"Extending Health Insurance Can be an Effective Stimulus"

Dean Baker says we should include health care reform as part of the stimulus package:

How Obama can save the US economy, by Dean Baker, Commentary, CIF: ...The country's economic crisis poses substantial dangers but it also presents enormous opportunities. ... Specifically, Obama can take advantage of the current economic crisis ... to jump-start national health insurance. Extending health insurance can be an effective stimulus that will provide an immediate boost to the economy. More importantly, it will provide the same access to healthcare that people in other wealthy countries have long taken for granted. ...

Economists from across the political spectrum are now calling for a large stimulus package ... The consensus is in the range of 2.0-2.5% of GDP, or $300-400bn a year.

This level of agreement among economists is encouraging, but the reality is that it is difficult to spend $300-400bn a year on short notice effectively. There are some no-brainers...: aid to state and local governments, extended unemployment benefits and extra money for food stamps and home heating oil assistance. This is money that will be quickly spent, boosting the economy, while helping those hit hardest by the downturn.

A stimulus should also include increases in infrastructure spending, which will come about by moving plans forward for projects already on the books. There should also be a substantial green component, involving retrofitting homes, businesses and other buildings...

However, after we get through this list, the sum total ... is probably still in the neighborhood of $150bn a year, at best half of the targeted sum. This ... gap ... will be filled by extending healthcare coverage.

As a basic outline, the government can give a substantial tax credit (eg $3,000) to employers who cover workers for the first time in 2009 and 2010. It can also offer a tax credit ...[to] employers who increase ... coverage. ...Credits can also be given to individuals who are ... not otherwise covered...

If 20 million workers get coverage through this tax credit, that would cost $60bn. If another 60 million get an average of $1,000 in additional healthcare benefits, this would cost another $60bn. If we also ... reduce the healthcare burden for Medicare beneficiaries ... by $1,000 each, this will cost roughly $40bn. The total cost would be $160bn a year...

At the same time..., we should open up the Medicare system, allowing all employers and individuals the option to buy into a Medicare-type plan. This is important, because a well-working public sector plan will be important to controlling costs over the long-term.

After 2010, the tax credits would be cut back, with the goal being a system of subsidies that pay the full cost for low-income people, but phase out at higher income levels. ...

Extending healthcare coverage in this way is effectively eating dessert before dinner, but this is exactly what we want to do to counter the recession. It is important that we spend money now to boost the economy. We will be getting double-value if this stimulus can be spent usefully toward meeting a longstanding goal, like providing national healthcare insurance, rather than just buying things at the mall.

Fixing the healthcare system so that costs are effectively contained will be a long and difficult political battle. ... However, we should be reassured by the fact that every other country has managed to contain their costs more effectively..., and they ... enjoy better healthcare outcomes.

Over the long run, the task of containing healthcare costs is clearly doable. The question for President Obama now is whether he is prepared to take the big leap... This opportunity may not come again.

Comments

[a]

"Fixing the healthcare system so that costs are effectively contained will be a long and difficult political battle. ... However, we should be reassured by the fact that every other country has managed to contain their costs more effectively..., and they ... enjoy better healthcare outcomes."

That's the important point. What the U.S. needs to do is to spend *less* money on healthcare - particularly on drugs.

It also needs to spend *more* money on prevention.

[Health Care Is Number One]

Fixing the health care business model is more important than more roads are. Why do we want to encourage more driving, when carbon levels are rising? We should be encouraging good health instead.

[meli]

I would like to see a serious investment in research into preventative medicine. It would add high quality jobs in an area that has the potential to dramatically cut costs in the future.

All of our investment into medical research right now is driven by the profit motive. That means any natural cures or steps which don't involve selling someone something don't get any attention. It is literally killing us.

[ken melvin]

Interesting, this proposal for paying employers, let them make their best deal with insurers; then, let the government make its best for the remaining. Moving forward, quality of life needs to be seen as productive; just as much so as making gidgets. Think health care, think alternate energy, think electrical grid, think mass transit, ... It would be pure reagonesque to build more freeways, as much so as bringing back the battleships.

[No Distractions]

We've seen at least two occasions when health care reform was allowed to slip off the agenda. Needless to say, the insurance parasites will do their best to have it happen again.

Getting rid of the tax we pay to insurance companies would be the best development the the budget, and the country, has seen in a long time.

Mr. Baker wants to be incremental: "Fixing the healthcare system so that costs are effectively contained will be a long and difficult political battle." Perhaps he's right; he usually is. I want a blitzkrieg. Take the insurance companies out all at once now. The longer they're allowed to dig in the harder it will be.

[Ninja Zombie]

Health Care is Number One,

How about this? We divert money from car-based infrastructure to bicycle-based infrastructure. It will probably improve health more than any medical care scheme, it will reduce carbon emissions, and it will increase the capacity of the roads.

Additional benefits: it's probably revenue neutral, as bike infrastructure is cheaper than car infrastructure.

Lastly, it will also make America more beautiful. Biking gives you great thighs, which is something the women of America truly need. Even NYC diet girls look ugly compared to a biker girl (let alone SUV driving fatties).

[Jay]

"I would like to see a serious investment in research into preventative medicine."

By preventative medicine you mean things like exercise and healthy eating habits? We know we are going to get a "drug czar". Will we get an "exercising czar" and a "food czar" as well?

Also notice how nowhere in there is the mention of NPV. I guess when a few people (the top 1%) are given a large concentration of power they can be expected to spend other people's money on other people recklessly.

[Jay]

And since socialists don't care about liberty I would not be surprised if the new food czar bans McDonald's, Wendy's Burger King etc. from selling any of the foods it currently offers, citing the externalities it causes on our health system. If we're lucky the government will take over all restaraunts and grocery stores we will only eat government approved foods like vegetables and fruits. Just take a look at how well the Venezuelan government runs the food supply.

[Jay]

"How about this? We divert money from car-based infrastructure to bicycle-based infrastructure."

Population densities (pop/km^2)...

Japan 339
Germany 232
Italy 193
France 110
U.S. (ex Alaska) 33

Get it???

[save_the_rustbelt]

Interesting idea, but I don't think it will work.

Employers, in a recession, are going to be hesitant to extend any benefit however it is paid.

An alternative would be a three year special expansion of Medicaid, including an effort on dental, preventative care, child health, etc., expanding both beneficiaries and services. The pipeline through the state programs is already in place.

[Jay]

"An alternative would be a three year special expansion of Medicaid, including an effort on dental, preventative care, child health, etc., expanding both beneficiaries and services."

With what money? I suppose we could create a 5% tax on all assets in excess of $200k excluding real estate and retirement savings. This would ahve two positive effects. The real estate market would receive a nice boost as people buy houses to avoid the tax. And the stock market gets a boost as people plow money in IRAs and 401ks to avoid the tax as well.

[ken melvin]

STR - unemployed eligible for Medicare?

[Health Care Is Number One]

"We divert money from car-based infrastructure to bicycle-based infrastructure."

Exercise is good, and should be encouraged. Mandatory bicycles won't work for many. You can't fit many groceries in a bicycle, snow in the North makes bike trails impassible, the elderly can't bike very far, and sheer distance in the burbs is too great.

That said, a lot of current driving is unnecessary. We should not encourage more driving than is necessary. More roads are not the way to go. Japan made this mistake, building pointless roads that few use. Meanwhile elder care in Japan was suffering a serious shortage. Japan should have diverted public resources to elder care, not roads.

In our case, fixing the business model in health care would lower prices, making health care affordable for the nation. The same amount of public money now spent to cover half our population would cover the entire population if we spent as much per capita as other nations. Higher prices are bad for consumers, lower prices are good for consumers.

[save_the_rustbelt]

Ken:

The way the state bureaucracies are structured it would make a great deal of sense to make the unemployed eligible for MediCAID. This move could be done very quickly (often the unemployment and Medicaid agencies are under the same umbrella, or if not at least have similar processing capabilities).

Phasing into Medicare would be a tougher administrative job, the system changes would take a long time to implement.

I would make the eligibility guaranteed for at least one year so no one would be in the short term problem of choosing a new job versus keeping Medicaid.

To save the state budgets the feds should pay 100% on the newly insured, and pay an extra __% on the previously enrolled. This helps solve state budget problems.

[anne]

"Just take a look at how well the Venezuelan government runs the food supply."

Care to reference this slanderous rubbish, and simply continue slandering on? I am all anxious waiting.

[kharris]

OK, we know that Baker wants a big expansion of health benefit coverage. So do I. That does not serve as an excuse to say a carrot is a banana. Some forms of spending are quite stimulative. Others offer very little economic stimulus. Do we know that health insurance is stimulative? If not, let's not get all dishonest and pretend that one policy goal will serve another.

That has been the whole trick with tax cuts. Business tax cuts have a very small measured impact of economic activity, though I suppose they are pretty good at shifting income and wealth patterns. Is the new boss to be just like the old boss, only substituting health benefits for taxes as the panacea? No thanks.

So, let's have a look at the stimulative effects of health benefit spending before we go diverting fiscal stimulus money to it.

Next problem. Fiscal stimulus should, in a well-arranged system, go away once the output gap has closed. Are we going to limit new health benefit spending to just that period in which there is an output gap? There may be some sense in that, if the benefit extends to those who have lost benefits due to job loss, or to those who are just entering the workforce and are unable to get a job mostly because the economy stinks. That would have a cyclical element. Otherwise, how does a new health benefit match up to a cyclical cure?

[kharris]

Rusty was making sense of a cyclical benefit program while I was busy writing. Tying a health benefit to jobless benefits would make the program cyclical. It would have the added benefit (a benefit from my point of view - others would disagree) of giving workers a bit less motive to tie themselves to employers. The gap between productivity gains and real wage losses in recent years suggests very strongly that power has shifted toward employers, away from workers. Workers now have to fear that their kids will have a hard time getting medical care if they don't salute every time they don't get a raise.

[burbed]

Infrastructure is more than just building roads - its maintaining what we have. How quickly we forget the Minnesota bridge collapse of a few years ago.

Its much more than roads too - its building new rails or reviving those that were no longer feasible once the USA became addicted to cars. Also, infrastructure includes power. Those in the North East will remember the regin wide power blackout from a few years ago. We have totally neglected these things for far too long.

[Walt]

The health care industry is probably at full employment. Spending more money probably will likely raise health care prices more than increase employment or output. If one wants to stimulate real output (not just aggregate demand), health care does not appear to be a great place to start. Long run, it might be that, like social security, government subsidized health care will make people feel more secure and reduce their savings and thus increase their spending. But that is long run.

[Jay]

Chavez never passed Econ. 101, so he doesn't realize that if you set price ceilings below the equilibrium price you get shortages...

http://www.washingtonpost.com/wp-dyn/content/article/2007/02/08/AR2007020801240.html

[Jay]

"The gap between productivity gains and real wage losses in recent years suggests very strongly that power has shifted toward employers, away from workers."

Lol. You compare mean productivity to median household income? I take it you never had a statistics class in your life. Or do you believe in imaginary normal curves? If your answer is yes, do you believe in flying pink elephants?

[anne]

"Chavez never passed Econ. 101, so he doesn't realize that if you set price ceilings below the equilibrium price you get shortages..."

Slander and ridicule on, for that suits a slanderer and ridiculer.

There is and has been no food problem in Venezuela, with poorer Venezuelans being remarkably well protected against food price increases. As with China, which is the model, price ceilings in Venezuela have been used remarkably well in assuring general access to well priced necessities.

[kharris]

Nice try, Jay. Did I cite either median productivity or mean income? I don't believe I did. So what you've really done is to create your own little straw man.

When we all get together to play regression tag, we'll argue what measures are legitimate. Till then, cut the crap. By the way, if your intent is to imply that workers' compensation has kept up with productivity gains, I'd love to see you try to make the case.

[anne]

"The gap between productivity gains and real wage losses in recent years suggests very strongly that power has shifted toward employers, away from workers."

Precisely so; but slanderers must slander and ridicule away for that is all they understand.

[reason]

Jay
is just in a bad mood because not only did his side lose the election, but they events are rapidly causing them to lose the argument as well. (Read EconLog recently, they are really going ga ga.)
But Jay please learn to be a bit subtler - socialism and social democracy are NOT the same thing.
Here is a nice blog post to read
http://trueconservative.typepad.com/trueconservative/2008/05/europe-vs-us-wh.html

[Jay]

"is just in a bad mood because not only did his side lose the election,"

Who said I support the Republicans? Are we know creating false dichotomies (you are either a republican or a democrat)?

[Jay]

"Nice try, Jay. Did I cite either median productivity or mean income? I don't believe I did. So what you've really done is to create your own little straw man. "

I'd like to see your numbers. Most studies I see use mean productivity and median household income. They also don't bother to adjust for the 20% decline in average household size (which many on this blog have claimed to be negligible).

[reason]

Jay...
surely the relevant statistic is average wages (per hour) not household earnings. And it is perfectly clear that a fall in average household size could ALSO be associated with a rise in the average number of earners per household. Stop playing stupid games.
And as for donkeys and elephants, I just assume you are fanatically against tax as all you propertarians are.

[Lafayette]

It only hurts when I laugh

Article: As a basic outline, the government can give a substantial tax credit (eg $3,000) to employers who cover workers for the first time in 2009 and 2010. It can also offer a tax credit ...[to] employers who increase ... coverage. ...Credits can also be given to individuals who are ... not otherwise covered...

Blah-blah-blah.

All the above are palliatives that do not consider the real goals and hurdles to an effective Health Care system. As if Universal Coverage was the Universal Answer. It ain’t.

We must distinguish between Preventive Health Care and Remedial Health care, for a number of reasons:
• Preventive Health Care is something learned from the youngest age, like how to be a couch potato. It must be taught in schools. Preventive HC is also a damn sight cheaper than Remedial HC and far more effective – when Remedial HC is called for, it’s already too late for the sick patient. (The doctor’s, however, just love it. It boosts their revenues.)
• With the current system, private insurance decides what will be paid and what not. So, Universal HC will not necessarily mean total coverage of all sicknesses. If left in the hands of private insurance companies, the level of HC will not expand one inch. Private insurance companies are not eager to pay for Remedial HC – they are eager to earn a profit by reducing costs. Only a Federally run program mandating universal coverage of HC both In Numbers (of people) and In Quality (of service provided) will bring effective HC to the American public. That cannot be done with the presently high pay-scales of HC-practitioners.
• Both Remedial and Preventive HC requires skilled practitioners. We need a crash program to train them. It will take 10 to 15 years. Let’s start now, because Obama won’t be around as PotUS when the fruits of this investment will show. Student Med-school grants followed up by a minimum time working in a National Health Service clinics/hospitals could be implemented.
• Only a federally run program will assure citizens proper coverage. Health Care is a Public Service, just like Defence – only the Federal Government can assure it is done right. The PotUS is C-in-C of our Defence Force. Why is the Dept. of Health not in charge of a far greater menace to society than bin Laden?

Obama will probably bend to the notion that “Something/Anything must be done”. Well, that’s the wrong notion. Just like his laughable proposition for a $5000 credit. That will buy you what sort of HC if you are seriously ill? A week in the hospital.

Others will say that bringing Private Hospitals back into the fold of Public Hospitals will be too costly. They never should have gone private, because now they are lucrative businesses. And has HC got any better?

It would be practicable to establish a parallel HC offering. Let people who want to utilize Private Medical facilities/practitioners do so. But, an alternative, lower cost HC offering should also be offered.

[anne]

Remember, this was through the expansion:

http://www.epi.org/printer.cfm?id=3091&content_type=1&nice_name=webfeatures_econindicators_income_20080826

August 26, 2008

Median Income Rose as Did Poverty in 2007: 2000s have been extremely weak for living standards of most households
By Jared Bernstein

Comparisons between 2000 and 2007 reveal:

* Median income fell further for working-age households than for all households because job and wage growth was particularly weak in the 2000s relative to past cycles.

* The poverty rate grew from 11.3% to 12.5%. During the seven-year cycle, the poverty rate declined significantly in only one year (2006). In contrast, poverty rates fell significantly in the 1990s.

* Family, as opposed to household, incomes were also unchanged over the cycle, for the first time since records were kept for this category starting in 1947. (The household income category, which includes single persons, was started in 1967.)

* Despite strong gains in earnings last year, men who worked full-time and all year lost ground in the 2000s. The median earnings of these workers "closely connected to the job market" were 3.1% lower than their level in 2000.

* After declining from 2003-06, women working full-time experienced strong earnings gains last year, up 5% in real terms. With last year's gain, their 2007 annual earnings were just 1.1% higher than in 2000.

* African American median household income rose 3.2% last year, but took a big hit overall in the 2000s, down 5% ($1,800).

* And yet workers were highly productive during this period. Output per hour, or productivity, rose 2.5% per year during the 2000 to 2007 cycle, compared to 2% in the 1990s, when family incomes fared much better.

[anne]

http://www.cbpp.org/3-27-08tax2.htm

October 22, 2008

Average Income in 2006 Up $60,000 For Top 1 Percent of Households, Just $430 For Bottom 90 Percent: Income Concentration at Highest Level Since 1928
By Chye-Ching Huang and Chad Stone

Average Income Gains, Adjusted for Inflation, 2002-2006

Dollar Increase
Percentage Increase

Bottom 90 percent
$1,446
4.6%

Next 9 percent
$14,496
10.0%

Top 1 percent
$321,132
41.8%

Top 0.1 percent
$1,809,824
57.6%

In 2006, the bottom 90 percent of households were those with incomes below about $105,000. The next 9 percent were those with incomes between $105,000 and about $368,000, and the top 0.1 percent were those with incomes above about $1,764,000.

[anne]

http://www.cbpp.org/8-9-05bud.htm

August 29, 2008

How Robust Was the 2001-2007 Economic Expansion?
By Aviva Aron-Dine, Chad Stone, and Richard Kogan

We examine Commerce Department, Labor Department, and Federal Reserve Board data on seven economic indicators: the gross domestic product, personal consumption expenditures, private domestic fixed non-residential investment, net worth, income from wages and salaries, payroll employment, and corporate profits. For each indicator, we look at average growth both since the economy hit bottom in November 2001 and since the last business-cycle peak in March 2001. We compare average growth over these periods with the average growth that occurred over comparable periods in the other business cycles since the end of World War II. (Growth is measured after adjusting for inflation, except for employment levels, where such an adjustment is inapplicable.)

For six of the seven indicators, the average annual growth rate between 2001 and 2007 was below the average growth rate for the comparable periods of other post-World War II economic expansions. Notably, this expansion was among the weakest since World War II with respect to both overall economic growth and growth in fixed non-residential investment. These two indicators should have captured any positive "growth effects" of the tax cuts.

The labor market also was weaker during the 2001-2007 expansion. Both employment growth and wage and salary growth were weaker during this expansion as a whole than in any prior expansion since the end of World War II.

The 2001-2007 expansion outperformed the average post-World War II expansion in only one area: corporate profits, which grew much more rapidly than average.

These conclusions hold whether one focuses on comparisons that examine the period since the expansion began in the fourth quarter of 2001, or comparisons that examine the period since the last business-cycle peak (i.e., since the 1990s expansion ended in the first quarter of 2001).

Annual Growth Rates Measured from Trough *

GDP
Consumption
Non-Residential Fixed Investment
Net Worth
Wages and Salaries
Employment
Corporate Profits

Current Expansion

2.8%
2.9%
3.9%
3.5%
1.8%
0.9%
10.8%

Post-War Average

4.3%
4.0%
6.0%
4.1%
3.8%
2.5%
7.4%

1990s

3.3%
3.2%
7.6%
4.1%
2.7%
1.9%
8.0%

* Average growth rate in 23 quarters after trough.

[save_the_rustbelt]

Kharris: and to clarify, this would not prevent long term reform efforts, but would put more care in the pipeline in a hurry, while potentially easing state budget problems.

Walt: there is enough slack in the system to provide more care to a meaningful, and keep in mind health care is a heavy fixed cost business, with only some areas having hevy variable costs. There will still be a nursing shortage but we can patchwork that as we have been.

[Andrew]

They also don't bother to adjust for the 20% decline in average household size (which many on this blog have claimed to be negligible).

CBO data on household income does, indeed adjust for household size.

[Keith]

Health care reform is great, but using it as "stimulus" is stupid. Stimulus policies are basically designed to put money out there as fast as possible to increase aggregate demand in the here and now.

That would not be the primary goal of the best health care reform, which should be to produce the best health care outcomes at the lowest possible cost to taxpayers.

For example, encouraging more foreign outsourcing of health care may be an excellent way to produce universal coverage and high quality health care at the lowest possible taxpayer cost.

Would Obama have the vision and the guts to do that? Is he smart and courageous enough to harness the genius and miracle of free trade and outsourcing to pursue important liberal social goals? Can he stand up to the unions and economic xenophobes to do this? I doubt it, but I'm willing to give him the cahnce to pleasantly surprise me.

[Patricia Shannon]

I started skipping over Jay's comments when I saw that stupid one about "socialists". I have a job, and don't have time to waste on ignorant meanness.

[Lafayette]

A fulcrum point

str: There will still be a nursing shortage but we can patchwork that as we have been.

You said it, "patch work". That is exactly the sort of HC system the US had degraded to, which is why it is 37th in the World Health Organization overall classification.

Patch work won't do to bring modern HC to a population of more than 360M people. Look at the top 15 nations on the above list. Only three of them are not European. All have government run Health Care systems. All are expensive, but since not one of those countries needs to nurture a Defense Military-Industrial-Complex, they can spend the money where it is most needed.

US Health Care is more expensive by about 5% of GDP than the principal European countries that spend around 10% (see here). For a Health Care performance that is absolutely mediocre (see here). This last ranking is based upon a number of parameters.

And, all this information comes from a WHO-study that is now 10 years old, so it's not the most recent. Still, a ranking of 72nd is nothing to crow about. I doubt much has changed, however, in a decade.

Sorry to bother everybody with "useless information", but I thought Health Care was a fulcrum point in the latest presidential campaign.

Got my bearings wrong, again, did I .... ?

[Lafayette]

Jay: U.S. (ex Alaska) 33 Get it???

Get what? Since when did population per square footage ever justify a high density of cars. That should make Africa a car driver's paradise.

A high car density could also mean that obese people don't like to cram their fat asses into public transportation?

[Lafayette]

As thin a string bean

HCINO: The same amount of public money now spent to cover half our population would cover the entire population if we spent as much per capita as other nations. Higher prices are bad for consumers, lower prices are good for consumers.

I didn't know we "consume" Health Care. But, why not?

I think rather, taking the onus of Remedial Health Care and placing it on Preventive Health Care would do much to lower the total cost of HC.

Not only, but high-cost health care reflects two factors. High cost HC-practitioners (average salary $150,000) and insufficient schooling of children in Health Care rules/guidance. Doctors aren't getting paid to prevent illness ... they make their money on curing illness.

This is a statement of fact and not a denigration of doctors. Who would refuse an (average) $150,000 salary as doctor to go to some school teaching kids how to eat healthy at a teachers (average) salary of a third as much. You'd have to be half-crazy to do that.

Obama is as thin as a string bean. That doesn't mean he is going to cure our over-indulgence in food. Nobody can do that but us.

[Insurance]

It is very interesting to see how others' feel about this. I'm not one to argue about politics-it seems futile to me-but i do enjoy seeing what other people think and how our views can be the same or very different.

[OhNoNotAgain]

Unfortunately the only thing that is going to make everyone eat healthier is an increase in the price of food that has a very low nutrition/calorie content ratio along with a similar increase in more localized food production. Combine a PSA/tax regime with a similar one against smoking (and fund it properly), and over the next decade it would take care of most of the problems that we're seeing. Use the tax to pay for the PSAs and ad campaigns.

[halbhh]

As many comments above show, there are a variety of good investments for stimulus dollars. We should put our eggs into many baskets.

Because it is more effective and more efficient.

A broader array of jobs will be supported/created by a broader array of types of stimulus.

Putting so much into health care only at once has a bad outcome: supply/demand imbalance will lead to yet higher prices!

[save_the_rustbelt]

Laf:

Last time I checked, many countries in the world were short of nurses, and were trying to seduce nurses from other countries.

Problem is:

1) lots of people don't want to be nurses
2) lots of people do not have the emotional toughness to be nurses
3) women have many career choices, men are not interested

We do need more educational resources. I proposed Ohio shut two law schools and open two nursing schools, not a popular position with the lawyers.

says...

Save the Rustbelt has the right idea. If you're looking for efficiency improvements, drop the $100bn a year wasted on the arbitrary malpractice system.

Although I agree our current system is completely screwed up, cutting provider payments is not stimulative. Most of the big targeted companies are public and will take 1 years worth of cuts discounted at their cost of capital.

The resulting loss in cap gains, corporate income tax, jobs. So there is a wealth effect. Destroying $5 in wealth to create $1 in cost reductions is not stimulative. Actually, the effect is worse than $5 (assuming 20% cost of capital), since unaffected companies will see their future prospects (and wealth reduced). Knowing that only 10% of a city has the plague doesn't make the other 90% more confident of survival.

I'm not saying the system doesn't need to be reformed, or that the single payer is not the way to go. Just don't delude youselves into believing this course is stimulative.

[Julio]

Lafayette,

"I think rather, taking the onus of Remedial Health Care and placing it on Preventive Health Care would do much to lower the total cost of HC."

On the mark as usual.

The main reason we need to take the patchwork of insurance companies out of the system; currently there is almost no incentive in the system for preventive care, and for keeping people healthy in general.

[Ninja Zombie]

Lafayette: "That is exactly the sort of HC system the US had degraded to, which is why it is 37th in the World Health Organization overall classification."

Those rankings don't measure what you think they measure. They measure a weighted average of various factors, including health care delivered.

One of those factors is "financial fairness", which basically penalizes non-socialized medicine. This is worth 25% of the total points in the ranking.

Is it any surprise that in a ranking scheme which penalizes the market-based systems, the market system comes out lower?

Note: health levels also only get 25% of the weight. So health levels are *just as important* as the free market penalty.

See here for details.

http://agoraphilia.blogspot.com/2007/07/whos-healthcare-rankings-part-1.html

[Larry]

@kharris - "Fiscal stimulus should, in a well-arranged system, go away once the output gap has closed."

Good point. Also, the changes we need are huge and their long-term impacts should be the focus.

"Tying a health benefit to jobless benefits would make the program cyclical."

Exactly. Health care in general doesn't have a lot of excess capacity. If lots of people lose their insurance that would change.

"giving workers a bit less motive to tie themselves to employers."

McCain's program attacks this at its root. I think it's a mistake to think in these terms until we stop taking on water.

@Laff - "We must distinguish between Preventive Health Care and Remedial Health care"

Another critical distinction is to separate the "insurance" part from the "coverage" part. You can't get fire insurance after the flames have started to rise. That would let insurance do what it's good at - cover the unexpected, at a cost that would be affordable for just about everybody. Existing conditions should be paid for from a separate funding stream. E.g., have an income-adjusted copayment with the balance coming from taxpayers.

"his laughable proposition for a $5000 credit. That will buy you what sort of HC if you are seriously ill? A week in the hospital."

What hospital is that? I bet it's multiples of that.

"Others will say that bringing Private Hospitals back into the fold of Public Hospitals will be too costly. They never should have gone private, because now they are lucrative businesses. And has HC got any better?"

Having distributed ownership drives competition. We're just starting to figure out how to rate provider quality. As we do so, that will increase competition and improve care. If it all becomes public, that opportunity will disappear.

@anne - "2000s have been extremely weak for living standards of most households"

Isn't a lot of this explained by the increasing absorption of money by exploding health care premiums, which doesn't show up as income?

[JasperPants]

Interesting discusion, vis a vis the potential benefits of a more egalitarian, "universal" health care model.

Are any of you commenters Canadian? British? I live in Ontario and have first hand experience, knowledge of a single payer, universal healthcare delivery model.

It seems to me a serious examination of the tradeoffs of our system should be part of your knowledge base.

A couple of early thoughts: Preventative care will likely not save as much as advocates are projecting. Also, some form of "no fault" immunity for doctors will likely be necessary or else your lawyers will vacuum any cost savings.

And here is the big question...under a US National Healthcare plan, would citizens be allowed to buy private insurance to get faster, higher end services from private hospitals? Or would this be prohibited?

If yes, how will you entice doctors and nurses to work in the public system? If not, how will you convince the millions of citizens that currently have speedy access to care to give this up AND pay higher taxes to boot?

[Selah]

How long do we have to wait to see if the bail-out package starting to take effect? Everyone seems to have his/her own suggestive solution to this economic crisis but none seems to fit in. The problem here is that the morale and the confidence of the consumer are down south. First, that feelings of hope and security needed to be restored. So hopefully, this new president elect Obama will bring us some hope and security; otherwise we probably need to start packing up and getting ready to find a new haven.

[BJ Feng]

So many questions! So many well reasoned doubts and negatives. Damn you all, do you have to think? Do you have to use your brain instead of your heart? Universal health care, whatever that means, will solve everything, that's all we need to know and understand.

It was all Bush's fault! He lied! His rich corporate buddies deliberately increased health care costs for profit! What we need is free health care for all and the very best health care for all without paying anything for it. All we need is to stop pandering to the rich and start using government for the middle class.

We can mandate all doctors and nurses work for nothing but food and shelter. Doctors are rich and have profited long enough. Any doctor who refuses to help Americans would be jailed or fined, it's time for the rich to do their fair share! As for nurses, they'll want to work for nothing because people want to help, without evil corporations, we'd all help each other.

Health care is not an industry that should be subject to profits! It's a fundamental right! So nurses should understand that they shouldn't expect to make "market" wages, we all know the market doesn't work anyway. They should be willing to work for whatever government decides to pay, only someone evil would want to make money in health care. People need to start focusing less on profits and wages and more on providing middle class America with their fundamental right to health care.

It's all Bush's fault! He made nurses and doctors greedy, and allowed them to exploit the health care system due to the lack of regulations. We just need to regulate health care and mandate that doctors and nurses work for "reasonable" wages and not expect to make a profit. It's time for the rich to contribute their fair share!

[Lafayette]

Privileged Health Care

NZ: One of those factors is "financial fairness", which basically penalizes non-socialized medicine. This is worth 25% of the total points in the ranking.

Is it any surprise that in a ranking scheme which penalizes the market-based systems, the market system comes out lower?

Brilliant deduction, NZ!!! I am sooooooo please you "saw through the subterfuge perpetrated by the WHO".

Now, like a smart person, ask yourself this question: "Why was the ranking system constructed in such a manner (a key weighting factor was subsidized medicine)." In the light of your considerations, you might answer this key question: What is the purpose of a national system of health care that people do not use because it is too expensive?

Then you will understand why Preventive Care cannot happen effectively for as long as the price of access (seeing your GP regularly or at the very first telltale sign of a medical anomaly) is not mandated at a low cost and subsidized by the state/federal government. Bingo! That's the key to how Preventive Health Care works.

And, that is what is happening. American Health Care has become a privilege of a certain class of people who are working for companies that can afford the expensive insurance policies that offer adequate HC. How many of Americans avail themselves of that privileged HC?

One sixth have no coverage whatsoever and it is estimated that another 35% have HC Insurance that is sub-standard, particularly in terms of total coverage. That leaves about half of Americans who benefit from a "privileged HC -nsurance scheme".

Here in France, I can get to see my GP (meaning any GP of my choice who chooses to be remunerated by the National Health Service) for $28 (the mandated price) -- seventy percent of which is reimbursed. In the UK, 100% is reimbursed. How much do you pay in the states?

En passant

How do companies recuperate the cost of expensive HC-insurance? By factoring it into the price of their goods and services. So, as consumers we pay an indirect tax for HC-insurance (of those privileged enough to have it) in the cost of all that we consume.

Now, if we pay for Military Services and a host of other Public Services directly out of the public purse (supported by our taxes), why not Health Care as well? Why must we support Health Care by indirect taxation, meaning paying companies to collect it (from their products and services) and then, in turn pay their private HC insurers?

It's downright stupid and adds to the cost of HC in America. Worse yet, these privatized HC-insurers have no incentive whatsoever to pay for Preventive Health Care. Such would just increase their costs and reduce their profits.

The Market System in America, in the case of Health Care, has got it wrong. All wrong.

[Ninja Zombie]

Lafayette: ask yourself this question: "What is the purpose of a national system of health care that people do not use because it is too expensive?"

Irrelevant, since "financial fairness" does not measure this. Financial fairness is sum |household income fraction spend on medicine - mean household income fraction spent on medicine|^3 (ignoring normalization).

If some people spend an affordable 5% of household income on medicine, while others spend 15%, the "financial fairness" measure will penalize this (both 5% and 15% differ from the mean). If *everyone* spends 25% of income on medicine, then a nation gets full credit on "financial fairness".

The latter case is more expensive, and worse for everyone, yet the WHO prefers it. I guess to them, equality trumps utility.

"Then you will understand why Preventive Care cannot happen effectively for as long as the price of access (seeing your GP regularly or at the very first telltale sign of a medical anomaly) is not mandated at a low cost and subsidized by the state/federal government."

Preventative care is a healthy lifestyle, plus a few routine screenings. Seeing your GP for every ache and pain is a waste of his time and yours.

"How do companies recuperate the cost of expensive HC-insurance? By factoring it into the price of their goods and services."

So you want to replace one tax with another. What is the benefit? You want to tax people to benefit (some) corporations? The main effect of such a scheme is to subsidize automakers at the expense of other industries.

"Now, if we pay for Military Services and a host of other Public Services directly out of the public purse (supported by our taxes), why not Health Care as well?"

Military protection is a public good. It is non-rivalrous (you and I can simultaneously enjoy dead Iraqis) and non-excludable (if you produce dead Iraqis, you can't prevent me from enjoying it if I fail to pay). The market will underprovision such goods, so government action may be helpful.

Health care (with the exception of epidemic prevention) is a private good. It is rivalrous (doctors can't treat you and me simultaneously) and excludable (I don't pay, I get no service). There is no reason to believe the market will underprovision such a good.

[Larry]

@Beej and Laff

It's nice to see your posts back to back. One thing Laff doesn't mention is that, a la Beej, doctors in France make a fraction of what the rich, greedy doctors make in the US.

[save_the_rustbelt]

"doctors in France make a fraction of what the rich, greedy doctors make in the US."

I suspect you haven't done any tax returns for family practice doctors lately.

[Lafayette]

One thing Laff doesn't mention is that, a la Beej, doctors in France make a fraction of what the rich, greedy doctors make in the US.

And, it is not for a lack of trying that I haven't mentioned it. I just can't find the average earnings of a doctor in France. I'll keep trying though.

Nobody can sway me from the conviction that European Health Care, which costs half as much per capita as the US, is more affordable because doctors earn less. As they should, because GP-salaries are capped by cost per visit as well as the cost of specialist interventions, both fixed by the state.

You gotta be crazy to think a cancer cure should only go to the highest bidder.

[Lafayette]

NZ: So you want to replace one tax with another. What is the benefit?

You don't understand the fundamentals of Social Fairness.

Under the present system of Health Care, 16% of Americans who do not have any coverage and 35% who have insufficient coverage pay for those who have 100% coverage.

C'mon, it's an obviously unfair manner in which to provide Health Care.

Besides, I want to cut out Private Health Insurers altogether. They are not tasked to provide Preventive Health Care, which is the key to a Rational Health Care system.

You are tiresome, NZ.

[Larry]

@rusty - "I suspect you haven't done any tax returns for family practice doctors lately."

I believe the numbers are average vs average. Family docs make less than average...

@Laff - "Social Fairness"

That's a new term for me. Where does it come from? I can make up a definition, but since you put it in caps, I suspect it must be somebody's official doctrine.

"Under the present system of Health Care, 16% of Americans who do not have any coverage and 35% who have insufficient coverage pay for those who have 100% coverage."

Actually, it's the other way around. The people who have insurance pay for those who don't. Those without insurance get a lot of health care, and while they pay for a lot of it, they also get a lot for free.

[Lafayette]

Larry: That's a new term for me. Where does it come from? I can make up a definition, but since you put it in caps, I suspect it must be somebody's official doctrine.

There are several phrases that mean much the same thing: Social Justice, Income Equity, Solidarity.

It's a notion that Americans are not familiar with ... that the benefit of the community is before that of the individual. It's not a doctrine, just a sentiment fairly widespread in Europe and unheard of in winner-take-all America.

[Lafayette]

Larry: The people who have insurance pay for those who don't. Those without insurance get a lot of health care, and while they pay for a lot of it, they also get a lot for free.

Facts, Larry, articulate facts. You're indulging yourself in sentiment. Another few steps and you'll be ranting about Welfare Queens.

Nothing is free, I agree, someone pays for it somehow. But, it is a fairly well known fact that 16% of the US population has no insurance coverage. The fact that hospitals have ER-services is NOT considered decent Health Care, for the numerous reasons I have given in previous comments.

Namely one, ER delivered HC is typically too late. You see, the "E" stands for "emergency".

[Ninja Zombie]

Lafayette: "Under the present system of Health Care, 16% of Americans who do not have any coverage and 35% who have insufficient coverage pay for those who have 100% coverage."

"Pay" is an interesting word. Could you explain what it means? Are you somehow suggesting that an illegal alien without health insurance is somehow paying the insurance premiums for a middle class worker with coverage?

Or are you simply asserting that everyone pays for medicare, but only a few receive it? If so, I've got a simple solution to that: eliminate medicare.

"Besides, I want to cut out Private Health Insurers altogether. They are not tasked to provide Preventive Health Care, which is the key to a Rational Health Care system."

Lifestyle choices are the only type of preventative medicine we are not fully exploiting at the moment. But if you want to push socialized gym memberships, I won't argue against it.

It's ridiculous to pretend that visiting a doctor for every sniffle is a solution to anything. All that's going to do is waste time and money, and *increase* costs.

[kharris]

Ninja,

Your comment on health rankings begins by asserting that "those" rankings don't measure what we think they measure, and then go on to provide very specific points. The very specific points seem to apply not to "those" but to "that" ranking. Whichever ranking system uses the formula you describe. There are a number of methods of ranking, however, which show the US far from the top. There are a number of single factors on which the US ranks well down the scale. It is not true that we are always ranking for fairness. The US pays more for health coverage per capita than any G20 country (which I suspect means more than any country at all) and does not rank high among G20 countries for results on a wide range of measures. The constuction of a some single measure of health care system performance does not change our poor performance on all the other measures.

[kthomas]

"But if you want to push socialized gym memberships, I won't argue against it."

I've felt for a very long time that this idea you expressed here would have profoundly good effect on the health of our citizenry.

The Gym is a miraculous place of healing and good health, for all people.

[Patricia Shannon]

It is common for doctors and hospitals to charge uninsured patients more than insured patients. This is because to get a contract with an insurance company, the medical people have to agree to accept lower payments than they otherwise would charge. The trade off is they get on the insurance company's list of providers. So the uninsured patients are charged more to make up for that.

I experienced this first hand last year. I haven't had health insurance (except for a little over a year) since 1990. I had cataracts, and was on the exact boundary (in my better eye) of being illegal to drive. I got on a plan one of my co-workers told me about. It's not insurance. It's a discount plan. The contract that medical providers sign with this company includes the provision that they will charge the discount patients the same amount they get from the insurance company for the insured patients.

I got one cataract removed, and a lens implant, and saved enough money to pay for about 3 years of premiums ($70/month).

[BJ Feng]

How much was your total out of pocket cost Patricia, if you don't mind? My quick calculations show that you "saved" $2520.

My theory is that hospitals charge high prices for non-insured surgery or treatment because they don't expect the person to pay up in full. That allows them room to negotiate the price lower, that is settle for 50% and then they can write off the other 50% as a charitable donation or something to that effect. In the worst case, they just donate 100% and can put that in their stats for total amount of services given away per year. Non-profits can justify their status based on the amount they give away per year.

Still it must be a money losing proposition or else emergency rooms would not be closing left and right all across the country. The uninsured do cost more than they pay, and someone has to make up the difference. The hospitals try to get what they can from the few who do pay, but have to make up the rest by charging insured people and health plans more.

I believe that the savings from preventive care is overblown. Heart disease and cancer are the two biggest killers. Both involve lifestyle choices, and we know that preventive care will do next to nothing to solve the underlying problem which is unhealthy lifestyle. If anything, all the patient will get is a cocktail of drugs to treat the symptoms. Preventive care in those cases will cost more, and have limited benefits, such as keeping alive someone with heart problems an extra two years or so. The drugs cannot cure the problem, yet cost a lot.

Cancer can be treated easier and more effectively if caught early. But someone who develops cancer is at risk for other types of cancer. Eventually they will die of some other disease relatively earlier than a person who doesn't have the underlying bad health and lifestyle. I read a study a while ago showing that even successful cancer treatment only allows an average of two or three extra years of life. I wish information on this aspect would be discussed more, I could be way off and this is very important for determining what we should do.

[Ben Park]

I don't know much about economics so I am posting a question. I will start medical school next year and I am concerned about taking on 150k+ in debt. Looking at current physician salaries and job outlooks I have come to wonder, Why if GPs or family care docs are in the highest demand why are they paid the least? Secondly what would Pres. Obama's health care plan mean for doctor's salary. I am leaning towards primary care but with the raise in tution costs I feel I will be persuaded to a higher paid specialty (assuming they still make what they do in 8 yrs).

[save_the_rustbelt]

Ben Park:

Go to dental school. The income is excellent and the lifestyle is much better.

If you do go to medical school, try to be in the top 20% of your class so you get a shot at a surgical specialty - ortho, neurosurgery, etc.

Avoid general surgery, as they get called in the middle of the night for a lot of PITA trauma causes, and appendectomies and lap-colies don't pay all that well.

Family practice docs get paid by the service, and if you look at the CPT codes and fee schedules you will see that a family doc has to see a lot of patients to cover the fixed costs and make a living.

According to some influential economists, we should cut health care spending (% of GDP) in half, supposedly by administrative efficiency blah, blah, blah. There will be further revenue compression in physician practices, without enough offset in costs.

[Patricia Shannon]

BJ, why do your "theories" always assume that the rich and powerful are good and well-intentioned?

[Patricia Shannon]

BJ,
I have previously posted in this blog at least one study that found that hospitals that did a good job on treating illnesses early, before they became severe, saved money. I'm not going to waste my time trying to find it, because it if you do read it, you will have erased it from your mind by the next day. One example would be that treating kidney infections will decrease the number of kidneys that fail. A single patient with kidney failure uses a lot of resources.

To the best of my memory, my cataract surgery (for one eye) was in the neighborhood of $6,000. I put a tissue over my glasses on the other side when I'm driving, because otherwise the view from the uncorrected eye interferes with the sight from the corrected eye.

If I hadn't gotten an IT job just in time to save enough for the operation, I would have ended up on disability, which would have cost the taxpayer enough in the first year to pay to have the cataracts removed from both eyes. I wouldn't have been eligible for Medicare for two years after becoming eligible for disability. I don't know whether Medicare would have have eventually paid to have the cataracts removed.

[benamery21]

Jay:On bicycles, mass transit, and population densities

Since the 2000 census found that 3/4ths of the U.S. population lives in 2.1% of the U.S. land area your point is a bit... umm ...blunted?

Population density

U.S.(ex hinterlands): ~1000 per km^2

[benamery21]

STR: Cutting healthcare spending in half is not purported by most (or any) influential economists to be possible thru administrative efficiencies, since administration is not 50% of healthcare spending (even in the U.S.) despite its unconscionably bloated share of that spending.

However, cutting U.S. healthcare system expenditures in half while improving outcomes is widely believed to be possible by economists (at least those in the reality based community) who recognize that such systems already exist.

The mechanism you are missing is the improvement of medical treatment quality (not by improving on occasional virtuoso performances but by executing the mundane perfectly every time and any time necessary) and thus eliminating system-generated healthcare demand created by systemic (not individual) error and neglect.

[benamery21]

The uninsured are not charged more to make up for lack of compensation by the insured, they are charged more because the provider has both pricing power and greed but lacks a conscience.

[Lafayette]

NZ: Are you somehow suggesting that an illegal alien without health insurance is somehow paying the insurance premiums for a middle class worker with coverage?

No, and neither the Welfare Queens. You forgot the Welfare Queens, NZ.

Or are you simply asserting that everyone pays for medicare, but only a few receive it? If so, I've got a simple solution to that: eliminate medicare.

Essentially yes. I repeat, companies factor HC-insurance costs into their products and services. Some of the cost is also paid by each worker who opts for the insurance, if available, and deducted from salary.

The problem is this and always has been: This fixation we have for "choice" was warped by the anti-Hillary K-street lobby to mean that your doctor would be specified by the state. (They will throw up just about any bullshit to confuse the issue.) I have a state mandated insurance in France that allows me to got to the doctor of my choice -- whether they are part of the National Health Scheme or not. If they are not, I am reimbursed up to the amount that I would have been allowed under the NHS. There are plenty of fully private doctors in France and they have a select clientele.

The part, in America, that is recuperated from products/services, we all pay for it as consumers – illegal aliens, Welfare Queens, and those who must work with companies that do not offer it – and today that amount is one out of six of the population. It would not surprise me if you think that "fair".

My simple solution is to extend Medicare to everyone. Medicare mandates pricing of certain medical services and is the ONLY way we will get a handle on HC-costs. This will allow doctors to accept patients either as NHS-certified or Private practitioners. From there, we let patients make the choice.

Clearly, most will flock to the NHS-service with its lower mandated prices. This means more patients but less revenue per patient and therefore less overall revenue. We are at the mercy therefore of yet another bunch of greedy people who seem to have forgot the Hippocratic Oath.

It's ridiculous to pretend that visiting a doctor for every sniffle is a solution to anything. All that's going to do is waste time and money, and *increase* costs.

Oh, yes, we are those hardy pioneer Americans of yore. We can take care of ourselves, right?

You are both right and wrong. Self-medication can perhaps take care of the sniffles. But, it cannot attend to a more serious malady of which we are ignorant that grows within us until -- at the ER, we get the bad news that "its too late, why didn't you come in earlier?"

Children should be pointed the finger in school for imminent obesity and placed with a doctor (GP or psychologist) to address the matter. That is preventive medicine, which is not happening in the US. We let them become couch-potatoes, so we should not be surprised that more than half the American population is overweight.

There are many cures to cancer nowadays that are effective, IF the cancer is identified and the cure given in time. But, that will not happen for as long as people do not go to GP’s for regular check-ups. And what does extending coverage to "all" mean. It means we are going to have one helluva medical bill at the prices now being charged. That insanity must be stopped.

But if you want to push socialized gym memberships, I won't argue against it.

Sarcasm is the last refuge of someone bereft of rational arguments.

You haven’t the foggiest notion of what the word socialism means, ensconced as you are in the conventional wisdoms of yesteryear, that are sadly wrong. But, NZ, you have plenty of company.

Which is why HC in America has become such a central issue to our well-being.

[save_the_rustbelt]

"The uninsured are not charged more to make up for lack of compensation by the insured, they are charged more because the provider has both pricing power and greed but lacks a conscience."

The uninsured as are charged more because federal regs cause the "retail" price to be at least 2x Medicare rates, very byzantine regs. Many of the balances end up written off regardless of the original charge.

On cost savings, I should have been clearer, the "save 50%" crowd believes a substantial portion of the savings can be in administration.

[Lafayette]

Less strategic to the nation

str: I should have been clearer, the "save 50%" crowd believes a substantial portion of the savings can be in administration.

I doubt that seriously. Admin costs, in ANY organization, rarely amounts to more than 10 to 15% of Total Cost.

They'd be papyrus-based in their paperwork to amount to much more. I suspect the above sort of statement is just more bullshit confusion from the K-Street cronies of the AMA.

We cannot have Affordable Health Care in America at the present practitioner wage-rates. These people are all in short supply, so they command high wages.

One of the solutions is an educational program to produce more practitioners. Another is to have them work in federally funded agency on Civil Servant wages. If we can do that for the Army, why not Health Care. It's less strategic to the nation?

En passant

In France, I pay my GP for a visit with my Credit Card. He acknowledges payment to the National Health Service electronically, which then credits my bank account automatically with 70% in reimbursement. If I have Mutual Insurance, they are informed electronically by the National Health Service and pick up the rest.

The only administrative people employed in the system are with the National Health Service.

If the illness is serious, the GP prescribes further tests. These are paid for in the same manner. If the tests conclude some serious illness, the GP makes the request to the NHS and the full cost of Remedial Care is fully covered by that agency. Pharmacy costs are included in the coverage.

The French National Health Service is considered the best in the world. Yes, it is expensive -- but France is not the world's policeman and its Armed Forces account for far less of the national budget.

How it runs is resuméd here, but it will require good French to understand the numbers.

One important point from those numbers: More than 50% of the cost comes from payroll taxes. Just like in the US, which means the cost is recuperated by the employer when factored into the total operational costs that determine pricing for goods/services sold. We all pay for Health Care, whether its good, bad or indifferent in quality. Most importantly, we all pay for it whether we have it or not, which is a gross injustice if our employer does not offer it.

Another important point: The French NHS covers 95% of ALL hospital care and 80% of all practitioner fees (meaning nurses, doctors, specialists, surgeons, pharmaceutical, hospital stay). And, the British NHS covers 100% of both hospital and practitioner and pharmaceutical costs.

And, what is the key to controlling costs of both Health Systems cited? Mandated practitioner fees, hospital service charges and pharmaceutical costs.

So, why not some affordable HC in America? It's about time. We deserve it ... why pay exorbitant prices just to make a certain class of doctors rich much better off than we are?

[emr]

Prevention should be the number one priority when it comes to saving lives, preventing diseases, and preventing death. Our healthcare system needs to focus on prevention instead of disease management . I guess there is no money in preventing diseases.