The Scooby-Doo Ending

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Christopher Carr

Christopher Carr does stuff and writes about stuff.

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40 Responses

  1. Avatar DensityDuck says:

    The crazy, stupid thing about this is that the United States already has a single-payer healthcare system. It’s called “Medicare”. If not having insurance is a problem–if the issue is “pre-existing conditions” and the insistence on group coverage and suchlike–then let people buy into Medicare.

    “That’s too expensive!” So limit care in some way. Tell Sarah Palin that if she wants to not have the Death Panel then she has to earn some cash and pay her own healthcare bills. (Note that “a specific treatment program that is approved by the government” is also a defense against malpractice abuse–if the doctor did exactly what the government said was required and it didn’t work, well, blame the government.)

    “It’s politically impossible!” Whenever you press someone on this statement, you end up getting something like “well you’ll never get the Republicans to vote for it”. And when you press them on that, you get “uh well because Republicans are bastards is why not”.Report

    • Avatar Kolohe in reply to DensityDuck says:

      It’s not something I’m opposed to anymore, but I still think universal health care (of the single payer or other varieties) would tend to work out the same a public education now. The middle class better off with it than without it, but the upper middle class getting the lion’s share of the resources due to their political weight. The rich mostly opt out and the poor mostly still get f***ed (because the poor always do)Report

      • Avatar Silver Wolf in reply to Kolohe says:

        As a Canadian who lives under this sort of system, I disagree with your assessment of how it will work. I think when Vermont and now Montana enact their single payer systems you will see most poor getting much better outcomes. My opinion is based on the outcomes I see in the provinces, even ones that have small populations and densities making the costs higher.

        I am guardedly optimistic.Report

        • I’m definitely watching Vermont and Montana enthusiastically. Will there be an exodus of talent? Will health care metrics significantly improve? Will neighboring state governments or residents attempt to take advantage in some way? Etc.Report

          • Avatar Silver Wolf in reply to Christopher Carr says:

            As long as the government keeps the prices reasonably close to the current level (for now at least) and tinker with the wasteful use of unnecessary tests and procedures I think the incentives to stay will outhweigh the incentives to leave.

            I strongly suspect the prices for individuals will drop for sure. Perhaps not as far as Canadian prices right away (We pay about 60% of what Americans pay) but when you take the profit incentive out of it it goes a long way. While the right will probably try to use anecdotal evidence to argue it is worse, having most everyone covered almost assures better statistical outcomes.

            Government issued hospital insurance cards with a photograph and perhaps some other security systems should reduce the fraud. I can’t see an actual state trying to take advantage of something like this as it would be clearly illegal.Report

    • Avatar Kimmi in reply to DensityDuck says:

      Cookie.
      I think with our conservative bodypolitick, this would have been a better plan. A lot of progressives wanted this one, actually. It seemed simple and easy to explain.
      Instead, we got the corporatist plan. Which, granted, eliminates Thelma and Louise (or whomever the insurance got to deepsix Hillarycare)Report

      • Avatar Silver Wolf in reply to Kimmi says:

        Technically you did get the universal health care plan and I believe in a way that is better than a national system. The ACA gives states the right to opt out if they create their own system that meets minimum requirements. In Canada the provinces run health care with some federal assistance and I believe that unlike national defense or immigration, states can and should run their own health programs.

        That said I believe it will be a long time before all 50 states go single payer.

        Taking bets on who will be the next state to go all socialist and announce universal health care. I say it’s one of the western border states.Report

    • Avatar Plinko in reply to DensityDuck says:

      I often heartily disagree with you, DD, but here I think you’re totally right here. Reducing health care costs without relying on magic requires some combination of either providing less services or paying providers less. Until we can agree that this is the case, no real progress will be made.
      If we can ever agree on it, then maybe we can start picking oxes to gore.Report

  2. Avatar Ryan Davidson says:

    The real problem here is that the US citizenry demands access to more health care than they are willing or able to pay for. The bill for this is now coming due, and the only way out of the situation that I can see is for people to get more content with less.

    This is particularly true in geriatric, oncological, and just generally end-of-life care. We spent $510 billion on Medicare in 2010, and two thirds of that was spent on the last six months of life. I’d imagine that health insurers’ numbers are slightly different, but not that different. By a rough estimate, something like 50% of all health care spending is on the last six months of life. Meaning that most of it is, by any objective standard, a complete waste. I’m sorry, it’s just not worth spending $250,000 to give grandma an extra few weeks on the ventilator.

    We stop doing stuff like that, and a lot of our problems actually go away.Report

    • Avatar Michael Drew in reply to Ryan Davidson says:

      Of course, if you’re a pretty healthy 30-year-old who’s never had much in the way of medical procedures other than getting your wisdom teeth out and having yearly check-ups and you get hit by a truck on your bike but live for a week or two before succumbing to your injuries, then you’ve just managed to probably do upwards of half of all your health care spending in the last month of your life, so those numbers at least a bit misleading. But I still think your overall point is a good one. The question is whether we are going to decide as a country how to reform late-life care (the route traditional Medicare defenders would prefer), or leave the decision to individual old folks to make when they reach that point (or sooner) by simply capping the amount that Medicare will pay for such care at some arbitrary number related to GDP growth and letting them work it out for themselves (the Ryan plan).Report

      • Avatar Ryan in reply to Michael Drew says:

        Actually, you’re helping me out here. True, getting hit by a bus when you’re 30 and dying two weeks later means that you aren’t spending a lot of money when you’re old. But you’re still spending a lot of money in the last six months of your life. I should have been clearer about that. Even the costs of long-term, chronic diseases like diabetes pale in comparison to the massive amounts of money that cancer or major trauma rehabilitation costs in a very short period.

        So yeah, I’m also largely opposed to the exorbitant amounts of money we spend on trauma victims. Sure, if we spend $2 million on the little girl that gets run over by a pickup truck, we can keep her alive. She’s never going to be the same again, and will be in and out of therapy, physical, mental, and psychological, for the rest of her life, but hey, she’s alive right?

        Right. But that doesn’t mean it as the right thing to do. Just because we can do something doesn’t mean we have to or even should. We could send about a dozen kids to college, even at today’s outrageous prices, for that money. Why should she get it instead of them? We could also have fixed a bridge in desperate need of repair, installed broadband for an entire community, or funded the entire arts program for a public school for a year. Who’s to say those aren’t better?Report

        • Avatar wardsmith in reply to Ryan says:

          Theoretically getting hit by a bus/truck/whatever puts the onus on driver/insurer of said bus/truck/whatever to pick up the tab. There are other ways for the young to die, getting shot being high on the list. One of the reasons we have such a high death rate is our tendency to shoot each other, something the Europeans can’t do as much of for various reasons (no guns being a major impediment).Report

          • Avatar Ryan Davidson in reply to wardsmith says:

            The fact that insurance exists is not actually a justification for spending too much on trauma care.

            And your gun control red herring is both logically a non sequitur but also completely wrong. Gun-related injuries account for a tiny, tiny fraction of deaths in the US, something like 31,000 a year, the majority of which are actually suicide. By contrast, over 2.4 million people died last year., and over 120,000 of those deaths were accidental.

            The rate of gun violence has an absolutely negligible effect on the death rate.Report

    • The real problem here is that the US citizenry demands access to more health care than they are willing or able to pay for. The bill for this is now coming due, and the only way out of the situation that I can see is for people to get more content with less.

      This.Report

    • Avatar DarrenG in reply to Ryan Davidson says:

      The problem with this is that other countries have similar proportions of costs going to terminal patients, yet still manage to spend a tiny fraction of what we do on health care overall while simultaneously providing decent basic health care to their entire population.Report

      • Avatar Ryan Davidson in reply to DarrenG says:

        Umm… numbers? All the numbers I’ve heard of suggest the opposite. This is why our cancer outcomes are pretty much uniformly better than any other country in the world.Report

  3. Avatar Scott says:

    CC:

    Why do you mock the idea that the high cost of insurance might inhibit hiring? Also, haven’t other provisions of Obamacare kicked such as coverage for children up to age 26? All the new requirements have costs that add up despite what the Dems will admit.Report

  4. I’m going to start using “embrace neurodiversity!” when parents bring in their disruptive, oppositional children.

    I’ll get back to you on how it plays.Report

  5. Avatar Rufus F. says:

    I wonder about the hiring thing from time to time because I live in a big steel town in Canada about an hour north of a former steel town (now rust belt) in the US. Most of the steel Hamilton produces goes down the lake to the states and I’ve wondered how it is that we can keep the mills going, but Buffalo couldn’t. Admittedly, they’ve had some problems here, particularly US Steel, but I’ve wondered if it isn’t easier for them over here because they don’t need to worry about their workers’ health coverage.

    As for the most likely scenario, how about Obamacare fixes nothing, premiums continue to rise until 30+% are uninsured nationwide, and single payer gets pushed through after a heated debate?- which is basically what happened in Canada.

    Finally, if you think French dubbing is amusing, check out Les Simpson sometime.Report

  6. Avatar Tod Kelly says:

    Good post, CC. I probably don’t even need to do this, but the disingenuous way that different constituencies frame the HC issue drives me batty. So even knowing you are not advocating the truth of any of these things, I feel compelled to comment:

    From Slate: “The causes of this year’s spike are debatable”

    No, they aren’t. Premiums went up this year because cost of usage went up last year. Just like it does every year. The worrisome part of the 9% increase isn’t that it happened this year – it’s that it happens every year (somewhere between 7-10% anyway). Seriously, how does the person that writes for Slate not know this? Has he never had health insurance until this past year?

    From Slate: “The Times says some analysts believe insurance companies are getting their price hikes in now before a provision kicks in next year requiring them to justify any double-digit increase.”

    Then the Times needs to get new analysts. See above. Again, what we pay in premiums this year is a direct reflection of what we paid last year, and even though we’re focusing on this years increase like it’s a conspiratorial enigma, it’s not. This happens every fishing year, and has for the past 50.

    Hayek Reasoning: “The reason employers are reducing coverage now while at the same time cutting payrolls is because it’s a buyers labor market.”

    No, because this is not a new trend. This has been escalating at a steady pace since the late 90s whether unemployment has been high, low or in between.

    Marxist response: “These monstrously high health insurance costs that are keeping employers from hiring”

    This might be true for some employers, but it isn’t for the majority. Employer healthcare-cost subsidies have not been kept stagnant, so it in itself has not been a reason to shrink headcounts. Rather, they have had employees pick up cost increases.

    And strong kudos to Ryan Davidson for this:

    “The real problem here is that the US citizenry demands access to more health care than they are willing or able to pay for.”

    It’s not the answer we want to hear; we’d much rather there a be a villain that is keeping us from having as much cake as we want without ever paying for it, but it’s right on target anyway.Report

    • Avatar wardsmith in reply to Tod Kelly says:

      Excellent points Tod. I think the other massive disconnect in people’s thinking (such as there is) on this subject is a complete lack of understanding of how INSURANCE IS SUPPOSED TO WORK.

      It is all actuarial. Given a sufficiently large population (n), one can spread the risk enough that costs can be accounted for, bills can be paid and (gasp!) profits can be accumulated (to account for the lean years – but don’t tell a liberal that because it just leads to whining and kvetching).

      Warren Buffet built his huge empire because he collected vast insurance premiums every year and INVESTED them! Here is where gov’t run ANYTHING will fail. Governments are HORRIBLE at investing viz Solyndra et al as just a current example. The gov’t can’t invest wisely because it invests POLITICALLY and that ain’t no investment at all!

      Single payer ultimately leads to single insurer, which ultimately leads to the gov’t running things, which negates the vast multiplicative value of INVESTMENT that gov’t ignores. Furthermore, much of the “profits” insurance companies show come from – you guessed it – investments and have nothing to do with last year’s premiums. Conversely premiums go up because expectancy tables change, investments tank , and the fished up gov’t changes the rules of the game – demanding new services be covered (shamans and holistic practitioners for instance).

      How to fish up this system? Do exactly what our gov’t can’t stop itself doing, constant MEDDLING.Report

      • Avatar Silver Wolf in reply to wardsmith says:

        The United States pays more than any other nation in health care and has some of the worst outcomes of all of the wealthy democracies.

        Per person Democracy Health Mortality
        Dollars Index Spending Infant Under 5 Adult
        Australia 41,982 9.09 2,886 4.4 5.6 83.6
        Austria 45,090 8.49 2,958 4.4 5.4 82.6
        Belgium 42,965 8.16 3,044 4.2 5.3 82.3
        Canada 39,217 9.07 2,998 4.8 5.9 82.9
        Denmark 55,942 9.52 2,743 4.4 5.8 80.6
        Finland 45,876 9.25 2,104 3.7 4.7 82.4
        France 42,091 8.07 3,048 4.2 5.2 84.1
        Germany 39,442 8.82 2,983 4.3 5.4 82.1
        Greece 30,305 8.13 6.7 7.8 81.9
        Iceland 36,873 9.65 3,159 2.9 3.9 83.3
        Ireland 51,128 9.01 2,455 4.9 6.2 81.3
        Italy 34,955 7.98 2,314 5.0 6.1 83.5
        Japan 39,573 8.25 2,249 3.2 4.2 86.1
        Luxembourg 94,418 9.10 4,611 4.5 6.6 81.6
        Netherlands 47,042 9.53 2,909 4.7 5.9 81.9
        New Zealand 25,354 9.19 5.0 6.4 82.2
        Norway 76,692 9.68 3,769 3.3 4.4 82.5
        Portugal 20,655 8.05 5.0 6.6 82.1
        Slovenia 24,583 7.96 4.8 6.4 81.5
        Spain 31,142 8.45 4.2 5.3 84.2
        Sweden 43,147 9.88 2,745 3.2 4.0 83
        Switzerland 66,127 9.15 3,847 4.1 5.1 84.2
        United Kingdom 35,728 8.15 2,317 4.8 6.0 81.6
        United States 46,443 8.22 5,711 6.3 7.8 80.8

        Most of the information above is from the CIA world factbook. The US is 2nd highest in infant mortality, tied for highest in juvinile mortality and second lowest in average life expectancy despite paying twice the average of all the developed nations in health insurance.Report

    • “Seriously, how does the person that writes for Slate not know this? Has he never had health insurance until this past year?” – Writers get health insurance? Writers get paid?Report

  7. Avatar Roger says:

    Christopher,

    As someone who spent much of his career designing insurance products (though never in health insurance), let me add some insights.

    A fundamental problem faced by insurance mechanisms is separating the feedback effect between costs and benefits. If poorly designed, it is possible to get a system that encourages unlimited benefits. The insured person logically pursues preventive maintenance, routine care, and rolls royce quality. In addition, special interests seek to free ride on the system by extracting rents from a system paid by someone other than the person getting the service. Of course, the insurance costs go up, but there is no direct feedback loop between the consumer’s actions and benefits and his eventual price. It spins out of control. It becomes increasingly expensive, so we start providing it free to the poor and this then just raises the cost more…

    The danger, to say it another way, is in socializing the costs while personalizing the benefits. US medical insurance did this BIG time with decades of employer paid insurance pools (due to funky tax laws) and Medicare. And most recent legislation has tended to make the feedback loop even more dysfunctional.

    That said, the Hayek free enterprise ending is not likely, as we are not dealing with a free enterprise system. It is way too clogged up. You can’t get back to normal based upon where we are by letting the current system play out. Well, I guess you can long term, but that is by letting the system first play out to disaster.

    The top down centralized system will fail because special interests have penetrated every aspect of the system. The rent seekers have too much to lose, and will do everything in their power to keep the rents coming — in some cases justifiably so (after all seniors are probably the biggest beneficiaries).

    I would recommend decentralized experimentation. Instead of arguing over rationalizations and creating compromises that nobody totally likes and that therefore never prove anything (I didn’t like this part of the system anyways, so of course it failed). We need to encourage competing, voluntary solutions at a state or local level. The special interests will of course stop experimentation too. Any experimentation into a better system is in effect experimentation at how to re-establish the feedback between the consumer and the payer and how to extract rent seekers from the process.

    I hate to say it, but I think the likely outcome is Murphy’s. The system will become totally dysfunctional and self destruct. It will then re-emerge like a Phoenix out of the ashes. For lack of space I will avoid describing how it could work.

    Yes, I strongly suspect that Murphy will win out and that my wife and I will have to get some of our health care out of the US. It is cheaper today (same care for less) to fly to Costa Rica (or for some to drive to TJ) and get major medical care than it is to get it in the US. All I need is the ability to buy a policy with the terms and conditions acceptable to my wife and me. Reasonable routine care and emergency care — a small part of health care costs — will of course be purchased locally.

    When the system breaks, the poor and elderly will be the hardest hit. The ironic thing is that we used them as the excuse to screw it up in the first place. Good intentions!Report

  8. Avatar Julie says:

    I am probably wasting my time commenting on such an old thread, but I have to push back a little against the idea that people routinely demand access to more healthcare than they are willing to pay for. My experience is often that doctors demand extensive, expensive testing before they are willing to offer any care–and sometimes, not even then.
    For instance, I have a painful chronic disease that probably won’t (but possibly could) kill me. Recently, I went to my doctor hoping for a limited prescription of pain medication for occasional use, so I wouldn’t have to call in sick to work on days the pain is really bad. Long story short, an ultrasound and colonoscopy and more than $1000 out of my pocket later (that’s with insurance), I found out, as I expected, that I’m not dying yet. I also did not get the (cheap) prescription I wanted nor any other treatment for my pain.
    I have often refused what I thought were excessive or unnecessary tests/treatments, but my refusals have sometimes resulted in me getting fired by my doctor and having to start over with someone new who wants to run all new tests. The patient only has a limited power in a situation where they actually need care to refuse doctor’s orders or control the costs of their care.Report

    • You make a good point, Julie. I’ve had similar experience managing asthma. I was told by one doctor that I would need to take medicine for the rest of my life, but I’ve always hated the way the medicine made me feel. This summer actually, I ran out of asthma medicine before I could switch to U.S. insurance, and decided instead of going through the absurd hassle we have only in this country of going to THE EMERGENCY ROOM to get a refill on a prescription of a medication I’ve been taking my whole life, I would just stop taking my medicine. I did, and four months later, I still haven’t taken any asthma medicine. In the meantime, I’ve managed to enroll in Mass Health, without which I wouldn’t be able to afford health insurance, and find a new doctor, who’s totally okay with me not taking any asthma medicine anymore.Report

      • For me, one of the biggest adjustments to the Canadian system was just this- they don’t send you for 27 tests and hold you overnight for observation if you had a fainting spell. Instead, you actually have to be somewhat aggressive if you want something specific, but you also don’t have to go through a lot of unnecessary crap that just costs money. In a situation like the one you’re talking about, the system would work better because they want to get you out the door as quickly as possible and if you can just tell them what you need, they’re happy. The flip side of it is they’re not remotely interested in babying you here and you sometimes have to stay on the doctor in order to get things you need. It’s weird. I’ve wondered if Americans could handle a system without the same perquisites and I don’t know if they could frankly.Report

        • Avatar DensityDuck in reply to Rufus F. says:

          If you had done the test you declared unnecessary, you *might* have spotted the life-threatening condition. Court finds in favor of the plaintiff, judgement in the amount of twenty million dollars.Report