Comments on the Health Care Debate

Last week, Mike Konczal got a little grief for saying that we have “the smartest comments section on the nets,” and while I’m not sure that’s literally true, I am frequently astounded at the quality of many of our comments. Instead of writing more on health care for today, I want to point you to a few comment threads on my previous post, “Medicare and the Public Option.”

1. StatsGuy on why the current reform proposals will subsidize and therefore increase overtreatment and drive up costs (which alone is worth the price of admission).

2. Russ and others on why nothing at all is better than reform without a public option (I don’t agree with him, though).

3. Carson Gross, anne, and Frank Tobin on high-deductible plans and making consumers aware of costs (I don’t agree with Carson, either).

And many, many more …

Also, StatsGuy recommends this article on the incentives faced by physicians, as do I.

By James Kwak

28 thoughts on “Comments on the Health Care Debate

  1. NPR planet money makes the following compelling argument:

    “health care paradox. Sometimes you can have too much information. Naked Economist Charlie Wheelan says knowing our genetic makeup is good for us but bad for the insurance industry. Wheelan argues that as soon as our insurance pool is “corrupted” by this information, healthy people will begin to opt out and people likely to get sick will be forced to opt in at higher rates.”

    Furthermore this is steering us toward a national health care system.

  2. This comments section is therefore devoted to commenting on our comments that we’ve commented on.

  3. In the article recommended by statsguy, a primary care physician with 22 years of experience who treats 3,600 patients wrote

    I know this is true because I am struggling to find a primary care doctor to take care of my wife and myself.

    Can a physician reading this blog, please explain to me why physicians with this much experience and ability can’t take care of themselves and their wives?

  4. I read the linked in 1 and 3 and the article at the end. I have a couple of thoughts about #3 that the article also brings up.

    Where are all these people with high deductible plans going for cheaper care? If I don’t like how much my doctor charges or what tests he orders, how do I find another doctor when there aren’t enough now? The article said it best, who knows someone that’s accepting new patients? I certainly don’t know enough doctors to switch every time I think I should get an X-ray instead of an MRI.

    In addition to that, how many people have been seeing the same doctor for years? Everybody I know that has switched doctors has pretty much agonized over the decision. They’ve spent many hours trying to find someone that takes their insurance, is accepting new patients, knows something about their specific problems or any number of criteria that matter to them. If there is no threat to a doctor losing customers (patients), there is no threat to lowering prices (controlling costs).

    Finally, I agree with those that say who knows how much we’ll be spending later by not spending some extra money now. If an MRI would be better but I only want to pay for that X-ray, how much am I risking later? If I can’t trust the doctor to make that call, then why am I seeing him in the first place?

    Which brings us to incentives. If only all doctors had the willingness to make the calls of Dr. Harris. If only all patients were willing to let their doctor make those calls. I agree we need to provide incentives to doctors to actually manage care. However, that means changing people’s attitudes about their care to one that allows it to be managed. As long as doctors are berated by their patients for making unpopular decisions, there won’t be any pressure to change the system.

  5. I’m a physician. You can’t take care of yourself or your spouse or children (or even close friends) because you need a great deal of emotional detachment to make decisions that may involve substantial risks. That’s the main reason. (There are also the less important facts that it isn’t possible to do a physical exam on one’s own body, and while it’s strictly speaking possible to draw your own blood for a test, it’s difficult and you’re likely to get injured doing it.)

  6. Also, when you’re really sick, your judgment is too impaired by illness to make decisions for yourself. All the more reason, by the way, why “consumer choice” in health care is a thin reed at best.

  7. “Finally, I agree with those that say who knows how much we’ll be spending later by not spending some extra money now. If an MRI would be better but I only want to pay for that X-ray, how much am I risking later? If I can’t trust the doctor to make that call, then why am I seeing him in the first place?”

    The best-kept secret of health care is that in truth your doctor usually doesn’t really know any more about these kinds of decisions than you do. To use your example of MRI vs X-ray, there are studies showing that in certain types of situations an MRI (or in some cases a CT scan) provides information that ultimately leads to better outcomes (easier treatments or more successful treatment or fewer side effects) than an X-ray. But there are other situations where the opposite is true. Unfortunately, in the majority of such choices no studies have ever been done. The MRI or CT always provides a more detailed picture–but it doesn’t necessarily follow that that extra detail is actually useful in managing the problem. Despite this wealth of ignorance, the use of MRIs and CTs has proliferated dramatically in all kinds of situations where they are of unknown value. And this is true even in the situations where the doctors don’t own and operate the imaging equipment–so it’s not just about self-dealing, though that does contribute to it.

    (To top it off, even where studies have been done, your doctor, more likely than not, hasn’t read them or doesn’t understand them. But that’s another issue.)

    This lack of knowledge is not likely to change without major reforms to health care research. Most medical research is funded by the National Institutes of Health (NIH), whose mission is primarily to foster biomedical innovation. Until very recently they have avoided comparative clinical effectiveness research entirely. They are starting to fund a little of this, but frankly, it will be a while before they develop the expertise to direct the funding to the best and most important projects. The agency that does know something about this is AHRQ (Agency for Healthcare Research and Quality), but their budget is minuscule and most of it is strictly directed to specific projects by Congress. (They used to be more independent but after they funded some studies showing that much spinal surgery is useless and then came out with some policy recommendations based on those, orthopedists and neurosurgeons lobbied Congress fiercely and their wings got clipped.)

    A sad state of affairs.

  8. Dr. Harris doesn’t get it. He’s not the doctor handing out the prescriptions for the expensive pills. And he’s not the doctor that gets rewarded for denying coverage.

    Isn’t it interesting that with all this talk of the free market, you never hear Newt Gingrich or Rush Limbaugh, or Glenn Beck mention HMOs??? Remember all the miracles HMOs were going to provide??? Remember HMOs were going to magically solve all the cost problems and everything was going to be super-efficient??? Funny now in 2009, when people still think including acronyms in their speech raises their IQ a minimum of 10 points, that acronym HMO has just MAGICALLY DISAPPEARED from the lexicon. You never hear Newt Gingrich, Dick Army, or Republican Senator Tom Coburn speak that beautiful acronym HMO anymore. Weren’t HMOs going to be our savior??? Newt baby…..Dr. Coburn……what happened to those cost savings the free market HMOs were going to give us???

  9. Health reform requires insurance reform. We must change the way we pay for health care, exclude non-value added intermediaries, and wring out excessive profits, executive compensation, and bonuses from third-party payers–insurance companies.
    Insurance companies do all they can to avoid risk. The original concept of individual insurance was to pay for high cost low probability adverse events to individuals by aggregating a large number of individuals’ relatively small payments to create a large fund and distribute risk among the large population. Health insurance companies’ foremost goal is not to distribute risk but to maximize profits. Minimizing loss-to-premium ratios maximizes profit. Minimizing loss is best achieved by avoiding risk. Risk is avoided by selective underwriting. Selective underwriting disaggregates risk. Insurance is sold at the highest possible premium to the least risky, sold at exorbitant prices to higher risks, and withheld altogether to highest risks. Claims management activities guarantee cutting losses quickly by denying claims, raising premiums, or canceling policies. Those activities effectively transfer the highest risks and costs to the public sector. Insurance regulation does nothing to require that insurance companies distribute risk instead of disaggregating risk. Until insurance companies are truly regulated—required to accept all applicants, proposed premium increases regulated with public oversight, and administrative costs and profit margins reasonably fixed—health care will be denied to those most in need, limited to those who can pay exorbitant premiums, and reasonably available only to the healthy. Health insurance must be regulated nationally to ensure that risk is distributed throughout the population. For example, insurance franchises could be alloted regionally to ensure that health care is uniformly priced. Optional health care—cosmetic, for example—can be the basis for competitive options and health care add-ons. A comprehensive basic health care benefit must be guaranteed to all at an affordable national premium. Adverse health risk must be distributed throughout the population. If we can do that we will reform health care.

  10. orthopedists and neurosurgeons lobbied Congress fiercely and their wings got clipped

    Does that violate the hippocratic oath?

  11. Until insurance companies are truly regulated—required to accept all applicants, proposed premium increases regulated with public oversight, and administrative costs and profit margins reasonably fixed

    …but it would still be private, right?

  12. Many have complained that the reckless US consumers spent beyond their mean. I was one of them until tonight. However, take a look at the
    2nd chart in this graph.

    Apparently, US personal consumption expenditure minus health care has been flat since the 60s relative to US GDP. In other words, excluding health care, Americans have been consuming about the same proportion relative to what they’ve produced
    for the last 50 years! Americans today weren’t spending more proportionally more than their grandparents did on none medical related expenditures.

    It is the US health care monstrosity that is the heavy burden on everyone’s shoulder for the last 50 years. If the US health care burden is more in line with other developed nations (many countries cost 1/2 or less with comparable health care statistics) the
    US household would have been significantly better off. The current crisis wouldn’t have been nearly as painful. Also just imagine how much more competitive the US business could have been if not for this

    Americans today did spend beyond their mean. The main reason is the US health care.

  13. I agree with the ER physician on this one:

    “Those activities effectively transfer the highest risks and costs to the public sector.”

    And the ER doc underscores my fear that an unreformed private sector competing with a “public option” will lead to the private sector taking money from the young and healthy and the public option becomes the dumping ground for the sick and poor.

    I do not see any “reform” coming out of the current public debate.

  14. Maybe so, but the cost shifting would be transparent. More of the sick and poor (a relative term that increasingly applies to what used to be called “middle class” at least with regard to an ability to pay for health insurance) are de facto availing themselves of the only universally available locus of care–emergency departments. For example, in 2003 visits to primary care physicians declined to 58.5% from 66% in 1980 an indicator that emergency departments are shouldering a greater proportion of the healthcare demand. The costs are mostly shifted to taxpayers. I think that some form of public option is essential to expose hidden costs, make the existing public option visible, provide an affordable source of health insurance to the middle class (sick and poor) and force insurance companies to pay for or eliminate their externalities (higher societal costs) through reduced premiums, profits, and increased competition. The public sector now essentially subsidizes high private insurance profits because of those externalities. I for one, do not believe a public option would cause the demise of private health insurance. One approach to introducing a public option would be to have actuaries determine what premiums should be charged to individuals who wanted to buy into Medicare at an early age, say 50, 55, 60 and make that option available gradually over a period of time and lower the age for optional Medicare insurance purchase over a period of time. If we don’t succeed soon, we will bankrupt our economy. Even now, guaranteed access to medical care is no longer available to the insured, the rich, the famous, or the powerful. That is because fewer specialists are taking emergency calls, hospital beds are increasingly scarce and patients are either boarded in emergency departments or transferred to other hospitals even in other states, physicians and nurses are leaving the healthcare professions at younger ages, outpatient appointments often take weeks to schedule, fewer students are seeking medicine as a career, etc.. Some form of an affordable option to insure all is essential. A limited public option already exists, we already pay for it, and insurance companies profit from it. Health care cost shifting, externalities, and human morbidity and mortality costs have to be recognized and accounted for properly in our economy.

  15. I agree with most of what you say here. But your claim that “fewer students are seeking medicine as a career, ” is, I think, incorrect. Check out:

    which shows that despite a slight dip in applications in the earlier part of this decade, the numbers have come back. And the quality of the applicants, as measured by MCAT scores and GPA is stronger than ever.

  16. Yes, of course, it does at least in spirit. Less clear if it violates the words, though broadly construed it seems to violate both:

    “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”


    “In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction…”

    Be that as it may, what with all the “consultancies” given out by drug companies as thinly veiled kickbacks for prescribing their products, and research fraud on the part of some drug-company financed academics, it is fair to say that professionalism in medicine is rather tattered these days.

  17. I empathize with the good doctor, but I also empathize with the millions of people who don’t have access to health care. Really people, there is only one decision. To paraphrase Thoreau: Give them access to health care and let the chips fall where they may.

  18. I have two sister-in-laws that are pediatricians. Collectively there are 15 grandchildren in this family — 4 are mine. Each one of those 15 children see other doctors in the practice but never the pediatrician sisters even if the medical need is during one of their rotations on-call. You probably wouldn’t be surprised at the number of people who automatically assume that each of the 15 receive free health care from one of their aunts.

  19. As a Canadian following the debate on health insurance in the United States I feel exhausted. So many different angles and permutations to consider. It seems to me health insurance is extremely complicated when the focus is on — protecting or appeasing — the profit motive. The question is why?

  20. James et al,
    may I say you are doing a wonderful service to the debate surrounding health care reform in the USA, as a European living in a major Asia city one has never had to worry about health care costs nor an excessive burden of taxation allegedly associated with such systems.
    So yes folks, you may be surprised to learn that one of the most free economies in the World – according to the Heritage Foundation – Hong Kong, actually has a national health service.
    Being a supporter of this, of course one is obliged to pay taxes.
    Its also surprising, that like in America, there is an actual large choice between private and state provision.
    Yes, this comes at a cost, and an ageing population does not help, however, if you are legally allowed to land and work in Hong Kong, you are covered by a health service modelled on that of the UK.
    So, for all those idiots sprouting socialist bullshit, could they please explain why the freest economy in the World can have both a nationalised, health service, freedom of choice to pay for health services and a low taxation rate.
    Unsurprisingly, it may have something to do with the fact that Hong Kong does waste money on military expenditure that perhaps could be better spent raising the health of the entire nation.
    One would appreciate comments and feedback as this is indeed an interesting juxtposition and one which can be used to attack those so opposed to change.

  21. Chris Rogers, raises an interesting point. The United States has the largest army in the world. A military rationale for security and defence purposes is understandable. But the question is: Why does does the world have a “military industrial complex” for economic purposes?

    The American military is nationalized. So why not health care? My conclusion is there is no economic or logistical reason why the United States cannot introduce a universal health care system that equals, if not exceeds, that in other advanced countries.

  22. Tippygolden,
    Thanks for your viewpoint.
    Actually, apart from the fact that Hong Kong is actually covered by China’s military complex, and before the change of sovereignty the UK, it does prove that by distributing the cake differently, much can be achieved.
    the key point is, and always has been, health care costs as a share of GDP is much lower in Europe than the USA and the basic health care outcomes are much the same, a part from the fact that a sizeable minority of the US population has no health care coverage, hence is some areas mortality rates from disease match those in third world economies.
    An absolute disgrace.
    I think it fair to say, that health care is a human right and not a paid for benefit that excluded the needy as business chases alpha returns.
    Whilst the UK health system has many detractors and lags behind cutting edge new developments in certain areas, the actual outcome, that is improving the health of the entire nation is much higher than found in the States.
    Given than welfare provision and basic health care was first introduced in Europe by a rightwinger, Bismarck, how fools can call it socialised medicine that threatens liberty, home and hearth beats me.
    Still, I’m just a communist according to many a fool who does not even have the decency to understand what the term means.
    One rests his case this evening.

  23. Not very often, maybe only a handful of times, do people bring up military spending. We talk about how in the world we might fund health care, but we don’t talk about how in the world we are funding the military. We talk about how we will fund S.S., Medicare/Medicaid, but we don’t talk about how we will fund the military – we just do it. Not barely a word was mentioned a few weeks ago when the military budget was allocated (or passed?) – close to 700b (I think).

    Hey, over the next 10 years, we need to come up with 7 trillion for military spending (today’s dollars) – makes health care look cheap!

  24. Some have argued that the decision on whether or not to adopt universal coverage in the United States is ultimately a — moral choice. — Completely agree it is shameful that the richest country in the world has citizens living in third world conditions when it comes to health care. Many Canadians and Europeans looking at this situation consider it excessive materialism and (sorry to put it this way) immoral.

  25. In this health care debate I have not seen much on the issue of the tax-free employer-paid health insurance. First of all, I’m all for single-payer insurance, which, in my thinking, is essentially a single national non-profit insurance company. However, assuming singler-payer is not in our immediate future, I think the question of tax-free employer-paid health insurance is a major issue to be considered. My reasoning says that tax-free employer-paid insurance is the primary cause of over-priced insurance resulting in over-priced care. This employer tax deduction has taken employee health care dollars out of the hands of each citizen. The health insurance companies love this arrangement because they then control the market, or in effect there is no market. Health insurance companies, like most American businesses, do not want to compete in a market but instead want to control their market, and they will do this by any means. They will lie, they will cheat, they will steal, and they will use tax deductions. If the employer tax deduction for health insurance were eliminated tomorrow, what would happen? This is not rhetorical question, I would like answers to this question for this elite group of erudite bloggers. My understanding is that employees would eventually gain control of their health insurance dollars and health insurance costs would be reduced as a result of a true market place for health insurance. Health care costs would also be reduced because there would not be any excess dollars in the system as there are now. It is my belief that excess dollars in the health insurance industry fuel the excess costs in the health care industry. With lower health insurance and health care costs the number of uninsured would be reduced from the present 47 million. Even with the elimination of the tax deduction we would still need the availability of public non-profit health insurance.

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