Morning Ed: Health {2018.06.21.Th}
[He1] The primary care physician shortage continues, especially in the South but really almost all over.
[He2] Well yeah. Otherwise it’s a horror story.
[He3] Somebody needs to inform the Brits of the abundant virtues of single payer health care.
[He4] Single payer is becoming more popular, but the support is pretty shallow. Supporters are going to have to sell it. (Which, as I’ve said before, I don’t think they will.)
[He5] A hospital in Britain has been accused of “shortening lives” through painkillers.
[He6] It’s kind of funny that I married a (now former) primary care physician because I never had one before I met her, I just went to a first-come-first-serve clinic and it was fine.
[He7] Will Eadie looks at nurse burnout. Ohio is concerned with them working too much overtime. The medical community has always done a good job of recognizing the impact of fatigue on all sectors but their own.
[He8] Gary Taubes blew up popular understanding of nutrition and weight, but his crusade is evidently falling apart.
[He9] No data is better than bad data.
He6: I wonder how they define “most.” I’m told I’m “supposed” to have every-six-months checkups because of my (generally well-controlled) hypertension and allergies, and that I need annual bloodwork because of a family history of a few things that are less dire if detected early. I dunno. I get that there’s a physician shortage and maybe this is sort of how you manage to ration out the time of the “few” doctors but frankly I’d be uncomfortable being told, “You don’t get to have a PCP any more, just go into the clinic every year and take potluck” ‘cos I’ve had some really terrible doctors in the past and I have a really good one now, and I’d be less likely to go and get checked up if I knew I might get someone who was rude or who thought all my health problems would be solved by my losing 50 pounds and they don’t want to see me again until I have, or who think I need an anti-anxiety med or whatever.
I also know someone who died of something that, had he gone to a doctor once in a while, it would have been found and likely he would have lived longer and had less pain.Report
To clarify, #1 isn’t a question of going to visit the doctor or not visit the doctor, but whether you have a single doctor or you go to a clinic with a single queue. Until I met Clancy, I always did the latter.Report
Do you count a single practice with multiple docs as a single doctor? I always went by the scope of the records — if they were working off a single medical history, they were a “single” doc.Report
Do not count that. If you see one doctor usually but when they are on vacation you go to the queue, that does count.Report
The issue for me is that some practices have a mix of great and terrible doctors, and if you don’t get to choose….well.
I have had some really bad doctor experiences in the past so I may be prejudiced but I would pay extra to keep my current doctor instead of getting potluck if it came down to that.Report
Yeah, that’s definitely true. Mom went from the queue to requesting a particular doctor at the clinic mostly to avoid a particular other doctor.Report
He4: It’s amazing how big a swing you can get in a poll just by reminding people that a massive increase in government spending will cost money, and consequently require an increase in taxes. These polls are so easily manipulable that nobody should ever take them seriously.Report
It’s mind blowingly obvious that we’re praying for healthcare no matter what, and the only question is how that payment is to be structured. And yet apparently this is surprising to some?
Single payer tends to mean we spend a little less on the whole because more people can afford to get things treated early before they become dire problems that are more expensive to treat, and sometimes you avoid the problem of a person who can’t afford treatment going around infecting multiple people who are then forced to.
But yeah – the US spend the most per capita on healthcare of any country with only mediocre results. Single payer would probably improve that efficiency somewhat, but mostly it’s just moving the burden to those who can best afford it.Report
Single payer tends to mean we spend a little less on the whole because more people can afford to get things treated early before they become dire problems that are more expensive to treat, and sometimes you avoid the problem of a person who can’t afford treatment going around infecting multiple people who are then forced to.
Do we have any numbers on this?
Remember when people said “we need to post calorie counts at restaurants and that will result in people eating less once they have all of the information in front of them”?
Ezra Klein had an awesome series on this sort of thing where he explained how great it would be in 2009 and 2010, and then, in 2013, he wrote a funny essay explaining “wait, here’s why that backfired”.
When I read explanations for why stuff will work because it will allow people to be better, I go back and remember Klein’s articles.
Anyway, your explanation of why Single Payer will be awesome strikes me as likely to result in explanations of why, technically, preventative care didn’t increase.
Which makes me wonder about the numbers.Report
I’m minimally skeptyical that single-payer driving down costs relatively to what we have now.
I am much more skeptical about single-payer driving down costs [1] by placing preventative care in reach of more people. Improving outcomes? Sure, prevention often does that. But it usually costs money. First you have to do your screening and testing (which isn’t free) and then you have to treat the stuff you find (which also isn’t free).
And a lot of time the stuff you find wouldn’t have amounted to much.
For example, cervical cancer screening is a fantastically successful public health intervention. It works by finding things that might become cervical cancer in the future and treating them. But many of the pre-cancers would go away on their own.
[1] Specifically health care costs. If you take a broader perspective where we include the effects of productivity lost to illness, things might be different.Report
Part of figuring out what, if any, savings could be realized is agreeing on a definition of what ‘single payer’ means. It seems to get used interchangeably with universal healthcare but there are lots of avenues to get to some kind of universal coverage that don’t involve a near totally socialized/government run system where the state is payer and provider (what you see in most other Anglophone countries fit this model).
The idea of savings in a Medicare-for-all type proposal would be in eliminating ‘administrative costs’ (read profit) private plans need to operate and the ability to force some price transparency (for example what Medicare will pay for a particular treatment is public information, not subject to back room dealings between providers and plans). There are real debates on what that savings (if any) would be but I don’t think we’ll ever know until we try it.Report
It seems to get used interchangeably with universal healthcare but there are lots of avenues to get to some kind of universal coverage that don’t involve a near totally socialized/government run system where the state is payer and provider (what you see in most other Anglophone countries fit this model).
I think it’s a lot like anything else. People mean some variant of “what I have now, only costing less and/or with a lot less hassle” (and people who aren’t in the top quartile probable think “like what people in the top quartile have, only costing less and/or with a lot less hassle”).
The tradeoffs will all be experienced by other people. Maybe we’ll put a lot of insurance people out of work. Poor dears. They should learn to code!Report
Anything that actually put an insurance company out of business is never going to happen. But what a lot of people on both sides don’t fully understand is how in bed HHS already is with the insurance companies. Talking about getting rid of them is as silly as pretending they’re operating in any sort of free market.
My guess is that the hope for Obamacare was that it would slowly evolve into a system where the government reimburses big insurance companies based on risk adjustment principles and starts pushing provider groups to band together into ACOs. You’re then getting to a place where hopefully you have universal insurance coverage the face of which is still private for most people plus some market based cost controls thrown in the mix and as a bonus no one in the industry loses their job.Report
Anything that actually put an insurance company out of business is never going to happen.
Pity. I imagine that where we’re trying to go wanders through seeing insurance companies as parasites.Report
Think of it as the price of a federal system of government that for a bunch of historical, geographic, and constitutional reasons needs help meeting its goals. Here’s an example that might help.
When I first went in house I worked at a company that provided a lot of important services to Medicaid patients. Many, many people on Medicaid get homecare which was how the service was delivered. This is a major cost saving aspect to the program, because it keeps people out of the hospital where the care is way more expensive. A lot of these people are also older, and live in the sticks in the rust belt or the rural south where care delivery and infrastructure are severely lacking.
Then this company got in very big trouble with CMS for issues related to reimbursement. When the government was deciding the sanction, it was ultimately much more lenient than a lot of people had expected. No one really knows why this was, but I have always believed it was because this company had infrastructure to get services to a lot of remote beneficiaries that the government cannot quickly or easily replicate.
So, while there is a parasitic aspect of this, the government actually needs a lot of these private entities as much as those entities rely on the government as a customer. The American state is fundamentally not in a position to do a lot of this work itself. Its not how any rational person would set up the system. But because we can’t go back to the 1870s and be Otto Von Bismarck any reform needs to account for the private sector players that the state relies on. Pulling them out isn’t only a matter of pulling out a parasite because it could have real consequences for people like those Medicaid patients.Report
Oh, I *KNOW* that there are going to be tradeoffs. I *KNOW* that we’re going yell “hurray! Finally! We’re doing it for cheap!” and then we’re going to have two sets of people yelling either “why isn’t this done right the way that rich people get it?” or “why isn’t this done fast the way that rich people can get it?”Report
Yes/No… another way to think of it is the cost of buying out all the insurance companies. Market Cap of the largest Insurance Providers
Cigna $42B
Anthem $61B
Aetna $62B
UnitedHealth $242B
The cost of buy-outs might a path dependent cost of transition. US has an annual total run-rate of $3.3T in healthcare costs. $3.3T might be a decent guess at just the transition costs alone. Not a bad investment, necessarily, but there’s no “revenue neutral” unicorn in any discussion.
In terms of “Turning the Ship” analogy, we need a bigger, harder to turn reference point than mere Ship.Report
See my anecdote above to Jay. Yes, you could do that, but this is premised on the idea that the feds can seamlessly step in. HHS/CMS has a lot of infrastructure and unlike other activities sending out checks plays to the government’s strengths. Still I am not 100 percent convinced it has the wherewithal to successfully make that transition (remember the Obamacare rollout debacle?), even if there weren’t entrenched interests at the federal and state levels that would fight it tooth and nail.Report
It’s kind of hard to get data on isn’t it? I mean, we can’t just take a country and say “OK, everyone in these districts gets universal healthcare and everyone in those doesn’t, and nobody is allowed to move within the country, especially not if you get sick and want to move where the healthcare regime fits your needs better, and everyone has to eat the same, and we’re going to ration alcohol and cigarettes, and if any county doesn’t finish their rations we’re sending you all behind the barn and don’t show your face until you finish all the cigarettes.”Report
Well, I guess it depends on whatever variables we all agree are completely orthogonal to what we’re trying to measure.Report
Remember when people said “we need to post calorie counts at restaurants and that will result in people eating less once they have all of the information in front of them”?
Ezra Klein had an awesome series on this sort of thing where he explained how great it would be in 2009 and 2010, and then, in 2013, he wrote a funny essay explaining “wait, here’s why that backfired”.
But price transparency in the healthcare market will drive consumer behavior to lower costs? How certain of that are you?Report
Price transparency means…
1) Insurance company B knows Insurance company C got a better deal.
2) Company B knows it’d be better off using Clinic A rather than D.
3) LOTS of medical activities become commodities.
4) Everyone with an HSA is strongly motivated to seek the lowest provider for all sorts of things.
5) Various applications and such can be created to sooth these activities.
So publishing prices is also forcing Health Care Providers to compete on price.Report
And then what happens?
This notion of market competition driving prices lower is left dangling, without anything connecting it to the proposed ideal.
“Lower” isn’t good enough, if it is still above anyone’s ability to pay.
It usually means “lower the the cost to within the means of an upwardly mobile dual income professional household. Who get ill, but not catastrophically so. Who have home equity somewhere to fall back on.”Report
Lower prices means more options. For you it means UHC might just be very expensive rather than impossibly expensive.
Lower prices is also a massively good thing in and of itself, fewer people get priced out of the market AND money currently being spent on insurance can be spend on other things (housing perhaps).Report
Price transparency won’t change anything if patients will continue milking the hospital because “hey I’ve already paid my insurance” and because “my insurance company requires me to visit this doctor and not anyone elseReport
I like the idea that universal health care will somehow be cheaper, but I reject the notion that this is a necessary selling point.
At present, people go bankrupt or die because of inability to afford health care.
If it costs more to prevent this, lets be honest about or priorities.
How much or how little would any of us pay out of our own pocket, to prevent this?
Would that number change if it was someone we know?Report
That’s kind of the thing isn’t it – you can make yourself better off by spending less or by earning more. Comes out the same.
Fewer people going bankrupt, losing work hours to illness, or being unwilling to start an enterprise because they need their employer’s health plan, is more foregone revenue than expenditure. But to the extent you can fix those, you’re better off even if the “healthcare expenditures” line item never gets reduced.Report
He4: Universal healthcare is popular until you get talks about the costs and specifics of the program. Then it starts to loose popularity fast. During the 2016 primary season, many Sanders supporters did not like getting told about the taxes necessary to pay for his programs. Welfare state measures tend to get implemented in the aftermath of wars or other calamities because people tend to be in we are all in this together mode. When the body politic is not in a we are all in this together mode, good luck.Report
Agreed… and there’s something different about selling a healthcare proposal and crafting a healthcare proposal.
There’s actually a lot of conservative support for a new healthcare model… especially once you leave the large Corporate sphere. Healthcare costs are an unequal tax on labor that hits small to middling companies much differently than large multi-nationals.
So I think you could “sell” a healthcare proposal that might appeal to a broad base but the people crafting it are the ones most sensitive to the various constituencies and veto points that don’t want their businesses disrupted.
And, there’s the math… in order to sell it, one has to distill it out of the policy wonk speak and into somewhat understandable math. The biggest selling *failure* I see is the appeal to Europe… the “Well, Europe/Canada have it, so it would work like that.” But as Will notes in his previous linked Post on the topic, which European Nation, Why Canada, Whatabout Singapore? As a *selling* tactic its a disaster, and a good chunk of why I think support evaporates; or to put it another way, there’s support for a system folks (sorta) know – Medicare – but nobody really shows the math on how we get from here to medicare for all.
Maybe we can’t even get there from here. I don’t know. But any *selling* discussion has to settle on a plan first, then outline the math. But we’re back to the delta between what people would want and what the “proposal crafters” can manage… the various path dependency issues we bop about periodically.
Of course… once you settle on a Proposal you open yourself to critiques and objections…fueled by the people who have the most to lose… so there’s an inherent bias to *not* settle on a plan but stay at vague hand-wavey promises… and then when you go to craft a plan, the veto voices have a lot of leverage and clout. And we’re in a sort of policy no-win loop.
So my counter-intuitive thought for the day is that to reform healthcare, a politician has to settle on a plan (and all that means) that will make him/her all but unelectable… then get elected… with long coat-tails too.Report
Why not Singapore? Vox did a pretty good analysis some time ago on why Singapore’s amazing free market healthcare system is a lot less free market than it appears on the surface because the government owns many of the hospitals, etc. Even if it was a free market system, I think that Americans would revolt at the forced savings aspect of it. Americans might not like the taxes needed for Canadian single-payer but it has the advantages of being non-paternalistic and easier to understand than most.Report
Shrug… that’s what selling is; what are the costs that need bearing for the benefits gained. You can’t just try to sell benefits without costs… and you can’t calculate costs (or benefits) without settling on a plan.
So yeah, as you point out… Canada plan has pluses/minuses, so too Singapore, or any other plan. There’s no plan that is self-evidently the right plan.Report
The Swiss/German model is a much clearer path for us give the path dependency thing. Uni HC throgh heavily regulated insurance companies and people with money can buy extra coverage. The ACA could easily work as a start to that.
However the House wants to cut a couple trillion or so from Medicaid/care so at least we’ve found the much promised Repub HC plan.Report
I think you’re right which is why the language barrier is frustrating. It limits what Americans understand universal healthcare to be. I think its very clear that Americans don’t want the NHS (it’d never work here) but not everyone understands that you don’t have to have one.Report
I agree that universal health care in the United States is going to look more like the Swiss/German/Israel Bismarckian model. The HMOs and insurance companies are going to be private but heavily regulated like other utility companies. I also think we are going to get more HMOs like Kaiser Permanente where the doctors aren’t independent but work for the HMO. The real big kicker is that American doctors make a lot more than non-American doctors. To control costs, your going need to find a way around this.Report
Huge numbers of well pain people will need to lose their jobs. Insurance agencies + HCPs + Others all have massive dueling bureaucracies that only deal with each other. And yes, Doctors, etc, might also need a haircut. The amount of waste in the system presumably runs into multiple points of GDP.
And I find it impossible to believe the gov has the political will to impose this. We’d have doctors running ads saying people would die. Politicians don’t like laying off millions of people. This is why I’d like to see market reforms like HCP being forced to publish and honor prices.
After we cut our costs to something sane we can talk about covering everyone. This is the disconnect between “UHC will save money” and “we flinch away from implementing it”.Report
Covering everyone when we costs is fine and dandy for the people who have good coverage now. In practical terms that means when the cost curve is bent enough the children of the people who are getting the short end of the stick now might see progress. Or their grandchildren.Report
Perhaps.
But the actual alternatives on the table are
1) Have brave politicians fire millions of voters in the face of people screaming that they’re killing people for the sake those people on the short end of the stick.
2) Not do anything. And given that I seriously doubt we can pay for the promises we’ve already made, this is also…
3) Break the system.Report
Big meh. Not true at all. There is an option to keep modifying the system along the lines started by the ACA aiming towards something like the German/Swiss system. Millions aren’t’ fired, the system isn’t broken and we already know we can increase the percentage of people insured. It was the R’s who took most of the cost controls years ago.
It’s a pretty basic scare tactic to claim everything must be destroyed, so i guess we have to do nothing.Report
More detail please. You’re going to increase demand. You’re not going to fire lots of people.
So does this mean large wait times with serious cost controls, two tears, or very large tax increases?
These would be the brave politicians we need to fire lots of people. Cost controls kill people, create large wait times, and are deeply politically unpopular.Report
“That working model of universal healthcare we see around the world?
Fine, but there is something uniquely broken and dysfunctional about America that makes it impossible. It can’t happen!”
American Exceptionalism, circa 2018.Report
Pointing to other models, claiming you’re going to take one feature from a complex system and get the same results, is like claiming you’re going to attach a car’s steering wheel to a scooter and it will go 60 miles an hour.
The way to bet is the normal laws of demand, supply, and price will apply.
This is why we keep flinching away from the cost of changing our system even if other countries get vastly different results. We’re typically not talking about importing the entire car, just the steering wheel.Report
I’m really struck by the attitude here.
Trumpism in particular and conservatism in general has at its core, a dark pessimism and sense of foreboding about the future.
Maybe it’s always been this way and I never noticed, but it seems like every option they can possibly conceive of, is a choice between awful and horrible.
Can anyone here point me to a major conservative figure who speaks in the language of joy and hope, of optimism and faith in a better future?Report
Rubio and Ryan pop into mind.Report
I didn’t mean tone, I meant content.Report
I was strictly referring to tone, not content. But I’m curious if your observation might not be an artifact of your definitions of left and right. Could you describe how it would, in your understanding, be possible to be an optimistic conservative? You’ve depicted conservatism as being little different than Klan membership, and I can get how you’d fail to see that as optimistic, but you can see how there’d be an upper limit on optimism in that model. I think this may also relate to my comments over on Kate Harveston’s article, although I haven’t thought through how.Report
Allow me to channel 1980 Chip, that young enthusiastic Reagan Republican….Ommmmmm
OK, tax cuts and regulatory cuts will unleash the creative potential of markets, allowing poor and uneducated people to create startup businesses shorn of the crushing burden of regulation.
There will be special government programs of enterprise zones to target and help these people enter the marketplace.
Second, an embrace of conservative morality will block the selfish “Me Decade” ethics of the 70’s, and return us to a communitarian ethos where everyone conforms to communal norms, pitching in to help each other, where families are strong and the private safety net resilient.
Ommmmmm….Report
Your first paragraph sounds very Kempian, and your second paragraph sounds non-Northeastern (basically, any party, any person who lives more than 500 miles from NYC). If you took what conservatives are saying, and filtered out the things that you personally perceive as racism, what would be the difference?Report
Not for nothing I wrote in Jack Kemp for president in 1992.
If I filtered out the racism, there wouldn’t be any difference.
But see, thats the thing. There is nothing left in the Republican platform anymore, besides white ethnic resentment.
A party that spends decades bellyaching about welfare mothers in Cadillacs, and that starts its Presidential drive on the site of a notorious Civil Rights murder, will not, did not, and never will, “target poor people to help them enter the marketplace” .
The desire of the Republican Party, as evidenced by its every policy enactment since 1980 is to use the stick of starvation to force people to work, and to use racism as a wedge between the working class.
The party that enthusiastically embraced a vision of Mexicans as rapists and murderers did not, will not and never will, embrace a communitarian ethos of traditional morality.
There is a respectable conservative vision. But to get there, one needs to unclench their fist and let go of that racial resentment.Report
“and that starts its Presidential drive on the site of a notorious Civil Rights murder”
Would you unpack that?Report
Ronald Reagan started his Presidential campaign in Philadelphia, Mississippi. The same city where only a few years earlier three civil rights workers were brutally murdered.
His speech centered around “states rights”.Report
He started his presidential campaign in August? Reagan started his presidential campaign in 1964. From what I can find, it was his fourth speech after the Convention. Otherwise there was nothing outstanding about the timing. Speeches before Labor Day aren’t significant. As for the content of the speech, I just read it (the link is below), and it does talk about states’ rights, but that wasn’t its center, and there’s no reason for the quotes you put around the phrase.
http://neshobademocrat.com/Content/NEWS/News/Article/Transcript-of-Ronald-Reagan-s-1980-Neshoba-County-Fair-speech/2/297/15599Report
When you asked me on a different thread if I thought the future would be better I instantly replied I was sure it would.
That doesn’t change that it’s magic thinking to believe taking one feature from a different system will give you all of the same results, nor that magic thinking has no place in a policy discussion.Report
Wouldn’t it be a wonderful to imagine a conservative vision of universal health coverage?
I mean, conservatives were first asked this question in 1933, then again in 1964, 1992, and 2010, and each time responded with “Let them die”, but still, its not too late, don’t you think?Report
Bring healthcare costs down and we’ll talk. Or just figure out a way to do it without magic thinking and without breaking the bank. Anything that breaks the bank isn’t worth the cost.
The mortality rate holds steady at 100 Percent. Every healthcare system has to let people die.
The issue then becomes what is the least politically painful way to do this. Promising everyone that you’re going to give them everything is great, how do you square that with budgets?Report
The mortality rate holds steady at 100 Percent. Every healthcare system has to let people die.
It’s embarrassing to watch an intelligent guy like you make this boneheaded talking point. Of course, it’s true that everyone dies eventually, but of course it’s also true that no one advocating for UHC is promising immortality, so on one level it’s just a silly strawman. But on another level it’s also true that there’s a hell of a difference between dying next week of a preventable or treatable illness/accident and dying of old age surrounded by your grandchildren.
Ultimately, this isn’t really an economic issue; it’s a moral issue that you’re attempting to argue around as an economic one and we just have very different moral precepts.Report
No, just “free” healthcare to everyone, no matter how sick and expensive they are or how worthless the treatment is. Terri Schiavo gets put on life support forever at state expense. A sedated demented 94 year old with cancer gets hip replacements and expensive cancer treatments. This link sums up the issues, which are present in all of these UHC systems.
There are obvious solutions, i.e. rationing and effectiveness evaluations. If you’re not willing to embrace death panels as part of the UHC package and argue for them then you’re not dealing with reality.
There are deep Blue states the size of countries. We see politicians there occasionally run on UHC, one assumes sincerely. These true believer politicians are the ones who flinch away from just how expensive UHC is.
If it saved money, then various states would already have it.
Ditto if it were just a matter of a small tax increase.
Ditto if it were just a matter of a large tax increase.Report
This is another example, where all this effort and energy is devoted to proving that any change is un-possible.
Death panels, really?
We already have socialized medicine for a large segment of the population. The military, elderly, the indigent all get socialized health care.
That is to say, we already provide this socialized health care to the oldest, sickest, poorest segments of the population.
But somehow delivering it to young healthy people is just crazy talk.
And of course, notice how the “astronomical” cost is, when placed alongside the budget for the military and prisons.
But this relates to my previous comment.
It would be nice to imagine universal healthcare is cheaper, but asserting that only leads to arguments like this, where “you will pay more!” is the trump card that shuts down debate.
Yes, I want to pay more. I want us all to pay more if it leads to healthcare being universal.Report
You already live in a Deep Blue state which is large enough to have UHC if your Leftish politicians would stop flinching at the price.
Their behavior suggests no matter how much more in taxes you think you’d be paying, it’s no where close to reality.Report
@dark-matter I’d be all for California to go for UHC if they could also deficit spend like the Federal Government could.Report
@chip-daniels, do you really think we can implement UHC without some type of rationing?Report
Do you think any system at all is going to provide infinite amounts of health care?Report
Do you think we don’t already have them?Report
Yes, right now we ration largely by price (even if that is handed off to insurance companies). As far as I can tell, UHC is basically an attempt to get rid of that.Report
Not really. We have essentially a type of single payer Gov UHC for senior citizens, disabled people, vets and many children. We have rationed , pre ACA based on employment status and whether people had pre-exsisting conditions. We’ve had a patchwork of systems and payers but we have not just rationed simply by price. The gov provides care for some of the expensive cases or we’ve pushed that onto ins companies/ hospitals.
We will always have some sort of rationing. What would advance the discussion is talking about the values of covering everybody vs. letting some people go without based on the choices of our system. Because as is amply shown in many other countries it is entirely within our grasp to provide a high level of high care to everybody. Not everybody gets everything they want but good care offered to everybody.Report
I think that’s a fair statement.
I’m fine with “values” (although I suspect you mean “ethics”). I also agree we’re always going to have rationing.
What I view as absurd is a refusal to discuss what kinds of rationing (cost controls, cost reductions via firing people, market competition, etc) we’re going to use in whatever system we want to replace the one we have.
What I’m hearing here is… we’re not going to fire millions of people, we will increase demand on the system, apparently it’s not going to increase costs more than a bit… the underlying assumption seems to be the Blue State politicians flinching away from the costs are doing so without reason.
Define “not everybody gets everything they want”.Report
Yes, lets have a discussion about the tradeoffs.
But in order do that, we would need to be honest about what is happening right now.
Because right now, there are death panels within insurance companies deciding who gets what treatment.
Right now when the insurance money runs out, sick people are dumped onto the street.
Right now people without money are barred from care.
Right people go bankrupt in exchange for care.
All the dystopian horrors invoked by UHC opponents are happening right now. They just don’t happen to the people who matter.Report
Yes, agreed with all of that. It’s absolutely appropriate to look at where we are now, and the current system’s strengths and weaknesses. I’d have put “cost” on your list of flaws btw.
Having said that, you’re basically pointing to all of the current system’s rationings and claiming whatever replaces it won’t do those… and imho any system will need to ration somehow. If you’re not planning on having a way to ration then your system isn’t workable.Report
Wouldn’t it be wonderful to imagine a Packers fan’s plan for a Bears victory? Oh, wait, that’s the exact opposite of what they want, so I guess we shouldn’t expect them to support it.Report
Well, that and @dark-matter ‘s comment above sort of illustrate what I mean.
The conservative vision is completely bounded by a “can’t -do” attitude, one where there is no possible alternative to poor people getting sick, going bankrupt, and dying in agony and poverty.
Every bit of energy and creativity is put to use to demonstrate why this must be so and to prove mathematically that it is un-possible.
But you know it wasn’t always like this?
People like young Chip imagined a world where families and churches and private charities supplied a robust social safety net, where no one had to die in poverty.
And old Chip still can envision this!
But here is the catch-
In order to have such a society of pious and selfless and altruistic Americans who gave generously of themselves to their neighbors, requires the same sort of hard work and sacrifice that it’s liberal counterpart does.
Because the same mindset that angrily declares “I’m taxed enough already!” is the same one that brushes aside the Salvation Army kettle saying “I gave at the office!”
Young Chip imagined Bedford Falls, but what we got was Pottersville.Report
By the standards of “young Chip”, we’re already at that level. The goal posts have been moved.
We measure “sacrifice” by “tax levels”. So… what level of taxation is enough? What I keep hearing is “more”.Report
Conservatives give way more to charity than liberals. We’re the ones who are trying to make private charity work. And there’s a big difference between “can’t do” and “shouldn’t do”. We think that government shouldn’t get bigger. If you want a conservatism that thinks it should get bigger, then that’s the problem. We’re can-doing all over the place, just not with bigger government.Report
Having actually worked at social service Catholic charity i never heard anyone, from the national office on down, think we could ever solve or truly cope with the problems we faced. Charities can be great but they have limits. In fact the well funded charity i worked for depended on federal grants to open new programs since that was a lot more stable then potentially unreliable donations.
You really can’t define the solutions to any social problem strictly in big or small gov or charity or no charity. Those are, at best, very crude terms nor do they actually address the actual problem.
Charity works best when the economy is great giving people more money to donate but fails when economy is tight or in poor areas where people have less money to give. Charity also works best when you have photogenic, sympathetic clients. If you have unsympathetic clients charity is poor model.Report
That’s wonderful!
But see, the actual measurable evidence says that this wasn’t sufficient, not prior to Social Security, not prior to Medicare, and not prior to Obamacare.
Despite private charity, people suffered in misery and died needlessly.
But you know what? If conservatives want to make private charity work, lets go with that.
Lets propose a framework of private charity that covers everyone, and leaves no one out in the cold.
What we know from history is that the primary safety net was the extended family and clan.
What is interesting from a modern perspective, is that they were actually not voluntary at all. They were enforced by shaming and social coercion, being more like taxes than donation. In fact, in medieval times, churches actually had the legal power to levy taxes.
This is what I meant, that if we had a culture that supported strong enforcement of tithing and donation, we would have essentially a liberal state.Report
A “tithe” is 10% of your “income”.
The gov spends 36% of the GDP. That’s more than 3 and a half “tithes” and uses the most gov favorable definition of “income”.Report
Shaming and coercion were features, not bugs, of the older systems. Big modern systems have to apply law without understanding the individual needs of the recipient. Smaller organizations (family, local church, even local government) can address the recipient’s needs better. They can prevent that free rider problem that statist systems are plagued by. To be sure, there are also problems that smaller, more immediate systems have to watch out for, but overall I prefer the smaller systems over the larger.Report
Well sure, there’re plenty of parts o’ the world that still run on shaming, coercion along with local and family control. People have been frantically running from those parts of the world to the modern one for over a century now.Report
No one likes shaming. Everyone likes goods given with no strings attached. The ideal that I’m looking for is where, if aid is needed, the family or community respond to the person’s needs, even the awkward ones like moral direction. In a modern society, the individual has the freedom to walk away from his tribe and risk living life on his own terms. I hope that people are coming here for the opportunity, not the free stuff (and by “free” I refer to zero cost as well as lack of obligation).Report
Well, that is the ideal we all want, right?
A world where communities are strong and supportive.
I guess my experience with history is that we, collectively, find it difficult to construct those communities because it chafes our desire for individual liberty.
These traditional communities tend to bundle things together- you are given access to the community financial support, but only by complying with their moral and religious dictates.
Modern liberalism avoids that by splitting financial support from our personal ethical choices.
I suppose my challenge to conservatives is this:
Given the contours of American culture, if we did in fact erect a social safety net enforced by shaming, where financial and social mores were all bundled together, would conservatives even like this, or would they find it intolerable?
Because conservative cultural mores are now the minority, tolerated by the majority.Report
There’s no way to give a short answer to that, so I guess it’s time for Pinky’s Unified Field Theory of Conservatism. You may not agree with much or any of it, but I just have to lay it out here because it’s sort of underlying a lot of my thinking.
First of all, most everyone starts out from a fiscally conservative, socially liberal position. It’s natural for a Westerner. Everyone does his own thing, and we collectively pay our own way. Picture your average non-political Austrian body builder turned actor turned governor – that’s the way he’s going to think. (I’d venture to say that even fiscal liberals think of themselves as fiscally conservative; they think the taxes just aren’t high enough yet.) But social liberalism’s primary trait is its failure to distinguish between the way of life that has historically led to success and its many alternatives. The most obvious example is the two-parent family. There have been many people who succeeded without one, and many miserable lives despite having come from a two-parent family, but on the whole a person is more likely to be better off if he was brought up in one.
Now, the socially liberal fiscal conservative will start to notice that the need for social programs is increasing. People are living higher-risk lives, and overall facing greater need. This leaves three possibilities. The libertarian-leaning fella will say that people made their own beds, and now they have to sleep in them. That’s great in theory; you can stick to the socially liberal fiscal conservatism consistency. But human nature doesn’t allow us to sit around when people are suffering; we want to help them. The libertarian will explain to the paraplegic that motorcycle helmets shouldn’t be mandatory, then wonder why he can’t crack 3% in the polls.
Second possibility: become more fiscally liberal, perhaps without even realizing it. The people want you to spend more, after all. They also don’t want their taxes raised. This is a solid option for your nonpolitical Austrian type. And if you can do this without realizing it, well, limited cognition means limited cognitive dissonance.
Third possibility: social conservatism. Preach what you practice. Become the least popular person in the room.Report
Fourth possibility, and the one that actually happened: Trump.Report
There are two ways of taking your statement that Trump happened: either that conservatism leads to Trump, or that Trump represents a kind of thinking that can result from conservatism. I don’t think either take is accurate. To the first (which is what I’d guess you meant), Trump is much more a phenomenon of celebrity, timing, and widespread disgust than of conservatism. We can’t know the future, but I see no sign that he represents a movement or will have a legacy. As for the second possible meaning of your statement, I see Trump as very, very early on his intellectual journey. He probably has the fiscal conservative, socially liberal bent that most Westerners start with, but he hasn’t built anything like a belief system, which is what my post was about.Report
Trump is what conservatism has turned into. We all hoped (at least I did) that he’d be ineffectual, because of his ignorance, short attention span, and terminal pettiness, but most of the conservative media and all of the conservatives in Congress have lined up behind him . His strongest support is among white evangelicals, so the social conservatives most of all.Report
Trump is who conservatives turned to.Report
So was You Know Who.Report
Sorry, who?Report
The one the French Right preferred to Blum.
https://www.haaretz.com/jewish/.premium-1872-france-s-first-jewish-pm-is-born-1.5237460Report
…and all of the conservatives in Congress have lined up behind him.
I have to admit that the Republicans overall in Congress have moved much less strongly than I expected. I’m on record here thinking that the legislative filibuster would be toast, and there were a half-dozen changes that would be made promptly. High on that list was the one-sentence add-on to the Clean Air Act: “For the purposes of this act, CO2 is not a pollutant.”
Tangentially, CO’s Gov. Hickenlooper has declared that (a) Colorado will follow California’s mileage standards instead of the feds, and (b) CO is joining the case to protect CA’s privilege to set those standards until Congress (not the EPA) takes it away. I view this as the first real evidence that Hick is really thinking about a 2020 run at the Presidential nomination as the western Dem instead of Harris or Bullock.Report
Good news! People already look to family and community for aid when needed. In fact that never ever stopped. They borrow money from family, they live with family, have family do their day care, etc, etc. Churches, synagogues, mosques offer all sorts of help. Community groups like food kitchens are in every mid size community. The family/community aid conservatives want has always been there.
However many of those community groups also want and use Fed aid when they want to increase their services. Most communities don’t’ have the resources or ability to build drug rehabs or provide for medical needs or do child protective service work. They need government, state or large city, which have more resources and steadier financials to do that. It’s easy to wistfully look back at an earlier age when family/community did everything. However no one had tens of thousands of dollars a month of hospital bills many decades ago. The things gov do came about because family/community couldn’t or wouldn’t do those things.
Anecdata: I had a guy in my office years ago who was pissed at the State for giving his wife health insurance for their child and food stamps. The State giving her that allowed her to leave him. Sure he was drunk often and abusive. But Their Religion, old fashioned Russian Orthodox fwiw, said the wives stay with the husband no matter what. The damned state was getting in the way.Report
There’s an important concept buried here that most people, and in particular most conservatives that pine for family and charity support as the solution, ignore or don’t even realize.
The reason people didn’t have tens of thousands of dollars in medical bills in the good old days was that the technology didn’t exist to treat a significant amount of things that can, and are routinely treated today.
Family and charity meant mostly palliative care. There were no hip replacements, no quadruple bypasses, no brain surgeries, cancer meant dying within months, high risk pregnancies meant lots of mothers and newborns dying. Basically, the only thing medicine from the 50s could cure were infections and broken bones. You don’t run tens of thousands of dollars just on antibiotics and casts.
Even if we wanted, we can’t do that anymore.Report
In fact, in medieval times, churches actually had the legal power to levy taxes.
Not only that but the church owned something like 1/3 of the land in Europe at the time. Many of those peasants were working the land rent-free.Report
RE: Optimism
1) The upcoming massive increase in productivity coming from robots will be a massively good thing for society and not leave people jobless and starving in the street.
2) GW will be slow enough that we adapt to it and/or increases in technology will take care of it.
3) The following will be better off in the future: Me, My children, Society in general, and the Poor.
4) The vast bulk of Trump’s fear mongering is political and self serving. The vast bulk of the Left’s fear mongering is political and self serving.Report
You’re not looking at primary care. Most of primary care in singapore is not in the hospitals. GPs are in clinics and polyclinics. The latter are government run and cheaper (for adult citizens* its about $13, children its half that.), but have longer waiting times. A private clinic visit usually costs between $25 to $30 and the waiting times are correspondingly shorter. Even private clinics are not unaffordable to most people except perhaps for the poorest in society.
Incidentally, I got rear ended yesterday and my neck got strained. I booked an appointment with the GP assigned to me by NHS and the earliest appointment I could get is a week from now. In Singapore, I could walk into a private clinic without appointment and get seen in half an hour.
*For permanent residents it goes up to $32 and $51 for non residents.Report
I have very good private insurance, and usually can’t get a doctor’s appointment in less than a week.Report
For us, this has always seemed to be less a matter of the insurance and more a matter of the particular office.Report
He6: Sure, someone in their twenties with no unusual issues and who avoids power tools can go the entire decade without seeing a doctor. I pretty much did. (This may be different for women, with their reproductive bits requiring constant attention.) But after thirty, you start falling apart. It begins gradually, but you find yourself discovering body parts you hadn’t known you had, and I don’t mean this in a good way. I was in my early forties before I broke down and got a primary care provider. This was fairly early in my marriage, and I came down with double pneumonia. When I gasped to my wife that I was willing to see a doctor, she thought I was on my death bed. A century ago I might have been. Antibiotics cleared it right up. At this point I am on enough routine medication–nothing dramatic: just stuff American males in their fifties take–that semi-annual visits are pretty much inescapable. If I delay too long, my doctor cuts off my refills.Report
I went to the doctor when I needed to. I just went to a clinic where I didn’t have my own doctor. I would just see whoever’s turn it was.Report
Correction: If you’re a man in your 20s. Women, at least those who might have a reason to want/need contraceptives, do need to see at least an ob/gyn on a yearly basis.Report
Hence the parenthetical about women and their lady bits.Report
Yeah, hormonal birth control is pretty much held “hostage” (as some people say). There may however be good reasons for this; I know a lot of people who wound up with some bad long-term effects and it can affect things like blood clotting.Report
He3 might have something to do with He5.
Just saying.Report
He5 is radioactive.Report
If they’re only shortening lives by 10^-22 seconds, I don’t see why anyone bothers.Report
(applause)Report
He8- Ugh Taubes. This is how a guy with a good insight takes a good idea then crashes and burns just because he is a zealot.Report
He2 — If greatly increased life spans did not come with longer periods of the diseases and infirmities of old age, our vibrant, healthy selves would have a few extra decades of doing vibrant, healthy things. Then, at some point, the odds that we would fall off a ladder, suffer permanent brain damage after a 30-year run as an NFL quarterback, or otherwise f**k ourselves up royally and for the rest of a depressingly long life would be close to a sure thing.Report
He7 – “The medical community has always done a good job of recognizing the impact of fatigue on all sectors but their own.”
People recognize that provider fatigue is no good. The problem is that handoffs are worse for patient care than fatigue.Report
You know how they say a conservative is a liberal who’s been mugged? Well a proponent of single-payer is any average guy that’s experienced a major medical event.
My wife is a cancer survivor, so yay! modern medicine. But the financial consequences are devastating. It’s not just the amount left over after insurance pays; that’s a lot of money but it would be manageable if it were just one entity. You could make arrangements to pay over time as they’re generally amenable to that.
No, a big part of the problem is the sheer number of entities that are in the mix. She started at the local clinic, got referred to the regional medical center, and then finally to Big City teaching hospital. And it’s not just “an” operation. There’s also all the aftercare and did I mention six months of chemotherapy? So we were getting bills from ~20 different hospitals, clinics, doctors, labs, etc. Oh, and of course all this stuff runs across the new year divide so your deductible resets in the middle. (Pro tip: schedule major medical crises for January)
Now all these entities are perfectly willing to work with you, “We just need [$25, $50, $100] a month. Surely you can do that?” Add it up.and the “reasonable” payment arrangements add up to four figures a month. And of course our income is down because she can’t work during all this and we’re already paying, at the time ~150/wk in HC premiums (now ~200).
So, yeah… at the end you’re in a hole you can’t hope to dig out of and then the collection agencies start up and the only sane course of action is bankruptcy. Not proud of that but what are you gonna do?
You want to say the system is broken, but there really is no system. Not in the sense of an organized protocol or process geared to a desired outcome.
But single payer? Taxes??!! I’m currently paying over $800/mo for HC coverage. For a plan with $1500 deductible and 20% to 50% copays depending on type of service and whether the provider is in or out of network. My taxes would have to literally increase by an order of magnitude from where they currently stand just to break even. So Taxes! doesn’t really move me. I figure if taxes are your biggest financial problem then you don’t really have financial problems. Suck it up butter cup. You’re advocating in your best interest and so am I.Report