Editore"s Note
Tilting at Windmills

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July 31, 2008
By: Kevin Drum

YOU AND YOUR DOCTOR....Tyler Cowen says that one of the reasons for rising healthcare costs is that people object to any limits on the amount of care they can get. Matt Yglesias demurs:

While people will naturally always want "all the care they want," people's desire to obtain health care is large part a result of their interaction with the health care system. If I'm feeling ill and want the doctor to prescribe me some antibiotics, but then he says "no no no, you have madeupitis and if you take antibiotics you'll die" then suddenly it seems I don't want the antibiotics anymore. Medical treatment isn't fun, people don't just want treatment for no reason. If you convince them that the treatment isn't useful, they really won't want it.

This is a common response on the left, but I'll confess to some curiosity about it. I happen to agree with Matt, but that's largely because I, personally, labor under a considerable fear and loathing of doctors. (OK, more loathing than fear, actually.) I avoid seeing doctors unless I absolutely have to, I don't like taking medication, and I basically feel that the least possible medical care is the best possible medical care. Put me in a hospital and all I want to do is get out before the staff kills me with a central line infection or a misfilled prescription. (Tell me again: why, exactly, is it that doctors seem to think it's cute that they have unreadable handwriting?)

But that's just me, a relatively healthy middle-aged guy, and the fact that I feel this way isn't an especially good guide to public policy choices for a trillion dollar industry. So would any GPs care to chime in on this? Do patients typically tend to demand boatloads of care they don't really need? Do they insist on taking drugs that won't help them because they saw them on teevee? Do they come back over and over and over until you finally cave in and provide expensive new treatments that are vanishingly unlikely to do any good?

As it happens, there's a fair amount of research to back up my neurosis-based view that patient demand isn't a huge factor in rising healthcare costs. A famous RAND study, for example, suggests that free healthcare has only a modest impact on demand for services, and other research fairly convincingly indicts supply-side issues (more doctors = more healthcare), institutional issues (intensive marketing campaigns from pharmaceutical and device firms), and incentive structures (if you pay doctors for prescribing services, they'll prescribe more services), among others.

Still, demand-side issues aren't trivial, especially for the over-65 crowd, which accounts for the majority of healthcare spending. So what are patients like on average? Are most of them like me and Matt, eager to avoid medical care unless it's absolutely necessary? Or are we outliers? Comments?

Kevin Drum 3:33 PM Permalink | Trackbacks | Comments (86)

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Comments

uh, Kevin, by definition we can't all be outliers. Just sayin'.

Posted by: bobbyp on July 31, 2008 at 3:42 PM | PERMALINK

Oops. Misread that. Just put a * at post #1 and sign it mhr

Thanks.

Posted by: bobbyp on July 31, 2008 at 3:44 PM | PERMALINK

"Still, demand-side issues aren't trivial, especially for the over-65 crowd, which accounts for the majority of healthcare spending. So what are patients like on average?"

I'd say that pretty much sums it up. Also, on average, patients are still alive.

Posted by: bobbyp on July 31, 2008 at 3:47 PM | PERMALINK

But that's just me, and the fact that I feel this way isn't an especially good guide to public policy choices for a trillion dollar industry.

Nobly conceded. I wish more people in positions of power could muster that level of detachment.

Posted by: ymr049c on July 31, 2008 at 3:49 PM | PERMALINK

But that's just me, and the fact that I feel this way isn't an especially good guide to public policy choices for a trillion dollar industry.

Nobly conceded. I wish more people in positions of power could muster that level of detachment.

Posted by: ymr049c on July 31, 2008 at 3:49 PM | PERMALINK

When it comes to medication and hospital stays, I am with Kevin.

I think it gets tricky with diagnostics, though. If there is a 10% chance that I have Disease X, but the only known test costs $5000, will insurance pay the $5000 for a 10% chance?

This goes for chest X-rays, MRI's, blood tests, etc. I may not want any more meds, but I sure as hell want to know if have Cancer, and the only way to find out is with a $5000 chest scan, even if the percentage chance is relatively low.

Posted by: BombIranForChrist on July 31, 2008 at 3:56 PM | PERMALINK

But Kevin, you're healthy. If you were 65 and overweight with type II diabetes and everything hurting then you will be much more aggressive in your need for care. Especially when you go to the first doctor, he tells you it's nothing, the second doctor tells you it's a tumor, and the third doctor wants to chop off your leg after a series of MRIs.

Posted by: Buzz on July 31, 2008 at 3:56 PM | PERMALINK

Yah, we don’t want healthcare while we are healthy, but just get cancer or develop a heart condition. Then we want organ transplants, stem cell treatments, MRI scans by the dozen and anything else that might prolong our miserable little lives. The spending on expensive heroic procedures verses plain old simple relatively cheap health maintenance is a serious issue for the American health care system.

Posted by: fafner1 on July 31, 2008 at 3:59 PM | PERMALINK

Some form of a bell curve? With one end in very expensive territory.

Posted by: keith g on July 31, 2008 at 4:00 PM | PERMALINK

Part of the meme comes from the Medical Profession itself, they treat everyone that comes in the door as if they are DEMANDING every possible treatment available when in reality, that covers a very small but vocal minority. In my experience most of the people I know are very similar to Kevin in attitude about seeking medical help - less is better, just get it done and let me out of here.

Posted by: ptm on July 31, 2008 at 4:01 PM | PERMALINK

I will say this as a physician: how much medical care a patient wants (specifically, how much money he wants to be spent on him or her) frequently depends on the medical condition you have.
In general, I would say most people do not want that much care for routine medical problems. But say you have cancer (I am an oncologist, by the way) and there is drug that costs $60,000/year (which is actually a reasonable price for many of our newer drugs) but that drug, at best, would only add 6-10 weeks months to your life. It probably is not cost effective to use the drug for only a modest benefit but I would suspect a large majority of people would still want the drug. I suspect the occurrence of this phenomena just in oncology has a large impact in the overall cost of medical coverage in our society. As another example, chemotherapy in early stage breast cancer only reduces the chance of the cancer coming back by 5-10% (at best) but studies have shown that ~80% of women still want the treatment after being informed of this relatively small benefit.
My broader point would be that it may be a mistake to evaluate health care costs in general by approaching it from your own perspective and rather look at where the money is being spent and why.

Posted by: Dr. No on July 31, 2008 at 4:06 PM | PERMALINK

I've heard that the patients who account for the majority of health care costs are those with less than three days to live. So we could cut health care spending by more than half if we just agreed to reduce life expectancy by only three days.

Wait...

Posted by: ogmb on July 31, 2008 at 4:06 PM | PERMALINK

So Mr. Cowan is arguing that insurance companies should be able to arbitrarily deny healthcare to clients who they feel want too much of it? Oooooh yeah, that'll work in a profit-driven industry.

I'd like to know whose definition of "all the care they want" he is using, because that, to me, is the crux of the matter.

Posted by: on July 31, 2008 at 4:07 PM | PERMALINK

I'm with Kevin on this.

Yeah, got the health insurance, got the money for co-pays, no problem.

And maybe it's just a remnant of adolescent attitudes, but even with the insurance, etc., I just about have to be keeling over before I'll see a doctor.

Why? Well, it's a PITA to get an appointment, you'll probably have to wait 7-10 days, and by that point whatever was bugging you will either have gone away or put you in the emergency room (or morgue). Or you've learned to live with it. So why bother?

And who the hell has time to spend sitting around the doctors office?

So yeah, there are big barriers to "demand"; and while some of them have to do with health insurance (and doctors overloaded, so you can't get reasonable appointments), a lot of it is just the society and age we live in.

I hear that "socialized" health care is terrible, what with the waiting lists. Yeah, whatever.

Posted by: Snarki, child of Loki on July 31, 2008 at 4:10 PM | PERMALINK

"As another example, chemotherapy in early stage breast cancer only reduces the chance of the cancer coming back by 5-10% (at best) but studies have shown that ~80% of women still want the treatment after being informed of this relatively small benefit."

How is that the least bit surprising? If anything I'm surprised that ONLY 80% want the treatment. The consequences here are virtually unquantifiable in a monetary sense. If you are 5-10% less likely to DIE, then why in the world do you NOT take the treatment? I don't know if the odds of you dying of a car crash during the next ten years improve by 10% if you wear seatbelts- it's quite possibly less, but it still doesn't stop me from wearing those damn belts.

Posted by: on July 31, 2008 at 4:15 PM | PERMALINK

So to sum up this post: "I think that demand-side issues aren't that big of a factor. Still, that's just anecdotal. Oh, also, there's a fair amount of research to back it up. Still, let's advance the debate by gathering more anecdotal evidence from anonymous sources!"

Posted by: OhioBoy on July 31, 2008 at 4:18 PM | PERMALINK

So what are patients like on average?

Average people are probably not influenced by the cost - free healthcare would not induce them to seek much more of it. Of the total population of patients that a doctor sees, however, there might be a significant minority that has an elastic demand with respect to price. Hypochondriacs probably go to the Dr. quite often.

Posted by: flubber on July 31, 2008 at 4:20 PM | PERMALINK

Listen to Dr. No. He/she is right on.

Sometimes I wish everyone in America could take a plane to England or a car to Canada and see first hand that so-called 'socialized' medicine is not bad.

The big bucks has got us all separated and thinking "I'm different from everybody else" when the truth is we all pretty much agree, at least on health care.

Posted by: Tripp on July 31, 2008 at 4:20 PM | PERMALINK

I'm in my 50s, I've never had any sort of doctor-phobia, and my doc is an attractive woman in her 40s who I'd ask out in a heartbeat if we were both single. But I don't go to the doctor unless there's a pressing need to do so. I've only got so much free time, and I'd rather spend it doing something fun than being in a doctor's office.

Posted by: low-tech cyclist on July 31, 2008 at 4:24 PM | PERMALINK

Let's do a thought experiment. Imagine that we all had something called car insurance, which would pay for fixing up our car. Imagine the insurance cost nothing.

Would we all go out and drive recklessly, wrecking our cars just because we could get them repaired later?

No. We'd still have the hassle of filling out forms and being without the car while it is being fixed and having to tell people we got in a wreck.

I say people will behave about the same when they deal with health care. Most adults will be sensible about it.

Posted by: Tripp on July 31, 2008 at 4:25 PM | PERMALINK

I'm healthy, but married to a man w/ a chronic health condition. This debate plays out in my house all the time. I prefer to steer clear of doctors and medications, and he treats any ailment as a reason to go see a doctor. He lambastes me and accuses me of not taking care of myself when I'd rather not see a doctor for something I feel is more or less under control or doesn't meet my threshold for needing professional medical care. I roll my eyes when he tells me about yet another appointment of his (not all the time of course -- he just spent 2 days in hospital last week). And fortunately our kids don't get sick very often, because he's always wanting to involve a doctor in every fever or whatever, and I'm, well, not. In the end, I think we're both probably getting the level of care we want/need. It's just our perspective that's different.

Posted by: Suzanne on July 31, 2008 at 4:28 PM | PERMALINK

Given the explosive rise in medical costs, it is amazing how little discussion there is of reducing demand for medical services. All the hot air is blown over the non-existent social security problem and there is virtual no public debate over the staggering projected future medical entitlement costs.

Just to throw it out there why wouldn't it make sense to have a single payer cover only medical procedures deemed "affordable" by some government budgetary authority. And then allow individuals to pay for private insurance, pay out of pocket for procedures or appeal to charity to pay for procedures deemed unaffordable?

This seems like an obvious way to curtail medical over consumption.


Posted by: ftm on July 31, 2008 at 4:29 PM | PERMALINK

Kevin,
I can at least reassure you about central line infections. Make sure they use a checklist...
http://www.nationalreviewofmedicine.com/issue/2008/02/5_patients_practice_2.html

Posted by: Common Sense on July 31, 2008 at 4:30 PM | PERMALINK

I thought it was funny that a post like this came after one on the glories of deep-fried Spam and deep-friend Snickers.

Yes, you may not like visiting the doctor... but talk about asking for it...

Posted by: lampwick! on July 31, 2008 at 4:34 PM | PERMALINK

Since June 5, 2007 the great bulk of my life has been spent taking my husband to doctors or therapists. (brain cancer) Generally doctors are no fun; you have to wait a long time while sitting in uncomfortable chairs (the sick and caregivers would be so much better if the doctors offices had recliners - I AM SERIOUS.) You have to negotiate with the other patients to see if you can turn off the TV. No fun at all.

Therapists are an entirely different matter. Speech therapy has been a succession of bright pretty young women who get paid to converse with him. In physical therapy he had to simultaneously play hopscotch, catch and recite the 4's table backwards. Occupational Therapy introduced jigsaw puzzles.
Cognitive therapy has sudoku.

The therapists are usually nice, interesting and on time. The insurance limits on therapy are way to low but I do understand why there are limits.

Oh, I haven't personally been to a doctor; no time.


Posted by: bostonian in Brooklyn on July 31, 2008 at 4:35 PM | PERMALINK

I always shake my head when I hear that doctors are prescribing truckloads of antibiotics to patients with viral infections because the patients insist. That makes no more sense to me than a parent buying a child a candy bar because the child insists. (Well, I guess the child doesn't have the option of choosing another parent, but still...)

Giving a patient a medication that isn't going to help the patient's condition, may actually be harmful to the patient, and generally facilitates the growth of antibiotic-resistant bugs, to everybody's detriment, seems to me to constitute gross malpractice.

I don't blame the patient, who doesn't know any better. But how difficult would it be for the doctor to take all of 60 seconds to explain why it's a bad idea? Or if that's too much of a strain, have a little handout printed up with the explanation?

Posted by: Swift Loris on July 31, 2008 at 4:41 PM | PERMALINK

Cowan says:
"As the possibility of a real Democratic majority draws closer, expect to see more and more cognitive dissonance on this issue."

I say, these guys are just pumping out hot air, and I expect to see more of it as the health care debate heats up as election approaches. No data, no analysis. He reads Krugman and spins a story, outta what? This line has been around foever in US healh care policy. Go back to 70s and you read the same line from the ultra-free market fanatics. That was over 30 years ago. Do they have any evidence at all that they can point to?

Posted by: more story telling? on July 31, 2008 at 4:42 PM | PERMALINK

So Mr. Cowan is arguing that insurance companies should be able to arbitrarily deny healthcare to clients who they feel want too much of it? Oooooh yeah, that'll work in a profit-driven industry.

That's what happens now. At least, it happens with my insurance company. They make a profit by collecting premiums and denying benefits. Open your eyes.

Posted by: Lifelong Dem on July 31, 2008 at 4:42 PM | PERMALINK

I'm 63, so I qualify as a senior. Here's my experience - just yesterday - at the major HMO operating in California.

I went to see the internist because I have tendinitis in my right wrist. It started a couple of weeks ago, and I've been icing it and taking ibuprofin since, but it is now swollen and warm. If you knew how much I dislike going to the doctor you'd appreciate what a bad mood this put me in. I arrived 15 minutes early (as instructed), paid my $15, and waited another 20 minutes to be weighed (why?), temperature and bp taken before I was put in a room to cool my heels for another 10 minutes. Doctor finally arrives (nice woman), and I proceed to show her my wrist. She also made appointments for xrays on my spine, blood test to check for inflammatory arthritis, etc. She's doing her job. She sent a prescription to the pharmacy for heavy duty ibuprofin and a wrist brace. Thank you. I proceeded to pharmacy where the sign said "For same day doctor prescriptions go to kiosk at pharmacy entrance". Hmmm. No kiosk. No place. I went to Information and expressed my confusion. He was even more confused than I was, "we don't have wrist braces here". My question was " why'd they send me here?" "For the ibuprofin" he says. "You have to get a note from the doctor to get a wrist brace from orthopaedics." Sigh. Okay. Back up to doctor's office, knock on door, explain to nurse assistant I need a note. He asks me to sit down and wait (again). After another 10 minutes I knock again and say to nurse assistant, "never mind. I'm too frustrated to wait any longer." He is apologetic. I am nice, but insistent - "never mind, please give me my paperwork back. I'm too frustrated to wait any longer." He looks at me sorrowfully (he's very sweet). I leave and proceed to orthopaedics where I encounter 3 young, bored clerks and no one else. I stand politely behind the taped line on the carpet and wait to be called. After they finish chatting they call me and I show them my paperwork (hoping they won't ask for a signed note), and tell them I need a wrist brace. She nods and asks me if I'd like to see it before I buy it. I am puzzled. I ask her what other choices there are. She looks puzzled, too, and shrugs. She asks me to sit down and I'll be called. I accept this as an inevitable part of the health care system as it exists today, and I sit down. I am behaving myself. Miraculously, a young woman in blue scrubs calls me within 5 minutes. I smile at her. She smiles back, and says, "which side is it?" and I tell her it's my right. "Ok, let's get you kitted out" she says cheerfully. I like this person. She gets a brace out and puts it on and says, "you'll have to pay for it when you go out". "Oh, I know", I tell her, "evidently the $575 they extract out of me on a monthly basis won't cover the cost of the wrist brace." She laughs, and says, "oh honey, don't even go there. I hear you." I pay my $20 and leave to live another day. The wrist brace is great. My wrist instantly feels better. I'm never going to take it off.

It's not the people that suck. It's the system. The system sucks. I'd rather see a shaman and pay him out of my own pocket than go to my HMO. Everything they make you do, every bureaucratic hoop, is designed to make you feel like an annoying intrusion in the Big Important Enterprise we call the American health system. If at all possible, I avoid going, and when I'm there I can't wait to leave. It's a system set up to discourage you from using their services, and as such, it works great.

Posted by: ExBrit on July 31, 2008 at 4:44 PM | PERMALINK

hmm... most of us on this comment list are probably not in the group of people who use the most healthcare dollars, hence we're not a representative sample at all.... My brother in law is a cancer sugeon, many of the people he sees are suffering the effects of a lifetime of neglect and bad habits, once he told me that he thought a bit of successful preventative care, or even public health education would save a huge amount of future surgery costs, but that's a hard thing to quantify those things, and we have to watch the tendency to cut "soft" things like patient education, when if it's effective, it may help prevent the diabetes epidemic from expanding even more.... but of course, no matter how many times you tell people that type II diabetes sucks, they'll drink a 72 ounce cola with their dunkin donuts every morning anyway....

Posted by: vax on July 31, 2008 at 4:45 PM | PERMALINK

I always shake my head when I hear that doctors are prescribing truckloads of antibiotics to patients with viral infections because the patients insist. That makes no more sense to me than a parent buying a child a candy bar because the child insists. (Well, I guess the child doesn't have the option of choosing another parent, but still...)

Swift Loris,

Ummm, that's an urban myth. Doctors aren't doing that. As you say, it makes no sense.

Posted by: Tripp on July 31, 2008 at 4:46 PM | PERMALINK

Hand-written prescriptions? I haven't seen anything so primitive in the last ten years from my "socialized" doctor.

Posted by: blowback on July 31, 2008 at 4:54 PM | PERMALINK

I'm in the 20% of women who decided against chemo for early stage breast cancer - radiation and tamoxifin only - after a second oncologist agreed with the first's suggestion that I probably was "cured already" following surgery." (No guarantees, of course, but the stats weren't all that alarming to me compared with the prospect of chemo brain.) I shed five pounds and joined a health club I visit three times a week. I check in with my my doctor once a year...now nine years and celebrating my 77 years! I do agree that the diagnostic tests are crucial, though.

Posted by: Monzie on July 31, 2008 at 5:01 PM | PERMALINK

You're an outlier, Kev. Look at how many ppl ask for antibiotics for viral infections, and the docs eventually break down to stop being hassled.

Meanwhile, the “ownership society’s” version of healthcare is flopping like a dead fish.

Posted by: SocraticGadfly on July 31, 2008 at 5:06 PM | PERMALINK
I always shake my head when I hear that doctors are prescribing truckloads of antibiotics to patients with viral infections because the patients insist.

While this is probably mostly a myth, there is probably a kernel of truth at its core: its true that some doctors are more prone to prescribe antibiotics before it can be determined certainly that an infection is bacterial (certainly, this is justified in some cases, based on symptoms, the patients medical history, etc.; individual doctors have differing interpretation of exactly when this is the case), and certainly patients who think they ought to be getting medicine will discover that over time and gravitate, within the freedom allowed by their healthcare coverage, to the doctors that tend to prescribe the most freely, and those patients that personally lean the other way will tend to gravitate to doctors on the other end of the spectrum.

Posted by: cmdicely on July 31, 2008 at 5:09 PM | PERMALINK

I don't understand why so many liberal bloggers take Cowen seriously. The arguments he makes against Medicare for all or single pay are already answered, as Kevin pointed out. Further, as a commenter rightly said, if people actually saw how other nations' insurance programs worked, they would be clamoring more for single pay or Medicare for all.

Broadcast corporate media simply refuses to point out the myths of the various objections to a national health insurance program and it gets drowned out by gaffe-hunting by broadcast reporters and commentators. It continues to be a sad state of affairs from a public policy perspective.

Posted by: Mitchell Freedman on July 31, 2008 at 5:10 PM | PERMALINK

I don't understand why so many liberal bloggers take Cowen seriously. The arguments he makes against Medicare for all or single pay are already answered, as Kevin pointed out. Further, as a commenter rightly said, if people actually saw how other nations' insurance programs worked, they would be clamoring more for single pay or Medicare for all.

Broadcast corporate media simply refuses to point out the myths of the various objections to a national health insurance program and it gets drowned out by gaffe-hunting by broadcast reporters and commentators. It continues to be a sad state of affairs from a public policy perspective.

Posted by: Mitchell Freedman on July 31, 2008 at 5:10 PM | PERMALINK

Monzie, My mom's in the same situation you are, she decided against chemo 2 years ago, she's fine now, and she decided the slight difference in odds versus the "chemo quality of life" were her deciding factor, she's 68 now, and so far fine without the chemo. Her son-in-law is a cancer surgeon, so she has some pretty good inside knowledge too.....

Diagnostic tests are an odd one for health insurance companies, I once worked as a system administrator in one, and I got the feeling that the company was in a bit of a bind:

1. pay for tests, get inconclusive results, repeat, add $$$
i.e. I recently broke my ankle, my doctor had it x-rayed, the x-ray showed small slivers and spots that were quite odd but had no symptoms, after a while of feeling my ankle, he told me that he treats people, not x-rays, so I was treated for the broken ankle, not the small slivers and spots in the x-ray, which may have been from a childhood fall, but seemed to have healed fine in their own way... it was a teaching hostpital, and the first student doc who looked at the x-rays wanted to operate ad nauseam, mentioning metal plates and all sorts of things....


2. pay for tests, get results that indicate cancer, but long time in the future, thus accidently damning the patient's future health insurance prospects, and probably insuring he/she will stay with your company as long as possible, otherwise it may be considered a pre-existing condition....

i.e. Many men test "postive" for prostate "cancer", but the growth rate may be so slow that they'll die of something else first


Posted by: vaxorcist on July 31, 2008 at 5:12 PM | PERMALINK

Ok, here's a scenario.

During my annual physical March, I mentioned some symptoms to my MD that were probably just ordinary back pain and a bit of acid reflux, but he wanted to make sure there were no physical problems and had me get x-rayed. An x-ray, 2 CT scans, an MRI and an endoscopy later, I had surgery to remove a tumor that was absolutely and completely unrelated to the original reason for the x-ray. (In fact, the first CT scan was for something suspicious-looking in the x-ray that itself turned out to be just an "artifact," but did show something else suspicious, etc etc.)

So that's, what, 5 pretty expensive and elaborate diagnostic procedures--one involving anesthesia--4 of which had nothing to do with the original symptoms that started the whole chain off. Which in raw numbers could look like a demanding patient overusing the system.

But really the whole episode was driven not by my desires or my Doctors' but by the technology itself. It all came about as part of looking for one thing and finding something else that we wouldn't have even known to look for if the technology hadn't been so powerful as to turn it up in the first place. Dunno how big a fraction of the over all problem this kind of thing is, but just anecdotally my surgeon said he sees it pretty often. The thing could have killed me if they hadn't removed it. But I never would have known about it if I hadn't asked about something else that was completely unrelated.

Posted by: DrBB on July 31, 2008 at 5:23 PM | PERMALINK

"If you are 5-10% less likely to DIE, then why in the world do you NOT take the treatment?"

In this instance, the treatment itself likely is not without risk, and at the very least is inconvenient/unpleasant. It's not as simple a decision as the comment suggests.

Posted by: PaminBB on July 31, 2008 at 5:29 PM | PERMALINK

I'm a doctor who specializes in clinical genetics. I see a mix of children with birth defects and people who may be genetically predisposed to develop cancer. In general, my patients and their parents are anxious and would rather be almost anywhere else than sitting on a plastic seat in the waiting room of a genetics clinic facing the possible diagnosis of a bad disease that they've never heard of.

It is true that the occasional patient will demand that I order every possible test as well as arrange to have their whole genome scanned. Every year I also see a few families who have the will, and means, to travel the four corners of the earth to seek care for their sick child. They're not just going out of their HMO provider network, they're going out of the state or out of the country. By the time I see them, they've already had a mega workup at another nationally known medical center (at full retail cost).

However, while these two types of patients are excess users of health care dollars, they represent only a small fraction of my patient population. The majority of my patients are quite willing to go along with whatever diagnostic and therapeutic strategy that I propose and no more.

Posted by: Platypus on July 31, 2008 at 5:31 PM | PERMALINK

Of course healthy people don't want huge amounts of health care. Of course going to the doctor is a pain.

Get diagnosed with stage four lung cancer and it's a whole 'nother thing. And when you are battling some major disease like that, you take all the care you can get -- whether it's likely to have a big positive impact or not. Because you're desperate. See the recent NYTimes piece on Avastin. Hugely expensive. Adds maybe a month to the overall prognosis. But speaking as someone who's mother is currently on avastin, there's no way someone is going to turn it down if offered. That one month average boost comes with a tail, and maybe your loved one will be in the tail, and if she is then its worth it.

So -- your experience has nothing to do with the relevant question.

Posted by: Maggie on July 31, 2008 at 5:35 PM | PERMALINK

All this theorizing is ignoring the data: the Europeans are paying less for health care, and are getting better outcomes.

Posted by: Joe Buck on July 31, 2008 at 5:47 PM | PERMALINK

*

Posted by: mhr on July 31, 2008 at 5:53 PM | PERMALINK

Boomers have high (perhaps virtually limitless) demand for "lifestyle" therapies. (Viagra, knee operations, etc.) Everything else, they want as little of as possible.

The real issue here, though, is whether people feel entitled to batteries of tests and therapies of dubious value. Take MRIs. Should everyone with a gimpy knee get an MRI? In most other countries, such demand is restrained by a fundamental supply constraint upstream (for example, British Columbia, pop. 4.4m, has fewer MRI machines than San Francisco, pop. 750K). In some cases such supply constraints may lead to those notorious waiting lists, but in a lot of other cases it just leads doctors not to have patients get questionably necessary treatments.

Why Americans are willing to let managed health care providers say no to them for treatments, but are unwilling to have the government say no, I've never quite been able to grok.

Posted by: Nils Gilman on July 31, 2008 at 6:00 PM | PERMALINK

When is Christopher Guest going to do a "Spinal Tap" style takedown of the medical profession's archaic culture of stupid arrogance. You want cavalier arrogance in a football quarterback, but in a doctor it's deadly.

Posted by: cogswell on July 31, 2008 at 6:03 PM | PERMALINK

"When medical care is considered to be "free," ie provided by the government, you can be certain that the demand for it will increase."

That's nonsense. Many medical treatments are very unpleasant, and some are very dangerous. People don't enjoy rectal exams. If they were free, people wouldn't "load up" on them. People also don't like chemotherapy. They don't always get it when even they 'need' it. Many would rather die than go through another round of chemo (my father and brother both made that choice). And surgery scares the hell out of many people. And when patients see the massive screws and rods that will help their spine, they usually become even more scared of the surgery. You can't honestly think that people will line up for unpleasant and dangerous treatment just because it's free, can you?

Posted by: fostert on July 31, 2008 at 6:15 PM | PERMALINK

Women basically have to get an annual exam at the ob/gyn if they want prescriptions for birth control...and yes, to some extent I "want" it, but for many women it's medically "necessary" to provide regularity for irregular cycles and extremely bad cramps. On top of that, preventing unwanted pregnancy saves everybody money. Of course, we all know from the recent John McCain fracas that the pill isn't covered by most insurance plans anyway, but I think it's worth pointing out that men don't have to go to the doctor yearly and therefore don't often consider the degree to which women do.

Posted by: CattyinQueens on July 31, 2008 at 6:16 PM | PERMALINK

With the drug that will reduce your chances of dying but is expensive, would anyone go, "Well, sure, I'm more likely to die, but hey--I'll be saving money!"
It is different, of course,if it changes things from 40% to 35%, rather than 95% to 90%, which is I hope is what you're talking about.

Posted by: pbg on July 31, 2008 at 6:18 PM | PERMALINK

Hey!! Here's a suggestion! Maybe we shouldn't let drug companies advertise their products on the teevee.

Posted by: Jay Ackroyd on July 31, 2008 at 6:18 PM | PERMALINK

In America there will be an increase in demand for services should universal health care be implemented, because there are so many people who cannot afford privatized health care now. Those people will want to see a doctor as soon as they can for ailments that have long gone untreated, and since there are tens of millions of them, there will be an initial increase in demand for medical services should the US include health care among its public goods like other first world nations do. Once that initial backlog is treated, one would expect an equilibrium to be reached between demand and supply.

Posted by: Brojo on July 31, 2008 at 6:22 PM | PERMALINK

A couple of minor points: subscribing antibiotics for viral infections. I don't know the prevalence, but both myself, and my coworker, when we get viral infections, the mucous buildup makes nasty bacterial secondary infections probable. So in our cases, the antibiotic is needed, not to cure the primary problem, but the prevent/cure a nasty secondary problem. So just maybe, this urban myth got started because of people like me.

I have a couple of common minor ailments, which are often treated expensively by the traditional healthcare system. A very good, alternative medicine provider showed me simple (costless) self treatment for these conditions. I bet MDs are totally unaware of these sorts of interventions. Their information comes mainly from drug companies, and medical device manufacturers, who have no incentive for news about cheaper alternatives to get out. I bet if I made a public issue out of this sort of thing, I'd be sued, so I keep quiet about it. If we had a single payer system, I bet they would be interested in cost effective measures.....

Posted by: bigTom on July 31, 2008 at 6:27 PM | PERMALINK

"When medical care is considered to be "free," ie provided by the government, you can be certain that the demand for it will increase."

That's nonsense.

It's not just theoretical nonsense as fostert pointed out--it's empirical nonsense. Medical utilization in Europe, Japan and the rest of the developed world is about the same as the US, or even less.

By the way, the type of care matters. The whole point of preventive medicine is to increase demand for general practitioner care, which decreases demand for specialists. The result is better health outcomes and lower costs for everyone.

It's really bizarre seeing someone whip out Econ 101 instead of applying common sense.

I look forward to seeing commenter mhr step out in the middle of traffic to negotiate a 'stopping price' with each oncoming car.

Meanwhile, I will be using the crosswalk.

Posted by: theo on July 31, 2008 at 6:37 PM | PERMALINK

"Maybe we shouldn't let drug companies advertise their products on the teevee."

That's probably the best suggestion on this link. Patients aren't very good at making medical decisions. In fact, they often are patients because they made bad decisions.

Posted by: fostert on July 31, 2008 at 6:51 PM | PERMALINK

The state of Oregon has come up with a solution. A terminal cancer patient there was recently turned down for his request for heroic, experimental, expensive treatment, and the rejection letter from the State included the helpful suggestion that the State would pay for assisted suicide. What a concept!

Posted by: DB: on July 31, 2008 at 7:11 PM | PERMALINK

My brother-in-law is a doctor (with patents and he is curing cancer in mice) says NEVER GO TO A HOSPITAL.

Read and follow, Younger Next Year, or the women's version. This book will tell you how to avoid getting the diseases of old age that we have come to accept as old age, but which is actually abnormal.

Posted by: lilybart on July 31, 2008 at 8:00 PM | PERMALINK

My brother-in-law is a doctor (with patents and he is curing cancer in mice) says NEVER GO TO A HOSPITAL.

Read and follow, Younger Next Year, or the women's version. This book will tell you how to avoid getting the diseases of old age that we have come to accept as old age, but which is actually abnormal.

Posted by: lilybart on July 31, 2008 at 8:01 PM | PERMALINK

Speaking for the under 65 crowd, who has time to visit the doctor when it isn't needed? Travel, wait and doctor time and we're talking a minimum of 2 hours. Frankly, I think it's BS that a majority of people rush to get more healthcare if it's covered at a reasonable level by insurance. ANd if it isn't, they're even less likely to go.

Posted by: Bob on July 31, 2008 at 8:01 PM | PERMALINK

I think a lot of the expense has to do with doctors worried about liability if they miss something. When I was a child you went to the family doctor who had known you and your family for years. If you had all the symptoms of, say, flu, he would tell you there was a lot of it going around, what to do, and to come back if it doesn't get better. Now the doctor will say there is a 95% chance it is flu, but let's do a lot of expensive tests to make sure it isn't the other 5%. So one ends up spending more time getting medical care than one might want.

Posted by: Andrea on July 31, 2008 at 8:05 PM | PERMALINK

My grandmother was a hypochondriac. To be fair to her, she did have a great deal of pain from arthritis during her last years, but for most of her life she was actually quite healthy. However, she was extremely afraid of infections, and after her nightly bath, examined her entire body for contusions, scrapes, bruises, etc. She painted each place with Merthiolate. The bathroom stank constantly of Merthiolate.

She also had a weekly appointment with her GP, and demanded that she be checked from stem to stern. Her kitchen had those old wooden cupboards stretching from about 5' off the ground to the ceiling, and the ceilings were about 12'. One entire section of that cupboard, ca. 7 linear feet, was consumed by the various meds she took.

I'm 62 and know a lot of people, and she's the only person I've ever known who actually CHOSE to go to the doctor this way. Most people I know HATE going to the doctor, including moi, for reasons others have listed above. And anyone who likes staying in the hospital is crazy, IMHO. You get no rest because they wake you up every hour or so for: taking vitals, drawing blood, wheeling you to xray or MRI or whatever for more tests, and if they do leave you alone, your roommate is coughing or moaning or summoning help, etc., etc., etc. They draw enough blood to make you anemic by the end of your hospital stay, even if you weren't to start with. Leaving a port in a vein at least means you are stuck less often, but port openings can become infected. And there's the general risk of acquiring an infection while in the hospital.

Brojo has a point, that some of the people currently getting no care because they can't afford it, would probably cause an initial bubble in use and expense in a single payer system, but how many of those folks have doctor phobias and still wouldn't seek health care?

DB: while I can believe that an expensive treatment option might have been denied to a patient, I find the part about paying for assisted suicide a little unbelievable in this context. Do you have a link?

Posted by: Wolfdaughter on July 31, 2008 at 8:26 PM | PERMALINK

Does this snarky comment:

"...(Tell me again: why, exactly, is it that doctors seem to think it's cute that they have unreadable handwriting?)..."

have any data behind it? Or is it just because you loathe doctors?

"...I, personally, labor under a considerable fear and loathing of doctors. (OK, more loathing than fear, actually..."


Posted by: Peter on July 31, 2008 at 8:46 PM | PERMALINK

As a pediatrician, I can tell you that some parents bring their kids in to the office all the time, often for very minor ailments. Most of what I see on any given day, probably 95% of what I see in the winter especially, is one type of viral infection or another. Sometimes I can understand why the parent brought them in: "Jimmy has a history of ear infections and I just wanted to make sure it wasn't his ear again". That makes sense to me. Sometimes I see kids that have had a sniffle that started that morning. That I have a harder time with. It amazes me that a parent with 3 children doesn't realize that a temperature of 101 does not necessarily require a trip to the doctor.


And, in the populations that I have ever worked with, free care does if fact influence the amount of health care demanded. When even a small co-pay was introduced, the number of patient visits dropped. From my point of view, this was a good thing. We still saw the kids that needed to be seen and saw less of the 'worried well'. From an administrative point of view? Since they are forever keeping track and compiling our 'numbers', I can imagine this may not have been seen as a positive result.
Either way, the co-pay was short lived.

As for demand for treatment... I see it all the time. An example: in the past few years, especially, there has been a big push to limit antibiotics, which I fully support. Many families appreciate this and don't want their kids on unnecessary medications but just as many get upset and demand that I treat their sick kid. I do take the time to try to explain the difference between viral and bacterial infections and the role of antibiotics(which actually takes way more than 60 seconds - go ahead and try it) but some parents insist that I do or give them 'something'.
When I was training, one doctor I was with who was in a private practice told me that he generally would give the patient what they wanted, because if he didn't, they would leave and go to another doctor who did.
Now that I am practicing, I find that the patients who are that demanding and would actually leave are probably the ones I would be happier to have gone. Makes it simpler for me.


As far as what drives use of health care resources?
This is a complicated question, of course, but I do note that in the Northeastern part of the country, which has some of the highest utilization of health care resources, they are also reimbursed at the highest rates. I am from the Northwest, where we typically have less overall and more efficient use of health care resources... and we are reimbursed at the lowest rates.

Posted by: on July 31, 2008 at 9:00 PM | PERMALINK

But the way health care is paid for, there's no real connection between need, want and receive.

If I break my toe, and need an orthopedic shoe so that it heals right, I need it. But my insurance only covers casts. So either I fork out for the shoe, or it doesn't heal right, and becomes a later problem.

If the doctor prescribes a medication: Either insurance covers it, and it costs some basic amount (like $40) or it doesn't. Insurance makes it so that I don't know if I'm choosing a medication that costs $100 or $50.

The whole system is completely divorced from any sort what is needed, what isn't, and what is received.

Posted by: Crissa on July 31, 2008 at 9:05 PM | PERMALINK

Advertising almost certainly has an effect on the number of prescriptions written:

From the Canadian Medical Association Journal (Sept. 2003)

"Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice."

DTCA is "direct to consumer advertising"

http://www.cmaj.ca/cgi/content/full/169/5/405

By the way, seniors are actually less likely than others to ask for prescriptions not suggested by their doctors.

Posted by: Mike on July 31, 2008 at 9:21 PM | PERMALINK

Dr. No said:

"My broader point would be that it may be a mistake to evaluate health care costs in general by approaching it from your own perspective and rather look at where the money is being spent and why."

This is exactly right. It's silly to look at healthcare costs from the perspective of healthy people who don't want much healthcare (I include myself in that category). The big bucks are spent on very sick people, often at the end of life. That is where expectations and resources come into potential conflict.

Dr. Jon

Posted by: Jonathan Dworkin on July 31, 2008 at 9:34 PM | PERMALINK

Wow, no one has yet mentioned the book "Overtreated"?! Check it out:
http://www.overtreated.com/home.html
http://www.sciencefriday.com/program/archives/200710125

Posted by: me on July 31, 2008 at 10:20 PM | PERMALINK

Does anybody think that one of the most significant factors here is the inefficiency of our system. We spend way more as a percentage of our GDP on health care with mediocre results at best. Of course there are outliers like very serious cancer cases. The huge bulk of health care expenditure is for routine care. Streamlining the system would reduce costs and offering decent preventative care might drastically reduce the advanced/serious cancer cases that present late to the physician. The idea that free healthcare would encourage overuse of the services is real but a small part of the picture.

Posted by: cwalker on July 31, 2008 at 10:30 PM | PERMALINK

I guess my sister would qualify as someone who wanted "boatloads" of care. See, she got a pain in her stomach so intense that it caused her to faint and hit her head. She was taken to the hospital, where they tested her in everything except what caused the problem, then gave her a couple of prescriptions for stomach acid, claiming that if she took them for two weeks, her problems would be solved. Instead, the acid leaving her stomach just made the problem worse.

Then there were the mis-administered tests that had to be readministered, and the "it's all in your head" doctors she had to put up with, before after a year, they finally confirmed that she had a malfunctioning gall bladder. So why do Americans demand so much care? Because they can't trust that the little care prescribed by doctors is the right care.

Posted by: wilder on July 31, 2008 at 10:32 PM | PERMALINK

It helps the discussion to not lump all health care costs into a single issue. What can be done to reduce costs of end of life care are different from elder care or maintaining health early in life. There are ways of reducing costs at each step. Reducing costs for people early in life actually involves more early intervention medical attention, inexpensive routine screening and wellness advice. This is NOT the culture of medical use in the US. In the US, the culture is to avoid doctors at all costs until the problem becomes unmanageable. At that point it may be much more expensive to fix. For example: What is the difference in prenatal care costs versus the costs of nursing a baby that is several months premature?

Posted by: bakho on July 31, 2008 at 10:55 PM | PERMALINK

One thing that will mitigate the effect of an increasing number of patients that were formerly insured is the change in the beauracracy from a profit-oriented insurance system to a single payer system. The streamlining will be significant. doctor's offices will have fewer people behind the counter coding, filing, talking to insurance companies and the doctors will also benefit from having less time dealing with insurance matters. This should free up some time to take care of a temporarily increased patient load.

The single payer will set the rules for diagnostics and treatment that will be clearer about what is allowed and what is not. The problem will be the same as it is with profit-driven insurance - who makes the rules.

My own situation is that I have had a chronic condition for more than 30 years and currently have no insurance and no prospects of being able to afford insurance on my own. I see my doctors far less than anyone thinks is sensible because of the cost of usually routine exams. In a single payer system I would certainly use more medical care than I am now. I'm sure that this would also be the case with many other uninsured with chronic illnesses. The uninsured who are well would still probably avoid doctors almost as much even if health care were "free".

Posted by: natural cynic on July 31, 2008 at 11:22 PM | PERMALINK

Kev, buddy, look. When I was a kid until about 20 I was plagued by sinus infections. I would get 3-5 each year and usually be sick 10-14 days and only antiobiotics would help to get me over the raging fevers it provoked. As such I definitely love doctors and have always had excellent relationships with them. In the last 5 years I have had to see them a lot less and am reluctant to go because consciously I don't want to cause some super bug to emerge. But I still wish I could ask for more treatment but my lefty conscience won't let me.

That said, these days if I have some VERY powerful codeine prescription cough medicine, I can get over sinus infections without further medication in about 10 days.

Posted by: MNPundit on July 31, 2008 at 11:23 PM | PERMALINK

I am a married 43 year old with no health care, eczema, a collapsed disc, and any other issues a woman my age may encounter. My husband works 60 hours a week in SC and the available health care is 700 a month for us and our two sons. What to do? He makes too much for Medical thank God but not enough to afford the premium.

Posted by: Shelly on July 31, 2008 at 11:46 PM | PERMALINK

I'm with Kevin. I do not like or trust the medical profession and have in my life seen one doctor that I thought was really good (he is now one of the most highly-placed MDs in the US, so my judgment was on target). And since it's practically impossible to get an appointment in any case, at least in the medical group I use, I can pretty much use an avoidance strategy. I note that I'm in my late 60s. However -- in a volunteer role, I provided transportation for several months for a woman in her 80s. She was quite alone, had a lot of nuisancy health problems typical for her age (incontinence, reflux) and she had approximately 100% access to medical care because of Medicare/Medicaid. I absolutely know that she went to see doctors to get out of the house and enjoy some conversation. She had completely whimsical reactions to them based entirely on personality, would immediately make an appointment to get checked when some interesting new disease was profiled on TV, was never compliant with treatment plans, etc. She probably saw 15 doctors while I was doing the driving. I eventually asked the agency to assign me to other people because she was wasting so much of my -- and the doctors' -- time. I would like to think that this is an untypical case ... but it certainly did make me understand why my own insurance requires a referral by a primary care physician!

Posted by: jhill on August 1, 2008 at 12:21 AM | PERMALINK

I'm late to the party like usual because I was sitting in my office until 8:15 tonight finishing up the list of phone calls to my more hypochondriacal patients. I tend to leave them for the end of the evening because they just take up so much time.

There are a bunch of reasos why we provide excess care -- income is only one of those reasons. Studies show that patients satisfaction rises with the number of tests that are ordered. Colonoscopies aren't popular, but MRIs are highly desirable. Liberals also like to discount malpractice as a cost driver, but the truth is that no one ever gets sued for overtreating -- just undertreating. That's clearly part of the calculation. Lots of times it's just easier to shotgun tests without thinking; it's convenient for the patient, easy for the doc, and nice to feel you haven't overlooked something exotic.

Ezra praises the VA for its efficient care. VA docs are federal employees and can't be sued for malpractice. I doubt that's entirely coincidence.

I signed a death certificate today for a patient who only agreed to hospice care this past Monday. I tried to explain it to her months ago, but she wanted to continue to explore every opportunity for treatment. Unhappily, she never got strong enough to go back to the oncologist to be polished off.

Posted by: J Bean on August 1, 2008 at 1:22 AM | PERMALINK

I have access to free health care, and last summer when I had a potentially serious eye problem, my local optometrist referred me to the NHS eye clinic. They called within an hour, and offered me an appt for that afternoon. I demurred, saying I was planning to take my kids to the beach. The caller was gobsmacked, and reminded me that if it were her eyes, she'd get in there right away.

So I decided to take that appt after all. But I agree; free medical care in no way makes me want more of it. I wish they'd quit thinking of it like ice cream.

Posted by: KathyF on August 1, 2008 at 2:14 AM | PERMALINK

Kevin,

I understand your aversion to the medical profession completely, but one thing you and Matt are overlooking is the huge elephant in the room- too many people want their dying loved ones to have every possible medical intervention that can prolong their lives, even if only for a few months. This is where the big money gets spent on medical care, and I can give you an example to put it in some perspective.

My paternal grandmother died in 2006 after being ill, senile, and bedridden for the last 2 and 1/2 years of her life. My parents took her into their home and cared well for her those last 2 and 1/2 years, but she was in and out of the hospital multiple times during this period with various bacterial infections and viral illnesses, and these stays usually were for 1 to 2 weeks at a time. Just the hospital care alone during this time was probably over $100,000 billed to Medicare. And my parents are not even the type to bug doctors to do everything possible to prolong a life that really wasn't worth living. In addition, I have watch a good friend's mother spend most of the last two years in hospital after hospital, with terms in between in nursing homes, dying of lung cancer. She has had multiple surgeries in this time- a time in which she doesn't even know who anyone is any longer, or even who she is, and all of this done because her family simply can't let go.

Posted by: Yancey Ward on August 1, 2008 at 9:36 AM | PERMALINK

Going to echo a lot of other people here and say while most of us never see doctors, we all know someone who loves being a patient because in some sense it means you're getting waited on. My stepmother, who has never worked outside the home a day in her life, sees doctors all the time but is convinced that single-payer insurance is a bad idea because then "those people who don't deserve it because they haven't paid for it" will, like her, go see doctors all the time. Why is she entitled to all this medical care? Because she's the kind of superior woman who can catch a rich husband, and having doctors wait on her is one of the perks of being a rich man's wife.

Posted by: Diana on August 1, 2008 at 11:25 AM | PERMALINK

Supply and demand aside, there is a philosophical issue barely touched on in this thread. That is, SHOULD health care be a for-profit industry? Many doctors, labs, hospitals, and insurers profit excessively from caring for our most basic needs (I know, I know, all commenters here are the exception to the rule.) I wouldn't deny anyone a good living from whatever employment they seek - but let's face it: even the nuns who own all the hospitals where I live run a for-profit industry and compete to squeeze each other out.

Posted by: Karen on August 1, 2008 at 12:13 PM | PERMALINK

Karen,

Unfortunately, supply/demand cannot be set aside. We can certainly run the entire system through government, or even non-profits, but without a profit motive somewhere in the provision of goods and services, the incentive to actually supply such things will be significantly reduced, while the inherent demand remains the same. At some level, the government has to obtain things from the private sphere, be that doctors, nurses, or hospitals.

Posted by: Yancey Ward on August 1, 2008 at 1:16 PM | PERMALINK

Some patients are hypochondriacal -- they are afraid fo illness and want medicine and therapy, no matter the cost. What they need is antidepressants, or meditation

There are doctors who size up their patients and say, "They want me to give them the works." They anticipate hypochondris.

Sometimes they do this so they can feel like saviors -- it is a quest for love and approval thing. A few physicians of course are crooks, ginning the insurance system for as much reimbursement as they can.

Posted by: Mike Finley on August 1, 2008 at 1:52 PM | PERMALINK

Speaking as a parent, I'd be quite happy with less intervention. Especially for routine issues. What parent can't recognize the symptoms of ear infection? But can I go and buy amoxiccilin myself like I could if I were in Mexico? No. I have to go through the rigamorole of an office visit so that I can get a prescription. I'll save the health care system a ton by make amoxicillin over the counter.

Posted by: Retief on August 1, 2008 at 3:24 PM | PERMALINK

Too late to inform this discussion, but Salon has a very interesting article today on the placebo effect that touches on many of the issues raised here.

Posted by: Swift Loris on August 1, 2008 at 3:35 PM | PERMALINK

In a commercial setting it is the doctors who have an incentive to over treat/prescribe. They are the main targets of advertising though the TV ads must help.

Overtreated is an excellent book on the topic as another noted.

Posted by: Matt on August 1, 2008 at 4:05 PM | PERMALINK

Pre-existing conditions force many people into working for companies indefinitely, limiting their chances of career growth, preventing them from starting their own business. Total national productivity is limited by the immobility of workers, but perhaps this limitation is another big business subsidy. It’s a good trade off for corporations: they pay an HMO for group healthcare, and in return they have more control over their employees. They can lay employees off, but dissatisfied employees can’t risk losing their insurance.

Single payer health insurance would be an enormous boost to local economies. More people would start their own small businesses, or to be able to be self-employed. The cost of private insurance cripples small business start ups.

We as a nation have become accustomed to being adversarial with our healthcare system.

Posted by: Edna Gardener on August 1, 2008 at 7:31 PM | PERMALINK

Edna is right. Lots of people would love to strike out on their own but can't buy (or in some cases, buy at a reasonable price) health insurance for themselves and their families. Single-payer universal health insurance would be a boost to the economy.

Posted by: on August 2, 2008 at 9:41 AM | PERMALINK

All this theorizing is ignoring the data: the Europeans are paying less for health care, and are getting better outcomes.

1) Western Europeans are less likely to live in poverty than Americans (being poor negatively affects health, even in places with robust UHC).

2) Western Europeans are less prone to drug abuse than Americans.

3) Western Europeans are less dependent on automobiles -- statistically the most dangerous form of transportation -- and so suffer significantly fewer premature deaths from car accidents than Americans.

4) Western Europeans suffer the effects of lethal criminal activity (primarily gun crime) far less frequently than Americans.

5) Western Europeans -- mostly owing to better diet and more exercise -- are significantly thinner on average than Americans.

If you account for the above, you'll find the European healthcare system does not deliver better outcomes than America's. It simply starts with a healthier population to begin with. You could still make an argument in favor of Euro-style UHC on cost alone, because by all accounts the healthcare systems of most Western European countries don't perform significantly worse than the US model. But then again, Americans do get something for their high healthcare expenditures. They get fancy hospitals with plenty of state of the art equipment. They get lots of desired non-necessary healthcare (cosmetic surgery). They get some of the world's best cancer treatment and longest cancer survival rates. They get loads of heroic medical effort targeting the very very old and infirm. As the saying goes, I'd rather be an 86-year old diabetic with a heart condition in the United States than Denmark. Different strokes for different folks, I guess.

Posted by: Boulevard on August 2, 2008 at 11:17 AM | PERMALINK




 

 

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