The Sucess of Socialized Medicine

[jeff]

To ess's post, the only point I would disagree with is that longer lifetimes in a population lead to population growth - the contrary is true: we as a species do our breeding way before we're elderly. If you look at populations like Japan and non-immigrant Europe, you see aging societies that are not even replacing their populations. Perhaps that answers James' question about the value of preserving those babies: who's going to be in the prime of their careers to support the elderly if we let the infants die? Apart from (IMO obvious) ethical issue. I'll elaborate on what gerontologists try to achieve for their patients: a long period of health and quality of life, with a steep, quick descent at the end.

James, I don't think we have to be as pessimistic about acceptance of new ideas, even if we're realistic about where we stand today. For example, 50 years ago there were still "colored" and "white" water fountains in this country, and other things that would be unthinkable today. There can be massive changes in perception over time.

For the philosophical question of what seniors provide, besides wisdom and continuity of family and culture (and people who get more tired during DE 15 touch bouts), and besides cultural and ethical questions, I think they provide a desired goal: People in their working careers hope to do well and live well in order to have a pleasant and comfortable old age. If that were precluded in Orwellian or Blade Runner style, our behavior during our so-called productive years would be more likely to be self-destructive. It's kind of why non-rich people in the US don't resent the wealthy as do some in other countries; we all harbor the hope that we too will be rich. Take away that possibility (or illusion...) and attitudes would change

[jBirch]

Originally Posted by jeff

To ess's post, the only point I would disagree with is that longer lifetimes in a population lead to population growth - the contrary is true: we as a species do our breeding way before we're elderly. If you look at populations like Japan and non-immigrant Europe, you see aging societies that are not even replacing their populations. Perhaps that answers James' question about the value of preserving those babies: who's going to be in the prime of their careers to support the elderly if we let the infants die? Apart from (IMO obvious) ethical issue. I'll elaborate on what gerontologists try to achieve for their patients: a long period of health and quality of life, with a steep, quick descent at the end.

Right, but you're forgetting about immigration and assimiliation. This is a global age where populations can move quickly and are quickly synthesised into their host populations. Places like Africa and China where there are large births per 1000, even though there are numerically higher infant mortality and death/1000, are able to fuel a society that loses more then it gains in the death/birth equation. With overpopulation a looming pressure, ought we be concerned about going negative growth for a while?

James, I don't think we have to be as pessimistic about acceptance of new ideas, even if we're realistic about where we stand today. For example, 50 years ago there were still "colored" and "white" water fountains in this country, and other things that would be unthinkable today. There can be massive changes in perception over time.

Nope, but sometimes there is value in NOT accepting new ideas. Inevitably in the quest for more and better, we lose what is good about the now.

For the philosophical question of what seniors provide, besides wisdom and continuity of family and culture (and people who get more tired during DE 15 touch bouts), and besides cultural and ethical questions, I think they provide a desired goal: People in their working careers hope to do well and live well in order to have a pleasant and comfortable old age. If that were precluded in Orwellian or Blade Runner style, our behavior during our so-called productive years would be more likely to be self-destructive. It's kind of why non-rich people in the US don't resent the wealthy as do some in other countries; we all harbor the hope that we too will be rich. Take away that possibility (or illusion...) and attitudes would change

Right, but isn't that provided regardless of how much over 65 you are? Ie// any longevity gains after 75 or so are just burden? Law of diminishing returns as it pertains to life-span?

James.

[jeff]

Originally Posted by jBirch

Right, but you're forgetting about immigration and assimiliation. (snip) With overpopulation a looming pressure, ought we be concerned about going negative growth for a while?

I mentioned immigration explicitly didn't I?

Originally Posted by jBirch

Nope, but sometimes there is value in NOT accepting new ideas. Inevitably in the quest for more and better, we lose what is good about the now.

Okay - and respect for the elders is quite traditional, so geezer preservation (along with getting rid of racism and so forth) are good things. The context you raised was "should we just give up since people are so resistant to change"; I answered that over time we do have changes; your answer to that is that we can lose valuable things by changing too much! So, are you saying we don't change but we change too much?

Originally Posted by jBirch

Right, but isn't that provided regardless of how much over 65 you are? Ie// any longevity gains after 75 or so are just burden? Law of diminishing returns as it pertains to life-span?

James.

Could be - I have no way of measuring that in a double blind study though!

[jBirch]

Originally Posted by jeff

I mentioned immigration explicitly didn't I?

Non immigration, I think. "Absence of immigration is not immigration" to paraphrase. But the point still stands in opposition to "babies to replace geezers". Your argument, if I understand it correctly, is that infant mortality is important to lower so that we have people to replace the productive members of society. If we can replace the geezers with immigrant babies then don't we have a non-problem in that respect? The geezers are still getting replaced so the net impact on workers per geezer is zero.

Okay - and respect for the elders is quite traditional, so geezer preservation (along with getting rid of racism and so forth) are good things. The context you raised was "should we just give up since people are so resistant to change"; I answered that over time we do have changes; your answer to that is that we can lose valuable things by changing too much! So, are you saying we don't change but we change too much?

Not just "so resistent to change" but so resistent that they will fight it vigorously. Arguably, WWI was just "resistence to change". Sometimes change really is bad.

I don't dispute (since I beautifully argued it in the first place) that the benefits are real in terms of the effect on the Health Indicators. In this case, I'm unsure whether the costs associated with imposing this beneficial change will outweigh the benefits to be reaped from that change in the long run. You have to factor the cost of changing into the economic equation and not just the projected benefits once the change is fully realised. And that's two things I haven't seen analysed in this discussion:

1) how to properly cost out the imposition of a state wide Universal Health Care system.

2) what the ramifications of the change are in units other then the Health Indicators. GDP effect would be an interesting one, as would worker productivity and ILO unemployment rate.

Analogy to illustrate my point: I looked at buying a VW TDI to save on gas. Trouble was, over the life of the car I would save less on the gas then I would pay for the premium of owning a TDI Engine!!! If such turns out to be the case with Universal Health Care, won't it have been an unwise decision to make?

Could be - I have no way of measuring that in a double blind study though!

Well, just wait till you and your wife are both blind and over 75 and get Inq to measure your usefulness based on your economic productivity.

James.

[jeff]

For part 1 ("live longer = good thing") I take that as a good thing axiomatically. I'm not worried about dystopias full of old geezers. Not 'in scope' to what I'm thinking about; I don't really have a dog in that fight right now...

For the change business: I just showed ("proof by existence") that dramatic social changes can happen within a lifetime. Their merits or disadvantages are a separate issue, my point being that we can't exclude such changes just because we're not trembling on the brink of doing them now. Frankly, this one is not such a leap compared to others, as we already have a spotty, inconsistent, incomplete health system - part private, part public. It's not a world order revolution.

If you want to put up a thread on the origins of WW I that would be interesting. It at least would be something new, rather than the topics we keep bringing up in this folder over and over again. (I find it a fascinating period since it was on the cusp of the modern world)

I think that the net lower costs in Europe and other countries with universal healthcare take care of the "initial outlay vs. incremental savings over the life of the equipment" analogy.

As far as going blind, I'll just have to learn to touch-type by Braille...

[jBirch]

Originally Posted by jeff

For part 1 ("live longer = good thing") I take that as a good thing axiomatically. I'm not worried about dystopias full of old geezers. Not 'in scope' to what I'm thinking about; I don't really have a dog in that fight right now...

It does illustrate a bias on your part in favour of Universal Health Care for non-rational reasons though.

I dispute the axiom because the data seems to imply a diminishing rate of return on age. Ie// Live longer means worse benefit for the nation per person. I don't dispute that live longer = good thing for one organism. I wonder if it is true for all organisms. I also wonder if there is a point of negative return. Given this, I can't see how "live longer = good thing" for all populations. I certainly wouldn't say this axiom applies to China or India and therefore, it isn't axiomatic.

Let's leave that question aside though since it only goes to underlying assumptions.

For the change business: I just showed ("proof by existence") that dramatic social changes can happen within a lifetime. Their merits or disadvantages are a separate issue, my point being that we can't exclude such changes just because we're not trembling on the brink of doing them now. Frankly, this one is not such a leap compared to others, as we already have a spotty, inconsistent, incomplete health system - part private, part public. It's not a world order revolution.

I'm wondering in this line of thought, not about whether the change is possible per se, but whether its cost outweighs its benefits. Your example of social change is not as appropriate in this context though as the COST of doing that change was mostly reflected in changing perceptions. Abolotion is a more appropriate comparison in that an entire industry was essentially wiped out overnigth.

Let's embark upon a definition of the problem of implementing Universal Health Care though so that we at least understand something about the costs of undoing what we currently have and putting something better in its place.

To provide Universal Health Care, the current system of Medical Insurance Providers would have to be changed. This needs to be done in an effort to turn health care into a truly non-rivalrous, non-exclusive public good (because of the free rider problem). If you were to leave Health Care as rivalrous, then you would essentially get a multi-tiered service where the poorest members would get poor health care. This seems, to me, to be a substandard solution to the problem and not truly Universal Health Care. Whether it confers the same improvements to the Health Indicators is another interesting question.

The current scheme of doctor/nurse/specialist compensation would also have to be totally reformed. Hospital funds would need to be changed and significant practices scrapped. I suspect that significant billing, accounting and IT infrastructure would have to be scrapped or reworked.

What other barriers to Universal Health Care are there and are they all surmountable in cost proportional to the projected gains? Beats the hell out of me.

I think that the net lower costs in Europe and other countries with universal healthcare take care of the "initial outlay vs. incremental savings over the life of the equipment" analogy.

This is "Apples To Oranges". Part of the reason why socialised universal health care was possible was because of the economic and social situation in those nations at the time. To implement it now in the US requires a lot more effort then it did at the time for those countries because the US has to undo all the momentum generated in the private sector first. I'm not sure that this momentum is stoppable at this point in a manner that allows the system to realise the gains in other nations.

The question posed really isn't whether Universal Health Care provides better health at cheaper cost. It's more along the lines of can the US afford to implement that change?

James.

[jeff]

Again, not really the parts of the question that really interest me, so please forgive my not getting really into it...

In brief responses: extension of age isn't the only benefit. Better quality of life throughout lifespan is another benefit (eg: pre-natal care -> healthier babies and mothers who then require less medical care to compensate for conditions that could have been prevented, ditto for immunization, screening for everything from diabetes to blood pressure to deafness). So, let's not be reductionist to just one facet. For my purposes, a healthier, longer lived population is a good thing. We don't need to construct elaborate scenarios of immensely aged people.

Second, the switching costs needn't be that great. A single-payer system that pays private hospitals, doctors and nurses would replace a multiple payer system. No problem - in fact an immediate net benefit due to the reduced paperwork complexity.

The 3rd part assumes that those countries didn't have well-established private medical systems before going to their current systems - which is not the case.

[jBirch]

Originally Posted by jeff

In brief responses: extension of age isn't the only benefit. Better quality of life throughout lifespan is another benefit (eg: pre-natal care -> healthier babies and mothers who then require less medical care to compensate for conditions that could have been prevented, ditto for immunization, screening for everything from diabetes to blood pressure to deafness). So, let's not be reductionist to just one facet. For my purposes, a healthier, longer lived population is a good thing. We don't need to construct elaborate scenarios of immensely aged people.

Right, but again you're merely asserting repeatedly that a healthier population is an exceptionally good thing. Why?

Second, the switching costs needn't be that great. A single-payer system that pays private hospitals, doctors and nurses would replace a multiple payer system. No problem - in fact an immediate net benefit due to the reduced paperwork complexity.

I think you're understating the complexity of the implementation problem here.

The 3rd part assumes that those countries didn't have well-established private medical systems before going to their current systems - which is not the case.

No, merely that the social and economic cost of switching is exponentially higher now then it was had the change been implemented back then. I think the assertion that the cost of privately funded health care (in real dollars) is the same as the cost of privately funded health care now is preposterous.

In the US alone, health care as a % of GDP has grown from 5% in 1960 to 15% in 2003 while Real GDP over the same period has gone from $2501.8 (USD-y2K) to $10320.6 (USD-y2k). This represents an increase in real GDP of ~4x and in % of GDP of 3x. So assuming the cost of switching is linear and compounding the problem using simple math, the cost of switching to public healthcare is roughly 12x what it was back then. This, of course, grossly simplifies the numbers and represents what is probably a best case in terms of costing. I can think of several ways that this number could be worse and a bare handful of ways that it could be better.

If switching to public healthcare in 1960 was, for most populations, extremely difficult and contentious, is it reasonable to assume the outcome being the same with the dice loaded 12x heavier to the nay side?

James.

[Gav]

If I may intercede to pose an observation:

Right, but again you're merely asserting repeatedly that a healthier population is an exceptionally good thing. Why?

Depends on why you think it's not good. You didn't define that here

I dispute the axiom because the data seems to imply a diminishing rate of return on age. Ie// Live longer means worse benefit for the nation per person. I don't dispute that live longer = good thing for one organism. I wonder if it is true for all organisms. I also wonder if there is a point of negative return. Given this, I can't see how "live longer = good thing" for all populations. I certainly wouldn't say this axiom applies to China or India and therefore, it isn't axiomatic.

You mention diminishing return but you do not define what you mean by that. Are we talking economic, political, health, innovation, tax burden, ethics, etc etc. Are you arguing along strict economic lines?

Jeff can hardly redefine/defend his position, or counter your argument, if you do not adequately define the basis of your opposition.

You don't define exactly what your objection is. The only example I can find in preceding posts refers to people at the extreme end of their lives. The concept of growing old and infirm is more complex than just: one day I will be young; the next old. It isa continuum and with increased longevity has come a longer middle period, lasting later into life, during which members are still able to put into the pot. Do not forget that concepts such as retirement and pensions (before you mention them) are modern concepts that I do not believe have kept up with the changes in the modern environment. It is entirely probable that we will all have to consider that fact that we will have to work until our 70's, or later, unlike [even] our parents. In addition we are seeing the death of the last generation before some of the more amazing and radical medical procedures - which extend useful life - became truly efficacious. It is currently dofficult to quantify exactly what the future holds for the generation after that (our parents) and ourselves.

[jBirch]

Originally Posted by Gav

Depends on why you think it's not good. You didn't define that here

No, I was just questioning the assumption of good. That's all. We are assuming that all increases in life span are good without any sort of evidence that that is indeed the case. It surely might be, but it's an undefined assumption upon which the rest of the case for Universal Health Care is predicated.

You mention diminishing return but you do not define what you mean by that. Are we talking economic, political, health, innovation, tax burden, ethics, etc etc. Are you arguing along strict economic lines?

Not really. Just poking holes in the assumption. We assume that all increases in life span are good things but we also know that those life span increases translate into complex effects on the nation. A possible problem is the concept of diminishing returns on increased age on the population at large. Older people generally don't work in highly productive capacities. Therefor, how much should we invest in them? We too can be considered to depreciate over time with the same effects on the nation as any other depreciating asset. Sometimes the cost of maintenance is too high to justify the continuing expense.

Jeff can hardly redefine/defend his position, or counter your argument, if you do not adequately define the basis of your opposition.

Fair enough. I'm taking a contrary stand to explore the problem more fully. Specifically, while the benefits are real in terms of their measurable effects, I see two flaws in the adoption of Universal Health Care.

1) The implementation problem is significant. This problem will significantly increase the cost of switching. Whether this cost is proportional to the gains is yet to be seen.

2) The gains are not quantified outside of the measurements. Basically, we can say that Universal Health Care increases longevity but I haven't seen any evidence that increasing longevity is good thing. It makes sense to think it is, but looking deeply at the question, it's not so obvious. We can spend lots of resources lowering those numbers but at what point does it stop being a useful expenditure for the nation?

You don't define exactly what your objection is. The only example I can find in preceding posts refers to people at the extreme end of their lives. The concept of growing old and infirm is more complex than just: one day I will be young; the next old. It isa continuum and with increased longevity has come a longer middle period, lasting later into life, during which members are still able to put into the pot. Do not forget that concepts such as retirement and pensions (before you mention them) are modern concepts that I do not believe have kept up with the changes in the modern environment. It is entirely probable that we will all have to consider that fact that we will have to work until our 70's, or later, unlike [even] our parents. In addition we are seeing the death of the last generation before some of the more amazing and radical medical procedures - which extend useful life - became truly efficacious. It is currently dofficult to quantify exactly what the future holds for the generation after that (our parents) and ourselves.

Absolutely: with increased life span it becomes more feasible to increase retirement/pension age. This might be a direct economic benefit to the nation and a great argument about why increased life spans are a good thing if it is. I can see a couple of questions that arise with its implementation though:

1) Longer period of employment = greater median salary. Is this offset by increased productivity?

2) Does the longer period of employment suppress starting salary rate for young couples, essentially putting more of a burden on parents to support their offspring into later and later years?

But implementing Universal Health Care without the additional change of increasing retirement/pension age might be counter-productive. What other ancillary changes would need to be made in order to effectively realise the benefits of Universal Health Care? What are the costs of implementing those?

Complex question without a clear answer, I think.

James.

[jeff]

I'll try to reiterate my previous response with slightly different wording, to see if that helps.

I've said it's a good for a population to be healthier and longer-lived. "Axiomatic" means that I take that as a base, rather than something that need be separately justified. There have been a number of political theories and fictional works (Orwell, Vonnegut) that describe countries where the old and sick are disposed of: we call them "dystopias". I do not believe that we should add up the dollar value of every individual and kill them or turn them into food if their expected return on investment goes into the red. Why have old age as the only criteria? Why not kill off younger people with crippling diseases? Why not enforce eugenics? "Mrs. Smith, you have cancer, but your kids are already grown so who needs you. Have a nice short life". Yeccch. When Swift wrote about eating babies as a remedy for economic problems it was a satire.

This strikes me as an example where use of economic thought is fundamentally misplaced - its knowing the price of everything but the value of nothing. I can see somebody saying "I don't feel like paying for this" or "it's too expensive and we have to set limits somewhere", but what does it mean to be "good for the country" if we institute policies that are "bad for the country's citizens"?

Perhaps I'm misunderstanding what James is getting at, but I don't see "living longer and better" as being anything other than Good Things, unless we're property of the State, to be discarded like old toothpaste tubes.

I've already mentioned that universal health care is far from solely being about end-of-life issues. If you insist on cost/benefit analysis, simply consider that universal healthcare provides currently-underprovided preventive healthcare to all ages (so things can be treated eariler and cheaply, or prevented entirely), and would also would treat currently underserved people in their economically productive ages so they could be returned to the workforce in their capacity as fully functioning drones.... In the long term, both cases will lead to longer lifespans because they were treated before they became old. In other words, simply drop this argument about expensive end of life care for the wrinkly geezers because it's reductionist, inaccurate, and woefully incomplete (as well as repugnant, to me at least).

I've also addressed the switching cost issues - the fact that other countries have done this shows that it has been done successfully, and using a single-payer system rather than a truly nationalized healthcare system would not be particularily disruptive at all. That would be a net savings in short-term.

[jBirch]

Originally Posted by jeff

I'll try to reiterate my previous response with slightly different wording, to see if that helps.

I've said it's a good for a population to be healthier and longer-lived. "Axiomatic" means that I take that as a base, rather than something that need be separately justified. There have been a number of political theories and fictional works (Orwell, Vonnegut) that describe countries where the old and sick are disposed of: we call them "dystopias". I do not believe that we should add up the dollar value of every individual and kill them or turn them into food if their expected return on investment goes into the red. Why have old age as the only criteria? Why not kill off younger people with crippling diseases? Why not enforce eugenics? "Mrs. Smith, you have cancer, but your kids are already grown so who needs you. Have a nice short life". Yeccch. When Swift wrote about eating babies as a remedy for economic problems it was a satire.

I know what you meant by "axiomatic". Most people would argue that the alternate extension of your argument (any and all cost to extend your life is justified) is an equally extreme position. If the answer is balance, then the question is where.

This strikes me as an example where use of economic thought is fundamentally misplaced - its knowing the price of everything but the value of nothing. I can see somebody saying "I don't feel like paying for this" or "it's too expensive and we have to set limits somewhere", but what does it mean to be "good for the country" if we institute policies that are "bad for the country's citizens"?

To paraphrase Spock, "the good of the many outweighs the good of the few". Good for the country being defense, bad for the country's citizens being a draft.

Perhaps I'm misunderstanding what James is getting at, but I don't see "living longer and better" as being anything other than Good Things, unless we're property of the State, to be discarded like old toothpaste tubes.

Morally and ethically, I agree with you.

I've already mentioned that universal health care is far from solely being about end-of-life issues. If you insist on cost/benefit analysis, simply consider that universal healthcare provides currently-underprovided preventive healthcare to all ages (so things can be treated eariler and cheaply, or prevented entirely), and would also would treat currently underserved people in their economically productive ages so they could be returned to the workforce in their capacity as fully functioning drones.... In the long term, both cases will lead to longer lifespans because they were treated before they became old. In other words, simply drop this argument about expensive end of life care for the wrinkly geezers because it's reductionist, inaccurate, and woefully incomplete (as well as repugnant, to me at least).

I apologise if you find the discussion offensive.

I've also addressed the switching cost issues - the fact that other countries have done this shows that it has been done successfully, and using a single-payer system rather than a truly nationalized healthcare system would not be particularily disruptive at all. That would be a net savings in short-term.

I defer to your knowledge then.

James.

[jeff]

No need to apologize James - I wasn't offended, and I in turn apologize if you thought I thought ill of you for your posts. My guess is that you're doing this as a thought-experiment, and there's nothing wrong with that. I also have no problem with "where do you put the balance point" for how much you're willing to spend on this or any other thing. If anything, I was saying why I can't get worked up on this as a meaningful contradiction to the value proposition of healthcare.

[jBirch]

No worries man. It was exactly that: a thought experiment. I believe in Universal Health Care from a moral perspective, that it is wrong to deny sick people help for any reason. Rational that decision is not, so persuasive arguments to folks who believe in the contrary end up almost being religious in nature.

I can see Inq's position better now. If you are able to bypass the moral argument (not that Inq isn't moral) and try to argue the facts to a rational conclusion you end up in a morass of "dunnos". The other side (us) ends up always reducing the argument to a moral one: that it is right, true and just for the nation to strive for peace, happiness, prosperity and longevity. That means that the reasons to do this action (and coerce everyone else to support it) are altruistic and not necessarily rational. Wrong therefor becomes a matter of personal opinion and not objective measurement.

Thanks for the discussion.

James.

[jeff]

Gee, if we're all in agreement, then we need something else to argue about! Are you gonna take a pass at World War I?

cheers, Jeff