Apparently Daniel Callahan does not plan on working for the Obama administration

It was only two days ago I vowed "no more health care blogging" but I never said "no more health care book blogging," so here goes.  Daniel Callahan's notable Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System soon will be out.  Here is his position:

I can sum up what I want to say in some simple propositions.  First, ways must be found to return to more basic levels of medical care for ever more patients (e.g., to emphasize prevention and primary care) and to make it more difficult to receive medical care at the higher levels (e.g., advanced expensive cancer treatments or heart repairs).  Second, the priorities for technologically oriented health care should begin with children, remain high with adults during their midlife, and then decline with the elderly.  Third, if the medical care received during those first two stages of life is good, the elderly will have a high probability of a good old age even if advanced technologies are less available to them.  Fourth, health care cannot be reformed, or costs controlled, without changing some deeply held underlying values, particularly those of unlimited medical progress and technological innovation.

I don't like his anti-innovation take in the fourth point but there's a lot of truth to what he says.  It's also the case that the public knows, at some level however incoherent, how prevalent such reasoning is in the thought leaders of the Democratic Party.  The Democrats are right about the need to constrain Medicare expenditures, but the more they attack Republican stupidity and lies, the further they are from understanding why Americans now trust them less with health care reform than before. 

The Hansonian analysis of the discourse is that one needs to signal a more extreme symbolic affirmation with the proper "showing that you care" values than what the other side is doing.  The Republicans have the more extreme rhetoric and in fact people are used to the idea of lies — very used to the idea of lies — dare I say welcoming of the idea of lies? — when it comes to "showing how much you care."  To attack them as liars is to play into their hands.  To pose as The Reasonable Technocrat, as Obama has done in response, is to play into their hands even more.

Comments

It's tempting to think, "Why don't we have a big debate, achieve consensus, and then introduce legislation?" But I think that it's more effective to change practice first and the consensus will follow.

Of course, not all changes are equally good.

If medical technology is driving cost increases, it is only because of the screwed up incentives in our current health-care insurance system. Where technology is applied to medical care that is not covered by insurance (Lasik eye surgery), innovation has driven costs down -- just as you'd expect, and just as technology has virtually everywhere else in the economy except insurance-covered medical care. This is (or should be) seen as an argument for consumers paying out of pocket (backed by high-deductible policies and HSAs), not government rationing of high-tech care for the elderly (no more hip replacements for you!) -- that's insane.

"Second, the priorities for technologically oriented health care should begin with children, remain high with adults during their midlife, and then decline with the elderly."

So you work hard your whole life, making sacrifices, paying taxes, and in the end you just get put out to pasture because you have no more useful work left in you. yeah thanks but no thanks.

"if the medical care received during those first two stages of life is good, the elderly will have a high probability of a good old age even if advanced technologies are less available to them."

Old age is never good, and is worse without advanced tech.

Wow, two comments already missing the point on reducing medical spending on the elderly. Maybe I can summarize it this way: for the same cost we can buy 5 extra quality life years for a kid versus 2 extra quality life years for a 70 y.o. Is that tradeoff a good one? Let's separate the debate over whether that tradeoff exists from whether it ought to be made if it does exist. Also, if you are benefiting from that tradeoff your whole life, Al's concern doesn't really apply, does it?

The technology issue begs the question of weather healthcare costs are in fact rising or if only spending is rising. As in the example above I spent more on my 42" HD TV than I did on my old tube TV but it is surely cheaper for what I get.

The question is why is spending rising and does the increase yield utils or is it just signaling a la Robin Hanson. Even better does it yield increased life time utils to be spending so much on healthcare late in life?

BTW I often see democrats make the same lies against insurance companies that Republicans are making against Obamacare.

If people were spending their own money, how again would this be my problem? Is the government trying to move towards people spending their own money? That'd be a hellz no, not even close. they are moving in the opposite direction. They are only doing anything because they think it is their money we are spending. But wait a second, they don't even see a problem with borrowing from old people (and Chinese) to pay right out to old people while putting the future tax burden on the young people.

If government controls a good portion of the research dollars, how again is this my fault?

I didn't tell Obama to jump in feet first to try to change everyone's values. In fact, I told him not to.

"So you work hard your whole life, making sacrifices, paying taxes, and in the end you just get put out to pasture because you have no more useful work left in you. yeah thanks but no thanks."

By that logic, then those that were just born, made no sacrifices, no hard work, and paid no taxes deserve no healthcare.

Mpowell,

If the tradeoff you are offering me is yearly checkups at a young age versus hip replacement when I'm 70, I'll pick the latter thank you very much. I'd also rather not have you or the govt make those kinds of decisions for me.

Maybe I can summarize it this way: for the same cost we can buy 5 extra quality life years for a kid versus 2 extra quality life years for a 70 y.o. Is that tradeoff a good one?

Well, first of all -- I don't believe it. That is, I don't believe that lack of medical care for kids is causing the need for heart-bypasses, hip replacements & etc for those same kids when they reach age 75+ and that small health care investments for 8-year-olds could stave off the need for heart-disease treatments for the elderly. But I do believe you could save a lot of money by denying expensive care to the elderly and so there's a ready market for justifications arguing that this is actually a *good* from a utilitarian perspective because of a hypothetical overall gain in 'QALYs'.

Also, if you are benefiting from that tradeoff your whole life, Al's concern doesn't really apply, does it?

But by that logic the only people who might stand to benefit from such a hypothetical tradeoff are now very young or not born. I'm pretty sure Al himself is far too old to benefit from investments in his health as a kid. Or are you suggesting rationing high-tech treatments for the elderly beginning only in roughly 2080?

I forgot! name calling is a great debate strategy and the best way to convince someone of your argument. When you talk about how technology *SHOULD* be focused on this or that, then you automatically imply that some kind of rationing determined by someone (you) should be done. You think you know what's best for me? I've built up alot of wealth and I am willing to spend it on technology to extend and make the rest of my life comfortable, and you're telling me I should instead give it to you so you can decide who deserves it more.

Gary: that's quite a jump from my statement to your conclusion. I'm not sure how you got there, Surely you don't still believe babies are delivered by storks.

It's the politics, stupid. Just as Krugman says.

There are at least 20 other health care delivery systems out there where the costs are less, and many if not most, of the outcomes better.

Pick one for Chrissake.

It all comes down to the cost of government funded health care. The solution is to restore that element to the real poverty stricken individuals, those that honestly, for some reason beyond laziness and culture cannot access enough money for life's necessities. This not more than 2 or 3 percent of the population. For the rest of us, the government just needs to get out of the road and leave us to hell alone.

Oh, they could do some good around the margins allowing for nationwide insurance sales and imposition of some useful tort reform but, in the end, the solution to ever more expensive government health care is not to be found by increasing government health care coverage.

Why is this not discussed more?

Look, comparing America's health care vis-a-vis with the rest of the World's is grossly unfair.

Let me ask you this: Neither America nor France have been invaded since WWII. Safety from foreign nations outcomes, per capita, are the same in each country. Yet America spends unfathomable amounts of money, per capita, than France on national defense. Clearly, America should adopt France's per capita defense spending. We should have adopted it back in 1946. Clearly, the French have been just as effective at maintaining their safety as the US has been.

Substitute "France" there with almost ANY other country in the world. Would that argument really make sense? If every country in the world adopted Belgium's per capita spending on defense since WWII would the world look like it did today? Would we be as free today as we are? (as free, not saying we are perfectly free, but if you don't think we are freer than the former citizens of the Soviet Union then I can't speak to you...)

America pays almost all of the costs of medical research. Medical companies receive almost all of their funding based on the returns generated in the US market. I have worked for professional healthcare investors in venture and public markets. Trust me, we will sell away the rights to the rest of the world for a pittance compared to the rights for America. And if the rights for America were worth what the rights to the rest of the world were, then we would NEVER invest in most of the companies we invest in. We could never make money seeding life science companies at the reimbursement rates of the rest of the world.

Trust me, there is a lot wrong with America's defense and healthcare spending. But the argument can't start with outcomes compared. The rest of the world has been piggy backing on America's health and defense spending for the past 60 years.

Not sure from the excerpt, but what is Callahan meaning about spending less on medical innovation. If he is advocating preventing everyone from spending on the latest and greatest medical interventions, then he is an insane eg/tot-alitarian. If his position is that third party payers can't be expected to pay for the very best for everyone, then his position is complete common sense, and we can debate the actual distribution of the fixed funds covering the population.

But make no mistake about it- each medical innovation that adds years and/or quality to life will increase spending on medical care. If it is you funding such spending, then you should be free do whatever it is you want to in this regard- this is the meaning of liberty, but if someone else is shouldering the financial burden, then you will have to negotiate for such care.

"the President must instead work on explaining every aspect of his health plan to the people, thus avoiding such mis-understanding in the future."

You don't know many 100 IQ people, do you?

Dennis, can we assume that "government just needs to get out of the road and leave us to hell alone" means that heathcare benefits should be taxed like other income?

And the consequence would also be that Medicare should be canned?

"The Democrats are right about the need to constrain Medicare expenditures, but the more they attack Republican stupidity and lies, the further they are from understanding why Americans now trust them less with health care reform than before."

Maybe so, in the current context. I have a hard time dredging up much sympathy for a political party that has demagogued Medicare cuts until very recently. And yet, Republicans get the recrimination.

I'm not fond of either of these toxic parties, but I find your analysis disingenuous.

good god, he comes right out and says his plan is to let the elderly die? And presumably by imposing some kind of system that actively DENIES them health care? WTF.

Yup. We need to start smoking again. And the Dutch in 1998 probably had a way lower BMI than the US in 2009, not to mention that they have a right to die law.

http://content.nejm.org/cgi/content/full/337/15/1052

The Health Care Costs of Smoking

Jan J. Barendregt, M.A., Luc Bonneux, M.D., and Paul J. van der Maas, Ph.D.

ABSTRACT

Background Although smoking cessation is desirable from a public health perspective, its consequences with respect to health care costs are still debated. Smokers have more disease than nonsmokers, but nonsmokers live longer and can incur more health costs at advanced ages. We analyzed health care costs for smokers and nonsmokers and estimated the economic consequences of smoking cessation.

Methods We used three life tables to examine the effect of smoking on health care costs — one for a mixed population of smokers and nonsmokers, one for a population of smokers, and one for a population of nonsmokers. We also used a dynamic method to estimate the effects of smoking cessation on health care costs over time.

Results Health care costs for smokers at a given age are as much as 40 percent higher than those for nonsmokers, but in a population in which no one smoked the costs would be 7 percent higher among men and 4 percent higher among women than the costs in the current mixed population of smokers and nonsmokers. If all smokers quit, health care costs would be lower at first, but after 15 years they would become higher than at present. In the long term, complete smoking cessation would produce a net increase in health care costs, but it could still be seen as economically favorable under reasonable assumptions of discount rate and evaluation period.

Conclusions If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.

So... if we're going to start judging who gets to live and die, do you really think it's going to come down to just age?

Is an 80 year old Senator's life worth more than an 80 year old retired bus driver's life?

Is a Pulitzer-prize winning author's or a Nobel prize-winning scientist's life worth more than that of a day laborer?

Is a 60 year old actor's life worth more than that of a 20 year old habitual offender gang-banger?

Once you accept the principle of allowing government to assign value judgments like this, you can be sure of one thing - the politically connected and the powerful will get better treatment than the rest. Also, the evaluations will be used to mandate behavior and to justify government intrusion in our lives - the overweight or heavy smokers need not apply for that angioplasty. Taxes will be applied to punish people who engage in various activities the government thinks are harmful to long-term health care costs.

Allowing the government to have the authority to make such judgments is terrifying and guaranteed to drive a thick wedge into our civil liberties.

Also, Ditto @ Dan H.

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