Health Care Reform in the US

[I_luv_saber]

Not everyone would be comfortable doing that, but I would be grateful if someone could explain to me why on earth the government should either be able to forbid me to make such a choice or fine me for not buying the policy!

I actually agree with this. While I am for regulatory reform, and I do see the logic behind wanting insurance madatory... I am generally against laws such as mandatory insurance laws, seatbelt laws, helmet laws, etc...

I do not argue that such things do not occur. I simply question the knee-jerk assumption that they are the norm, or are so common as to "prove" the existence of an SOP which produces them. I question statements like "they do it all the time" and "they rig the system".

It shouldn't be happening period. If an insurance company is doing a dishonest practice - such as denying payment and holding out in court until the one awaiting payment can no longer wait - the consumer needs to have a legal leg to stand on. This is about consumer rights and protection, not about lashing the poor insurnace companies.

Let me make something clear, I don't mind that insurance companies profit in their business. They SHOULD profit. If they can make a damn good profit, then good for them. But they should NOT be making profit via dishonest means at the expense of the consumer. As long as their profit is an honest profit, I have less of an issue with the whole situation.

I even question the "they", frankly.

This is just too much conspiratorial thinking for me. In my experience people and organizations are not competent enough to pull of conspiracies and keep them from being exposed as conspiracies

It's not some vast conspiracy... it is a company wanting to make the most money possible by paying out as little as possible. Rememer: Externally, your A/R should move as fast as possible and your A/P as slowly as possible... don't pay what you can get out of paying, and make sure you get payed as fast as possible. The only time you want A/P to move fast is internally, where you need to spend all your money to show the higher-ups you need more budget money. Crappy, but that's how it generally works.

Which is all well and good until you resort to dishonest means to do that...

[lindajdunn]

http://www.urban.org/publications/411915.html

I know nothing about this group, it's funding sources, etc. Allegedly it's non-partisian and its study allegedly shows a public option is needed.

It also states that the reason a public option is needed is because private insurance companies are NOT competitive.

[dcmdale]

So I know that the real Health Care discussion has moved to the Korea thread, but I am posting here anyway.

Capitalism has always been somewhat a two-edged sword: Capitalism tends to move society to structure its economy amorally (some might argue ruthlessly) in the direction of efficiency. In a perfectly efficient model, one would expect that society would be willing to expend resources on an individual if and only if the expected present value of their future contribution to society equals or exceeds the cost of maintaining that person. Balancing this is that because death (particularly premature death) is inefficient, such a society will tend to invest heavily in research to reduce the cost associated with keeping people alive (through reducing food costs, improving infrastructure, etc, as well as medical research) and to improve their economic value (through education, etc). If we look at money as the medium for making these evaluations, it becomes apparent that our society is deeply influenced by this model.

I think that making comparisons between countries with socialized models and the U.S. model is problematic. The U.S. model invests heavily in medical R&D. My guess, though I am willing to be proven wrong, is that because of the economics involved, that a much higher percentage of U.S. patients costs are reinvested in future medical advances than the costs for patients in socialized countries. That is, I believe that socialized countries are likely piggybacking on advances financed by the American system. *If* that is true, then socializing American medicine would either have the result of stifling medical research, or that the costs for the rest of the world would have to rise (and the Americans would not get as much relief as they anticipate). I also expect that trying to actually substantiate this hypothesis would be a huge exercise in conflicting numbers.

If capitalism tends to push us towards efficiency and we see that many aspects of our society have actually been pushed that direction, how come our expenses are so high?

1. Because the preservation of life has a strong economic value for the one who is dying, there is a tenancy for us to be willing to spend whatever it takes within our capability in order to preserve it. A free market will happily slurp that up. Part of the reason that we spend so much is that we have so much to spend (and insurance fits in huge here--a bout with cancer may well cost the same as the person's entire lifetime income). The moral issue here, of course, is that the rich have more resources to spend than the poor--but that is kind of the definition of being rich.

2. There are tremendous inefficiencies embedded in tradition and regulation. I am less concerned about the FDA et al than with the relics of the guild system. I cannot believe that in a greenfield you would design a health delivery system that looks anything like we have today. The guild system existed/exists primarily to restrict competition and maintain profits.

3. Massive amounts of money creates opportunity for fraud. The temptation to cheat increases as the expectation of rewards for cheating (reward * chance of getting it) exceeds the risk (danger * chance of losing). Part of the reason that we don't associate big American business with the notion of efficiency is that anyone who has ever been inside a F500 business will readily identify with self-promoting people who claim successes and move on before the factual failures catch up to them. My personal experience with senior tenured faculty at 3 major university teaching hospitals suggests that academic/scientific cheating is pervasive--not necessarily total fabrication of results of research never done, but bending experimental results to fit theories. The more god-like the researcher, the less likely that the research will be replicated (or contrary studies published).
4. Lots of others.


If solving all of the issues was easy, it would have been solved long ago. Universal insurance will actually exacerbate some of these issues--particularly, the average cost per person will go up, not down. I am certainly not one to argue that the moral answer should be governed by economic efficiency; OTOH, if we don't take into account the full economic impacts, we won't be anything good.

[Inquartata]

Oh sure, you may be able to afford checkups and screening, but only the wealthiest among us could afford to pay out of pocket if something goes wrong with us. A hospital stay is ferociously expensive,

Agreed.

But how do we get from that---a description of a situation---to a government change in that situation? From "I can't afford that" to "Taxpayers should give me that"?

and government has a lot less to do with it than one might think, despite being the default punching bag that they are.

I am not convinced. ( Surprise! )

What I was talking about is the well-known phenomena of HMOs rationing access to expensive services even when medically indicated, the equipment and staff were available (no "scarcity" in the normal meaning of the word), and the patient has paid for coverage.

First, what is the proof for "well-known"? And I use the word "known" in the sense of "proved by evidence" as opposed to "felt in my bones to be true"...

Gee, Inq - I don't know why you need to disagree with me when I was essentially agreeing with you

Meh, you really don't know me at all, do you?

Her interests are aligned with them in so far as she needs them to be paid for the work she does,

I see where her interest is in being paid...I don't see where theirs are at all aligned with that.

Yet those laws were so fragmentary, incomplete, and ineffective that they were of little practical value, especially with the societal changes described in that link.

Well, but that's not what you asked me, and not what, by inference, you were arguing. You asked "what regulation existed?", not "what effect did it have?". ( And the inference, it appeared to me, was not "they weren't effective" but "there were none". )

I go back to your question,"Teddy Roosevelt signed the law that created the FDA in 1906. What regulations did you think applied before that?"

Not "what effective regulations", notice!

Then when I answer---you change the question!

Naughty.

Are you seriously suggesting that the consumers would buy the food that had the ground up rats in it if they knew about it?

Bah, another changed question!

I was answering this one: "Why then did companies at the time, say, during Coolidge administration, not compete with one another to create the safest products."

The answer to THAT question is, because "safest" is not the dominant quality which consumers, on average, seek. The dominant factor is price, and that is the basis on which producers tend to compete. That's the only assertion there...

You and Miltie might prefer regulation to disclose information rather than specify standards.

Yes.

I don't see why. You explained the costs of the supply chain. You didn't say "this product is POISON!" (old joke "and such small portions, too!") That would get more attention from the typical consumer.

Heh, yes. The absurdity was this big, strong football lineman who just thought that contemplating the fact that milk came from cow udders was so "icky" that his mind shied from the very subject. I was very entertained.

Absolutely. That's an effect I've previously mentioned.

Right...but AFAIK it's an unproven effect. Has anyone even attempted to test the proposition? I just don't know...and thus I can't accept it as an assumption...

The stock market became viable as the engine of capitalism because regulations made it other than a way to gull the rubes. Really.

Eh...I don't buy Rockefeller or Carnegie as "rubes".

I'll just pass it to my linguist friend, Rosetta Stone. She's good at that sort of stuff.

Nice one. ( prohibited---well, you know )

Any relation to Eliza Stone? ( and AGAIN )

And just how effective was that, eh? It kept LA from having smog, or GE from putting PCBs in the Hudson, or mining companies from leaving cyanide in ground water? The "interference" you cite was negligible.

Again...that's not what you asked me.

I thought you abjured use of Wikipedia!

I abjure it for other people!

Where's the "IMO" that goes with that kind of sentence, huh?

It's, uh...in white text. Yes, that's it...that's the ticket! Just ask my wife...ah...Morgan Fairchild!

[Inquartata]

Simply including it for a simple, easy to explain example, nothing more.

So, then...what IS your evidence for "they do it all the time"?

I'm not sure what proof I could put forth that would be considered "objective".

I'll settle for "Not obviously biased".

the GOBS of commercials for lawyers with the SOLE PURPOSE of fighting insurance companies? You don't think this huge volume is filling some need?

Frankly I think it's intended to create a need.

"Does your Gran have bedsores? It must be neglect or abuse by the nursing home! Call the law firm of Grift and Graft right away!"

A lot of these commercials are just mining for clients by leading them to a conclusion, IMO.

I'd not that NONE of these situations should happen in the first place because there should be regulations in place preventing companies from doing it. Even a handful is inexcusable.

Inexcusable? Perhaps. Evidence of massive conspiracies, or systematized abuse? No.

Name me a walk of life, anything at all in which human beings are involved, which is completely free from transgressions. There are corrupt cops, and you can read about a lot of examples...doesn't mean that it's pervasive, much less that all law enforcement needs to be "reformed". Law? Politics? Let's not get started!

I very much doubt that.

Hmm.

You doubt that lower-cost producers tend to drive higher-cost ones out of business?

Perhaps we could ask General Motors, Ford or Chrysler?

Get thee to an economics class, go!

Seriously---everyone should! It will make for much better citizens!

Regardless of cost though, the underhanded practices done by insurance companies should be illegal.

Just what this country needs---more laws...

And not coincidentally, of course---more lawyers...

But that's not a good reason for letting an industry get away with the stuff this one does.

So...there are really NOT, after all, any prosecutions or court judgements attending these incidents of abuse?

If there are, how is that "letting" anyone do anything?

Does that mean we never change anything because we don't know for sure what will happen?

As silly as buying a pig in a poke?

We have a system that we KNOW works. We can make small changes, to see whether they work. Test cases. Experiments---you know, the scientific method. Why opt instead for massive, sudden systemic changes? Because there's a charismatic man in high office who wants us to do so?

And why believe that this time, regulation will work! More laws will solve the problem that previous changes in the laws have not because...an untested young Democrat says they will?

[Inquartata]

http://www.urban.org/publications/411915.html

Allegedly it's non-partisian

Heh. A clue, perhaps:

"In the mid-1960s, President Johnson saw the need for independent nonpartisan analysis of the problems facing America's cities and their residents. The President created a blue-ribbon commission of civic leaders who recommended chartering a center to do that work. In 1968, the Urban Institute became that center."

Mr. "Great Society" Johnson? "Mr. "War on Poverty" Johnson? That guy?

Seriously, though, the report looks worth a read when I have the time. I look askance at a few of their baseline assumptions, just from a cursory glance, but we'll see. Thanks for that.

It also states that the reason a public option is needed is because private insurance companies are NOT competitive.

That's one of the assumptions I wondered about. Their evidence seems to be that the industry has gotten more concentrated, and because 3 or 4 firms constitute 65% of most local markets. ( I'll have to see how they define "market". ) But seriously? 3 or 4 firms=noncompetitive? Since when?

I mean, that probably applies to most industries today. Certainly it looks to apply to, say, supermarkets in my city. Electronics stores...Best Buy, Fry's...used to be Circuit City, but it went out of business. Hey! That means the industry got "more concentrated"! Which means it must have gotten more profitable! Hmm...

They also seemed to think that revenues which increase faster than medical costs means greater profits. Odd...

But this requires deeper examination.

[Inquartata]

Capitalism has always been somewhat a two-edged sword: Capitalism tends to move society to structure its economy amorally (some might argue ruthlessly) in the direction of efficiency. In a perfectly efficient model, one would expect that society would be willing to expend resources on an individual if and only if the expected present value of their future contribution to society equals or exceeds the cost of maintaining that person.

Just to be perverse: Doesn't that sort of sound like North Korea?

death (particularly premature death) is inefficient,

Is it?

[Phaeton]

The assumption that public information will help markets step in line misunderstands the common consumer. How many people will look up detailed health information? How many people can interpret that information?

We have to process so much on a daily basis that adding more information to the already existing amount seems to be of negligible benefit. There is a lot of public information on drug interactions and proper dosage. Yet, how many consumers take their antibiotics or other medication properly? Not nearly enough. If people don't read the information, no change is made, and they cannot help adjust the quality or price of healthcare.

This alone is not an ideal solution.

[Inquartata]

The assumption that public information will help markets step in line misunderstands the common consumer. How many people will look up detailed health information? How many people can interpret that information?

Economically speaking, this implies that those who do not value the information have still made a rational, utility-maximizing decision and the market is still working as it should...

As for interpretation, again, someone will go into business to do it for them. Like "Consumer Reports".

Hmm, I have the strangest feeling of deja vu...

[Phaeton]

Economically speaking, this implies that those who do not value the information have still made a rational, utility-maximizing decision and the market is still working as it should...

As for interpretation, again, someone will go into business to do it for them. Like "Consumer Reports".

I don't understand how any uninformed decision can be considered a rational decision. How important that information is information as well, and information that consumers do not necessarily have.

That said, I don't want Consumer Reports dealing with my health. I don't need that third party involved. I realize my doubt in the value of information touches on a number of issues (such as informed cosnent) but how much can a third party really help an individual, and how much can an individual understand about his or her health without a degree. At the moment our schools give little no education. Yet, we punish the ignorant ?

[I_luv_saber]

So, then...what IS your evidence for "they do it all the time"?

Eh, I posted links above!

Simply throwing my lot in with the rest.

I'll settle for "Not obviously biased".

In a case like this, where there is one party accused of doing something wrong, there is no real objectivity as the only ones who would have evidence of this are those... doing the accusing!

Basically, I don't think there is ANY evidence out there that is not biased in one way or the other.

Frankly I think it's intended to create a need.

Tort reform is most definitely needed, as I've pointed out before.

Inexcusable? Perhaps. Evidence of massive conspiracies, or systematized abuse? No.

I've posted multiple links already.

Regardless, inexcusable acts should not be allowed to legally take place (whether they happen often or not). If murder were a rare occurence, should we cease to outlaw it?

Name me a walk of life, anything at all in which human beings are involved, which is completely free from transgressions. There are corrupt cops, and you can read about a lot of examples...doesn't mean that it's pervasive, much less that all law enforcement needs to be "reformed". Law? Politics? Let's not get started!

Great cop out.

Just because "it happens all the time" does not make it OK. We do our best to keep order IN all walk of life. In law enforcment, we see many places hiring Independant Police Auditors... in politics, we have review boards and... the people! In most walks of life, you cannot always stop transgressions... but there is a solid method in place to stop most of it and address what does (and where there is none, yes, that needs to be reformed!).

Hmm.

You doubt that lower-cost producers tend to drive higher-cost ones out of business?

Yes, because if tort reform is instituted as well, their A/P goes much lower as well, hence they can "take the hit". Not to mention I'm not for a public option

Just what this country needs---more laws...

And not coincidentally, of course---more lawyers...

Meh... all the lawyers out of a job from the tort reform have a new place to go

So...there are really NOT, after all, any prosecutions or court judgements attending these incidents of abuse?

1) If you've spen all your money on your healthcare, HOW are you to afford a lawyer?

2) As I said, a favorite tactic is to hold things up in court in order to force the person to low-ball settle out of court.

Not even to mention the HUGE lobbying power of insurance (almost on par with the infamous tobacco and oil).

We have a system that we KNOW works. We can make small changes, to see whether they work. Test cases. Experiments---you know, the scientific method.

I think regulation is a pretty small change. It's the same system after all, just more regs. Regardless, I'm fine with working our way there...

Why opt instead for massive, sudden systemic changes? Because there's a charismatic man in high office who wants us to do so?

Good God, man! I don't agree with his plan or a public option!!! I've fought it vehemently in the past!!! GAAAAHHHHHH!!!!!!!!!!!

And why believe that this time, regulation will work!

Because regulation DOES work. The trick is finding the sweet spot in-between over and under regualtion. Also exactly WHAT you regulate matters.

I see no reason to see it would not.

[I_luv_saber]

As for interpretation, again, someone will go into business to do it for them. Like "Consumer Reports".

Great! Let's make health care MORE expensive to the consumer!

The U.S. model invests heavily in medical R&D. My guess, though I am willing to be proven wrong, is that because of the economics involved, that a much higher percentage of U.S. patients costs are reinvested in future medical advances than the costs for patients in socialized countries. That is, I believe that socialized countries are likely piggybacking on advances financed by the American system. *If* that is true, then socializing American medicine would either have the result of stifling medical research, or that the costs for the rest of the world would have to rise (and the Americans would not get as much relief as they anticipate).

Very interesting point. Not sure if it has merit, but rep for a thought I hadn't heard of before...

[Hauptman]

Economically speaking, this implies that those who do not value the information have still made a rational, utility-maximizing decision and the market is still working as it should...

As for interpretation, again, someone will go into business to do it for them. Like "Consumer Reports".

Hmm, I have the strangest feeling of deja vu...

That's fine if the so-called experts like Consumer Reports are truly reliable.

I pity anyone who relied on the financial "experts" in 2006/2007. :P


Edit: Just saw this... good for a laugh in retrospect... http://www.billshrink.com/blog/worst-financial-gurus/

[jeff]

So I know that the real Health Care discussion has moved to the Korea thread, but I am posting here anyway.

Thank you for the valiant attempt to put the conversation where it makes sense... Ain't gonna work!

Capitalism has always been somewhat a two-edged sword: Capitalism tends to move society to structure its economy amorally (some might argue ruthlessly) in the direction of efficiency. In a perfectly efficient model, one would expect that society would be willing to expend resources on an individual if and only if the expected present value of their future contribution to society equals or exceeds the cost of maintaining that person. Balancing this is that because death (particularly premature death) is inefficient, such a society will tend to invest heavily in research to reduce the cost associated with keeping people alive (through reducing food costs, improving infrastructure, etc, as well as medical research) and to improve their economic value (through education, etc). If we look at money as the medium for making these evaluations, it becomes apparent that our society is deeply influenced by this model.

Indeed, and not just capitalism. I supposed we could decide to emulate the Inuit and throw elderly people onto an ice floe when they are no longer able to support themselves. We don't behave that way, even though a purely economic process might suggest that. Heaven forbid.

Where the analysis really breaks down on is that health care expenses (and associated research) sharply escalate for the old and ill. If you looked at the distribution of costs (at least in the US), it is sharply skewed to elder care, in particular end-of-life care, typically for the last 6 months to a year of people's lives. That's where the bucks go in general - to individuals who have no future economic contribution because they are dying, and to research into late-life/end-of-life ailments.

If we actually based expenditures on future economic value of the individuals involved, we would spend more money on pre-natal and early childhood care. But we don't, and we lag other first world nations. That's why our infant mortality figures are so sadly worse than others.

I think that making comparisons between countries with socialized models and the U.S. model is problematic. The U.S. model invests heavily in medical R&D. My guess, though I am willing to be proven wrong, is that because of the economics involved, that a much higher percentage of U.S. patients costs are reinvested in future medical advances than the costs for patients in socialized countries. That is, I believe that socialized countries are likely piggybacking on advances financed by the American system. *If* that is true, then socializing American medicine would either have the result of stifling medical research, or that the costs for the rest of the world would have to rise (and the Americans would not get as much relief as they anticipate). I also expect that trying to actually substantiate this hypothesis would be a huge exercise in conflicting numbers.

I've addressed part of this above. Bear in mind also that much medical research is already taxpayer funded. I read medical journals sometimes and the "Funded by NIH Grant xxxxxx" pops up a great deal. Certainly there's a great deal of private medical research, but we're not unique in that. There are non-US med and pharma companies.

If capitalism tends to push us towards efficiency and we see that many aspects of our society have actually been pushed that direction, how come our expenses are so high?

I disagree with the premise that inherently capitalism pushes towards efficiency. Sometimes yes, sometimes no. So-called "socialist medicine" costs less while scoring better on quality metrics (Germany, France, Scandinavia for examples). Or do about the same as us, while costing very much less (UK).

A recent NYT magazine article described the city with the most expensive health care in the US. A Texas locale (hence, protected by state laws on medmal), with the same distribution of ages and immigrants demographics as other Texas places with far lower costs, yet exorbitantly expensive. Why? Because they have for profit institutions, including physician-owned ones, who know that the more tests and procedures they prescribe, the more money they make.

Rather than hypothesize fruitlessly, I request we take a careful read of this Economist article: http://www.economist.com/opinion/dis...ry_id=13900898

1. Because the preservation of life has a strong economic value for the one who is dying

Incorrect as written. The dying individual has a strong interest, but it's not an economic one.

there is a tenancy for us to be willing to spend whatever it takes within our capability in order to preserve it. A free market will happily slurp that up. Part of the reason that we spend so much is that we have so much to spend (and insurance fits in huge here--a bout with cancer may well cost the same as the person's entire lifetime income). The moral issue here, of course, is that the rich have more resources to spend than the poor--but that is kind of the definition of being rich.

Yes, and unless you're literally rich, you cannot afford to have any such disease if you have no insurance.

2. There are tremendous inefficiencies embedded in tradition and regulation. I am less concerned about the FDA et al than with the relics of the guild system. I cannot believe that in a greenfield you would design a health delivery system that looks anything like we have today. The guild system existed/exists primarily to restrict competition and maintain profits.

I've argued over this with Inq quite a bit - fruitlessly, I suppose. I really want there to be an FDA, and I really want there to be a regulatory system that demands some proof of competence before people can prescribe narcotics or cut living tissue. And, since we cost a lot more than other countries that also have guild systems, this clearly is not the reason.

3. Massive amounts of money creates opportunity for fraud. The temptation to cheat increases as the expectation of rewards for cheating (reward * chance of getting it) exceeds the risk (danger * chance of losing). Part of the reason that we don't associate big American business with the notion of efficiency is that anyone who has ever been inside a F500 business will readily identify with self-promoting people who claim successes and move on before the factual failures catch up to them.

Oh yeah!

My personal experience with senior tenured faculty at 3 major university teaching hospitals suggests that academic/scientific cheating is pervasive--not necessarily total fabrication of results of research never done, but bending experimental results to fit theories. The more god-like the researcher, the less likely that the research will be replicated (or contrary studies published)

All the more reason for (cough) regulation, eh? It's not as if the lay population enjoys parity of information to detect such frauds.

And, don't forget that a great deal of the fabrication is due to profit motives of private sector fudging. Look at the recent scandals with Medtronic, or older ones involving Vioxx. Let's not make this a private vs. public sector argument. Suppression of bad results in order to let a product out the door is a very serious problem - and that's purely a "capitalist" issue.

4. Lots of others.

Okay, I believe you

If solving all of the issues was easy, it would have been solved long ago. Universal insurance will actually exacerbate some of these issues--particularly, the average cost per person will go up, not down. I am certainly not one to argue that the moral answer should be governed by economic efficiency; OTOH, if we don't take into account the full economic impacts, we won't be anything good.

We must take into account the economic impact, but I think we should benchmark against "best of breed" nations in health care and try to figure out how to gain as good efficiency and quality as they do. It should not be a foregone conclusion that universal insurance costs more when there is proof-by-existence out there in the world to refute that.

[jeff]

Agreed.

But how do we get from that---a description of a situation---to a government change in that situation? From "I can't afford that" to "Taxpayers should give me that"?

Your characterization should be "we taxpayers (and more to the point, voting citizens) - decide to provide this for our nation". And how we get there is pretty obvious: because the current way doesn't work all that well.

I am not convinced. ( Surprise! )

No surprise.

I have made a bit more of study of this than you have, I believe. Do you how much a non-reusable harmonic scalpel costs? No government regulation involved in its price nor in the doctor's option to use one.

And since countries with deeper government intervention than ours cost less, the idea that higher costs are a necessary property of government intervention is obviously wrong.

First, what is the proof for "well-known"? And I use the word "known" in the sense of "proved by evidence" as opposed to "felt in my bones to be true"...

Well known as has been widely covered in the media, including direct statements by HMO executives and healthcare providers, and documented many times on this board. It's been witnessed and documented, let's move on. It's not about "feeling". This is real.

I see where her interest is in being paid...I don't see where theirs are at all aligned with that

You just changed from the question you originally posed "are her interests actually aligned with those of all the agencies and forces against whom she inveighs?" You did not ask at the time if their interests were aligned with hers.

However, I am glad you've made this reversal, since you now explicitly accept the statement I've made many times and that Donna made (we're citing her interest right here) that "I'm getting squeezed on another side by the private insurance carriers who want to pay less (so they can keep more of the money they collect for themselves), and yes they do offer incentives to their staff to keep costs down via denials. I have to have extra staff just to track down and make the insurance companies pay what they by contract have agreed to pay me, but don't."

So, let's not dispute whether or not the HMOs ration or refuse to provide care. It's real. Patients see it. Providers see it. Stop demanding further proof for something that has already been repeatedly proven.

News flash: from a co-worker today Health care rationing is alive and well in this country - we don't need socialized medicine to get that, we have for-profit insurance. My Ortho has decided the case for me getting an MRI before the United Healthcare req of 4 weeks is worth arguing with a UH Dr for approval.

Well, but that's not what you asked me, and not what, by inference, you were arguing. You asked "what regulation existed?", not "what effect did it have?". ( And the inference, it appeared to me, was not "they weren't effective" but "there were none". )

I go back to your question,"Teddy Roosevelt signed the law that created the FDA in 1906. What regulations did you think applied before that?"

Not "what effective regulations", notice!

Then when I answer---you change the question!

Naughty

No, merely my imprecise language, which I should never do with you, because you'll return to that instead of the issue at hand. Come, come, Inq. On 6/19 I said How about 'pertinent' regulations. Teddy Roosevelt signed the law that created the FDA in 1906. What regulations did you think applied before that? You may emphasize "applied" if you wish.

Bah, another changed question!

I was answering this one: "Why then did companies at the time, say, during Coolidge administration, not compete with one another to create the safest products."

The answer to THAT question is, because "safest" is not the dominant quality which consumers, on average, seek. The dominant factor is price, and that is the basis on which producers tend to compete. That's the only assertion there...

I've refuted that several times: the consumers did not know about the ground up rats, downer cows, etc. In fact, when those facts were revealed they sharply declined their consumption, so it did dominate when the facts were made available.

The dominant factor is price only when the consumer thinks the products are safe - and that's where regulation comes in as an essential part of an effective market.

Yes

And only regulation that would force that to happen...

Right...but AFAIK it's an unproven effect. Has anyone even attempted to test the proposition? I just don't know...and thus I can't accept it as an assumption...

Then discuss it as a point of argument. I've given supporting arguments and evidence (eg: regarding meat consumption and the NYSE). I've seen economics articles that make that statement. It's hardly a bizarre claim.

Eh...I don't buy Rockefeller or Carnegie as "rubes"

They were the card sharp side of the table... Actually, their money came from oil and manufacturing, not Wall Street, so they're poor examples. Do a bit of study of pre-Depression Wall Street and how financiers worked the system and you'll have a better understanding.

Again...that's not what you asked me

Perhaps not literally. But now that that confusion has been fixed, you can respond to the point I intended instead of dwelling on this tangent.

I abjure it for other people!

Cool. Now we're all free to ignore the prohibition!

It's, uh...in white text. Yes, that's it...that's the ticket! Just ask my wife...ah...Morgan Fairchild!

Paging Jon Lovitz!

[Bayou Bum]

I have made a bit more of study of this than you have, I believe. Do you how much a non-reusable harmonic scalpel costs? No government regulation involved in its price nor in the doctor's option to use one.

And since countries with deeper government intervention than ours cost less, the idea that higher costs are a necessary property of government intervention is obviously wrong.

Sure I know how much it costs, I've used them. But you are forgetting the benefits. I admit that it is cheaper in other countries, but then you aren't comparing like systems. For example, in India, those same NON-REUSABLE harmonic scalpels are used many times in order to reduce costs. Is that what you really want in the US? Oh, you probably do because it is cheaper.

You are right, costs don't necessarily go up, but quality definitely goes down.

[jeff]

You're a surgeon? Well, I'm surprised.

No, of course it's not the answer to reuse devices that are not meant to be used, and it's completely absurd for you to compare the United States to an "emerging" but still extremely poor country like India instead of first world countries. And it's Inq that wants everything to be calculated on the basis of economics - not me. You have us confused.

Here's the issue: figure out the non-recoverable cost of the harmonic scalpel, go look at how much the HMO (or Medicare, for that matter) will reimburse for the entire procedure, and ask yourself where the heck the shortfall can be made up. Then ask yourself "isn't there a way to do this procedure without using that expensive device, and with as good an outcome for the patient." Frequently the answer is yes. And in no case can the cost of this procedure - with or without that device - be blamed on the dad-gumm gummint.

[jessicasimpson]

I supposed we could decide to emulate the Inuit and throw elderly people onto an ice floe when they are no longer able to support themselves.

If only there were more active volcanoes in Florida

[Hauptman]

Jeff, you make a good point about the economics of medical efficacy.

The pharmaceutical industry is the biggest offender. They would come out with a new drug, do the minimal tests comparing it to a control group and possibly a placebo. If the drug showed statistically significant results they then marketed the hell out of it.

Patients would see the ads and demand the drug from their doctors. The doctors would get a full-court press to use the drug which often included all sorts of swag. Even if the doctors were completely honest, they would never have the time (or even the training) to analyze all the research themselves, and influence is hard to avoid.

Here's the big problem; that "statistically significant" result from the drug may have minimal practical effect. Such as allowing cancer patients having an average extended lifespan of as little as a month. At the same time the drug would be marketed for tens or even hundreds of thousands of dollars.

Here's the part I really love; until recently the drug companies were not required to compare their drugs against already existing standard treatments. The country would pay out billions for a drug and then later it would be found that the old drug we used for 50 years was really better after all!!

One of the worst offenders out there are the statins for reducing cholesterol. Yes, statins effectively reduce cholesterol (and may have other positive effects), but there is not much clear evidence that cholesterol is really dangerous. It does corellate with heart disease, but also with high triglycerides, high saturated fat intake, and obesity in general. There is little conclusive evidence that lowering just the cholesterol through statins reduces mortality at all. Yet in this country we spend tens of billions of dollars annually on statins!!

Our romance with high-tech, "latest and greatest", "more is better" is a huge waste of money and resources. Besides, the largest portion of our health care expenditures can be directly tied to the myriad health damages of obesity. Blah...

[DonnaP]

I agree with Inq's thought process of not jumping on "they" and "always" - I actually preach those same lines myself all the time. You are looking for examples of chronic and repetitious problems, I have so many it's hard to know where to begin and I need to be careful for HIPPA purposes. Here are a few reasons why I feel nervous about more Gov't run healthcare....

Lets take Medicare -
An older woman with arthritis would benefit from a splint to ease her pain and help her be more independent. I am not an authorized DME dealer with Medicare (expensive to do and maintain) - so I buy a $17.00 splint, and charge $22 for it. (covers s&h, tax and a little profit) Because older woman has Medicare, she can buy it from me cash, or else she needs to go down the street to get it where it is "covered" at 80% by her Medicare. She comes back to me with the splint and the bill. She was charged $125 for the splint. She still had to pay $25 out of pocket and the rest goes to Medicare.

Now before anyone yells FRAUD - hold on nelly. Medicare has published rates, and $125 was the allowed pricing on that splint.... Now this is in fact why there needs to be a crack down in some places - but keep in mind, that the government did this. Do medical providers charge this - sure if they are DME providers, but they are allowed to, so why not??

At the same time, as a private practitioner, I have a $1750 annual cap on the services I can provide a Medicare patient. If a patient goes to a non-for profit hospital, they have unlimited coverage, provided it is "medically necessary". Rediculous - again - government made rules. So sure, there is waste, but it is government imposed waste and if the money is there, someone is going to work the system to collect it.

The problem is simply "cutting" back unilaterally isn't going to work and services will end up getting cut. That is what I am starting to see happening - certain services are now being denied - not on a case by case basis, but simply, sorry - we don't pay for that procedure any more. So what do I do if someone needs something that I can no longer provide - I provide it anyway..... I just don't get paid for it.....