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Morals and Medicine

06 Jul 2007 01:15 pm

Brian Beutler notes the fear that Michael Moore has put into the hearts of insurance executives. It seems to me that the main cause here is that Moore has gone where liberal health wonks fear to tread, touching not only on the policy issues but on the question of ethics. He helps tap into the anti-capitalist folk instincts that worry Bryan Caplan. The crux of the matter is that ordinary people think that if there's a sick person, and you're in a position to help the sick person, that you ought to help the sick person.

Insurance companies strengthen this commonsense moral obligation by actually entering into contracts -- you pay them, each and every pay period, so that when you're sick, they'll help you. But insurance companies are largely in the business of devising excuses to avoid helping you when you're in need. They employ people wake up every morning, drive to the office, and work all day denying sick people health care. The labors of these individuals line the pockets of the companies' executives. Most people find this repugnant. Bloodsucking vampires and flesh-eating zombies have the excuse of being driven by insatiable urges. Insurance companies have free will and just choose to do bad things because they're greedy.

That's not an argument that'll win you high grades in a public policy class or get you made a fellow at a think tank. It's demagogic and anti-intellectual. But it's effective and not, I think, entirely wrong

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Comments (106)

One thing I hear a lot from right-leaning Democratic types on this is that they don't understand the "sense of entitlement" of people who think that they should be provided health coverage by their government.

What you rarely hear pointed out is that the belief that my money is my money and I have no obligation to use that money to help a sick person in need is itself a certain kind of "sense of entitlement" as well.

APS

Insurance companies have free will and just choose to do bad things because they're greedy.

Moore actually points out that these companies are legally obligated to do these bad things, as means for increasing profits for their shareholders. He then uses that to illustrate why he opposes for-profit health care.

The belief that you should help a sick person if you have the means and ability to help them is anti-intellectual? I think you have to use a pretty strained definition of intellectual to say so.

In case you missed Stephen Hunter's ultra-lame review in the Washington Post, I reprint it below. This review needs to be widely debunked for the know-nothing piece of dishonesty that it is, especially since this is probably the main review that Washington decision-makers will read of this film (and it will be capsulized in every coming issue of the Post's "Weekend" entertainment magazine).

Note particularly the spot where he defends the insurance companies for their enthusiastic denial of claims because "would the system work if everybody got what they wanted"?

'Sicko': Michael Moore's Anemic Checkup
By Stephen Hunter
Washington Post Staff Writer
Friday, June 29, 2007; C01
"Ladies and gentlemen, I think we can agree on two things: The American health-care system is busted and Michael Moore is not the guy to fix it."

No, Virginia, I'm pretty sure a link would have sufficed.

Let's nationalize health care already: put the heatlh insurance companies out of business, cap physician salaries at $120k and nurse salaries at $40k (real savings there!) and offer treatment to every American and illegal alien at no cost. When smart Americans stop applying to medical school, we can just recruit some hack doctors from Arab countries like Britain did. Can't imagine that ending badly.

Speaking of populism, huh Harry?

"if we nationalizez healthcare teh a-rahbs will getz us wit bombz!"

It used to be the commies, Very clever!

Because of course no Americans would ever choose to get a doctorate in a field if they were only going to earn $120,000, right? The existence of professors kinds of cuts against this logic.

Generally, if you raise a big enough stink you can get what you need. That's why Moore had a hard time finding good examples of anybody dying from lack of care -- for example, he admits the guy who was denied a stem-cell transplant died just three weeks later, which suggests it was hopeless and the insurance company made the right decision. On the other hand, lots of people likely just give up fighting and die quietly, although that's probably true in any system. The British, for instance, are notorious for deferentially agreeing with their NHS doctors to die quietly without demanding budget-busting longshot treatments. No country can afford to provide whatever all patients want.

Still, the incredible stress the haphazard American system induces in people should have been emphasized more directly in Moore's movie.

Before we get all technical and worried about commies and hippies, lets try a little Churchillian logic: The US healthcare system is the best except for all the others.

We can do better.

Hey Harry, do you know what percentage of physicians in USA are not born and educated in America?

A component of the solution of the health care crisis would be for us to fund quality medical schools abroad and get the best local students to get education there. After graduation they will run to get the $120K per here in USA, just as the engineers from the American funded foreign engineering schools have flocked to America and made substantial contributions to the technological revolution of the last two decades.

It's not only "folk instincts" that may hold that the current system is morally problematic. I don't know whether, say, John Rawls or Peter Singer or any of a number of eminent ethical philosophers would get a good grade in a public policy class or be offered a job at AEI, but what they'd have to say about the subject likely would be more than just 'effective & ... not entirely wrong.' The system is morally indefensible, & there's nothing intellectually suspect about saying so.

When smart Americans stop applying to medical school,

What the fuck would you know about smart Americans, Red?

Just a little fact - the most profitable health insurer has a profit margine of 7.6%. If half of our healthcare spending is gov't (7.5% of GDP) and the other half is private, (again 7.5% of GDP). Then if we took all the profits out of the insurance industry that would only save us %0.0056 of GDP.

If the gov't pays or a private insurance company pays they both need legions of faceless bureaucrats to approve each claim. The NHS has thousands of employees who's only job is to make sure they don't pay for anything they don't have to.

“Fok instincts”? Yes, basically correct.

But how about that 19th century philosopher and labor organizer, Karl what’s-his-name, who cut through folk instincts to the inner core of the problem: “the fundamental contradiction between market exchange and social need”?.

Insurance companies have free will and just choose to do bad things because they're greedy. That's not an argument that'll win you high grades in a public policy class or get you made a fellow at a think tank. It's demagogic and anti-intellectual. But it's effective and not, I think, entirely wrong

Not entirely wrong? How about, almost entirely right?

Come on man, grow a pair.

I've been covering the insurance beat at a business journal for the last year, and have indeed spoken on a regular basis to the schlemiels (mostly attorneys) whom Matt imagines getting up, going into their office each morning, and narrowly and tortuously construing policy language to deny necessary healthcare, home/auto repairs, workers' compensation, etc. to insureds; and yes, said schlemiels don't seem to exhibit human emotions, though such feelings are rare in the insurance industry. The lobbyists are even worse. They've all got arge houses in the suburbs, chem-green lawns, nice suits -- and no effing souls!

I would like to see a law requiring employers to buy health insurance and life insurance for employees from the same company. When I had lymphatic cancer in 1997, if I had needed a $150k stem-cell transplant, I would have very much liked it if the insurance company's incentive structure would have been either to pay for my $150k transplant or pay my $400k in life insurance to my widow.

> Moore actually points out that these
> companies are legally obligated to do these bad
> things, as means for increasing profits for their
> shareholders.

The vast majority of insurance companies, from 1500 on, were founded as mutual organizations (later mutual corporations), not joint-stock companies/corporations. Partly this was because joint-stock companies are younger than insurance comapanies, but I have to think a large part of the reason for this was that joint-stock insurance corporations suffer from exactly the type of moral hazard that Matthew describes. Mutual corporations aren't totally immune to this (witness State Farm's behavior in the Gulf states post-Katrina) but the incentives are nowhere near as strong.

Of course here in the USofA we spent the 1990s dismantling all the mutual insurers and mutual health-care providers and replacing them with the "more efficient" joint-stock model...

Cranky

Justin-

Karl and "folk wisdom" agree, and why not? Experience of life under capitalism naturally leads people towards the premises of Marxism* -- that's kind of the whole point of it. Still mostly true, no matter how unfashionable -- lots of people think that "From each according to his abilities, to each according to his needs" is in the Constitution.

(* Or in the exact opposite direction. It's these charming contradictions that keep life interesting.)

Re: But insurance companies are largely in the business of devising excuses to avoid helping you when you're in need.

This is a gross overstatement. Insurance companies do not so much deny their suscribers care; it's actually uncommon for them to deny a healthcare authorization outright (and the people who handle authorizatiions are qualified medical personnel: generally RNs with perhaps a MD on staff for very complex cases). Most of their cost savings come at the provider end, by limiting what they pay out to doctors and hospitals, generally though not always in a way that does not obviously impact the patient. Look at an EOB next time and see all the discounts and cuts the insurer applies to the doctor's bill with the result that what the doctor gets is usually about half of what he asks for. Public programs do exactly the same-- and usually they are much better at it since they have the law behind them as well as contractual agreements. Your average private HMO is positively spendthrift comapred with what Medicaid is willing to pay out on claims.

Gotta wonder who pays JonF's bills...

Sailer's idea actually smacks of genius.

The NHS has thousands of employees who's only job is to make sure they don't pay for anything they don't have to.

No, it doesn't. The bureaucracy in the NHS is primarily concerned with resource and waiting list management; it has nothing to do with the authorisation of treatment. There may be waiting lists for non-urgent treatment, which needs some bureaucracy to manage equitably, but treatment is never contingent on the decision of a bureaucrat.

Jmo's calculations would be accurate only if profits were the only reason private insurers cost more. They have much higher overhead, because it takes more work figuring out if they actually want to pay or not. In addition, the doctors' profits are reduced by the need to have a staff on hand dealing with all the insurance companies's demands. So, Jmo's calculations are misleadingly incomplete.

The paperwork generated under the American health care financing system is a nightmare, perhaps worse than the paperwork generated by the income tax.

Gotta wonder who pays JonF's bills...

Can we please stop using this line of argumentation? It's perhaps the most retarded fallacy ever, mixing a healthy batch of ad hominem with a big red herring.

Hell, I don't even agree with JonF, but it's silly to assume that you are the only one being sincere while everyone who disagrees with you is obviously being paid to do so. Attack the argument, don't fall for the fallacy.

Can't imagine that ending badly.

Funny thing about the Internet. It's got these "search engines" where we can look up "facts" and "data" and use those things to resolve competing claims and such.

So, assuming for a moment that your straw man version of the NHS is at all accurate, has the system in fact ended badly? Let's find out.

Per capita health care spending:
UK - $1,675
US - $4,271

WHO health care rankings:
UK - 18th
US - 37th

So, they are ranked quite a bit higher than us, and spend only 40% as much money. Oh dear God, please save us from this socialist nightmare.

Alan:

"The bureaucracy in the NHS is primarily concerned with resource and waiting list management"

Waiting list and resource management has the same effect - who gets treated and who doesn't. If you need an MRI under the NHS someone needs to decide how long does the waiting list can get before they have to buy another MRI.

I would also assume that waiting lists are in order of acuity not first come first serve - or some hybrid of the two. Someone needs to rank everyone.

Thanks Phaedrus. We have to say over and over, US healthcare is the most expensive, it is the least efficient, and it is the least inclusive in the world. Unbelievably, it is among the least effective, It is a really bad "system." We can do better.

As Matt noted the other day the mystery is why anyone defends it. We could pick any other healthcare model and have more money and better public health.

Alan - as the supreme court of Canada ruled - "access to a waiting list is not same as access to health care."

They may approve your angioplasty but if they only fund one cardiac cath lab in your city - and you die of a heart attack in the mean time - how is that any different from not getting any treatment at all.

And it most definitely is a bureauracrats job to determine how many cardiac cath labs to fund under the NHS.

Re: Gotta wonder who pays JonF's bills...

A major financial corporation which is NOT involved in insurance. However I have worked in health insurance in the past. I know how the system works. Is the system broken, requiring major reform? Absolutely, and I've argued for that on this and other blogs. But that does not justify wild, outrageous Jacobinical rhetoric.

Pitkin (@ 2:29 pm) –

I agree, but here’s the contradiction that interests me.

Our host says, correctly, the following:

"Insurance companies have free will and just choose to do bad things because they're greedy."

That is an insight into the inherent nature of the market system that was famously discovered and eloquently stated by Adam Smith. (see Wealth of Nations as well as Moral Sentiments, replete with quotes on this point).

But then our host proceeds immediately to dance the modern shuffle, in order to separate himself from the “radical rabble” and appear acceptable to the people that count:

"That's not an argument that'll win you high grades in a public policy class or get you made a fellow at a think tank. It's demagogic and anti-intellectual. But it's effective and not, I think, entirely wrong."

Note the emphatic judgement: “It’s demagogic and anti-intellectual.” Now, would he choose to say that about Adam Smith? I doubt it. So, why then? That judgement actually negates completely what he says next: “… it’s effective and not …entirely wrong” (even if this statement is as wimpy as you say it is in your comment @ 2:13 pm).

Not much to add, except that Jmo is probably a troll. Anyone who makes so obviously stupid a mathematical error has to be trying to make a certain side look bad (we'd save around 100 times more than the number you put out; you misplaced a decimal). Not even touching on the other errors.

Honestly, Jmo, they make themselves look bad enough. No need to put up strawmen to knock down, if merely because their actual claims are just as bad, albeit more subtly wrong.

I certainly didn't mean to suggest that some form of rationing doesn't take place within the NHS, but to contradict the rather obvious attempt to equate the rather inhumane and dysfunctional authorisation, or more accurately, non-authorisation of treatment by insurers trying to maintain profit margins, and a system that actually is trying to maximise its resources to provide treatment for people who need it, and which is very popular with its consumers.

I certainly didn't mean to suggest that some form of rationing doesn't take place within the NHS, but to contradict the rather obvious attempt to equate the rather inhumane and dysfunctional authorisation, or more accurately, non-authorisation of treatment by insurers trying to maintain profit margins, and a system that actually is trying to maximise its resources to provide treatment for people who need it, and which is very popular with its consumers.

If we did a study and looked at a sample of 80 year olds in the US, Japan, France, and the UK who were diagnosed with cancer that could be treated with chemotherapy, do you think the % of Americans who opted for treatment vs. hospice, care at home, etc. would be higher or lower than in Japan, France or the UK?

From what I've read - American's - for any number of reasons, are much more likely to insist on heroic end of life care than people in other countries.

In any reform we undertake - I think we need to tackle the issue of heroic end of life care.

I don't see anyone willing to address that issue.

$120,000/yr is a decent salary for an honorable profession; especially if the cost of medical school gets subsidized.

If the motivation is to make money, then one should go into Big Pharma or insurance companies...

...oh wait...fuck it.

JMO:
0.075*0.075=0.0056
for me, it reads %0.56 of the GNP, not 0.0056

Not peanuts. But the problem is not only the profit. It is also the cost of getting that profit: sales people, ads, claims managers, CEO...

You know, some really math-savvy people have estimated it, and from very shaky memory it is close to 20% of private health care costs.

I am sure that if you google it, you can find the right number.

The American health care system is an awfully stupid one, but the real problems are largely not the ones Moore chose to focus upon. The problem is less a tightwad system not spending enough on dying people than the enormous amount of paperwork, stress, waste, and dysfunctional economic incentives built into the system.

"If the motivation is to make money, then one should go into Big Pharma or insurance companies..."

The average American physician makes a lot more than the average American scientist in Big Pharma or the average professional at a health insurance company.

There is big money potential (and big risk) in little pharma though. However, if you raise the capital gains tax high enough, and enact price controls on drugs, you can probably discourage some folks from trying to discover new drugs.

Singaporedoubter - sorry about the decimal.

In order to convince me you would have to let me know why this wouldn't work for the auto industry.

Let us say that instead of Ford, GM, Honda, Toyota we just had one gov't car company. With all the money they saved on CEOs, sales people, advertising, and developing competing models - that gov't car company should be able to sell much better cars for much less money.

Does anyone think that would be true in real life. If you don't why would healthcare be any different.

Insurance companies are the only health care constituencies holding down health-care costs in this country. Who else is going to do it? The government has completely abdicated this responsibility with Medicare and Medicaid. What will prevent health care spending from becoming 50 or 60 or 80% of our GDP?

"Because of course no Americans would ever choose to get a doctorate in a field if they were only going to earn $120,000, right? The existence of professors kinds of cuts against this logic."

Oh, you'll still get some Americans interested in becoming physicians. But the most talented and ambitious Americans will channel their ambitions elsewhere.

The economics of health care are quite a lot different than the economics of consumer durables. I'll leave that for the reader to figure out.

Along the lines of Matt's comment on Moore's observation that corporations have a legal obligation to deny coverage, I'd definitely recommend checking out my old corporate law prof at Boston College, Kent Greenfield's book on the inherent contradiction.

http://www.amazon.com/Failure-Corporate-Law-Fundamental-Possibilities/dp/0226306933 .

Also, aside from being too timid, Matt is right on. After seeing the movie, my conservative med student fiancee had to agree that medical care is a market where it is simply immoral to profit.

Insurance companies are largely in the business of devising excuses to avoid helping you when you're in need. They employ people wake up every morning, drive to the office, and work all day denying sick people health care. The labors of these individuals line the pockets of the companies' executives.

Well, a bit, but they also drive down costs,given that the market's competitive.

Well, a bit, but they also drive down costs,given that the market's competitive.

Well, I don't know if they "drive" down costs in the sense of offering a better product at lower rates, but they certainly "hold" down costs, in the sense of restraining spending that would otherwise be made, because they have the contractual authority to do so.

To address Harry's nonsense: First, while many docs to go to medical school to make good money, most understand that there is a ceiling, and that if they wished to become extremely wealthy, they should go into business or law. Instead, there is a value that most medical students place on helping people. The economic calculation is not a matter of mere (hundreds of thousands of)dollars and cents.

This is borne out by the fact that the number of open slots in American medical schools is severely restricted, just how the AMA likes it. Every year thousands of the very intelligent and well qualified American students are turned away, or forced to attend medical school in other countries. Even if a few docs motivated primarily by money left the profession, there is a deep talent pool to replace their numbers.

If the average doctor's salary placed them comfortably in the upper middle class rather than among the wealthiest, there would still be plenty of American docs. Despite what you heard from Neil Cavuto. http://www.talkingpointsmemo.com/archives/015023.php

That's not an argument that'll win you high grades in a public policy class or get you made a fellow at a think tank. It's demagogic and anti-intellectual. But it's effective and not, I think, entirely wrong

Then one might also argue that in publicly-funded health care systems, stone-hearted government bureaucrats work all day at devising ways to deny and delay health care to people in order to keep spending within budget.

One might indeed, if one were very foolish.

"Minimizing health payments, subject to the risk of litigation" and "Spending to achieve the best health outcomes, given a fixed global budget" are not the same.

No, of course those things are not the same, but "not the same" does not mean "foolish." Either way, someone is being denied health care that could benefit them, and perhaps even save their life.

One of the ironies of the American health care funding system is that our custom of getting health insurance through employers goes back to General Motors' decision during WWII to get around government price controls on labor by offering health insurance as a free fringe benefit to attract more workers. In other words, it was an act of corporate generosity by the supposed evil corporation lampooned in Moore's first movie, "Roger and Me," to get around government-mandated stinginess.

Unfortunately, it turned out to be a sub-optimal way to finance health care, but we've been stuck with it ever since.

Not that you'll learn that from "Sicko"!

"while many docs to go to medical school to make good money, most understand that there is a ceiling, and that if they wished to become extremely wealthy, they should go into business or law."

Interesting that we have this thread on the same day as the opportunity ("Head Start") one. Physicians average higher incomes than business or law school graduates. And you don't need to go to Harvard or another elite medical school to have a path to the upper middle class as a physician. Anyone who graduates from an accredited American Medical school is virtually guaranteed a healthy six-figure income. This is hardly true for graduates of accredited but non-elite law and business schools.

Medicine (and affiliated professions) remain a meritocratic pathway to middle- and upper middle-class lifestyles for many Americans who weren't lucky enough to go to fancy prep schools or Ivy League colleges. Aren't lefties always preaching about education as the pathway to success? If you nationalize health care, flood the country with foreign HB-1 engineers, hike capital gains to discourage business investment -- what pathways are you leaving to those who want to try to advance themselves?

Easy to pick on insurance companies-- nobody likes them. Medical costs make up 80-85% of the costs of heath care, and the rise in premiums reflects the rising costs. Want to attack profits? Look to the providers. Want to blame someone for the incresing costs? Look to the self indulgent who create the need for services by overeating and failing to take care of their own health. People like Moore.

There should be a system that covers the types of diseases or accidents that are not the result of personal choice. There should also be some reflection of increased contribution by the fat asses who caused their own problems.

The ONLY way to reduce costs is to ration care, by type or by frequency of use, or by the amount of time a doctor will spend with you. A government solution will ration care. The consumer model also rations care by forcing consumers to take some responsibility for the costs and frequency of use. Take your pick what you want-- lower costs and rationing, or ever increasing costs with shuffling the costs onto everyone else in your risk pool.

And the fringes of life will have to be examined. Neonatal ICU care and end-of-life care eat up enormous dollars. In a government plan, who decides when to make the effort?

Posted by Phaedrus | July 6, 2007 3:23 PM :"Funny thing about the Internet. It's got these "search engines" where we can look up "facts" and "data" and use those things to resolve competing claims and such."

Alas Phaedrus, if only it was that simple. Where are the facts and data in your post?

Posted by Phaedrus | July 6, 2007 3:23 PM:"Per capita health care spending:
UK - $1,675
US - $4,271"

I'll go with those. But:

Posted by Phaedrus | July 6, 2007 3:23 PM:"WHO health care rankings:
UK - 18th
US - 37th

Posted by Phaedrus | July 6, 2007 3:23 PM:"So, they are ranked quite a bit higher than us, and spend only 40% as much money. Oh dear God, please save us from this socialist nightmare."

Yes but is that a fact or a piece of data or an opinion? The problem is that anyone can set up a system of rankings that suits their ideological bias. In the case of the WHO and the UN that is inevitably a Big Government Statist bias. What is their methodology?

From their site:

"In designing the framework for health system performance, WHO broke new methodological ground, employing a technique not previously used for health systems. It compares each country’s system to what the experts estimate to be the upper limit of what can be done with the level of resources available in that country. It also measures what each country’s system has accomplished in comparison with those of other countries."

Oh brilliant! They are not looking at what the US does but what this bunch of pin heads thinks it could be doing. So they set up individual targets for every country - what *they* think is a good health care system and then they judge success and failure. In other words it is a comparison NOT with other countries but with a fantasy of their own creation.

This, needless to say, is not only gross dishonest but also useless for any comparative basis.

They also say:

"WHO’s assessment system was based on five indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system’s financial burden within the population (who pays the costs)."

Notice how several of these factors have nothing whatsoever to do with health care and are in fact politically based. What does it matter if there are any health inequalities? Only to an ideologue is it more important that everyone gets the same rather than everyone gets good enough health care even if that means some get excellent health care. America leads the world in patient satisfaction. I also don't think that is important but notice they balance it with "responsiveness" which is an interesting concept needing expansion. Yet another measure of inequality. And finally yet another measure of, I assume, the lack of the sort of inequality they like (I'd guess what they want is a system that provides everyone with equal health care but that the rich disproportionately pay for). As you can see the only factor here linked to genuine health care concerns is patient satisfaction which is a poor measure of the excellence of a health care system.

Your post was not exactly full of facts and data was it? Rather it was full of WHO hiding socialist propaganda by deliberately lying. Which is not something I accuse the WHO of lightly.

MI:"The crux of the matter is that ordinary people think that if there's a sick person, and you're in a position to help the sick person, that you ought to help the sick person."

With all due respect I am not convinced that is true. We are all in a position to help people dying of AIDS and TB in Africa. We could follow Peter Singer's recommendation (but not his practise I notice) and donate all our income above the absolute minimum we need to survive in order to alleviate their suffering. I assume none of us are going to do so any time soon. We are all in a position to help the poor and suffering in the world. I did not do so today. I will not do so tomorrow. I have more important calls on my time and money that starts a little closer to home. No doubt this will generate the usual howls of out rage but it is simply true - we are all in the same position and the plight of the poor in the Third World will not keep many of us awake tonight. A genuine discussion of health care would not begin with banal statement of moral certainties which sound good but are simply not true. We all instinctively recognize that not all sick people have unlimited calls on our resources. Of course we all deal with that in different ways. I expect most people here do so by claiming to work hard to make even richer people pay more or even everything to help the poor in Africa. In other words they shift the moral burden to someone else. But I could be wrong.

Jmo's calculations would be accurate only if profits were the only reason private insurers cost more. They have much higher overhead, because it takes more work figuring out if they actually want to pay or not. In addition, the doctors' profits are reduced by the need to have a staff on hand dealing with all the insurance companies's demands. So, Jmo's calculations are misleadingly incomplete.

High marks in that public policy class

Most of the professors who taught in my MPH program had expertise in an actual science, such as epidemiology. But the guy they had teaching us about this made-up ideology called "managed care", that then dominated what thinking there was at the time on the public policy of health care financing, was a clear stand-out from this crowd of actual academics. He was basically just a shill for the managed care industry.

Most of the money we pay for health care in this country right now gets funneled through a health insurance industry that has no reason to exist, that performs no useful function, not productive, not distributive (it just distorts both the production and distribution of health care services), an industry that exacts a 20% surcharge for performing this non-service. Expertise in American health care financing is essentially expertise in this tangled, and totally unnecessary, web. So, yes, of course you won't get high marks from most experts for pointing out that the subject of their field of expertise should simply be abolished. The theologians still haven't foregiven us for heliocentrism and Evolution, and the astrologers still have their knives out for astronomy. We need to make the public policy experts on health care financing in America as obsolete as experts in heraldry, and for roughly the same reasons.

Most of the money we pay for health care in this country right now gets funneled through a health insurance industry that has no reason to exist, that performs no useful function, not productive, not distributive (it just distorts both the production and distribution of health care services), an industry that exacts a 20% surcharge for performing this non-service.

Okay, then let's just get rid of private health insurers. Since they perform no service, they won't be missed. Everyone can just pay for whatever health care services they want out-of-pocket.

Er, wait....

Posted by Glen Tomkins | July 6, 2007 5:48 PM:"Most of the money we pay for health care in this country right now gets funneled through a health insurance industry that has no reason to exist, that performs no useful function, not productive, not distributive (it just distorts both the production and distribution of health care services), an industry that exacts a 20% surcharge for performing this non-service. Expertise in American health care financing is essentially expertise in this tangled, and totally unnecessary, web. So, yes, of course you won't get high marks from most experts for pointing out that the subject of their field of expertise should simply be abolished. The theologians still haven't foregiven us for heliocentrism and Evolution, and the astrologers still have their knives out for astronomy. We need to make the public policy experts on health care financing in America as obsolete as experts in heraldry, and for roughly the same reasons."

I'll agree that the management of America's health care is uniquely incompetent if not corrupt. BUT it is not true that health care management could be abolished. Someone has to decide what to fund. Insurance companies try to cap costs with HMOs. Governments do more or less the same thing except the public has no choice in the matter, the decisions are not public and no one has a clue what is going on. Britain for instance has the National Institute for Health and Clinical Excellence or NICE. It decides if an operation is cost effective. If it is, you can have it. If it isn't you can't. The result is that people have no idea what treatments are available or not. They have no appeal. They have no choice. They are usually not even informed. If the government wants to give them that treatment that can have it. If not, they can't. Essentially the British government is one large compulsory secretive HMO. Oddly enough discussions like this prove that ignorance is bliss - what people don't know they are not getting, does not upset them.

The NHS by the way, employs more people than anyone else except the Chinese Army, the Indian railways, Walmart and the US Department of Defense. About 1.5 million people - out of a total of 60 million or so.

Oh No, HeiGou and Mixner, you aren't thinking far enough ahead. Eliminate all health insurance and things would be just fine. It would take some time, but pretty soon all things unnecessary would disappear under the free market principles that would govern the "market." A few hospitals would cater to the wealthy and the rest would set prices to the market. Doctors would get by without billing staff and everything would even out. Then mutual assurancce societies would start and well, some people would be cared for and some would not. Until there was some sort of public health emergency, no one would care if we got sicker on average. Its a perfectly acceptable public policy and I guess compared to that, our "system" looks pretty good.

But although our "system" is better than the one that doesn't exist, it is worse than every other system which we would reasonably want to compare ourselves.

But although our "system" is better than the one that doesn't exist, it is worse than every other system which we would reasonably want to compare ourselves.

No it isn't.

Britain for instance has the National Institute for Health and Clinical Excellence or NICE. It decides if an operation is cost effective. If it is, you can have it. If it isn't you can't. The result is that people have no idea what treatments are available or not. They have no appeal. They have no choice. They are usually not even informed. If the government wants to give them that treatment that can have it. If not, they can't. Essentially the British government is one large compulsory secretive HMO.

As one might expect from Mr "Autocracies were always richer than democracies", none of this is true. Oh,hang on,the first sentence is true. Everything else is bullshit. I'm not saying HeiGou is a liar, but it is bullshit.

http://www.nice.org.uk/

I'm not sure who has the final decision, but NICE certainly plays a leading role in deciding which drugs and other treatments the NHS will provide, and which are denied to British people because they are deemed to be too expensive.

Mixner,

Of course we would have a single payer, a Medicare for All system, that would take over from private insurance in paying for medical services. But its overhead would be closer to Medicare's 2-3% than private industry's 20%. And that doesn't even take into account the savings to the providers of health care of not having to untangle the web of the competing and conflicting requirements of the private insurers.

HeiGou,

The standard of care defines what care patients should receive. And that standard of care, presently and under any single payer system I would support, is defined almost entirely by non-governmental entities. These are many and varied, ranging from simply the empirical standard that most practitioners of a given specialty employ, augmented by explicit standards set by their professional organizations, and some input from state licensing authorities and NGOs like the JCAHO.

Nothing about a single payer system requires that the single payer practice any form of that misguided, largely discredited, ideology of "managed care", whereby the payer tries to maximize his profits by minimizing what he has to pay. The single payer's sole function should be to pay the bills, for whatever the standard of care says the patient needs.

Posted by Alan de Bristol | July 6, 2007 6:38 PM:"As one might expect from Mr "Autocracies were always richer than democracies", none of this is true."

Well you might expect it. However most sensible people know pretty much everything I say is true. As was my original comment you allude to. As is this.

Posted by Alan de Bristol | July 6, 2007 6:38 PM:"Oh,hang on,the first sentence is true. Everything else is bullshit. I'm not saying HeiGou is a liar, but it is bullshit."

Would you be so kind as to point out precisely where and what I said was bullshit? You mean that NICE does not decide if the NHS will provide a medical service or not? That they are not in the business of making the same sort of decisions than a HMO would make? Please explain. I am sure that we would all love to hear exactly why you think my comments, and not yours, are bullshit.

Posted by Alan de Bristol | July 6, 2007 6:38 PM:"Everything else is bullshit. I'm not saying HeiGou is a liar, but it is bullshit."

Because I am mildly annoyed enough to actually spend time on this, let's look at the site you mention:

http://www.nice.org.uk/

What does NICE do?

Who we are

The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
Read more about who we are.
What we do

NICE produces guidance in three areas of health:

* public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
* health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
* clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.


About technology appraisals

Technology appraisals are recommendations on the use of new and existing medicines and treatments within the NHS, such as:

* medicines
* medical devices (for example, hearing aids or inhalers)
* diagnostic techniques (tests used to identify diseases)
* surgical procedures (such as repairing hernias)
* health promotion activities (for example, ways of helping people with diabetes manage their condition).

We base our recommendations on a review of clinical and economic evidence.

* Clinical evidence measures how well the medicine or treatment works.
* Economic evidence measures how well the medicine or treatment works in relation to how much it costs the NHS - does it represent value for money?

Aim of technology appraisals

NICE is asked to look at particular drugs and devices when the availability of the drug or device varies across the country. This may be because of different local prescribing or funding policies, or because there is confusion or uncertainty over its value. Our advice ends the uncertainty and helps to standardise access to healthcare across the country.

The NHS is legally obliged to fund and resource medicines and treatments recommended by NICE's technology appraisals.

As I said, the NHS is just one big State run compulsory HMO. Which decides what sorts of procedures can be done. Or not.

Of course we would have a single payer, a Medicare for All system, that would take over from private insurance in paying for medical services.

So then your claim that private health insurers do not provide a service was false, wasn't it?

I've seen no serious case that a government-provided single-payer service would be superior.

But its overhead would be closer to Medicare's 2-3% than private industry's 20%.

High administrative costs are an inevitable consequence of the oversight necessary to distinguish valid claims from invalid ones. A government service with low overhead would be unable to make those distinctions and the costs would just be transferred to some other part of the system.

Posted by Glen Tomkins | July 6, 2007 6:52 PM:"Nothing about a single payer system requires that the single payer practice any form of that misguided, largely discredited, ideology of "managed care", whereby the payer tries to maximize his profits by minimizing what he has to pay. The single payer's sole function should be to pay the bills, for whatever the standard of care says the patient needs."

Everything has to be rationed. Even medical care. There is no amount of money that could not be spent on medical care that would not produce a better health outcome. Everyone involved usually wants the doctors to do as much as possible - regardless of the cost - even if the improvement is marginal. Every single medical payments system needs someone to cap spending. It needs someone to decide what procedures will or will not be funded. Every single one. Even a single payer. They may not be interested in maximizing profits, but they will still have to manage their budgets so that they do not over spend. The NHS is terrible at this and all the reforms of the past few years have tended to revolve around making the PHTs do this. The single payer has a budget. The job is to make sure that they do not spend more than that budget, that it is spent as wisely as possible, and perhaps there is a lobbying job to make sure the government gives them ever more money. No single payer system can simply pay out every single bill. Britain has NICE - who decided, in the interests in cost effectiveness, only to perform sight-saving procedures on one eye of the afflicted people because two eyes could not be justified on economic grounds - to decide what should or should not be funded. If I could be bothered looking into Canada's system I'd find a similar Qango I'd bet. Cuba likewise.

OK.

Nice is not a government agency. So your idea about it actually mandating or forbidding treatments is completely inaccurate.

A really, really cursory search on the internet would reveal that more criticism is levelled at NICE for being more permissive of the range of drug treatments it advises than similar bodies in other countries.

As is absolutely crystal clear from their literature and all literature from other sources in discussion of its role, it has a significant advisory role but has no role in mandating the actual range of treatments Health Authorities provides, and therefore has absolutely no role in decisions related to provision of healthcare in individual cases.

So, as I said, apart from the first sentence, everything you said was worthlessly inaccurate, made up on the spot to compensate for your actual lack of knowledge or intellectual honesty. I don't think you actually know what the truth is or care, you just make statements conforming to your own prejudices to try and bolster your lack of the aforesaid faculties.

This, I believe, conforms to the classic Frankfurtian definition of bullshit.

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"Nice is not a government agency. So your idea about it actually mandating or forbidding treatments is completely inaccurate."

Right there you have lost whatever residual respect I had for your integrity. First of all I never claimed NICE was. At least I have no clear recollection of doing so. Feel free to quote me.

Second, NICE is a government agency. Specifically it is a Special Health Authority of the NHS. You know, the National Health Service. You may have heard of it. It is an arm's length government agency but it is a government agency nonetheless.

Third, your second statement simply does not follow from your first. Ignoring the fact that it is utterly inaccurate and as I quoted earlier:

"The NHS is legally obliged to fund and resource medicines and treatments recommended by NICE's technology appraisals."

From, I should not have to point out, NICE's own website which you kindly provided a link to. Would you please be so kind as to explain to me why the website that you provided, NICE's own official website, seems to be under the impression that, yes indeed, the NHS is legally obliged to find and resource anything NICE recommends?

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"A really, really cursory search on the internet would reveal that more criticism is levelled at NICE for being more permissive of the range of drug treatments it advises than similar bodies in other countries."

I am sure the relevance will hit me soon, but in the meantime would you please point out what this has to do with anything I have said?

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"As is absolutely crystal clear from their literature and all literature from other sources in discussion of its role, it has a significant advisory role but has no role in mandating the actual range of treatments Health Authorities provides, and therefore has absolutely no role in decisions related to provision of healthcare in individual cases."

Isn't it interesting they are under a completely different illusion. Perhaps you would be so kind as to ring Sir Michael Rawlins up and tell him that he is working under the delusion that he has the statutory power to mandate a whole range of treatments to the NHS, as the NICE website claims, but that luckily you are here to put him right? Ta, thanks old bean.

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"So, as I said, apart from the first sentence, everything you said was worthlessly inaccurate, made up on the spot to compensate for your actual lack of knowledge or intellectual honesty."

Given that not a single word I have ever said has been worthless, except in the usual pearls before swine sense, and that you have not a single clue about what you are talking about, I am not going to take that personally. You are not only incapable of reading what I said and quoting it accurately and honestly, you are unable to read your own sources, you are utterly ignorant of the NHS, you do not have a clue what a qango is, and you are generally wasting my time. If I thought for a second that anyone would be so delusional as to believe a word you write, I'd be mildly upset about those comments. But you reassured me on that point.

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"I don't think you actually know what the truth is or care, you just make statements conforming to your own prejudices to try and bolster your lack of the aforesaid faculties.

Posted by Alan de Bristol | July 6, 2007 7:12 PM:"This, I believe, conforms to the classic Frankfurtian definition of bullshit."

Really? Here's a more reasonable explanation: projection. The seeking of our own faults in others. You are vaguely familiar with the concept from an objective theoretical perspective? As opposed, of course, to the lived reality.

"Doctors would get by without billing staff and everything would even out."

Actually, some physicians do work this way. The WSJ published an article about this "pay at time of service" medicine. One primary care physician they profiled took no insurance -- not even Medicare or Medicaid -- so he needed no billing or administrative staff. He also stocked his own commonly prescribed meds, which he sold to patients at about cost, IIRC. The cost for a typical visit: about $30.

Before replacing the entire U.S. health care system, it might be worth exploring ideas like this.

Of course, PATOS wouldn't work for catastrophic illnesses, but it appears to lower costs for routine care. Combining PATOS clinics with high-deductible, low-cost health insurance for catastrophic illnesses might be worth examining.

HeiGou,

To avoid confusing the issue for an American audience, single payer, or National Health Inmsurance, does not mean that we would have a National Health Service (NHS) in this country. Nor would we need to have something like NICE to centralize defining the standard of care for services that the single payer would be obligated to pay.

That said, even in systems, such as the UK's, that do have an entity like NICE to define what services the single payer has to shell out for, do you have any evidence that the standard gets defined in ways that deny people care that they need? Oregon's Medicare system got a lot of publicity years ago when they instituted a system whereby a panel of medicos and politicians would, working with whatever budget the state legislature alotted that year, rank the medical services the system might be called on to pay for, and draw a red line where the money gave out, and below which the services that ranked too low would not be funded. What never got any publicity, however, was that they never red-lined any medical service that had been proven to work. One year they red-lined liver transplantation for some indications for which it had been tested, but proven not to work. Such tyranny!

The difference between an HMO's denial of payment for medical services, and the denial of even an entity such as NICE, would be that the HMO has an economic interest, and a fiduciary duty to its shareholders, to at least try to deny payment no matter what the benefit of the proposed medical service. Even a system that centralized the determination of the standard of care with something like NICE, which, again, is not being proposed for the US single payer system, as long as the centralized body entrusted with this definition was not run by or for profit that would be made by denying care, can be trusted to not shade its decisions to systematically deny care.

The standard of medical care, like the standards of any field of expertise, cannot be fully transparent to a lay person, precisely because they involve specialized knowledge and expertise. But we can leave the determination of this standard to experts who, unlike an HMO, have no interest in minimizing and denying services. The experts who define this standard in our current system, and there is no reason for us to change that aspect of medicine even as we radically change how medical services are paid for, are, in addition to not having an interest in denying care, not even centralized in some sort of NICE. This is as much transparency as a lay person needs in knowing whether or not they can trust the standard of care, that there should be, transparently, no economic interest to deny care in the people who are entrusted with defining that standard. HMOs flunk that test. Don't tar NICE, and certainly not the de-centralized system we have for defining the standard, with the brush of the deservedly hated HMOs.

The NHS is legally obliged to fund and resource medicines and treatments recommended by NICE's technology appraisals.

This doesn't mean that this restricts treatment. This means if they advise that a particular drug treatment can be effective, it has to be provided.

From the BMJ

"Since decisions by NICE are made without consideration of a budgetary constraint but its guidance is mandatory for purchasers,do favourable decisions write open cheques for the NHS to honour?"

So, according to the BMJ, it's a given that NICE recommendations are made without budgetary constraints, but according to you in your original
post, it decides on the basis of cost-effectiveness...I'll go with the BMJ on this one,and so I have to think your original point was bullshit.

The BMJ piece also compares NICE to other apparently less permissive agencies.

The point is, the mechanism by which an independent agency comprised of academic medical establishments and societies assesses and then recommends drug treatments (without budgetary constraints, according to the BMJ) for use by the NHS means the government which is legally bound to provide these treatments, irrespective of cost, becomes in your fetid imagination, the Govt acting like an HMO.

Sorry, still looks like complete bullshit.

here's the BMJ link.

bmj.bmjjournals.com/cgi/reprint/327/7423/1061.pdf

That said, even in systems, such as the UK's, that do have an entity like NICE to define what services the single payer has to shell out for, do you have any evidence that the standard gets defined in ways that deny people care that they need?

Almost a million Britons are waiting for admission to NHS hospitals.

Only about 40% of British cancer patients ever get to see an oncologist.

Delays in the treatment of colon cancer under the NHS are so long that about 20% of cases considered curable at the time of diagnosis are incurable by the time of treatment.

Or consider the plight of the poor fellow described in this article from The Observer. After waiting seven months for a referral from his GP, he was diagnosed with prostate cancer. He then had to wait an additional eight weeks for a body scan to see if the disease had spread to his bones before he was allowed to see a specialist. He was told that "the NHS scanning machine was reserved for private patients for a certain period each day and was often unused." He ended paying 180 pounds (about $360) out of his own pocket so he could jump the queue and get his scan within three days.

Ah, the wonders of efficient, humane, egalitarian socialized medicine!

Britain has NICE - who decided, in the interests in cost effectiveness, only to perform sight-saving procedures on one eye of the afflicted people because two eyes could not be justified on economic grounds - to decide what should or should not be funded. If I could be bothered looking into Canada's system I'd find a similar Qango I'd bet. Cuba likewise.

I'd really like you to cite evidence for that. And, in Britain, it's a QUANGO.

HeiGou,

"Everything has to be rationed. Even medical care. There is no amount of money that could not be spent on medical care that would not produce a better health outcome. Everyone involved usually wants the doctors to do as much as possible - regardless of the cost - even if the improvement is marginal. Every single medical payments system needs someone to cap spending."

Spending more on medical care is absolutely and fundamentally not a way to maximize its benefits. We limit treatments to licensed medical providers if and only if they are inherently harmful. You can go buy and dose yourself with as much acetominophen as you care, because it is almost impossible to get into trouble with it unless you intend yourself harm. But you aren't allowed to decide for yourself whether or not you or yours gets brain surgery, or to perform such, because it is almost impossible not to do great harm mucking around in the brain. Only the very rare indications of much greater harm if you don't get brain surgery, could possibly justify anyone mucking around your brain with a scalpel.

Medical services self-ration. You don't want any more, not an iota more, of medical services than you absolutely need. Had your screening colonoscopy yet? Want another? Want twelve more before Labor Day? Want a liver transplant? I'll give it to you for free. What, you say you don't need a liver transplant!? But they're so costly, they must be valuable! There's even a better than 50% chance you'ld survive.

The underlying fallacy of the late unlamented managed care movement, was the idea that there is any sort of moral hazard in third party payment for medical services. I worked for twenty years in military medicine, a completely "socialized" system. I never faced any sort of cost constraints from higher headquarters. And my patients had an inalienable right to seek medical attention, practically 24/7, absolutely cost-free, no co-pays, etc. This resulted in a system whose costs, and utilization by patients, are practically identical to free-market US health care systems that have all sorts of money incentives on all the players. The use of medical services is simply not monetary cost-driven, because the non-monetary costs so greatly exceed the monetary ones.

The British tend to be more deferential to authority, so when their NHS doctors tell them nothing can be done, they tend to die quietly. Americans are ornerier, and believe in throwing money at problems, such as death. I doubt if this would change under a different financing mechanism.

The British tend to be more deferential to authority

Given the perspective of the last 6 years in this country, as a Brit, I have to give that a really hollow laugh.

Re: The government has completely abdicated this responsibility with Medicare and Medicaid.

What are you talking abiut? Medicare and Medicaid are far stingier with their reimbursements than any private insurer.

Re: High administrative costs are an inevitable consequence of the oversight necessary to distinguish valid claims from invalid ones.

Then how does Medicare manage with such low overhead? And by the way. A lot of that can be done by software nowdays. Ever hear of a claims edit system? I wrote one a few years ago. Weeds out bogus charges at a fairly good clip. You still need a live human at the end to look over the result, but you don't need a whole army of them.

JonF,

Then how does Medicare manage with such low overhead?

By failing to seriously restrain spending. That's why there's so much waste, fraud and abuse in Medicare. That's why we spend a huge proportion of our health care resources on enormously expensive end-of-life care that produces little benefit at great cost. That's why Medicare is headed for bankruptcy in little more than a decade.

Seriously, did anybody not find "Sicko" an insult to their intelligence? Yglesias seems to view it as useful prolefeed to get the yahoos worked up to vote the way he wants them to. But, considering all the great material on our dysfunctional health care finance system that Moore had to work with, he still ended up mostly drawing attention to himself and how he was trying to yank our chains.

Re: By failing to seriously restrain spending.

Except that is not true: Medicare reimbursements rates are lower than those of most private insurers.

And yes, Medicare does deny claims too, if the i's are not dotted and the t's are not crossed. Medicare does not simply cut a check for every bill that comes in.
Here's a particularly egregious example: Back in 1989 my father (slowly dying of emphysema) was prescribed oxygen 24/7. Medicare ended up denying months worth of claims for this oxygen, since my father's doctor had not turned in the right paperwork. (Due to the way the system is set up, the medical equipment company had to eat those denied dlaims and could bill my father for them)
Not good enough? Here's another. A doctor in the town where I grew up went to jail for defrauding Medicare with totally bogus claims.
Finally, you may wish to consider the fact that there's a break-even point in this matter of administrative costs, and that many private insurers are well past it: they spend so much trying to deny claims that it actually costs them (and all of us) more than if they throttled back on this and focused fraud prevention more on major abuses. After all, public systems both here and abroad have lower administrative costs and (!) lower per capita costs, which suggests that massive fraud can be prevented without massive expenditures.

JonF,

Gee, two uncorroborated anecdotes. There's a persuasive argument.

Medicare's lack of spending restraint isn't simply a matter of the amount of "reimbursement" for specific kinds of health care intervention, it's the lack of restraint on the number and circumstances of interventions. That's why Medicare will spend tens or hundreds of thousands of dollars to extend the life of a sick, elderly person by a few months. And it follows from Medicare's lack of serious cost-benefit oversight.

"Medical services self-ration. You don't want any more, not an iota more, of medical services than you absolutely need."

This is about as ignorant a statement as I've ever heard re: health care. If this was true then we should institute a universal health care plan without any budget or cost constraints whatsoever, since the costs are self-rationing and we should provide all medical care free of cost to all citizens.

I was going to write a post addressing the Mixners and Guang-jous on this thread, and all their scary, scary claims about national health. But you know what? These guys are history, especially when SICKO rolls out nationwide (and moviegoers get a real look at national health systems elsewhere). None of the objections they've raised (the substantive ones, leave aside the bright-shiny-object ones) can't be handled in a rational single-payer system. Dealing with these guys issue by issue in threads like this is a waste of time and energy. Better to put the energy working for single-payer universal coverage.

"That's why Medicare will spend tens or hundreds of thousands of dollars to extend the life of a sick, elderly person by a few months."

Mixner, I agree with some of your points up-thread, but not this one. The Raison d'être of Medicare is to treat sick, elderly people. Extending a patients life by "a few months" is a non-trivial amount of time -- especially if you are an elderly patient, or the spouse or child of one. Considering how powerful older Americans are politically, I doubt you are going to see major limits on their care.

DougR,

"Better to put the energy working for single-payer universal coverage."

Knock yourself out, but I think you will find that the vast majority of Americans who have health insurance are going to be wary of giving it up for your year zero plan. Nationalized health care is for lefties what privatized Social Security is for righties: something that seems so logical to you if only the stupid yahoos were willing to give up what they have now. Plus, you are messing with the AMA, which has the deep pockets to hit back, hard. Expect plenty of thirty-second spots about people in Britain dying of cancer before they get through the waiting list.

Also, the power of Michael Moore's movies was tested in '04. His movies' chief power is to make him rich, not to help Dems win elections.

Re: Medicare's lack of spending restraint isn't simply a matter of the amount of "reimbursement" for specific kinds of health care intervention, it's the lack of restraint on the number and circumstances of interventions.

Huh? I honestly can't make a head or a tail out of the above. Are you just spewing learned-sounding words to continue a debate or do you have a substantive point to make actually supported by logic or empirical evidence?
Let's try this from another angle: what are Medicare's pay-outs per capita (that is per covered patient) vs the pay-outs per capita for any reasonably large-sized health plan (Kaiser, the Blues, Aetna etc.). Bearing in mind of course that Medicare covers the population most likely to have high healthcare costs: the elderly and the disabled.
Or try this: Medicare is funded by a payroll tax which amounts to less than 4% of national wage/salary income. Health expenditures overall are running at 15% (ballpark figure) of GDP. Now, yes, Medicare is suffering a serious deficit. So: thought experiment: raise the payroll tax to a level where the deficit closes. Is it over %15 of GDP (or whatever the the exact figure is if you want to be fussy)? If the answer is No, then your point is falsified and Meduicare is cheaper per capita than the healthcare system as a whole.
I await your reply.

Re: That's why Medicare will spend tens or hundreds of thousands of dollars to extend the life of a sick, elderly person by a few months

I am seriously skeptical about this claim. It is supposedly true that in the last six month large amounts of money are spent on a dying person. That does not mean necessarily that their life is actually prolonged. They might well live out those six months regardless-- but in states of hideous pain and degradation. If that's the case, if the money we spend at the end of life allows a minimal level of comfort and dignity to the dying, then isn't that money well spent?
Prove to me that the money is being spent "futilely" and with no ethical purpose. Otheriwse your resentment of these expenditures should earn you a visit from three ghosts next Christmas, and (if you persist) a spot in a certain nether realm where the incurably greedy and uncharitable are said to dwell.

Re: This is about as ignorant a statement as I've ever heard re: health care.

Actually it is spot on true, and unless you are a hypochrondiac, you can find the easy proof in your own life. Do you run to the doctor absent serious need? Would even if you didn't have to pay a penny? I have gold-plated corporate benefits. I have not visited a dictor since February despite the fact that I have suffered A) a chest cold B) a badly bruised knee C) chronic lower back pain.
Ordinary people are more likely to put off medical care when they shouldn't than to seek medical care when they don't need it. If that is not immediately obvious from real life then I have to wonder if you 9and your freidns and family) are either psychologically disturbed or else members of an alien species.

DougR-- These nit picking dead end supporters of american healthcare are history. You know who is happy with their healthcare? People over 65 and they are a group that is growing larger not smaller. You know who is unhappy? People under 65 without employer-based coverage. The most that can be said against CMS is that it is underfunded. If the healthy part of the population was part of the CMS system, the cost per recipient would go down, not up. If employer-based insurance expanded its coverage, the cost per recipient would go up, not down. Yes, most healthcare systems are rationed and we wish they weren't. Yes, someone is going to tell us what and when and how we will be treated in close cases. But if public health is part of what we view is important about our society, something has got to give. Michael Moore packs 'em in because he articulates what most Americans sense: that our system is expensive and inefficient. We can do better.

"These nit picking dead end supporters of american healthcare are history. You know who is happy with their healthcare? People over 65 and they are a group that is growing larger not smaller. You know who is unhappy? People under 65 without employer-based coverage."

Peter, help me with your logic here. You say people over 65 (those with access to Medicare) are happy with their health care. So why would they want to risk it by switching to a new system? Then you say people under 65 without employer-based coverage are unhappy. OK, but that represents what -- 15% of Americans? If the other 85% (who have employer-based coverage) are happy with their health care, why would they want to switch to a new system? Wouldn't they (and the seniors) be wary that the new system may be worse for them than the current system they like?

It's heartening how quickly lefties can go from abject despair (2004) to over confidence.

Posted by Glen Tomkins | July 6, 2007 7:39 PM :"To avoid confusing the issue for an American audience, single payer, or National Health Inmsurance, does not mean that we would have a National Health Service (NHS) in this country. Nor would we need to have something like NICE to centralize defining the standard of care for services that the single payer would be obligated to pay."

Well it would not rule out something like the NHS. I don't see this as a model anyone would want to adopt, but the models being pushed here are Cuba's and one that would abolish all private health insurance. Both of those are more radical than the NHS. The problem is that although the system does not work so well in America, the alternatives are vague. Everyone has *a* model that they might support even if no one model would gain majority approval.

I don't see how something like NICE can be avoided. You can do it on a state by state basis similar to, I assume, how Canada does. But someone or some body has to decide if it is worth doing both eyes. If not NICE, who?

Posted by Glen Tomkins | July 6, 2007 7:39 PM:"do you have any evidence that the standard gets defined in ways that deny people care that they need?"

Define need. I think that abuse is vastly more likely in a single State provider system. But that does not mean it will occur at once. There have been problems in the UK over things like Herceptin. A lot of women felt they needed it and they sued to get it.

http://www.guardian.co.uk/science/story/0,,1742168,00.html

Posted by Glen Tomkins | July 6, 2007 7:39 PM:"What never got any publicity, however, was that they never red-lined any medical service that had been proven to work. One year they red-lined liver transplantation for some indications for which it had been tested, but proven not to work. Such tyranny!"

Sure. In the short term the problems are unlikely to be obvious. But a government monopoly is a worrying thing. Over the long run problems are likely to arise. The other problem is not saying no when they should. Political pressure (and NICE was set up so that the government could pretend someone else was making these decisions) means that NICE is more often likely to be over-ridden and money spent to no useful end. An enormous percentage of the Australian Health care budget is eaten up by two or three conditions - from memory the problems arose with an anti-smoking drug and a drug to lower blood pressure where moderate exercise was likely to be more effective.

Posted by Glen Tomkins | July 6, 2007 7:39 PM:"The difference between an HMO's denial of payment for medical services, and the denial of even an entity such as NICE, would be that the HMO has an economic interest, and a fiduciary duty to its shareholders, to at least try to deny payment no matter what the benefit of the proposed medical service."

I am not convinced that is the case. An HMO that gets a reputation for rejecting all payments, or even too many treatments, is unlikely to attract or retain too many customers. There is a problem in the US that too many people are insured via their job and companies may not have the same set of interests as their employees do. But HMOs are in business to be in business. That does not include killing their clients wherever possible. Every story of someone denied a finger is valuable business lost.

Posted by Glen Tomkins | July 6, 2007 7:39 PM:"But we can leave the determination of this standard to experts who, unlike an HMO, have no interest in minimizing and denying services."

If governments pay of course they have an interest in minimizing and denying services. What is ironic about this is that you make these claims despite the fact that health care in the US takes something like 14 percent of GDP. They are doing a very very poor job of minimizing expenses and one of the real problems in the US is huge over-prescription of things like MRIs in case the doctor gets sued. Even if you assume that a third of spending gets eaten up by administration, that leaves 10 percent of GDP going on medical services which is greater than Britain's.

Posted by Glen Tomkins | July 6, 2007 7:39 PM:"This is as much transparency as a lay person needs in knowing whether or not they can trust the standard of care, that there should be, transparently, no economic interest to deny care in the people who are entrusted with defining that standard."

So you're defending the British practise of not informing patients of their options but telling them what they are going to get? I agree that it seems that ignorance is bliss for a lot of Americans and they would prefer not to know, but I am not convinced that blindly trusting the doctor is the way to go. Remember the Tuskegee example.

Steve Sailer,

your bit about GM being generous and introducing the present system of employer based coverage.

OK,for the sake of it let us concede that the corporate world is nice to the people. But then the union has to be even nicer and more clever: the head of the UAW argued at the time with GM boss for a portable single payer system instead.

But it was a no-no for the Country-club: it would have smacked of communism you know. Strange how it recalls me strongly of the rationale of 2-3 commenters here...

Posted by Alan de Bristol | July 6, 2007 7:47 PM:"This doesn't mean that this restricts treatment. This means if they advise that a particular drug treatment can be effective, it has to be provided."

Indeed, but NICE has the other role as well which is to decide (or issue "guidance") on which treatments are not effective and hence should not be funded. As the article makes clear their threshold is 30,000 pounds per QALY as everyone except NICE's chairman admitted to the WHO. Which means they are denying treatments on the basis of cost effectiveness. Here is an obvious problem. What if I value my life more than 30,000 pounds per QALY?

Posted by Alan de Bristol | July 6, 2007 7:47 PM:"So, according to the BMJ, it's a given that NICE recommendations are made without budgetary constraints, but according to you in your original
post, it decides on the basis of cost-effectiveness...I'll go with the BMJ on this one,and so I have to think your original point was bullshit."

Except I have quoted NICE in support in the past, so it is me and NICE who says this. Let me quote them again:

http://www.nice.org.uk/page.aspx?o=202425

We base our recommendations on a review of clinical and economic evidence.

* Clinical evidence measures how well the medicine or treatment works.
* Economic evidence measures how well the medicine or treatment works in relation to how much it costs the NHS - does it represent value for money?

On top of which the article contradicts itself - see the discussion on cost per QALY. They are, as the article admits, coy about talking about it but they are clearly using the 30,000 pounds/QALY as a threshold for treatment.

So as far as bullshit goes, we have me on one side, with two of your own sources supporting me - both NICE and the WHO in fact, and on the other we have you. Who does not read the sources that you provide or perhaps cannot understand them. I think we can all see where the bullshit is coming from.

Posted by Alan de Bristol | July 6, 2007 7:47 PM:"The BMJ piece also compares NICE to other apparently less permissive agencies."

I have no doubt there are some.

Posted by Alan de Bristol | July 6, 2007 7:47 PM:"The point is, the mechanism by which an independent agency comprised of academic medical establishments and societies assesses and then recommends drug treatments (without budgetary constraints, according to the BMJ) for use by the NHS means the government which is legally bound to provide these treatments, irrespective of cost, becomes in your fetid imagination, the Govt acting like an HMO."

Sorry but in what sense in a branch of the NHS, all of whose members appear to be appointed by the Government as far as I can see, which cannot even consider an issue until the Government asks it to and which is regularly over-ridden by politicians count as "independent"? The BMJ does not say what you says it says in the sense it contradicts itself and if it did, what NICE says is obviously more important. And yes, this is the NHS acting like an HMO. It does what they do. They decide if a treatment in worth providing except in Britain you have less choice as the NHS does not ask for co-payments.

Posted by Alan de Bristol | July 6, 2007 7:47 PM:"Sorry, still looks like complete bullshit."

I agree but you are getting better. The sensible thing would also to become less rude and then you'll look less foolish when I am mildly provoked enough to point out where you are wrong. As you are.

Fred--
Sorry to skip some steps. !5% have no insurance at all. They are really unhappy and anything would be an improvement. About 15% are insured outside group or employer coverage. They are unhappy. Some of the folks with employer-related insurance are happy but most are not. But their coverage is expensive, often has limited coverage, and frequently means that you can't change jobs. That's why Michael Moore is striking such a chord. This is a shrinking part of the population. Thus, the system is going to change because the happiest part of the population is growing in size and the unhappiest is growing. And The medicare population is not going to change its coverage.

You can pick the, nits, criticise NHS, or whatever, the fact is that JonF is right. You are history. We can do better.

JMO,

About the private Car industry being the most efficient:
I didn't see you respond to the others commenters explaining to you that not all product are equal and that health care ain't no car. So I will guess you agree, after having checked some ecomic theory, and will stop there.

I have now one other question:
what do you don't like with the swiss system? Could you envision the US going for that? It would allow the US going from the most expensive to the second/third most expensive (depending if $ or PPP). It may not seem much, but the spending gap is so big , that it would mean a lot of $$. I am positively sure the quality would not suffer.

And you will keep private insurance, over 50 % of the provider being capitalists, no federal mingling in the price system...In fact, I can not think of another rich country not being the US with less governmental participation in the system. By the way, not sure if it is a coincidence that they belong to the most expensive too, you?

Or do do you consider that the fact that they offer universal coverage through mandatory insurance disqualify the swiss system?
I am asking, because I would like to know once for all if we are speaking about efficiency, ideology or simply "USA!USA!" here. Mixner and HeiGou opinion is welcome too.

PS: nobody is allowed to blather about Switzerland's lifestyle and homogeneity of the population before having conclusively proved that such factors trumps the political and economical choices. Valid proof would be finding a single state in the US spending less or about the same on health care than England (not UK: England has the most immigrants) and with same or clearly better results.

My comment about homogeneity may have not been crystal clear, I try again

I'm sure that you can find one of the 48 states with more anglo-saxon population than England, and with no worst lifestyle. The Britons have quite bad eating habits, and always had ;-), and high obesity rates, from what is reported lately.
Than just check the spending.
So we should be able lay to rest the discussion for the most efficient between Private vs. Public health care, shouldn't we?

Homogeneity of Switzerland? Fer Pete's sake, they don't even speak the same language!

This thread is about the trolliest I've seen, and I say that because they struck at Matt's post like a salmon goes for a flasher- and then other commenters struck at the troll's posts, just like salmon going for a flasher.

Which kinda got me wondering why we call it a troll fishery when most of us think a troll is a short creature that lives in the forest. I doubt, however, that many Scandihoovians will be reading this thread. They seem to be happy with their socialized medicine and probably wonder how there can still be any debate about the matter here.

This should be good practice for the public debate which will develop as more Americans realize that we in fact are not Number One, we are friggin' Number Thirty Seven! and pay twice as much as whoever is Number One.

The key here is not to try to convince the trolls, but to develop methods of verbally stomping them which convince an audience that can actually respond to facts, logic, and humor.

Make no mistake, the upper classes stick together, and even more so in this case, where they so obviously get the lion's share of the benefits from the money our government invests in improving health care. The rightwing propaganda mills will go into high gear as more Americans start to ask WTF is going on around here.

Like Scooter Libby, the verdict may be in, but they still have friends in high places who are pretty good at pulling the rug out from under the public interest.

So, practice away, but remember, we're not trying to convince the troll, we're trying to convince the audience.

> goes back to General Motors' decision during WWII
> to get around government price controls on labor
> by offering health insurance as a free fringe
> benefit to attract more workers. In other words,
> it was an act of corporate generosity by the
> supposed evil corporation lampooned in Moore's
> first movie, "Roger and Me," t

Actually, it was an act of corporate desperation. Particuarly by the aircraft manufacturers who were forbidden by the War Production Board from giving their vital machinists any raises or promotions. As a result those skilled people were quitting in droves, walking across the street to the competitor, and getting much better pay packages. Out of greedy self-interst those manufacturers started casting around for ways to give their employees more compensation without raising wages and paying for medical care was one of the tools they used. Nothing generous about it; just the standard Smithian self-interst.

Cranky

Posted by serial catowner | July 7, 2007 9:07 AM:"Which kinda got me wondering why we call it a troll fishery when most of us think a troll is a short creature that lives in the forest."

I am sure it is also related to "trawl" which is what most trolls do.

Posted by serial catowner | July 7, 2007 9:07 AM:"This should be good practice for the public debate which will develop as more Americans realize that we in fact are not Number One, we are friggin' Number Thirty Seven! and pay twice as much as whoever is Number One."

America is Number 37 if you use the twisted methodology used by the WHO which rewards socialism. If you measure, say, patient satisfaction the US is Number One. Why do you think that is?

Posted by serial catowner | July 7, 2007 9:07 AM:"The key here is not to try to convince the trolls, but to develop methods of verbally stomping them which convince an audience that can actually respond to facts, logic, and humor."

Well good luck with that. Usually the people who respond with stompin' are those that can't respond to facts, logic or humor much less use them.

"Actually it is spot on true, and unless you are a hypochrondiac, you can find the easy proof in your own life. Do you run to the doctor absent serious need? Would even if you didn't have to pay a penny?"

Are you really this blind to facts? Do you honestly believe that people will not consume more health care if they do not have to pay for it?

Anecdotal evidence is silly here, but since you seem to think it is valid I can offer a retort to your claim. I tore a ligament in my thumb last year, and after my initial treatment the doctor recommended a few visits to a hand therapist. I went once and she did some massage and flexibility exercises, and when I saw the bill (I have a $2500 deductible, so this all out of pocket) I didn't go back. Had I not been paying I definitely would have gone back a few more times. Bearing some of the cost (or in the case, all) convinced me to limit my health care consumption, and to avoid treatment that was not absolutely necessary. Why do think people don't clear their plates at an all you can eat buffet?

Peter,

"Thus, the system is going to change because the happiest part of the population is growing in size..."

I still don't get this. If, by your reckoning, more people are happy with their current coverage, why would these folks agitate to change it?

"...and the unhappiest is growing."

If this is true, then it's more plausible that this group might be in favor of change to a single-payer system.

The key here is not to try to convince the trolls, but to develop methods of verbally stomping them which convince an audience that can actually respond to facts, logic, and humor.

Well, I did that with the facts and links to NICE and the BMJ. The troll then comes back with nonsense, of course, but I think most readers to comments and this site recognise the troll for what he is, so it really only needs to be once.

Posted by Alan de Bristol | July 7, 2007 4:00 PM:"Well, I did that with the facts and links to NICE and the BMJ. The troll then comes back with nonsense, of course, but I think most readers to comments and this site recognise the troll for what he is, so it really only needs to be once."

Actually Alan that is not what you did. You simply mis-stated, repeatedly, what NICE and the BMJ said. I don't think you lied deliberately. I simply don't think you have that much self awareness. But facts you do not have. Nor even a basic understanding of the NHS.

Which would not matter as the world is full of idiots posting on the internet, except you are so rude about your ignorance. Here's a free tip - when you are arguing with someone on a subject you know nothing about, try to maintain a basic level of politeness. It will hurt less when you're shown to be wrong. Oh, and a lot more self awareness might be nice too - you are not as smart as you seem to think you are, you are certainly not as well informed, and your opponents are not actually evil people (and hence you are not a super hero coming to rescue the planet from the clutches of Lex Luthor).


Comments closed July 20, 2007.

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