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kallend

Interesting PBS article on healthcare costs and outcomes

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Every decent doctor I know has a #1 complaint - the patient DEMANDS the quick fix and refuses to listen to discussions about nutrition and exercise

and it's even easier to take a pass on the real fix when the 'quick fix' is paid for by someone else



So it is easier for the Doc to prescribe and they get benefits in return. Indeed, the doctor plays no role in this at all. :S


no need to strawman this - I agree with you too. But I want to emphasize that our health is OUR own responsibility first and foremost. Ditching the blame to 'anyone else', even the doctor, is a non-starter IMO.

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Driving is a one dimensional activity - a monkey can do it - being proud of your driving abilities is like being proud of being able to put on pants

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The US healthcare system sucks if you put emphasis on cost.

The US healthcare system is great if you put emphasis on access to healthcare.

The US Healthcare system is great if you put emphasis on quality of healthcare.

Notice how much the article spoke about the quality of healthcare delivery? And said that in the US it is pretty damned good?

Qualitative analysis is meaningless unless you define what you are qualifying. To limit the cost of healthcare necessarily means that access and/or quality will suffer. There is no rational argument against that.


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Ditching the blame to 'anyone else', even the doctor, is a non-starter IMO.



And not recognizing that theer are multiple spokes to this wheel is a non-starter as well. I agree that ditching all blame on doctors is assinine. absolving them from blame is assinine as well.

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What part of HEALTH is it that you don't understand?

If the US had the greatest HEALTHcare system we wouldn't have such a sucky life expectancy in comparison with other wealthy nations.
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The only sure way to survive a canopy collision is not to have one.

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What part of HEALTH is it that you don't understand?



That's a loaded question. If I were to ask you whether you misrepresent my thoughts, would your answer to that question be the same as to this question?

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If the US had the greatest HEALTHcare system



As a professor, I'm sure that you as much as anyone understand that you cannot force education on anybody. You can do your best to instruct and teach the student, but it is up to that person to deliver on the education part.

Now picture a doctor who instructs. Some people get it. Others don't. Most don't want to be taught. I don't blame professors or teachers for the large number of failures that we have on the educational side.

As an educator, what are your thoughts on people who just don't want to be educated?


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As an educator, what are your thoughts on people who just don't want to be educated?



They exist in all societies and all nations. Lame excuse for the failings of the US HEALTH care system.
...

The only sure way to survive a canopy collision is not to have one.

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...As an educator, what are your thoughts on people who just don't want to be educated?

As far as I am aware, no one is likely to experience death or be disabled because they failed to take or pass any of the classes I teach.

A problem I have with your prescription for access to health care is that it entails making a subjective value judgement about the worthiness of the patient to receive treatment. It may be an easy call to say that the 30-year old obese diabetic with congestive heart failure is "unworthy" because their condition is almost certainly self-imposed, but what about the assault victim whose only "offense" is to have to walk through a sketchy neighborhood to get home from the bus stop? Perhaps you will say that your prescription is objective, because access to care will depend only on a patient's ability to pay, but ultimately that "objectivity" rests on a subjective assessment that a person's worth is contingent on nothing more than their wealth. By this metric, the 85-year-old millionaire "deserves" any level of medical care they wish to pay for, but the 22-year-old college student who's in a work/study program and also works weekends to pay their bills "deserves" nothing, because every dollar they make that isn't spent on necessary rent and food is invested in their education. Basing someone's worthiness to receive medical care only on the size of their bank account completely discounts the value of everything they might accomplish in their life, be it future earnings, creative accomplishments, businesses built, and so on.

If your argument that access to low-cost or "free" health care is what makes people unhealthy were correct, then people in Canada or Europe should be even less healthy than Americans. Judging by lifespan and obesity rates, to name just two metrics, that does not appear to be the case. I suspect the factors at play are much more nuanced, and involve factors like amount of time spent walking vs riding in cars (public transit, widely used in Europe, requires some measure of walking), and cultural factors such as social acceptability of unhealthy foods (here in the South they fry everything) and lifestyles (being obese is normal in some social groups in America, less so elsewhere). Income disparity also plays a role, in that it takes money to buy really healthy food, and generally the wealthier people seem to have more time to go to the gym, play tennis, go skiing in Vail etc than people who are struggling to make ends meet with two or three minimum wage jobs. Note that this is not meant to be an exhaustive listing of differences between the US and all the other countries. One thing that is often thrown out there is that "Americans are different", and "you can't compare Europe (or any specific country) with the US", but that line of argument is just lazy. We are all Homo sapiens, the basic physiology of Europeans is no different than Americans (for example, Europeans are unlikely to have more "brown fat" than Americans just because they are European). If one wishes to insist there are intrinsic differences, one should be prepared to point to specific cultural or social factors (such as behaviors) that explain the differences.

Out of curiosity, as a lawyer, what are your thoughts on people who engage in criminal behavior yet lack the resources to pay for legal representation if they are caught? Do you disagree that people should be entitled to legal representation, through a taxpayer-funded public defenders office, despite an inability to pay? Do you think that I should have a portion of my taxes go to pay for such people, despite the fact that I have never engaged in criminal activities and that I would not be eligible for taxpayer-funded legal representation if I was to be arrested for anything?

Don
_____________________________________
Tolerance is the cost we must pay for our adventure in liberty. (Dworkin, 1996)
“Education is not filling a bucket, but lighting a fire.” (Yeats)

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As far as I am aware, no one is likely to experience death or be disabled because they failed to take or pass any of the classes I teach.



Right. But people die and get disabled because they don’t want to follow medical advice. And of course, then want to sue the doctor for failing to prevent that gaseous gangrene that resulted in a foot amputation.


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A problem I have with your prescription for access to health care is that it entails making a subjective value judgement about the worthiness of the patient to receive treatment.



The suggestion that I am making is that it leaves it up to the patient to decide the worthiness of the treatment. I’m saying that here the patient is always deciding and making those decisions based upon resources paid for by others. “My insurance won’t pay for my blood pressure medication.” Well, sounds like you won’t, either. You don’t think it’s worth your money? Here’s a solution – eat more vegetables, stay off the nicotine, etc.


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It may be an easy call to say that the 30-year old obese diabetic with congestive heart failure is "unworthy" because their condition is almost certainly self-imposed,



No. I’m saying that we are actively promoting a societal moral hazard whereupon the economic costs of the individual choices are being paid for by others.

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but what about the assault victim whose only "offense" is to have to walk through a sketchy neighborhood to get home from the bus stop?



I have a problem with you equating an acute emergency caused by the intentional act of another with a chronic condition brought about by individual choices.

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Perhaps you will say that your prescription is objective, because access to care will depend only on a patient's ability to pay, but ultimately that "objectivity" rests on a subjective assessment that a person's worth is contingent on nothing more than their wealth.



That’s not what I’m saying. I’m saying that the cost of healthcare will go down dramatically when it is no longer free. I’m saying that when a person has a cold, that person will decide whether it’s worth $50 to go to the doctor. It’s a much easier thing to go to the doctor when the $50 is paid by someone else.

Similarly, if a patient is paying $150 per month for his blood pressure medications (versus a $10 per month copay) that person will himself feel the cost of his behavior and there is an actual financial incentive for him to do something about it.

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By this metric, the 85-year-old millionaire "deserves" any level of medical care they wish to pay for, but the 22-year-old college student who's in a work/study program and also works weekends to pay their bills "deserves" nothing, because every dollar they make that isn't spent on necessary rent and food is invested in their education.



If a 22 year-old has the same issues as an 85 year-old, then what’s that say about the college student’s choices? I remember those days of working two jobs and taking an excess study load so I could graduate before my scholarship ran out.

Still, it must be stated that choosing the 22 year-old over the 85 year-old is what is being done all over the world today. Say there’s a liver and you’ve got to decide whether the 85 year-old or the 22 year-old gets it. The 22 year-old will get that liver. Why? Because he’s got a life of earning (and tax paying) ahead of him and the 85 year-old has lived long enough. Eh?

Which would you choose? I say that I’m a person who does not want to make that choice. Others are comfortable with making it on the basis of society – the individual will yield. Governments are already choosing who is worthier.

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Basing someone's worthiness to receive medical care only on the size of their bank account completely discounts the value of everything they might accomplish in their life, be it future earnings, creative accomplishments, businesses built, and so on.



Right. And I say that if a person chooses to drain his health it will result in draining his bank account, a person will be more likely to choose money in the bank. That’s not happening. People are choosing to drain other peoples’ bank accounts. Hence, massive public spending on health.

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If your argument that access to low-cost or "free" health care is what makes people unhealthy were correct, then people in Canada or Europe should be even less healthy than Americans.



You’ve forgotten something – access. It could take months for a person in Canada to obtain treatment and plenty of treatments here in the US aren’t available there. It happens all the time – people pay their own money to come to the US for treatment they cannot get in Canada or Europe or elsewhere. People choosing to pay their own money so they can survive when their home system has decided they are not worth the cost.

EVERY SINGLE ONE OF THOSE SYSTEMS THAT YOU MENTION RATIONS ACCESS. The US system was also one that rationed access based on ability to pay. Then the US, in 1986, moved to a system of free-for-all in the emergency room without rationing. Expense skyrocketed and trauma centers shut down. Now the ER is a place where I can wait for 36 hours with a broken hand.

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cultural factors such as social acceptability of unhealthy foods (here in the South they fry everything) and lifestyles (being obese is normal in some social groups in America, less so elsewhere).



Of course. These are powerful roles. It’s also acceptable in many cultures to live off disability.

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Income disparity also plays a role, in that it takes money to buy really healthy food



That’s been a key grievance of mine. Subsidies make the unhealthy food cost less at point of purchase. Want to increase the price of soda, snack food and beef? Eliminate corn subsidies and see how expensive HFCS becomes.

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generally the wealthier people seem to have more time to go to the gym, play tennis, go skiing in Vail etc than people who are struggling to make ends meet with two or three minimum wage jobs.



It’s odd that I look at the wealthy people I know (and I know plenty) who haven’t taken more than four days in a row off in years. I think your image of the wealthy is a bit off. The middle class – with two weeks of paid vacation per year – seem to be the one who get vacations and the like.

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One thing that is often thrown out there is that "Americans are different", and "you can't compare Europe (or any specific country) with the US", but that line of argument is just lazy.



You call it lazy. I call it reality. I hate to break it to you, but around here we do not imprison scientists and fine them multi-million dollars for failing to warn of an earthquake. That happened in Italy – arguably the first of the first-world countries.

The US is a country that was created by distrust of government. Our Constitution has as an underlying theme that government cannot be trusted and so is limited. We are the square peg. It’s the denial of this that is results in trying again and again to do something that won’t work.

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the basic physiology of Europeans is no different than Americans



Ever do any work in a hospital? Did you know that a key part of a patient history is race? True. Because each race tends to suffer from different morbidities. Did you know that Native Americans develop adult onset diabetes at more than twice the rate of whites? Did you know that Hispanic and Vietnamese women get cervical cancer at twice the rate of whites?

This is in America. These are profound differences that exist in our own country. You pointed to the South. It’s different from the Northeast. And from the Northwest.

Your positions are irreconcilable. The healthcare needs and prevention are different with different geographies in the US. To say that it is lazy to suggest that cultural and physiological needs are different is to, well, be lazy by failing to identify and address the differences that do exist.

The differences are there. Denial of these differences is like denial of the brick wall in front of you.

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If one wishes to insist there are intrinsic differences, one should be prepared to point to specific cultural or social factors (such as behaviors) that explain the differences.



Earlier you wrote that not even all Americans are the same.
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cultural factors such as social acceptability of unhealthy foods (here in the South they fry everything) and lifestyles (being obese is normal in some social groups in America, less so elsewhere)



Differences are differences.

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Out of curiosity, as a lawyer, what are your thoughts on people who engage in criminal behavior yet lack the resources to pay for legal representation if they are caught? Do you disagree that people should be entitled to legal representation, through a taxpayer-funded public defenders office, despite an inability to pay?



I think that whenever the government is trying to deprive a person of that person’s freedom that person should be entitled to have assistance. Take a capital murder case – the government wants to kill a person.

I think that you have pointed to a crucial difference in this: what is the difference between taxpayer funding for assistance when the government wants to kill you and taxpayer funding when the government wants to keep you alive? If the taxpayer dollars are going toward prosecuting someone, then the person facing the power of the government should also have some protections.

Note – that person cannot get taxpayer paid counsel when that person is sued civilly. There is no right to counsel in child custody proceedings. Or in other interpersonal matters.

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Do you think that I should have a portion of my taxes go to pay for such people, despite the fact that I have never engaged in criminal activities and that I would not be eligible for taxpayer-funded legal representation if I was to be arrested for anything?



Yes. Because it’s in the Constitution as a specific guarantee. And because your tax dollars are going toward his prosecution.

Note: I really enjoy your posts. I hope I explained my viewpoints better. My point is not that anyone is worth more than anyone else. My point is that what we are worth is an individual choice. If a person says, "I'm not worth spending $150 of my own money in heart meds but I'm worth your money" why are we enabling that?


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Note: I really enjoy your posts.

And I yours. You always make me think about what I believe, and why, which I really appreciate.

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I hope I explained my viewpoints better.

Yes, and thanks for that.

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My point is not that anyone is worth more than anyone else. My point is that what we are worth is an individual choice. If a person says, "I'm not worth spending $150 of my own money in heart meds but I'm worth your money" why are we enabling that?

To some extent, I can agree with this. Certainly I agree it would help if people had more financial skin in the game. However, your point assumes that people actually have an opportunity to make a choice. Perhaps they are weighing that $150 a month for meds against their country club membership fees, but for many $150 a month represents a real hardship. Not a "giving up cable", but losing their job because they now can't afford a car, and public transit doesn't run when they need it to get to or home from work. Then there are the really serious cases, where treatment runs to high five figures and up. If everybody had a similar sized pot of money, and could allocate it to this or that as they say fit, one could perhaps justify saying "too bad so sad, you shouldn't have spent all your money on Pokemon cards". Given that a round of chemotherapy can run $80,000 or more, though, there's no choice to be made for most people.

You use the term "choice" a lot, in the sense that people choose unhealthy behaviors because they know (or believe) they won't be held accountable for the cost to treat them. I can't disagree that this is a problem. However, not all medical issues result from choices people make. I did not (or I don't recall) choosing my parents. Yet, I have certain costs imposed on me because of family history of certain diseases. I have even been told that should I ever leave my current job (where I am covered under a group plan) I would likely have trouble getting health insurance because of conditions that developed in close relatives after I started work here. People get bitten by mosquitoes and get West Nile, or they get listeria from eating contaminated lettuce. Shit happens. Whether you live or die should not be contingent on your bank account, IMHO.

Let's say we agree that we don't want the health care (or health insurance) system to encourage unhealthy behavior. Can we also agree that not every medical problem is caused by lifestyle choices? What kind of a system might one propose that discourages poor lifestyle choices without simultaneously threatening economic ruin or worse (denial of treatment) to people whose disease is not a result of choices they made? Or would you argue that such collateral damage is worth it to keep freeloaders at bay?
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I have a problem with you equating an acute emergency caused by the intentional act of another with a chronic condition brought about by individual choices.

Yet, both require medical care and that must be paid for somehow. In that regard, injuries from an assault are no different from encephalitis brought on by the bite of an infected mosquito: both are acute emergencies requiring immediate care. Do doctors and hospitals bill assault victims differently than other patients?

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I’m saying that the cost of healthcare will go down dramatically when it is no longer free. I’m saying that when a person has a cold, that person will decide whether it’s worth $50 to go to the doctor. It’s a much easier thing to go to the doctor when the $50 is paid by someone else.

Will it? Perhaps. Consider, though, what would happen if the doctor used to see 100 patients with colds a week, and now they see 10 (9/10 decide to tough it out without seeing a doctor). Where the doctor made $5,000 a week from cold patients, now they make $500. Yet, they still have to pay rent, malpractice insurance, office staff, maybe still student loans. So, what's to keep the cost of an office visit from going up to compensate? Maybe competition, but if every doctor in town is facing the same pressures I'd bet that the cost per visit isn't going to be declining. Sure, the cost of the health care system in total may go down if people decide to forgo treatment, but that's no guarantee that cost or access for individuals will improve.

Many cutting edge treatments are just highly expensive by their nature. The next big thing in cancer treatment is likely to be genome sequencing from tumor biopsies, so as to identify specific mutations associated with the specific patient's cancer. This will allow the doctor to prescribe specific drugs designed to counter specific genetic defects. Genome sequencing is coming down in cost, but the equipment is very pricy and the staff to run the analysis have to be very highly trained, so costs are likely to remain significant (a couple of thousand dollars). Producing patient-specific drug cocktails will always be more pricy than mass market one size sort of fits all therapies. Cancer therapy is likely to become even more expensive than it already is, although it is also likely to be much more effective.

Although there is a benefit in terms of cost savings to the overall system that results from encouraging people to self-ration their use of health care, there are also costs. People walking around, going to work or to the coffee shop, with an infectious disease are much more likely to spread that disease to others. Should going out in public, where one might be exposed to infectious individuals, be considered a "poor lifestyle choice"? Also, some diseases will not get better if left untreated (like a cold does); costs go up dramatically, and chances for a favorable outcome go down, the longer one delays treatment. Any overall saving to the system from people self rationing care can easily be overwhelmed by a few patients whose condition is worsened by delaying treatment.

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If a 22 year-old has the same issues as an 85 year-old, then what’s that say about the college student’s choices? I remember those days of working two jobs and taking an excess study load so I could graduate before my scholarship ran out.

I remember those days too. I did not have financial reserves that would have allowed me to pay for treatment of a major medical emergency; I assume you were in the same position. In my case I wasn't too worried about it, because I was living in Canada at the time and so I had decent health insurance. I suppose you were just fortunate to not be hit with anything too major. Since moving to the US, though, I have known students who were not so fortunate, including one who died from a condition that would have been survivable had she not self-rationed her access to health care for too long. But when your "choice" is between rent, tuition, food (pretty modest, considering how slender this young lady was), and a bus pass (couldn't afford a car), and you're too proud to rack up bills you can't pay, then it isn't surprising that one would put off going to the doctor until the pain became intolerable.

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You’ve forgotten something – access. It could take months for a person in Canada to obtain treatment and plenty of treatments here in the US aren’t available there. It happens all the time – people pay their own money to come to the US for treatment they cannot get in Canada or Europe or elsewhere. People choosing to pay their own money so they can survive when their home system has decided they are not worth the cost.

It happens the other way too. Medical tourism from the US to Canada is growing, because the cost of care is so much cheaper in Canada and the quality is as good as the US. Here's the difference: Americans going to Canada are usually after treatment they can't access in the US, because of pre-existing conditions limitation or out of pocket costs, whereas Canadians going to the US are primarily interested in jumping the line for an elective procedure they can get (but may have to wait for) in Canada, and they are wealthy enough to pay the 4-5X higher US bill. In a few cases, you have smaller communities on one side of the border and much larger cities right across the border. Of course the larger community will have the bigger hospitals and a wider range of services. For that reason, people from Windsor will go to Detroit for some specialized services, and people from upstate New York or Vermont may go to Montreal.

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You call it lazy. I call it reality.

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Did you know that a key part of a patient history is race? True. Because each race tends to suffer from different morbidities. Did you know that Native Americans develop adult onset diabetes at more than twice the rate of whites? Did you know that Hispanic and Vietnamese women get cervical cancer at twice the rate of whites?

By "lazy", I meant that when one answers the question "why do the same medical procedures cost 3-5X as much in the US as they do elsewhere?" with "Americans are different than Europeans or Canadians", that answer lacks any specific detail that might allow one to get at the actual nature (and so possible solutions) to the problem. Let's say we were able to magically switch all the American population to Europe, and the European population to the US. Would the cost of the US health care system immediately fall to European levels? Would the European system immediately jump to US levels? If we checked in a generation from now, where would costs be? If Americans are genetically more disease prone, if it costs on average 5x as much to achieve the same medical outcome as it costs to treat a European with the same condition, then one would expect the cost of the European health care system to rise, and the American system to fall, correspondingly. I doubt, though, that that is what would happen. The problem (it seems to me) with assuming that the cost differences are due to biological differences between Americans and Europeans (or Canadians) is that it discourages examination of other, structural features built into the US system that inflate costs.

I agree with your comments about legal representation for the indigent, I was just curious to see how you compared that to health care for the indigent.

All in all I agree with you that we don't want to encourage unhealthy behavior, and one way to do that is to make people responsible for more of the cost of their treatment. Where we seem to disagree is that I don't see any practical way to distinguish between "lifestyle diseases" and things that we risk just by being alive (like infectious mosquitoes), and I dislike the idea of a system where we expose people to serious risk of death or disability, coupled with permanent financial ruin, when they have the bad luck to get sick or be injured. Insurance (including health insurance) is intended to mitigate financial damage by spreading risk over a large population, but when I sign up for any insurance plan I accept that there is some chance (reflected in my premiums) that someone somewhere may try to game the system, for example by burning down their house. Insurance plans penalize smokers by charging higher premiums, and they could do so for other risky behaviors. That would provide a financial incentive for people to avoid those behaviors, without resorting to a strictly "user pays cash for service" system that exposes everybody to risk of financial devastation or loss of care. My wife's insurance, for example, charges a certain monthly premium, but then she can earn credits for participating in work-organized walks/5K runs, losing weight, etc. It's remarkable to look around her workplace and see people who have lost 20-50 pounds in order to get that monthly credit.

Cheers,
Don
_____________________________________
Tolerance is the cost we must pay for our adventure in liberty. (Dworkin, 1996)
“Education is not filling a bucket, but lighting a fire.” (Yeats)

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However, your point assumes that people actually have an opportunity to make a choice.



There are people who have no choice in their health. Those are: (1) kids; and (2) those with congenital disorders.

Juvenile cancers, type 1 diabetes and childhood obesity are not really costly as far as health care goes. Adult obesity? Yep. Adult cancers? Yep. Those are choices that are made. (of course, public health also means safe neighborhoods. Kids don’t’ play outside anymore. Often for good reason. I cannot blame sedentary entertainment entirely on Madden. There’s a cultural issue, as well – that culture of violence and abuse).


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For many $150 a month represents a real hardship.



Yes. It does. Putting substances in your body to counter the effects of substances you put in your body is also irrational. A lot of money can be saved by not putting the stuff in your body that necessitates $150 per month in medications. If they feel the hardship instead of society feeling it, I’d bet that medications would not be needed as much.

That’s my point. There is no incentive for an individual to prevent the cost when the individual will not bear the cost.

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Given that a round of chemotherapy can run $80,000 or more, though, there's no choice to be made for most people.



Insurance can be used for this. If insurance is used to cover catastrophic events (as insurance is used in every other damned thing) then we’d see cost go down on that, as well. Car insurance doesn’t pay for new windshield wipers, tires, oil changes, gas and washes. Imagine the cost of a vehicle if that were to happen? Think you’d see fuel costs rise as it becomes scarce? I do.

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Yet, I have certain costs imposed on me because of family history of certain diseases.



Yes. Those aren’t the costs that are eating us alive. Obesity, diabetes, alcohol and smoking are. Particularly obesity. These are lifestyle diseases. How many times have we seen “fundraiser for Skygod who hooked in on his new rig (only had 30 jumps on it in the three weeks since purchasing it) and had no insurance. Fuck that. It enables irresponsible behavior by covering every swinging dick who puts individual accountability behind all else.

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Can we also agree that not every medical problem is caused by lifestyle choices?



Absolutely.

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What kind of a system might one propose that discourages poor lifestyle choices without simultaneously threatening economic ruin or worse (denial of treatment) to people whose disease is not a result of choices they made?



History. Diabetes is a good one. Have type 2 diabetes? Your ass. Have emphysema? Your cost. There are plenty of these things.

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Or would you argue that such collateral damage is worth it to keep freeloaders at bay?



It’s a tough decision and there are fine lines. Some people will, in a sense, be screwed. But if a person is on notice that if she develops diabetes in the next twenty years that she will be paying for it herself, then there isn’t a screwing, is there? It’s put out there – this will not be covered. Therefore, get your kids checked for Type 1 diabetes and help them for the future.

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injuries from an assault are no different from encephalitis brought on by the bite of an infected mosquito: both are acute emergencies requiring immediate care. Do doctors and hospitals bill assault victims differently than other patients?



No. Hospitals don’t bill a suicide attempt or an OD any differently from a car accident.

To narrow – my issue is not with the cost of acute injury. Insurance should be there to cover that – give peace of mind. My issue is with chronic conditions brought on by expensive choices.

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Consider, though, what would happen if the doctor used to see 100 patients with colds a week, and now they see 10 (9/10 decide to tough it out without seeing a doctor). Where the doctor made $5,000 a week from cold patients, now they make $500.

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Wow! Costs are being cut as we speak by lowering the payments to doctors.

And yes, the doctor will eliminate back office billing staff and medical coding specialists and the like. And the insurance companies and federal government will eliminate tens of thousands of jobs.

This WILL lower the cost of healthcare and do so by eliminating the inefficiencies that the system has caused.

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So, what's to keep the cost of an office visit from going up to compensate? Maybe competition, but if every doctor in town is facing the same pressures I'd bet that the cost per visit isn't going to be declining.



No. but the total cost of health care will go down. A lot. Which is the primary policy problem right now, isn’t it?

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That's no guarantee that cost or access for individuals will improve.



I’m not talking about lowering individual costs. I’m talking about lowering total cost of healthcare in the country. If you want to do it, that’s the quickest way. Give people a skin in the game.

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Producing patient-specific drug cocktails will always be more pricy than mass market one size sort of fits all therapies.



This is already a problem with orphan diseases. No real solution has been found for it despite a couple of acts of Congress in the last thirty years.

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Although there is a benefit in terms of cost savings to the overall system that results from encouraging people to self-ration their use of health care, there are also costs. People walking around, going to work or to the coffee shop, with an infectious disease are much more likely to spread that disease to others.



Absolutely. But they do the same thing by going to the doctor, don’t they?

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Should going out in public, where one might be exposed to infectious individuals, be considered a "poor lifestyle choice"?



No. It’s probably a good lifestyle choice and the sooner in life the better, thus enabling them to build up resistance. Those who are immunocompromised are an exception to this.

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Also, some diseases will not get better if left untreated (like a cold does); costs go up dramatically, and chances for a favorable outcome go down, the longer one delays treatment.



Yes. Which is where education comes in. Education is not just about preventative care. It’s also about when to seek care. People roll the dice all the time (check out every ad about a person who stopped their insurance and suffered a heart attack and now insurance won’t pay to keep them alive). A catastrophic insurance company would be wise to give discounts to those who have a physical once a year.

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Any overall saving to the system from people self rationing care can easily be overwhelmed by a few patients whose condition is worsened by delaying treatment.



The problem is many already do that. Hence, the number of amputated feet in diabetics.

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I remember those days too. I did not have financial reserves that would have allowed me to pay for treatment of a major medical emergency; I assume you were in the same position.



Yes. It’s how I figured out that I could pay cash up front to a doctor and get treated. An ER visit for me cost $220.00 with up front cash. No, it wasn’t easy. But – it worked. The next time I got septicemia I did the same thing at urgent care. They’ll negotiate and up front cash talks. Lower costs? Cash is a great equalizer.

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I suppose you were just fortunate to not be hit with anything too major. Since moving to the US, though, I have known students who were not so fortunate, including one who died from a condition that would have been survivable had she not self-rationed her access to health care for too long.



That’s kind of the weird thing about it. If only others had paid for her she would have lived. But – having to pay herself for it she chose not to? Yes, it creates some weird priorities. It’s completely irrational, isn’t it?

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But when your "choice" is between rent, tuition, food (pretty modest, considering how slender this young lady was), and a bus pass (couldn't afford a car), and you're too proud to rack up bills you can't pay, then it isn't surprising that one would put off going to the doctor until the pain became intolerable.



I’ve got a history of it. It’s been predicted that it will kill me. And I’m insured.

Medical tourism from the US to Canada is growing



Yes. I can see that. People freeloading off of Canada now. I take it that my good friends to the north don’t like it.

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By "lazy", I meant that when one answers the question "why do the same medical procedures cost 3-5X as much in the US as they do elsewhere?



One can look at the bills. Then look at what one is paid. Sure, that hysterectomy is billed out at $1,800.00. But Medicare pays $80 for it. Medicaid? Also a pittance. They reimburse pennies on the dollar.

Thus, because of the low reimbursement that cost gets spread to others. The government puts a price cap on health care reimbursement. And so the costs get made up elsewhere.

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Let's say we were able to magically switch all the American population to Europe, and the European population to the US. Would the cost of the US health care system immediately fall to European levels?



Depends on whether the Europeans would want to start treating different diseases.

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Would the European system immediately jump to US levels? If we checked in a generation from now, where would costs be?



Unknown. Costs can always be controlled by limiting access or limiting quality. Price caps lead to rationing.

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If Americans are genetically more disease prone



No. there are just more variety in genetic diseases.

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if it costs on average 5x as much to achieve the same medical outcome as it costs to treat a European with the same condition, then one would expect the cost of the European health care system to rise, and the American system to fall, correspondingly.



Not necessarily. And the “same medical outcome” seems a bit odd. I’ll have to think about this, because I think that there may be some foundational issues with the underlying point of “cost” and “outcome.”

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it discourages examination of other, structural features built into the US system that inflate costs.



Every health care delivery system shares a tripartite relationship of goals: (1) cost; (2) access; and (3) quality. One can have a high quality system available on demand. As a rule it will be expensive. This is what the US has. One can have a high quality system that is low cost. By rule it will be rationed. One can have a low cost system available on demand. By rule it will be low quality.

I have not seen a solution to this problem. I can only see a way of lowering costs to society by placing the costs on the individual and policies designed to prevent moral hazard. Look at NYC – banning large sodas because of the cost to society – the cost is shifted to freedom. That’s their way of controlling moral hazard.

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I don't see any practical way to distinguish between "lifestyle diseases" and things that we risk just by being alive (like infectious mosquitoes),



I will admit that some decisions will be arbitrary. But it’s why I want to keep the government out of it. Most of this is presupposing a national coverage system.

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and I dislike the idea of a system where we expose people to serious risk of death or disability, coupled with permanent financial ruin, when they have the bad luck to get sick or be injured.



We used to do that. And health care was much cheaper. It’s when we sought to help the outliers that costs exploded.

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Insurance (including health insurance) is intended to mitigate financial damage by spreading risk over a large population,



I think we’ve hit on something. “Insurance” is designed for peace of mind regarding catastrophe. Health insurance has been perverted from peace of mind re: catastrophe to “gotta cover everything.” It’s a BIG reason why costs have increased – it has made healthcare a commons.

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but when I sign up for any insurance plan I accept that there is some chance (reflected in my premiums) that someone somewhere may try to game the system, for example by burning down their house.



We prosecute those people.

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Insurance plans penalize smokers by charging higher premiums, and they could do so for other risky behaviors.



And I think that they should for all preexisting conditions brought about by individual choice. Yes, even skydiving injuries.

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It's remarkable to look around her workplace and see people who have lost 20-50 pounds in order to get that monthly credit.



Thanks for the example. Let’s see about doing this nationally.


My wife is hotter than your wife.

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OK True Story:

I am a widower and I am dating an MD same age as me.

Two weeks ago she was jogging in her home town and was tripped by another jogger. Hit her head on the sidewalk and was knocked unconscious. Someone called 911 and she was hauled off to the local hospital. She (possibly foolishly) had no ID or insurance card on her person.

Hospital#1 stapled up the back of her head and sent her home (walking, in the rain). No insurance = minimal assistance.

2 days later she was so sick and obviously concussed that I took her to a different ER, ALONG WITH HER INSURANCE CARD. They did a CAT scan and immediately sent her to the neurology unit. MRI scan next day showed contusions and hematoma in the brain.

It's now 2 weeks later and she is still an in-patient. She will be off work until January.

Crappy care at hospital #1 because she didn't have proof of insurance with her, was concussed and therefore unable to deal with the situation.

Final straw: in today's mail she received a bill for $2,500 from hospital #1.

Yes, the US health care system works fine for some, but this really showed up its serious deficiencies.
...

The only sure way to survive a canopy collision is not to have one.

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Contact legal counsel re: EMTALA violation. Sounds like she wasn't stabilized.



Several of us have suggested that. Since she is an MD herself she is very reluctant to take that advice.

FACT remains, the US healthcare system may be very good for many, but it also SUCKS big time for others.
...

The only sure way to survive a canopy collision is not to have one.

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My last ER 'incident' was only stitches....and was more than that with insurance.
[:/]

I'm sure that's only just the beginning of the bills.
.



Yes, hasn't had the ER doc's bill yet.
...

The only sure way to survive a canopy collision is not to have one.

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I don't disagree that routine care (annual physicals, sniffley noses) should be out-of-pocket. With non-Medicare insurance, this already happens due to annual deductibles (I pay the first $400 out of pocket, which covers a few visits to the doctor). I've argued before (and I might have got the idea from you originally) that health insurance (like fire insurance) should protect against catastrophe, not minor issues.

I somehow got the idea you were opposed to insurance, and favored a strict pay-for-service system. I guess I got that wrong.

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Adult cancers? Yep. Those are choices that are made.

Not always. Sure, many cancers result from smoking, obesity, etc, but it is a pretty extreme exaggeration to say they all are. Radon from the decay of radioactive minerals in the bedrock and soil is common in much of the country; it accounts for an estimated 21,000 lung cancer deaths per year, including almost 3,000 in people who have never smoked. I had my house site tested, and when I built it I paid for ventilation pipes under the house to reduce radon entry into the house, but it is impossible to reduce it to zero. Every building in North Georgia (for example) has the same issue; Atlanta is a real "hot spot". Making a "choice" to avoid radon would likely move you to other areas with different environmental cancer risks, such as increased UV and cosmic rays at higher elevations. Many plants we eat contain compounds that increase mutation rates and cancer risk. For example, celery (especially when slightly wilted) contain furanocoumarins that react with DNA and cause mutations. Many fungal contaminants of grains (and other things) contain potent mutagenic compounds. Indeed, rates of oral, esophageal, and stomach cancer are way down from historical norms, due to the use of fumigants to kill fungi in stored grains. What all this means is that significant numbers of people who avoid risky behaviors such as smoking will still develop cancer, including lung cancer. It seems ridiculous to consider eating fresh vegetables, or just breathing, as a "risky behavioral choice".

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I’m not talking about lowering individual costs. I’m talking about lowering total cost of healthcare in the country.

My mistake, I thought you were talking about both.

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Although there is a benefit in terms of cost savings to the overall system that results from encouraging people to self-ration their use of health care, there are also costs. People walking around, going to work or to the coffee shop, with an infectious disease are much more likely to spread that disease to others.



Absolutely. But they do the same thing by going to the doctor, don’t they?



One (or two) visits to a doctor's office hardly compares to days/weeks/months of interacting with large numbers of unsuspecting people at work, while out to eat, while riding the bus/train/plane, or in social situations

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Should going out in public, where one might be exposed to infectious individuals, be considered a "poor lifestyle choice"?



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No. It’s probably a good lifestyle choice and the sooner in life the better, thus enabling them to build up resistance. Those who are immunocompromised are an exception to this.

Not so much, if we're talking tuberculosis, or (as an extreme) ebola. Maybe so, if we're talking a common cold.

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That’s kind of the weird thing about it. If only others had paid for her she would have lived. But – having to pay herself for it she chose not to? Yes, it creates some weird priorities. It’s completely irrational, isn’t it?

Not so completely irrational. Most illnesses pass on their own, especially when you're young. I'm not young, yet I still don't go to the doctor at the first hint of sickness, in fact I still wait until it's clear the problem isn't going to clear up on its own. I'm sure you would not advocate that people incur bills they can't pay, in fact I imagine you (like me) consider that a positive character trait. If someone is in a situation where an ER visit means you have to stiff the landlord (risking eviction) or not paying tuition (risking not graduating, and losing everything you have invested in your education to that point), one would have to be pretty darned cold-hearted to call a person "irrational" for waiting a while to see if the illness cleared up on its own (as it usually does). You talk about "education", as in "when to seek care", but often that means expecting people to self-diagnose without medical training or equipment. Is it a heart attack, or just really bad heartburn? Which is worse for "national policy": people dying of a heart attack because they thought their pain might be due to heartburn, or people who "waste resources" by going to the ER, thinking they are having a heart attack when it's really heartburn. A visit to the ER, getting hooked up to an ECG, and a cardiology consult will run a couple of thousand dollars at least. Plenty of incentive for people to "give it another hour to see if it gets better". All in all a great way to ensure the system spends less money overall, if you don't mind the body count.

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and I dislike the idea of a system where we expose people to serious risk of death or disability, coupled with permanent financial ruin, when they have the bad luck to get sick or be injured.



We used to do that. And health care was much cheaper. It’s when we sought to help the outliers that costs exploded.

I think you should also consider that costs exploded when medicine actually became able to do much to treat disease. Few people recognize that antibiotics such a penicillin became available only after WWII. Before that doctors could sometimes diagnose, but treatment with leeching and mustard packs was generally ineffective. They could set broken bones, though. The first generation or so of antibiotics were remarkably inexpensive, but thanks to drug resistance those are long gone, and today's drugs are orders of magnitude more expensive. However we also have technologies that would have seemed like science fiction to 1950's era doctors, such as MRIs. Those technologies have made medicine remarkably effective, but also remarkably expensive. Who would accept 1950's level of care if they could pay 1950's prices today?

I very much suspect any simple model to explain the high cost of the health care system would be doomed to failure. Many of the variables have complex effects on the system. Extending care to all regardless of ability to pay has certainly increased costs, but denying care to a significant number of people would also increase many people's exposure to infectious disease. Shifting costs back to patients, especially for "lifestyle diseases", may produce significant savings up to a point, but beyond some point those savings will come at the cost of lots of dead and disabled people, and a huge increase in the number of medical bankruptcies (which already account for 62% of all bankruptcies).

I agree that there are big problems with how health care is paid for. I agree that providing a significant financial incentive to avoid lifestyle diseases could help a lot. I think that an immediate, and ongoing incentive, such as higher insurance premiums, are more likely to work than a threat of bankruptcy and denial of treatment that may or may not happen, at some undefined time in the future. While people might get the message about obesity/heart disease/etc when they start to see huge numbers of people cut off from health care after the system devours their house, retirement savings, and kid's piggy banks, I don't think that is an appropriate course of action for a civilized society, and I don't believe it is necessary to accomplish the objective either (if the objective is to rein back costs). I also don't think we have addressed the costs imposed by the unnecessary testing and "defensive medicine" necessitated by our predatory legal system. Estimates of that cost range from 26% of the cost of the whole medical care system (certainly an exaggeration for political purposes) to a more realistic 2-3%, but that still amounts to tens of billions of dollars per year.

Thanks for the discussion. I've had to think about, and look up info on some topics I've wondered about for a while.

Cheers,
Don
_____________________________________
Tolerance is the cost we must pay for our adventure in liberty. (Dworkin, 1996)
“Education is not filling a bucket, but lighting a fire.” (Yeats)

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Contact legal counsel re: EMTALA violation.

Just curious, haven't you argued that EMTALA should be repealed? I may be mis-remembering, of course, but even our ongoing discussion in this thread implies that you believe extending care to those who can't pay/don't have insurance is a leading cause of the financial difficulties of the system.

Don
_____________________________________
Tolerance is the cost we must pay for our adventure in liberty. (Dworkin, 1996)
“Education is not filling a bucket, but lighting a fire.” (Yeats)

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