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A Quick Shot of Healthcare, Part 4 – Deconstructing Sarah Palin . . . Again

By Brian | September 9, 2009 | Share on Facebook

On the eve of President Obama’s address to a joint session of Congress regarding healthcare reform, the former governor of Alaska, Sarah Palin, has written an Op-Ed piece in the Wall Street Journal. What follows is an object lesson both in how news media must be consumed these days, and some enlightening facts (enlightening to me, at least) about the current healthcare debate.

First, I read the AP wire story about Sarah Palin’s Op-Ed, which appeared in my daily news feed, the substantive portion of which reads as follows:

The former Republican vice presidential candidate says “common sense tells us that a top-down, one-size-fits-all plan will not improve the workings of a nationwide health care system that accounts for one-sixth of our economy.”

She also reiterated her claim that so-called death panels would make end-of-life decisions, a notion that has been widely discredited.

She suggests options including equalizing tax breaks for people who do or do not get benefits through employers; providing Medicare recipients with vouchers to buy their own coverage and reforming tort laws.

Wouldn’t be a Sarah Palin story without the phrase “death panels,” now would it?

So, I proceed to the Wall Street Journal’s online site to find Sarah Palin’s Op-Ed piece myself (the AP article did not provide the link). It is predictably filled with kitschy phrases (“We stand strongest when we stand with the weakest among us”) and rhetoric (“Common sense tells us that the government’s attempts to solve large problems more often create new ones.”) And like an aging rock & roll band, she eventually thrills the crowd with her greatest hit:

Is it any wonder that many of the sick and elderly are concerned that the Democrats’ proposals will ultimately lead to rationing of their health care by—dare I say it—death panels?

Here, Sarah Palin makes the same mistake as Barack Obama, Barney Frank and all the rest. Merely by using the term, she ensures that anything else she has to say on the subject will be left out of the AP wire story, and all the stories that follow it. She sinks her own message in favor of her favorite talking point.

But wait! What’s this?

Now look at one way Mr. Obama wants to eliminate inefficiency and waste: He’s asked Congress to create an Independent Medicare Advisory Council—an unelected, largely unaccountable group of experts charged with containing Medicare costs. In an interview with the New York Times in April, the president suggested that such a group, working outside of “normal political channels,” should guide decisions regarding that “huge driver of cost . . . the chronically ill and those toward the end of their lives . . . .”

This is why you have to go find the source material yourself. Nothing I’ve read about healthcare thus far has mentioned an Independent Medicare Advisory Council, or IMAC. Google News returns 40 articles using the phrase, as compared to 2,300 using the phrase “death panel.” And the top two results for “Independent Medicare Advisory Council” are entitled Deja vu: Palin and Death Panels and Palin Stars in Death Panel 2. The third link is the WSJ Op-Ed itself.

Not only that, but the vast majority of the articles that discuss death panels (along with the vast majority of TV talking heads, wire stories, blog posts, etc.) talk about the proposed funding for quinquennial end-of-life discussions, and how it does or does not amount to the government encouraging doctors to euthanize elderly patients.

But these IMAC’s sound closer to the real thing, no?

We press on. In this case, to the White House Blog post by Peter Orszag, the director of the Office of Management and Budget. He fills in some details:

The Independent Medicare Advisory Council (IMAC) would be an independent, non-partisan body of doctors and other health experts, appointed by the President, confirmed by the Senate, and serving for five-year terms. The IMAC would issue recommendations as long as their implementation would not result in any increase in the aggregate level of net expenditures under the Medicare program; and either would improve the quality of medical care received by the program’s beneficiaries or improve Medicare’s efficiency.

EITHER improve care OR improve efficiency? Shouldn’t it be “improve care AND improve efficiency?” Are we really suggesting that the IMAC can improve care if they do it without spending any extra money, but they can save money any way they want, even if it reduces the quality of care? And who approves the IMAC’s recommendations?

As with the military base-closing commissions, this proposed legislation would require the President to approve or disapprove each set of the IMAC’s recommendations as a package. If the President accepts the IMAC’s recommendations, Congress would then have 30 days to intervene with a joint resolution before the Secretary of Health and Human Services is authorized to implement them. If either the President disapproves the recommendations of the IMAC or Congress passes such a joint resolution, the recommendations would be null and void, and current law would remain in effect.

This approach would free Congress from the burdens of dealing with highly technical issues such as Medicare reimbursement rates while rightly giving them, your representatives, a say in the matter. Moreover, this kind of body would enable the health care system to respond to a very dynamic market and technical landscape, making Medicare policy more responsive and effective in the future. All together, the IMAC proposal would make sure that there is someone always on the beat, looking for ways to bend [the health care cost growth] curve.

Give our representatives a say by freeing them from the technical details? Apologies, Director Orszag, but that kind of logic is Palin-esque. And comparing the process to military base closings? Those discussions are famous for putting “not in my district” ahead of “what’s best for the country,” aren’t they?

If you want to go one source deeper (I did), here’s the letter Director Orszag sent to Nancy Pelosi along with draft legislation to implement the above strategy.

Now, I know I run the risk of losing all credibility if I suggest that Sarah Palin may have been right about something, but the IMAC sounds to me like a group of people, appointed by the President to a five-year term, accountable to him alone, removable only by him, who can decide that elderly people (who they have never met, interviewed, or examined) cannot have access to a life-extending or life-saving treatment, simply because they are “bending the cost curve” to “improve Medicare’s efficiency.” Couldn’t a reasonable person call that a “death panel” if he/she were so inclined?

But wait, there’s still the matter of intent, no? I mean, what President would sign-off on such a proposal? For that, we need to go to one more source – the New York Times interview that Sarah Palin quotes from. Listen to Barack Obama talk about the end of his own grandmother’s life (this from April, 2009 – emphasis mine…):

President Obama: I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

The New York Times: And it’s going to be hard for people who don’t have the option of paying for it.

Obama: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

The Times: So how do you — how do we deal with it?

Obama: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

So here’s the scenario: A newly formed IMAC decides that Medicare will no longer pay for hip replacements for elderly women with terminal diseases. The proposal is estimated to save $X million per year. The President and the Congress have a chance to veto, but they don’t, and the Secretary of Health & Human Services implements the change. Presto – we’ve saved $X million without those pesky “normal political channels.”

The next day, two women with terminal cancer break their hips. The first is the grandmother of a wealthy politician, who pays for her hip surgery out of pocket. She either recovers and spends the next three to nine months free of hip pain (and maybe watches her grandson elected President of the United States?), or dies from complications due to surgery.

The other woman is the grandmother of a middle-class American who cannot afford to pay for a hip replacement himself. She spends the next three to nine months bed-ridden and suffering. She, her family and her doctor (who has examined her and understands her family situation, her mental health, her quality of life, etc.) all believe that the hip replacement is worth the risk, but it cannot happen because the Independent Medicare Advisory Council has made its decision, and the President and the Congress have approved.

I don’t know about you, but this is the scenario that will run through my mind the next time someone talks about a third party coming between me and my doctor.

That former beauty queen from Alaska may just have a point…

Topics: Political Rantings | 24 Comments »

24 Responses to “A Quick Shot of Healthcare, Part 4 – Deconstructing Sarah Palin . . . Again”

  1. Jeff Porten says at September 10th, 2009 at 10:49 am :
    Well, far be it from me to let you think that Palin has a point, so let me change your mind.

    First — the BRAC (Base Realignment Commission) was specifically developed in order to avoid NIMBY objections. Everyone agreed that we needed to cut down on domestic bases, but since a base shutdown essentially makes the area a ghost town, no representative can support it. The BRAC was an advisory panel, but it made its recommendations in blocks — Congress could accept or reject them, but there was a legislative agreement not to cherry pick to save the base in the district of a powerful representative. It wasn’t perfect, but it worked better than anything that had been tried previously.

    So, in considering the IMAC, first you have to decide whether you want the 20″ or the 24″ model… no, sorry, wrong iMac.

    The IMAC is meant to bring a technocratic input to a similar situation. Put it this way: let’s say two nominees for the IMAC were Sherry and myself. Whom do you think would be a better choice? I consider myself a lay policy expert, but hell, I’d vote for Sherry.

    Here’s how it will work (because this is how it has to work): IMAC makes recommendations to the president. President can approve part or all of the recommendation. It then goes to HHS. That’s the Constitutional part of the equation. If Obama imposes limitations on his ability, such as a 30-day waiting period or the ability to accept recommendations only in full, that’s a gentleman’s agreement rather than a law.

    On the other hand, his executive actions must be revenue-neutral, because all spending power is vested in Congress. He can make rulings which allocate discretionary funding, but he can’t change the allocations. Hence, the IMAC will get much more done if they stick to the powers which the president already has. Likewise, if the president makes an executive decision of which Congress disapproves, they can zero out funding for that choice legislatively.

    So what Obama is proposing is this: “I’m going to appoint a panel of experts, and I’m going to listen to them. It’ll be my choice what to do, as is true with all executive decisions, but I’ll create a window for Congressional input.” Hell, that’s about the most reasonable presidential decision I’ve heard in a long while.

    On to your scary scenario — and does Sherry read these things before you post them? I’d love to hear her input on this. Anyway, as I read it, your argument is a load of… your argument won’t happen for the following reasons:

    1) the elderly are covered by Medicare. Medicare has strict guidelines for end-of-life issues which prevent “cost savings” from the sort of “let the elderly rot” scenarios you propose.

    2) even if the IMAC has recommendatory power over Medicare, there is a huge debate going on in order to deal with end-of-life care, and no one is arguing in favor of “let them suffer so we can save money”. Hip surgery is expensive and dangerous — on the other hand, you can treat pain with morphine. Is it a big deal if someone with two months to live gets addicted to painkillers? That’s a debate worth having.

    3) we already have a system which doles out health care based on ability to pay. This system will continue, unless someone introduces the idea that the law restricts doctors from providing treatment. (Of course, they’ve done this with abortion services, so if you want to avoid kill Granny scenarios, the track record for restricting care by law is Republican.) In any sane scenario, the wealthy will continue to pay for whatever they want; those without means will go from zero care to a level of care recommended by a panel of experts. In my book, zero plus something is usually considered to be a positive number.

  2. Brian says at September 10th, 2009 at 1:47 pm :
    Thanks for the clarification. I’m not intrinsically opposed to the creation of an expert panel, I’m just pointing out that this particular panel seems to have some very impactful decision-making power.

    Your 3 bullets about why my scary scenario won’t happen don’t ring true to me. To wit:

    1) This describes how Medicare works today. The proposed IMAC would have the power to change that in order to “improve the quality of medical care received by the program’s beneficiaries or improve Medicare’s efficiency,” so long as their “implementation would not result in any increase in the aggregate level of net expenditures under the Medicare program.” Tell me again how a decision to stop funding hip replacements fails to meet this standard?

    2) No argument that the debate is worth having, although the end-of-life debate that’s currently going on is around doctor reimbursement for discussions about living wills and the like – it has nothing to do with what Medicare covers and does not cover. This, by the way, being the (accurate) argument for why the bill contains no “death panels.” The IMAC seems to summarily end the debate, by assigning the decisions about hip replacement vs. morphine to a Presidential appointee in Washington, rather than your doctor.

    3) Agreed that the wealthy will continue to pay for what they want. But those without means don’t have zero today – they have Medicare (it sounds like you’re confusing the uninsured with the elderly). If the IMAC votes to reduce medicare coverage (because hip replacements are wasted on those with terminal cancer, in my example), then those people go from something to less than something, which is usually considered a negative number.

    And if we’re talking about an expensive diagnostic test that catches a disease early, or an expensive drug that works for a small percentage of patients, rather than hip replacements, I can easily see how these decisions could lead to increased death rates. Ergo, the “death panel.”

  3. Suzanne says at September 10th, 2009 at 7:34 pm :
    Brian, there’s already a powerful third-party between you and your doctor. It’s the insurance company! No insurance plan is a blank check for any and all available medical services. All insurance plans, Medicare included, make decisions about what doctor you can see, what hospital you can use, what care is covered by your plan and what care is not covered.

    Even worse, the insurers get to deny claims at their discretion. It isn’t hard to turn up stories about people getting shafted by the insurance companies:

    http://tinyurl.com/ms56s2 – a one sided press release, but interesting nonetheless.

    http://tinyurl.com/mjz3a6 – got insurance? read the fine print!

    Who’s currently making these “covered benefits” decisions for Medicare? If we don’t already have a panel of medical experts deciding what’s included in the coverage, we have to assume it’s being driven by bureaucrats and bean counters. Which group do you want making those decisions when you’re depending on them to provide a decent set of benefits?

    When a private insurer defines benefits to minimize expenses and maximize profit, it’s the good old free market economy at work, but when the government does it to Medicare, it’s rationing by death panels. I smell a double standard.

  4. Janet says at September 10th, 2009 at 10:05 pm :
    I think Suzanne’s made really important points. I’d much rather have a thoughtfully-constituted panel making decisions about what kinds of care might be covered than different bureaucrats in each state. And I’d like everybody to have access to it, whether or not they have jobs (or wish to change jobs – tying health insurance to specific employment restricts the free movement of labor necessary to an unconstrained free-market economy, though that isn’t my objection to it). I’d also rather have a public, transparent process – decisions made by insurance companies are inscrutable, opaque, difficult to challenge, and based primarily on the profit margins of the companies – as they should be in an unconstrained free-market economy, but Adam Smith certainly recognized that the invisible hand does not take care of human welfare, so if that’s a priority for people, then government intervention is necessary. It’s why we have child labor laws, OSHA, etc., rather than simply letting the marketplace set wages at levels that workers consider compensatory for whatever they might perceive the risk to be. And if there were some established care guidelines, then maybe we all wouldn’t be subjected to excessive, intrusive, and unnecessary tests that have been proven repeatedly not to enhance care outcomes (and sometimes to decrease them) but have become necessary to protect against litigation.

  5. Brian says at September 11th, 2009 at 12:16 am :
    Are we talking about private insurance here, or are we talking about Medicare? They are two very different things.

    Medicare does not vary state by state, and it’s coverage is very explicitly spelled out ahead of time (it has to be, since it covers such a wide range of patients). You also don’t lose your Medicare coverage when you experience life events, such as moving or changing jobs (can you be on Medicare and have a job, or do you have to be retired? Not sure about that…)

    As I said above, I’m not against having a panel of medical experts determine what is covered under Medicare. I’m concerned about a presidentially appointed panel that is not accountable to anyone, however. Today, if Congress reduces Medicare benefits to unacceptable levels, we can vote them out of office. With the IMAC in place, we can vote the Congresspeople (and the President) who approved the change out of office, but the people who made the decision keep their jobs for five years (or until a new President fires them). Being accountable to the people is a powerful motivator.

    As for this old saw about insurance companies denying claims to increase their profits – Suzanne, you were with me for two of my five years in that industry. Remember Loss Ratios? Combined Ratios? Loss Adjustment Expenses? Insurance companies don’t make money denying your claims. They make money by keeping you as a customer so they can invest your premiums (read this for more detail). There will always be anecdotal stories about incompetence, aggressive marketing, creative underwriting and outright fraud. These stories are horrific and an idea that minimizes them is a good idea. But that’s not the free market at work. That’s a flaw in the free market that needs to be addressed.

    Today, the insurance companies are incented to do the right thing to keep their customers, and the government is incented to do the right thing (via Medicare) to keep their power. Who/What will incent the IMAC?

  6. Jeff Porten says at September 11th, 2009 at 12:54 pm :
    Brian, you’re making a bizarre error in logic by stating that universal health care for the elderly is so utterly sacrosanct that you won’t brook any changes in benefits — but you have no position on universal care for anyone younger. Never mind cost — the most effective way to ensure healthy septuagenarians is to provide health care for quintegenarians twenty years earlier. (And, yes, this is also much cheaper.)

    Once you include the question of limited public resources, if you started from first principles, you’d completely flip the system we have: provide universal care for the young and healthy when it is far cheaper to do so. When those young people become old people, you rely on the investments made on the long-term health of that population to lower their overall health costs.

    Personally, it seems to me that the all-you-can-eat medical buffet model is unsustainable, whether it’s provided by private plans or the federal government; the sole exception seems to be Japan, where doctors make solidly middle-class wages. On the other hand, they’ve come up with a system where some procedures are 1/50th as expensive as they are here, as an innovate response to cost containment. We have no such restraints here, so we don’t bother with such methods. I’d like to know why we’re not borrowing their ideas.

    Anyway, that’s merely a logical fallacy — you go off the deep end when you talk about unaccountable panels. The president is accountable, as is Congress; changes to a government system answer at the ballot box. That’s far more built-in oversight than exists in the private model, where companies answer to shareholders.

    And I’ve heard you make the argument before that insurance companies desperately retain their customers for that sweet, sweet, investment capital; this seems in contradiction with the practice of rescission, and the enforcement of pre-existing conditions as a barrier to care. The counter-argument — that for-profit insurance companies want to maximize their premiums and zero out their payments — makes a hell of a lot more sense to me, and seems much more demonstrable by the numbers.

    Finally, you make my overall point against pure capitalism better than I ever have:

    But that’s not the free market at work. That’s a flaw in the free market that needs to be addressed.

    No, that’s the free market at work. It’s only a flaw outside the profit system, where we actually consider health outcomes. Internally, it works just fine — and it’s why the free market is failing us.

  7. Suzanne says at September 11th, 2009 at 4:08 pm :
    Brian, I think your argument about insurance companies wanting to retain customers is a little naive.

    Property/casualty insurers are motivated to keep you because it’s very easy to switch insurers. An hour or two of shopping, a couple phone calls, and I’ve got new auto insurance.

    If I want to change my health coverage because the service stinks, I’m stuck until the annual enrollment period, and then my choices are confined to whatever my employer offers (if I want something affordable). If I’m in the middle of a health crisis, I’ve got to worry about whether the new plan will cover my existing condition.

    Getting health insurance through your employer basically makes you a captive audience, which lowers the incentive for the insurer to treat you well. It’s true that insurance companies make their profit from the float, not your premiums, but you’re ignoring the fact that a denied claim represents an amount of money that they’re retaining for investing purposes rather than paying to the policy holder, i.e. lowers claims payouts = lower reserves = more money for investing.

    We’re hearing way too many stories about claims denials for it to be considered anecdotal. How about the Wendell Potter testimony?

    http://tinyurl.com/lgajd2

    Personally, I think a single payer system for all, decoupled from employment and geographic location, would improve the situation.

    The alternative could be a completely free market solution similar to the way you get other types of insurance – directly from the insurer. No more group buying through your employer. We become one big collective of 300 million and the insurers compete head-to-head for every policy holder. With increased regulation of minimum benefits, coverage for pre-existing conditions, and the ability to change your coverage at will, the insurers would have more incentive to treat you well. Employers could make tax free contributions to healthcare savings accounts, which you would then use to buy coverage.

    As for Medicare, yes, you can have a job and be on Medicare. You become eligible at 65, and your benefits are not affected by income level.

    I’m still confused about your “concern”. Why do you expect the IMAC to be directly accountable to the general public? You don’t have that power with any other insurer. If you don’t like the benefits offered by Aetna, you can ask them to change, or you can try to go to another company, but you can’t really get Aetna’s executives fired, nor can you force them to do anything, can you?

    The elderly are Medicare’s captive audience, just like the rest of us with the private insurers. If they don’t like the benefits offered by Medicare, they can buy supplemental plans. If you can’t afford better benefits, well, that’s life in the free market.

    What we need is more transparency and accountability across the insurance industry as a whole, not just for Medicare.

  8. Suzanne says at September 11th, 2009 at 5:34 pm :
    One other thing that’s bugging me. Your old post refuting Sicko relies on statistics for the property/casualty insurance industry. How’s that relevant to a discussion about health insurance? Casualty and health are two different things. Where are your numbers for the health insurance industry?

    You should watch the Bill Moyers interview I linked above. My buddy Wendell makes some very pointed remarks about medical loss ratios and how they affect profits and stock prices.

  9. Brian says at September 12th, 2009 at 11:10 pm :
    @Jeff: increasing funding for preventative care for younger adults doesn’t lower the cost of end-of-life care. It may extend life, but eventually, we’re all going to die of something for which there is no cure. And that is going to cost money.

    As for the accountability of those who control costs, your assertion that the President and Congress are held more accountable by the ballot box than companies are by their shareholders has no basis at all. Private companies are judged every quarter, and changes come swiftly when results aren’t achieved. The trick, of course, is to align those corporate (profit) incentives with the goals of the customers (the patients). This isn’t at all unique to healthcare – cf. the Chinese companies that were caught making shoddy children’s toys last year. They might have thought they were increasing profits by reducing production costs, but in a matter of months, there were recalls and boycotts all across their primary market (America). Could the government be forced to change that quickly?

    Look – this has been an excellent discussion, and I totally concede the point that “death panels” or “cost-containment councils” or whatever you want to call them exist today, and will continue to exist in the future. The argument about which is better – having an insurance company deciding what’s covered or having the government deciding what’s covered is an interesting one to be sure.

    But it wasn’t my original point. My original point was how quickly we jumped to “Liar, liar, pants on fire!” on both sides of the aisle. Sarah Palin obviously intended to derail Obama’s reform message with her inflammatory phrase (which, by the way, just screams Frank Luntz to me, no?), but President Obama and others are lying too when they claim that their plan has no such mediating group.

    And finally, with regard to your constant bashing of the “free market,” criminal behavior and fraud are never part of any free market of any credibility and size. As I’ve said many times now, “free market” does not mean “free-for-all bartering.” All markets have rules – some established by government regulators, some established by the participants themselves. You can’t point to the existence of fraud and claim that the market begets it, but then ignore the existence of retribution for that fraud as something the market also encourages.

  10. Brian says at September 12th, 2009 at 11:41 pm :
    @Suzanne: great points regarding the distinction between the P&C market and the Health market. I think the two become more similar when you consider that the “consumer” in the case of health insurance is the employers, not the employees. An insurer that is treating the employees badly on a consistent basis needs to be ousted by the employer, based on feedback and pressure (up to and including quitting) from the employees. I’ll grant you that this extra layer of feedback makes the health industry less elastic than the P&C industry.

    As for denied claims, you’re making two factual errors. First, denying a claim does not lower the loss reserve on that claim unless the claim is actually closed. And in the case of a health policy, a denied claim usually means the patient is following a different course of treatment, which means the reserve stays open for different reasons. Second, a denied claim and the associated continuation of that case leads, by definition, to increased Loss Adjustment Expenses, which comes directly off the investable balance (as opposed to a reserve, which can at least earn interest while remaining in allowable, liquid investments). We have both met claims examiners who’s principle goal was to settle claims quickly and accurately manage reserves. I don’t recall ever meeting anyone who’s primary goal was to lower the loss ratio.

    As for Wendell Potter a, I think he’s telling the truth, but he’s severely cherry-picking his facts. For instance, the health fair he saw paints a powerful picture – long lines of people being treated in animal stalls because they can’t get insurance. But how long would the line look if you put it next to the 250 million Americans who are treated in hospitals or doctor’s offices? Why is he blaming Cigna’s policies (including, of course, the food service on its corporate jet) for the plight of people were are not Cigna’s customers? And why didn’t Bill Moyers ask him how Cigna’s customers were doing at that time?

    And as for Michael Moore, please don’t let the fact that his political opponents tried to sink his movie lead you to believe that his movie contained an absolute truth. I’ll once again call on my friend Ilya to recount the story he told me about British health insurance (he lived in England for three years). The summary is this: if you’re healthy (regular exams, routine tests, etc.), NHS is terrific – no wait times, no bills, no rationing. And if you’re critically ill, NHS is also terrific – lots of resources go to the critical cases. But if you have a chronic condition, or a condition that might lead to something critical, you could be lost in the shuffle forever – years to see a specialist, half-hearted diagnoses, rules about what’s covered or not, etc..

    Michael Moore picked the right people to interview and got his movie made. But you did a better job of laying out the two primary alternatives in one blog comment than he did in months of “research.”

  11. Ilya says at September 13th, 2009 at 11:04 am :
    Heh, no matter which circles I travel these days, people seem to be very interested in my perspective on NHS :-)

    Brian, you summarized it almost correctly. Actually, NHS is terrific for anything that requires a simple – often, involving a common remedy, – fix or a routine procedure (you would have to wait for a while for the latter, to be honest, but you wouldn’t be cross about it, I suppose). And yes, it does provide access to medical services for everyone, poor or rich. But just as it is in the States, the rich have advantages, in the form of “private” insurance, which gets them complicated treatment faster and arguably of higher quality, while going through NHS – the only route available to the poor – would involve waits of months, if not years, in cases of non-trivial treatment. And the quality of service you get on NHS dime is, well, exactly what you paid for it.

    Unless – and this is where the example of Stephen Hawking was hilariously dumb – you have a condition like something Dr Hawking does, in which case you might expect to be taken care of rather well.

    You can find anecdotal evidence to support either side of the argument, I suppose, so my personal experience with NHS – largely positive, do not get wrong! – is just as relevant as Moore’s selectively misrepresented poppycock. Anyhow, I don’t think it is awfully relevant to the argument at hand, only inasmuch as the notion of universal coverage is being at the heart of the problem, and of costs – not just in monetary sense – inherent in implementing it. I find myself largely on the same position as Suzanne @7, although I recognize that the quality of service under the single-payer system would plummet, expressly because of one of my biggest gripes with Socialism – removal of incentives to competition and advancement…

  12. Brian says at September 13th, 2009 at 11:22 am :
    Thanks, Ilya. For the record, my only other “in-depth” anecdote around nationalized health care was very similar – my grandfather came down with glaucoma in Isarel when he was 88 years old (glaucoma is more serious than some might think in the elderly, as difficulty seeing often leads to difficulty walking, which can lead to serious falls).

    His first doctor told him the waiting list for the surgery was four years. When he told them he was 88, they said “we’ll see what we can do.” He wound up having surgery on the first eye (the eyes are done separately to avoid total blindness during recovery) about a year later. I’m not sure when (or even if) he had the second eye done. He passed away (from something unrelated) at the age of 94.

    As for Suzanne’s points @7, I’m not thrilled at the single-payer option for the reasons you suggested. I like the other suggestion (make health insurance more like auto insurance), but President Obama explicitly ruled it out last Wednesday, calling it a radical departure from what we have now and too much simultaenous change.

    Best bet at this point, in my opinion, is Newt Gingrich’s suggestion (I know, Newt Gingrich – not often my favorite, but he’s got a point here): break the problem into seven or eight separate bills, and pass each one separately. Then, even if only three or four pass, we start chipping away at the problem rather than winding up doing nothing & throwing political food at each other…

  13. Jeff Porten says at September 16th, 2009 at 1:42 pm :
    increasing funding for preventative care for younger adults doesn’t lower the cost of end-of-life care. It may extend life, but eventually, we’re all going to die of something for which there is no cure. And that is going to cost money.

    Now you’re just pulling conclusions out of your ass. The numbers don’t back you up. Ask Sherry what the cost implications are for an untreated diabetic who presents himself on his 65th birthday, versus someone who remains pre-diabetic through proper maintenance. Anyone who suddenly drops dead has zero cost implications, aside from the ambulance.

    your assertion that the President and Congress are held more accountable by the ballot box than companies are by their shareholders has no basis at all. Private companies are judged every quarter, and changes come swiftly when results aren’t achieved.

    By their shareholders, not by their customers. On the basis of profit, not health outcomes. Don’t get me wrong, I can make cost arguments when I choose to do so–but to make this about cost is so fundamentally wrong that I vacillate between calling it callously obtuse, and obliquely evil.

    The last few years have proven that we can spend trillions of dollars on killing people and propping up the status quo, with little reflection and damn near zero political debate. From our actions, you know our priorities. At the moment, healthy Americans is not a priority. I’d like to see that change.

    They might have thought they were increasing profits by reducing production costs, but in a matter of months, there were recalls and boycotts all across their primary market (America). Could the government be forced to change that quickly?

    Christ, Brian. What organization do you think issues product recalls? Last time I checked, it was the federal government. And you’re making this argument in defense of a system which has arrived at its current status over a seventy-year period. Right, that’s nimble. My ass.

    President Obama and others are lying too when they claim that their plan has no such mediating group.

    Let’s make this very simple.

    On December 7th, 2002, a doctor told me that they had done all they could for my mother, and it was time to turn off the machine which was keeping her alive. As a nonmedical expert, I accepted this advice.

    On December 5th, 2002, the decision was made (pretty much without my input) to put her on that machine. The bill for this was a large chunk of the $250,000 invoice I received. Had this not taken place, there would be no way of knowing evaluating the doctor’s assessment that there was a reasonable chance of her recovery; she simply would have had a 100% mortality rate.

    The difference between a doctor’s assessment of which care is best, versus a cost-based assessment of which care is best, is qualitative. It is, in fact, one of the fundamental underlying precepts of both science and morality.

    with regard to your constant bashing of the “free market,” criminal behavior and fraud are never part of any free market of any credibility and size.

    To quote my favorite line of the year, “on what planet do you spend the majority of your time?” Criminal behavior and fraud are human behaviors; pretending otherwise is downright naïve. (And I find it interesting that “protection from fraud” is one of the driving principles for Republicans to kill social programs, but is spontaneously not the government’s problem when it’s free market fraudulent activity.)

    Again, let’s make this simple: in my opinion, a company which sells insurance and then revokes it when it’s needed is committing fraud. At the moment, a legal form of fraud. But the term has no meaning if you don’t think that the contract is not only about providing care, but the promise that such care will be provided when needed.

    But how long would the line look if you put it next to the 250 million Americans who are treated in hospitals or doctor’s offices?

    This is the kind of thing that makes me just want to stop debating this with you. Your argument is that our system works decently for most people. My argument is that anyone who is either not included in “most”, or who may fall out of the category of “most” in the future, is a moral failing of our system.

    Most Africans were not captured and sold as slaves in the 18th century. Most slaves were not murdered or raped by their owners. Slavery provided an economic system which drove the world’s economy for the better part of three centuries. It worked for most people. Many profited heavily from it. And it really sickens me to envision the debate we’d be having if this were 1858.

    I’ll once again call on my friend Ilya to recount the story he told me about British health insurance

    There’s a popular logical fallacy which goes like this: Americans are the most industrious, self-sufficient, and infused with a “can-do” attitude in the world. And yet, when it comes to comparative government, you can trust us to make the worst possible decisions about what to adopt from other countries.

    Japan, Switzerland, Germany, Canada, and the UK all provide different models. Some of them have private insurance. (None of them have private for-profit insurance, which in a rational world would indicate that this is one of the ways in which our system is broken.) Your presumption that our system will adopt the worst of these models indicates your fundamental belief that Americans are too damn stupid or indolent to act on factual evidence and copy what works elsewhere.

    Best bet at this point, in my opinion, is Newt Gingrich’s suggestion (I know, Newt Gingrich – not often my favorite, but he’s got a point here): break the problem into seven or eight separate bills

    Again, you’re just being naïve here. Gingrich’s “proposal” is a political calculation. Break it down into eight bills, throw it into a divided chamber, and allow the right wing echo chamber to whack at it over a prolonged period of time–this allows the defenders of the status quo to kill four of them, water down three, and pass the last as “reform”.

    Here’s what you’ll get if that happens: a government mandate which steers 50 million new customers into private business, with too little funding to provide universal coverage. That’s the path of least resistance, and millions of dollars are being spent in order to ensure it occurs. What it will mean is no change to our expression of our political morality, no real change to health outcomes, and virtual debt slavery for the people who currently cannot afford health insurance.

    Of course, thanks to Max Baucus and conservative Democrats, the health industry is pretty far down this road regardless of what format the bills will use.

  14. Brian says at September 16th, 2009 at 5:30 pm :
    Ask Sherry what the cost implications are for an untreated diabetic who presents himself on his 65th birthday, versus someone who remains pre-diabetic through proper maintenance. Anyone who suddenly drops dead has zero cost implications, aside from the ambulance.

    Sure, if you compare an untreated diabetic to someone who “suddenly drops dead.” But what are the cost implications of a 65-year old diabetic vs. an 85-year old diabetic? The same if not more, right? Preventative care extends life. It doesn’t guarantee that we’ll all live long enough to be killed by buses while crossing the street.

    Christ, Brian. What organization do you think issues product recalls? Last time I checked, it was the federal government.

    Check again. When the Chinese toys were found to contain lead, Mattel recalled more than 10 millions toys. The federal government’s role was to “warn parents to make sure children are not playing with any of the recalled toys” and to bitch about China to the press. Last I checked, Mattel was a corporation (you know, those folks who only care about profits?)

    The difference between a doctor’s assessment of which care is best, versus a cost-based assessment of which care is best, is qualitative. It is, in fact, one of the fundamental underlying precepts of both science and morality.

    I’m confused. This is exactly my point. Your mom was put on that machine because two conditions were met: 1) the doctor decided she needed it, and 2) the doctor was reasonably sure that whoever was paying for it would be willing to pay. If a group like the IMAC decided that Medicare would not cover such a machine (admittedly, an extreme hypothetical example – no one’s suggesting they’d remove coverage for a breathing tube…), then the doctor would not have been able to use it.

    And, to Suzanne’s point above, private insurance companies are in the same position today for younger folks as the proposed IMAC would be for Medicare. Which only goes to prove that “death panels” exist today and will exist in the future, no matter what plan we adopt. The term may be hyperbolic, but the concept exists.

    Brian: criminal behavior and fraud are never part of any free market of any credibility and size.

    Jeff: Criminal behavior and fraud are human behaviors; pretending otherwise is downright naïve.

    Seriously? I suggest that fraud is not part of a legitimate market and you read that as me suggesting that fraud is not a human behavior? There are humans who operate outside of the rules of the market, you know. Ever hear of Bernie Madoff?

    Again, let’s make this simple: in my opinion, a company which sells insurance and then revokes it when it’s needed is committing fraud. At the moment, a legal form of fraud. But the term has no meaning if you don’t think that the contract is not only about providing care, but the promise that such care will be provided when needed.

    You can wish it to be simple, but sadly, it is not simple. A company that revokes insurance because it’s needed is committing fraud (fraud, by definition, is always illegal).

    An insurance company that refuses coverage because the policy doesn’t actually cover the claim is not committing fraud at that point, but may have committed it in the past (in the form of deceptive marketing). Also, the insured’s employer may have been negligent in not communicating clearly what the policy did and did not cover when the employee signed up for the health plan. Finally, the insured may have been provided the coverage information and not read it carefully (or forgotten about it until he/she got sick). To expect the insurance company to say, “Aww…that’s OK, you poor thing, we’ll cover you anyway” is, IMHO, unreasonable under any plan.

    And finally, an insurance company that revokes coverage upon discovering that the insured lied when they took out the policy is also not committing fraud. I know it’s not politically correct to say this now (just like we can’t blame homeowners for taking out mortgages they couldn’t afford or consumers for believing that their credit cards’ “low introductory rate” wasn’t permanent), but there are people who get sick, take out an insurance policy, and then quickly make a claim. That, too, is fraud. Of course, there are grey lines here (insurance companies that revoke coverage because you didn’t tell them you have acne, etc.). Those cases should (and do) wind up in courts of law, sometimes with disasterous consequences. Statistics abound, but both sides tacitly agree that this is an extreme minority situation, despite all the press it’s been getting.

    This is the kind of thing that makes me just want to stop debating this with you. Your argument is that our system works decently for most people. My argument is that anyone who is either not included in “most”, or who may fall out of the category of “most” in the future, is a moral failing of our system.

    Most Africans were not captured and sold as slaves in the 18th century…

    Wait a second… You’re comparing uninsured Americans to slaves who weren’t murdered or raped? And I’m the sick one?

    This part of the argument started as semantics and has devolved into the ridiculous. The current health care system is failing 15% of the population. Of the remaining 85%, it’s serving some of them very well, most of them (including myself) well enough, and some of them not as well as it should. If you feel the need to declare the sum total of this a “moral failure,” go right ahead. I submit that while it might feel good to shout it from the mountain top, it does nothing to help bring about the needed change, and may even hurt its chances by provoking stronger reactions from those who disagree.

    Your presumption that our system will adopt the worst of these models indicates your fundamental belief that Americans are too damn stupid or indolent to act on factual evidence and copy what works elsewhere.

    Well, I never said we’d adopt the worst of the models or that we’re stupid or indolent. I’ll note, though, that you have no trouble comparing our system to other countries when you’re trying to prove that we’re the “52nd worst health care system in the world” or whatever the oft-repeated stat is.

    Ilya’s description actually squares a lot of seemingly opposing facts for me, which is why I asked him to recount it here. We hear so much from people like Michael Moore about the fantastic care that NHS and other systems like it provide; couples having babies without ever paying a bill, patients getting antibiotics without filling out any forms or waiting for appointments, etc.. But then we also hear horror stories about the months-long or year-long waits to see specialists, and we read that life expectancy from a cancer diagnosis is five times longer in the United States than in England. The idea of common and/or centralized healthcare being readily available, but specialist care being complex and inaccessible answers both these claims well, and makes logical sense in a single-payer system (or even a multi-player with centralized controls). We can talk about the pros and cons of such a system, or we can just shout at each other. Because, “can do attitude” or not, if we adopt such a system, we most certainly will need to deal with those scenarios.

    Again, you’re just being naïve here. Gingrich’s “proposal” is a political calculation. Break it down into eight bills, throw it into a divided chamber, and allow the right wing echo chamber to whack at it over a prolonged period of time–this allows the defenders of the status quo to kill four of them, water down three, and pass the last as “reform”.

    I have no doubt that Gingrich has political motives much like the ones you describe. I say I agree with him not because I’m naïve, but because I think there’s a odds-on chance we’ll wind up with nothing at all the way we’re headed, or something that is purely “reform in name only.” If Obama would pick and choose his eight bills carefully, he could probably identify one or two that would generate broad, bi-partisan support (tort reform, for instance?) and actually take real steps towards reducing health care costs, improving coverage, etc..

  15. Jeff Porten says at September 16th, 2009 at 11:16 pm :
    But what are the cost implications of a 65-year old diabetic vs. an 85-year old diabetic? The same if not more, right? Preventative care extends life.

    Point being, with early treatment, you can prevent diabetes entirely. And since you asked, anyone who makes it to 85 likely has a mild case: life expectancy for those with diabetes drops by eight years.

    When the Chinese toys were found to contain lead, Mattel recalled more than 10 millions toys. The federal government’s role was to “warn parents to make sure children are not playing with any of the recalled toys” and to bitch about China to the press.

    The article you pointed me to quoted the CPSC before anyone from Mattel. Last *I* heard, recalls are always coordinated through the CPSC, and sometimes initiated by them, depending upon how cooperative the company is being.

    I can’t call myself an expert here — so if you want to find a product recall which was totally private, and without government assistance, feel free to point me to it. This wasn’t it.

    If a group like the IMAC decided that Medicare would not cover such a machine (admittedly, an extreme hypothetical example – no one’s suggesting they’d remove coverage for a breathing tube…), then the doctor would not have been able to use it.

    I’m not sure what part of this isn’t clear. There was no particular value to my mother living two days longer in a coma; the value was in the doctor’s assessment that she had a good chance of recovery. If there were evidence-based research and panel recommendations which stated that she would not have a good chance of recovery, then I’d expect my doctor to make a different recommendation — or more likely, not to provide the option at all.

    So when I hear the IMAC is made up of doctors and experts, I presume that this is based on what actually works, and that if care is rationed, it’s those treatments which have little chance of success.

    I suggest that fraud is not part of a legitimate market and you read that as me suggesting that fraud is not a human behavior? There are humans who operate outside of the rules of the market, you know. Ever hear of Bernie Madoff?

    Whose fraud extended for how many decades, and whose regulatory oversight was prevented by free market ideology?

    Perhaps we’re just arguing semantics here, but I don’t think so. You’re conveniently defining the free market as exclusionary to the natural ills which result from it. A similar defense could be made for feudalism.

    Finally, the insured may have been provided the coverage information and not read it carefully (or forgotten about it until he/she got sick). To expect the insurance company to say, “Aww…that’s OK, you poor thing, we’ll cover you anyway” is, IMHO, unreasonable under any plan.

    Well, there’s a difference between you and me — I don’t think that it’s appropriate or good public policy to denigrate the sick as “you poor thing” and deny them health care. Call me silly.

    Anyway, you point out a good example of legal fraud: policies and forms which are impossible to understand without a medical education. The average person has no fricking idea what kind of coverage is necessary in coming decades, or the cost of catastrophic care. I think it’s unreasonable to expect such expertise, and unnecessary under a universal coverage regime.

    there are people who get sick, take out an insurance policy, and then quickly make a claim. That, too, is fraud.

    Call me sympathetic to people who manage to get health care they’d otherwise be denied.

    But you raise one good point: it’s fallacious for us to refer to this as insurance. Your car might not get stolen, and your house might not burn down, but you are going to need health care.

    You’re comparing uninsured Americans to slaves who weren’t murdered or raped? And I’m the sick one?

    I’m pointing out that an argument which states that “85% of the people are doing alright” is not necessarily a moral argument. Slavery came to mind. I was thinking of also including post-Weimar economic recovery as another example of a regime where most people did alright at the expense of a minority.

    The current health care system is failing 15% of the population.

    You keep quoting that statistic. I’ll point out the following:

    1) current unemployment and underemployment is 16.6%. There is some percentage of full-time employment which either doesn’t offer coverage, or doesn’t offer affordable coverage. (Can’t find this number, dammit.)

    2) according to this source, 33% of Americans under 65 went uninsured temporarily between 2007 and 2008. This compares to 25% between 1990 and 1992.

    3) even if your health insurance is never interrupted, there is some population N which fears the loss of coverage, or the crippling of their finances. Ironically, such perceptions can increase stress, and decrease health and quality of life.

    I don’t have statistics for these, but I’d say that right now the health care debate is dominated by people who genuinely have excellent coverage which they’ll never have to worry about, and those who are kidding themselves that they’ll never face these issues. I’d consider the health care system to be deeply flawed for all but the first group.

    I submit that while it might feel good to shout it from the mountain top, it does nothing to help bring about the needed change, and may even hurt its chances by provoking stronger reactions from those who disagree.

    Pardon me if I’m not being polite to the self-proclaimed pious when I point out that they’re rejecting the tenets of their own religions. Isn’t that the sort of thing you’re supposed to shout from a mountain top?

    you have no trouble comparing our system to other countries when you’re trying to prove that we’re the “52nd worst health care system in the world” or whatever the oft-repeated stat is.

    37th. I’m not “trying to prove” anything, I’m quoting the World Health Organization. And be careful, because here you’re adopting the rhetorical technique of those who say that people “believe in evolution”. It’s not becoming to you.

    We hear so much from people like Michael Moore about the fantastic care that NHS and other systems like it provide

    As much as you enjoy tearing down whatever Michael Moore has to say, I’m afraid it’s simply not relevant here. The NHS is nationalized health care, not health care insurance. The most radical proposal on the American table is single-payer with private doctors.

    I also note that you argue against universal statements from the NHS with anecdotal evidence. I’m glad to respond with anecdotal horror stories about delayed and denied coverage under our current patchwork system. Fact is, no one has any idea what the flaws will be in a universalized American health care system. If you can quote me statistics from Medicare or the VA, then maybe we have the potential for a rational debate there. Otherwise, you’re just parroting scare tactics, while I’d like to think that I’m pointing out actual evidence of what currently occurring.

    I say I agree with him not because I’m naïve, but because I think there’s a odds-on chance we’ll wind up with nothing at all the way we’re headed, or something that is purely “reform in name only.” If Obama would pick and choose his eight bills carefully, he could probably identify one or two that would generate broad, bi-partisan support (tort reform, for instance?) and actually take real steps towards reducing health care costs, improving coverage, etc.

    As I’ve said before, I don’t give a flying fig about bipartisan support. Democrats won the election; I’d like to see them learn how to wield power effectively. That’s one thing I’ll give Republicans: they know how to turn razor-thin margins into a juggernaut which crushes objection.

    My thinking: if Obama is the leader that we elected him to be, then this is his chance to prove it. The speech was a good start. Next step is to actually command the debate: 47 million people should be one hell of a voting bloc, and I completely fail to understand why they’re not being marshaled against dithering Democrats and potentially moderate Republicans.

    There’s a simple argument which isn’t being made: “The Republicans were unable to dismantle Medicare in 2006, so they didn’t succeed in killing granny, but they are continuing to promote the death of your uncle.”

  16. Brian says at September 17th, 2009 at 4:50 pm :
    Point being, with early treatment, you can prevent diabetes entirely. And since you asked, anyone who makes it to 85 likely has a mild case: life expectancy for those with diabetes drops by eight years.

    Point being, with early treatment, everyone’s eventually going to get something. So, if you avoid diabetes entirely, you may just live long enough to get cancer. (Cheery discussion, ain’t it?) Oh, and the 8-year figure is comparing diabetes sufferers to non-diabetes sufferers, not 65-year olds to 85-year olds.

    The article you pointed me to quoted the CPSC before anyone from Mattel. Last *I* heard, recalls are always coordinated through the CPSC, and sometimes initiated by them, depending upon how cooperative the company is being.

    I can’t call myself an expert here — so if you want to find a product recall which was totally private, and without government assistance, feel free to point me to it. This wasn’t it.

    The first three words in the article I pointed you to are “Mattel announced recalls.” It quotes the CPSC chairperson, an Illinois senator, a New Jersey congressman, and the CEO of Mattel. How in the world does the order of the quotes matter? When a recall is required, the retailer issues the recall, the retailer refunds the consumer the money and/or replaces the item, and they work with the CPSC to coordinate the logistics – CPSC helps with communication, negotiation with other parties (China, in this case), and probably with whatever financial assistance/tax implications there are to the company (just guessing on that part).

    Here is another example – Thomas the Tank Engine toys (sorry – all my recall examples are children’s toys, because those are the ones I would hear about when they happened). Note the headline, “RC2 Corp. Recalls Various Thomas & Friends WOoden Railway Toys Due to Lead Poisoning Hazard.” Note the URL (cpsc.gov), and the phone numbers at the top (coroprate phone number first & bolded, CPSC number, CPSC media relations person).

    Your original argument was, “Christ, Brian. What organization do you think issues product recalls? Last time I checked, it was the federal government.” Now that I’ve shown you that that’s not even remotely true, you’ve morphed to “find a product recall which was totally private, and without government assistance.” Christ, Jeff….

    If there were evidence-based research and panel recommendations which stated that she would not have a good chance of recovery, then I’d expect my doctor to make a different recommendation — or more likely, not to provide the option at all. So when I hear the IMAC is made up of doctors and experts, I presume that this is based on what actually works, and that if care is rationed, it’s those treatments which have little chance of success.

    And if your mother’s doctor disagreed with the IMAC experts? I don’t mean to harp on a particularly sensitive, morbid example, but if it were me, and the doctor that had actually examined my mother reached one conclusion and a panel of medical experts had reached a different conclusion in an abstract way, I’d be very concerned about the panel’s decision taking precedence.

    Since you gave a personal example, here’s one from me: Sherry had an MRI two years ago (she’s fine). This year, her doctor suggested repeating the MRI to make sure nothing had changed (she’s still fine). The insurance company denied coverage of the MRI, saying that she’d already had one, and an ultrasound would be cheaper and just as effective. Rather than running to a town hall meeting, she had her doctor call the insurance company and explain that the ultrasound wouldn’t allow him to compare the two pictures, which was the point of repeating the test. The insurance company relented and allowed the test.

    In the case of IMAC, the coverage decisions become laws. I presume that an appeal would require a lawyer and a court. Now, like President Obama and his grandmother’s hip replacement, we would likely have paid for the test out of pocket, rather than fight a legal battle, but not everyone has that option.

    Perhaps we’re just arguing semantics here, but I don’t think so. You’re conveniently defining the free market as exclusionary to the natural ills which result from it. A similar defense could be made for feudalism.

    Perhaps it is semantics. Most free markets (including the financial markets) have rules prohibiting fraud, and regulatory bodies assigned to find and prosecute that fraud. Madoff broke the rules. The fact that it took so long to catch him is a failure of the regulatory body (the SEC, in this case). If the activity is “part of the free market” than the regulation and prosecution must also be considered so. As opposed to feudalism, where the plight of the serfs is an openly accepted part of the system, and no one would ever (or could ever) change it. Please tell me you see the difference here…

    Well, there’s a difference between you and me — I don’t think that it’s appropriate or good public policy to denigrate the sick as “you poor thing” and deny them health care. Call me silly.

    You’re silly. (Sorry, couldn’t resist…) Seriously, though, you’re sitting at a poker table and bet your last $50 on an Ace-high straight. Your opponent has a flush. You tell him it’s your last $50 and you really need the money. If he doesn’t say, “you poor thing, you take the pot,” is he denigrating you and denying you money? Of course not. Similarly, if your policy covers doctor’s visits and not hospital stays and you need a hospital, expecting the insurance company to pay for the hospital anyway is far-fetched. Accusing them of denying you health care is downright dishonest.

    Anyway, you point out a good example of legal fraud: policies and forms which are impossible to understand without a medical education. The average person has no fricking idea what kind of coverage is necessary in coming decades, or the cost of catastrophic care. I think it’s unreasonable to expect such expertise, and unnecessary under a universal coverage regime.

    Sorry, I don’t need a medical education to understand “80% of hospital stays” vs. “0% of hospital stays up to a $2,500 annual maximum out-of-pocket” (these are the two choices at my current employer). And I don’t think it’s unreasonable to expect people to understand this when they choose their healthcare. I will agree with you that many people just pick the cheaper option when they start their new job, and blame the insurance company when they learn what they bought. That isn’t “legal fraud” (still a mysterious term to me), it’s shirking personal responsibility. Unless, as I said earlier, the coverage was hidden in some fine print or behind some legalese, or some HR/benefits person at your company lied to you about what it said and told you not to read it…

    And as for universal coverage, note that “universal” means everyone is covered, not everything is covered. It would still be vitally important that people understand what their coverage provides. Under such a scenario, it would also be important that they understand how new rules/laws passed by an IMAC-like counsel would affect their coverage going forward.

    Brian: there are people who get sick, take out an insurance policy, and then quickly make a claim. That, too, is fraud.

    Jeff: Call me sympathetic to people who manage to get health care they’d otherwise be denied.

    Again, seriously? Lying to an insurance company to obtain an insurance policy right before going in for treatment is OK? How about stealing food when you’re hungry? Kidnapping a baby if you’re infertile? Holding up an emergency room to steal the vicodin because you’re a drug addict?

    Crime is crime. You may understand the criminal’s reasoning, but that doesn’t make it okay…

    it’s fallacious for us to refer to this as insurance. Your car might not get stolen, and your house might not burn down, but you are going to need health care.

    Wow…three in a row. Seriously? We’re all going to die – is life insurance bullshit too? I’m not even sure what your point is with this, but it goes back to the whole “ability to modify the meaning of any opposing argument into something that is self-evidently wrong” thing. The term “insurance” has a definition; no need to make up a new one.

    Pardon me if I’m not being polite to the self-proclaimed pious when I point out that they’re rejecting the tenets of their own religions. Isn’t that the sort of thing you’re supposed to shout from a mountain top?

    It depends. If you want to convince the world that the “self-proclaimed pious” are actuall inherently evil, then shout away. If you want to make things better, though, then you get off the mountain and work out a practical solution.

    37th. I’m not “trying to prove” anything, I’m quoting the World Health Organization. And be careful, because here you’re adopting the rhetorical technique of those who say that people “believe in evolution”. It’s not becoming to you.

    Yes, and in quoting the World Health Organization you’re telling part of the story. Like how we jump from 37th to right near the top when you remove accidental death and violent crime from the statistics. Or how survival rates from first diagnosis are five times higher here than elsewhere.

    The fact that you consider your facts facts and my facts fictions does not make me an “intelligent design” advocate.

    Fact is, no one has any idea what the flaws will be in a universalized American health care system. If you can quote me statistics from Medicare or the VA, then maybe we have the potential for a rational debate there. Otherwise, you’re just parroting scare tactics, while I’d like to think that I’m pointing out actual evidence of what currently occurring.

    Heh…so no one has any idea what’s going to happen, but you’re pointing out actual evidence of what’s currently occurring? Neat trick…

    I’m not telling anecdotal horror stories. I’m trying to draw logical conclusions, based on how these systems function. If you have universal coverage/single-payer/centralized rules for coverage, then it makes perfect sense that the very common occurrences (having a baby) and the very simple occurrences (antibiotics for an ear infection) would be handled very well, and the uncommon or complex occurrences (“Doc, it hurts when I do this”) would strain the system.

    Medicare and the VA are in the same boat right now. A senior citizen can get his/her normal checkups without a problem, but refer them to a specialist and you wind up in administrative hell. Add 30-40 million people to that model (more likely much, much more) and it only makes sense that the situation exacerbates. This isn’t a criticism or an argument against reform, it’s an attempt to work out a working solution. But, alas, it’s lost amongst the noise…

    There’s a simple argument which isn’t being made: “The Republicans were unable to dismantle Medicare in 2006, so they didn’t succeed in killing granny, but they are continuing to promote the death of your uncle.”

    Once again, not so simple:

    http://factcheck.org/2009/09/senior-scare-yet-again/.

    Unless by “command the debate” you mean win the argument, even if you have to lie to do it…

  17. Jeff Porten says at September 20th, 2009 at 5:47 am :
    Point being, with early treatment, everyone’s eventually going to get something. So, if you avoid diabetes entirely, you may just live long enough to get cancer. (Cheery discussion, ain’t it?)

    Look, there are two ways of looking at this. I’m taking the “promote the general welfare” argument, which holds that treating people is a moral imperative regardless of whether it costs money. But since you’re fixated on the cost containment argument, I’m engaging you there as well.

    You seem to be saying that “health care will always cost money, so why bother?” So, sure — if you believe that extending people’s lives is going to cost you more money down the road, feel free to refer to my other reasons for doing this.

    That said, AFAIK, when you consider the health costs of gerontological outliers, people who live the longest tend to drop dead suddenly rather than waste away. Dropping dead suddenly is cheaper than wasting away, even if you add up the extra 20 years of maintenance it takes to get there. The jury is still out on whether this is a possible goal for everyone, and not just the winners of the genetic lottery, but the implication is certainly there that the cost increase of universal preventive medicine will be lower than the cost reduction of currently necessary crisis procedures.

    Your original argument was, “Christ, Brian. What organization do you think issues product recalls? Last time I checked, it was the federal government.” Now that I’ve shown you that that’s not even remotely true

    You haven’t done that in the slightest. You’ve asserted that product recalls take place thanks to the beneficent ministrations of enlightened oligarchs, and that government regulators somehow look on like idiot stepchildren in the process. My understanding, in contrast, is that it tends to be the CPSC which does the heavy lifting. Neither of us have proven either case.

    What we need is the flowchart of “how recalls happen”, with emphasis on where the motive forces occur. Personally, I can infer which of us is correct from the history of seat belts and airbags — but hey, here’s a golden opportunity to make me eat crow with your mad Google skills.

    And if your mother’s doctor disagreed with the IMAC experts?

    Right — when dealing with end-of-life care, it is completely rational to believe that the most likely source of hard ethical questions, life-and-death decisions on limited information, and bureaucratic nightmares will be disagreements between the IMAC and the doctor. As opposed to, say, the 10,000 sources of the same issues which I actually did have to deal with.

    Gotta tell ya, Brian — in both cases, having an outside panel of experts with a cookie-cutter set of recommendations, against which to compare what I was hearing from my parents’ doctors, would have made my life easier even if they told me what I didn’t want to hear. I have absolutely no idea what I would have done if I had been told “no” instead of “maybe” at certain key points — or whether either of my parents benefited from my acting on “maybe” and my own ability to guess. Unfortunate side-effect of that whole “comatose and uncommunicative” thing.

    The point, though, is that someone will be writing those guidelines, and I believe it should be done by MDs instead of MBAs. And if some of those MDs should lay down a law or two — as opposed to the present system of “empowering the patient” with unlimited responsibility, based upon whatever scraps of contradictory information he can amass — well, you won’t catch me saying that this is automatically the worst of all possible worlds.

    the doctor that had actually examined my mother reached one conclusion and a panel of medical experts had reached a different conclusion in an abstract way, I’d be very concerned about the panel’s decision taking precedence.

    I find it amusing and baffling that, in your private insurance anecdote, the doctor can take it upon himself to work the system, but you assume that the same doctor will be utterly powerless elsewhere. My understanding of how government guidelines and private bureaucracies work is that there is typically more leeway when dealing with Medicare. And I wonder if your story would be different if we were discussing a denied medical procedure rather than a diagnostic.

    In any case, yes — we agree that the doctor should have latitude. On the other hand, that same doctor can’t be incented to chase miracles, because I can damn well tell you that the patient is generally quite happy to go for the PowerBall medical treatment, and to hell with the odds.

    In the case of IMAC, the coverage decisions become laws. I presume that an appeal would require a lawyer and a court.

    I can’t tell you I know how it works; I can say that no one ever said “no” when my father’s treatment was covered by Medicare. Most of the time, his care took place without any kind of consent from me, and took on a self-perpetuating life of its own — presumably Medicare-covered throughout.

    But let’s be clear: what we’re arguing here is whether government-run health care is more Kafkaesque than our current system. All I’m hearing so far is that you’ve got the kind of health coverage which, so far, has been mostly bereft of giant cockroaches. Glad to hear it — but since you’ll probably not switch to a public plan anytime soon, would you mind remembering that your “horror stories” are in fact much less horrible than the current state of affairs for many other people?

    If the activity is “part of the free market” than the regulation and prosecution must also be considered so. As opposed to feudalism, where the plight of the serfs is an openly accepted part of the system, and no one would ever (or could ever) change it. Please tell me you see the difference here…

    You know what? We should probably just drop this part of the discussion. Because my reply here would have started to point out that Western free market economies are just as staunchly based on forced labor in developing nations as any feudal system. Which would have led to an exegesis about whether capitalism is inherently exploitative, or is only exploitative in its present incarnation… and you know, I just don’t think that’s going to lead to a rational debate.

    Seriously, though, you’re sitting at a poker table and bet your last $50 on an Ace-high straight. Your opponent has a flush. You tell him it’s your last $50 and you really need the money.

    Look, I know you’re just reaching for a metaphor here, but it failed. Rule one of poker: play with stakes you can afford to lose. We’re talking about health care — the metaphor only works if the person who takes the pot shoots the loser through the forehead.

    if your policy covers doctor’s visits and not hospital stays and you need a hospital, expecting the insurance company to pay for the hospital anyway is far-fetched.

    Fine. How’s this, instead: a medical policies which do not include hospitalization are immoral. On the working theory that hospitals have been part of modern health care for, oh, 150 years or so. Does that work better for you?

    I don’t need a medical education to understand “80% of hospital stays” vs. “0% of hospital stays up to a $2,500 annual maximum out-of-pocket” (these are the two choices at my current employer). And I don’t think it’s unreasonable to expect people to understand this when they choose their healthcare…. Note that “universal” means everyone is covered, not everything is covered. It would still be vitally important that people understand what their coverage provides.

    You remind me of the guys who think that computers lost some of their oomph when you no longer needed to be a 6502 or 8088 assembly programmer to use one. I fail to understand what you’re so enamored of needless bureaucratic complexity — you, like most people, seem to mistake “choice of insurance” for “choice of health care”.

    Me, I just want to not get sick, and get better faster when I do. Seeing as how the (set of ways in which I can get sick) closely maps on a Venn diagram to the (set of ways that all humans can get sick), then your complexity is really just masking the fact that, by choosing some subset of coverage, you’re creating a (subset of ways in which you can get sick) which makes it either impossible or exorbitantly expensive to get well.

    Reminder: exorbitantly expensive, for people who don’t have money, means you don’t get well.

    This is not a universal feature of health care; some countries have managed to do away with this entirely. When you get sick, you get the treatment you need. What a concept. I think we should try something like that, even if it costs money.

    Lying to an insurance company to obtain an insurance policy right before going in for treatment is OK? How about stealing food when you’re hungry? Kidnapping a baby if you’re infertile? Holding up an emergency room to steal the vicodin because you’re a drug addict?

    Really, Brian. Don’t ask me questions that you don’t want to hear the answers to, okay? Excepting that cute bit about kidnapping… you’re goddamn right I can put myself in the shoes of someone who is going hungry, desperate for medical care, or addicted to drugs. And I can damn well be compassionate about how I might judge such a person — I might even go so far as to question why people are hungry, rather than simply punish people for stealing food.

    Crime is crime. You may understand the criminal’s reasoning, but that doesn’t make it okay…

    Well… I sincerely hope you’re never in a situation where you have to question this belief. I suspect it might be painful.

    Like how we jump from 37th to right near the top when you remove accidental death and violent crime from the statistics. Or how survival rates from first diagnosis are five times higher here than elsewhere.

    Brian, how many times are you going to ask me to call bullshit on you? You’re quoting a single paper which used statistics from 1986-1992, as your bulwark against a survey, presumably across thousands of such studies, by a global health organization.

    And on second thought, I’m going to call bullshit on that second stat, because any medical procedure which was 500% better than its alternative would be adopted elsewhere. It might be in the paper you cited. But it doesn’t pass the smell test.

    You’re building an argument which says, “No, really, we’re nearly the best, and I’ve got the paper to prove it. The World Health Organization is wrong.” And I’m suddenly realizing… you might as well be arguing in favor of intelligent design, considering the scant relationship between your conclusions and your evidence.

    Heh…so no one has any idea what’s going to happen, but you’re pointing out actual evidence of what’s currently occurring? Neat trick…

    Where I can, I’m drawing from the experience of other countries which I’d like us to mimic or model. You’re absolutely right, though, that the bulk of my argument is pointing out the many ways in which the system currently sucks for the uninsured — which you are countering by saying, “no, really, it’s not as bad as you think it is.”

    This kind of strikes me as the equivalent of me, based on my deeply held beliefs and long educational background, explaining to Sherry what it’s like to be pregnant.

  18. Brian says at September 21st, 2009 at 6:11 pm :
    You seem to be saying that “health care will always cost money, so why bother?” So, sure — if you believe that extending people’s lives is going to cost you more money down the road, feel free to refer to my other reasons for doing this.

    Close. I’m saying, “health care will always cost money and someone will have to pay that money.” That doesn’t mean we don’t bother, but it does mean that we don’t have an endless supply of money to spend.

    That said, AFAIK, when you consider the health costs of gerontological outliers, people who live the longest tend to drop dead suddenly rather than waste away.

    I have no idea where you got this notion. I’ll check with Sherry, but my sense is that people who live a very long time tend to have multiple, chronic (as opposed to acute) medical problems crop up. When they “drop dead,” it’s usually due to one or more of these problems becoming too much for the body to handle. And until they do, we tend to treat each and every problem – individually and/or collectively. Any idea what nursing homes cost? Recent experiences of friends and co-workers suggest that $10,000 per month is not uncommon.

    You haven’t done that in the slightest. You’ve asserted that product recalls take place thanks to the beneficent ministrations of enlightened oligarchs, and that government regulators somehow look on like idiot stepchildren in the process. My understanding, in contrast, is that it tends to be the CPSC which does the heavy lifting. Neither of us have proven either case.

    Translation: your examples are meaningless to me because they appear to prove your point. Find me a flowchart (and, if possible, the broom of the Wicked Witch of the West).

    Look – the various consumer protection agencies have the power to shut a company down if they’re endangering their customers. They can fine them out of existence or they can criminally prosecute the people who work there if they wish. But if you buy a product from a company, only the company can decide to give you your money back and/or fix your product for free. If they choose not to, they risk incurring the penalites I just described.

    Do you want more examples? I googled “auto recalls” and found a list of auto-related recalls for August of 2009. Note the domain: dot.gov. Let me give you some quotes:

    Curt is recalling certain Class 1 receiver hitches…

    Lift-U is recalling certain wheelchair lifts…

    AFX is recalling certain model FX-28 motorcycle helmets…

    Girardin is recalling certain model year 2008 G5 and MB II school buses…

    Jaguar is recalling 34 model year 2010 XF vehicles…

    Hyundai is recalling 82 model year 2002-2003 Sonata vehicles…

    Daimler Bus North America is recalling certain . . . transit buses…

    BMW is recalling certain model year . . . motorcycles…

    Girardin Minibus is recalling certain model year . . . multi purpose vehicles…

    Girardin is recalling certain model year . . . non-school buses…

    Newmar is recalling certain model year 2003 and 2004 motor homes…

    Quality Vans is recalling certain model year 2004 through 2008 vans…

    BMW is recalling certain model year 2009 Z4 30i and 35i vehicles…

    Blue Bird is recalling certain Model Year . . . school buses…

    Personalized Vans and Trucks is recalling certain vans…

    Dutchmen is recalling certain model year . . . trailers…

    Toyota is recalling certain model year 2010 Corolla vehicles…

    Volkswagen is recalling certain model year 2009 and 2010 passenger cars…

    It goes on for two more pages. And here’s a page that links to each monthly report since March. All in all, I’m estimating roughly 200 recalls in the past six months – each and every one of them initiated by the company who made the product, and collected and reported by the government agency that oversees their industry. These agencies, for the record, are not idiot stepchildren – they are doing their jobs. They are informing the public about health and safety concerns, and working with the companies that serve the public to get the word out, handle logistics, etc..

    Can I assume that you still believe I’ve proven nothing?

    And if some of those MDs should lay down a law or two — as opposed to the present system of “empowering the patient” with unlimited responsibility, based upon whatever scraps of contradictory information he can amass — well, you won’t catch me saying that this is automatically the worst of all possible worlds.

    No, not the worst of all worlds. But definitely something worth discussing. I’m willing to bet that there are just as many people who would blame the government for nothing less than murdering their parents if they heard “no” instead of “maybe,” especially if their personal doctor disagreed with the panel’s decision.

    To be clear here: I’m not talking about the doctors “working the system” (although I know that goes on as well). I’m talking about the doctors having reasoned discussions with both the patients, their families, and the claims examiners about what would be best in the long run, both from a medical and financial standpoint. That discussion, IMHO, puts the people with the right vested interests in the room together to reach the “right” answer (quotes meant to indicate that sometimes, there is no “right” answer).

    Fine. How’s this, instead: a medical policies which do not include hospitalization are immoral. On the working theory that hospitals have been part of modern health care for, oh, 150 years or so. Does that work better for you?

    Another “Jeff is really treading into places he doesn’t understand” moment. I’ve never heard of a medical policy that doesn’t cover hospitalization at all. The choices are almost always around what you pay in what circumstance. As I said above, in my case, I have two choices: low deductible and high deductible.

    “Low deductible” means I pay a co-pay every time I see my doctor (usually between $15 and $35). I pay a similar co-pay every time I buy medication. If I need medical care above and beyond the standard appointments (i.e., tests, scans, procedures, lab work, hospital stay, etc.) the insurance covers 0% until I reach a relatively low annual deductible (I think it’s around $400), and then covers anywhere from 80% to 100% of the cost. When I’ve reached a maximum out-of-pocket for the year (usually $1,500 or so) – not counting co-pays or the deductible, then insurance covers 100% of the cost. So, in the worst case, I pay roughly $2,000 plus all of my co-pays for the year (probably in the $2,500-$3,000 neighborhood).

    “High deductible” means I pay actual cost every time I visit the doctor, buy medication, or receive additional medical care (a single doctor’s visit could cost upwards of $200). When I reach a maximum out-of-pocket (deductible) for the year (I think it’s $2,500 or $3,500, but I could be wrong – this isn’t the plan I use), the insurance pays 100% of the remaining costs for the year. So, again, worst case – I pay roughly $2,500-$3,500 per year.

    The difference, of course, being that in a good year, where all I have is regular doctor’s appointments and non-emergency medications (coughs & colds, for intance), I pay a lot less money under the low-deductible plan (just the co-pays) than under the high-deductible plan. The flip side? The low-deductible plan is significantly more expensive than the high-deductible plan.

    So what happens? Someone signs up for the high deductible plan and doesn’t read/understand what he/she bought. Later that year, after paying monthly premiums for a while, he/she has a car accident and is rushed to the hospital. When he/she gets out, the hospital presents a bill for $2,500 and the person flips out. “How dare my insurance company not pay for my hospital stay? This is America! Making me pay for my own hospital stay after collecting premiums all year is immoral and wrong!!!”

    Obviously, there are other permutations. This is just one example.

    This is not a universal feature of health care; some countries have managed to do away with this entirely. When you get sick, you get the treatment you need. What a concept. I think we should try something like that, even if it costs money.

    That’s simply not true. In the countries you refer to, if you need one of the services paid for by your tax dollars, then you get the treatment you need. If you need a specialty service, or if no one is quite sure what you need, you enter a beauracracy that can produce horrible anecdotes for the other side of the debate.

    For the life of me, I can’t understand this need to paint one side as nirvana – neither side is, and that should be intuitively obvious to anyone who’s thinking about this…

    you’re goddamn right I can put myself in the shoes of someone who is going hungry, desperate for medical care, or addicted to drugs. And I can damn well be compassionate about how I might judge such a person — I might even go so far as to question why people are hungry, rather than simply punish people for stealing food.

    I can be compassionate as well. But compassionate means putting the person in treatment rather than prison. It doesn’t mean just giving them the food, and then excusing their breaking into my home, stealing my property and endangering my family. We should help the desparate in our country by providing services they can avail themselves of legally and without endangering themselves or others. It’s not always easy, and it’s not always cheap. But making the laws of the land optional is never the right answer.

    And on second thought, I’m going to call bullshit on that second stat, because any medical procedure which was 500% better than its alternative would be adopted elsewhere. It might be in the paper you cited. But it doesn’t pass the smell test.

    Suggesting that you haven’t read the paper, or what I wrote about it. A 5x survival rate means a better or earlier diagnosis, followed by agressive treatment. Diagnose the same cancer and apply the same treatment a year later, and your survival rate can plummet. Which is why the various anecdotes about availablity of specialists and complex diagnosticians ring so true. This kind of reality is distorted by folks who use politically-charged words like “rationing” and “death panels,” but it’s a reality we should study and discuss.

    You’re building an argument which says, “No, really, we’re nearly the best, and I’ve got the paper to prove it. The World Health Organization is wrong.” And I’m suddenly realizing… you might as well be arguing in favor of intelligent design, considering the scant relationship between your conclusions and your evidence.

    Heh…it’s the George W. Bush argument all over again. “You don’t agree with me 100%, so you’re clearly 100% against me.”

    I’m weighing evidence that paints the American health system in both positive (U. of Iowa) and negative (WHO) lights, and seeking to understand how they two groups studied different datasets and reached different conclusions. WHO didn’t remove accidental death and violent crime. Were they wrong? No. They made a choice. If we’re discussing life expectancy (e.g., in the context of, say, whether we should fund more police in a given country) then it’s a perfectly valid way to slice the data. If we’re discussing health care reform, I think it should be removed (others may disagree).

    You’ve read a study (WHO) that corresponds with your world view (or the world view of “your side,”) and now make it your business to disparage any other study that reaches a contradictory conclusion. You won’t discuss the merits of their data analysis methodology. Instead, you’ll twist my words (“our system is the best,” “the World Health Organization is wrong”) and then throw in a reference to an unrelated, previously discredited topic (intelligent design) just to cement my insanity.

    Do you think the University of Iowa is a disreputable source? If so, say so. Do you think they made faulty assumptions and therefore reached poor conclusions? Do tell – I’m happy to discuss it with you and learn something from our discussions. Until then, my conclusions are just as tied to evidence as yours are. And suggesting that our health care system is the best at something doesn’t mean I believe it’s the best at everything. But why throw the baby out with the bathwater? Is it so “your side” can “wield their power” and “win the debate?” Meh…

  19. Jeff Porten says at September 23rd, 2009 at 11:41 am :
    That doesn’t mean we don’t bother, but it does mean that we don’t have an endless supply of money to spend.

    Ah. We appear to have reached the point of the discussion where you talk to me like I’m an idiot.

    I have no idea where you got this notion. I’ll check with Sherry, but my sense is that people who live a very long time tend to have multiple, chronic (as opposed to acute) medical problems crop up.

    I’ll be glad to hear Sherry’s take on this, and revise my opinion if I’m wrong. This is based on an ad hoc impression I’ve heard from following the Aubrey de Grey crowd (you saw his TED lecture, yes?), and what I’ve heard about centenarians–all of whom, by definition, spent most of their lives without the benefit of recent medical technology. It might be true that their last six months cost as much as anyone else’s, but it’s generally not true that they require decades of gerontological care; people who are on that trendline don’t live that long.

    At least, that’s my understanding; I’m no expert.

    Any idea what nursing homes cost? Recent experiences of friends and co-workers suggest that $10,000 per month is not uncommon.

    First hand, as you should probably remember. And if you can point to people who survive decades of nursing home care, that invalidates my thesis. Centenarians spend their time in cheaper assisted living facilities if they need care at all, and spend as much time in nursing care as the shorter-lived.

    I’m estimating roughly 200 recalls in the past six months – each and every one of them initiated by the company who made the product, and collected and reported by the government agency that oversees their industry.

    I’m trying to figure out if you’re being deliberately obtuse. What you’ve established is that, in the event of a recall, the language which is used is “company X issued a recall”. This says absolutely nothing about whether recalls are initiated by the companies in question, or are initiated by regulatory agencies. As you point out, the CPSC and other agencies have the power to force the issue… so you are correct if most of these recalls start out within these companies, and are merely coordinated through the CPSC, while I am correct if most companies would not recall their products unless the federal government were sitting on their shoulder.

    Hence, my request for a flowchart. On the other hand, if you like, we could look at the historical record of product recalls to see how often they occurred before regulation was instituted. As most regulation stems from observed failures, I’m comfortable starting here.

    I’m willing to bet that there are just as many people who would blame the government for nothing less than murdering their parents if they heard “no” instead of “maybe,”

    No reason to postulate hypotheticals here — there are over forty years of data available thanks to Medicare. Show me the horrific track record of the federal government putting people to death in that program, and I’ll concede you have a point. Seems to me, though, that if this were the case, we would have long since heard about it. And in the absence of that dog barking, it sounds to me like you’re engaged in some needless fearmongering.

    I’ve never heard of a medical policy that doesn’t cover hospitalization at all.

    In that case, you’re not paying attention. Or you’re limiting your consideration to people who can choose to afford a decent health plan, and/or paying high deductibles out of pocket.

    What I’m referring to, first, are the hospitalizations which take place with some degree of choice on the part of the patient; in these cases, people who can’t afford their deductibles are forced to choose between debilitating suffering, or bankruptcy. With regard to compulsory hospitalizations, you might end up with both–the hospitalization forces you into penury, but the insurance might not cover ongoing care after the patient is stabilized. Especially if the bankruptcy ensures that you can no longer afford your premiums, or the debilitation ensures that you lose both your job and your insurance group. And, of course, anyone who cannot afford or get insurance must avoid hospitalization at all costs, or be pauperized.

    Your statements presume several things: 1) ability to pay from savings or ongoing budgeting; 2) maintenance of employment; 3) maintenance of insurance coverage. Drop any of these three (and losing one will likely exacerbate the others), and the insured falls into a black hole.

    Someone signs up for the high deductible plan and doesn’t read/understand what he/she bought.

    Yes, I think this is also an issue, and I think you’re being remarkable facile about the incentives in the system for private insurers to reap the benefits of such misunderstandings. (“Whoops, you thought you were paying for X, but you were really paying for Y, now that you need X. Bzzt, thanks for playing.”) But beyond that, play by the rules, and you’re in good hands with Allstate only so long as you can continue to meet the financial and work prerequisites.

    “Making me pay for my own hospital stay after collecting premiums all year is immoral and wrong!”

    Again — pretending for the moment that everyone gets the hospitalization they need, the people into whose mouths you’re putting these words have just survived a catastrophic event. Frequently, this involved prolonged suffering and loss of income. You’re entitled to your (callous and inhumane) opinion here about their “getting what they deserve” by way of a crushing invoice, but really, it’s not becoming to point and laugh at them for their ignorance.

    In the countries you refer to, if you need one of the services paid for by your tax dollars, then you get the treatment you need. If you need a specialty service, or if no one is quite sure what you need, you enter a beauracracy that can produce horrible anecdotes for the other side of the debate.

    Conceded: my statement was sweeping, and it might not be 100% true. It is, however, largely true, based on what I’ve been hearing from experts on comparative international health systems. Cf. any of the recent interviews or writing by T.R. Reid.

    I have no doubt horrible anecdotes exist everywhere. It’s also possible to be killed in a street mugging in Japan–but it’s nearly unheard of there, while it’s common here. Equating one to the other is… well, let’s just call it an invalid form of argument so I can remain nominally civil.

    I can’t understand this need to paint one side as nirvana – neither side is, and that should be intuitively obvious to anyone who’s thinking about this…

    I can’t understand your need to put my position in absolutist terms; it’s another way of calling me an idiot. What I said was that our system is predicated on immoral precepts, while universal coverage systems are not. It is intuitively obvious that our system mostly works for the steadily employed middle-class, provided they can maintain that status; most people do, but your right to health care is predicated on this. It’s intuitively obvious that every other health care system fails for some individuals, but as these are not predicated on social class, they are not immoral.

    Feel free to disagree with me about morality; that’s a subjective statement. Although I’d be interested in hearing your moral defense of why someone whom is unable to work due to illness, should have their health care revoked because they are unable to work.

    But compassionate means putting the person in treatment rather than prison. It doesn’t mean just giving them the food, and then excusing their breaking into my home, stealing my property and endangering my family.

    Christ, Brian. Poor people must really terrify you. I’m not sure how you made the leap from theft to B&E and endangerment.

    Just so we’re clear: having had the shit beaten out of me twice, I am not forgiving of the people who used me as a punching bag so they could help themselves to my wallet. Your right to eat does not supersede someone else’s right to not bleed. Nor does your right to eat excuse you from laws regarding property.

    However, what I was saying is that the three conditions I mentioned–going hungry, desperate for medical care, addicted to drugs–are all a hell of a lot more common here than in similarly wealthy nations, so we shouldn’t be all that surprised when some people in these situations commit crimes, rather than simply curl up and die. Moral public policy would see these as root causes, and address them; you can thereby infer my position on our public policy.

    Suggesting that you haven’t read the paper, or what I wrote about it. A 5x survival rate….

    Yes, Brian, I read the paper, which is how I know that you’re basing your argument on statistics compiled between 1986 and 1992. Let me restate, alright?

    1) One paper, reviewing one set of data, may or may not be orthogonal to the data set compiled by the World Health Organization. If nothing else, since the WHO has many more researchers than that paper had authors, and since the health report is compiled annually, and as the WHO survey is based on a much larger data set, your conclusions are invalid in the face of overwhelming contrary evidence. The number 37 comes from the 2000 report–the last year that WHO included rankings in the report–but the data is still compiled annually, and those results repeatedly demonstrate the failings of our health care system.

    But in case you want to do your own reading, here’s the World Health Statistics 2009 report. (Just at random, I note that 1% of Americans don’t have clean drinking water, which seems to drop us into 40th place behind countries which do better.) Home page for all reports is here.

    2) The data is old; in fact, it nearly perfectly correlates with our years as Penn students. Even if it is still accurate regarding treatment in the United States–which would be a supposition without data–it presumes that no one else in the world read the paper or implemented its findings.

    3) The data disagrees with other measures. Most experts, including the WHO, say that the US is top-ranked for emergency or crisis care. Cancer is a long-term treatment, so it doesn’t parse that cancer would be where the US would show a 5x improvement.

    3a) The only type of cancer I have direct knowledge of is prostate cancer, which I researched when my father was diagnosed in 2002. At that time, US treatment procedures were far more aggressive than those commonly used in Europe, provided the cancer was not far advanced. Advanced cancer is treated aggressively everywhere. Life expectancy outcomes for incipient cancers were similar for both aggressive and nonaggressive treatment, as of 2002. This particular data point appears to diverge from the conclusions which the Iowa paper, which in turn gives me cause to doubt the conclusions you’re drawing from it.

    4) I disagree with you that “it’s a perfectly valid way to slice the data” to leave out high incidences of morbidity — but without putting more time than I care to into statistical analysis, I have to leave this in the realm of gut feeling. Quickly, though: the US has a much higher violence rate, and best-in-class crisis health care, which means we’re outliers on both metrics. Dropping those from aggregate figures strikes me as similar as saying, “let’s consider sub-Saharan African mortality, after we remove HIV and conflict mortality.”

    You’ve read a study (WHO) that corresponds with your world view

    Alright, now you move from generically calling me an idiot, to specifically calling me an idiot.

    Worse, you accuse me of deliberately disregarding science. This is a dire insult, Brian, so pardon me while I completely demolish this paragraph.

    First: my world view for a very long time was that the United States had among the best health care in the world, but that it was a damn shame that we didn’t have universal coverage. I believed that lack of coverage was a smaller problem–because when I first became interested, it was a smaller problem. Several data sources, including but not limited to the WHO report, changed my mind over the past 20 years.

    and now make it your business to disparage any other study

    I’m not disparaging any other study. I am critiquing the one you presented to support your argument. Please see the above paragraphs, where I think I am extremely detailed as to why I find your argument and references unconvincing.

    You won’t discuss the merits of their data analysis methodology.

    I am certain that this is not the first time I’ve brought up the “old data” argument, and I suspect that much else of what I said above is a repeat. What part of “methodology” won’t I discuss when I am specifically arguing against both their data set and their statistical breakdowns?

    Instead, you’ll twist my words (”our system is the best,” “the World Health Organization is wrong”) and then throw in a reference to an unrelated, previously discredited topic (intelligent design) just to cement my insanity.

    It’s not about the topic, Brian. It’s about the logical basis of your analysis, which is as faulty as the intelligent design crowd. They start with a single fact–”there are gaps in the fossil record”–and conclude that evolution is fatally flawed.

    You start with a single paper, and think that this means it is entirely equivalent to the WHO World Health Report.

    Just for fun: go to the WHOSIS database search page, and click on the tabs. Does that begin to give you an idea of the size of the WHO data set?

    Well, that’s one of the databases they use. They have others. In fact, they pretty much have access to all of them, because most of the world’s governments are member institutions, and share their own data. Do you consider the CDC a reliable source? The WHO data is a superset including the CDC’s.

    The document I’ve been quoting, Brian, isn’t “a study” any more than Van Pelt Library is “a book.” It is the survey of the world’s health data. Which doesn’t make it infallible, but does make it damned definitive. If you want to argue with it, it helps to understand what went into it, and to choose a contrary data set which, for example, was generated in an adjacent decade.

    Do you think the University of Iowa is a disreputable source?

    Not qualified to judge, nor do I need to. I put faith into the peer review system, and I’m inferring that the paper you’re quoting was peer reviewed purely because it had the right page layout.

    Do you think they made faulty assumptions and therefore reached poor conclusions?

    I think they made some questionable statistical choices, and the age of their data set weakens any present-day arguments based on the paper. But I’m not questioning their conclusions–I’m questioning yours, which you’re basing on a small amount of data, while demonstrating your inability to even accurately judge the terms upon which a conclusion’s merit is based.

    I’m happy to discuss it with you and learn something from our discussions.

    I haven’t been able to find a definitive measure, but I’m fairly certain that I pointed you to several terabytes of information with that WHO link above. If you can’t find new information there–or at the very least, understand why you’re comparing apples to the gross annual output of Florida–then you’ve proven yourself ineducable.

    Likewise, I have neither a PhD nor an MD, and I have never claimed either. Why do you think I keep telling you to ask Sherry? Point me to something new, and I’ll be glad to learn it.

    Until then, my conclusions are just as tied to evidence as yours are.

    Sure. Except that I’m referring to an ocean of evidence, and you’re claiming your koi pond is just as big.

    And suggesting that our health care system is the best at something doesn’t mean I believe it’s the best at everything.

    Well, let’s recap what you believe, shall we? So far: the IMAC is similar to death panels (original post, paragraphs 9 and 14); the IMAC can reduce quality of care (paragraph 11); government-run insurance is unaccountable (paragraph 16) and will lead to inequities of care (17 & 18); private companies are more accountable than government agencies (comment 9, paragraph 2); insurance companies have no (or little) financial incentive to deny claims (comment 10, paragraph 3); criticism of the private insurance industry is not warranted by the data (10-4); the number of uninsured is insignificant compared to the number of insured (10-4); British patients wait longer for treatment than Americans (10-5); some British patients are never treated (10-5); nationalized health care systems do not care about blindness in the elderly (12-2); the existing system is best incrementally tinkered with rather than changed (12-4); cases where insurance is revoked are extremely rare (14-8); statistical evidence comparing health systems is unreliable (14-17) but anecdotal evidence comparing those systems is not (14-18); US cancer survival rates are 5x higher than in the UK (14-18 & 16-15); major change in American health care will probably fail and hence should not be attempted (14-19); private insurance will be more generous and scientifically based than government care (16-6 & 7); people who choose the wrong health care policy deserve not to be covered because of their mistake (16-10); a measure of life expectancy in the Iowa study negates a survey by the WHO which measured far more factors (16-15); the WHO study does not constitute “actual evidence” (16-17); universal health care cannot provide specialists (16-18 & 19).

    Those were all quotes, more or less. Now I’ll sum up: you’ve spoken well of Palin and Gingrich, both of whom rather transparently want to kill reform. You distrust both Obama and any form of government control of health services. You maximize governmental inefficiencies, and minimize the same problems in the private market. You think anything but small changes to the system is doomed to failure. My conclusion: if you think you’re in favor of reform, you’re kidding yourself.

    And for this entire mountain of supposition and assertion, you rely on a paper from the University of Iowa which might not say what you think it says, might have said it a decade ago, and doesn’t refute what you think it refutes. Which normally is par for the course; I’m sure that I don’t document half of what I assert.

    But then you accuse me of ignoring science, and since we both have one source, we’re all equal. In fact, you are ignorant of the data you are refuting, and proudly so, having apparently dismissed all United Nations data as left wing bias. A fifth grader shows more understanding of the scientific method and the value of empirical data than you have in this debate. A basic grasp of the structure and mission of the WHO and its member organizations would deny you your argument, yet you claim it is the intellectual equivalent of my own.

    You could have joined me in an informed debate with a half-hour’s time in Google and reading my original documents, but you are apparently so contemptuous of my argument and my sources that you haven’t bothered to do so. I’ve read your paper and refuted it, which you casually ignore.

    And to switch back to my own unprovable assertion, you’ve done all of this in defense of a system which increases the sum total of human misery and unnecessary death, which I conclude to be immoral.

    I believe, Brian, that your core belief is that health services are better provided by the private market, and that a major change will decrease the public welfare. It is precisely this assertion which the WHO data refutes, by demonstrating how health care is delivered by the existing systems which I am advocating we copy here. You have failed to make a cogent argument against this. Should you choose to amount one, I look forward to that debate; however, I would vastly prefer that you acquaint yourself with readily available data, and first determine whether your core convictions are actually defensible.

  20. Brian says at September 24th, 2009 at 1:50 am :
    I’ll be glad to hear Sherry’s take on this, and revise my opinion if I’m wrong.

    OK, I asked Sherry. Her first reaction was, “it depends on the patient.” On average, though, her opinion (paraphrasing as best I can here) is that preventative care, healthy diet, exercise, etc. can lead to longer and higher quality lives, but that the longer you live, the more health care you are likely to consume. The most costly example she could think of is strokes. The cost of post-stroke treatment can be incredibly high, and the longer you live, the more opportunity you have to get one. The idea that people who live to extremely old age (90s, 100s) typically die quickly and with limited medical care is, to use her word, ridiculous.

    What you’ve established is that, in the event of a recall, the language which is used is “company X issued a recall”. This says absolutely nothing about whether recalls are initiated by the companies in question, or are initiated by regulatory agencies.

    I’m being obtuse? I’ve shown you government documents that say (over and over and over again) that the private companies issue the recalls, but that says nothing about whether the recalls are initiated by the companies?

    Here’s the document we’re both looking for – the CPSC Recall Handbook (sorry, no flowchart).

    When a company learns of a “potentially hazardous product that they manufacture, distribute, import, or sell,” they fill out a form on the CPSC’s website, which kicks off a recall. The CPSC has a process for them to follow (classifying the Hazard, Putting Together a Corrective Action Plan, planning an effective public notification, etc.) News Releases are written and released by the CPSC in conjunction with the company and always begin with the phrase “Company X Recalls…”

    As for agency-initiated recalls, the CPSC can initiate contact with the company, but the “most timely and effective source of information about such products” is the company contacting the CPSC. Reading through the documentation, I would imagine that a company that knew of a problem and did not initiate their own recall would be absolutely roasted in the media, let alone by the CPSC itself.

    Brian: I’m willing to bet that there are just as many people who would blame the government for nothing less than murdering their parents if they heard “no” instead of “maybe”

    Jeff: Show me the horrific track record of the federal government putting people to death in that program, and I’ll concede you have a point.

    Ah yes, but once again that would be a different point than the one I’m making, wouldn’t it? MY point was that if the government were to say “no” to a procedure over the protests of the attending doctor, the patient’s loved ones would likely blame the government for a bad result. Given that Medicare’s coverage is the broadest in the nation (hence, its tendency to lose billions of dollars per year), the dog does not, in fact, bark.

    Brian: I’ve never heard of a medical policy that doesn’t cover hospitalization at all.

    Jeff: In that case, you’re not paying attention. . . people who can’t afford their deductibles are forced to choose between debilitating suffering, or bankruptcy.

    See what you did there? I suggested that most (all?) medical plans cover hospitalization to some degree. You told me I wasn’t paying attention, and then gave an example where people can’t afford the deductible their policy stipulates BEFORE IT COVERS HOSPITALIZATION. This is precisely the kind of rhetorical tap dance that leads you to claim that you’ve proven me wrong, when in effect, you’ve proven me right.

    The issue of being able to afford a medical plan that provides enough coverage to avoid bankrupting the patient in the worst-case scenario is a separate, and important, issue. Despite what you think of my ideas, I wholeheartedly agree that this problem needs to be fixed. I’ll even go as far as to agree that the public option would fix it. Where I’ll disagree with the President is his assertion that it will do so in a deficit-neutral way. And yes, I’ll point out that once the government goes down that road, they necessarily get into the business of deciding what to cover and what not to cover (the “mandatory future spending cuts” that Obama mentioned in his joint-session speech), the first of which will be hailed as a “death panel decision” by those who seek to damage him politically.

    You’re entitled to your (callous and inhumane) opinion here about their “getting what they deserve” by way of a crushing invoice, but really, it’s not becoming to point and laugh at them for their ignorance.

    My opinion involves them getting what they paid for, not getting what they deserve. As you are no doubt aware, there are many situations in which what people pay for is less than what they deserve. Regulation and/or government assistance is an appropriate response in that case, and it’s something we should be (and are) discussing. But if you go down the slippery slope of expecting companies to pay more than what the policy stipulates, then you wind up with either bankrupt companies or companies that decide to stop writing health insurance policies, focusing instead on business lines in which contracts between the parties are honored. If that’s what you’re advocating, then I’m happy to call you callous and inhumane as well. Unfair? Well, OK then…

    Christ, Brian. Poor people must really terrify you. I’m not sure how you made the leap from theft to B&E and endangerment.

    Wow, that was rude. You said you could understand how a starving, sick and drug-addicted person could break into my home to steal my food and (at least implied) that they shouldn’t be punished for that crime. As a father and a husband, I can tell you without equivocation that if a starving, sick, drug-addict breaks into my home, my family is endangered. I don’t care if he’s penniless or a millionaire. He scares me because he’s desparate, under the influence of a foreign substance and IS IN MY HOME. How you get from there to “Poor people must really terrify [me]” is truly beyond my comprehension.

    Yes, Brian, I read the paper, which is how I know that you’re basing your argument on statistics compiled between 1986 and 1992. Let me restate, alright?

    [Lengthly commercial for the World Health Organization redacted]

    Oh, Christ. First of all, the University of Iowa study is from 2006, not 1992. Their life expectancy data (Page 16) and their homicide and transportation death data (Page 17) came from . . . wait for it . . . The World Health Organization’s 2004 report. Their cancer survival rate data (Page 19) came from the U.S. National Cancer Institute (2003) and the International Agency for Research oN Cancer (also 2003).

    But more to the point, I never said that their study disagreed with the WHO’s studies. You did. What I said was that the WHO, despite it’s wide and impressive variety of data sources, doesn’t report on life expectancy while correcting for non-healthcare related deaths. This makes the studies complementary, not contradictory. But, ONCE AGAIN, anything that doesn’t agree with you, must be defined as disagreeing with you, and so I’m a) calling you an idiot, b) ignorant of the “real” facts, and c) “disregarding science.” Fan-freakin-tastic.

    Oh, and this:

    Dropping those from aggregate figures strikes me as similar as saying, “let’s consider sub-Saharan African mortality, after we remove HIV and conflict mortality.”

    Certainly, if we’re discussing sub-Saharan African healthcare, this would be a ridiculous thing to do. But what if we were studying sub-Saharan African crime rates? Traffic accidents? Murder rates? Would it be wise to include HIV deaths in our statistics? Of course not. The question that you’re trying to answer matters. The “right answer” isn’t dictated by the data you happen to have…

    Well, let’s recap what you believe, shall we?

    OK, wow. This is the first time anyone’s actually created an index of my written work before. So, kudos for that. Unfortunately, in summarizing my thoughts down to sentence fragments, you’ve once again found round holes for many of my square pegs. To wit:

    • “British patients wait longer for treatment than Americans / some British patients are never treated” – what I said was, “if you’re healthy (regular exams, routine tests, etc.), NHS is terrific – no wait times, no bills, no rationing. And if you’re critically ill, NHS is also terrific – lots of resources go to the critical cases. But if you have a chronic condition, or a condition that might lead to something critical, you could be lost in the shuffle forever – years to see a specialist, half-hearted diagnoses, rules about what’s covered or not, etc..” So yes, SOME British patients wait longer for treatment than Americans, but many (most, in fact) do not.
    • “nationalized health care systems do not care about blindness in the elderly” – what I said was that my 88-year old grandfather was put on a 4-year waiting list for glaucoma surgery in Israel, which was eventually reduced to one year (for one eye only). I made no judgement about how much they cared about his eyes – only a factual statement about how long he had to wait. I left out the part about how my parents pleaded with him to come to America, where my parents’ doctors said they could operate on him immediately.
    • “the existing system is best incrementally tinkered with rather than changed” – what I said was, “break the problem into seven or eight separate bills, and pass each one separately. Then, even if only three or four pass, we start chipping away at the problem rather than winding up doing nothing & throwing political food at each other.” The “Tinkered/Changed” continuum was entirely your invention (and, quite frankly, I’m not sure what you even mean…)
    • “major change in American health care will probably fail and hence should not be attempted” – what I said was, “I think there’s a odds-on chance we’ll wind up with nothing at all the way we’re headed, or something that is purely “reform in name only.” If Obama would pick and choose his eight bills carefully, he could probably identify one or two that would generate broad, bi-partisan support (tort reform, for instance?) and actually take real steps towards reducing health care costs, improving coverage, etc..” which seems to be exactly the opposite of “should not be attempted.”
    • “people who choose the wrong health care policy deserve not to be covered because of their mistake” – what I said was, “I will agree with you that many people just pick the cheaper option when they start their new job, and blame the insurance company when they learn what they bought. [which is] shirking personal responsibility. Unless . . . the coverage was hidden in some fine print or behind some legalese, or some HR/benefits person at your company lied to you about what it said and told you not to read it.” In other words, if you don’t read what you’re signing before you sign it, shame on you, but if someone’s trying to con you,
      shame on them.
    • “a measure of life expectancy in the Iowa study negates a survey by the WHO which measured far more factors / the WHO study does not constitute “actual evidence” – I think we covered this above, but just to reiterate: The UIowa study doesn’t negate the WHO study, it augments it because, depsite their vast resources, WHO did not factor out irrelevant data to this discussion, likely because they didn’t prepare their data specifically for this discussion. So yes, the WHO study is “actual evidence” of mortality rates around the world, but it’s not “actual evidence” of the state of our healthcare system. Apologies if such subtleties fly in the face of the Democratic and Republican talking points on the topic…

    Those were all quotes, more or less.

    Less.

    Now I’ll sum up: you’ve spoken well of Palin and Gingrich, both of whom rather transparently want to kill reform. You distrust both Obama and any form of government control of health services. You maximize governmental inefficiencies, and minimize the same problems in the private market. You think anything but small changes to the system is doomed to failure. My conclusion: if you think you’re in favor of reform, you’re kidding yourself.

    I read about the IMAC in Palin’s Op-Ed, which led me to a whitehouse.gov website where I learned more about the proposal, and I agree with Newt Gingrich on the specific point he made about how to get healthcare reform done. But since you’ve branded them “transparently [against] reform,” my comments about specific points they made at specific times brand me as against reform, even if I don’t consciously know it.

    Do you see why I stay up until 2AM refuting such nonsense?!?!?

    A fifth grader shows more understanding of the scientific method and the value of empirical data than you have in this debate. A basic grasp of the structure and mission of the WHO and its member organizations would deny you your argument, yet you claim it is the intellectual equivalent of my own.

    Well, a studious fifth grader would have checked the dates on the UIowa report more carefully. But that aside, you are equating the nobleness of the WHO’s mission and the vastness of its structure with scientific method which, of course, are completely unrelated things. I could take the WHO mortality data and use it to prove that the Yankees are better than the Red Sox, but if I tried to claim “scientific method” in my argument because I quoted such an auspicious organization, I would think you’d bash me over the head with a statistics textbook…

  21. Jeff Porten says at September 25th, 2009 at 2:54 am :
    The idea that people who live to extremely old age (90s, 100s) typically die quickly and with limited medical care is, to use her word, ridiculous.

    Noted, and Sherry’s is one of the few opinions which I trust more than my own. If I happen to come across a reference to where I came up with this, I’ll post it. Until then, consider me disabused.

    I’ve shown you government documents that say (over and over and over again) that the private companies issue the recalls…. News Releases are written and released by the CPSC in conjunction with the company and always begin with the phrase “Company X Recalls…”

    With the use of the word “always” you demonstrate that the documents you cite are completely irrelevant as to the question of whether recalls are the result of private market self-regulation, or active regulation by the government agencies. Which, if I remember correctly, is what started this particular debate thread.

    Given that Medicare’s coverage is the broadest in the nation (hence, its tendency to lose billions of dollars per year), the dog does not, in fact, bark.

    So your argument is that Medicare avoids the problem of bad press through denying coverage, by not denying coverage? Interesting. Yet private insurance is better, somehow. You’ll recall that “it costs money” is rather low on my totem pole of arguments against health care provision.

    You told me I wasn’t paying attention, and then gave an example where people can’t afford the deductible their policy stipulates BEFORE IT COVERS HOSPITALIZATION.

    Ugh, again. You’ll recall, perhaps, that the crux of most of my arguments as to the immorality of the current system involves the uninsured. Who don’t have hospitalization, I think you’ll agree. But since you insist upon the superiority of the free market in providing coverage, it is necessary to engage you as to the deficiencies of underinsurance.

    You seem to believe that if an insurance policy mentions the word “hospital”, it’s sufficient hospitalization. My thinking is that if someone is financially driven to avoid hospitals when they are medically necessary, then in effect they don’t have hospitalization. A full hospital bill which drives someone into bankruptcy is functionally equivalent to deductibles and surcharges over insurance which drives someone into bankruptcy.

    Despite what you think of my ideas, I wholeheartedly agree that this problem needs to be fixed. I’ll even go as far as to agree that the public option would fix it. Where I’ll disagree with the President is his assertion that it will do so in a deficit-neutral way.

    Holy shit. Ladies and gentlemen, Jeff and Brian have actually reached a point of agreement. Let us all take a moment of silence to observe this occasion, as it might not happen again in our lifetimes.

    Personally, I think Obama was insane to include that “not one dime” comment. His health care plan could turn a profit, and Republicans will undoubtably be able to come up with some formulation which “proves” that Obama’s plan is costing money. And since I have absolutely no idea how you can plan to run this program even at break-even, it seems likely that that’s going to be a broken promise… a promise worth breaking, mind you, but still.

    I’ll point out that once the government goes down that road, they necessarily get into the business of deciding what to cover and what not to cover (the “mandatory future spending cuts” that Obama mentioned in his joint-session speech), the first of which will be hailed as a “death panel decision” by those who seek to damage him politically.

    Not at all true, IMO. Last I heard, the House bills have several plans in the public option, which provide a range of care with a range of premium costs. The cheapest plan is, by definition, the most basic and restricted. Denial of care in one plan is only a “death panel” if people are unable to change to a different plan.

    And that said — has anyone ever provided an actual example of denying life-sustaining care? All I’ve heard about is restricting octogenarian hip transplants in the UK, which is presumably an edge case. For all I know, that is more effectively treated with painkillers, once you include the likelihood of complications or death from a hospital-acquired infection. I have trouble with the idea that “mandatory spending cuts” will be applied to life-sustaining treatment; there are plenty of other areas which are more fertile places to begin.

    then you wind up with either bankrupt companies or companies that decide to stop writing health insurance policies, focusing instead on business lines in which contracts between the parties are honored. If that’s what you’re advocating, then I’m happy to call you callous and inhumane as well.

    I’m sorry, but how is it even possible to be considered “inhumane” when taking a position on contract law? Inhumane is in regards to humans. My position on the importance of protecting corporate profit might be called callous — hell, I’d be proud of that moniker — but inhumane? That’s like me calling your style of argument blue and reminiscent of spinach.

    And yes, if you haven’t noticed, I am advocating that companies stop writing health insurance policies, in the hope that we stop shipping off health care dollars into private profits. I thought I was clear about that.

    You said you could understand how a starving, sick and drug-addicted person could break into my home to steal my food and (at least implied) that they shouldn’t be punished for that crime. As a father and a husband, I can tell you without equivocation that if a starving, sick, drug-addict breaks into my home, my family is endangered.

    Right. Okay, so this is a fairly important point.

    So back in the 1970s, George Gerbner at Annenberg came up with the “scary world” theory, which goes like this: the more local news you watch, the less trusting you become. Essentially, the then-nightly news diet of 30 minutes of crime and disaster gave people a mistaken impression of the odds of bad things happening to them. Said theory has been proven in repeated experiment, and now can be translated to “the more news you get from TV, the more dangerous you think the world is.”

    What I said:

    you’re goddamn right I can put myself in the shoes of someone who is going hungry, desperate for medical care, or addicted to drugs. And I can damn well be compassionate about how I might judge such a person — I might even go so far as to question why people are hungry, rather than simply punish people for stealing food.

    And what you heard:

    It doesn’t mean just giving them the food, and then excusing their breaking into my home, stealing my property and endangering my family.

    You see the difference? Stealing your property is the only part of that which is equivalent to what I said, and even then, you’re making the leap from “food” to “property”. My value system includes a case-by-case judgment there; there’s a difference between picking your pocket and stealing your car.

    But in the other clauses: breaking into your house and endangering your family? You made those up. I was referring to justifiable theft; you grew that into justifiable violence, and/or the justifiable threat thereof. Fact is, when I was thinking of theft, I was thinking of exactly that, which translates into crimes like pickpocketing, shoplifting, and opportunistic theft.

    So the question I have is, why did you presume a personal threat? Hell, you should know that if someone were trying to break into your house when your kids were sleeping, I’d be the first guy out on the porch defending your family with a cigarette and a can of hairspray. So clearly, I’m not advocating increased threats to your family.

    Anyway, I’m sure you have your rebuttal halfway mentally written — so take a moment to think about this, okay? This is one of those unconscious assumptions I keep talking about. You are more frightened by theft than I am, because you assume it means different things. I’m frightened by muggings; theft is something very different.

    Oh, and by the way — apologies for my being rude. I try to go no further than abrasive.

    First of all, the University of Iowa study is from 2006, not 1992.

    Ah. First, thanks for that link again. I spent a frickin’ hour looking for it yesterday, and had to write from memory.

    Second, that’s not a study. That’s a set of Powerpoint slides. If I had remembered that you weren’t using a peer-reviewed paper as a reference, I would have included that as a major point of argument.

    Third, I just looked up the two co-authors in PubMed, so I could stop by the BioMed Library and refer to the actual peer-reviewed paper that I assumed these slides were derived from. Surprise! There isn’t one. Those two have co-authored five papers, none on the topic of the slides.

    Fourth, citation for “1992″, now that I have it again. Slide 19, titled Five-Year Age-Adjusted Cancer Survival Rates. Footnote 1: “year of diagnosis, 1986-88.” Footnote 2: “year of diagnosis, 1985-1989.”

    A five-year age-adjusted cancer survival rate can take zero years (patient dies day after diagnosis), or up to five years, but no longer. So that data set is, at latest, referring to data compiled in 1994 in Europe, and 1993 in the United States. The papers cited are from 2003; the slides themselves are dated 2006.

    Fifth, a note on your source. Honestly, until now I haven’t much questioned whether your sources were accurate, having made the assumption that the slides were based on peer-reviewed data and published in a medical journal. But now I’m poking into it a bit. The link itself is from the American Enterprise Institute — not exactly what I consider to be an unbiased source of health information.

    Robert Ohsfeldt has a PhD in Economics, not a medical degree. His second Google hit is his bio on the Independent Institute website, which Wikipedia says writes about the “unique value of free-market entrepreneurship on all aspects of economic issues”. They look like they’re ideologically similar to Cato rather than Heritage. They don’t publish their donor sources.

    John Schneider has a PhD in health economics, and his name is too common for me to rapidly determine his affiliations outside of U. Iowa.

    This is not to say that the slides themselves are inaccurate, or that the authors necessarily have an axe to grind. But when I see authors who write from a certain perspective presenting to an audience which shares that perspective, I’m not required to take it with the same credence that I would give to, say, a peer reviewed medical journal. Or even better, a study which has been replicated elsewhere.

    What I said was that the WHO, despite it’s wide and impressive variety of data sources, doesn’t report on life expectancy while correcting for non-healthcare related deaths.

    C’mon. Have you actually checked? I haven’t. I’ve read portions of their annual reports, but I haven’t checked those databases I linked you to, and I expect that you haven’t, either.

    Beyond that, as I said in my last post, I don’t have the statistical background necessary to explain well — it’s been 18 years since I took a graduate-level stats class — but I question whether the methodology of removing those “relatively insensitive” health outcomes is valid. Especially since homicide and transport outcomes are entirely dependent on crisis and traumatic care, at which the US excels.

    This makes the studies complementary, not contradictory.

    Once again. Thanks to the link, I can now say that neither one of these reports is a study. One is a survey and analysis of a huge amount of medical data. The other is a Powerpoint presentation.

    How many times do I have to say that I do not agree with the methodology used, before you stop repeating that this source is as valid as any other?

    But, ONCE AGAIN, anything that doesn’t agree with you, must be defined as disagreeing with you,

    Yeah, I’m getting sick of hearing this.

    You know I have strong opinions. You also know that I am rarely lacking for factual evidence to back them up. I may be unconsciously selective of which facts I remember, but I don’t believe every opinion is equal — so if I have an opinion which I’ve accidentally based on bullshit, I will change it.

    You said that I quoted the WHO only because they support my worldview. You said that I disregarded any study which does not conform to my opinions. You continue to say that I am closed-minded and ignorant because I will not take the AEI Powerpoint presentation as holy gospel, despite the fact that I have repeatedly explained why I have issues with its methodology.

    You can call me a zealot — frequently I am. But you are calling me an ignorant zealot. Which I am not. My worldview comes from the data contained in reports like the WHO’s, not the other way around. When I have an opinion which contradicts scientific evidence, I change it, or I move myself back into the “I don’t know” category.

    So, yeah. You did cross this line, and now you’re defensively angry because I called you on it. I respect many, many sources and opinions which disagree with me. You’re one of them. This is not, for the reasons I’ve stated.

    if we’re discussing sub-Saharan African healthcare, this would be a ridiculous thing to do. But what if we were studying sub-Saharan African crime rates? Traffic accidents? Murder rates?

    The title of the presentation includes the words “the U.S. health-care system.”

    If it needs be said: yes, it is an interesting data point to normalize life expectancy without traffic deaths or murders. I just have no idea if it’s a significant data point. And since there’s no actual study to back up this (again…) Powerpoint presentation, I have absolutely no idea what significance was attributed to this number by the authors. You seem pretty impressed by it, though.

    Unfortunately, in summarizing my thoughts down to sentence fragments, you’ve once again found round holes for many of my square pegs.

    Yes, I am well aware of what you said. I had to read it in order to index it, now didn’t I? And while you, for some reason, don’t like hearing your own words rephrased accurately (which I stand by), I’m happy to repeat my conclusion that your arguments are all slanted in finding disfavor with any change from the status quo, and in defense of the existing system of providing health care.

    Round holes and square pegs? What, you can’t stand hearing that I think your opinions may be biased? I thought that was a given. What we argue is whether we can back up our respectively biased opinions, which is why you piss me the hell off when you blatantly state that my opinions aren’t based on fact, and are immune to new information.

    since you’ve branded them “transparently [against] reform,” my comments about specific points they made at specific times brand me as against reform, even if I don’t consciously know it.

    Yes, absolutely. Let’s say you agree with the philosophical statement that health care reform should be done incrementally. Hence, you support the idea that legislation be broken up into eight bills. This, I believe, is a direct quote.

    Meanwhile, Gingrich proposed that precisely because of a political calculation (at the time, anyway), that eight bills would allow them to kill parts of the legislation, which in turn would ensure that the passed legislation would likely fail as well, since a piecemeal process can’t affect anything systemically at issue. After two or three years of failure, Gingrich expects that his party can resume power, and he can kill off what did pass in the first round.

    You say you are in favor of reform, but distrust any legislative process which would allow it to pass. You think Gingrich is being reasonable, which makes you a manipulated dupe in my view; that sound bite was carefully crafted to sound reasonable to people like you, which in turn gives him the ammunition he needs to break up the proposal and drown it in a bathtub.

    a studious fifth grader would have checked the dates on the UIowa report more carefully.

    A studious person knows how to read a footnote. I quoted those years from memory. You apparently have failed to notice them, even now.

    you are equating the nobleness of the WHO’s mission and the vastness of its structure with scientific method which, of course, are completely unrelated things.

    No, I’m pointing out the vastness of its data set. And yes, I am pointing out that the WHO includes many people with medical degrees, and is cited by people with medical degrees. Your source was written by economists. These are not equal. Yours is not invalid, but these are not equal.

    And incidentally, I am presuming that the scientific method was used in compiling the data in the WHO databases, because otherwise, what would be the point? Apparently, Drs. Ohsfeldt and Schneider agree, because they also think that the data is worth citing.

    if I tried to claim “scientific method” in my argument because I quoted such an auspicious organization, I would think you’d bash me over the head with a statistics textbook…

    Honestly, Brian, at this point I think I’d have to bash your head in with a Wall Street Journal and a copy of The Wealth of Nations, because those seem to be the only references you trust. You’re demonstrating a near-complete scientific illiteracy on how medical research is done, or the relative validity of one source versus many sources.

    If nothing else… we’re debating health care. I’m citing a health organization. You’re citing a right-wing think tank. That alone should give you some pause. If it doesn’t, then there probably isn’t any common ground on which to bring this argument.

  22. Brian says at September 25th, 2009 at 4:34 pm :
    With the use of the word “always” you demonstrate that the documents you cite are completely irrelevant as to the question of. . . .

    “always” was a link to recalls.gov, on which all of the recalls start with the words “Company X Recalls.” I didn’t mean it literally…

    You seem to believe that if an insurance policy mentions the word “hospital”, it’s sufficient hospitalization. My thinking is that if someone is financially driven to avoid hospitals when they are medically necessary, then in effect they don’t have hospitalization.

    If someone is financially driven to avoid hospitals when they are medically necessary, then they have insufficient hospitalization, not no hospitalization. Isn’t this, er…gramatically obvious? I mean, you just accused me of believing the opposite in the previous sentence!

    Last I heard, the House bills have several plans in the public option, which provide a range of care with a range of premium costs. The cheapest plan is, by definition, the most basic and restricted. Denial of care in one plan is only a “death panel” if people are unable to change to a different plan.

    I had not heard that, but if it’s true, then we’re right back where we started. The folks who can’t afford the more expensive public option get less healthcare. Then, someone (like, say, Sarah Palin) points out a poor soul who would have been treated under a more expensive public plan, but wasn’t under their current plan, and bemoans us as the “only wealthy nation that does not provide everyone with…” It seems all roads lead back to cost vs. benefit, no?

    All I’ve heard about is restricting octogenarian hip transplants in the UK, which is presumably an edge case. For all I know, that is more effectively treated with painkillers, once you include the likelihood of complications or death from a hospital-acquired infection.

    Actually, the octogenarian who needed the hip replacement was Obama’s grandmother who, to my knowledge, was not British. That said, hip fractures in the elderly can be very serious:

    The death rate for hip fracture patients is higher than for other people of the same age who do not sustain the injury. About 24 percent of hip fracture patients over age 50 die within 12 months after injury because of complications related to the injury and the extended recovery period.

    In addition to working in geriatrics, Sherry has done a lot of specialized work on falls, and she mentions this all the time…

    I’m sorry, but how is it even possible to be considered “inhumane” when taking a position on contract law? . . . And yes, if you haven’t noticed, I am advocating that companies stop writing health insurance policies, in the hope that we stop shipping off health care dollars into private profits. I thought I was clear about that.

    You answered your own question. Reserve requirements limit the number of people a single insurance company can insure, so forcing companies out of the health insurance business could, in a very real way, increase the number of uninsured. Which, by your own definitions, I would think would be considered inhumane.

    That is, of course, unless you move to a public option/single-payer system, where the insurer (the federal government) is already too big to fail…

    But in the other clauses: breaking into your house and endangering your family? You made those up. I was referring to justifiable theft; you grew that into justifiable violence, and/or the justifiable threat thereof. Fact is, when I was thinking of theft, I was thinking of exactly that, which translates into crimes like pickpocketing, shoplifting, and opportunistic theft.

    I keep my food in my house. If someone’s stealing my food, they’re breaking into my house. And yes, my food is my property. If not, where do we draw the line? Can someone justifiably steal my winter coat? My prescription drugs? My car?

    This is one of those unconscious assumptions I keep talking about. You are more frightened by theft than I am, because you assume it means different things. I’m frightened by muggings; theft is something very different.

    I’ll admit that I saw this coming, based on our previous discussions, but I still don’t buy it. In my opinion, you’re hiding behind sociological theories to turn my defense of basic property rights into some deep-seeded, bigotry-based fear and/or hatred of people who are not like me (socioeconomically, racially or otherwise). I’m sure there are people in the world who are afraid of poor people, and those people may be afraid of poor people breaking into their homes, mugging them, stealing their food, etc. simply because those events involve poor people.

    But there are also people in the world like me. I have no fear whatsoever of poor people. I do, however, fear criminals. And if a given criminal is poor, I feel no obligation to deny my fear of the criminal in order to prove my lack of fear of the poor. It’s almost Rumsfeldian in its logic, no?

    Second, that’s not a study. That’s a set of Powerpoint slides. If I had remembered that you weren’t using a peer-reviewed paper as a reference, I would have included that as a major point of argument.

    I’m glad I saved you that embarrassment.

    Peer-reviewed papers are required for original research, in order to check research methodology, errors in data sampling or collection, etc.. Once they’re published, other researchers are free to crunch the numbers to produce new conclusions. If you required peer-review on every analysis of published data, then we’d have to collect source data each and every time we wanted to draw a new conclusion about existing research!

    Third, I just looked up the two co-authors in PubMed, so I could stop by the BioMed Library and refer to the actual peer-reviewed paper that I assumed these slides were derived from. Surprise! There isn’t one. Those two have co-authored five papers, none on the topic of the slides.

    Same point, I think, but to reiterate: the peer-reviewed papers that the slides were derived from were the WHO papers and the papers from the two cancer research groups. The fact that the U. of Iowa guys are published authors speaks to their academic integrity, I guess, but this isn’t their research, nor are they claiming it is…

    Fourth . . . A five-year age-adjusted cancer survival rate can take zero years (patient dies day after diagnosis), or up to five years, but no longer. So that data set is, at latest, referring to data compiled in 1994 in Europe, and 1993 in the United States. The papers cited are from 2003; the slides themselves are dated 2006.

    This goes back to the “data you have” vs. “data you need” discussion. I can’t speak to the U.S. National Cancer Institute’s data collection techniques, but I’d assume that they track patients consistently over many years and decades. The fact that the slide you’re reading says “five-year survival rates” doesn’t mean the data they’re using stopped being collected in 1993. Chances are, they followed all of these patients until they died. In any case, in 2003, they published a paper and chose to use five-year stretches of data from 1985-1994. My guess is that more recent data was either incomplete or unavailable in 2003, but I obviously don’t know for sure. Then, in 2006, the U. of Iowa guys chose to use the 2003 paper as a source for their analysis.

    Fifth, a note on your source . . . made the assumption that the slides were based on peer-reviewed data and published in a medical journal. . . link itself is from the American Enterprise Institute — not exactly what I consider to be an unbiased source of health information.

    Robert Ohsfeldt has a PhD in Economics, not a medical degree . . . John Schneider has a PhD in health economics

    The title of the study is “How Does the U.S. Health-Care System Compare to Systems in Other Countries?” The table of contents highlights spending, health outcomes, and access to care. These are economists looking at the health care system from an economic perspective. I wouldn’t expect the authors to have medical degrees, nor would I expect it to be published in a medical journal. Doctors publishing in medical journals talk about cancer cells and the things that can kill them, not about how long patients survive or how much their health care costs.

    As for the American Enterprise Institute, all those folks did was put the study on their web server. They likely did so to make a political point, but unless you can prove that Ohsfeldt and Schneider are somehow affiliated with them, I think the web server involved here is irrelevant.

    Brian: What I said was that the WHO, despite it’s wide and impressive variety of data sources, doesn’t report on life expectancy while correcting for non-healthcare related deaths.

    Jeff: C’mon. Have you actually checked? I haven’t.

    You’re the one who pointed me here. Click on the “Indicators” tab and scroll down. They have various cuts of mortality rate (by age, by gender, by disease, etc.), but they don’t have “excluding crime and accidents.” I thought I’d struck gold when I saw “mortality rate for injuries,” but that turned out to be the percentage of injured people who died. Of course, if WHO has done this, I’d love to see it.

    Brian: But, ONCE AGAIN, anything that doesn’t agree with you, must be defined as disagreeing with you,

    Jeff: Yeah, I’m getting sick of hearing this.

    You’re right. I got angry and I apologize. It was unfair of me to call you closed minded.

    And while you, for some reason, don’t like hearing your own words rephrased accurately (which I stand by), I’m happy to repeat my conclusion that your arguments are all slanted in finding disfavor with any change from the status quo, and in defense of the existing system of providing health care.

    Jeff, you “quoted” me as saying British patients wait longer for treatment than Americans when I said that most of them wait less. You “quoted” me as saying change should not be attempted when I said we should do it differently so we make sure that something gets done. You “quoted” me as saying people deserve to lose their coverage when I said people should read what they sign, but we should make sure what they read is clear.

    I’ll resist the urge to repeat my sin so quickly after apologizing for it, but how in HELL can you say you’re accurately quoting me? Especially when you go through such a careful analysis to “prove” to me that I disagree with MYSELF?!?

    You’re demonstrating a near-complete scientific illiteracy on how medical research is done, or the relative validity of one source versus many sources.

    If nothing else… we’re debating health care. I’m citing a health organization. You’re citing a right-wing think tank. That alone should give you some pause. If it doesn’t, then there probably isn’t any common ground on which to bring this argument.

    We’re debating health care reform, not health care. It’s an economic problem, a social problem, and a moral problem, but it’s NOT a medical problem. If you want to discuss which drug we should be giving the cancer patients, we can comb through medical journals. Then you could help me with my “scientific illiteracy on how medical research is done.” But when the question is how to provide 40 million people who don’t have insurance with insurance, then yes – it’s good to get a few economists involved.

    And, as if this really needs saying, the University of Iowa is not a right-wing think tank. If the ACLU put the same presentation on their web site, would it carry more weight?

  23. Jeff Porten says at September 28th, 2009 at 7:14 pm :
    “always” was a link to recalls.gov, on which all of the recalls start with the words “Company X Recalls.” I didn’t mean it literally…

    Ugh. I can’t believe we are still talking past each other on this. Your evidence that the market tends to self-correct was the language of “company X recalls”; my rebuttal was that the universal use of this language means that it says nothing about whether a particular increase in public safety stems from private companies, government regulation, or some weighting of the mix of the two.

    And honestly, the issue here isn’t recalls, but rather how this reflects on our particular biases in favor of private or government action; you tend to favor the former, so it seemed to me that weaknesses in your argument in this issue may be reflective of weaknesses in your overall argument. I hadn’t expected us to go off down this bunny trail quite so long as we have.

    If someone is financially driven to avoid hospitals when they are medically necessary, then they have insufficient hospitalization, not no hospitalization. Isn’t this, er…gramatically obvious? I mean, you just accused me of believing the opposite in the previous sentence!

    This doesn’t strike me as a sound argument — your phrasing allows you to incorporate insufficient hospitalization into your overall statistics of how well the current system is working. (People with any hospitalization are left out of the 47 million, right?) From the perspective of someone who is determining whether they can afford a particular hospitalization, however, if their insurance will leave them with a price they can’t shoulder, it might as well be zero care.

    I’ve got a simple underlying philosophy here: medical decisions should be made for medical reasons. Yours is much more cost-driven, which remains morally untenable in my view.

    I had not heard that, but if it’s true, then we’re right back where we started. The folks who can’t afford the more expensive public option get less healthcare. Then, someone (like, say, Sarah Palin) points out a poor soul who would have been treated under a more expensive public plan, but wasn’t under their current plan, and bemoans us as the “only wealthy nation that does not provide everyone with…” It seems all roads lead back to cost vs. benefit, no?

    Of course, when you’re the guy writing the roadmap. The people who want the roads to lead to health outcomes first, costs second, don’t have nearly the megaphone that polls would indicate we should.

    I’d be very amused if the Republican talking point becomes that public options are not generous enough. That’s certainly not what they’re saying now.

    And yes — no question, the choices of what will be covered under various public options is crucial. I can certainly envision a situation where the liberals are out in the street protesting that the publicly covered are being denied necessary care. To be honest, I haven’t bothered familiarizing myself with the details of the House plan at a level this granular, because learning about competing bills which are going to conference tends to be a waste of time.

    Suffice to say — if you want to argue that the public options are not generous enough, I’d be happy to agree with you. I’m in favor of single-payer, and failing that, a very thorough public insurance plan. I’ll support legislation offering a range of less comprehensive care only if it’s the best we can do.

    Actually, the octogenarian who needed the hip replacement was Obama’s grandmother who, to my knowledge, was not British.

    We’re talking past each other again. Obama’s grandmother is an anecdote about people with private coverage and personal means. I was referring to the reference I previously cited concerning how such decisions are made by the NHS — which, with a population of 61 million, is not so much an anecdotal data point.

    No argument regarding the seriousness of elderly bone fractures; the point I was considering (and on which, I’m not expert) is that the elderly are the most susceptible to hospital-acquired infections, which is a medical reason to consider alternatives to hospitalization. How this compares to the risk of not outright replacing a fractured hip, I have no idea.

    Reserve requirements limit the number of people a single insurance company can insure, so forcing companies out of the health insurance business could, in a very real way, increase the number of uninsured.

    In the absence of a public option, of course. But you make the argument that, if done poorly, a hybrid public-private system could ensure that the profitable patients are insured by for-profit entities, while the costly patients are heaped upon the government. This is my argument in favor of single-payer; hybridization seems to me to be an excellent method of providing loopholes which increases overall public cost with a constant siphon into the private pocketbook. An alternative option, however, is private non-profit care, which lessens the incentive to game the system; IIRC, cf. Switzerland and Germany.

    That is, of course, unless you move to a public option/single-payer system, where the insurer (the federal government) is already too big to fail…

    Not sure what point you’re making here. Yes, I think it’s taken as given that if the government goes broke (which I think is generally taken to mean defaulting on T-bills), the world’s economy goes to hell in short order. No question that the American economy is too big to fail, and that Americans benefit from this situation.

    What bugs me is that we’ve collectively shown repeatedly that we are willing to spend hundreds of billions of dollars with little deliberation, but public health financing isn’t important enough to be put into a category with military expenditures, financial bailouts, and the ever-popular tax cut.

    I keep my food in my house. If someone’s stealing my food, they’re breaking into my house. And yes, my food is my property. If not, where do we draw the line? Can someone justifiably steal my winter coat? My prescription drugs? My car?

    There are many lines that can be drawn, and most of them are nowhere near the boundaries of your house. The better question is, why do you have an absolute right to property, while others do not have an absolute right to eat?

    The system we have now is very much in agreement with you: some people’s rights are defended with the full force of law, while others, not so much. I have no problem with debating these philosophical questions on the merits, but I tire of hearing, in essence, “I got mine, fuck everyone else.”

    But in case we need another digression… someone steals your winter coat. (From an office coat rack, or on the train. No personal threat involved.) The cost to you is the replacement. The cost to the thief, if he doesn’t steal it, is hypothermia. I’ll stipulate that anyone who steals your coat with lesser needs is not part of what I’m trying to discuss; I’m referring to a subset of crime that’s driven by survival needs.

    You’re saying that the cost of your coat is morally equivalent to freezing to death? Because I’m thinking that a philosophy like that is wholly dependent on who gets to own a coat.

    In my opinion, you’re hiding behind sociological theories to turn my defense of basic property rights into some deep-seeded, bigotry-based fear and/or hatred of people who are not like me (socioeconomically, racially or otherwise).

    Hiding? I’m wearing my sociological theories in blazing sunlight. And the moment you mentioned “breaking into my house and threatening my family”, you stopped talking about property rights — you switched to human rights. The deep-seated, class-based (not bigotry-based) fear of people who are not like you is what conflated a threat against your property to a threat against the people you love and wish to protect.

    A fire breaks out in your house. Do you a) fight the fire to protect the house, or b) get your family the hell out? Seems to me, you’d accept any increase in risk to your property against even a miniscule increase in risk to your family. That gulf in values is what you leapt when you conflated theft with personal risk, by presuming that criminals would see the two crimes as equivalent. I presume that the desperate are far more easily driven to crime than sociopathy.

    But there are also people in the world like me. I have no fear whatsoever of poor people. I do, however, fear criminals. And if a given criminal is poor, I feel no obligation to deny my fear of the criminal in order to prove my lack of fear of the poor.

    I strongly suspect that if we could get you into a psychological study while hooked up to an MRI, you’d be extremely quickly proven wrong on this statement. You believe this to be true because it comforts you to do so — which is the underlying basis of most of our beliefs. I’d argue that your switch from theft to violence is a fairly clear indication of where your thinking leads on this issue — and your defense of your position as “obviously” correct and unbiased indicates that you haven’t really looked at it much.

    Peer-reviewed papers are required for original research, in order to check research methodology, errors in data sampling or collection, etc.. Once they’re published, other researchers are free to crunch the numbers to produce new conclusions. If you required peer-review on every analysis of published data, then we’d have to collect source data each and every time we wanted to draw a new conclusion about existing research!

    Wait. You’re saying that peer review is only necessary for original data collection, not data analysis?

    Oooooookay.

    Brian, that’s… um. That’s just wrong. You do have to return to source data every time you publish a conclusion from that data. Most of the time, in most fields, we have nearly infinite amounts of unanalyzed source data already stored, waiting for researchers to make sense of it. LHC data is measured in terabytes per second of experiment. You want to come up with a new theory of particle physics, you can turn to the LHC warehouse rather than get your own time in an atom smasher — but you damn well can’t expect your conclusions to be accepted without peer review.

    Again, I’m not saying that the Powerpoint presentation is entirely wrong. I’m saying that by commonly accepted conventions, it’s unscientific. Very different conclusion — and factually accurate.

    the peer-reviewed papers that the slides were derived from were the WHO papers and the papers from the two cancer research groups. The fact that the U. of Iowa guys are published authors speaks to their academic integrity, I guess, but this isn’t their research, nor are they claiming it is…

    You’re speaking nonsense. The conclusions they present are their research, independent of whether they collected the source data they’re using. Their names are on it, which means (in political parlance) they own it. I’m asking the most basic question of any scientific conclusion — are their methodology and conclusions peer-reviewed? — and seeing that it is not, I’m relegating the presentation to its proper place in the scientific hierarchy: it’s an op-ed.

    I can’t speak to the U.S. National Cancer Institute’s data collection techniques, but I’d assume that they track patients consistently over many years and decades. The fact that the slide you’re reading says “five-year survival rates” doesn’t mean the data they’re using stopped being collected in 1993.

    Again, you’re speaking nonsense, and here you’re speaking nonsense about something you can deduce yourself. Of course the NCI collects data on an ongoing basis. But when you say that you’re doing a five-year survival study, you’re discarding the data for anything which happens afterwards, for the purposes of that study. The latest year of diagnosis cited was 1989, therefore, the last data point incorporated is, by definition, 1994. You want to cite ten-year results, then you’re using a different data subset.

    It doesn’t matter at all why the data is out of date; I expect, as you said, that there are lag times between collection, publication, and availability. That doesn’t make a damned bit of difference. What matters is how it affects your argument. You stated that American health care is 5x better than European health care for cancer survival rates — note the crucial use of the present tense. You cite a non-peer-reviewed presentation, which documents that its conclusion is based on data which is between 15 and 20 years old. Even if you were making a sociological point about comparative health care when we were using 2400 baud modems, your extrapolation that this is an accurate portrayal of current comparative outcomes is completely unwarranted.

    I just tried to find a more recent comparison on the same measure, but my medical research skills aren’t up to the task. Maybe yours are. In any case, here is the latest report of the American Cancer Society, which references data as recent as 2006. It’s restricted to the US, so it doesn’t speak to outcomes by health care system; on the other hand, it does demonstrate that we’re not restricted to talking about data from 20 years ago.

    These are economists looking at the health care system from an economic perspective. I wouldn’t expect the authors to have medical degrees, nor would I expect it to be published in a medical journal.

    Economics journal, then? Journals on health care delivery? Such things exist. I’m fairly sure that there are sciences aside from medicine which frown on authors pulling conclusions out of their ass, which is why peer review is the standard for scientific publication.

    Doctors publishing in medical journals talk about cancer cells and the things that can kill them, not about how long patients survive or how much their health care costs.

    Yeah. Right. Again, ten seconds spent Googling would demonstrate that this is silly and inaccurate. Feel free to poke around here for an idea of the range of entire journals devoted to topics beyond cancer cells, let alone the papers published in them.

    As for the American Enterprise Institute, all those folks did was put the study on their web server. They likely did so to make a political point, but unless you can prove that Ohsfeldt and Schneider are somehow affiliated with them, I think the web server involved here is irrelevant.

    Here is the AEI event at which they spoke.

    This is their book, published by AEI Press.

    These are the biographies of the people invited to discuss the presentation. Pardon me for thinking that the discussion was not exactly balanced.

    Click on the “Indicators” tab and scroll down. They have various cuts of mortality rate (by age, by gender, by disease, etc.), but they don’t have “excluding crime and accidents.” I thought I’d struck gold when I saw “mortality rate for injuries,” but that turned out to be the percentage of injured people who died. Of course, if WHO has done this, I’d love to see it.

    Alright. Time to roll up my sleeves and hit some source data. If you want to follow the bouncing ball, I’ve uploaded the spreadsheet I’m using here.

    First — the reason why I have trouble with your cancer outcome statistics. Refer back to page 19 of the AEI PDF. It claims that American five-year survival statistics are, across the board, better than the countries they choose to highlight. American outcomes are between 6.3% and 42.8% better than the average of all other cited countries.

    Compare that to cancer mortality rates, downloaded just now from WHO. The latest data is from 2002. The US ties with Italy in 23rd place; of the countries chosen in the presentation, Sweden and Switzerland beat us with 11th place. Denmark is the only cited country whose survival rates are worse than ours by a larger range than ours are compared with Sweden’s and Switzerland’s.

    Now, obviously, these data do not directly correlate; I presume that Uzbekistan’s position in first place (nearly half the mortality rate of the US) has more to do with incidence than treatment. Likewise, the WHO table refers to annual statistics, rather than five-year results. But I have trouble with the AEI measure showing a 21.8% average improvement, versus a 2.2% improvement in actual measured mortality. Either the AEI presentation cherry-picks the data; or it chose a measure which exaggerates the improvement in outcomes; or the data it is relying upon is outdated. Unless you believe that Sweden and Switzerland has lower overall mortality, and worse five-year survival results?

    On to life expectancy. Honestly, I don’t think I have the statistical chops to do this properly, so I’ll make a best guess. Incidentally, you and I have exactly 38 years left to argue this.

    Actual deaths in the US in 2005 (latest year reported): 2,448,000; actual rate, 8/100,000. Homicides in 2005: 16,740. Vehicular deaths in 2005: 45,520. Percentage of all US deaths related to homicide or motor vehicles: (16,740+45,520)/2,448,000, or 2.54%. The change in overall rate of death from these causes is not large enough to display on the Census table; it’s overwhelmed by rounding error.

    I have no idea how this correlates to the AEI “standardized mean fatal injury rate”, which shows a smaller increase of 2.12% in life expectancy. However, I draw the following conclusions:

    1) The US standardized mean shows the US in first place with life expectancy once you exclude homicide and vehicular deaths. We have no way of knowing how this was standardized (again, lacking a paper detailing the statistical methodology). I therefore have no way of analyzing this, but I’m somewhat disinclined to take it at face value having spelunked the numbers in the other table; it’s awfully convenient that the numbers show us consistently in first place.

    2) Qualitatively, I have issues that the mortality causes they are excluding are also the areas in which the US provides — by many agreed-upon measures — the best care in the world. Specifically: crisis, trauma, and golden-hour care. I infer that these kinds of medical care most likely involve a huge chunk of our overall costs — most of these patients go straight to an emergency room. So what I’d like to see is an equivalent measure of percentages spent on this kind of care: it seems to me that, if you’re going to accept at face value that we “really” have better life expectancy “but for” these causes, then perhaps your view on the costs of universally extending care “but for” these causes would differ as well.

    how in HELL can you say you’re accurately quoting me? Especially when you go through such a careful analysis to “prove” to me that I disagree with MYSELF?!?

    Suffice to say, I have no intention of going back and rereading my citations in order to “prove” that I quoted you accurately. We both have the source material. I did that to show that your bias is clear from your choice of which statistics to cite, which areas to focus upon, and what conclusions you draw. And no, I wouldn’t be much surprised if your argument turns out to be self-contradictory when it tends towards the illogical. The amount of argument you’ve rested on the AEI presentation alone speaks volumes to me about how you’re aggregating data and forming your opinion — or rather, how you’ve formed your opinion and then sought out your data. (Or thirdly, how you formed your opinion based on data from biased sources, without questioning much what they’re trying to sell you.)

    It’s an economic problem, a social problem, and a moral problem, but it’s NOT a medical problem. If you want to discuss which drug we should be giving the cancer patients, we can comb through medical journals. Then you could help me with my “scientific illiteracy on how medical research is done.”

    Again, medical research concerns itself with a hell of a lot wider range of issues than you seem to think it does. My thinking is that two semi-rational people, seeking points of agreement, would seek out scientific data on how best to improve health outcomes. Start with health, then factor in strategies based on costs and benefits of each outcome.

    Your belief that this should be left to the economists is exactly the damn problem, not just with health care. It’s the American set of blinders for how we approach every problem, and usually our answer is, “It costs too much, so let’s just live with the issue as long as humanly possible.”

    I’m happy to debate — and learn from — economics when it comes to discussing whether a proposed strategy is likely to be effective. Therefore, there are things to be learned from economic analysis of single-payer and public-option plans. But to make that initial choice based solely on economics is precisely the mindset that most obviously divides us. When I look at those AEI tables, it’s pretty clear to me: our outcomes show that black Americans aren’t worth as much as white Americans. This whole debate tends to undervalue the uninsured in similar ways.

    Which honestly is why I can’t understand some points of debate — it’s inarguable that we spend more money for deeply unequal distribution of care. Other countries win on the economics of health care, as well as many metrics of measuring care. The only way to defend the present system is to ignore both the amount we spend and the inequities of distribution.

    And, as if this really needs saying, the University of Iowa is not a right-wing think tank. If the ACLU put the same presentation on their web site, would it carry more weight?

    As if this really needs saying: neither one of us knows bugger-all about the University of Iowa. Frank Luntz was once Penn faculty; does that say a damn thing about his pronouncements? University of Anywhere gives us a bare minimum standard by which to judge an author; for better standards, this is why peer review is important.

    And of course you should judge the sponsorship of anything you read, whether it’s on the AEI website, the ACLU website, or funded by Exxon. I personally think it would be rather easy to document that the ACLU has a much better track record of not bullshitting than the AEI — I’m fairly confident which organization has a better accuracy ratio if you want to check their respective pronouncements from 2001-2008. Not that you would give a damn about accuracy in this regard, because your mind is already made up that “ACLU” means dismissible.

  24. Janet says at September 30th, 2009 at 12:17 am :
    You guys amaze me. You also clearly are able to get by on less sleep than I can. But it’s great to read.

    I hesitate to add anything when I haven’t (and won’t) take the time to link to everything, create spreadsheets, etc. But, tossing caution aside, I’m going to raise a different kind of point. And I do have a PhD – and while it isn’t in anything scientific, it does mean I know a fair amount about peer review, research standards, and university politics. I’m also about the only one in my family who doesn’t have the stats chops you both wish you had; what I know is far more from the dinner table than from that one class I took at Penn.

    What I want to add is this: there’s another population of professionals involved here, and they work in public health. Some of them are MDs but lots of them are PhDs. One of them is my sister (a PhD) who happens to work for NCI at NIH. And her speciality is in prevention, risky behaviors, and cancer. I’d get her involved, but she has even less time than I do.

    You’ve talked a lot about doctors, and about government panels. First of all, those government panels include doctors. And second of all, those panels are in a position to assess best practices in a way that clinicians aren’t always. Studies of medical practice have shown for a long time that doctors see the problems that they know how to handle – surgeons are more likely to think operations are necessary, etc. My sister’s been talking to me for years about the over-treatment of prostate cancer, for example; this year, finally, recommendations were made about not treating men over a certain age (75? I don’t remember). This is because lots and lots and lots of men – probably most men – will develop prostate cancer. The vast majority of them will die of something else. So for them, treatment is not only expensive – and it is – but it is also invasive, and is quite likely to have side effects with real impact on quality of life: incontinence and impotence. So most of the men who are treated for prostate cancer, at significant cost on a number of levels, would have been better off if they had not intervened. It would also have cost less. But there are the much smaller percentage of cases for whom prostate cancer is fast growing and will kill them if it isn’t treated aggressively. The trick is in telling the difference, and culturally speaking, we tend to have a great deal of difficulty waiting and watching – though that’s exactly what’s recommended. Why am I being denied my surgery? the patient asks; well, because you’re probably better off without it. I know my sister would move that recommendation against treatment to a much lower age if it were up to her; I also know that she does not have annual mammograms (because of her understanding of the data, not because she is busy) and strongly recommends that I don’t, either. (She is five years older than I am.)

    About morbidity and mortality – yes, ultimately mortality is 100%, because we all die (even Walt Disney and Ted Williams). But a lot of the work now is being done on the compression of morbidity – the amount of time we are sick before we die. We can’t say that someone who dies at 100 will use more or less medical care than someone who dies at 70, but we can say that’s the goal, and that preventive care available throughout the life span is more likely to contribute to that than untreated chronic medical conditions. On a humane level as well as an economic one, that should be our goal; no one cherishes those days in hospitals at the end of life. We will be fortunate if we go quickly. Cancer is an obvious illustration of this; yes, if we live longer, we have more time to develop cancer. But if we have good preventative care, we might be less likely to behave in ways that increase our likelihood of getting cancer. If we understand more about best practice, we might be less likely to treat cancer if we get it later in life. All of these issues affect the costs of our end-of-life care.

    I agree with Jeff that we are making moral arguments here. You guys went back and forth about whether the US health care system doesn’t work well for 15% or for more of the population. I have to say I don’t really care on one level, because “even” 15% is too much for me. I don’t really like those bumper stickers that talk about heath care being a “right” – I’m not comfortable with that language. But I do think it’s a moral obligation, one that our society should choose to make. Personally, I think that’s the more powerful case. It’s also why health insurance doesn’t parallel life insurance. Life insurance doesn’t benefit me; it protects people I care about. I am, indeed, sure to die (much as I’d rather deny it). So I don’t have life insurance in case die, the way I have car insurance in case I’m in an accident (and because the state of CT requires it); I have life insurance in case I die sooner than I would expect to, and specifically because I have dependents. When they are older, and self-supporting, I will drop the life insurance. I’ll have car insurance as long as I’m still driving. And I’ll always need health insurance (and am very fortunate to have access to an excellent plan – one for which I am eligible as a public servant, a state employee). We call them all “insurance,” but there’s a fair amount of apples and oranges here, especially when what we’re really debating on the moral level is about access to health care; “insurance” is both the conduit and the barrier to that access.

    Finally, on a human note – my God, Jeff, I’m so sorry. What a horrendous situation for you to handle. My heart aches.

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