Health Care Reform and Fairness

Over at the Washington Post this week, it’s back to health care reform, and our topic is fairness. Specifically, somebody has to pay if we’re going to have near-universal coverage. Do you think it should be the people who benefit immediately (the uninsured middle class*) or do you think the payment mechanism should have nothing to do with the beneficiaries (like Medicare and, to an extent, Social Security)? I think this comes down to two concepts of what government programs are for. If the former, you probably want low (or zero) subsidies; if the latter, you probably want to tax the rich, tax gasoline, auction off emission permits, or something like that.

* This is a simplification, I know. But basically, the very poor have Medicaid and will still have Medicaid after reform; most of the insured middle class have employer-based coverage or Medicare, and that isn’t going anywhere in the short term. In the long term, as we’ve argued elsewhere, everyone benefits (except the super-rich) because of increased health care security.

By James Kwak

55 thoughts on “Health Care Reform and Fairness

  1. I am for a progressive tax on individuals. Make it seamless and more or less invisible, like social security or medicare. Take it out of the hands of employers. When looking at the current elements of proposed reform, I am struck by how complicated this is going to be for the average Joe. Subsidies? Comparing multiple plans? It all sounds like more paperwork and guesswork about what would be better for my family. Also, it is geared to make someone pay till they squeal…then they get some help…maybe. That’s insult to injury if you’re really sick. This could be so much simpler. No co-pays, no deductibles, Medicare for all.

  2. It’s hard to understand how you, James, could even write this post, given previous posts like “You do not have health insurance”, and the hundreds of intelligent comments submitted since then. It’s as if all of Simon’s posts and our comments have fallen on deaf ears.

  3. Remind me, what is the logic behind the way Medicaid and Medicare are funded? Why would that logic not apply to the current debate?

  4. Expanded coverage can easily be paid for through increased efficiency. No one has to pay. With US health care consuming 17% of GDP and resulting in poor outcomes, it would not be difficult to re-engineer the US health care system so that it consumes less than 15% of GDP, achieves universal coverage and generates tier one outcomes.

  5. Isn’t this horse dead yet? Stop beating it James.

    The insurance industry has won. The fact that we’re even talking about “who will pay for it” is proof of that. Let’s be honest, “it” means “profits of the insurance industry”. Forcing/mandating health insurance is like having gas or food insurance. So now, instead of paying $2.50 a gallon for gas, I can pay my “gas insurance” company $3.25 (factoring in the 30% profit/overhead of the insurance industry)? The ONLY thing that will help the PATIENT is a single payer system that eliminates all the greedy little hands in the pot that profit from transferring from one party to another. For those arguing that single payer is bad, I agree that there are lots of reasons it’s bad (bigger government being a huge one), but as an initial step, single payer is the only way to kill the beast that is the powerful insurance lobby.

    Game, set, match. $1.5 million a day in lobbying buys more of the same.

  6. Why not have Medicare based coverage for everyone? As an option! You would have private (All the major health companies), and Medicare (public) can be supplemented by employers, employees, taxes, etc.

  7. “Because the marginal utility — the amount of extra enjoyment gained — of one dollar is much lower for a rich person than for a middle-class person, it is also the most painless way to generate tax revenue.”

    It’s correct that the marginal utility of money diminishes for each individual with increasing wealth, but you cannot compare intrapersonal utilities. Unless you’ve invented a utilometer.

  8. It’s commonly known they spend 1/2 a billion per year…or more.

    Actually, that’s cheap considering the hundreds of billions a year they rake in as a result.

  9. Does anyone know if there is somewhere a graph showing average out-of-pocket total (premiums, copays, deductibles, meds, etc) healthcare costs as a function of income?

  10. /rant

    I will start out with honesty. I probably don’t know what the hell I am talking about, so feel free to correct me. I don’t understand how any of the proposals really make any difference, and it is driving me crazy. We will just be having this debate again in another 5 years.

    Universal coverage does not = cost control. After a one time adjustment for efficiencies, single pay does not = cost control. Our health care system is set up to find cures for life ending diseases such as cancer, where people will pay almost anything for hope, and that cost just keeps going up.

    Real cost control is reducing prices to doctors so that they don’t do the procedure anymore or reducing reimbursement rates on medications so that alternatives are found. But this sounds suspiciously like rationing and that is difficult because we are talking about peoples lives. What type of health care should be considered a god given American right and what is a luxury and needs to be paid for by the individual?

    Can we stop discussing how we are not going to ration and have a discussion on how to ration so that health care will meet our societal goals. Starting with a Utopian outcome of “All You Can Eat for All” means we certainly can’t afford it but we can die trying.

  11. Before we’re done, everyone’s going to choke on the mandate and the associated cost. Yet there’s an easy way to avoid that, and to satisfy those who want to stay with what they have: adopt Medicare for All, with a private option (like Medicare Advantage, but without the government subsidy for the insurance companies). Capitate for those who choose the private option, and pay for the whole thing through income taxes and modest premiums, just like Medicare. Savings in the cost of delivery will keep these costs low — something that can’t happen under the current proposal.

  12. I think there’s another issue here, one that it’s nearly forbidden to talk about: do we tax individuals to subsidize insurance industry profits? Do we tax the bottom half of the middle class, probably many of them into the lower class, to keep up those profits? Because the insurance industry adds little value to health care. In fact, it seems to destroy value.

    There is also a pragmatic issue that isn’t much discussed: health care seems to have the curious property of being a “good” which capitalism provides poorly. A health care system that shuts people out usually provides worse care to the people who can get care than an inclusive system. So, rich people in the USA end up getting care on the level of poor people in the UK. This also happens in Mexico: the rich in Mexico are very rich, but they cannot get very good health care in Mexico, despite a respectably medical education system. For that, they must go elsewhere. I don’t know why this is. It may be related to some of the issues Gawande covered in that now-famous New Yorker article. There are probably also systemic issues with the educational systems and the social systems that support health care. In any event: the practical result is that a system that provides universal coverage to people at all levels of income provides better care at all levels of income. The three-tier class system (really four tiers, if you count undocumented aliens) implied by the Baucus proposal has not yet been tried, but I very much doubt it will achieve levels of care comparable to the simpler and more comprehensive systems used in the rest of the world.

  13. “Universal coverage does not = cost control.”

    “After a one time adjustment for efficiencies, single pay does not = cost control.”
    If you have every single person in the same pool, and a governing body trying to keep costs down (for example, because if the government was the single payer, they really don’t want taxes to go up and be thrown out of office by the angry mobs) they have the ability to control cost by saying “We need a pill for this ailment!” Now, the company that can get that pill the cheapest without sacrificing quality now gets the contract with that single payer. The manufacturer gets a guranteed 300 million person pool to sell their drug to exclusively, and the government gets the cheapest price available (in theory). In some countries with a universal system, germany/japan for example, they have a governing body that pulls together everyone and sets prices. An MRI in japan is about $100, every doctor, no matter where you live. An MRI in America is probably over $1,000 (and can vary in price greatly depending on many many factors). This is because Japan set the rate, and worked with Toshiba to manufacture cheaper MRI machines which are now being exported all around the world.

    The rest of your post is my understanding of the situation we are currently in, however. All proposed bills don’t fix the problems, and only delay the problem further into the future, after the health insurance companies feel comfortable to start jacking up the prices again.

  14. An excellent piece, of course. I hadn’t seen it today until you called my attention to it.

    Lindorff would seem to have gotten over last year’s rose-colored glasses period concerning Obama. Has launched a number of well-reasoned polemics of late. Nothing like a swift kick in the groin to take the romance out of voting for one or other of the Regime’s parties.

  15. I think you’re exaggerating just a little when you say we’ll probably be taxing many in the middle class into the lower class, but your point still stands. The fact is that we’ve lowered taxes to ludicrously low levels in the United States,…and while people of all incomes have lower taxes today than their counterparts had a generation ago, the top 0.01% and the top 0.1% have seen their taxes decrease much more enormously any other income group.
    Source: table 1 –

    It’s unfortunate that we can’t adopt one of the simpler and more comprehensive healthcare systems of the rest of the world. The Baucus bill represents an incremental attempt to patch up the leaks in our existing system, and I haven’t made my mind up about it yet. Ultimately, what I’m afraid of is a situation akin to the stimulus/recovery package…we water it down so much in an effort to win bipartisan support, we don’t get the bipartisanship we’d hoped for, and the we end up passing a bill too weak to accomplish its original purpose and with the Republicans using its failure against us in the next election.

  16. The fact that the national discussion on “health care reform” ignores actual health and better, less expensive therapies which are already available is disheartening, James.

    Many, many Americans are convinced that “medicine” and “health care” only means:
    1. Drugs promoted by pharmaceutical companies
    2. Expensive tests ordered by an MD
    3. Surgical and other invasive procedures

    And in fact, those are the main things insurance companies pay for. Not much else is considered valid therapy.

    For some reason, most American patients and MDs find the often ghost written, pharmaceutical company financed studies published in medical journals to be the only source of medical truth. But it’s not as well understood that many of these “medical journals” receive significant funding from pharmaceutical marketing departments.

    Many Americans willingly ask MDs to prescribe drugs they learned about from TV commercials, and the MDs often happily comply. (What kind of fools are we?)

    And we turn a blind eye toward free vacations, speaking fees, appearance fees, chemotherapy rebates, and high priced lunches given by pharmaceutical companies to MDs in exchange for “nothing in particular.”

    Meanwhile, by and large, health insurers only pay for these corporate endorsed, often dangerous, ineffective, expensive therapies while denying or limiting coverage for non invasive, safe and effective — but not profitable to anyone therapies.

    Why is this?

    Why don’t you write a post about this stuff, James?

    Here’s some reference material:

    1. Why our Health Matters – Dr. Andrew Weil, MD. (Graduated from Harvard Medical School. Surely you can take the time to examine his views.)

    2. The Truth About the Drug Companies: How They Deceive Us and What to Do About It – Marcia Angell, MD (Currently lectures at Harvard and was once the editor in chief of the “highly respected” New England Journal of Medicine.)

    3. What Your Doctor May Not Tell You About Cholesterol – Stephen R. Devries, MD (Associate Professor of Medicine, Northwestern University Medical School. Sorry, he doesn’t teach at an Ivy League School. But, he has really interesting things to say about the unnecessary use of expensive statins, and inexpensive treatments those at risk for cardiovascular disease can use — even though they aren’t covered by most insurance policies. Which means that inexpensive treatments are more expensive than expensive ones.)

    As Dean Ornish, MD, professor of Medicine at UCSF Medical School has remarked, these inexpensive, safe and effective treatments and lifestyle modifications could save a lot of money and a lot of lives — IF WE COULD JUST CHANGE THE REIMBURSEMENT SYSTEM.

  17. Doug, you have gone right to the heart of the matter.

    No one in his right mind believes this twaddle about, “there will be a cap on costs, but no cap on benefits,” (Pelosi) or Obama’s claim that we can cover everyone through mandates or subsidies, cut a half trillion dollars from Medicare, have no reduction in quality of care or outcomes, and not raise the deficit by “a single dime.” This is crazy talk, and everyone knows it.

    Doug has got exactly the right take on it. Let’s get busy on the debate over whose grandma we’re going to pull the plug on. Like a health care version of Willie Sutton might say, that’s where the money is.

    It will be comforting for us to know that the all-wise appointees of the present and future Presidents will be able to set proper “societal goals” to determine rationing standards. Death panels? Tsk, tsk. They’re “societal goals” panels! Ask Ezekiel Emanuel. He knows what’s best for us. I’m willing to have myself put down for the good of the state, aren’t you, comrade?

  18. This is another reason why I don’t have health insurance. I’d rather spend my money on things that actually improve my health. Insurance only pays when something goes horribly wrong. In fact, in my case, something has already gone horribly wrong, and allopathic medicine is of little help in mitigating or curing it. This happens more often than we want to admit. If I bought insurance, I couldn’t afford to buy the holistic helps that make me feel better and preserve the function I have been able to retain.

    In a way, pricing people out of the mainstream medical system can sometimes be a blessing. That necessity is the mother of invention, and leads to the discoveries of cheaper and yet better modes of treatment.

  19. It’s actually about 700K per day, but, details. The rest of that $1.5M is advertising to the public, funding tea parties, paying for Fox news and Limbaugh, etc.

  20. And the actual right way to do this would be single payer for routine checkups, births, well baby, government clinics for those without insurance, etc. and catastrophic coverage, which the government picks up, and let the insurance companies and Medicaid or Medicare cover everything else. Set a “trigger” for catastrophic as Snowe likes, and when you go over that amount it kicks in your government single payer care.

    Geez, it’s so simple anyone could figure it out, if we had any legislators with actual brains.

  21. As a physician, I find your comments about “free vacations, speaking fees, appearance fees, chemotherapy rebates, and high priced lunches” offensive. The reality is that 99% of physicians are not even allowed to use a pen given to them by a pharmaceutical company. I have never received any of the things you mention for free in 10 years of practice. Meanwhile, the politicians that handed down these rules bask in the glory of prostitution rings, free limousine service, and under the table mortgages from Countrywide.

    According to the Kaiser Family foundation, for every dollar spent on healthcare in this country, providers (physicians and others) get 22 cents. Half of this goes to overhead (remember most of us are the dying breed of small business owners). Cut every physician’s salary in half and maybe you’ll get a 5% savings. Good luck finding a doctor then. Doctors make less now than 10 years ago (google easy comes up with multiple article support of this decrease). Care to enlighten me which of the other components of the health care system (insurance, pharmaceutical, trial lawyers, hospitals) can say the same?

  22. I haven’t been convinced that a single payer leads to better cost control, it just seems like a contrivance to delude the public into thinking there is a free lunch. I still see the benefits (aside from paperwork standardization) as the result of the government making standard of care decisions (directly or indirectly deciding what treatment will be received). There is nothing that says the government can’t set the price of MRIs or allow the health insurance companies to collude with Medicare/Medicaid when negotiating with the drug companies…

    But do we really want that? Is there a reason cost controls will be more politically viable under a single payer system? The political pressure seems like it will be just as great to overpay.

    Monopolies work so well everywhere else, I am sure forming one in health care will fix everything!

  23. “Monopolies work so well everywhere else, I am sure forming one in health care will fix everything!”

    Yeah, because Utilities are so overpriced. How about we sell our utilities to private companies, let them compete on the free market, and let them trade the future value of the utilities on the free market!

    …Wait a minute.. this sounds familiar.

    Also, The government setting cost controls doesn’t have to be single payer.

    If the urge to overpay is so high, then why do other countries that have government regulation on the costs of health care have the opposite problem as us, not paying DOCTORS enough?

    I’ve always said that if you think that getting rid of for-profit insurance and regulating the insurance company enough to be fair (taking care of pre-existing conditions, recission, etc) then fine, that’s what the Swiss did, but I REALLY don’t think that America will regulate the insurance companies enough. It’s just not part of America’s psyche.

  24. Under the Baucus proposal, the insurance industry has a huge incentive to raise rates to sop up all the money that the middle class would otherwise save, and a mandate to do it. So, now, tell me why they won’t do it.

  25. Nothing in any of the current proposals prevents you from buying supplemental insurance.

    There does seem to be a strange contradiction in your arguments, however:

    On the one hand, you are against government paying so much for health care. On the other, you are against the government choosing _not_ to pay for particular procedures (while leaving you with the freedom to pay for yourself or through private insurance).

    Do you see the contradiction?

    If government provides _any_ sort of safety net, then by definition it must either pay for everything or not pay for everything. Paying for every possible procedure is a ‘very bad idea’. The alternative is that government pays for some things – those for which there is strong evidence of value – and that individuals are responsible for covering any other procedures beyond this minimum floor of coverage.

    Thus, you must be against any sort of government payment whatsoever. Including Medicare. Is that so? Your arguments remind me of those who boisterously demand that the government stay out of Medicare.

  26. I often thought that the US healthcare system ,spending as much as it does, couldn’t be as universally awful as it is depicted in many places, including Michael Moore’s movies and this blog.
    So did anyone read the article in today’s NYT… on life expectancy in the US as compared to other countries?

    “….Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America’s health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis. ”

  27. “the very poor have medicaid’…but most poor people are not eligible for medicaid. medicaid requires that you be poor AND that you be a child, have children, be pregnant, or be disabled. most poor people don’t fit those categories, alas…

  28. Speaking of fairness, it would seem that the only logical way to deal with health care in America is a single payer system like Canada’s. We can’t “build” on a system (per Obama, whom I otherwise love and trust) that is set in financial quicksand, and is not really about having a healthy nation (unless having lots of waste and abuse and rich insurers is considered healthy). You have to have and amazing (and quite dark) sense of humor to take the Baucus bill seriously. It is an utter absurdity that would ensure that the status quo is served, but actually becomes worse.

    The public plan option is okay, but even Medicare has lots of flaws and is highly subject to abuse. Part of the high overhead cost of private insurance is caused by the need to protect against fraud, and the other is to protect against having to pay out benefits whenever possible. In Canada, everyone just pays taxes and gets health care paid for, while the delivery system remains private (how is this socialist?).

    Let’s face it, we can’t build effectively on a completely broken system. We can’t even get trained physicians to practice general medicine because the pay scales are so out of wack.

    This is kind of like a corporate restructuring which does nothing but stir a pot of crap, only to create a whole new and larger set of problems by not really reforming things.

  29. “It is just not part of America’s psyche”…

    Americans cannot make the difficult decisions that are required to produce cost effective health care. We cling to myths like health care is a right, I should have access to all treatments at no charge, access to health care does not depend on socioeconomic status, etc, etc. It sort of reads like a health care American dream.

    I am not necessarily against a public plan, but the regulation/rationing part needs to be figured out, not a residual of whatever structure is chosen. Because if you start to build a system that tries to fulfill “the dream”, it is destined to fail. No matter how much money you throw at the problem, at some point you still have to tell somebody’s grandma that the US taxpayer will not pay for their experimental last hope treatment.

  30. I’m sorry you find it offensive, Brian. I truly am.

    I find it offensive that my doctor asked me take a stress test in her office without first informing me of the price tag ($1200). (Wouldn’t it be better to tell patients about that aspect of a test before it’s sold to them?)

    I find it offensive that I’ve witnessed pharmaceutical company representatives lunch appointments in every physician’s office I’ve visited in the last few years.

    I find it offensive that physicians I’ve visited do not offer to provide me with a copy of my test results automatically, without being prodded.

    I find it offensive that medical boards use the law to restrict practitioners with alternative approaches to cancer treatment (Burzynski, for example), naturopaths, acupuncturists, chiropractors, etc.

    I find it offensive that doctors who treat Crohn’s disease continue to insist to their patients that diet modification provides little or no benefit, preferring instead to use surgery, or steroids like prednisone or risky drugs like humira. This is especially offensive in the face of a growing collection of crohns patients who have used dietary modification to bring themselves into remission? (Why don’t doctors take a look at this phenomenon and get behind it?)

    I find it offensive that many MDs remain willfully ignorant of the benefits of nutritional approaches to the treatment and prevention of various diseases despite the publication of scientific studies in peer reviewed journals and patient case histories that demonstrate such therapies are useful, safe and often inexpensive. (Are you familiar with the history of folic acid supplementation for the prevention of neural tube defects during pregnancy and how long it took the government and doctors to recognize its benefits? Do you know about the value of niacin and fish oil for the regulation of serum cholesterol, or the value of deglycyrrhizinated licorice root for GERD? Do you use these things in your practice? How many physicians do you know who do?)

    Brian, there’s plenty to be offended by. But the reality is, the disease management system we have in America today is not working as well as it could, and there are no good reasons for it.

  31. SJ and JK wrote: “if you think that all Americans should have the right to a minimal level of health insurance, you probably think health-care reform is good for America, pure and simple, and favor increasing taxes on the people who can actually pay them.”

    Shocking!!! This would mean increasing taxes on people who earn millions of dollars a year. It could put a dent in the market for luxury goods.

  32. Al,
    It sounds like you’re truly bitter at a system that has not met your needs. It also sounds like you’ve done a fair amount of research and have a pretty strong opinion about healthcare. Why not apply this to good use? If you don’t have it, why don’t you get some medical training and start practicing the type of medicine that you think needs to be provided? Please report back your experiences once you’ve “walked the walk”. I’d love to hear them.

  33. I’m with you Brian N.

    ~$300bl ANNUALLY would be saved by merely standardizing billing ALONE. The health care industry distrust is well deserved but unfortunately, aimed at the wrong people. Insurers, big pharma and the Lobbyists who have super megadollars to spend in Congress to assure their existence and profits remain sadly intact.

    Legislating insurance coverage will effectively produce the worst of ALL worlds. You can’t run health care like a toy-r-us because you can’t exactly shop around for a total hip replacement. The free market paradigm has proven itself false after decades to prove it could provide more accessible care, efficient care and keep costs contained. The absolute opposite happened in spades as the self-interested won out over public interest and ethics in honoring their contracts to individuals by insurers was lost. The rest of the nearly 60 million people are shut out, tens of millions UNDER insured in a system which rewards bad/illegal behavior in abundance.

    By mandating health insurance like homeowners or car insurance only creates the opportunity for more abuses from insurers to individuals AND to the costs to government. It isn’t the same and cannot be managed the same as its vastly more complex/demanding. Its obvious but those who profit will keep the anger focused publicly elsewhere. MSM won’t report about it as their ad revenues come from the endless commercials from big pharma. Tort reform is also mandatory to any reform in health care.

    The only way to lower costs is a single-payer system which produces a large enough base to negotiate costs and streamline billing. Profits aren’t evil but a 400%/dose PROFIT on a sole source neo-natal respiratory distress medication is OBSCENE. One of thousands upon thousands of examples.

    A Civilized society provides for its most vulnerable citizens who are UNABLE to provide for themselves. Nothing like fighting an insurer when your in a fight for your life with cancer or weak/ill otherwise. The dark underbelly of capitalism became the rule rather than the exception.

    Lets not reward those who have proven themselves unworthy of trust in countless ways with horrific personal costs to people when they are most vulnerable. The practice of medicine/nursing is a vocation with intangible rewards; its sad that even that has been circumvented as those who excessively profit have made the ability of those who do practice in the interest of patients jobs unrealistically/unnecessarily difficult and stressful.

  34. People who work for large corporations have supposedly seen little growth in wages because the company is subsidizing their health insurance and the “cost” of the employee to the company includes that tab. So though wages have remained stagnant, someone else is picking up the insurance tab – so as the president likes to say, they don’t have to change a thing.

    (Reform in America! Keeping the status quo for most!)

    However, people who do not have insurance now have also seen stagnant wages in the last decade, without the big company to pay for insurance. So the idea with our reform is to add the uninsured to the rolls of the insured (insurance companies must be thrilled with all this new business!) and they get to pay for it or be fined a fairly substantial fine if they don’t purchase a plan.

    We’re not “reforming” the delivery of health care – we will continue to have the most expensive system in the world with less than superior outcomes – with more customers for insurance companies.

    It really sounds like the reform we’re getting is yet another way to stick it to the middle class.

  35. I am amazed that you can mention fairness and “near”-universal coverage in the same paragraph. Leaving some people without health care may fit your notions of fairness. It doesn’t mine.

    Novel concept for policy wonks: start with the ethics, explicitly, and only then go to logistics. You are making ethical choices even when they aren’t explicit, they’re just worse than you would make if you thought about them.

  36. I feel taxing the small business men more would lead to further economic damage then any good as the would have to cut the excess cost by either cutting down salaries or the job itself. Every policy has a pro and a con to it.

  37. The ethical arguments are not nearly as clean-cut as you seem to think:

    First, some people fundamentally differ in opinions over what is ethical. Taxing working people or people who save to pay for health care for non-working or non-saving people strikes many as unethical. Good luck getting a consensus on “ethics” prior to engaging the “implementation” debate.

    Second, you presume that health care is a right, not a privilege, and that it is wrong to refuse to give the very best care to people who have no incomes (regardless of the reason why – which could be a selfish career choice or a genetic condition over which they have no control). By this logic, helping the poor in the US is wrong – we SHOULD be helping the WORLD’s poor. Yet, the “health care is a fundamental right” movement seems more focused on extending $12,000 a year coverage to all Americans than $100 a year coverage to the poorest in Haiti, which is a few hundred miles off our coastline.

    So is your argument about morality, or about political power?

    3) No matter how you cut it, there is – eventually – a tradeoff between free care and efficiency. Period. Any system of government care MUST concede that there needs to be (eventual) limits on the extent of care. Rationing is a must, and government must propose a credible mechanism for rationing. And yes, that means – at some point – denying ultra-expensive care that could prolong a life by a few weeks or months.

    Many sane individuals would rather lose a few weeks, or even a month or two, of life (especially if it’s on a ventilator and inundated with opiates) than burden their family with $100,000 of debt. I would. But that choice is different when the government is footing the bill…

    And while there are many cases of deserving people who have been denied care (and this must be addressed), let’s concede to the conservatives that there ARE cases of individuals who do not save, consume excessively, do not buy insurance even though they could, do not materially contribute to society, but then become ill (sometimes due to their own choices, like smoking or drinking or high risk sports or unprotected s3x), and then loudly demand that society provides them with the best possible care in the world. Do these people really deserve that care? And what are the long term consequences to incentives of providing it to them?

    So while you dismiss the arguments of “policy wonks”, they have done a better job at framing the real arguments and trying to come up with a solution than the polarized polemical “moral” camps on either side of the spectrum. The “policy wonk” debate is over pragmatic implementation options; The “ethical” debate has devolved into mudslinging and namecalling and outright hysterics (on both sides of the spectrum).

    I have little patience for conducting an ethical debate in a vacuum, and then trying to extend the outcome of that debate to the real world.

  38. If Versailles hadn’t taken single payer off the table, the country would have at least $350 billion a year to play around with, and that goes a long way toward paying for the program. (HR676, the Conyers single payer bill, has several well-thought-out funding mechanisms, including a transactions tax; section 211) Every country with a single payer program at least half our per capita cost, and all of them have better health care outcomes. The French, for example, live two years longer, on average.

    Of course, single payer isn’t a bailout for the insurance companies. There is that.

  39. Alright, alright. You raise a fair point.

    And the truth is: I’m not a good candidate to train to become a medical practitioner. That really isn’t where I belong. I don’t have the temperament for it and I’m not in a position in life to go back to school now.

    So you’re right: I have not walked the walk of a medical practitioner. And it’s very unlikely I ever will.

    But I have walked the walk of patient and one who has loved ones who are patients who are not being treated in ways that seem good enough, safe enough or even comprehensible to a lay person with some common sense.

    What is our medical system doing to us?

    In any case, just about all of the points I raise originate from MDs who do walk the walk. I’m not just pulling this out of thin air or generalizing based on my personal experience and research.

    But still let me ask: is pointing out the lack of medical credentials or experience enough to silence the critics of the pharmaceutical industry, the insurance industry, the and the medical profession? Is that all it takes?

    Isn’t there a role in this discussion for concerned citizens, researchers, bloggers, patients, and journalists?

    BTW, there’s yet another story about questionable pharmaceutical industry practices on Bloomberg today:

    “AstraZeneca Denied Drug’s Diabetes Link Years After Warning ”

    It may not seem like it, but I am truly grateful that an actual doctor has taken time to engage in this discussion with me on this blog. Thank you for your time and attention.

    And for what it’s worth, in my book, most MDs are WAY WAY above politicians. And I am not a fan of our current “tort system of medical oversight.” That makes almost no sense to me either. What a terrible way to try to bring quality control into a system of health care delivery (Gee thanks John Edwards!). No arguments from me there.

  40. My solution to health care reform would be true competition and the revival of consumerism in health care market. We need to introduce competition back into health care. What other industry are you provided a service without knowing the cost upfront?! We should be able to go to a website and see what the real cost of surgeries are on a national basis and the fat happy physicians and hospitals marking up procedures and drugs 500-1000% should be shunned from the marketplace. why not have hospitals compete for your business and you as a consumer be able to shop the best price and the most value? Check out this website, good resource for small group employers. Lets make health care more affordable TODAY!


  41. There is no contradiction. I believe in separation of health care and state. I believe in the separation of education and state. I’d like to separate the state from most things in life.

    But… if you must involve the state, then decide how much subsidy people should get, open up the marketplace (instead of the ridiculous amount of regulation and restriction of the marketplace we have now, where one cannot buy insurance across state lines, where some health care is tax advantaged and some is not, etc.), and let people have the widest possible choice of exactly where to spend that subsidy. Even if they choose unwisely.

    Freedom, man. It’s a trip.

  42. The ethical arguments are a lot more clear-cut than you are willing to admit, and I have noticed no vacuum. Physicians for a National Health Program–ethical policy wonks who actually study public health–has estimated that the Baucus bill, which would leave about 25 million people without coverage, would result in about 25,000 unnecessary deaths a year (based on a recent study when about 44 million were uninsured and such deaths were about 44,000 a year). If it is hysterical to be concerned about those thousands of individuals dying prematurely, not to mention the grief and often severe economic hardship experienced by their survivors, then let us by all means have hysterics.

    I too have little patience: with those who try to negate the value of other people by producing hypothetical arguments about their supposedly irresponsible behavior. And as you like statistics, please keep in mind that three-fourths of medically related bankruptcies are of people who had insurance when they got sick or hurt.

  43. When you need a hospital, you’re generally in no position to shop around for the best price…unless it’s an elective surgery.

    The objective of preventive health care is to deliver as little of it as possible while maintaining a reasonable standard of health. That’s exactly the opposite of a growth market where the general rules of competition apply.

  44. So what is the minimum level of care that we can provide to prevent the 25,000 deaths… And that is the medical benefits that the plan should provide. No more, no less. As a nation this is a worthy goal, and structured in this way I think the costs can be realistically controlled.

    But since blowing an ACL is not life threatening and the expensive cancer treatment does not prevent a death, just extends it for a very small time, most people would want to still have private medical insurance.

    I am guessing that most people who favor the universal plan find this option unpalatable. Something has got to give. As a society, I do not see any way that we can afford comprehensive coverage for all. Now if you want to take on a worthy goal like saving lives it becomes a very different debate.

  45. I am not arguing against medical overhaul – I’m arguing against conducting this overhaul by engaging in an a priori ethical debate in the absence of “wonkish” details, and then building a policy.

    This process presumes that ethics can be determined in the absence of consequences, or that consequences can be known in the absence of empirical knowledge. This is precisely how the ideological right engages public policy – would you have the ideological left proceed in the same manner?

    Even the “simple” ethical example you offer is not simple. Your argument about 25,000 unnecessary deaths implies that the opportunity and incentive costs of not covering these 25 million people are negligible. They are not.

    In practice, we could save well over TWO MILLION lives a year – many children – if we simply extended existing vaccines to the world’s poor. And this would incur a FRACTION of the cost of covering that last 25 million people. Plus it would yield tremendous side-benefits, including reduction in domestic infections and the emergence of antibiotic resistance bacterial strains. Yet where is _that_ in the hierarchy of policy priorities of our supposedly ethical-focused colleagues who demand universal US coverage no matter the cost (and oppose free immigration)?

    The “ethical” argument presumes that “No US citizen should suffer… All US citizens have an inherent human right…”

    This argument is self-contradictory. Why are the “human rights” of US citizens greater than the rights of other humans?

    And if indeed all human rights are equal, then what (other than self-interest, or pragmatic policy limitations) is the argument for rolling out top-tier health care to US poor rather than mid-tier coverage to 10 times as many of the world’s poor at much lest cost?

    Ethical goals and implementation details (like costs) must be considered jointly.

    “Mortality estimates can be used to prioritize public health interventions. For VPDs, these estimates indicate the number of deaths that could be averted if existing vaccines were used to their fullest potential. In 2002, among diseases for which vaccines are universally recommended, WHO estimates that fewer than 1,000 children aged <5 years died from polio; 4,000 children died from diphtheria; 15,000 children died from yellow fever; 198,000 children died from tetanus; 294,000 children died from pertussis; 386,000 children died from Hemophilus influenzae type b (Hib); and 540,000 children died from measles (4). Among adults, 600,000 deaths were attributed to hepatitis B virus infections, the majority of which were acquired in childhood. In addition, other diseases can be prevented by vaccines that are not universally recommended by WHO. During 2002, the largest numbers of deaths from these VPDs among children aged <5 years were attributed to pneumococcal disease (716,000) and rotavirus infection (402,000) (4) (Figure 1); 240,000 adult deaths were attributed to human papilloma virus infection (WHO, unpublished data, 2002). During 2002, approximately 1.9 million (76%) of the 2.5 million VPD deaths among children aged <5 years worldwide occurred in Africa or Southeast Asia (Table)."

  46. Policy is inescapably political, and politics was originally a branch of ethics, however farcical that may sound at present.

    Your argument about what “we” could do for world health with money not spent on US health care sounds a bit like someone proposing to lock his aunt in the attic and give her money to charity: no matter how worthy the charity, the act is a usurpation. What is at issue is not only the right of all people to well-being but the right of citizens to a voice in setting the policy of their country–and no small voice either.

    In any case, the argument is something of a canard, as it implicitly assumes the only money available for allocation to world health is that which would otherwise be spent on US health, when, without even starting on the question of tax policy, we might consider many other sources, most notably in the vast and grossly under-scrutinized defense budget.

    I’m done for now. Don’t think I don’t value the wonks, I do. I’m all for good data, just don’t think they confer exceptional powers on their producers.

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