Jacob Hacker: "Socialized Medicine"

Jacob Hacker says its time to adopt a national health plan:

Let's Try a Dose. We're Bound to Feel Better., by Jacob S. Hacker, Commentary, Washington Post: "Socialized medicine" is the bogeyman that just won't die. The epithet has been hurled at every national health plan since the New Deal -- even Medicare, which critics warned would strip Americans of their freedom.

And now it's back. Republicans from President Bush on down have invoked the specter of socialism in denouncing Democrats' attempts to expand publicly funded health insurance... Never mind that nobody is proposing to turn doctors into public employees and hospitals into government institutions -- the literal meaning of socialized medicine. ...

But the critics have it backward.

The best American medical care is indeed extremely good, but much of our system falls short -- especially when you consider how costly it is, how heavy a burden it places on employers and families, and how many it excludes. And far from being a threat, getting the government more involved in health care would actually reduce costs, improve quality and bolster the U.S. economy... If socialized medicine means doing what our public-insurance programs and other nations' health systems do to control costs, expand coverage and improve the quality of care, it's high time for a little socialization. ...

Other industrialized nations have ... seen the benefits of public insurance. ...[M]edical inflation in most of the industrialized world has slowed dramatically... But ... U.S. spending on health care has continued to rise rapidly... You'd think that those lower costs abroad would mean worse care. (You'd certainly think that if you listened to GOP candidates sneering at the British, French or Canadian systems.) But the closer one looks, the more unexceptional -- and often downright mediocre -- U.S. care looks. ...

It's time ... to embrace a government role in health care, rather than run from it. Americans seem ready. They increasingly back government action to expand health coverage -- by more than 2-to-1 margins in recent polls. And the old bugaboos of government control don't seem to scare them as they once did. ...

Corporate America, too, seems more ambivalent... The nation's automakers, for instance, ... spend more on health care than steel. No wonder they're talking about "national solutions" to reduce the medical burden.

The political landscape is shifting, too. ... Both Sens. Barack Obama and Hillary Rodham Clinton are arguing that workers whose employers don't provide coverage should be able to buy into a public program modeled after Medicare. ... That's wise, because the only proven way to provide good affordable care to all Americans over the long run is to expand public insurance.

Don't take my word for it. The Lewin Group, a well-respected health-care consulting firm, recently estimated the potential impact of a health plan I've developed... The proposal ... resembles the plans of the leading Democrats, whom I've advised... According to the estimates, this proposal would cover all but a tiny sliver of the non-elderly population... Yet it would actually reduce national health spending, cost the federal government an eminently reasonable $50 billion a year (about what the Medicare drug benefit costs) and save states and employers big money.

How is it possible to cover everyone without driving up costs? The one-word answer is "government" -- specifically, government's ability to lower service prices, streamline administration and get a better deal on drugs, thus reducing medical inflation over time. And these are only the direct savings. Reducing the burden of health care on employers will allow them to compete more effectively (and on a level playing field) with foreign producers. Just as important, making coverage affordable for everyone will allow people to change jobs or start their own businesses without the fear of catastrophic costs or the hassle, expense and inadequacy of individually purchased coverage.

Maybe socialized medicine doesn't sound so bad after all.

Comments

[save_the_rustbelt]

"And far from being a threat, getting the government more involved in health care would actually reduce costs, improve quality.... "

I've spent the past two months reading just about everything of consequence written in the past decade on US healthcare reform, from all angles.

A couple of observations:

1) most of the advocates for reform look at the system from a very macro view, I have yet to find any of them who have made any effort to detail a transition plan or operational plan, probably because none of them seem to know much about operational issues.

For example, both Clinton and Obama appear to want a universal electronic medical record, problem being there is no system that will do this, and it may entail trashing all of the existing EMR systems, an incredible mess.

2) the statement above is a wild generalization and I very much doubt it can happen.

If we were doing this in 1960 it would have a better chance of succeeding, but we are way down the road, and the transition and operational issues are massive.

I should say, if the government makes a giant mess it will be very good for my household income, but I would rather get rich some other way.

Beware of what you wish for.

[Farrar]

STR
"For example, both Clinton and Obama appear to want a universal electronic medical record, problem being there is no system that will do this, and it may entail trashing all of the existing EMR systems, an incredible mess."

Great! That'll put all those unemployed programmers back to work.

[ilsm]

STR,

Google it!!

Engineering data is wildly more diverse.

Handling medical imagery is already being done.

Search engines, new emerging data architectures.

No problem.

The SW folks are ready to go.

[paine]

"it's high time for a little socialization. ..."

another neo socialist

[paine]

btw
we need to brake apart the specialist handi craft system
with its three operation specialty types earning 7 figures
and create more technical jobs that require 12 months training out of high school assisted by machines and expert programs

just a suggestion
since we all wanna to a health gosplan tune

[Scott Ferguson]

"Engineering data is wildly more diverse.

Handling medical imagery is already being done.

Search engines, new emerging data architectures.

No problem.

The SW folks are ready to go."

When was the last time a large government computer system WASN'T scrapped before it could be implemented?

Heck, even Microsoft tried to to rewrite Word from the ground up and had to abandon th effort.

These things are NEVER straight forward. I took a class in Grad school on Information Filtering in which each student took the records from a typical hospital stay and tried to make chronological listing of events - not pretty! Even if we can write the programs, hospitals and doctors would have to change their record keeping procedures to accommodate the design decisions of the new database. That will be an incredible pain.

[ken melvin]

Damn change is hard. Why do people fight change so?

[anne]

The ultimate trick of modern Republicanism is always to show that nothing is possible ever never that Republicans do not wish. There is no national health care system in France or Germany or Australia or Japan or Sweden or Spain or Canada or Britain. The European Union which is larger in all sorts of telling ways than we are has no health care for no one. The French die in the bloody streets for lack of French computers computing.

Such is Republican nihilism. The question however is whether having already had an increase in infant mortality in Mississippi when public health care spending was last cut, why is Mississippi cutting public health care again?

[bakho]

If it costs less, someone who is currently milking the system will get less. Would it help to be upfront about who those losers would be? Would it help ID those special interests that are fighting change?

Part of making the system work would be to add primary care and health education services. That part could use some thought.

[anne]

Though there are immediate conservative complaints when the point is made, we might pay attention to how much we lag Europeans and Asians simply on high-speed, real high-speed, Internet access. The answer is not population density, since Boston and Los Angeles and Atlanta are dense enough. We are lacking in social spending, lacking in infrastructure development, hard and soft infrastructure, and a shameful unwillingness even to care for the health of needy children shows our lack beyond any technical difficulty in so caring.

[Andrew]

Republicans from President Bush on down have invoked the specter of socialism in denouncing Democrats' attempts to expand publicly funded health insurance.

Weird, since those same Republicans already benefit from 'socialized' medicine (as in, paid for with tax dollars).

Who else has their healthcare paid for with tax dollars? The military, hordes of faceless bureaucrats and civil servants, law enforcement (federal and local), prisoners (over 2 million and rising, go USA!), poor children (in most states), the elderly, veterans, indigent emergency room patients...I'm sure I'm missing a few.

We have socialized medicine, its simply a disjointed mess. Worse, the government has promised their corporate owners not to use their considerable market share to drive costs down (cf. Shrub's Medicare 'reform'). It is probably unreasonable to a expect sensible healthcare plan to make it through the Congressional meat-grinder.

[save_the_rustbelt]

ilsm:

Have you ever done a systems conversion in a health care facility? Even from a functioning system to a better system it is extremely intense work with lots of crisis points (see "critical path method") and tremendous FUBAR potential.

And keep in mind the majority of providers will be going from paper to digital, which can be even tougher (and I have done that also).

Not to mention paying for it, which would be subsidized by the feds (Clinton and Obama plans), but would still be a Herculean task.

I'm not against healthcare reform, but I won't see any economists in the trenches making it work.

The bigger the mess the richer I get, so I should vote for Democrats this year.

[save_the_rustbelt]

"Part of making the system work would be to add primary care and health education services. That part could use some thought."

I am currently doing some projections (using sensitivity and scenario analysis techniques) and I see a good possibility that family practice docs will have lower incomes.

In fact, most physicians will have lower incomes, but an orthopedic surgeon can more easily absorb a 20% then can an FP.

Operational design is critical. No one is paying much attention to that.

[anne]

No; this is terribly, terribly wrong.

Millions of veterans and their families have no health care insurance. Millions of needy children were just denied health care insurance by 2 Presidential vetoes and by Congressional Republicans who upheld the 2 vetoes. Medicaid have been cut these last years, and is being cut presently.

Tens of millions of people lack health care insurance from children to adults, from veterans to the fully employed and on....

[save_the_rustbelt]

In the book shelf behind me there are, I estimate, 12000 - 15000 pages on the shelf labeled "Medicare and Medicaid billing" subtitled "getting paid and not going to federal prison."

The recent summary and commentary of the Stark III rules ran 500+ pages of fine print, and this is just a grain of sand on the great beach of federal health care regulation.

One of the false premises of healthcare reformers is that a government system would save vast amounts of money via simplification. Don't count on it.

[anne]

http://www.nytimes.com/2007/11/09/opinion/09fri2.html

November 9, 2007

Veterans Without Health Care

Although many Americans believe that the nation's veterans have ready access to health care, that is far from the case. A new study by researchers at the Harvard Medical School has found that millions of veterans and their dependents have no access to care in veterans' hospitals and clinics and no health insurance to pay for care elsewhere. Their plight represents yet another failure of our disjointed health care system to provide coverage for all Americans.

The new study, published in the American Journal of Public Health, estimated that in 2004 nearly 1.8 million veterans were uninsured and unable to get care in veterans' facilities. An additional 3.8 million members of their households faced the same predicament. All told, this group made up roughly 12 percent of the huge population of uninsured Americans.

Most of the uninsured veterans were working-class people who were too poor to afford private insurance but not poor enough to qualify for care under a priority system administered by the Veterans Affairs Department....

[save_the_rustbelt]

Anne:

A year or so ago Paul Krugman said the VA was the best healthcare system in the country.

????

(Hint: Krugman was wrong and this article is more accurate.)

[anne]

There is no reason to lower the incomes of physicians. The idea is absurd. The need is to protect the health of needy children, not to harm physicians in any way? Protecting the health of pregnant women in Mississippi will not and must not lower the incomes of physicians.

Always Republican deceitful rubbish, all the time.

[anne]

We could easily have what Europeans have, which is no tuition at public colleges and universities which would make becoming a physician remarkably less of a burden.

[evagrius]

From Orcinus regarding Medicaid eligibility;

Bernice Todd's Choctaw family roots are sunk deep in the soil of Oklahoma, a state whose very name is Choctaw for "red people." But in the middle of a debilitating battle with cancer, Todd, a 39-year-old who cleans homes at a trailer park and baby-sits for a living, lost her state Medicaid health care coverage because, although she's a Native American, she could not prove she is a U.S. citizen.

While Todd's case is rich in irony, she is one of tens of thousands of Americans who are falling victim to a new federal rule—aimed at keeping illegal immigrants off the Medicaid rolls—requiring that recipients prove their citizenship and identity with documents many don't have.

Naturally, the idea for the rule change behind this travesty came from the nativist wing of the GOP:

States have always been required to check a Medicaid applicant’s eligibility, which includes citizenship. But a July 2006 rule, enforced by the federal Centers for Medicare & Medicaid Services (CMS), now demands specific documents as proof, such as a passport or a birth certificate, driver's license or military record. States face fines if they don't comply.

The rule, which neither CMS nor the Bush administration requested, was adopted by the Republican-dominated Congress in 2005 despite the fact that there was no evidence that undocumented immigrants were falsely claiming U.S. citizenship to get Medicaid.

"This rule was the answer to a problem that really doesn’t exist," says Donna Cohen Ross, an analyst with the Center on Budget and Policy Priorities in Washington, a nonpartisan research organization.

In fact, the year the rule was passed, Mark McClellan, then the administrator for CMS, said that a report by the CMS inspector general did "not find particular problems regarding false allegations of citizenship, nor are we aware of any." Most states agreed with that assessment.

"In 2007 we added $1 million to our budget just to handle the cost of this new rule when we had absolutely no indication there was a problem with illegal immigrants getting Medicaid in Kansas," says Andrew Allison, Kansas Medicaid director and deputy director of the state Health Policy Authority....

So far, he says, Oklahoma has uncovered no illegal immigrants on its rolls. And Arizona, where immigration is a huge issue, has filed two reports since the rule went into effect, each saying the state uncovered "zero" illegal immigrants among its 1 million Medicaid recipients. Kansas has found one illegal immigrant on its Medicaid rolls.

A U.S. Government Accountability Office survey of the states last year found that that the requirement caused eligible U.S. citizens to lose Medicaid coverage while increasing administrative costs. A close analysis of six states, the report says, showed that for every $100 spent to implement the rule, only 14 cents was saved.

In fact, nationwide the rule has added millions of dollars in administrative costs.

[Andrew]

Anne (and evagrius? not sure if you were addressing my comment),

I believe you misunderstood. I know firsthand the problems with VA and Medicaid health care. I am trying to say that many of the very folks who are spreading the red scare of 'socialized medicine' benefit from from exactly such a system. Additionally, tax dollars provide healthcare for millions of Americans, but the programs are generally inadequate in both service and coverage.

The problem is not that we don't have socialized medicine. The problem is that the socialized medicine we have is a horrific mess. I believe framing the discussion as such will help deflate the red scare nonsense so a reasonable debate about reforming the system can take place.

[save_the_rustbelt]

"There is no reason to lower the incomes of physicians. The idea is absurd. The need is to protect the health of needy children, not to harm physicians in any way? Protecting the health of pregnant women in Mississippi will not and must not lower the incomes of physicians."

The idea is not absurd, revenue reductions will happen, and the theory that cost savings will balance the reductions and preserve incomes is a fanciful idea that will not work.

As Dr. Hacker says:

"....specifically, government's ability to lower service prices,...."

[save_the_rustbelt]

I took a couple of minutes to reread Prof. Hacker's extremely impressive vitae, and the one thing I cannot find is a single day either working in the healthcare sector or consulting to any healthcare entity.

He is a brilliant man who writes very well, but an expert on healthcare issues? Hmmmmm.

[robertdfeinman]

Having a government-administered health care system has several moving parts.

The first, and most important, is to provide coverage for "everyone".

The second, is to control costs. There are many areas where costs can be contained. Not everyone even agrees as to what the causes of high costs are. Among the candidates: over compensated doctors, unnecessary procedures, overpriced drugs and medical equipment, insurance company and other middlemen inefficiencies and profits, high malpractice insurance premiums, and frivolous malpractice suits.

I've never heard the argument that computerizing the system will be a make or break issue. I get computerized statements from my insurance company and from Medicare every month. This seems to work smoothly. To make this fully integrated is something that can happen over time. It's not a show stopper.

What we have now is a lack of will. There are too many making a living off the status quo and none of them want to see their livelihoods put at risk. There was a study out yesterday that found that the majority of Republicans think the present system is working well (and is better than those in Canada, Japan and Europe) while Dems think it isn't.

It's hard to have a rational debate about future policies when a large segment of the population is woefully uninformed. In actual fact the US doesn't have the "best" system when measures of outcomes are looked at. When the American myth of superiority is shown to be false then the national propaganda machine goes into high gear and makes sure that the truth doesn't come out.

Pathetic.

[Gordon Gecko]

Socialism is only good when it is applied to Wall Street losses. Any other time it is un-American.

[Winston]

I am currently doing some projections (using sensitivity and scenario analysis techniques) and I see a good possibility that family practice docs will have lower incomes.

Good. In fact, we should lower doctors' incomes even more by implementing free trade in medical services.

While dissecting the arguments of free trade apologists (i.e., most economists), Dean Baker of the Center for Economic and Policy Research makes a sensible proposal:

It is also important that the licensing standards be made fully transparent. It would also be useful to allow for students to be tested in their home countries (by U.S. certified testers of course). This will allow smart kids in India, China, Mexico, and elsewhere to train in their home country to meet the requirements necessary to be a doctor, lawyer, architect, or some other professional in the United States. If a student in the developing world passes the appropriate test and gets licensed, then they should have the same opportunity to work in the United States as student who was educated in New York or Los Angeles. This would be free trade in professional services.8 Just as it is cheaper to produce shoes and toys in the developing world than in the United States, it is also cheaper to educate doctors and lawyers in the developing world. In the absence of the obstacles to trade in highly paid professional services, most professionals in the United States would be educated in the developing world.

It is worth noting that it is possible to ensure that developing countries are not harmed by this brain drain. It would be a relatively simple matter to impose a tax associated with the issuance of a work permit that would be repatriated to the country of origin to finance the education of more professionals. Since a large percentage of the most highly paid workers are in licensed professions, there is little basis for concern that these workers will work off the books to evade taxation. By the nature of their work, they have to be openly available and visible to the public. For this reason, highly paid professionals will be far less likely to work off the books than custodians, dishwashers, or other workers in relatively low-paying jobs.

[anne]

Andrew; we really do have socialized health care, only socialized in the worst possible way.

STR; I am completely sympathetic to the problems in detail, with which you are familiar, what we surprisingly lack however is a political sense that comprehensive health care insurance is desirable or realistically possible.

[Winston]

Sorry, that should probably read, "While exposing the hypocrisy of free trade apologists. . . ."

[Winston]

Sorry, that should probably read, "While exposing the hypocrisy of free trade apologists. . . ."

[Noni Mausa]

bakho asked: If it costs less, someone who is currently milking the system will get less. Would it help to be upfront about who those losers would be?

I would imagine they would be:

--insurance companies and insurance company middlepersons
--corporate health care department personnel (bean counter variety)
--lawyers

...in other words, the people who tussle over who gets benefits. Then there are big pharmaceutical companies, who would have to negotiate their drug prices as do US Medicare and other national health departments.

Ah, but who would benefit? These very same people would benefit even if they lost their jobs. Imagine not paying $1000 a month or more for insurance, imagine not dreading job loss and the associated loss of coverage, imagine 300 million people unwinding that particular national nightmare and all sleeping a bit better at night.

Noni

[Andrew]

Ah, but who would benefit? These very same people would benefit even if they lost their jobs.

I agree with you, Noni, but this point is thin ice. It is the same argument used to convince folks at manufacturing jobs that 'hey, you lost the means to support your family, but look at all the cheap crap you can buy at WalMart!'

Now there is a huge qualitative difference between health care and WalMart refuse, but let's not make the same mistake the free traders made and ignore those who may really be hurt by a reformed health care system. The middlefolk of these companies are only going to be better off if we make sure they can get another good job.

[dissent]

I don't understand the transition worries.

We already have 'transition' to govt funded care embedded in the system.

For example, my insurer is Kaiser. It accepts Medicare patients for an overall HMO fee it negotiates with the govt. It doesn't have to use govt software (for heaven's sake!) to run its records system in order to do this. You can have employer covered insurance with Kaiser and transition to Medicare funded Kaiser after you retire. Where's the problem?

I believe Edwards' plan took the approach that there would be a default govt funded plan like Medicare that would cover those who did not have health insurance.

Forecasting the most complex and difficult transition scenarios is letting the perfect be the enemy of the good. Obviously, we should build on what we already have.

[Farrar]

"I've never heard the argument that computerizing the system will be a make or break issue. I get computerized statements from my insurance company and from Medicare every month. This seems to work smoothly. To make this fully integrated is something that can happen over time. It's not a show stopper."

Right !

It took close to ten years to complete the uniform on line French system, and it probably isn't finished yet. But during that time there were no breakdowns, and the system kept chugging along getting better all the time.

[Noni Mausa]

The middlefolk of these companies are only going to be better off if we make sure they can get another good job.

That's very thoughtful of you, Andrew. But in effect, the middlefolk are currently making a living by selling people something they cannot use at a price about double the world average.

"They have their reward", as old what's-his-name said.

There are scads of people who haven't got jobs at all, much less good jobs, who maybe should get first helpings at the buffet before the middlefolk get in line for seconds.

Noni
heartless, sorta
.

[Andrew]

According to NAICS, around 450,000 people are employed directly by the health insurance industry, with an average wage of $48,500. I'm just guessing, but I'd say you could safely double the number of employees for indirect jobs like the folks who work for health care providers solely to deal with insurance paperwork (of whom I know a few).

I am a strong proponent for health care reform, but sending nearly a million middle class jobs down the social experiment toilet bowl is not a matter anyone can just ignore. Part of making reform possible in the first place will have to include letting these people know reform does not mean 'so sad, too bad, find another way to provide for your family.'

[anne]

There is something as maddening as disappointing to health care insurance discussions, but I do not know how to counter. Simply discussing the need for general insurance coverage led to charges that insurance an requirement could force us to choose between insurance and meals and meals really are necessay. Mention expanding insurance coverage, and suddenly the problem is data keeping and computers to keep the data, as though there had been no record keeping to begin with even before computers. Then, there is the problem of who will suffer if I am allowed insurance and, of course, the suffer-ers will be doctors.

So come the complaints, while all I think is that moving to universal health care insurance is really a remote possibility. When a supposedly reasonable state such as Oregon will not vote to protect the health of needy chilren for the costs of a few packages of cigarettes, what am I to think?

[anne]

Andrew:

"According to NAICS, around 450,000 people are employed directly by the health insurance industry, with an average wage of $48,500."

Of course; and there must be industry participation even if there is a public-private competition among insurers that leads gradually to change to public insurance. The need is to be inclusive, not threatening in a self-defeating way.

[Bruce Wilder]

The transition, as STR points out, will be a huge task. We won't get from here to there, without devoting enormous resources to the transition.

Delivering healthcare is undergoing a significant transition, regardless of whether the government funds insurance. The practice of medicine is moving away from a craft model toward a technically managed process model. The reform of medical recordkeeping, which is going on whether gov't funds insurance or not, is part of enabling that managed technical processes model.

Personally, I think strict "single-payer" is simply impossible, let alone a true "socialized" single administrative organization. But, we could switch to tax-financing of basic health insurance, in a way that allowed the health insurance companies to also transition into a more socially useful role.

The main trick, politically, will be to come up an initial plan, from which there is no turning back. I, personally, think the key is tax-financing. Find a tax that can escalate to 12-15% of GDP, impose it, and let employers flee the scene. Once the employment-based scheme is dead, and the insurance industry is sucking on the tax tit, undoing "socialized medicine" will be impossible.

Then, you can work out the details, safe behind a lobbying wall that the Republicans will never be able to scale.

[Icarus]

So, in this push towards uber-socialization I see running as a consensus on this blog, is there room for private markets?

What happens to those of us who don't want to depend on a govt, and prefer to pay a premium, and get a certain quality of service; aka, private markets. There are millions of people like this, who have no trust/faith in many govt services, and don't want to rely on such bureaucratic care.

Can I opt out, not suffer double payment, and simply take care of my own life, and my family's?

I suspect not.

[dale]

anne, even the citizens of supposedly reasonable Oregon can be swayed by lopsided corporate campaign spending on election ads. Now, I admit that being swayed by corporate media campaigns is evidence of unreasonableness- but reasonable decisions are probably more easily made when the decision making process is liberated from the influence of money. We need to help ourselves to be able to reason well.

[JRossi]

The idea that outpatient electronic health records improve care is at best an unproven hypothesis and at worse yet another technophilic mass con, perpetrated on the great American public by the same folks (or similar folks) that gave us the panacea of managed care. See Linder et al Arch Int Med 2007;167: 1400-1405. Maybe it will work, maybe not. It certainly has decreased efficiency in my practice, with no apparent morbidity or mortality improvement. Time will tell, but don't believe in it just because it sounds good. I make no comment on inpatient EHRs-I haven't looked into those.

[anne]

Before being spoiled rotten last night, as I prefer to be, I happened to hear a report on American toys that are evidently being made with a chemical that turns lab mice green and since green lab mice are considered a problem in Europe, the European Union has banned the green-mice causing chemical much to the dismay of American toy makers for whom green-mice are a mere diversion.

Europeans toys will not turn mice or children green, and still children in Europe have not gone toyless. American children, well, who will know for a few more years, and besides we are told by a mathematics professor from George Mason (where else?) that green children are more decorative and not to worry, American children are happily playing with green-mice causing toys.

The point, you ask? The point is the chemical industry was shunned in lobbying in Europe, but not in America. Money counts, and Oregon prefers cigarettes to healthy children as long as the children belong to other Oregonians.

[anne]

J Rossi:

"The idea that outpatient electronic health records improve care is at best an unproven hypothesis and at worse yet another technophilic mass con, perpetrated on the great American public by the same folks (or similar folks) that gave us the panacea of managed care."

The idea that paper-replacing technology is the answer to lessening either my health costs or needs (cough, cough) is darkly comical. There is a reason I date doctors, though.

[anne]

Health care costs little interest me, at least for the time, not when war costs are of absolutely no concern. Better health care, for those who have too little care is what matters; while a system laden with administrative and monopolistic supplier costs is readily made less costly as more care is delivered.

Meanwhile, if you're not a doctor, no chance.

[anne]

http://www.nytimes.com/2008/03/23/us/23health.html?hp

March 23, 2008

Gap in Life Expectancy Widens for the Nation
By ROBERT PEAR

WASHINGTON — New government research has found "large and growing" disparities in life expectancy for richer and poorer Americans, paralleling the growth of income inequality in the last two decades....

[Oh, brave new world, that has such people in it.]

[anne]

http://shakespeare.mit.edu/Comedy/tempest/thetempest.5.1.html

1611

The Tempest
By William Shakespeare

Act V. Scene I.

Before Prospero's cell.

Here PROSPERO discovers FERDINAND and MIRANDA playing at chess

MIRANDA

Sweet lord, you play me false.

FERDINAND

No, my dear'st love,
I would not for the world.

MIRANDA

Yes, for a score of kingdoms you should wrangle,
And I would call it, fair play.

ALONSO

If this prove
A vision of the Island, one dear son
Shall I twice lose.

SEBASTIAN

A most high miracle!

FERDINAND

Though the seas threaten, they are merciful;
I have cursed them without cause.

Kneels

ALONSO

Now all the blessings
Of a glad father compass thee about!
Arise, and say how thou camest here.

MIRANDA

O, wonder!
How many goodly creatures are there here!
How beauteous mankind is! O brave new world,
That has such people in't!

PROSPERO

'Tis new to thee.

[anne]

So now we understand, or not, that income and wealth disparity and lack of proper health care in this land of health care finer than fine, lack of even say health care for pregnant women has dire consequences.

[Here I am thinking of Easter eggs, and all that jazz. Can I sing Ode to Joy now?]

[robertdfeinman]

Anne:
Just for the record the mathematician who tried to debunk the story about phthalate laced toys is Rebecca Goldin. Her activism (or misdirection) comes from her affiliation with a front group name STATS:

From the little public information about their "independent" donors:

Funders

Richard and Helen DeVos Foundation

Grants

For a total of $50,000

Date Amount Purpose Recipient Funder
1-1-2002 50,000 STATS' research and analyses to promote the sue (sic) of accurate data in public policy discussion Statistical Assessment Service John M. Olin Foundation, Inc.

Funny how the same core group of super wealthy rightwingers keeps popping up whenever there is disinformation to be provided.

It's not as if George Mason was just willing to be affiliated with such groups, but they seem to actively seek the connections. And yet they are chartered as part of the state university system...

[anne]

Thank you so much Robert; what a gem you are.

[anne]

When the sweet Rebecca Goldin was asked if American mothers might worry about having green-children since European mothers were worried enough to avoid having them, the answer was "if everyone was jumping off a bridge would you jump off after?"

[Oh, brave new world, that has such people in it.]

[SanFranciscoJim]

Half of all lifetime health care costs are spent in the last six months of a person's life. I think this is what Socialized medicine really does: it sets up a big government bureaucracy that can say "no" to people's desperate schemes and the natural tendency of families to say "yes, do everything you can to save Mom" when the sad truth is, nothing can be done.

Right now, no one is incentivized to say no, in any circumstance and since no one is actually paying with their own money, it is easier to say yes. Most of the time, we should just put Mom on a morphine drip and let her go. I actually worked in a hospital where they did an expensive operation on an 82 year old woman that had incurable cancer and less than six months to live. A Catholic hospital, naturally. Why even put her through the suffering?

The VA system is actually a great example of how to improve health care delivery, including medical records standardization and electronic delivery of records, or so I hear. I don't have any first hand experience.

http://www.cbo.gov/ftpdoc.cfm?index=8892&type=1

The government could greatly speed the advent of electronic health care records by requiring everything to be done with a set of standard forms. They can use either the military or VA medical records system as the model. If you wanted to get reimbursed by medicare you would have to follow the government standard. I don't know why they don't do this already, in fact.

[dale]

One problem with that SFJ is that we don't often know when the last 6 months of a person's life (even an older person's) is- until they die. And then it become a retro-active prophecy- serioulsy ill folks do need a lot of medical services- and even then, some of them die.

I'm not saying that there are not some difficult choices to be made. But they are difficult and not so easily conformed to a "last six months of life" formula.

[german_reader]

One of the most bizarre and ridiculous aspects of the conservative propaganda against universal health care, socialized medicine in the United States is the regular pointing to problems and imperfections in other countries , ignoring completely the many failures of the U.S. system.

It's true socialized medicine / universal health care aren't perfect and we have to fight as much as the U.S. against rising expenditures , inadequate treatment or long waiting times. But we do it at much lower costs and without leaving 20-30% of the population uninsured or underinsured. And no one faces the risk of going bankrupt because of health care costs. The U.S. system is not only very expensive, it also exceptionally ineffective.

Conservative opponents of socialized medicine especially like to show the obvious problems of socialized health care in the U.K.. And it seems to be true, dental care in the U.K. is anything but satisfying and waiting times for some kind of operations are unacceptable. The British system ( or any other universal health care system ) is far from being perfect. But Great Britain spends only 7.7% of GDP on health care ( in most other industrialized nations 9-10% ) compared to nearly 16% in the U.S.. And that's unadjusted for the more advantageous age structure in the U.S.. In absolute numbers the U.S. spends around two and a half times more on health care per capita than the U.K. ( two times more compared to other countries). That's rather a fair comparison.

Just a rhetoric question: How would the situation in the U.S. look like if we'd cut the health care expenditures there by more than a half and leave anything else unchanged: the overpaid doctors, the health care insurance system with its multi-million dollar boni, a pharmaceutical industry which spends more on advertising than research and is protected by patent laws, import restrictions against to much external competition etc.?

Guess it would come close to Ecuador ( if it not already does ).

The main problem in the U.K. ( or elsewhere ) is not socialized medicine or universal health care. It's the chronic underfunding of some sectors of the health care system and organizational deficits in others. This could be addressed without much problems by internal reforms inside the existing health care system or - where unavoidable - higher spending in selected sub-sectors. Even a moderate increase of health care spending in the U.K. to average international levels would probably give an enormous boost to the general quality of health care in the U.K.. An increase to U.S. levels would not only allow a super-duper luxury version of universal health care for all, but also leave enough space for the kind of Britney Spears, Paris Hilton luxury treatment, ( especially conservative ) Americans are so proud of. All this without excluding major parts of the population from health insurance or the permanent risk of bankruptcy for many others.

It seems to be constant accompaniment of the U.S. system private or public that it's not only very expensive but also extremely ineffective. And even where it seems to be cost effective at a first glance, it's only so by privatising social risks, social exclusion, relocation of costs into the future ( high debt levels ) or externalization of costs in the form of social distortions or the waste of human and natural resources.

Universal health care should be only the starting point of a general revision of America's socio-economic system.

[JRossi]

Good point Dale. The view is always crystal clear through the retrospectoscope. But SFJ also has a good point. Sometimes people that just you know are gonna die get the big dance when the little dance would IMHO be better. Sometimes it's hard to stop, when the pt and family are pushing you, not to mention your own financial incentives. YOU (society) need to come to some sort of decision regarding the parameters of how we practice. Good luck with all that.

[Icarus]

SFJ brings up the key point, which is a society's attitude towards death, and health care treatment. In this example, it's quite difficult to say 'no', and it's in no one's interest.
The patient's family doesn't have cost on its mind. The health care practitioner often practices in fear of litigation, and also has a tough time connecting budgets to day to day care.

At some point, we have to connect cost of treatment into the equation, and make tough decisions on cases without fear of litigation.
How could the state of Florida say 'no' to Terry Shiavo's family, and come away $15 million dollars better off, able to spend that money on a greater number of people? How can emergency rooms say 'no' to people who have no capacity to pay, and yet can incur hundreds of thousands of dollars in services?
These are the tough questions we have to answer to curb the cost, and approach towards medicine. But, many will scream that it's unfair, as certain people will not get services to stave of death at all costs.

[Cyrille]

"How can emergency rooms say 'no' to people who have no capacity to pay, and yet can incur hundreds of thousands of dollars in services? "

Er, no, that's precisely the question that should no longer be asked.

Anytime it's about health (that is, not stuff like plastic surgery), ability to pay should not even come into the picture.

[anne]

German Reader:

"One of the most bizarre and ridiculous aspects of the conservative propaganda against universal health care, socialized medicine in the United States is the regular pointing to problems and imperfections in other countries, ignoring completely the many failures of the U.S. system.

"It's true socialized medicine / universal health care aren't perfect and we have to fight as much as the U.S. against rising expenditures, inadequate treatment or long waiting times. But we do it at much lower costs and without leaving 20-30% of the population uninsured or underinsured. And no one faces the risk of going bankrupt because of health care costs. The U.S. system is not only very expensive, it also exceptionally ineffective...."

We are collectively shamefully incapable of introspection, and resultingly destructive and self-destructive.

[hari]

I think its foolish to repeatedly spook yourselves with terminology such as "socialized medicine" because outside UK it doesn't exist anywhere else in EU (as far as I know). Our doctors are all private practioners and negotiate their professional service rates directly as a collective (union!). They're definitely NOT a previleged lot. And they do a good job of service in the place of their practice.

US problem is one of ideology - it's like an infantile paralysis! Unless and until you're able to overcome your bloody stupidity (yes! that's what it is) there will be no health care of value to satisfy the demand and specially for the uninsured ones.

[anne]

Hari:

"Our doctors are all private practioners and negotiate their professional service rates directly as a collective (union!). They're definitely NOT a previleged lot. And they do a good job of service in the place of their practice."

Spooking ourselves with terminology is what we repeatedly do, as a means of ending discussion. We are wildly ideological, but we deny even that we are. Only others are ieological, so the terminology is a mask we use.

[Real Person from the Real World]

One thing, we need to stop thinking that health care is some commodity to be sparingly doled out. New technology is always evolving, and while there is a cost, the new advances are worth it. Costs are inflated by all the middlemen, and the right to charge whatever the market will bear, because of the notion that somehow, the market is always right. Middleman follow, extracting their cut, and there are more and more layers of them. Meanwhile we allow a patent to provide monopoly power to the seller, and then extend it over and over and over. Then there is the undeniable appeal to parties involved, of the competitive amassing of more money and toys then someone else. The amount of toys one accumulates should stop becoming the measure of success. We need to acknowledge that some aspects of society are better when spread broadly, and that everyone, even obese smokers who are couch potatoes have a right to health care.

[Patricia Shannon]

Just last night I was reading ("New Scientist", I think), about how very expensive new medications are being used to treat cancer, w/o research into how much medication is actually needed to do the job, and how long a time is really necessary, because the drug companies benefit. I'll give details later.

[BJ Feng]

Rationing is a huge issue that needs to be discussed. Right now, everyone expects health care providers to do all they can to keep a person alive regardless of the cost. It is unacceptable to say, sorry, but there's a 95% chance of you dying in the next 6 months and the cost of treatment isn't worth the potential benefit. You know that there will be outrage, and the 5% who do survive longer than 6 months will make a huge issue of how the health care provider was "wrong".

All health care systems based on insurance require a "middleman" to collect payments from the healthy and reallocate those resources to the sick. The question is whether the government can do this more efficiently than the private sector. Given past performances and data on large government programs, the answer should be an obvious NO.

Those who advocate a government run program have to explain why they think the government can be more efficient in providing health care given the performance of other large government programs. Most answers revolve around cutting payments to doctors and hospitals which would have the effect of reducing supply (of doctors and hospitals) and is not a good solution. Medicare costs have risen far beyond inflation even with the reductions in payouts and restrictions, there is simply very little evidence that the government can do a better job than the private sector in regards to providing health care.

We can compare our US system to others, but people have to consider that we have the 3rd most populous nation on the planet. The number of people that will be covered is magnitudes higher than what the systems in Britain, France, and Canada currently deal with. We have to consider if those systems are scalable or if the "high" cost of US health care is due in part to the large number of people in the system.

[Cyrille]

Er, the EU has more people than USA.
Pretty much all of them are covered, at a fraction of the cost of the partial USA coverage.

That's a fake issue.

[reason]

BJ Feng
Huh? Do you ever read your own stuff?

If you took Western Europe as a whole, you have a clear counterargument to your (strange) argument from scale.

One of the problems we have in the world (as a result of computerisation) is that increasing returns to scale are now much more common than they were, and the result is monopolisation (winner take all markets).

The logic of insurance makes it problematic for the free market (in particular there are huge information problems for the purchaser - they cannot forsee the future policies of the firm they choose to insure with - and no one will take over a bad risk in the future). But there is anyway a completely different problem with medical insurance, we expect an element of social insurance to be included. No one wants to live in a world where the infectious and chronically ill are lying in the streets untreated. Need and ability to pay do not necessarily go together. Yes there is, and will always be an issue with what services are provided to whom in what circumstances. But that difficult choice will have to made whether insurance is private or not, and is not relevant to the decision.

[reason]

Cyrille,
it seems we posted in parallel.

[BJ Feng]

The EU does not have a monolithic entity responsible for health care, nor a single health care system. People have posted differences even between Britain and France. Regardless, it was more of a question than anything else. I don't know how easily scalable health care systems are, but that should be considered. We, in the US, could be facing an unique situation.

[Icarus]

BJ Feng/Cyrille...

I think we hit one of the kernal issues. There are many who do want to connect ability to pay, and cost of treatment, to the decision to treat. And, this isn't considered 'barbaric', but prudent. There are others (the 2 of you I presume), who don't want any calculus of cost/benefit, into the equation to treat.

I suspect that we won't bridge that gap. But, it is part of the problem of socializing medicine. There are simply too many people who don't want to pool their health care dollars with obese smokers who are couch potatos. Do they have such a right?

If we believe in private markets, they do. Even if we believe in private and public markets co-existing, they do.

The quesiton is...who pays for those obese smokers? If you're asking the professional classes, or capitalist classes to pay for this, I suspect there will be a collective outrage, or flight. If you expect to put this into the product costs of goods, I suspect it'll breed more imports and off-shoring.

I tend to believe that it is an individual's responsibility to contribute enough to society to warrant their costs. Of course, in situations of inability, the family, or clan should be the natural provider of funds. If they can't, we then move to municipal and state charities.
Inherent in this argument is that some people have to accept death, and that will cause all sorts of resentments.

Also, the key social shift is to encourage, through policy, that people have the amount of children they can rationally afford. Putting a child into this planet, without the funds to maintain a secure and healthy household, is irresponsible, and a recipe for the cycle of poverty. No amount of govt handouts will change that. The bottom line is that the capitalist and professional classes have no interest, or obligation, to finance the healthcare, food requirements, education requirements, and all sorts of other desired entitlements, of irresponsible parents.
Such a logic will lead to pervers outcomes.

In order to better build a healthy, and less poverty stricken society, we need to inculcate the ethic of care, personal investment, restraint, and prudence. No govt agency can susbstitute for that.

[Patricia Shannon]

From New Scientist Magazine,Dec. 1, 2007 page 8

http://www.newscientist.com/channel/health/mg19626323.600-paybyresults-pricing-opens-up-better-cancer-drugs.html

"Pay-by-results pricing opens up better cancer drugs"

This article discusses the high cost of cancer drugs.

Recently,people with certain types of early-stage breast cancer in the UK, New Zealand,and Australia had to pay up to US$70,000 of their own money for a year's treatment with the drug Herceptin. Only an outcry from patients forced the health systems in these countries to pay for the drug. Eventhen,the New Zealand government chose to fund only a nine-week course, with patients having to make up the difference if their doctors prescribe a full year's treatment. In the US, it costs up to $250,000 to buy drugs that will extend the life of someone with advanced colon cancer by an average of just 22 months.
...
In the US, 1 in 8 cancer patients have defaulted on debt payments due to their treatment costs and have been contacted by a debt collection agency, according to a survey by the non-profit Kaiser Family Foundation, even though they have some form of health insurance. Tor those without insurance, the proportion is far higher.

In the case of a drug that doesn't work for 1 in 3 people, the drug's manufacturer proposed a pay-for-performance deal. The final negotiationis that the British NHS will pay only for patients who have tried another treatment but relapsed, and will only pay if blood tests show it is working.

The article also pointed out that when drug companies do clinical trials, they tend to use the maximum tolerated dose rather than the minimum dose that might be effective, and that independent studies can show that much less is needed. Eg, 9 weeks vs 1 year.

This is an area where government expenditures are surely justified.

[Patricia Shannon]

http://news.yahoo.com/s/ap/20080325/ap_on_he_me/healthbeat_cancer_costs;_ylt=AllPLifZau2uR0fU8_72vhCs0NUE

Weighing costs in choosing cancer care
By LAURAN NEERGAARD, AP Medical Writer Tue Mar 25, 6:00 PM ET

[dale]

Medicare cost increases have outpaced inflation. But so have private medical costs. I believe the existing government health care costs have increased more slowly than private sector. But the main point is that there is not a medicare cost crisis. There is a health care cost crisis- public and private. And a properly designed universal plan of coverage will help contain costs. Other advanced nations get equal or better health outcomes for half the price.

And Social Security- as an example of a large government run program spends about 1% of what it pays out in benefits per year for administrative costs. I wonder how much such costs are for private pension and insurance plans?

[BJ Feng]

Health care costs must rise as the demand for health care increases. Why? Because we need to attract workers into the health care sector. To get each additional person, we have to offer a better wage than what they could get elsewhere. So some guy in IT, or more likely a person in college thinking about majoring in computer science, has to be lured into the health care field. Same with econ majors who would otherwise go on to finance.

We can't limit wages indefinitely like some people advocate, or else you won't be able to attract more doctors and nurses and people into the field.

This is not an argument about the current US health care system vs. others, I've already discussed that aspect. My point is only that as boomers age and demand more health care, we'll have to spend more (all things being equal) to get more health care providers into the system. The system itself can be improved as stated before, but I doubt that it can be accomplished by limiting how much doctors and those in the profession earn.

[reason]

BJ Feng,
your argument assumes that health care cannot be made more labour efficient. I thought one of the main arguments for single payer (especially pushed by PK) was that the current system was very inefficient, with many people employed unproductively in trying to stop people from recieving payments or alternatively trying to overcome those trying to stop the payments.

[Cyrille]

For a second I considered replying to Icarus, but then I realised that replying to someone equating the proposition that, as long as it's pure health that is at stake, ability to pay should not come into the equation with "[not wanting] any calculus of cost/benefit" is of course useless.

Of course, it gets even worse after that...

As for BJ, if you want to attract people to health studies, what about making those studies free? Should work a treat...

[Icarus]

So Cyrille, are you ok with the state of Florida spending c. $15 million on Terry Shiavo?...or cases which are similar?

It's quite easy to state that everyone should get everything, but, as any economist must know, we have finite health care resources. That money could have been spent on more people, improving the health of greater numbers.

[Cyrille]

No, I was not OK with the silly waste on Schiavo. That was not related to health -she was dead already.

This has nothing to do with universal healthcare. We have that in France, and we don't waste millions on dead people.

"It's quite easy to state that everyone should get everything"

Possibly, but the thing is, I never said that. Or anything remotely resembling that.

[Patricia Shannon]

Cyrille, I sympathize with your frustration in trying to have a rational discussion with Icarus. I believe it is a waste of time. He has nothing of value to say, and is incapable of learning. For him, any discussion is a war, not an exchange of information and ideas.

[Patricia Shannon]

The benefits of leaving everything to private interests, with no government regulation at all:

http://www.sciencedaily.com/releases/2008/03/080325163756.htm

Some Cancer Trials May Have Incorrectly Reported Success: Review Finds Flaws In Study Design And Analysis

ScienceDaily (Mar. 26, 2008) — A new study reviewing 75 group-randomized cancer trials over a five-year stretch shows that fewer than half of those studies used appropriate statistical methods to analyze the results. The review suggests that some trials may have reported that interventions to prevent disease or reduce cancer risks were effective when in fact they might not have been.

More than a third of the trials contained statistical analyses that the reviewers considered inappropriate to assess the effects of an intervention being studied. And 88 percent of those studies reported statistically significant intervention effects that, because of analysis flaws, could be misleading to scientists and policymakers, the review authors say.

“We cannot say any specific studies are wrong. We can say that the analysis used in many of the papers suggests that some of them probably were overstating the significance of their findings,” said David Murray, lead author of the review study and professor and chair of epidemiology in the College of Public Health at Ohio State University.

“If researchers use the wrong methods, and claim an approach was effective, other people will start using that approach. And if it really wasn’t effective, then they’re wasting time, money and resources and going down a path that they shouldn’t be going down.”

Murray and colleagues call for investigators to collaborate with statisticians familiar with group-randomized study methods and for funding agencies and journal editors to ensure that such studies show evidence of proper design planning and data analysis.
...
“Am I surprised by these findings? No, because we have done reviews in other areas and have seen similar patterns,” Murray said. “It’s not worse in cancer than anywhere else, but it’s also not better. What we’re trying to do is simply raise the awareness of the research community that you need to attend to these special problems that we have with this kind of design.”

The use of inappropriate analysis methods is not considered willful or in any way designed to skew results of a trial, Murray noted.

“I’ve seen creative reasons people give in their papers for using the methods they use, but I’ve never seen anybody say it was done to get a more significant effect.

Of course, people who stand to profit by inppropriate analysis methods would never do that on purpose. Yeah, sure.give me a break.

[Icarus]

Oh Cyrille,

But she was not "dead", according to our US health system. She may have been a 'vegetable', but, that is still alive, and hence could warrant costs.
The state spent $15 million keeping her a vegetable. It's costs like these which have to be curbed off the top, and we need a legal process to do it. Right now, there is none.

And, the tough issue here is who/how we decide which life we can rationally help. What can we afford to do?

[Icarus]

Patricia $2.10 Shannon,

You may want to spend more time considering why some people choose to sleep on the couch instead of working through medical school, and leave the exchange of information and ideas to those who choose to be awake, and work smart.

[Cyrille]

There is a specific kind of meanness in implying that people who are unfortunate enough to have a condition that requires them to have a regular sleep pattern lest they fall seriously sick are necessarily lazy sloth.

Or that discussion should be limited to people who think that there is nothing to life besides one's career. I chose not to work at McKinsey's, largely because of their crazy hours. Does that mean they only should take part in the exchange of information? My impression was rather that they were not very worthy contributors, since their awareness of the world beyond their offices was apparently rather low.

[Icarus]

Cyrille,

It's convenient that some people want more sleep, and live without focus on careers...but, then want to collect handouts, or, argue for more handouts.

Anyone can have a life beyond their career. The point is that one's career is the vehicle to sustain security and material need. If one can't sustain a career which doesn't provide that, and yet produce children which further exacerbates costs issues, isn't this a recipe for the cycle of poverty? Instead of blaming others, one should look at one's choices.

There is a world beyond uncritical procreation. Pick up a book, exercise a little, perhaps visit another land. Popping out children, sleeping over career building, and whining for further handouts is not a path out of economic insecurity.

[Patricia Shannon]

Cyrille, if Icarus was talking about me, thank you for your reply. I don't pay attention to him. Regular readers of this blog know what he is. He is pitiful. Only someone very much lacking in self-esteem and the ability for connection with others would think the way he does. From my experience, he will probably never change, but there is a possibility.

[Lafayette]

Living in a bygone world

Article: Never mind that nobody is proposing to turn doctors into public employees and hospitals into government institutions -- the literal meaning of socialized medicine.

Well, if it quacks like a duck ...

Policemen, Generals, Air Traffic Controllers, Judges, Firemen, Prosecutors, Teachers ... they are all Public Employees. Does that make them any less of a professional or any more of one? Of course not.

When a nation has a Critical Service that it must make available to the largest part of the population at the least cost possible, then that service is rendered as a Public Service. There is no shame in that, just good, common sense.

Of course, no one cares to mention that a GP's median salary in America is three times that of secondary school teacher. GPs are really, truly worth three times as much as educating the nation's children? Only if we let it happen.

We are living with dotty, old-fashioned notions in a bygone world. Let's wake up and smell the coffee.

[Icarus]

Patricia $2.10,

Lets see...a lack of self esteem? Hmmn. Funny, that the person blaming the world for their inability to take care of their own life is whining that others with a sense of personal responsibility are lacking "self estemm". I now wonder if you even know what it means.

We may disagree on quite a bit. And, we may even think the other ridiculous. But, between the two of us, I don't need handouts from others, and don't plan a life where I will. How's that for 'self esteem'?