, why not do so in manner befitting your obvious “smarts”….

  6. CBS from the West

    Well, I’m a physician, too. But I disagree with much of what Brian N has said.

    Although I am not currently on board with the current proposals for health reform because too much has been left unspecified, it is the hospitals, doctors, pharmaceutical and insurance companies that have been raking the country over the coals for lo these many years. Under fee-for-service the procedures and tests just keep exploding in number and price, about a third of them useless or worse, with the insurance companies gleefully taking a a cut of the handle off the top.

    So why do we spend nearly twice as much per capita as other OECD countries on health care? Brian N points to malpractice. Well, yes, that is undoubtedly a piece of it. But I have yet to read a serious economic analysis that suggests that malpractice contributes more than a few percent of the overall problem. And in those states that have instituted some kind of tort reform, such as Texas, the costs did not subside or even slow their growth–they just followed along with the rest of the country. I agree that malpractice suits are ridiculous–they sometimes penalize doctors for practice that is _better_ than the “standard of care,” they are sometimes brought solely to tap “deep pockets,” and they do nothing to improve the quality of care–if anything they worsen it. It is time we ended this lawyers’ racket and replaced it with a fair administrative injury compensation system. But don’t expect that to make much of a dent on health care costs.

    As for obesity, it is a contributor, too. The extent of it remains to be seen. While it is currently driving up expenditures on heart disease and diabetes, it may end up saving us money if the mortality rates get increase and if people die of those things before they have a chance to get a really expensive cancer. Truth is, nobody really knows yet what the impact of obesity on health care expenditures will be in the long run.

    In other respects, though, patients are a contributing factor. There is a predominant cultural belief in our country that more health care services means better health care. Patients flock to physicians asking for treatments or tests they’ve heard about and are often very insistent in spite of careful and detailed explanations, supplemented with references, why what they are asking for is useless or even harmful. To what extent this prevailing belief is just a part of our culture and to what extent it derives from the manipulations and disinformation campaigns of the health care industry itself, I don’t know. Many doctors are similarly afflicted themselves–my guess is that much of the useless care is provided by doctors who, in good faith, believe it is warranted and are either shielding themselves from exposure to, or in denial of, the evidence to the contrary.

    Finally, I do agree with Brian N about one thing: I have lost faith that Obama is in it for the better good. Far from a government takeover of health care, we are today witnessing the takeover of the government by the health care oligarchs (that is, that part of it not already taken over by Finance).

  7. Remind me which of your six prongs are best served by the current system of fragmented employer-based health insurance?

    James and others on this blog have made several suggestions that touch on all the areas you have referenced. It is bizarre to argue that the current system which is defined by the problems you cite is best positioned to address them. That “population-based program” you suggest to pay for healthcare would be a national insurance program.

    As for the whole “no idea” bit, I think the volume of work Simon and James has produced this year speaks to a pretty strong knowledge of the topics they discuss. If you disagree, it’s a big internet; I’m sure you can find Art Laffer somewhere.

    http://tauntermedia.com/2009/08/06/im-with-stupid/

  8. James is lying again.

    Several prominent democrats heavily involved in formulating the public option including our President , Daschle and former Governor Lamm have said things that clearly indicate Seniors will be denied care for cost reasons. When asked by the daughter of an mentally alert 100 year women who received a life saving operation whether that same operation would be available to others in the same situation, at live at the ABC Town Hall our President clearly did not say yes, and gave the impression the answer would be no.

    Obama and his minions are clearly lying. They won’t appear at anything but a staged rally, with plants posing as doctors. They say the public can keep its present coverage, when the plan is clearly designed to force people into the public option plan.

    Seniors concerned are warranted. Britain’s health care system , upon which the public option is modeled, regularly denies care to those thought undeserving.

    News reports say the Death Panels have been removed from the bill. However, Obama and his black pill gang can’t be trusted at this point at all, because of their consistent deceits and lies.

    I can’t wait until November 2010 when these socialist thieves, liars and con men are thrown out on their butts. America hates to be bullied and conned. Obama’s approval ratings are at only 48% and falling fast, after only six month in office, even with a fawning press watching his back and promoting his agenda at every turn.

  9. The reason health care reform is in deep trouble is because no one knows what it is. Obama has not laid out his proposal.

    What’s going on is very typical backroom dealing, where the wise men go behind closed doors and come out a few days later. You can’t run a national government this way.

  10. “News reports say the Death Panels have been removed from the bill.”
    You mean the “death panels” that were never in any bill?
    I can forgive people who promote the lie, though. We all exaggerate a little at times. Haven’t we all tried to win a debate at times by telling old people that their government is going to kill them to save money?

  11. being by now a (retired) senior myself I kind of understand the reaction of your US-seniors as you describe it, because one fact of life is the longer you have lived the more often you or others close to you have been lured by false promises just to find yourself screwed.

    So one gets kind of naturally less trustful less enthusiastic about anything new – therefore the safe way is to defend what you have with all your might and believe very little of what you get told will be an improvement or a necessary change if you want not to become anti-social.

    As to not caring for the plight of the youngers I guess seniors know only too well that these will be screwed no matter how.

    And of course the exorbitant sums being grabbed by people who know how to get cash their way helps vastly a general mood of NO (by the way I do not mind for example sports stars’ incomes, they really generate earning possibilities for a lot of “normal” people, not just for a select few of carpet weavers, modern artists or nail designers)

  12. I agree with a great deal in the post – however, I find it extremely disingenous to overlook the long history of the democrats demagoging the issue of Medicare “cuts” (see Clinton versus Dole). It is ironic, as you note, that seniors, the group most indoctrinated that any REDUCTION IN GROWTH of a benefit is a cut, will block healthcare reform.

  13. I wonder whether health care is really the issue.

    It seems to me that there is a context that could indicate that the process and content of “health care reform” policy should be re-worked.

    That context, to me, is a growing disaffection between the population and the state. There is so little trust in the state’s morality and its effectiveness that any new program will be met with great scepticism.

  14. post partizan depression

    Couldn’t agree more -especially the last part about Obama and the government takeover by the oligarchs (We have already had direct experience with his hand over to the banking oligarchs). Might I might suggest that the first thing we should do to prevent your problem with patients asking for treatments they don’t really understand is to once again block drugs companies from advertising on television. I laugh every time I see one of their ads but they must work because drug companies have bigger budgets for advertising than for research-really sad but not unexpected.

    Given americans spend almost twice as much on healthcare as other industrialized countries and get less for it, I don’t understand how healthcare reform could possibly lose this debate. I wish the democrats bill included the ability for consumers and businesses to buy into medicare then we might get somewhere but IT DOESN’T. Without that the current bills are a giveaway to the private insurers who have already proven they do not do healthcare better or cheaper or more efficiently. How in the world is that not self evident???

  15. here’s an explanation of Israel’s health care system
    - sounds really great to fabulous
    - it seems the shorter a system is in existence and the less it had to deal with pre-existing conditions the better it fits present times

    I wonder why he makes such vague references to catastrophic cases though – maybe if you ask him he will elaborate

    http://yaacovlozowick.blogspot.com/2009/08/health-care-in-israel.html

  16. Why is the conversation about “mandatory” health insurance? Do we have food insurance? Gas insurance? How about a government-run HSA that collectively takes care of catastrophic healthcare? We should pay for healthcare like we pay for food and other basic necessities. An informed consumer is a frugal consumer. The only way to make healthcare cheaper is to decrease the number of hands in the pot. And now the politicians want their hands in the pot as well. How is this a solution?

    My point earlier about the 6 prongs of healthcare is that you can’t ignore ANY of them. Physicians and healthcare providers get 20 cents for every dollar spent (Medicare data via CBO). Isn’t a little disingenuous to say you can fix the problem by going after one subgroup? Especially if it’s the subgroup that gives a certain politician less campaign contributions than the others?

    As a society we have to decide that if you want a la carte, you pay a la carte prices. If you want cheaper more efficient healthcare, you have to take some things off the menu. For example, 10% of the Medicare population consumes 67% of the total Medicare spending (Kaiser Foundation study, 2009). That is neither cheap nor efficient. I would vote for the latter system. However, it seems with the outrage this debate is creating many in America want the former. I do agree with Eric F that the spending is so out of control with the current government that the American public is pushing back on ANY new spending bills.

  17. If you want cheaper more efficient healthcare, you have to take some things off the menu.

    then Atul Gawande & Co must be completely wrong
    - to date wherever I could measure him against personal experience he seemed very plausible and trustworthy to me (note: in my world even the trustworthy can err ;-)

    http://www.nytimes.com/2009/08/13/opinion/13gawande.html?th&emc=th

    also, I do not know which measure contributed how much to keeping German health cost in check but my sinusitis doctor’s office and the adjoining hospital department both had streamlined their procedures the whole patient-”flow” between 1991 when I stayed in the hospital and 2003 when I stayed there again
    - I felt a lot better in the stream-lined version, clear directions, less confusion, etc. and even the nurses didn’t seem to be as stressed out as the first time
    - as to personal care received from the doctor it hadn’t changed despite all the outcries of how we poor patients wouldn’t be well taken care off anymore. The doctor was excellent the first time around as he was the second and the outcome both times made my life a lot better.*)

    Oh and I forgot the first time I had pre-surgery just an X-ray taken, the second time I had to go into on of those noisy machines which made a lot of really interesting looking pictures of my head – so actually something probably not cheap had been put on the menu!!!

    *) that my nose was such a mess to start with was not his fault but the enthusiasm of doctors to solve everything with the knife which fashion ooops science demanded for a long time after 1948 when I was “cut into shape” for the first time

  18. Seniors oppose health care reform for the same reason they oppose all other reforms. They know the devil is in the details, that the ‘reform’ inevitably will be coopted by special interests and the net result will be further impoverishment of the citizenry, including them. Seniors have been already impoverished by the Fed/Treasury zero interest money blizzard, which leaves those with financial assets forced to live off capital. Anyone older than 65 who still trusts politicians in either political party has been asleep longer than Rip Van Winkle. I have yet to hear anything sensible about HOW health care will be reformed, but I do not disagree that it should be extended to everyone on the same terms. Unfortunately, doing this would require that we eliminate employer provided plans, and private insurance plans, and fee for service, and monopolistic restrictions on the supply of physicians, and profit making hospitals, and damn near everything else that has grown up around medical care in my lifetime. For myself, I avoid doctors and hospitals at all cost.

  19. Senior’s who enroll in and pay for Medicare Part B if they can afford it, also enroll in and pay for a private Medicare supplemental plan which pays that part (about 20%) of medical bills not covered by Medicare. Then if they can afford it,enroll in and pay for in a private Medicare Drug benefit to get prescription coverage with a justly maligned donut hole.
    I’m enrolled in and pay for Medicare Part B and a Medicare Advantage Plan (like the type James mentions above). The gov’t sends my Part B money to a Medicare Advantage Plan and I pay another monthly fee to the Advantage Plan. The Medicare Advantage Plan provides excellent health and drug benefits coverage. There is no donut hole for drug benefits…. and unlike traditional Medicare preventive care is provided.
    In fact, with the availability of yearly physicals, eye care yearly,gym membership assistance, dietary and wellness programs and drug benefit coverage without a donut hole, Medicare Advanage has alot of the atributes that a reformed Medicare should have.
    I think the government’s problems with these plans is that unlike traditional Medicare they don’t shift as many costs to the individual consumer… it seems to me that Obama should be aiming at a plan that provides Medicare Advantage like benefits to all.

  20. I don’t know about the national AARP organization supporting or not (40 years away fro AARP membership, don’t keep up) but I went to Rep. Carnahan’s (D-MO) Forum on Aging in American (the one where 6 people were arrested) and the MO AARP representative, who was on the executive committee, spoke very forcefully on the need for reform. He was non-partisan, reminding the crowd that every presidential candidate in 2008 said the system needed reformed and not explicitly supporting a particular reform, but that didn’t seem to matter to the protesters who booed and hissed at the mere mention of reform.

  21. James – I think you’re a little naive on this one. Of course seniors are going to oppose healthcare “reform” more than the rest of us. They’re at the top of the pyramid scheme; all they need to do is ride it out another 5 – 10 years. I don’t think anyone could plausibly claim that healthcare reform would improve service and/or reduce costs for individual seniors so they have the most to lose. I think the younger you are, the more likely you are to support healthcare reform (or the more likely you should be) because you have the highest lifetime tax bill, which grows by the day on current government spending trends.

  22. Paul — have you ever lived in a country with government-run health care? I live in Canada. The kind of crazy stuff you’re imagining just doesn’t happen. I have an aunt with early-onset Alzheimer’s who lives in France. She has first-class care at government expense and will have it for the rest of her life.

    Vulnerable people are WAY better taken care of in countries with government-run health care than they are in the US. You have it exactly backwards.

  23. Is anyone else tired of how the old, infirm and irresponsible suck the life of the young? More and more resources are being used to appease the elderly and soon to be elderly at the expense of the young. The took poor care of their bodies and continue to do so, but still expect to live forever. They never saved a penny, and expect taxes to fund their retirement. They demanded services, but never wanted to pay for them. They elected tax cutter and wondered why the deficit exploded. And now they have the gaul to call my generation (the Y’s) young, lazy and ignorant? I don’t know where this comes from. Virtually every person I went to university with, myself included had to both take out student loans and work to get through. Most had jobs since highschoool. At the same time we enter the economy competing with 50 year olds for entry level jobs and facing the burden of being taxed into oblivion for their misdeeds. And to boot, they didn’t have enough kids so a tiny working population will have to support a giant cohort of infirm, sick and poor boomers. No system, ecological or otherwise can devote so much resoucres to propping up the past rather then investing in the future. What if during the lean time mother bears began eating their young? That is what is happening, it is the rise of the gerentocracy. To all the young who don’t want to be bankrupted to sustain the boomers, lets raise up, and vote these vampires(in that, they suck the life out of the young) out of power (this will be tough as they have a numerical advantage). We are younger, smarter, more worldy, more compassionate (I know this letter might suggest the opposite); we need to be the mammals eating the eggs of the dinosaurs.

  24. tyson… wow.. I hope any universal care which passes contains generous mental health benefits!

  25. Im Canadian, I already have them. But thanks for your concern Greg.

  26. No we don’t have food or gas insurance, I know you’re going there because those are necessities as opposed to comparing health care to buying a flat screen tv, but it’s still a disingenous comparison. You don’t have situations where your food or gas costs suddenly go from $500 / mo. to a $75,000 lump sum – yet that’s exactly what happens with health care costs. That’s why we have health insurance, for the same reason we have homeowners – everythings fine until the house burns down and now you need $200K.

    The second myth in your argument is the “informed consumer” myth. Health care is not like other stuff – you can put off purchasing a consumer good, you can put off buying a new car, you can even eat raman noodles and not visit your mother on weekends to save money on food and gas bills. You also know if you’re buying a Sony at one store, it’s a Sony at another with a cheaper price. When you need heart surgery, cancer treatment or whatever the major medical expense is – the average person doesn’t have the emotional ability or ususally the technical knowledge to negotiate with a health care provider for cheaper care – nor is anyone comfortable going to the IKEA of health care for a life saving operation. I do agree that doing some of your own research and study so you can make better decisions along with your doctor or doctors is fantasic when confronted with different treatment options etc. But what is the average person going to do if one doctor tells him he needs and MRI and another tells him he doesn’t?
    If he’s not paying for it, he’ll get the MRI – if he is paying for it and can’t really afford it, then he won’t. Neither of those decisions are based on whether the patient actually needs the test or not.

  27. You can join AARP at 50, so you are a very articulate 10 year old.

  28. I like Brian’s and Tyson’s comments. I’m a boomer who has voiced concerns over federal spending habits for over 30 years. I’m a senior manager in a small manufacturer in northern Wisconsin. I just like to profitably create good jobs for people. I don’t trust either political party to really be thinking about the greater good. Here are some of my thoughts re healthcare.

    1. Brian’s comments about lawsuits were not directed at the cost of the lawsuits or the insurance. It was directed at the cost of the additional testing doctors do, whether needed or not, to make certain some patient or doctor doesn’t use fake medical knowledge in front of a panel of their “peers” to hold the doctor accountable for the stupid behavior of the patient or natural consequences of what is still an inexact profession. Those additional tests are one item really help raise the cost of healthcare.
    2. Where is it written we should provide healthcare to people who make stupid decisions? I’m all for a some minimum level of healthcare for all (conservative though I am). But take care of lung cancer for someone who smoked for 50 years? Brain surgery for a motorcycle rider who had an accident while not wearing a helmet? Diabetes care for someone who overate, ate the wrong foods and willingly lead a sedentary lifestyle? Give me a break! Has anyone ever considered expecting a little bit of personal responsibility?
    3. Simple economics. Supply and demand. If we provide more healthcare to more people without providing more supply while artifically holding prices down we will always end up with a shortage of supply. Ergo, despite the protestations of the politicos, you will end up with a system similar to that in Oregon where some healthcare just doesn’t happen. Rationing has to occur.
    4. I have periodically looked at healthcare in other countries. More often that not the healthcare is very good – when you can get it. Yes there are always exceptions that I’m certain I’m about to hear about. But more often than not patients have to wait for surgery or even an appointment. May even be assigned which physician they can see. That is why you will often find private healthcare insurance still thriving where national healthcare is provided “free”.
    5. Stop telling me how much more expensive healthcare is in the U.S. compared to elsewhere until you can answer this next question. How much of the U.S. healthcare dollar to which you refer is actually used to provide healthcare to non-Americans at places like Mayo, Cleveland Clinic, etc.? Subract those dollars out. And how much of our healthcare dollar is spent at world-leading research and teaching hospitals, resulting in better care world-wide without any subsidies or even “thank you” from the rest of the world? I know, we don’t do it all here in the U.S. but we do a lot of it.

    I have more thoughts but they’ll have to come at a later time.

  29. @MK
    Don’t be so black and white about it – my point is this: Why do we expect health insurance to pay for EVERYTHING? Why not have national catastrophe insurance to cover the house fire. Insurance works well for infrequent catastrophic events. We are currently forcing health insurance to pay for all health care costs – that makes no sense. Insurance is a risk based strategy. When you use health care regularly and the insurance company profits from each encounter, how is that a risk based strategy for the lower costs items?

  30. Building on supply/demand argument. One way to reduce healthcare is substantially increas the number of doctors. America, and Canada is far worse for this have less doctors per capita then Europe. If we were to increase the number of providers of healthcare, cost should go down. Some will argue that the quality of care may go down, but I don’t really see that. Currently, getting in to Med school is really hard, and the difference between a 3.9 student and 3.65 student is usually a part time job. This is one way, among many that healthcare costs could be lowered, although it has a longer time horizon.

  31. Couple of points.

    One thing that hurts tort reform is that human nature dictates that doctors will still perform unneeded tests for decades after the obstensible reason for them, fear of lawsuit, is gone. People take actions that make them feel safe, not ones that actually make them safe. People get the deadbolt for the door and the security system after the robbery takes place. So doctors are still going to order the tests because fear of lawsuit is what they grew up with.

    As far as getting more doctors out there, good luck with that. AMA will fight to keep the standards high, because it benefits those already practicing. If I’m a made doctor, and I CAN do something to prevent more competition, and I’M ALLOWED to do somthing to prevent the competition from entering the workplace, it only makes sense that I do so. Nothing wrong with creating irrational fear in the marketplace to further my own aims. And any individual doctor can hide behind the big arm of the lobbying group and claim no individual responsibility.

  32. Reformists could very well lose this debate, because most of the extra money that Americans pay for healthcare is going to the very people who are trying to block reform.

    In other words, our high health care costs are a reason for reform to fail, not a reason that it will succeed.

  33. Precisely. In fact, you’ve very cogently explained why insurance for health care doesn’t work.

    A system of pay as you go sounds great, until you are faced with the choice of whether to let someone die because they didn’t have the foresight to save enough money to cover there care.

    And if everyone saved enough money to pay for the worst case scenario, our economy would collapse.

  34. I haven’t really followed the health care debate so I don’t know if this article has already been mentioned:

    http://www.theatlantic.com/doc/200909/health-care

    It’s the cover story of this month’s Atlantic. I find it very thought-provoking.

  35. On point 2:

    If you think that people ride motorcycles without helmets, or smoke, or intentionally do things to get diabetes because they know that they would get treatment when they suffered a severe brain injury, or got lung cancer, or lost a leg from diabetic complications, then you are not very familiar with how humans think. If the physical consequences of doing these things don’t dissuade people from them, it’s highly unlikely that a doctor’s bill will. There really aren’t a whole lot of people out there who go BASE-jumping because they know they’ll get their ER visit covered.

    Point 3

    Yes, rationing has to occur. Currently it’s being done with a price mechanism. It should be done based on need.

    Point 4

    The US ranks far below every other developed, western country in most health care metrics. The fact that the wealthy will always want their own elite version of health care does not change that fact.

    Point 5

    If you know what percentage of our health care budget is going to foreigners, please tell us. Otherwise, we will assume that you don’t.

    I don’t really have a problem with point one, other than to say that it is something we should look at and try to fix. But it’s not going to solve the problem.

  36. “We are younger, smarter, more worldy, more compassionate”

    I think you’re anger is legitimate but you should work over the text turn it from a rant in an argument

    other than that remember I really had to laugh at the above sentence: what a complete list of what we thought ourselves to be
    we were all that, exactly that and danced to the music of Bill Haley and Elvis Presley

    oh and we were told that it would be near criminial if we would dare to have children – ever heard of the Club of Rome and similar doom sayers – lots of smart people were as alarmist about too many babies as “they” are today about Global Warming. Too many babies was the apocalyptic threat of my smart worldly compassionate (sic) young years.

    If you promise me a smooth painless death drifting away while in a pleasant high of the kind I felt during wake up time from a short narcosis, we could talk about meeting in about 20 years that’s when my saving account should be about empty. There would still be enough to compensate you handsomely (by European standards) – Should I get infirm earlier we could move that date – Now is that an offer????? Would that soothe your rage?

  37. some guy in a cube

    The American health care system is fcked-in-the-head, like the yahoos disrupting the town halls. This problem – and its solution – should be so obvious to anyone with half a brain, that it is a mystery to me what all of the fuss is about.

    The solution is simple: Medicare For All (Single Payer). How do we pay for it. Simple: Take the money from the War Machine. Will the Empire do this willingly? Not s chance.

  38. In case anyone wants another physician viewpoint, I enjoyed and agree with the following:

    http://www.americanthinker.com/2009/08/obamacare_and_me.html

  39. “2. Where is it written we should provide healthcare to people who make stupid decisions? I’m all for a some minimum level of healthcare for all (conservative though I am). But take care of lung cancer for someone who smoked for 50 years? Brain surgery for a motorcycle rider who had an accident while not wearing a helmet? Diabetes care for someone who overate, ate the wrong foods and willingly lead a sedentary lifestyle? Give me a break! Has anyone ever considered expecting a little bit of personal responsibility?”

    What a brillant brillant idea this is! I am all yipperi with excitement, let’s get started immediately, the world can’t wait for such ingeniousness.

    But as we are not yet in the Utopia would you please explain where you would draw the line?

    There is a lung cancer patient asking for surgery claiming to have never smoked. Let’s even assume there is a blood test to check and then surprise! the blood test shows the man has inhaled deeply for quite a span during this life time. The man protests, sues for his right to have the operation, detectives are sent out to all the places where he has been during his long and interesting life and lo and behold he was in Paris working in an office with three other guys who maniacally smoked the Gauloise Bleu and refused to open the window because they didn’t want to freeze. What do you do now, provided the man is still alive? Do you decide via a bonus point system? A responsible person certainly never would have gone on working at that terrible Parisian Office no matter how interesting and beneficial to the world the job was. And there are also the reports of the man having tried a puff or two in school – another bunch of minus points. But I think by now the man is dead, you have spent huge amounts of money to fight the man’s claim, much much more actually than the treatment would have cost. But you have Zucht und Ordnung (Discipline and Order) in the system

    The horror is it could work with everybody spying on everybody with health cards on which all medications all tests are recorded it will sure become possible to catch any evildoer and sucker of the system and take him to task. But maybe in that horror of a tomorrow we should also measure the joie de vivre a man is capable of and grant him some bonus points and leeway for that.

  40. the bind is that when you pay only for the catastrophic you will have a large part of the population who know something is brewing but wait for the catastrophic

    in other words you will create a threshhold and threshholds are notoriusly difficult to manage in any bureaucratic system. They read wonderfully simple on paper and the solution to all problems until reality hits them and then you spend more time and money on fiddling with the finde points and so on and so on – to establish clear cut rules is very very hard work and proposals worth to be checked never go like “and then you just …”

    even where you have a health system that is accessible without cost any time people often go to see a doctor only when a wound has already festered

  41. Germans might not know more about the practice of medicine, but they are the world’s masters at efficiency and effective delivery of services. If Americans want to learn how to cut costs without sacrificing quality, they should learn from the Germans.

  42. The main effect of restricting the number of American medical school graduates is that demand is met by talented foreign-educated doctors, both in the U.S. and abroad. In some hospitals in the U.S., foreign trained doctors outnumber U.S. trained ones.

  43. How do we pay for it?

    Actually this isn’t even a legitimate question, because adopting this system would save money.

  44. See the Atlantic monthly magazine link in Brian N’s comment on August 14, 2009 at 4:04 pm for another reason why people avoid treatment in hospitals when sick.

  45. excuse me the link was in BlackSwan’s comment on August 14, 2009 at 3:00 pm

  46. Your doctor friend states: “The average career of a woman in medicine now is only 8-10 years and the average work week for a female in medicine is only 3-4 days.”

    Is this a fight about the idea of women in the workplace too?

  47. James–
    First, consider these folks are multipli-motivated. Ie, they care if the USA goes down the tubes; they sense this thing is a camel, BO has no clues about economics of healthcare.

    But the real issue is they simply don’t trust him or Congress. They know they are being hurried and bambozzled.
    in hindsight, BO might have had a chance if he’d taken a more “educational” approach that would include being open about trade-offs, who may have to give up something for the common good, the economic dynamics of the current system etc.

    But in typical lefty fashion he tried to pull a fast one, vilifying every stakeholder while wheeling and dealing with them sub rosa, saying we must do this ASAP or the world wll end. bottomline: people aren’t as stupid and BO is.

    In my opinion the administration hasn’t even seriously considered alternatives involving less government intervention. the “reasoning” goes thusly: the system has problems, it MUST be private industry’s fault, ergo, we must have a massive government plan. We can’t go there directly so we create a public option that is guaranteed to suck all the air out of the room eventually. (In this last strategem, they do know how the econ will work.)

    Finally, dr. Kwack, they are just a bit smarter than you I’d say.

  48. Never underestimate the smarts of the American people, eh JEJ?

  49. @1: Those additional tests are one item really help raise the cost of healthcare.

    Doubtful that they change it that much. While practicing defensive medicine is widespread, they (A Mass. study) estimate that it only accounts for about 8-15% of the increase in costs. That leaves 85%-92% due to other reasons.

    @2: Good decisions can be promoted. As an example of the way it could be promoted, incentives to build cities so that people don’t have to drive everywhere, or better food standards that prohibit harmful additives. Or taxing cigarettes and alcohol for the costs of treating the lung and oral cancers.

    @3: Less rationing than now, due to the amount of money saved. People conviently forget all the cases where health care is rationed now.

    @4: Almost completely untrue. The waiting is less than in the U.S., for example in countries like France and Germany.
    Now, in the U.S. for a non-urgent appointment you might have to wait 4-6 months.

    @5: Those private clinics are making a (modest) profit off of people who can afford come there from all over the world. Do I detect some xenophobia in your comment?

    Your “thoughts” are valuable because they seem to represent the sort of unfounded opinions and fears kicking around in “boomer” brains.

  50. This coming January Medicare is due a 21% reduction in payment fees for physician services based on the sustainable growth rate (SGR) formula. However, its likely that just as in past years, Congress will pass legislation to disregard the SGR for supposedly one more year. Since the SGR formula has not been honored since 2002 its evident that it is an unrealistic formula and just a budgetary game now to avoid an accurate accounting of medicare costs.
    In reviewing the CBO’s analysis of HR3200, that legislation appears to address SGR by replacing it and using a more realistic inflation based update. The CBO estimates this adds $245 billion to the cost of HR3200 over ten years.
    Ultimately CBO estimates that the net cost of HR3200 over the next 10 years is $239 billion. Since that number includes the $245b costs of a more realistic accounting of medicare costs (by doing away with SGR) I contend that HR3200 is revenue neutral.

  51. Francois-

    I unfortunately have to deal the our government’s bureaucracy almost on a daily basis in my work- and that bit about ” the kind of crazy stuff your imagining” happens all the time. In fact, I grown very weary of all the crazy stuff our local bureaucracy here in LA comes up with.

    Hey, bout a quote from our Dear Leader Buraq:

    THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
    I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

    LEONHARDT: So how do you — how do we deal with it?

    THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

    Exactly what are we talking about here in a ” Very difficult democratic conversation” and by a ” independent group that give you guidance”. By “independent group” he couldn’t mean “death panels” could he? Giving guidance over what? End of life counseling or what?

  52. he couldn’t mean “death panels” could he?

    I prefer the term “death squads”

  53. JEJ, I think you’ve hit on it. It’s about trust. Health care is the catalyst for realization that we just do not trust these numbskulls. The beloved Senator Grassley is my Senator. Near 70% approval ratings, thank you very much. At one of his townhall meetings I saw a sign: “The next election will be an ejection.” Yup. I think the last straw has broken the camel’s back.

    We’ve seen the government just screw over 95% of the country to benefit the finance industry. Following that, an attempt to pass an energy tax (which will also be a boon to Wall Street though carbon credit trading) in a deep recession, following a decade of global cooling.

    Specifically in the health care arena, we see evidence of regulatory capture at the FDA, in the form of attempted clampdowns of non-toxic cheap non-patentable alternative medicines (herbs, vitamins, food concentrates, etc.) and approval of dangerous drugs that, after $1 billion of development and testing to get approval, are found — surprise! — to have severe and heretofore unknown side effects.

    The House bill HR3200 gives czar-like control to the Secretary of HHS and a panel of presidential appointees to determine what must be covered in “approved” insurance plans that we are forced to buy. They will also dictate prices. This also means they can dictate what will NOT be covered. This is “death panel” by stealth. They will make life and death decisions, not on an individual case with Sarah Palin pleading before bureaucrats for health care for her Downs son, but by whole categories of coverage for whole categories of people being written off.

    With the government’s record of success in accomplishing just about anything in the past ten years, but especially anything influenced by big money (health care is the biggest money of all), I think that anyone who would even trust Washington with control over veterinary care of their dogs is living in an alternate universe known as HopeyChange Land. Enjoy your illusion. Some of us still are in the reality based community. We know things need to change, but do not see the government as an agent of change for the better. We hold this truth to be self-evident.

  54. You make some very good points, Eric.

    Who thinks that it has not occurred to Obama (the masterful politician) that this czar-like control given to bureaucrats (many, if not all, appointed by the president) will cause an even greater gusher of lobbying contributions to himself. People in congress must be thinking the same thing. Their influence to make even tiny changes to such a huge and powerful government-controlled health care system would be worth many millions to companies lobbying for favors. It’ll be a bonanza that will do wonders for keeping politicians in office.

    Giving the government too much power is dangerous.

    If we are to have some meaningful, effective reform of health insurance, let’s be sure that the laws include specific restrictions on the power of government.

  55. eric,

    I too enjoy a delicous slice of cynicsm pie,and it’s a great comfort against the winds of a complex debate, that rquires difficult choices. I respect those who argue here and elsewhere for why they dont think the proposed healthcare reforms will not work. But in reality we have 50 million un-insured people, for which an illness can be catastrophic, and we are supposedly an wealthy and compassionate country.

    What I find so objectionable is the cowardice of the claim of Government incompetence, or the venom bubbling so close below the surface that flows so easily towards Obama, a guy who walked into the toughest job in America, at the worst possible time in modern history. It seems an easy out for so many to beleive the worst in him, yet insist they love this great country, but will not overcome personal prejiduces to care for it.

  56. build cities so that people don’t have to drive everywhere

    successful example please …

  57. most of all Germans shouldn’t have been allowed to remain Germans after the war but what empire thinks it needs empire will get

  58. Paul
    with new end of life care homes popping up all over the place where if one is “lucky” one may be forced to lie around years waiting for death to come I think end of life counseling i.e. clear words of what the interests of those involved are, would be very welcome to many seniors.

    After all regarded strictly from a financial point of view the care home loses business once you stop breathing. While the possibly murderous wishes of relatives who want to be relieved of the “burden” get discussed all over the place, care homes’ incentives only seldomly so. Because health care providers are people with overall higher morals than sons and daughters?

    other than that your comment would be nice at the recent “Management Consultant” post

  59. ” (herbs, vitamins, food concentrates, etc.)”

    except for herbs with which mankind has the experience of millenia to draw on the stuff is potentially dangerous superfluous money-grabbing nonsense

    and even with herbs if applied in new forms or concentrations or just over-enthusiastically we have had to realise that those may trigger very unpleasant allergic or oversensitive reactions
    - because the ancients already used them doesn’t make the stuff free of unpleasant side effects quite the contrary it is because they are effective and even strong medicine that the knowledge has been passed on from generation to generation.

  60. reality sure outclasses comedy easily

    by the way the hookers I have met tended to be very decent women, polite customers, considerate neighbours

    http://www.thedailybeast.com/blogs-and-stories/2009-08-13/from-hookers-to-health-care

    “a supposedly grassroots network of national activists that happens to “partner” with the health-care and insurance industry-funded lobbying firm Freedom Works”

    and with sex scandals in his books …
    - iare his American-style ones or a real ones i.e. including collusion/corruption of some kind or just buyer of service?

  61. I prefer to read it in my print copy when it will finally have managed the long voyage to another continent*)
    and for the time being I chose to be offended by the wording of the headline which is way to sensational for a very serious theme and the tone of the first paragraphs seemed to reinforce that first impression

    *) really funny how American efficiency doesn’t include some of the most simple services – contrary to the magazine business your antique book shops take rarely more than a week to have ordered books in my brief case while using the cheapest transport available

  62. I believe I disagree wirth your last sentence:

    “** As far as I can tell from their website, the AARP is neither for nor against health care reform in general; they say they are working to make sure that health care reform is good for their constituency.”

    On thier home page at:

    http://www.aarp.com/

    they have a link:

    Health Care Reform: Get the Facts

    which specifically debunks a number of the opposition myths regarding health care reform.

    They also have a number of bulletins and articles such as:

    Government Watch

    supporting health care refrom (indeed the administrations health care reform).

    And in addition they are running TV ads supporting health care reform.

    However, a number of elders I have interacted with do not believe AARP is supporting health care refrom AND in general they do not make this obvious on thier front page.

    It has been suggested that perhaps they are trying to have it both ways on this issue.

  63. Is anyone discussing life expectancy in the debate? Sorry if this has been mentioned. Wouldn’t seniors value a couple of extra years of life?
    If informed about such stats wouldn’t seniors care about infant mortality (never mind feel shame)? …there is a whole body of research looking at health care and quality of life during infancy and childhood being critical to life expectancy. See for example http://www.amazon.ca/Social-Determinants-Health-Canadian-Perspectives/dp/1551302373 and references therein.

    http://www.ccsd.ca/pubs/2002/olympic/indicators.htm

    http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

  64. It is not a “claim” of government incompetence, as in, “I claim to have seen a UFO.” It is a scientific observation, as in, “I walked outside and saw the sun was shining.” Verifiable and repeatable by anyone who wants to walk outside and look at the sky.

    Venom, yes. I plead guilty to that. I see our country being destroyed by collusion between evil men and government (and evil men in government). If we reduce the scope of government, we reduce the power of evil men of influence. Health care is just another money pot. The corporate masters of that money pot will dribble a bit back to Congress and the regulators (as they pass out of government through the revolving door that leads to the corporate medical world). In return, they will get… well, you know the rest. We’ve seen this movie before. That’s not cynicism. It’s realism. Anyone who doesn’t have a venomous distaste for that simply isn’t particularly moved by injustice and immorality.

    I don’t believe the worst about Obama. I don’t think he wants to do bad things. My observation is that his primary goal is to be the Big Cheese. But he cannot plead innocence. He lobbied for TARP. He appointed Clinton retreads for his cabinet. He supported the trillions for banksters, paltry billions (paltry by comparison) for the victims of bankster fraud. And he has the lowest regard of all for the taxpayers, who make it all possible. He thinks that is expedient. He’s not evil. He’s just another political egoist who is wrong about most things.

  65. back in 1960 when even getting photocopiers to work (fill in the liquid then drain) was tricky I was in charge of rather complicated filing cabinets no A to Z or by numbers. My boss loved me to excel at making the masses of paper easily accessible and I enjoyed it. So each year before I went on vacation I would go over the whole thing, streamline it, if necessary create new departments collect others under a new headline etc. Then write it all down and leave it on his desk so he wouldn’t be lost in an emergency while I went on my month long vacation (terrible those Europeans, I know)

    I am telling you this because in my perception this is what is wrong with almost all organisations. There should be regular overhaul, tightening, enlarging all at the same time not with the purpose of firing or hiring people but with the purpose of integrating all those patch-up jobs that daily business has necessitated over time (think of rearranging the shelves in your cellar and no I do not mean a variant of Mao’s permanent revolution). Why it is almost never done? maybe there is too little prestige in it. It certainly isn’t because it is too difficult, operating in a severely and randomly patched up environment is terribly complicated.

    that said I think both of you are right in a way: those that say stop enlarging government as well as those who want a new agency.

    Bosses dreamt for a time they could manage it from high above by forcing the computer on the “cubicles”. It didn’t work out for lots and lots of reasons, one being that there are printers

  66. If we reduce the scope of government, we reduce the power of evil men of influence.

    Actually, government is just a modality through which they act. There are a potentially infinite number of others as well.

  67. Silke-

    End of Life counseling was mandatory in the House Bill. It’s fine for those who want it, but it definitely isn’t acceptable to be “counseled” to give up costly life saving care, if one wants to live. There is no way for an “independent group” of bureaucrats to make a reasonable decision. The most precious of our rights is that of life. None of you socialists may the right to take it away. Just because you want government run health care, does not give you the right to take the next step and tell people how to live their lives or die, just because it’s more expensive. Assuming the cost burden of health care is no excuse. People with insurance can live their lives now as they see fit, and it should stay that way.

  68. S.,

    You are exactly right. Pay to Play schemes in our big cities work exactly that way; the politicians grab as much control as possible to insure that payoffs to them are necessary to conduct normal business.

  69. Just because you want government run health care, does not give you the right to take the next step and tell people how to live their lives or die, just because it’s more expensive.

    From a mass-murder standpoint, private insurers are probably doing a better job than government could ever do. They even shut down Obama’s mom.

  70. Paul,

    Are you a person who is concerned with the Federal debt and annual deficit? Are you a person who knows that every US citizen and registered alien over the age of 65 is enrolled in a government insurance program known as “Medicare”? Do you know that the program known as “Medicare” is not adequately funded and will start demanding that the special “bonds” issued by the Treasury Department to the “Medicare Trust Fund” will begin being cashed in 2012, two years from now?

    At that time the bonds which are redeemed will have to be paid from the general revenues; since we’re already in serious deficit, we’ll be issuing new bonds to the general public (knock on wood) in order to redeem the special bonds. Sort of borrowing from Li-Fung to pay Tim.

    Over the next decades the problem will only get worse.

    How do you propose to deal with the problem, Mr. Death Panels? Slash the coverage? Cancel the program outright?

    How will those “solutions” be any different from having the Death Panels? Well, it will be somewhat different. Instead of people coming together to discuss what sort of conditions should and should not be covered in a public forum, it’ll just just mean that all of the poorer old folks will have been queued for the ovens since they won’t be able to pay for the care they expected to receive from the government.

    You HAVE TO propose something to have standing in this discussion. Just saying “NO!” to every idea means that the country goes completely bankrupt in a decade or decade and a half.

  71. I WISH Obama were negotiating with someone other than Big Pharma behind closed doors. At least then he could plant his flag behind a specific plan. At this time I understand that there are six draft bills in various committees in both houses of Congress. There are no “paired” bills appearing in both the House and Senate with the same features. Not even close.

    What we’re all arguing about it hypotheticals.

    IMO all the bills are an overreach. I think what we should focus on is prevention of family financial armageddon. The “public option” should consist of a manadatory $5,000 deductible (adjusted for inflation) plan that kicks in when out of pocket expenses reach that point. It has no exclusions for pre-existing conditions, it has not lifetime or annual maximum. The only requirement is that the patient or a health insurer has paid $5,000 during the calendar year.

    Once that point is reached, the private insurer if there is one or the patient has no further financial liability.

    This allows everyone — INCLUDING the health insurers to make rational choices about how they get to $5,000. Does a patient buy supplemental private insurance that maybe pays 75% up to the $5,000 limit? Does she or he “self-insure”?

    I would also include in the legislation a section forbidding “discounts” between insurers and providers of greater than 10% of the provider’s charge to a non-insured patient. The insurance company provides a guarantee of payment, and that’s worth something to the provider. It’s reasonable to give a discount for that certainty of payment. But it is RIDICULOUS that the insurers commonly beat the providers for 40-50%. The guarantee of payment is not worth that much to the provider, and since most sign up with every plan that will take them, it doesn’t bring them business.

  72. Silke,

    Well, FU and your anti-art BS. If someone weaves a “carpet” that someone else wants to pay $200K for, it’s not skin off your nose, you jealous twerp.

  73. Pete,

    No, he has explained how ONE FORM of health insurance can work very well. If everyone were enrolled in a catastrophic coverage plan it wouldn’t cost very much for the annual premium, and nobody would have to worry about inflicting financial ruin on their family if they get a wasting illness. The insurance companies wouldn’t have to worry about it either, so they might actually start treating their voluntary patients nicely.

    Without the enormous liabilities they have now, they would probably also not be too averse to pre-existing conditions.

    Silke,

    Granted with a catastrophic system there might be “gaming”. But in fact one cannot “wait” until the catastrophic system “kicks in” because it DOESN’T EVEN KICK IN unless the patient — or his voluntary insurer — pays the deductible! So people would still have an incentive to go to the doctor for primary visits.

  74. go to Frankfurt, drive east up into the hills of the Vogelsberg a traditionally poor region and look at the castles they built there and look at the remaining old houses and note how poor and ramshackle they originally were
    - I happen to care about the life of the people in those ramshackle houses (if you drive a bit further north their sons were grabbed and sold to the US as soldiers, ever heard of the Hessians?)

    so now you have seen a landscape were nobody but the high end craftsman often from far away could make more than the most meager living off the castle owners, drive down into the Rhine-Valley, take the route from Rüdesheim to Wiesbaden/Mainz and enjoy a look of all the beautiful well designed homes the Bürgers could afford to build because they could generate income independent from the castle owners

    Now as economic theory that maybe all wrong but being of a simple mind I can’t help it that these images pop into my mind quite often when I read things

    other than that you should polish up your manners and your knowledge of history before you spout insults

  75. here’s a senior’s moment in health care
    via Sara Paretsky from France

    http://www.nytimes.com/2009/08/16/magazine/16lives-t.html?ref=magazine

    “Six months later, the bill arrived. For X-rays, an EKG, 10 hours in the emergency room, a doctor, a cardiologist, technicians, nurses, drugs and even the surly gatekeeper, we were required to pay $220. I might put up with a lot of ugly bureaucrats for that.”

    though that seems way to cheap to me even for a wonderfully well organized public system it may be good for tourisme and thus help create jobs …

  76. Anandakos, here are some ways of dealing with problem:

    1. How bout starting with an actuarially sound Medicare and Social Security program? When Social Security was started the average life span was 55, now it’s 78 and we have hardly raised the age of eligibility. Raise the age for Medicare eligibility to a point where people are actually elderly and need government assistance. That age in my mind is at least 72. That will cut a tremendous amount of money out of the system.

    2. Since it’s start Congress had added a whole bunch of “poverty” programs to Medicare. Dump them. If you must have them- separate them out and account for them separately.

    3. Many wealth Americans receive Medicare- they shouldn’t. The system just like the proposed public option is rigged to force people into Medicare; if you don’t go in when you can you can never get in. Medicare should be a minimum care assistance program that provides adequate care- not the Cadillac level of care it provides now; a program that can be supplemented with private programs. A major problem with the healthcare system now is that almost the entire system, including the insured, are shielded from the true cost and as a result spend freely as if it isn’t real money.

    4. Tort Reform. Tort defensive medicine has raised the cost by at least 25% by some estimates. America has twice as many nurses as other counties just to document treatment defensively.

    5. There are alternative medicine treatments that would help the elderly greatly if used . The elderly typically suffer from decades of accumulated toxins generated by too many drugs, conflicting drug treatments, and the highly processed food diet that we Americans eat. Auto immune related disorders like allergies, lupus, Candida, Epstein Barr, Fibromyalgia, acid reflux, and leaky gut syndrome are a few of the disorders thought to be caused by those toxins, drugs and processed food. These disorders in turn cause inflammation and weaken the immune system leading to a whole host of other disorders including cancer, diabetes and heart problems. There are treatments like liver and kidney cleanses. colonics and other treatments that rid the body of these toxins.

    Furthermore there are treatments banned by our regulatory system like the SCIO machine which not only can scan the body to diagnose disease, but can treat disease using small doses of radio waves.

    Others have also put forth many fine solutions to the problem; more government is not the solution.

  77. gee that’s it
    “There are treatments like liver and kidney cleanses. colonics and other treatments that rid the body of these toxins.”

    Colonics – hurray!!!!!!!!
    I know that Ghandi obsessed about cleaning his insides but forgot the method he liked but I seem to remember that a lot of forerunners/enablers of fascism
    also were enamoured by gut cleaning and its methods – to be allowed to fiddle around as a certified authority with that body opening must have its attractions

    the Freudians among you should be able to refute that with his writings on what makes a person an anal character (not that I hold Freud, whom I haven’t read, in any way responsible for such nonsense) – to date I could never even imagine what he possibly might have meant by an anal character always thought he was talking about the self-controller

    it’s a pity, Paul, that the sensible stuff worth to think about you write gets overshadowed/blanked out by such … do not know a word for it

  78. AARP membership begins at age 50. They should be looking out for members age 50-64 who are not eligible for Medicare. I suspect many of these people would not be eligible for health insurance due to pre-existing conditions if they ever lost their employer plans. Here’s a natural lobby to support expanding Medicare by lowering the age limit. Why haven’t they done so?

  79. thank you
    next question:
    is it really the cities which create the most mileage?
    in my remote mountain village the youngsters on their Saturday night outings would easily drive 3 to 4oo kms each in order to stop in at all the discos, not to mention my 25000 kms just to get to work and back and I had a comparatively short commute.
    Even driving pools wouldn’t diminish that number by much because for all the shopping except the most basic you had to drive down into the valley and that with a 70/80 million population on a fraction of your territory.

  80. Silke, that’s a question for a different debate. Cities are being designed around the concept that Americans should only have to waddle at most 20 meters per day. Combined with a sedentary lifestyle, it’s a big health problem in the U.S.

  81. I agree with everything in this post. I just said the same thing (although not as well) to a friend who kept sending me updates on the healthcare debate. I’m sick of the whole thing–conservative talk show hosts who say things to scare old people, and stupid people who believe everything they hear without thinking things through. I’m just going to let them all fight it out and go about my business eating right, exercising, getting enough sleep, and not taking medications for every imagined problem in my life. I’m sixty and look fifty because I treat my body the way it’s designed to be treated. Preventative medicine is the way to go and people need to get off their fat butts and take care of themselves so health care dollars can be spent on true emergencies!

  82. Paul,
    the socialists were the only ones who still had parts of their honour intact in 1933 after the Reichstag had voted to give Hitler dictatorial powers. So for me to be called a socialist is having been rewarded a badge of honour

  83. the recent Obama Op-Ed in the NYT has left me with an uneasy fantasy

    I understand Obama has made health care one of his main topics – I have been told that all presidents dream of figuring big in the history books (our Helmut Kohl brabbled something about the “Mantel der Geschichte” (coat of history) swirling around him when the GDR was finished. Gore Vidal claims Kennedy dreamed of getting a war, something with Chruschtschow – actually there are amazingly few of those stories I happen to have read, so either the claim of the wish to make it into history books is not true or leaders are carefully not to talk about their dreams.)

    now one way to get more than a paragraph in history books is having been a leader hindered by perfidious forces to make the forces of salvation victorious i.e. being an honourable failure

    Question:
    was Obama so unrealistic in his promises in the NYT because he knew from the beginning or knows now insuring the millions of uninsured was a hopeless one?

  84. It’s hardly a hopeless one. Right now those people use only emergency rooms–the most costly form of medical care–creating a tremendous strain on emergency rooms. Everyone else ends up paying for that.

    His promises are realistic, but he’s not going to carry through based on the lobbying of the insurance industry.

  85. I am really happy to see many are aware of this one.I already have one.

  86. here is the City Journal’s (Manhattan Institute) comment on Sarah Paretsky’s piece

    http://www.city-journal.org/2009/eon0824gs.html

    what a mix of true, half-baked and misleading points and thus enlightening in its own special sense that
    those distancing themselves from Sarah Palin are not spelling out their “facts” like she does but insinuate them

  87. Yakkis–
    Read some history–Hitler was a socialist.

  88. sorry, should have said the social-Democrats but in a way you are right
    - if you are interested there is Götz Aly who has a book on how the masses let themselves be bought by the National socialists – seems it hasn’t found an American publisher http://en.wikipedia.org/wiki/Götz_Aly
    maybe because the author himself is a former Maoist or something like that? or maybe because it is such a tedious read – Aly speaks a lot better than he writes.

  89. Are you the same JEJ posting comments on youtube?