How to debate health care policy

by on October 16, 2007 at 5:12 am in Medicine | Permalink

Health care policy should be debated through micro-facts.  Let’s consider a few:

1. American health care outcomes look much better once we adjust for race and other demographic factors, including violence and car crashes.  Some groups — such as Asian-American women — have remarkably good health care outcomes.

2. Some of the health care savings of other systems occur through price effects (e.g., doctors are paid an average of $60,000 in France) and do not involve real resource savings.

3. American’s high expenditures, however wasteful they may be, nonetheless drive much of the world’s medical innovation.  Medical innovation is also a public good to some extent and no the pharmaceutical companies are not simply parasites on the NIH and universities.

4. America has a different structure of interest groups. and therefore a single payer system in the United States would not operate as does a single payer system in other countries.  It would more likely favor the interests of doctors and insurance companies, for a start.

5. If we take the international health results/expenditures data at face value (and we shouldn’t), they imply that greater access to medical care does not itself improve health outcomes.  So we should be careful in how we use and cite such results.

6. Health care outcomes improve with income even under single-payer systems.  Our best estimates suggest that this gradient is no steeper in the United States than it is in Canada.

7. Having health insurance does improve your health care outcomes, but not to an amazing degree.  The largest benefits are arguably the alleviation of financial risk, and no I am not meaning to slight that factor.

8. Pharmaceuticals, unlike many forms of health care, have large and noticeably positive effects on individual health.

9. The major Democratic health care plans on the table all, one way or another, admit they will spend more money on health care.  The fact that other countries spend less therefore does not help predict the change in spending that would result from these plans.

(Sorry for the lack of links, I am on the road, google back to previous MR posts for documentations.)

Now here is how to debate health care policy.  Ask a defender of single payer systems (or other possible reforms) how many of these points he or she accepts.  Settle on that list, noting that residual disagreements may well remain.  Then debate what the list means for what America should do about health care policy today.

Here’s how not to debate health care policy.  When you hear one point on that list, bring up in response that other countries spend less and produce better health care outcomes and that therefore we should copy the systems of those countries.

But libertarians, I am not letting you off the hook either: Isn’t there some form of further government intervention into health care that could help somebody?  And if your basic model is that governments steal as much money as they can, and then waste it all, shouldn’t we then jump at the chance to institute health care subsidies of this at least partially helpful nature?  The alternative is simply that the money gets wasted some other and worse way.

Adam October 16, 2007 at 6:06 am

I’d say that rather than focusing on how health care is provided or payed for, the focus should be on how doctors are licensed. That whole system needs to be opened up, one way or another, so that the number of doctors that come to the market is more directly pegged to the demand for them.

One way this could be done without doing away with licensing entirely would be to allow people to get their licenses if they spend a certain amount of time training under doctors who already do–so that in those hospitals where the ratio of patients to doctors was especially high, pressure would be put to train new ones.

Allowing the supply of doctors to more closely mirror the demand for them would make medicine on the whole more affordable. Another way to go about lowering the cost would be to pass laws limiting the circumstances under which a patient may sue a doctor; and putting a cap on the amount of money that can be paid should the patient win.

anon October 16, 2007 at 6:36 am

Some of the health care savings of other systems occur through price effects (e.g., doctors are paid an average of $60,000 in France) and do not involve real resource savings.

One reason for this is that licensing of doctors in France is far less onerous than in the U.S. The increased supply of doctors may not be a “resource saving” strictly speaking, but surely it is economically meaningful.

Anonymous October 16, 2007 at 6:59 am

‘American health care outcomes look much better once we adjust for race and other demographic factors’

Ah, the last defense used when defending America’s health care system, one which is sadly no more tenable than any of the other excuses for a system which sets world standards in how much is spent on it while returning results that would not make Italy or Portugal envious.

‘The researchers who were funded by several US and UK government agencies, set out to look at the social and economic factors affecting health but shifted emphasis when large differences emerged between the two countries. The study looked both at the way people reported their own health and – to guard against any bias from self-reporting – at objective biological markers of disease from blood tests. Altogether there were about 15,000 participants.

Samples in both countries were limited to whites and excluded recent immigrants, so as to control for racial and ethnic factors.

“This study challenges the theory that the greater heterogeneity of the US population is the major reason the US is behind other industrialised nations in some important health measures,† said Richard Suzman, programme director at the US National Institute on Ageing, which co-funded the research.

http://www.ft.com/cms/s/0/6c9dee06-d9ff-11da-b7de-0000779e2340.html?nclick_check=1

To keep quoting from that bastion of British socialism, the Financial Times –
‘The researchers are struggling to explain their findings. Their analysis shows that lifestyle factors – particularly the fact that Americans are more obese and take less exercise – cannot account for the whole discrepancy. though they may provide a partial explanation.

Different health systems may also be part of the story. The researchers note that the US spends $5,274 per head on medical care while the UK spends $2,164, adjusted for purchasing power. But Britain’s National Health Service provides publicly funded medicine for everyone, while Americans under the age of 65 have to rely on private insurance.

Prof Marmot suggested that, while the healthcare provided by the British state health service was not superior to the private US system, it provided important psychological reassurance.

As the researchers say in the journal paper: “To a much greater extent England has set up programmes whose goal is to isolate individuals from the economic consequences of poor health in terms of their medical expenditure and especially earnings and wealth reduction.†’

Why let facts intrude on popularly held American beliefs, since as we all know, America has the best health care system in the world, as long as you ignore actually being healthy – shockingly, the British system, the sick man of Europe, so to speak, is returning empirically better results for lower cost.

But just keep tweaking those figures to get the right demographic – I bet the health outcomes for those earning more than 100 million dollars a year and their families are fantastic in the U.S.

Erik October 16, 2007 at 7:21 am

Socialize the whole goddamn thing country right away and be done with it. Why drag out the inevitable? Freedom and liberty is dead as principles of government.

happiness October 16, 2007 at 7:31 am

Interesting point about not including car deaths or violence – sort of like how American unemployment statistics simply skip over the fact that the world’s largest prison population (America Number 1, all the way) doesn’t count as being employed or unemployed – out of sight, out of mind, it seems.

Though it remains open by what is meant by ‘adjust’ – for example, since much of the inner city gun violence is paid for from public funds (amazingly, a shot drug dealer is likely to receive more public money in care in a few hours than the total amount spent on his public education), do you mean that eliminating this subsidy from the picture would make America’s private health care system look better?

Or do you mean that if we excluded the amount of money spent on health care due to gun injuries (freedom has its price, but why include it when talking about health care), America would look better? Sort of like if the Russians could exclude alcohol, their health care system would also look better in various rankings?

Or do you mean that because Americans drive a lot, and thus not only suffer a higher rate of accidents, but also suffer from obesity in part due to their lack of physical activity, the adjustment for car driving should be a minor one – sort of like the number of Asian-American women in the total population – roughly 2.5%. (I think Catholic nuns have a fairly decent health outcome too, by the way – why not mention them when ‘adjusting’ the numbers?)

Different Jeff October 16, 2007 at 7:38 am

I think Tyler’s restrictions on the debate make sense from the standpoint of trying to determine if/how to alter our system.

However, I still am very curious about the debate he specifically abrogates:
How and why can Canada, for example, deliver equal or better health care outcomes for half the price?
Whether or not we can realistically create such a system here, I think it would be fascinating and important(kinda in the
mechanism v application way) to understand.

I am also tired of working and interested in embarking on a life of crime. I don’t want to directly physically hurt someone or
end up in prison, and am only looking to pull in approximately 50K per year. Anyone with a suggestion that is used will be
rewarded with 50% of the first 15K I pull in with your method. Please ust click the comment sig and email so as not to interfere with the
discussion here. Thanks.
with

J October 16, 2007 at 8:18 am

Could anyone shed some light upon the 45+ million uninsured Americans? How many of them are young and healthy people who prefer paying 40 USD a year for treatments and drugs they need to shelling out hundreds of dollars for insurance?

M. Hodak October 16, 2007 at 8:39 am

This post, like so much else in the debate about “health care policy” is more usefully thought of as two debates: a debate about health care economics, and a debate about health care policy. I appreciate that Tyler has a lot to say about both, but it still muddies the waters to not consider these items separately.

I don’t think one can have a sensible discussion about health care economics if both parties don’t understand or acknowledge the inherent trade-off between access, innovation, and cost. Anyone who thinks we can have full access (which doesn’t exist even in countries with “universal coverage”), the American pace of innovation, and Canadian costs is simply delusional. Assuming that Americans can improve on all three via non-market mechanisms is very likely assuming away scarcity of some resource or other.

The policy argument is different. It must answer questions like, “For a given economic result, under what conditions is it acceptable for the government to intervene on personal decisions about treatments,” or “Even if the economic results might be better under a government-controlled system, to what extent do we want the allocation of scarce societal resources to be distributed via political rather than market mechanisms?”

The tendency today is to assume that if one can show that Canadian or French style systems produce better economic results that one should automatically accept their policies. As a practical matter, people’s policy positions tend to color their view of the data. People biased in favor of “universal health care” ignore that access in Canada or France is far from universal. People biased in favor of less governmental involvement are unwilling to admit that they don’t care if children die because their parents were too poor to afford decent care, and the private charities weren’t enough to make up for that.

Russ Nelson October 16, 2007 at 8:55 am

Why are we talking about ”Canadian” health care when we should be talking about ”Ontario” or ”Quebec” or ”B.C.” health care?

Our federal government has no power to run a health care system. Only our states do. So we should be talking about the MN or CA or NY health care systems.

Jody October 16, 2007 at 9:14 am

As apparently one of the apparently few libertarians to respond, let me say that if government MUST intervene (more than it already has), then the only intervention should be across the board cash distribution of some amount which should not explicitly earmarked for health care/insurance, but its use for health care should be strongly encouraged. Encouragement should be read as PSAs. I would agree to an opt-out program if it weren’t for slippery slopes (for a relevant example see the SS reform of 1983)

As far as those doubting the facts, given similar inputs, the US health care system really does produce superior results. See survival post-cancer diagnosis, or how Canada handles its a significant fraction of its premature births.

Michael Foody October 16, 2007 at 10:02 am

I think we should spend less for health and get more. The fact that other societies manage this buy such a large margine means that we are making some mistakes. The type of mistakes we are making is that we are buying things that aren’t really health care and calling them health care. The left often characterizes the mistake we are making as making HMOs rich and the right even more absurdly claims that the mistake we are making is making trial lawyers rich. Really the mistake is in thinking that health care can do far more than it can. We want to believe that we have achieved more mastery over life and death than we have. In america we spend a great deal on things that work relatively poorly like cancer treatments, and far less on things that work relatively well like pre-natal care. If our nation’s consumption of food was like our consumption of health care we would spend far more on escargots than on potatos.

Peter October 16, 2007 at 10:20 am

Yawn. Unless we address America’s monstrously high spending on futile end-of-life care, any discussion of health care reform is just rearranging the deck chairs on the Titanic.

M October 16, 2007 at 10:32 am

Unfortunately, the AMA is opposed to measures that would increase the supply of physicans or others that can do their job. The AMA is perhaps the most effective union in this country.

Jeffrey Miller October 16, 2007 at 11:11 am

“Having health insurance does improve your health care outcomes, but not to an amazing degree. The largest benefits are arguably the alleviation of financial risk, and no I am not meaning to slight that factor.”

This factor that you are not slighting should not perhaps be factor 7. It should be factor 1 or 2 or 3. If you have a serious medical condition in this country, your only hope of getting insurance is through your employer. If your employer does not offer insurance, or if you are self employed, or if you lose your job, your medical condition will make it impossible to get insurance on your own – on any terms. Without insurance, your medical problem will likely lead to financial ruin. This doesn’t seem fair or socially desirable.

not October 16, 2007 at 11:23 am

Ned – sorry, if you want the shortest waiting times, you need to fly to Germany. Germany has a system which has many features of the American system – high costs, for-profit medical care provided by doctors, hospitals, drug companies, etc.. It also has some elements that Americans still fondly think they have – such as being able to choose any doctor they wish (a true AMA fairy tale, worth all the billions spent on promoting it). And it has a few things which Americans of a certain age might remember – for example, a local doctor in walking distance, or even doctors that make regular house calls.

And I don’t think Germany is importing too much in the way of American medical technology – at least, I have never seen any American names on any the equipment here.

As an interesting side note – on the radio news was a report about researchers (Heidelberg, most likely) growing heart valves – they should last ten years, and be available in a couple of years. But don’t worry, if it comforts you, I’m sure that somewhere, you can find enough ‘American’ science to say that the work is completely and utterly derivative or banal, depending on your mood.

Virgule October 16, 2007 at 11:44 am

I see a lot of people mention that the US does a better job treating cancer. This is bunk. It is true, as you say, that the survival rate is much higher in the United States than in any European country. However, the mortality rate is paradoxically at pretty much the same level across all industrialized countries. (Ezra Klein has a graph that shows this on http://ezraklein.typepad.com/blog/2006/05/i_wonk_because_.html , The New Republic has a long article on this, but it is subscription only: http://www.tnr.com/doc.mhtml?i=w070409&s=cohn041007) The reason is that for several reasons, partially different traditions, partially the fear of malpractice suits, the United States health care system diagnoses and treats a lot of tumors as malignant even though they are essentialy benign. Compared to Europe, this inflates both the incidence level and the survival rate, but it does not actually produce better results in terms of the mortality rate. Moreover, it wastes a lot of resources on invasive treatment of patients who do not actually need treatment.

Virgule October 16, 2007 at 11:46 am

Moreover, regarding the waiting lists, you might want to check out this Businessweek article http://www.businessweek.com/magazine/content/07_28/b4042072.htm Waiting times in the US are in fact often as bad or worse than in Europe. Additionally, patients often have to wait for a long time for approval from insurance companies before treatment.

Bertil October 16, 2007 at 12:43 pm

Just to correct Xmas on French system:
– most French Doctors work to the point of exhaustion, especially if they are in a hospital; I don’t know if the 60k figure includes the students (five years of close to full-time activity with almost no pay), but this might lower the average; from the figures you are giving, free medical education has a multiplied effect on total health costs — all other heath statistics being equal;
– the 35h rule has been a concern since the beginning for nurses and medical assistants, and is currently under revision; safety seems to be a strong opposing argument (you do not want an tired nurse to do injections); the consequence has been an even greater burden on MD students: has this selected even more altruist people, and isn’t that good? Young people seem to cope with exhaustion better, and future MDs appear more reasonable, and delegate when they feel dizzy.
– the link you provide is more then two years old: more people died in other countries because that heat wave was not detected as early there, but it only was properly measured here thanks to a state-of-the-art epidemiological alert system; cooling equipment was promptly installed, up to the point that a month after, newspapers were mentioning over-reaction.

I would consider that social role explains both the French & the German system: being a doctor means a lot there, and this non-monetary benefit seems to help. Technology (mostly pharmaceutical) transfer is certainly true, but probably more so with other countries, for similar reason.

Virgule October 16, 2007 at 1:21 pm

Bertil, I think you mean “healthy” (=sain in french), not sane (=pas fou) ;)

Jody October 16, 2007 at 1:48 pm

Is anyone else amused by how much this thread has illustrated Tyler’s suggestion on how NOT to have a health care discussion?

henry10 October 16, 2007 at 2:18 pm

The barriers to entry into the medical profession could be reduced by eliminating the requirement that doctors go to medical school. What is currently taught in the first two years of medical school, mostly textbook medicine, could be taught as a Medicine major in colleges. The last two years of medical school, which are mostly devoted to clinical training, could be incorporated into the current residency programs, which cost doctors nothing, and actually pay a living wage.

A program such as this would drastically reduce the cost of a medical education and make such an education available to many more people. Without the high cost of a medical education, and the consequent indebtedness of beginning doctors, the need for high doctor fees would be substantially reduced.

Noah Yetter October 16, 2007 at 2:31 pm

Tyler’s last statement is puzzling:
“And if your basic model is that governments steal as much money as they can, and then waste it all, shouldn’t we then jump at the chance to institute health care subsidies of this at least partially helpful nature? The alternative is simply that the money gets wasted some other and worse way.”

Unlike other commenters I will cop to this being, in fact, my basic model. However that does not imply we should try to get the government to waste money on health care. It does not matter what government wastes money on, that’s what [b]WASTE[/b] means. To imply that it will be effective somehow is to state that it is not wasted and thus contradict the aforementioned basic model.

In effect you’re suggesting that if I believe government wastes the resources it steals, I should try to get it to… not waste them. Why yes, I certainly would like that, but it doesn’t seem any likelier here than anywhere else. The best case alternative isn’t that they waste the money elsewhere, that’s simply equivalent. It would be better if they just burned the money.

Mark Addleman October 16, 2007 at 3:02 pm

There are a couple of big arguments that I’ve found helpful in opposing government run health care:

1) There scarcely an industry more regulated than healthcare. Who can practice is regulated, what they can do is regulated, who can pay them is regulated, how much you you can pay them is regulated, what you can injest is regulated… How is more regulation going to solve the problem?

2) Health care is too important to leave to politicians. Do you really want Larry Craig deciding what medical treatment you can have?

John Dewey October 16, 2007 at 4:05 pm

Richard leon: “do you support social, political and financial structures which create significant infant mortality and deny health care to a significant proportion of the population?”

Are you implying that social, political, and financial structures in the U.S. “create significant infant mortality and deny health care”? Neither happens in the U.S., of course.

In the first place, infant mortality is driven by lifestyle choices. Furthermore, the true infant mortality rate in the U.S. is comparable to that of other nations.

Health care is available for everyone. Health insurance is available to those who deem it important enough to pay for it. A very small percentage of Americans who do not possess health insurance are actually legally uninsurable in most – bit not all – states.

nelziq October 16, 2007 at 4:41 pm

Lets start with just 2 facts:
Combined personal and governmental expenditure on healthcare is higher in the US than in any G8 nation (i.e. nations with comparable wealth)
Health results are lower, weather it be life expectancy, infant mortality, availability of care, etc.
Higher cost and lower returns. All other facts you bring up are incidental.

Martin October 16, 2007 at 5:26 pm

Two weeks ago, I wrote a detailed analysis of the Quebec health care system. Here are the main lessons learned (you can read the whole article by clicking on my name below):

Lesson #1: limiting the supply of medical services is not a fair or efficient way to limit costs.
Lesson #2: markets should set the wages of medical professionals, otherwise they are not getting fair compensation.
Lesson #3: privately run facilities deliver better service at a lower cost.
Lesson #4: keep medical malpractice insurance costs low. Perhaps insurance against malpractice should be abolished altogether.
Lesson #5: immigrants should cover their health insurance costs.
Lesson #6: the government should be conservative in the size of the baseline insurance package to avoiding defaulting.
Lesson #7: information used by the insurer and insuree to enter in an insurance contract must be identical.
Lesson #8: achieving downwards pressure on price of a medical act is not possible without cash compensation paid directly to the patient.
Lesson #9: private insurance contracts must be limited to short periods.
Lesson #10: there is no good way for private insurance to provide universal health coverage.

Floccina October 16, 2007 at 8:46 pm

IMO you should add this to the list of debating points:

Most Americans are buying more healthcare than they would if they had more control over the packages that they can buy. E.G. I think that if people could buy insurance that would not cover the least economic care (highest cost per average year of life saved), they would. Doctors seem to look at hopeless cases and try this or that expensive thing.

Floccina October 16, 2007 at 9:33 pm

For those who feel compelled to object to Tyler’s points.

http://www.guardian.co.uk/australia/story/0,,1802705,00.html
“The damning figures also show that 70% of the Aboriginal population, who number almost 500,000, die before the age of 65, compared with 20% of non-indigenous Australians. The average life expectancy for Aboriginal men is 59, compared with 77 for non-indigenous males, according to the report by the Australian Institute of Health and Welfare.†

http://www.cbc.ca/story/canada/national/2005/04/11/UNNatives-050411.html
“Life expectancy among the Inuit is 10 years lower than the rest of Canada.†

http://findarticles.com/p/articles/mi_m0PCG/is_2002_Sept/ai_105657385/pg_4
“In New Zealand the difference between Maori and non-Maori life expectancy was 8.1 years for males and 9.0 years for females. The situation in Australia, even allowing for some variability in the reliability of the estimated life expectancies, was dramatically worse, with differences of 21.5 years for males and 20.0 years for females. Indigenous Australians can expect to live only around three-quarters as long as all Australians. Maori, on the other hand, have an expectation of life about 90 per cent of that of non-Maori.†

http://www.guardian.co.uk/medicine/story/0,,1691741,00.html
“For here in this multi-deprived inner city area, the average life expectancy of a male is just 53.9 years. In Iraq, after 10 years of sanctions, a war and a continuing conflict, suicide bombs and insurgency, the average man has a good chance of making it into his 60s; the life expectancy of a male there is 67.49. In Iran it is 69.96, in North Korea, 71.37 and in the Gaza Strip it is 70.5.

Statistics recently revealed that the Calton ward has not just the lowest life expectancy in the United Kingdom and Europe but of many areas of the world. A child born in the Calton – locals always prefix a “the” to Calton – arrives into an environment saturated by drink, drugs, smoking and poor diet. A baby girl has more of a chance of survival – her life expectancy at birth 74.8.†

http://www.theage.com.au/articles/2004/04/27/1082831568285.html

http://www.encyclopedia.com/doc/1G1-105657385.html

To compare infant mortality because of differences in live births in case with complications you need to add infant mortality rates and rates still birth. Then you need to adjust for fertility treatments which product higher levels of multiple births and infant mortality. Then you need to compare by race and ethnic group because differences in groups are significant for example people from African decent have twice the rate of multiple birth as those from Chinese decent and have a much higher rate of infant mortality. Interestingly Americans of Mexican descent have a lower rate of infant mortality than other Caucasian Americans. You also need to adjust of the age of the mother. If you control for all the above the USA does a little better than Great Britain in infant mortality.

But… Socialized medicine might benefit us by bring down the cost. I would like to see the target set at 5% of GDP. From what I understand the Dutch set it at 10% of GDP. Quality of medical care and even access to medical care in the USA is not likely to change a great deal in net if medicine is socialized but it could, if it is done right, save us a lot of money.
Why because IMO people buy much more healthcare than they want.

Bernard Yomtov look at the eight Americas study

Rpche October 17, 2007 at 12:16 am

Nothing in the Constitution permits the federal gov’t to provide healthcare.

Kimmitt October 17, 2007 at 2:04 am

Secondly, I’m not convinced of (3), (5), and (9). In particular (9) — I’m currently paying $500 a month for insurance; is it the expectation that taxes will increase by more than this amount?

Ned October 17, 2007 at 8:56 am

Not –
I hate to rain on your parade, but an OECD study (http://www.oecd.org/dataoecd/31/10/17256025.pdf) shows that 19% of Germans wait three months or more for elective procedures or consultations versus 5% of Americans – and that means all Americans, including those with no insurance. Actually, the German health care system has a lot of advantages, but waiting times, though relatively short by European standards, are much longer than in the USA.

save_the_rustbelt October 17, 2007 at 9:03 am

I spend a great deal of time reading on health policy and finance and this is an immensely thoughtful outline – not for complete agreement or disagreement but as a discussion template.

Kimmitt October 17, 2007 at 1:50 pm

By the bye, where are y’all getting your insurance such that you aren’t waiting months for elective procedures? Seriously, I’ve got family scattered across a half-dozen states, and all of them — even the ones who work for insurance companies — have horror stories.

GK October 17, 2007 at 2:23 pm

Also, to those who attack the legitimate point of adjusting health care outcome for race :

Grow up. Note that Asians in the US have higher incomes than whites, and that Asians in the US will have better life expectancies than Asians in Britain, Canada, or Japan.

Show me a country with a large black population, where blacks have a higher life expectancy than in the US. Show me one.

Thus, you cannot discredit the point of adjusting for race.

Roger October 17, 2007 at 3:18 pm

Those arguing against point one miss the a fundamental of epidemiology: you have to compare like denominators and numerators to have valid comparisons. Fact: the US is a multi-ethnic society; fact: different ethnic groups have different morbidity and mortality rates; eg sickle cell among blacks, tay-sachs among Ashkenazim. Does economic status play a factor? most definitely and results of morbidity and mortality should also be adjusted for SES. But SES cuts across ethnic lines, thus the need to consider ethnicity in doing epi comparisons.

Cure rate is one way to measure the effectiveness of the medical intervention as some have suggested; but, a better way, IMO, is use survival rates after 10 years. When that is used as a measure the US does very well indeed being surpassed only by Japan with respect to its treatment of diabetes.

It is also worthwhile to be specific as what aspects of health care we are discussing: access to health care? effectiveness of the intervention? cost benefit of the intervention? Health care is a costly part of our GDP, but the precision inherent in the list under discussion is valuable indeed. Thanks for posting it.

David H Dennis October 17, 2007 at 3:24 pm

A hospital is just a lousy hotel in which you have to share your room with someone else. Baseline cost of Motel 6-style accomodations is about $35 a night, or $17.50/night when one room is shared between two people.

If you have $20,000 worth of expensive stuff in the room to monitor you, and it has a lifetime of 10 years, fine. $20,000/10/365 is $5.48 a day.

Nurses make something like $50,000 a year. You have about 10 patients per nurse. You’ll need four shifts to cover 24 hours. Two of those shifts might require 50% higher rates to attract someone. So we have $13.60 per day per nurse for day shift, $20.40 for night. Let’s sum that up and get $68 a day
.
Therefore, a hospital room should cost roughly $90.90 a day. Add in miscellaneous stuff and say it’s a round $100.

I was rather alarmed to see a medical bill where I was charged $680 a day for a semi-private (read: not private at all) hospital room. TV and phone calls would have been billed extra; both are free at Motel 6.

Doctors fees, tests and other stuff were billed separately and the final bill was over $8,000. The insurance company negotiated it down to $3,000. Still, that sounds like way, way, way too much given the amount and quality of services I received. (I received numerous tests, none of which I was informed about; if I’d known their costs I probably would have declined them. I also had my hand pricked numerous times; why not just do it once and get all the blood you need then?)

I would really like to know why this is and how it can change. I don’t want medical insurance because I don’t want to feed this insanely expensive and wasteful system.

I vote for a new type of medical service, ones we can afford to pay for out of pocket without horrendously expensive intermediataries like insurance companies.

While the costs of surgery have ballooned out of all proportion, I can’t help but notice that LAZIK eye surgery, requiring extremely expensive equipment and skilled labor, has declined in price by over 50% over the last few years. That’s what happens when people actually pay directly for services – costs go down over time, not up.

Let’s see more like that, please?

D

willis October 17, 2007 at 3:49 pm

How we should debate health care is irrelevant. Most voters pay no attention to such debates. They notice only brief snippets referring to health care, such as ads featuring children demanding that health care be “fixed.” Until rational analysts of health care join the debate in kind, they will have no listeners.

Enlighten-NewJersey October 17, 2007 at 4:28 pm

Healthcare spending in the U.S. averages $6,102 per person and in Canada, $4,932 per person.

Roger October 17, 2007 at 4:57 pm

John Dewey: Your nurse to patient ratio median is about right. And to be licensed, Hospitals have no choice as these ratios are directed by state or other accrediting bodies. And in many cases, the nurses are scheduled and work irrespective of the hospital’s daily census.

Joe - Dallas October 17, 2007 at 7:15 pm

Some very good points above on how socialized medicine should be compared with the current US system. The first step in any discussion is to compare apples to apples. The data should be adjusted to compare similar polulation groups with the outcomes, not to skew the data for your personal political preference ie not manipulated.

Many proponents of single payer systems point out the significant differences in health care costs in US vs single payer countries – not realizing that the single biggest cost difference is the funds spend for “end of life treatment” ie to prolong life just a few extra days. (I am not advocating euthanasia)

An axample of needing to compare apples with apples is the often cited comparison of cuba’s lif expectancy with the US life expectancy:
Cuba ethnic makeup: mulatto 51%, white 37%, black 11%
Cuba life expectancy: 77 years
Cuba GDP per capita: $4,100

USA ethnic makeup: white 81.7%, black 12.9%, Asian 4.2%
USA life expectancy: 78 years
USA GDP per capita: $43,800

Have these numbers been adjusted for premature deaths – car crashes, gang violnce, etc?
Are the cuban numbers even reliable? the USA ethnic makeup is off – only 1.2% hispanic?

In summary – make an honest effort to debate based on comparable data points.

Ignorance is Bliss October 17, 2007 at 7:53 pm

Here’s my 2 cents:

1) We need to break the link between employment and insurance:
1a) Employer paid insurance, Individual paid insurance, and out-of-pocket spending should all receive the same tax advantages.
1b) For the employer to get the tax break, they must offer the employees the option of a voucher to buy their own insurance

2) We need to break the link between insurance and routine healthcare expenses.
2a) Insurance should pay for serious expenses such as cancer, stroke, or a serious car accident.
2b) The per-visit ( not annual ) deductable should be higher than the cost of a routine visit.
2c) Insurers would have an incentive to subsidize preventative care because it would save them money over the long run.

3) We need to create a link between lifestyle choices and costs.
3a) Insurers can charge more for smokers, people who are obese, or people who don’t maintain cardiovascular fitness
3b) High deductables ( see 2b ) will also add to this link

4) We need to reduce the costs related to lawsuits
4a) We should give people the right to waive their right to sue for punative damages, pain and suffering, and similar damages in exchange for lower doctor’s fees.
4b) Patients could still sue to recover the costs of future medical care caused by a doctor’s mistake, and could sue to get a doctor’s medical license revoked.

Jim October 17, 2007 at 8:38 pm

Debate limitations may or may not work, for some people are very passionate about this particular social policy. I am a semi-liberterian, so here are some of my thoughts:
1. Doctors and hospitals render a lot of free care. They don’t get a bit of governmental recognition for this. SOLUTION: Let them post their prices twice a year, binding on them for six months per listing, then give them a 50% tax credit for the care they render. So a $4,000 ACL knee surgery gives the doctor a $2,000 tax credit. If the hospital gives away $5,000 of care helping them render care for the same patient, they get a $2,500 tax credit, which they could sell on the open market. Who determines who qualifies for free care, which must be decided inh advance? Any government agency dealing with social services and any 501(c)(3) NGO. The IRS audits the doctors and the hospitals. Believe it or not, it should be cheaper than the expensive federal / state agency costs administering Medicare, Medicaid, and all other “free” health care.
2. I don’t want the government to pay my medical bills for a disease or sickness which has a cure just over the horizon, while I die from the disease. Freeze bill paying for two decades, and increase the heck out of medical research. My mother died of an incurable, irreversible, inoperable cancer – been there, seen that, over that. Find more cures.
3. Every 5 years, at 40, 45, 50, 55, 60, 65 and more frequently than that after 65, offer very complete and comprehensive physical exams, head to toe, with MRIs, cat scans, X-rays, tradmill tests and the like to find everything wrong, even when people feel fine and think they are disease free. Find the silent killers before they kill. This would be free, and it would be voluntary.

ezag October 17, 2007 at 10:33 pm

The reason healthcare is in disarray in the US is cost shifting. Mediaid and Medicare do not pay their cost of service, so hospitals and doctors shift the cost to people who have insurance. In addition, hospitals are required to take in patients that do not have insurance and cannot pay at all. Some of this cost is borne by local governments, but, again, much of it is shifted to people that have insurance. It is hard to find a doctor that will take medicare or medicad patients for the simple reason that they cannot cover their cost of service at current reimbursement rates.

It should be no surprise that the cost of insurance is escalating faster than inflation and the inflation of medical costs. Each year, marginal buyers of insurance give up and drop their insurance because it is too expensive.

Doctors are in a weak postion compared to drug companies, insurance companies and hospitals. If you look at the cost of a procedure or hospital visit, you’ll find that the doctor cost is always under 10% of the bill. Often it is under 5% of the bill. Focusing on doctor cost does little to change that bill…if you quit paying them you’d reduce the bill 10%.

It has been a good game…politicians have been able to buy votes by supplying medical services and pushing the costs onto those that buy insurance…unfortunately the horse is about dead. The only hope is to force people to buy insurance…then the government can ration medicine as they do in most of the single payer systems.

John Dewey October 18, 2007 at 4:00 am

ignorance is bliss: “For the employer to get the tax break”

It is the employee who gets the tax break on employer-provided health insurance. An employer rightfully can deduct labor cost expenses. The employer can choose to pay the employee all cash. Or the employer can offer some combination of cash and health insurance benefits.

An employee who receives all cash pays income tax on his entire compensation. An employee who receives cash and helath insurance is taxed only on the cash portion.

Why would those employees who now receive tax-free health insurance – negotiated for them using large group buying clout – ever choose to give up that tax break? Americans who enjoy employer-supplied health insurance do not want to change. Their elected representatives know this.

Ignorance is Bliss October 18, 2007 at 7:32 am

John: “Why would those employees who now receive tax-free health insurance – negotiated for them using large group buying clout – ever choose to give up that tax break? ”

As I explained, they would not give up the tax break because they would get the same tax break on the money they spend themselves, either on insurance or out of pocket medical expenses.

As far as the large group buying clout, if a large number of individuals were able to choose their insurance for themselves, other means of aggregation would be possible. The AARP, AAA, NRA, NAACP and many church denominations would offer group rates to their member. However, if your employer negotiated plan is the best, you are certainly welcome to stick with that.

Why would people want this? So that they can make rational choices about where they work independantly from their rational choices about what health insurance they need.

Employers are not ‘dishonest brokers’, but their interests are not the same as their employees’ interests.

Rational decisions about healthcare spending will never happen as long as the people consuming healthcare are not the same as the people paying for healthcare.

Anonymous October 18, 2007 at 10:31 am

I’m perfectly satisfied with my employer-provided health insurance plan.”
Good for you. Mine is acceptable, but it’s not what I would choose if I had the money to spend myself, and it’s not so bad that I would change jobs to get something better.
I have neither the time nor the desire to investigate the thousands of potential health care providers.
Then don’t.
I have no desire to pay anyone other than my employer to research and negotiate on my behalf.
Then don’t.
Millions of employees in the U.S. feel the same way.
Good for them.
What right do you or anyone else have to change the arrangements we have with our employer?
None. What right do you have to insist that I pay taxes on my individual healthcare spending while avoiding taxes on your employer provided healthcare spending?

How is my interest in providing health benefits for my employees different from their interest in having me provide that benefit?
You have an interest in having your employees remain in your employment to maintain their benifits. Many employees would like to be able to change jobs without having to change insurance policies. If I change jobs in the middle of the year, even to another company whose insurance is exactly the same coverage through the same provider, I still have to pay a whole second year’s worth of deductable out of my pocket, using already taxed dollars.

Employees pay for their health care when they negotiate health insurance benefits as part of their compensation.
Yes, they do. And sometimes employees turn down what would otherwise be the best job because they don’t like the healthcare package, and sometimes they accept a job with a healthcare package they otherwise would not choose just because the overall job is better. My question is why do we want to bundle these two unrelated decisions into one choice, forcing many to compromise on one or the other? If we seperate them, then I can choose the best job and the best insurance for my needs.

John Dewey October 18, 2007 at 11:30 am

“What right do you have to insist that I pay taxes on my individual healthcare spending while avoiding taxes on your employer provided healthcare spending?”

I do not insist that you pay taxes on your individual healthcare spending. I would favor reducing to 0 the threshhold for deductibility of individual health insurance premiums. I also favor sales taxes as a replacement for income taxes, and ending all deductions.

“Many employees would like to be able to change jobs without having to change insurance policies.”

My employees were given that option, but declined. Every union has the right to negotiate away health insurance benefits. I haven’t heard of any large unions doing so. Have you?

“why do we want to bundle these two unrelated decisions into one choice, forcing many to compromise on one or the other?”

I cannot answer for everyone, but I think I already answered for me. I have neither the time nor the desire to investigate and negotiate with hundreds or thousands of potential health care providers. I also appreciate the time I save when I can walk over to my coworker and learn how to navigate my health insurance procedures.

If you are truly bothered with employer-provided health insurance, become self-employed. or move to Canada. Why do you want to change a system that most Americans are perfectly happy with, just because you are not?

perianwyr October 18, 2007 at 1:04 pm

I also favor sales taxes as a replacement for income taxes, and ending all deductions.

Thanks for giving me a pretty strong reason to not take any of your proposals seriously.

Brutus October 18, 2007 at 2:36 pm

Re: Waitng periods and rationing

I wonder if anyone notices the main cause for these increasing these 2 things in the US is the overuse by those very people held up as an example of single-payer success–Medicare and Medicaid clients.

My parents are retired down in God’s waiting room just north of Tampa, and talk of weekly trips to the doctor. My girlfriend is a nurse case manager at a major teaching hospital in Boston, and 65% of her patients are Mass Health (Medicaid).

A valuable commodity that is GIVEN away will be used to the point of bankruptcy…

John Dewey October 18, 2007 at 5:06 pm

Ignorance is bliss,

Right. When someone disagrees with your idea, it must be because that person is uninformed.

Health insurance coverage hasn’t changed much since 2003. Politicians have made inroads in creating an issue where one did not exist, but the fact remains: health insurance coverage hasn’t changed much recently.

Here’s a link to an October, 2004, Health Insurance survey by the Kaiser Foundation:

Health Insurance Survey

Here’s some insights about those persons covered by employer-provided programs:

1. 72% rate their plan as “A – Excellent” or “B – Good”

2. 58% agree with this statement: “My health insurance is good and I feel well protected when it comes to my family’s health care needs”

38% agree with this statement: “My health insurance is adequate but I worry that my family might have health care needs that it won’t cover”

3% agree with this statement” “My health insurance is inadequate and I feel worried about my family’s health care needs not being paid for”

3. 79% say their employer is doing the best they can to provide their family with affordable insurance coverage.

4. Only 7% would prefer to buy their own policy with cash in lieu of company provided benefits.

Ignorance, if you have some facts to dispute the findings of the Kaiser Survey, please provide them. Otherwise please stop insinuating that I do not know about the attitudes of employees toward their health insurance plans.

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