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Tilting at Windmills

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September 7, 2006
By: Kevin Drum

MARKETS IN HEALTHCARE....If we treat healthcare like any other market, allowing consumers free rein to purchase the services they like best, will it produce high quality results? A recent study suggests not:

Researchers from the Rand Corp. think tank, the University of California at Los Angeles and the federal Department of Veterans Affairs asked 236 elderly patients at two big managed-care plans, one in the Southwest and the other in the Northeast, to rate the medical care they were getting. The average score was high about 8.9 on a scale from zero to 10.

....In the second part of their study, the medical researchers systematically examined 13 months of medical records to gauge the quality of care the same elderly patients had received....The average score wasn't as impressive as those in the patient-satisfaction surveys: 5.5 on a 10-point scale. But here's the interesting part: Those patients who graded the quality of their care as 10 weren't any more likely to be getting high-quality care than those who gave it a grade of 5. The most-satisfied patients didn't get better medical care than the least-satisfied.

Surprise! Patients are poor judges of whether they're getting good care. And if consumer preferences don't map to high quality care, then a free market in healthcare won't necessarily produce better results or higher efficiency, as it does in most markets.

Back to the drawing board. Perhaps a national healthcare system would be a better bet to reduce costs, cover more people, provide patients with more flexibility, and produce superior outcomes. After all, why are we satisfied with allowing the French to have a better healthcare system than ours even though we're half again richer than them?

Kevin Drum 1:13 AM Permalink | Trackbacks | Comments (103)

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Comments

Does France have a good health care system? A few years ago, I recall large numbers of seniors dying during a heat spell.

Posted by: ex-liberal on September 7, 2006 at 1:17 AM | PERMALINK

France has just about the best healthcare system in the world. But, yes, people still die in France regardless. They haven't quite licked that yet.

Posted by: Kevin Drum on September 7, 2006 at 1:21 AM | PERMALINK

Someone told me, maybe he made it up, but in "ancient" China, doctors were paid a monthly retainer, and when you got sick, the payments stopped.

Just a thought.

Posted by: jim p on September 7, 2006 at 1:24 AM | PERMALINK

Those patients who graded the quality of their care as 10 weren't any more likely to be getting high-quality care than those who gave it a grade of 5. The most-satisfied patients didn't get better medical care than the least-satisfied.

Surprise! Patients are poor judges of whether they're getting good care. And if consumer preferences don't map to high quality care, then a free market in healthcare won't necessarily produce better results or higher efficiency, as it does in most markets.


Wrong Kevin. Ever heard of the placebo effect? If patients THINK they're getting health care, this makes them healthier due to the placebo effect. Customer preferences by their very nature DO map to higher quality care. So your argument against using the free market to determine health care is simply bad.

Posted by: Al on September 7, 2006 at 1:33 AM | PERMALINK

Al, I hate to disagree with you. However, recent medical studies have shown that the the plcebo effect is more-or-less worthless.

The real question is whether the government would give good, efficient health care. The example of the post office comes to mind.

In my opinion, the VA works well because government employees actually provide the care. They're fully responsible. However, if the government only paid for the health care, the system would likely be quite inefficient, as Medicare is.

Posted by: ex-liberal on September 7, 2006 at 1:39 AM | PERMALINK

Come on, Kevin, don't you be dissing the Libertarian dream of everyone being an expert in everything.

Posted by: Disputo on September 7, 2006 at 1:46 AM | PERMALINK

can't speak to France, but Germany is damn good, and they spend relatively little. it was a bit frustrating this summer, though, dealing with the intermittent physician strikes...something a US health care system would have no patience for. get it? patience! ha.

Posted by: Marc on September 7, 2006 at 1:54 AM | PERMALINK

Al explains the "placebo principle" of Republican governance:

If citizens THINK they're getting competent foreign policy, this makes them safer due to the placebo effect.

Posted by: theo on September 7, 2006 at 2:05 AM | PERMALINK

Does France have a good health care system? A few years ago, I recall large numbers of seniors dying during a heat spell.
Posted by: ex-liberal

seriously ... someone posted this?

In my opinion, the VA works well because government employees actually provide the care. They're fully responsible. However, if the government only paid for the health care, the system would likely be quite inefficient, as Medicare is.
Posted by: ex-liberal

currently, MDs in my hospital are paid dependant upon what myriad dipshit insurance companies decide the services were worth, which works out to less than 50% of the services provided. MediCal is generally a fairly good payer relative to many.

again ... are you actually being serious? short of fee for service where the MD takes on ALL the responsibility, there is already an existing inefficient middleman, which frankly isn't any better than your boogeyman of "government beuracracies."

Posted by: Nads on September 7, 2006 at 2:12 AM | PERMALINK

One other lesson is that things that a patient can evaluate, but which might not be so critical for quality of care--like how quickly she can see a doctor--will matter a lot to acceptance of a new healthcare regime.

Posted by: ogged on September 7, 2006 at 2:20 AM | PERMALINK

Nonsense! Health care is just like big-screen TVs! Only, you know, different!

Posted by: craigie on September 7, 2006 at 2:31 AM | PERMALINK

Does France have a good health care system? A few years ago, I recall large numbers of seniors dying during a heat spell.

I try to be civil, but really, you are a retard

Posted by: craigie on September 7, 2006 at 2:32 AM | PERMALINK

Okay, if no one else will tackle the France thing seriously, I will.

First, it wasn't just France. Between 35,000 and 50,000 people died heat-related deaths across Europe during that heatwave. Blaming any one healthcare system is absurd.

Second, in 1995, Chicago had 465 heat deaths in one week. Extrapolated to the European population, that equates to about 124,000 people. That was one week, not a full summer. Of course, urban areas will have higher casualty rates from heat waves, but not about 20 or 30 times higher, which is what it would have to be to be equivalent.

Third, that was an anomale never even approximated before in modern history. You need more than one data point.

Fourth, a substantial portion of France takes most of August off, which means the country was without significant numbers of healthcare workers; that wouldn't be replicated in the States.

Fifth, even if all those things weren't true, most people who die in heatwaves die because they don't take care of themselves and don't seek treatment. The healthcare system can't force people to go to a hospital. That's why the news always asks us to check on elderly relatives.

Posted by: jhupp on September 7, 2006 at 2:44 AM | PERMALINK

I need to correct something. The math in my second point is obviously suspect. While 124,000 people in one week is correct, my mental full summer estimate extrapolated from 124,000 is really absurd. It should have been more like 200,000, so the European equivalent would need to be only 4 or 5 times higher to be equivalent, not 20 or 30. Eesh, but the point still stands.

Posted by: jhupp on September 7, 2006 at 2:57 AM | PERMALINK

Kevin has written at length about the French health care system, as regular readers should know. The bullet point recap is that France's health care system is one of the very best in the world, provides universal coverage, same day appointments and same day referrals to specialists, and it manages all of this at roughly HALF the cost of what the US citizens pay for health care.

Of course, Republican attacks on 'socialized' medicine rely heavily on half-truths, distortions, and 20+ year old stereotypes. For example, I've heard some cite "scandals" in France about the costs: many doctors offices are located in very nice neighborhoods, even resort areas - which adds unnecessary expense. But those criticisms never seem to provide a complete story, which is that even with those unnecessary expenses, it still costs half as much as American health care.

Or take the 20+ year old stereotype of long waits and rationing in Britain. Yes, conservatives in Britain mismanaged healthcare decades ago. But that's no longer an accurate criticism under Blair.

Conservatives make a living by preaching that government doesn't work, then when they gain control they prove it.

The obvious lesson is: don't vote for conservatives.

Posted by: Augustus on September 7, 2006 at 3:19 AM | PERMALINK

Re; "If we treat healthcare like any other market, allowing consumers free rein to purchase the services they like best, will it produce high quality results?"

Yes - for paying customers, it will.

Posted by: Randy on September 7, 2006 at 3:24 AM | PERMALINK

Kevin Drum >"...After all, why are we satisfied with allowing the French to have a better healthcare system than ours even though we're half again richer than them?"

Only Al & similar pay check trolls are "satisfied" because they have no thinking ability beyond what they are handed for talking points

You, however, know better as do the rest of us so don`t be like these folks :

"Members of Congress tell the truth -- the whole truth -- only about a quarter of the time when debating major legislation on the floor of the House and Senate.

Instead, legislators mostly rely on half-truths, misleading exaggerations or outright inaccuracies when debating the nation's business..." WaPo

"We are all individual molecules of a great social gas." - Huxley

Posted by: daCascadian on September 7, 2006 at 3:37 AM | PERMALINK

Ahh, yes, doctors in 'unnecessarily expensive places' - we wouldn't want our doctors to live and work in the same places we do!

They should Diversify their Income, then!

Posted by: Crissa on September 7, 2006 at 4:01 AM | PERMALINK

"...After all, why are we satisfied with allowing the French to have a better healthcare system than ours even though we're half again richer than them?"

Because the French have the stones to bring the country to a halt for such things, while Americans are too busy arguing about American Idol?

Posted by: ahem on September 7, 2006 at 4:14 AM | PERMALINK

But we can't have national health care here! Why the poor ex-liberals of our great nation would simply get the vapors having to share the same health plan with those swarthy black and brown types! We can't let that happen, can we?

Posted by: Dustbin Of History on September 7, 2006 at 4:43 AM | PERMALINK

People keep using France as an example of a national health care system that works without examining the source of its success. A question that needs to be asked is whether or not we can replicate their success here.

We can't; at least not yet. We don't have the excess capacity to deal with a full national system, and even if we started to build now it would take many years. If we try to start a system before our infrastructure is ready, we will then, truly, have the worst health care system in the world.

It is true that the French spend less on healthcare than we do, but you can't just look at the total amount spent. Some of that savings comes from lower incomes to health care providers, for instance, which would never be allowed here. The French also spend more money in other places than we do, on the education of their doctors and nurses, for example, or on the aforementioned infrastructure. Comparisons can only tell you one part of the story.

In any event, switching to a national health care program here without adequate preparation is a recipe for disater, regardless of the quality of dentists in Paris.

Posted by: Point C on September 7, 2006 at 6:10 AM | PERMALINK

I would just like to say that I despise people like Dustbin, who post the most vile sorts of remarks and cover them under a veil of liberalism -- ad hominem attacks coupled with revolting language.

I can't imagine the disease of the mind that would put such ideas in one's head. Although I'm sure Dustbin does not consider himself a racist, clearly those thoughts must have come from somewhere. I know such things would never occur to me, except that every day such disgusting phrases are presented to me on progressive web sites. I resent that sort of comment, but what I resent more is that they are never given the treatment they deserve. Such things simply should not be allowed to stand, regardless of their purported liberal intention.

Dustbin and his ilk are racists. At what point will people stand up and support civility?

Posted by: . on September 7, 2006 at 6:39 AM | PERMALINK

By the way Kevin, American "Were" half as rich as the French. This is no more the case thanks to the dollar drop. Soon we will be poorer than Europeeans.
I guess one can't use the dollar printing machine forever. The Illusion has to stop and we are going to pay the price... no more affordable vacation in Paris.

Posted by: Camember on September 7, 2006 at 6:45 AM | PERMALINK

Great post, Kevin. If verified this study SHOULD have profound ramifications on a rational society. However, using the same standard to evaluate the American electorate based on the last presidential election, couldnt one reasonably conclude that democracy might not be the most cost effective form of government?

Posted by: Michael7843853 G-O in 08! on September 7, 2006 at 7:18 AM | PERMALINK

Most hard-core market advocates haven't actually ever taken a course in economics. If they had, they'd realize that for markets to work efficiently, every consumer must have perfect knowledge of what is being bought. Since it takes several years of highly concentrated training to acquire such knowledge in the healthcare field, it's absurd to think most consumers would have such klnowledge, and therefore the "efficiency of free markets" hypothesis does not apply.

Posted by: CN on September 7, 2006 at 8:08 AM | PERMALINK

The same people who are incompetent to judge as consumers are equally incompetent to judge as voters and will just elect idiots.

That's right, we need to be ruled by Philosopher Kings (like Drum) who will make the necessary decisions for us idiots. Once our smart and wonderful govt makes our decisions for us, all will be well. I sure am glad the people in govt aren't as self-interested as the mere mortals on the outside.

Posted by: Scott on September 7, 2006 at 8:21 AM | PERMALINK

Point C:You might be right, but to be honest, I don't think there's the time to go slow and build up infrastructure, to be honest. If something isn't done soon, either the society or the economy (or both) is going to collapse. I give it 20 years.

Posted by: Karmakin on September 7, 2006 at 8:31 AM | PERMALINK

Economists have long considered markets like this.
One of the key assumptions of the efficiency of the market is full information. When one party does not have full information, the market is almost certain to be inefficient. Classical cases are medical services, legal services, educational services and religious services. In many of these markets an acceptable degree of efficiency is maintained by a mechanism described as a Trust Market. The seller takes actions which very publicly show that he is not merely trying to maximize her profit. These might include: codes of conduct (think of the Hippocratic oath) or legal restrictions (think of universities only being able to invest in governemtn bonds) or pro bono work. While not entirely familiar today, this was the landscape in those fields in early 20th century America. The fact that these trust mechanisms have eroded largely explains the recent and growing ill repute of these professions. This is not to say that trust mechanisms are the only way for these markets to work. Regulatin and government monopoly can work as well. Just don't expect freely competitive markets to work efficiently on their own.

Posted by: dan on September 7, 2006 at 8:35 AM | PERMALINK

Economists have long considered markets like this.
One of the key assumptions of the efficiency of the market is full information. When one party (usually the seller) does not have full information, the market is almost certain to be inefficient. Classical cases are medical services, legal services, educational services and religious services. In many of these markets an acceptable degree of efficiency is maintained by a mechanism described as a Trust Market. The seller takes actions which very publicly show that he is not merely trying to maximize her profit. These might include: codes of conduct (think of the Hippocratic oath) or legal restrictions (think of universities only being able to invest in government bonds) or significant pro bono work. While not entirely familiar today, this was the landscape in those fields in early 20th century America. The fact that these trust mechanisms have eroded largely explains the recent and increasingly unsavory reputation of these professions. This is not to say that trust mechanisms are the only way for these markets to work. Regulation and government monopoly can work as well. Just don't expect freely competitive markets to work efficiently on their own.

Posted by: dan on September 7, 2006 at 8:38 AM | PERMALINK

Drum, you claim either:

A. You are one of the elite who can judge his own healthcare and deserves, on that basis, to be our Philosopher King on the issue.

B. You are equally incompetent to judge health care and thus have no business going on about the subject.

Posted by: Scott on September 7, 2006 at 8:40 AM | PERMALINK

CN,

Re; "...for markets to work efficiently, every consumer must have perfect knowledge of what is being bought."

No, for markets to work perfectly, every consumer must have perfect knowledge.

First, as perfect knowledge is an impossibility, perfect is not the standard for efficiency. Or if you wish to still believe that it is, how can government compete with the markets on that standard? How can any small group of individuals in government possibly have more perfect knowledge of the many billions of transactions which make up the economy than the billions of people who are directly involved in the transactions? It is true that the free markets are not perfectly efficient, just significantly more efficient than the next best option.

Posted by: Randy on September 7, 2006 at 8:51 AM | PERMALINK

Scott, that was silly. While Kevin or I or anyone else with a concern about public policy are not experts in every field that matters does not mean that we are not able to read and understand scientific studies about those fields. If you and George W Bush cannot understand such studies, you would do best to stay quiet until you have learned how. Don't just start making silly claims based on the talking points of your troll masters.

Posted by: freelunch on September 7, 2006 at 8:55 AM | PERMALINK

Kevin, you _do_ realize you've just invalidated every Canadian who brags about how popular their healthcare system is. If the cattle cannot judge their own care, they can't judge govt care either.

freelunch, if the cattle cannot pick the expert who will manage their private healthcare, they cannot pick the one who will manage their public healthcare. If 'research' will give them that knowledge for public care, it will give them that for private care.

If Kevin really is one of the cattle who doesn't know good or bad healthcare when he sees it, he can shut up.

Posted by: Scott on September 7, 2006 at 9:03 AM | PERMALINK

Randy, the problem we have in the healthcare market is that consumer expectations are inconsistent with good medical care. As consumers we act as if we want Marcus Welby instead of Gregory House, even though the story lines tell us that House would provide better medical care.

Even worse, we think we can diagnose our own illnesses. That is not to say that we don't need to learn to cooperate in maintaining our health. We do, but it was criminally irresponsible for Congress, the FDA and FCC to allow the advertising to consumers of prescription drugs and the selling of fake drugs, excuse me, dietary supplements without any proper safety procedures and we are fools to keep popping drugs that won't help for diseases that don't matter that much. Antibiotic overuse is just one example of our foolish approach. As a group Americans not only have imperfect knowledge, we have beliefs about health that are harmful to us.

Posted by: freelunch on September 7, 2006 at 9:10 AM | PERMALINK

I don't understand conservative's opposition to universal health care??? - It is the ultimate pro-life agenda: It would reduce abortions, lower divorce rates, lead to healthier children, provide long-term care to people like Terri Schiavo, prevent many elderly "mercy killings" and on and on. And don't say it would be too costly, either. We are pissing $1 billion a week down our collective legs in Iraq - this country could easily afford health care for every citizen without raising taxes significantly.

So, what's your problem, conservatives????

Posted by: The Conservative Deflator on September 7, 2006 at 9:12 AM | PERMALINK

Scott, I realize that objective scientific information is extremely unpopular in what passes for conservative circles these days, but you are still making false assumptions about this to justify your opposition to improved health care. In the United States, we have already demonstrated that expensive health care is not necessarily good. The US is the least healthy of the developed countries, yet is spends the most per capita. No matter how you spin it, the current system has been inefficient and ineffective.

Yes, there are things we can do today to change that. We can force hospitals and doctors to publish statistics about their effectiveness (not just a bunch of subjective testimonials but real, documented evidence). We can force hospitals and doctors to publish their prices -- and not allow them to discriminate in pricing. We can force drug companies to publish ongoing effectiveness studies. We can ban their consumer-oriented ads and not allow any of their marketing expenses to be tax deductible. We can include a real health education program in high schools that is serious about teaching students how to help their health remain high over their lifetime and how to be a good, helpful patient.

If our citizens are cattle when it comes to health care, it is because our government has failed in educating them and allowed those with economic agendas to miseducate them about health. Once again, the anti-regulatory claptrap of so-called conservatives undermines effective regulation and effective results.

Posted by: freelunch on September 7, 2006 at 9:23 AM | PERMALINK


kevin: If we treat healthcare like any other market, allowing consumers free rein to purchase the services they like best, will it produce high quality results?

is that why porn now outsells "regular" feature films in america?

Posted by: thisspaceavailable on September 7, 2006 at 9:28 AM | PERMALINK

Is anyone doing the analysis with Medicare D? You know . . . What percentage of people chose a plan that covered their current medication at a relatively low cost, how many plans they considered, etc.

A lot of people went through agents who only sold something like 2 or 3 plans out of 60.

Posted by: Drink Coke on September 7, 2006 at 9:40 AM | PERMALINK

>"If we treat healthcare like any other market, allowing consumers free rein to purchase the services they like best, will it produce high quality results?"

It's not the purchasing side that's the problem... it's the SUPPLY side. The supply of physicians is largely controlled by a private professional organization, the AMA. Take them out and the situation will change... while we are at it, might as well take out the ABA too.

Posted by: Buford on September 7, 2006 at 9:41 AM | PERMALINK

Freelunch,

I hear you, but the knowledge problem is solved by doctors, not government. The free market created the healthcare system that we have now - the system which many have decided that everyone should have access too. Its a damn good system, it just isn't free.

As I've said in other posts, the solution is to raise money so that the government can do what it does best - provide welfare for those who cannot afford to pay for what the free market can provide. But the money does not have to be raised solely at the expense of the existing private healthcare system. The nationalized health care folks are victims of tunnel vision. And its costing them, because the private system knows it is being picked on and is fighting back tooth and nail. Stop trying to nationalize healthcare and start raising money, and you just might get something done.

Posted by: Randy on September 7, 2006 at 9:58 AM | PERMALINK

Very interesting post, though not too surprising. I'm wondering if the same kind of study would reveal that satisfaction with universities also correlated poorly with their quality(an issue raised by Dan, as well). After all, in those cases, if consumers had perfect knowledge, they wouldn't need the universities, would they?

Posted by: Barry on September 7, 2006 at 9:59 AM | PERMALINK

Blah, blah. There is a whole economic literature on "credence goods." Basically, these are goods where consumers typically are uninformed and have to rely on experts in order to make a decision. Example: Your mechanic says you need to change the water pump on the car. You believe him not because you know anything about water pumps or cars, but because you believe him.

Anyone interested (probably just Kevin), you can read more in the Journal of Economic Literature at http://www.atypon-link.com/doi/abs/10.1257/002205106776162717

Posted by: renat on September 7, 2006 at 10:01 AM | PERMALINK

Buford,

I totally agree. The AMA, FDA, and other control freaks have driven up the cost of medical services to the point that the poor are left with only two options; government assistance or self medication. Much of our current problem would simply vanish if many of the restrictions placed on RNs were lifted.

Arnold Kling raised the point briefly at EconLog, but passed it over for his book because it is simply not feasible in today's political environment.

Posted by: Randy on September 7, 2006 at 10:04 AM | PERMALINK

Does France have a good health care system? A few years ago, I recall large numbers of seniors dying during a heat spell.

People died in France? Damn socialized medicine! Good thing our so called free market system has licked that problem.

Posted by: klyde on September 7, 2006 at 10:08 AM | PERMALINK

Kevin, just a question about the methodology of the Rand study: if you chose some other market (housing, cars, education, ballpoint pens, whatever) and performed a similar analysis (comparing the subjective assessment of the consumer to an objective evaluation of product quality by the researcher) do you really suppose that you would not find similar gaps between the subjective and objective assessments? Or that there would be little or no association between the objective evaluation and the subjective evaluations (the consumers getting a 5 at least as likely to give their product a 5 or a 10)?

I don't know what you think about that, but I suspect that this sort of disconnect is the rule rather than the exception (you might call it the Stockholm syndorme of consumption). People like to believe that they've made good choices and are happy with the choices they have made, so they have to be really unhappy to express disappointment (essentially with themselves). There is no reason why any objective measure of value would line up consistently with consumer preferences. This suggests that if markets are efficient and effective resource allocation and social accountability mechanisms, it is for reasons that have little or nothing to do with any putative close connection between consumer satisfaction and product quality.

Posted by: Rich C on September 7, 2006 at 10:23 AM | PERMALINK

It's a very interesting factoid you presented Kevin. If consumers are incapable of acertaining their level of care then classical economic theory would prove that health care can not be an efficient market.

HA!

Posted by: Nemesis on September 7, 2006 at 10:25 AM | PERMALINK

Randy on September 7, 2006 at 9:58 AM:

Stop trying to nationalize healthcare and start raising money, and you just might get something done.

Yeah, like, with all that extra money raised, medical costs are going to go down and what's wrong about the US healthcare system is going to fix itself. Riiight...And getting rid of the AMA will actually improve the quality of care.

Like I keep saying, you really haven't thought this through, have you, Randy?

So again, why exactly do people such as yourself oppose a form of universal health care in the US? No one seems to be able to provide a good argument against it...only some easily rebuffed factoids and a lot of ideological hyperventilating.

Posted by: grape_crush on September 7, 2006 at 10:29 AM | PERMALINK

We are pissing $1 billion a week down our collective legs in Iraq - this country could easily afford health care for every citizen without raising taxes significantly.

Go do some math (use Canada's per capita health costs as a starting point) and get back to us on that.

Posted by: helmuth on September 7, 2006 at 10:31 AM | PERMALINK

How the hell do you tell exactly what quality of care you're getting from medical records? Somebody writes down "did a crappy procedure today?" or "cut some corners on diagnosis?"

Posted by: gary on September 7, 2006 at 10:36 AM | PERMALINK

"French Health Care Service on Verge of Collapse"

Posted by: luigi on September 7, 2006 at 10:44 AM | PERMALINK

Grape,

First, I'm not opposed to universal healthcare. I'm opposed to doing it at the expense of the current system which is working just fine for its paying customers. Second, no matter what kind of universal system you put in place, its going to require money. So lose the tunnel vision and start thinking of how to raise the necessary funds. Third, of course costs are going to rise. Anytime you throw money at a problem the cost is going to rise. So don't you think you might need a broader source of revenue than what exists in the private healthcare system?

Posted by: Randy on September 7, 2006 at 10:53 AM | PERMALINK

I'm in favor of single payer, but the study just suggests that a free market system based on patients' subjective choices will not work efficiently. You could correct his if, under the free market system, Rand (or someone) studied each hospital and posted their findings, and patients could then choose a hospital based on this objective measure. I still don't think a free market system is the right way to go, but structuring incentives and creating transparency should be helpful in a single payer system as well.

Posted by: RM on September 7, 2006 at 10:59 AM | PERMALINK

How the hell do you tell exactly what quality of care you're getting from medical records?

Autopsy reports are generally pretty accurate.

Another obvious sign would be silly procedures prescribed by nurse practitioners (negative pregnancy tests, cheap antibiotics prescribed, anti-inflamatory drugs, etc.) instead of blood work, x-ray, consulting doctors, or referring to specialists.

Cheap healthcare frequently means you get treated for the disease that is the best guess of an undertrained technician instead of a more vigorous diagnosis followed by the best treatment. You'll sit around longer with a broken foot, asthma, etc. before you're fixed up.

Posted by: B on September 7, 2006 at 11:07 AM | PERMALINK

Randy on September 7, 2006 at 10:53 AM:

I'm opposed to doing it at the expense of the current system which is working just fine for its paying customers.

That's the point; it's not working 'just fine' for many paying 'customers', Randy, and even worse for nonpaying 'customers'...Or for doctors, which have to put up with multiple layers of insurance bullshit in order to care for their patients.

its going to require money

And I'll repeat my same reponse to that from previous thread when you brought it up.."Well, duh.." There are several flavors of UHCs with different means of generating funding; generally through some form of taxation. Figure out which one is the least offensive to you and quit bringing up the obvious. Talk about 'tunnel vision'...

The only critiques of some sort of public health care plan you've given here or the prior thread is "We need more money to pay for health care for people without it!" and "I'm not paying for unemployed welfare queens!"

Which is to say that you have no solution other than throwing more money down a hole and letting the uninsured 'eat cake'...The health care system in the US is broken and throwing more money at it alone ain't gonna fix it.

Posted by: grape_crush on September 7, 2006 at 11:17 AM | PERMALINK

"Another obvious sign would be silly procedures prescribed by nurse practitioners (negative pregnancy tests, cheap antibiotics prescribed, anti-inflamatory drugs, etc.) instead of blood work, x-ray, consulting doctors, or referring to specialists.

Cheap healthcare frequently means you get treated for the disease that is the best guess of an undertrained technician instead of a more vigorous diagnosis followed by the best treatment. You'll sit around longer with a broken foot, asthma, etc. before you're fixed up. "

And your evidence for any of this is??

Doesn't exist, does it. Fool.

Posted by: CN on September 7, 2006 at 11:49 AM | PERMALINK

My mother recently had some medical care while on vacation, she just turned 70. She thought the care she received was super fantastic. The clot in her carotid artery prevents her from having a critical point of view. Everyting is super fantastic to my mother, altough she is finally realizing Bush is a bad president, so I hope the opening up of this artery will restore at least some objective critical thinking.

Old people are made happy by just being polite to them, which I think is why they say the medical care they are receiving is so good. I would like to see all medical care subject to statistical quality controls.

Posted by: Hostile on September 7, 2006 at 11:54 AM | PERMALINK

It is true that the free markets are not perfectly efficient, just significantly more efficient than the next best option.

Based on what ? (in regards to healthcare)

Posted by: Stephen on September 7, 2006 at 12:06 PM | PERMALINK

ex-liberal: In my opinion, the VA works well because government employees actually provide the care. They're fully responsible. However, if the government only paid for the health care, the system would likely be quite inefficient, as Medicare is.

Ah, so you're in favor of a fully "socialized" system (like Britain), rather than a universal insurance approach (like France, Germany, Canada, Japan, Australia, etc.).

Well, I don't agree, but everyone is entitled to an opinion.

Posted by: alex on September 7, 2006 at 12:07 PM | PERMALINK

Markets don't always give you the best products; Beta was better than VCR, but VCR won the market battle; Apple's OS was better than Microsoft's, but we all know how that played out.

Health is not a commodity; to apply market principles to health care is just stupid. I'm all for leaving VCR's, computers and other "widgets" to the whims and vaguaries of market forces, but my health (and that of my parents and my children) is far too important. I have to live in the real world, so I don't have too much faith in the magic market fairies to make everything right.

Posted by: A Hermit on September 7, 2006 at 12:08 PM | PERMALINK

Grape,

You know, I'm not sure why I'm even arguing with you about this. The truth is that you will not be able to do what you want to do.

There will always be people who are willing to pay more to get better service - who will pay more for the best doctors, the best equipment, private rooms, no waiting, or home visits. You won't be able to change this. You might be able to drive the best medical professionals away from public service (a trend which has already begun) but you won't be able to tap into the money that the wealthy are willing to spend on healthcare. They will simply turn to private clinics and private doctors. All the best medical professionals will follow the money, go private, and leave the public system with second rate doctors, long waits, and publicly funded facilities.

Take my advice. Start looking for money. Because you're not going to get it out of the current system. And you're going to need a lot if you insist on driving the big money away.

Posted by: Randy on September 7, 2006 at 12:11 PM | PERMALINK

Point C: In any event, switching to a national health care program here without adequate preparation is a recipe for disater

The answer is to phase it in. Kerry proposed this in the 2004 campaign. Start with universal catastrophic insurance.

Posted by: alex on September 7, 2006 at 12:13 PM | PERMALINK

Shorter Randy, ex-liberal et al:

Since every other advanced economy has already solved the problem of providing universal health care at affordable prices, what we must do is to come up with some other completely untested system which none of them use and which may fail to provide universal coverage or cost savings, but which will certainly funnel gazillions of dollars to private US corporations.

Posted by: brooksfoe on September 7, 2006 at 12:35 PM | PERMALINK

Randy on September 7, 2006 at 12:11 PM:

You know, I'm not sure why I'm even arguing with you about this.

Lol - Because we're both kinda stubborn like that. The point is that we are talking and making an honest attempt to understand the other's side.

The truth is that you will not be able to do what you want to do.

Same thing was said about racial integration, women's right to vote, and a host of other sensitive issues. It's a matter of national will.

There will always be people who are willing to pay more to get better service.

And with a two-tier system such as Australia's, they can get the better service that they desire; Canada's system isn't the only model out there, you know...Or maybe you don't. Well, now you do; research away.

You might be able to drive the best medical professionals away from public service

Unless a licencing requirement is that they spend X amount of time caring for public program patients...See? Problem solved!

..but you won't be able to tap into the money that the wealthy are willing to spend on healthcare.

Heh. You lack imagination, Randy...All sorts of ways to gather the money, just not enough will to do so at this time.

All the best medical professionals will follow the money, go private..

Not if a requirement is in place such as the one I stated above.

..and leave the public system with second rate doctors, long waits, and publicly funded facilities.

Second-rate doctor or no doctor? Oh, that's an easy one, Randy...

Because you're not going to get it out of the current system.

Which is why we want to build a better system, Randy. Sheesh.

Posted by: grape_crush on September 7, 2006 at 12:52 PM | PERMALINK

Point C above makes some excellent points about why it would be difficult to "switch" to a universal health insurance mechanism in the States, but he misses one critical point. Solidarity.

In the international health insurance literature, "single payer" or "universal coverage" is referred to as "social health insurance." We supporters of SHI here in the States don't like to use that term because of its instant association with "socialized medicine," the fear-word bandied about by the right.

One key concept of SHI is "solidarity," the concept that the relatively healthy/wealthy ultimately subsidize insurance coverage and health care for the relatively poor/unhealthy. That's why we'll have so much difficulty with universal coverage here. Many Americans generally don't want to subsidize anything for anyone, whereas in Europe it's understood that cross-subsidy is part of the social compact.

Remember the ads the insurance companies ran during the ill-fated Clinton-era attempt to propose a universal coverage system? The ads were all about reinforcing the viewpoint that "we don't want to pay for someone else's care." Basically, at a national level, on average, we really don't give a shit if people are without insurance.

How the hell do you tell exactly what quality of care you're getting from medical records?

This is done all the bloody time in health systems and services research. Get some clinical evaluators working on your research team, dude. It's not rocket science.

Posted by: Wonderin on September 7, 2006 at 1:08 PM | PERMALINK

Grape,

Re; Licensing requirement equals problem solved.

You do realize you're talking about slavery, don't you? That is a much predicted eventual outcome of socialism. And when the doctor just doesn't quite get around to seeing his or her public patients, what will you do? Throw her in jail? Perhaps 20 lashes in the public square? Or what if the waiting time for public patients grows from months to years? Or the best medical facilities and practitioners move to the Bahamas. How will you solve these problems? Maybe the lash - but more likely with cash - and so we come full circle. Problem solved? Not hardly.

Posted by: Randy on September 7, 2006 at 1:10 PM | PERMALINK

Randy: You do realize you're talking about slavery, don't you?

Hmmm, slavery. By your rather broad definition jury duty is also slavery. Of course a doctor would be required to only put part of their time into the public system, and they will be paid for it, and nobody is forced to be a doctor. Sounds more like a licensing requirement to me.

Heck, the gov't forces me to pay taxes on the money I earn. That's part of my income (equivalent to part of my time). Isn't that slavery? Since I pay taxes...

[clears throat]

Swing low, sweet chariot, coming forth to carry me home!

[new verse]

Gotta fill out a 1040...

That is a much predicted eventual outcome of socialism.

Is that before or after the dictatorship of the proletariat?

BTW, please define "socialism".

And when the doctor just doesn't quite get around to seeing his or her public patients, what will you do? Throw her in jail?

Nah, that'll just cost the taxpayers more money.

Perhaps 20 lashes in the public square?

That appeals to my nostalgic side, but some bleeding heart will probably complain. Maybe a fine, with the ultimate penalty being a loss of license.

Or what if the waiting time for public patients grows from months to years?

Then that will mean that inadequate resources are being spent, or they're being spent inefficiently.

Since countries like Japan have a fixed price they pay per procedure, and they have no shortage of doctors, I don't see that we'll have a problem either.

Or the best medical facilities and practitioners move to the Bahamas. How will you solve these problems? Maybe the lash - but more likely with cash - and so we come full circle.

Full circle on what? That medical care costs money?

Hint: the first, and perhaps only truly ironclad rule of economics, is that there is no such thing as a free lunch. However, some lunches are a better bargain than others (that's what economics is all about). And, ideology be damned, all empirical evidence shows that a UHC system is a better bargain.

QED

Posted by: alex on September 7, 2006 at 1:48 PM | PERMALINK

What patients want and what is quality care are two completely different things. Patients want access to any doctor or service at any time whether or not the doctor is good or care appropriate. Closed systems like the VA and Kaiser Permanente consistently rank at the top in quality measures because care is coordinated, appropriate care decisions are made by medical professionals and electronic medical records give the full patient picture. These types of systems allows for much better monitoring of chronic diseases as well as easy evaluation for drug interactions which can be fatal at times.

Unfortunately, many people don't like closed systems because they see it as a "restriction" on who they can see for services. We could quickly improve quality of care and reduce cost through VA like systems but you will get a lot of resistance from patients as well as the medical establishments. Patients equate freedom to go where they want with quality even though that is not generally true.

Posted by: John Mills on September 7, 2006 at 1:49 PM | PERMALINK

I generally run away screaming from anyone who makes the argument "we intellectuals think that individuals don't make good decisions for themselves, so we are going to get the government to make them for them." This is the fast lane to serfdom

Here is the false premise: If the intellectuals judged that the individuals involved were getting poor care when the individuals thought is was good care, this does not necesarily mean the individuals were wrong. It could mean that the intellectuals and the individuals studied judged care on different dimensions and with different priorities. Or it could mean that the individuals studied had incomplete information about their care and their choices. Neither justifies a governemnt takeover of the industry.

Posted by: Coyote on September 7, 2006 at 1:52 PM | PERMALINK

John Mills: We could quickly improve quality of care and reduce cost through VA like systems but you will get a lot of resistance from patients as well as the medical establishments.

Then how do you explain the satisfaction of those in the VA system? Or that many more people want to get into it than are able to. The president of the VFW wants all vets to get it. I think he's right. After that we can offer it to all Americans.

Posted by: alex on September 7, 2006 at 1:53 PM | PERMALINK

It is true that the free markets are not perfectly efficient, just significantly more efficient than the next best option.

Ah, another worshipper of the Invisible Hand who dropped out of Econ 101 before the midterms. I'm shocked....

Posted by: Disputo on September 7, 2006 at 2:14 PM | PERMALINK

Grape,

Re; "Of course a doctor would be required to only put part of their time into the public system..."

Well that's good news, but its going to take more than a couple of hours a week to meet the demand.

But why do you even think you will be able to make this happen? Doctors and hospitals are dropping out of the public system even now. Dropping medicare patients right and left. Hospitals closing their ERs or new ones being built without them. Obstetricians and General Practitioners abandoning rural areas. Nobody is doing anything about it. What makes you think that the situation will change for the better under a universal system?

P.S. Yes, use of the word "slavery" is hyperbole, but you can bet your ass it will be tossed in your face the minute you try to pass your "licensing requirements". And you'll lose. Because this is still America - land of the free. If you're not seeing this, its because you haven't set foot outside a blue state (or blog) in too many moons.

Posted by: Randy on September 7, 2006 at 2:21 PM | PERMALINK

Disputo,

I'm writhing in the crushing grip of your reason :)

Okay doc, show me a more efficient system than the free market. Start with the system objective. Remember that it is not the objective of the free market to bring about "social justice".

Posted by: Randy on September 7, 2006 at 2:25 PM | PERMALINK

Randy, I was going to respond to your latest post, but alex got there first and did a much better job of countering your arguments than I possibly could have...

Since you are "not opposed to universal healthcare", and your current set of arguments have been effectively countered and nullified, what are your other objections to setting up a form of universal health care system here in the US? Are they purely ideological, based on a fear of change, or something else?

Posted by: grape_crush on September 7, 2006 at 2:30 PM | PERMALINK

Regarding health, we are not consumers, we are patients. Ask somebody having a heart attack if he or she wants to first check Consumer Report to see who the best doctor or hospital is in the area before calling 911.

Universal health care/single payor system is the only solution.

Posted by: Leftofcenter on September 7, 2006 at 2:48 PM | PERMALINK

"Markets don't always give you the best products; Beta was better than VCR, but VCR won the market battle; Apple's OS was better than Microsoft's, but we all know how that played out."

According to technical experts Beta is "better", but everyone who bought a Beta player ended up regretting their decision. If you were magically transported back to 1980, would you buy Beta or VHS? If you answered Beta, then you're an idiot; if you anwered VHS, then you must think that VHS is superior.

I'd say the technical experts were wrong, because they based their assessment on the technology not on the customer needs. Consumers wanted a player that would be around in 5 years and still be able to play movies. The ones that bought VHS got what they wanted, the ones that bought the "superior" Beta got an expensive paper weight.

When DVD's first came out, they were technically inferior to VHS - after all you couldn't record on them, you couldn't watch your home movies on them, and the DVD players cost 5 times as much as a VCR. How could stupid consumers possibly think such an abomination was worth buying? We should have forced everybody to hold onto their Betamax and outlawed DVD's.

Judging whether one product is better than another is always subjective. The rating of the doctors by medical experts only took into account medical records. They did not rate how well the doctor communicated with the patient; whether or not the doctor bothered to answer the patients questions; if the doctor put the patients mind at ease or not; how long the patient was kept waiting; etc. These things may not be important to you, but evidently the patients surveyed find them important.

Posted by: c on September 7, 2006 at 2:49 PM | PERMALINK

grape,

Call me stubborn or foolish, whatever, but I don't see that you have countered or nullified my arguments. You simply commented on all of them.

But again, I have no objection to government welfare in the form of health care. I do recognize the need for it. I'm even willing to help pay for it. All I'm saying is that the new system should leave the existing system in place. I don't even care if it competes with the existing system as such competition could have beneficial results. Raise as much money as you can, and use it as effectively as you can.

Forget the wealthy. They are going to have better houses, better cars, and better dressed wives than we have. And they are going to get better healthcare than we have. But if we all chip in, we can create an affordable system for us. And it can be done quickly. Once you bypass the objections and political power of the wealthy, its a simple matter of passing the hat and hiring the professionals.

Posted by: Randy on September 7, 2006 at 2:51 PM | PERMALINK

As Kevin says, patients often do not evaluate the care they received realistically. And as others above have mentioned, in matters of health care, people don't operate on complete and accurate information. Others yet have mentioned that this is also true of other types of purchases which people make.

However, there are 3 large differences between health care and other types of purchases.

1. With many purchases, such as buying clothes, cars, computers, houses, toys, other durable goods, car and life insurance, etc., if you make a wrong choice, it will probably not be life-threatening or result in permanent maiming.

2. Also, for food, housing, insurance, durable goods, etc., you have the time to comparison-shop. Not everyone takes the time to do so, but they can if they choose.

With health care, your choices are first circumscribed by what sort of health plan you're on. Many have a list of doctors. That list is usually quite capacious in the larger urban areas, but still not unlimited.

It's almost impossible to get complete information on the physicians you can choose from. Public Citizen Health Research Group used to put out Questionable doctors disciplined by states or the federal government, but this hasn't been published since 2002, and then for regions rather than the whole country. It also was organized by state, then alphabetically by doctor, but there was no alpha index of doctors' names. So if you were researching a particular individual, now practicing in your state, but not having had reportable problems in your state, the only way to see if he/she had had problems in another state was to look at every other state, and I believe also the various territories and protectorates like Puerto Rico.

You can go to your state's Board of Medical Examiners or the equivalent. Many states' Boards do have a list of doctors against whom complaints were lodged. BOMEX in Arizona offers that information. But it's sketchy and not much more than whether the doctor was disciplined or that the complaint was dismissed with no action taken. And complaints against physicians need to be taken with a large grain of salt. I would avoid physicians who had 2 or more complaints lodged against them, though.

But what I've said thus far is based upon the assumption that you have the time and interest to do some investigation before choosing a physician. If you or a near and dear one is having a heart attack, an acute asthma attack, is bleeding out, is in terrible pain, is having uncontrolled vomiting, has broken bones, is suffering the first epileptic attack, etc., you are going to take the first medical help you can find. THERE IS NO TIME TO COMPARISON-SHOP. THERE IS NO TIME TO CHOOSE.

And you will pay whatever you need to pay, or your insurance will pay it. Or your insurance will pay whatever they can negotiate to the hospital or clinic where you get your care, and the hospital or clinic will eat the rest and pass the costs on in some other fashion.

3. With our current fragmented health care system, there is little incentive for a given insurance plan to pay up front for expensive preventive medicine which can head off problems down the road, because the likelihood is that another insurance company down the road will be taking care of the problem not headed off, and probably more expensively. This is bad for the overall economy, drives healthcare costs up in general, and sure as hell is bad for you as the individual patient. One of the reasons the VA has become a model of healthcare is the lifelong investment in patients, with the incentive to head problems off at the pass.

In sum, health care has certain attributes, some of which I've named above, which are true regardless of whether health care is privately or publicly funded, and which mean that Econ 101 principles are likely to result in inefficiencies. Health care is just plain better with some kind of single-payer network, as experience in other industrialized countries attests.

Posted by: Wolfdaughter on September 7, 2006 at 2:51 PM | PERMALINK

Alex,

I do see potential in a VA like system. Build them, fund them, hire staff, and when you go there the care is free or minimal. With limited resources, the waits would be long and the providers probably not the top in their fields, but those who can afford it will still be able to chose to pay for private care.

As a limited test, I have suggested attaching free clinics to existing ERs. Staff them with PAs and RNs. You show up at the ER. If you have a true emergency, you go to the ER. If not an emergency, you have another choice. If you prefer paying to waiting, you go to the private system. If you prefer waiting to paying, you go to the free clinic. Fund them with a 1% payroll tax. Operate as many as possible. Start in the major cities.

Posted by: Randy on September 7, 2006 at 3:02 PM | PERMALINK

I get really really tired of conservatives opposed to single-payer health care bringing up the heatstroke deaths in elderly in France a few years ago. This is supposedly an indictment of France's healthcare system.

It wasn't the healthcare system at fault here. This happens any place where summer temps rarely go into the triple digits (F) or even above 90. And it's mostly elderly or infants and very small children, whose internal thermostats don't work as well as those of other age groups, and whose mobility to get to a cooler environment is limited.

Others have pointed out that rises in heatstroke deaths have also occurred in the U.S. when summer temps spike in areas usually relatively cool in the summer. This has happened in Chicago, New York, etc.

I live in Tucson. Despite often having temps in the triple digits, we have very few heatstroke deaths. We do have a few every year. An confused elderly person in a nursing home manages to get outside and their absence isn't noted for several hours, by which time they're dead. And believe me, every time this happens, there is a HUGE outcry and that nursing home is in deep doo. Or we have newcomers to the area who don't know about dealing with such temps, who spend a lot of time outside in the sun and drink heavily to boot. But we don't have huge spikes in heatstroke deaths some summers and not others.

Why? Our houses and public buildings are almost universally equipped with at least an evaporative cooler, and many houses and all large public buildings with airconditioning. Any new home has one or the other or both cooling methods. This is just part of the expected cost of building a new home and nobody would buy one without cooling. Also, malls are airconditioned, and people whose houses aren't well cooled can escape to malls or other public buildings.

But many homes in places like Chicago, or Paris, weren't built with any sort of cooling. If global warming continues to make summer temps higher in such places, perhaps it will become standard for new dwellings to have cooling built in. But that isn't the case now, and to blame heatstroke deaths on the extant healthcare system is foolish. Those of you who keep bringing this up should be ashamed of yourselves.

Posted by: Wolfdaughter on September 7, 2006 at 3:08 PM | PERMALINK

Randy/thomas said:

Okay doc, show me a more efficient system than the free market.

It depends on the nature of the good to be provided.

If you didn't know that, you have no business being in this conversation.

Posted by: Disputo on September 7, 2006 at 3:10 PM | PERMALINK

Wolfdaughter: I live in Tucson. Despite often having temps in the triple digits, we have very few heatstroke deaths.

Not suprising. A snowfall that Minnesotans would barely note will cripple a place like Florida (they do get a few flurries in northern Florida every third blue moon).

Our houses and public buildings are almost universally equipped with at least an evaporative cooler

OT, but how well do those things work? Here (Long Island, NY Metro area) the humidity is worse than the heat. But in a dry place like AZ I'd think that the extra humidity would be welcome.

Posted by: alex on September 7, 2006 at 3:17 PM | PERMALINK

Randy -
that's different from status quo ... how, exactly?
The ERs are being used as free clinics, which is one of the major things killing public hospitals, and driving up costs for customers who can pay(insured or out-of-pocket).
Universal coverage will allow people to get treated BEFORE THEY NEED TO USE THE E.R. !

We don't want this system to be part of the problem, we want it to be a solution to the problem.

BTW - part of that problems is infectious diseases and the fact that they are unable to differentiate betwixt the insured and uninsured or the poor and affluent. If you breathe, and don't live in a bubble, you are at risk for however long other people are at risk becuase they don't have access to primary care.

Posted by: kenga on September 7, 2006 at 3:17 PM | PERMALINK

Randy on September 7, 2006 at 2:21 PM:

Well that's good news, but its going to take..

Er, that was alex, not me. Please try to keep up. ;)

Doctors and hospitals are dropping out of the public system even now.

Hell, doctors are dropping out of the private system even now...between haggling with insurance companies over getting paid and forking over tons o' cash for malpractice insurance...I can give you a few personal anecdotes where doctors no longer deal with insurance and want payment up front, leaving the patient to haggle with the insurance companies for reimbursement.

Remember, all the stuff you mention is happening under the current US system, Randy...

What makes you think that the situation will change for the better under a universal system?

What makes you think that it can never be better than what it is now, Mr. Negativity?

Because this is still America - land of the free.

Yep; United We Stand, Divided We Fall, and all that, right?

Posted by: grape_crush on September 7, 2006 at 3:21 PM | PERMALINK

hey grape - quote him that bit out of the preamble to the Constitution, y'know, that "promote the general welfare" part?
I always get misty-eyed when I read that ...

Posted by: kenga on September 7, 2006 at 3:26 PM | PERMALINK

kenga,

Yes, the ERs are failing because they are being used as primary care clinics and not receiving sufficient funds with which to do so. This is an immediate problem.

What I'm suggesting will require public funding to establish. The reason to attach the free clinics to the ERs is because the ERs are already on prime centrally located real estate. You check in at the ER, but you don't necessarily get seen there. If your symptoms are non-emergency, you are immediately referred either to the free clinic or private primary care clinic - your call.

Its not a 100% solution. Just a solution to an immediate critical problem. Triage if you will.

Posted by: Randy on September 7, 2006 at 3:27 PM | PERMALINK

You know guys, you are assuming that because I am against nationalizing the entire system that I am against accomplishing anything. You need to check your assumptions at the door. I'm trying to show you a way to achieve immediate results.

Posted by: Randy on September 7, 2006 at 3:30 PM | PERMALINK

Disputo,

Re; "It depends on the nature of the good to be provided."

No shit, Sherlock. Did you miss the part about naming the objective?

Here, I ' l l t r y t o w r i t e m o r e s l o w l y.

Posted by: Randy on September 7, 2006 at 3:35 PM | PERMALINK

Randy/thomas, give me a break jackass.

If you actually knew that the nature of the system that most efficiently allocates a good is dependent on the nature of that good -- instead of pretending you did -- you would never have asserted in the first place that the free market is the most efficient allocator of goods.

Your credibility is zero in this forum.

Posted by: Disputo on September 7, 2006 at 3:41 PM | PERMALINK

Disputo,

Ahh, you hurt my feelings :)

But seriously, you give up too easily. Try just answering the question. You claim to be a learned fellow, so certainly you must be a seeker of knowledge. Who knows, you might learn something. But hey, if you'd rather just sit up there on high and pass out insults... its your life.

Posted by: Randy on September 7, 2006 at 3:51 PM | PERMALINK

Randy on September 7, 2006 at 2:51 PM:

I don't see that you have countered or nullified my arguments. You simply commented on all of them.

False. And judging by your 3:02 PM post, some of what is being said is starting to sink in.

But again, I have no objection to government welfare in the form of health care. I do recognize the need for it. I'm even willing to help pay for it.

Kudos to you!

All I'm saying is that the new system should leave the existing system in place.

And a two-tier plan would do that for the most part. The objections would come from what would become the second-tier private insurers, who would experience a drop in revenue as businesses stop offering private insurance plans, causing those companies to contract with potential 'consumers' directly. You'd still be able to buy private insurance for 'gold quality care' if you chose...Why is that hard to understand?

Forget the wealthy.

What the wealthy do isn't the issue; the wealthy can afford health care. A lot of other people cannot, which is why we are having this discussion...

its a simple matter of passing the hat and hiring the professionals.

As I wrote earlier, it's a matter of will...

Randy on September 7, 2006 at 3:02 PM:

I do see potential in a VA like system.

...Which is what many people mention when discussing a successful model for a universal health care system.

With limited resources, the waits would be long and the providers probably not the top in their fields.

Increase the resources and be satisfied that you're getting health care, even if it's not from the top doctor in the state you live in...Not every doctor out there graduated at the top of his/her class...

but those who can afford it will still be able to chose to pay for private care.

Yep; in a two-tier system, they can. You don't even have to call it 'universal health care' if you want - call it the Bush Legacy Medical Coverage Program for all I care.

As a limited test..

Sounds great; some decent ideas implementing health care that is available to everyone.

Posted by: grape_crush on September 7, 2006 at 3:56 PM | PERMALINK

kenga on September 7, 2006 at 3:26 PM:

..quote him that bit out of the preamble to the Constitution, y'know, that "promote the general welfare" part?

Funny; I did almost exactly that on the previous thread...

Posted by: grape_crush on September 7, 2006 at 3:59 PM | PERMALINK

Somehow Kevin's comment threads have become the equivalent of lunch with the kindergarten. Any subject brings forth the stupidest responses, and no matter how often you explain something to the trolls, they just don't get it.

Given the speed with which some major world-shaking changes are approaching, the trollery resembles the conversation of the Confederates as their own incompetence brought down the Rebellion. To the very end, they nattered on about how wrong the North was, and how the Union would regret freeing the slaves.

In fact, given the chance, most of today's trolls would explain to us how the war was really about tariffs, and most of the slaves were better off as property of Massah. The trolls are not just slow learners, they are no-learners. Strange to say, they're against "social promotion", but giving them an extra century to learn the facts hasn't helped at all.

As for the idea that we don't have the capacity to provide care for everyone, that's pure baloney. Your doctor works three days a week, half the nurses leave the field a few years after graduating, and most hospitals are 30-50% empty on any given night. If free markets worked at all, our overbuilt system would be sucking patients in like a vacuum from neighboring countries.

But we're not, because our "free market" system is actually a monopoly system sucking the money from patients who have no choice about where they seek care. Way past time for a change.

Posted by: serial catowner on September 7, 2006 at 4:10 PM | PERMALINK

Well grape, we seem to have mostly philosophical differences. On the implementation side, we're not so far apart. I believe the biggest difficulty will be crossing the "equality" barrier. A two tier system, while doable, will be open to charges of inequality. If we can get past that, we might actually get something done. If not, we'll still be arguing about it a decade from now.

Posted by: Randy on September 7, 2006 at 4:28 PM | PERMALINK

Randy, i'll accept for the moment that you want to accomplish something. I think you need to re-consider that what many of us would like to see is "nationalization".

Insofar as trying to achieve immediate results, here are some things you should google search for, and then cogitate on:
Mohammed Mossadegh
Mujahideen Afghanistan
tuberculosis multi-drug resistant
H5N1
They're not strictly related, but they bear thinking about in the context of doing things much the way we have in the past, and the risks involved in living in a society where some people have sharply limited access to quality health care.

Posted by: kenga on September 7, 2006 at 5:17 PM | PERMALINK

Randy, except for the partial exception of some plastic surgery markets the system we have today is not a free market system. There are governments as regulators and payors, businesses and insurance companies that control services and have far more control of the boundaries than either the doctors or the patients.

Let me repeat, this is not a free market and has not been one since the first Blue Cross was formed.

Posted by: freelunch on September 7, 2006 at 5:31 PM | PERMALINK

freelunch,

I agree. Way up at the top of this thread I commented that the goal of the free market is to provide services demanded by paying customers, and that the purpose of government is to provide welfare to people who would rather not, or can not, pay the full price. The health care system we have is hopelessly confused about this, and it is causing problems. I think its important to separate the two. The conversation has evolved to a near agreement on the need for a two tier system (I'm probably reaching to use the word agreement, but please bear with me). A government run tier to provide welfare, and a privately run tier to meet the demands and expectations of customers with the ability to pay. It doesn't have to be one or the other. It can be both. In my opinion, it has to be both.

Posted by: Randy on September 7, 2006 at 5:48 PM | PERMALINK

Anyway, WRT to Kevin's post, I was thinking of my mother's bridge-playing friends. They all think modern medicine made it possible for them to live so long. After all, their husbands are dead!

In reality, they're white women who spent their lives in suburbia and never endured any serious stress. Even cigarette smokers last a surprising length of time with this kind of luck. If they had been stressed out, or toiled at a loathsome job for decades, they'd be as dead as their husbands.

Well, nobody likes to admit that their good fortune is simply the result of easy living, so all of these ladies have tales of their medical adventures, how their lives were in danger and their doctor saved them.

In reality, people born at the same time as them, who had real problems like Type I diabetes, cancer, or epilepsy, died before any meaningful cure emerged.

The medical industry convinced a lot of people that a long and happy life resulted from "seeing the doctor regularly" when it actually resulted from the power of the US dollar after WW II.

Americans are in for a big shock when "the doctor" can't keep pulling the same rabbit out of the hat.

Posted by: serial catowner on September 7, 2006 at 6:52 PM | PERMALINK

Alex, you asked about evaporative coolers, or as they are more popularly known, swamp coolers.

In a humid climate they would not be particularly effective. Here in Tucson they are VERY effective in May, June, September, and October, when the air tends to be quite dry and there usually isn't that much rain. In fact, in June, the humidity can get close to 0 percent.

But in July and August when we get our monsoons, they aren't as effective. They still work okay when the humidity is maybe 20-40 percent, but not much higher than that. Recently we've had a lot of rain in Tucson (second wettest summer on record). It's been cool as a result, lots of days in the 80s, some in the 90s on days when it doesn't rain. I often just run my cooler on "stun"; i.e., just use the fan and don't turn on the water pump. This means indoor temp is same as outdoor temp, but the breeze created makes you feel subjectively cooler.

I would not advise swamp coolers for highly humid climates, though.

Posted by: Wolfdaughter on September 7, 2006 at 7:58 PM | PERMALINK

I worked in the Arizona Health Sciences Library, which serves the Univ. of AZ College of Medicine, for 32 years (retired as of 6/30/06). During the last 10 years of my employ I was one of the people interviewing prospective medical students.

The system we use is that medical student applicants spend some time with the physician who runs the admissions program, and with his admin assistants, who are the ones scheduling the applicants' interview days. They also spend about 90 minutes with another physician, often from Tucson in general and not affiliated with the College of Medicine. And about an hour with other COM faculty members, who may or may not be actual physicians. We librarians were part of this latter team of interviewers.

Our purpose is to try to get to "know" the applicants a little, apart from grades and MCAT scores, which we never see. In a very limited time, we interviewers try to create a less formal atmosphere where we ask them about why they want to become physicians, what sorts of hobbies they have, what volunteer work they have done in health care, what other exposures they have had to health care such as shadowing physicians, what sort of families they have and how they see their relationships with families and friends, what sort of leadership roles and teamwork roles they have taken (club memberships and the like), if they have exposure to other cultures, etc.

We observe their reactions to the various questions and try to get an idea of them as people.

Naturally, the applicants are putting their best feet forward. When asked why they want to become physicians, they realize that they probably should not reply that they want to make a lot of money, although even in today's climate, many of them will. The typical answer is that they want to help people and that they love science and find the study of human anatomy fascinating. They almost always know physicians whom they admire greatly and who they see have helped people and they want to emulate that.

I always ask them why they would choose being a physician as opposed to a nurse or an EMT, say. They usually answer that they see themselves as being able to have more control over how they offer health care, and some mention liking diagnosing and the "science" of that. Nurses and EMTs also diagnose, but they have to back that up with the physicians' diagnoses and the former don't have the final say in diagnosis.

I've been very impressed with the quality of the applicants I've interviewed over the years. The overwhelming majority are young, earnest, idealistic, really hoping to make a difference. They usually have impressive records of volunteering in clinics and/or doctors' offices and/or ERS. They have done work in clubs, frats, sororities, church groups, where they mostly have done some leadership, such as running clubs or running fund-raising programs. They have tutored other students. They have worked with families and children from disadvantaged homes. Some of them have spent summers in places like Yucatan, helping physicians deliver health care there. And so on.

Also, Arizona's COM actively encourages students to enter family practice, and to practice for a while at least, in a rural or underserved urban area. Many applicants mention specifically plans for such careers, although people often don't really know what type of medicine they would like to practice until their 3rd or 4th year of med school.

The interview process in which I played a part is also designed to encourage people from all ethnic groups and socioeconomic statuses to apply. These admittedly somewhat subjective interviews supply information to the Admissions Committee, above and beyond the candidates' grades and MCATs and the essays on their applications, said info very difficult to obtain elsewhere. The majority of applicants have good to excellent grades and MCATs anyway, so the Admissions Committee must make very fine distinctions when they decide whom to admit. So a person from a rather poor background who has had to work part- or even fulltime, or who had infirm relatives to care for, is given recognition of that, and may be admitted over someone who has not had to deal with such challenges.

In my observation, the medical students, and nursing and pharmacy students I have known in my career, are pursuing these careers out of a genuine desire to help others. They do want to get a decent living, but the money isn't their first motive.

So I would not be concerned that some sort of universal health care would mean that physicians and other health care professionals would leave health care in droves. Some probably would, but many physicians would probably be glad not to deal with the hassle of multiple insurance companies with multiple forms and regulations, making reimbursement for services often a nightmare.

In my 32-year career I have worked with many professors, medical, nursing, and pharmacy students, and practicing physicians, nurses, EMTs, etc. A substantial majority would favor a universal health care system. They know for a fact that our current system is broken!

Posted by: Wolfdaughter on September 7, 2006 at 8:31 PM | PERMALINK

"With many purchases, such as buying clothes, cars, computers, houses, toys, other durable goods, car and life insurance, etc., if you make a wrong choice, it will probably not be life-threatening or result in permanent maiming.

2. Also, for food, housing, insurance, durable goods, etc., you have the time to comparison-shop. Not everyone takes the time to do so, but they can if they choose."

But it's a lot easier to make good choices in purchasing all these things: carfax, consumer reports etc. But how does one find out that his primary care physician is a quack? sued x-number of times for malpractice etc.

Posted by: Brian Boru on September 8, 2006 at 1:05 AM | PERMALINK

Wolfdaughter,

Re; "So I would not be concerned that some sort of universal health care would mean that physicians and other health care professionals would leave health care in droves."

Good post - and an interesting point. But it will depend more on how these people are treated over time than on their enthusiasm as young people starting new careers. How many of the most talented will stick around when the choice is between very long, very stressful, low paid days in public health service, or private health care where they are well rewarded and their days are under their own control. People can only handle so much stress. Take away the rewards and they can handle even less. They will rationalize it. "Hey, I'm still helping people," or "The young folks can do their time in the trenches just like I did." Look at the inner city public schools. Teachers often get a start there, but they leave as quickly as possible.

The solution will be more money. Either the people will have to be paid more to stay, or more people will have to be hired to reduce the stress. But I wouldn't count on replacing compensation with professionalism - no matter what young people say.

Posted by: Randy on September 8, 2006 at 4:32 AM | PERMALINK

Cmon kevin and AL this aint no time to pull a socratic
dialogue dualistic diatribe.

Posted by: Trinary Suka on September 9, 2006 at 12:35 AM | PERMALINK

The solution will be more money

money is paper with an IOU printed upon it...Promissory note.

Monopoly money.

Posted by: Trinary Suka on September 9, 2006 at 12:37 AM | PERMALINK




 

 

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