The point is that in our current system, lots of people don't have a doctor at all. They only participate in the system when they get so sick that they have to go to an emergency room. There also is a lot of emphasis on later specialty training that is picked up by medical students, unlike the system seventy years ago when most doctors were without advanced papers.

I thought we had already concluded that Tyler Cowen was an idiot. 20+ countries, all spend less, all do better -- that's a hell of a lot of data, and it sounds like Tyler Cowen (still an idiot) is working as hard as he can to ignore it.

Even more Nurse-Practitioners would be a good thing - where GPs are in short supply.

And I am in love with Nurse-Practitioner-Midwives, esp. when they work out of OB-GYN offices with lots of MDs and specialization accessible. Then you can have your midwife experience but know that if there's a serious complication she/he can hand you over to the specialist.

In France everybody gets a midwife/nurse unless there's a problem, then you get the OB.

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Which is a pretty good description of the French system. When we talk about Canada and Britain, we are not talking about the best or most likely models for the U.S. France, however, is a much better example, in that it has, as one study described it, "a high floor and an unlimited ceiling." Americans would never accept the Canadian or British systems, but the French system -- if you don't call it that! -- would stand a much better chance.

Oops. I accidentally deleted the quote that should have started my post. Here is is:

"Our goal should be to provide decent care to everyone, with the market free to operate on top of that."

Which is a pretty good description of the French system. When we talk about Canada and Britain, we are not talking about the best or most likely models for the U.S. France, however, is a much better example, in that it has, as one study described it, "a high floor and an unlimited ceiling." Americans would never accept the Canadian or British systems, but the French system -- if you don't call it that! -- would stand a much better chance.

Comparing OB to midwife-with-OB-backup, based on my sample of two babies - first kid was birthed by a "top" OB in Berkeley, member of a "top" practice with a bunch of "top" doctors. I was given sloppy, harried, disorganized care. Genetics testing, sonograms & other tests were done off-site by contractors, leading to communication screw-ups that made us nuts. The actual OB who delivered #1 was someone from another practice substituting that night, whom I'd never met. Whatever.

Nurse-midwife for baby #2 saw me regularly, stayed on top of everything, was matter-of-fact, punctual, thorough, efficient and orderly. Genetics counseling was in the same office. Had I needed specialized tests/amnio they would have been done by doctors on staff in the practice, on site. Sonogram done on site. No communication screwups. Had there been any complications, the OB called in would have been somebody who partners with the midwife. I delivered in the hospital next door, easily and with no trouble. (and she wouldn't let me have my epidural! Wah! Saved my insurance co. a lot of money and I managed fine without it)

I got better care from the midwife and I felt secure that in case of trouble (and trouble happens) I would have probably gotten better care from the midwife's partners than from the frazzled bunch over at Berkeley's "top" practice.

We need more nurse-practitioners and nurse-midwives in this country = not only for the poor but for everybody else, too. Not every medical condition requires a hyper-specialist.

The most useful health car are drug testing, nicotine cessation programs, and blood sugar testing. Add some daily exercise to this and medical insurance become cheap.

Nothing Kevin says will change this fact, but he will spend all of your money doing everything but the obvious. Most of us will sit around on the couch in fear that anything we do will cost us a huge government fee for Kevin's programs.

The present system where medical students are forced to go deep into debt exerts great pressure on them to go into lucrative specialties. Why not give med students a free ride if they go into family practice and/or serve a few years in public service. The medical establishment discourages this because they prefer the status quo. The military adopted this model with the Uniformed Medical Services Med School, but they had to fight the AMA the whole way.

As to nurse practitioners and physicians assistants, 90 percent plus of all medical visits are routine. A good nurse practitioner or PA needs to deal with the routine and know to recognize the special cases and pass them up chain. My own experience is that most nurse practitioners and PA’s have good attitudes and are happy in the career they trained for, while a lot of family physicians providing the same services feel overtrained and underutilized.

I seemed to detect in KDs post an assumption that the marginal dollar goes only to certain favored groups. An alternative interpretation is that the marginal dollar goes towards the extremely ill, regardless of group membership. In the latter case, we can argue about the cost effectiveness -of say a publically funded heart transplant for someone with very low survival prospects.

A possible good solution which would both extend health care to everyone and retain the incentives necessary for a maintained tempo of medical advancement is: Extend 2001 health care to everyone. Anything ten years old or anything just as or more effective than ten-year old technology which is also as cheap or cheaper would also be included.

Most people with jobs would want to pay for high-tech for now care, so the government burden would not be excessive. Yet everyone would get very adequate care, and certainly much better than uninsured care. The incentive for fast-paced medical advances would remain. Patents for medical technologies would only remain effective for seven years after first wide-scale marketing.

Thus, if we progressives advocate for a public financed healthcare system, we should also be advocating (for example) for relatively more public funding for GPs and less for the fanciest new high-tech equipment, which overwhelmingly gets installed in rich hospitals that serve rich communities.

If we get a publicly financed healthcare system there will be a huge demand for general practictioners whenever the current *overtreatment* by specialists (excessive diagnostic tests, unnecessary procedures and pharmaceuticals, etc.) of the American well-insured starts to diminish and the previously uninsured or underinsured start seeing doctors for proper routine preventative care again. We won't have to advocate for more GP's, we are simply going to need a lot more of them. The real problem is what sort of incentives are you going to have to put in place to get those extra lower paying GP's? I also agree with the others about utilizing a lot more nurse-practitioners and PA's, to help solve this problem.

Sorry, I switched from ten to seven halfway through but didn't go back and change everything.

Well, actually, no. The RN can make referrals just like the MD, and a lot of this is referrals. All you really need for that is a 4-year RN.

Then there are a lot of GPs who can't afford to see Medicare patients because the reimbursement is so low. Increase it to at least cover their office expenses and you'll have more. Doing that would not be very expensive, they get reimbursed about $35 for a 15 minute office visit, so they're making less than a plumber charges in my neighborhood, and you know the Halliburton plumbers get paid a lot better than plumbers in my neighborhood.

Sadly, there is no known medical cure for the abnormal lightness of Tyler Cowen's intellect.

I believe that it was on Matthew Holt's blog that I saw the statistic that 70-80% of US MDs are specialists vs. 70-80% of European MDs who practice general medicine. (And I might add that in salary US primary care docs make just about what their European colleagues make.) I wonder how much the difference contributes to the higher costs in this country.

I recently had a patient come into my office with a sprain. She had had a snowmobiling accident two weeks earlier and came in because she still had some swelling, pain, and bruising. I tried to convince her that she needed to let the injury heal, but she insisted on an MRI, so I reluctantly sent her to the orthopod who, of course, ordered a ($1000) MRI. Guess what? I had the same injury myself a couple of years ago and chose to treat it with ... nothing and in time it healed completely as hers will too. I'm not sure how you would have convinced her to see a NP to save money.