I beg you to please tell me:

What will it take for people to no longer link to Megan "I got mine, bee-atch, screw all you" / "I took a econ class once so I'm an expert"?

Here's the best way to handle this kind of idiocy: ask for evidence.

You'd rather have hip replacement here than in Europe. Why? Are the outcomes better here than there? Error rates? Rehospitalizations? Hospital acquired infections? (And, while we're on the topic, perhaps you can tell me why hip resurfacing, a far lower impact and safer procedure than replacement, was cleared for use in the EU years before it was here?)

Don't just tell me where you'd rather do it. Tell me why and show me the numbers, Megan. I'm listening.

Dear Megan McArdle: Please Go Galt and stop interfering with our attempt to fix our third-world healthcare system.

"...no systematic difference..."

Baloney. There are huge differences in the US alone. Studies are showing wild disparities in the US in end of life care, i.e., Stanford gives better care for less than about 1/3 of the nation's healthcare providers. So there are systematic differences in the US by itself. The US can make huge savings just cutting out the incompetence from that one class of care.

It is criminal that Republicans are blocking smart people from coming up with smart healthcare solutions in the US.

Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans.

An employer that dumps their health plan (provided, of course, that the health plan actually providers value to the employee) makes employees less dependent on the emplyoer, and therefore more likely to leave, particularly its most talented workers with the best prospects elsewhere. As long as employers size allows them to negotiate better deals for private insurance than individuals would get individually, and as long as they are able, therefore, to provide better plans for the price than their employees would be able to purchase on their own, employers will have a positive incentive to maintain those plans.

Of course, if the private, employer-negotiated plans don't provide anything better than employees could get on their own for the same price—whether public or private—then there is no incentie to keep the plans, but no harm to the employee in them being dropped either.

So, regardless of what any status quo comparisons between the current US private and any existing foreign public system on any particular procedure says, any argument asserting that harms result from the particular incentive McArdle alleges to exist here is clearly spurious: the incentive does not exist except where it would have no harm.

One need not even to consider whether or not the incentive or harm would exist, since it is clear that if the incentive exists, the harm does not, and vice versa.

What America is best at is delivering a lot of complicated care in extremis, and "quality of life" treatments.

Incorrect.

What the American health care "system" (the hodgepodge of uncoordinated public and private systems hardly deserves to be characterized as a system) is best at is failing (or perhaps "refusing" would be a better term, since it usually involves conscious, deliberate decisions, not mere accidents) to deliver service until the most critical and expensive need is created by that failure, which is precisely the opposite of providing "quality of life".

Would some kind person please parse this piece of crap and tell us which universe megan really comes from.

"Since private systems have so far found it virtually impossible to deny many treatments for long, this will mean that millions of budget constrained people will find themselves with less available treatment than before."

At the extreme end of procedures, we do them the best, because sensible people usually won't do them at all. But those radical treatments usually don't work. My mom was given the go-ahead on a bone marrow transplant four months after going through a Richter's Transformation (chronic lymphatic leukemia to large cell lymphoma- very rare and always fatal) . The doctors put her chances of surviving the procedure at 20%, and her chances of surviving three months after that at under 5%. There really wasn't much point in doing the procedure, but the insurance company approved it anyway. She died before the harvest could be done. There really is no point in wasting valuable resources on expensive, last-ditch efforts like that.

McArdle reminds me of folks from the Society of Creative Anachronism, the medieval reenactment group. To quote a member, "No one plays the part of a peasant dying of the plague".

The difference, of course, is that SCA types are playing lords, ladies, knights and craftsman for fun. McArdle is playing a journalist for a living, her views have an impact on public policy. and missing a vital (and tragic) part of the story.

The other difference is that the SCA types seem more serious about their scholarship.

@Chocolate Thunder -

The evidence on the rest of the industrial worlds's healthcare systems is already in. They live longer than us on average. They have lower rates of infant mortality on average. In fact the US (the richest country in the world) tends to score towards the bottom on most healthcare indexes when compared to other industrial nations.

"I'd rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby."

What seems weird to me is that McMegan seems to think that a hip replacement is strange and unusual care when in fact it's much more comparable to having a baby than it is to, say, a bone marrow transplant.

I'd also be curious to see what the rate of hip replacement per capita is in that socialist hellhole, England, as compared to the US. I strongly suspect that we aren't exactly kicking ass in getting "quality of life" care to people who need it even if those lucky enough to afford it here have shorter wait times. Part of the reason we have shorter wait times is that fewer people can afford to get the surgery in the first place. If everyone in the US who medically needed a hip replacement was able to get one, we would definitely have longer wait times.

But I guess McMegan doesn't mind rationing care by ability to pay as long as it means she can step over the bodies of her fellow citizens as she goes into the hospital for her elective surgery. After all, what's the point of having health care if any Tom, Dick or Harry can have it?

Also, I wonder about the relative probabilities of a woman getting a hip replacement, and having a baby.

It's funny McArdle should use hip replacement surgery as her example. She probably isn't aware of the Yvonne Watts case that was decided a few years ago:

http://news.bbc.co.uk/2/hi/health/4985512.stm

That case, before the European Court of Justice established the right of British citizens to go abroad for treatment when the wait for a particular procedure is too long in the UK, and the NHS has to pay for it.

The case involved a woman who was told she would have to wait 15 months for hip replacement surgery, and decided to go to France where it was available immediatly at the same cost as charged under the British NHS. The British courts denied the claim because, even though the system allows for such payments when there is "undue delay", the 15 month wait Watts was given was within the targets set by the NHS.

The ECJ ruled that what constitutes "undue delay" is a clinical decision, not an administrative decision.

That sort of decision seems to completely wipe away all the usual conservative arguments about against government involvement in health care decisions.

And, while I don't know how hip replacement surgery fares in the Netherlands, France is the most popular medical tourism destination for UK citizens who don't want to wait in the British queue for hip replacement. And now the NHS has to pay for it too. Their minimally invasive techniques are cutting edge and the prosthetics are supposedly some of the best in the world. Or so I'm told. I should be about two decades away from my first hip replacement...knock wood (does particle board count?).

Should the dog wag the tail or should the tail wag the dog? McCartle's argument, even if true, is that it is more important for us to have wonderful health care when confronted with extreme medical conditions at the end of life than it is for us to have wonderful health care when faced with the normal and routine illnesses that occur through out life. I would hope to have wonderful care both during the first decades years and at the end of life, but if given a choice I would prefer wonderful routine care over heroic procedures at the end.

The thing about Megan McArdle is that she just plain makes stuff up and asserts it as fact. And she gives the impression that she really doesn't see anything wrong with that.

Megan McArdle wrote: "I'd rather be here to have a hip replacement ..."

Sure you would.

Unless you are like my brother, a musician in New Orleans, who needed a hip replacement and had no insurance. And had to endure a year of constant, excruciating pain until he was able to find a charitable organization that would put him on a waiting list for a hospital that would perform a pro bono hip replacement, and then had to endure more months of constant excruciating pain until he eventually got to the top of the waiting list.

McCardle gives every indication of being a clueless, phony upper-class twit. If rich folks like her can get the medical care they need or want when they want it, then what's the problem?

I don't like the whole 'pretend for the sake of argument' tone to the piece.

First of all: My 91 year old grandmother lives in Switzerland. Broke her hip. Received a hip replacement surgery that weekend. No rationing. No nothing. in the US, most hip replacements are done on socialized (medicare) medicine.

Secondly: Pacemaker? Are you freaking kidding me? Since when has Medicare EVER denied a pacemaker to someone who needed it because they were old. GIVE ME ONE FREAKING EXAMPLE. ONE. It has never happened.

The whole argument of the piece is sophistry. Intellectual masturbation. I have nothing against it as practice for a High School Debate Team. But, please don't act like ANY of the arguments are worth being given the benefit of the doubt. They are made up. BS

Hilzoy wrote: "If not, you're relying on the assumption that the people you're imagining actually have health insurance. In this context, that's not a valid assumption."

Actually, that is a valid assumption if you're one of the people with a decent health insurance plan. Lots of people in this country do, and if the reform package will or may result in them losing that insurance, then the reform package is a bad deal for them. There would still be a moral argument for them to support reform, of course, but not a personal quality-of-care argument.

My sister, pre-Medicare age, lives in France and broke her hip. Not only did she obtain free, perfectly satisfactory surgical intervention. She was also provided with a month in the Pyrenees where she received physical therapy.

Why waste time arguing with a fool? McArdle lives on smug arguments-by-assertion like, "America is best at is delivering a lot of complicated care in extremis, and "quality of life" treatments." She's entirely too self-centered to grapple with the idea that reality exists outside of the freshman debating team of her mind.

The evidence on the rest of the industrial worlds's healthcare systems is already in. They live longer than us on average. They have lower rates of infant mortality on average.

But they're not as free. And surely that must count for something. Only their blinkered Euro-ness keeps them from trading their health-car delivery system for our glorious freedom-delivery system.

The point that Ms. McArdle here is being badly missed, I'm afraid. Voters each have their own circumstances and perspectives, and most of them have some kind of private health insurance. It is possible that many of them will be forced onto a public plan if one exists, and it is possible that this public plan will be less likely to fund expensive procedures with not-very-high success rates or less impact on longevity or quality of life than private plans are. We know this is possible because we see that it is true in other countries, such as Canada. (Also, in a sense, this fact is the very STRENGTH of a public plan - it may lead to more rational insurance money allocation, and better systemic outcomes per dollar spent). I think, unless one is simply fighting every inch of ground for the sake of it, one must concede this truth. Therefore, it is not crazy for one of these privately insured voters to be concerned about this. Yes, it is selfish in that this voter doesn't consider other (uninsured) folks; yes, it will still be theoretically possible for these folks to pay for the procedures themselves (although probably not possible in practice for many things that insurance would refuse to fund). But it's not a crazy concern for the voter. Voters are understandably less worried about systemic outcomes and more worried about individual outcomes for them.

Right? Can we at least all agree that the sky is blue?

There are WAY too many Old People- thanks, in large, to modern medicine. If only they'd do the Right Thing- (see ice floes analogy earlier today. . .)

But Old People vote; hence Medicare, and the prescription drug debacle of G W Bush.

What we need is long term health insurance, a la Social Security and Medicare. BOTH of which are deducted from your weekly paycheck. Anyone remember the concept of a health savings account?

A government mandated policy- car insurance, for example- deducted from your payroll every week. Twenty bucks, or so, to cover catastrophic events.

Really, really BASIC coverage for everybody. (Like Social Security- who can realistically "live" on their SS check?)

Then ANOTHER deduction, for that Health Savings Account. It's like a 401(K). An additional twenty bucks a week. Or forty. Or four hundred, if you can afford it. Money invested,(T bills?) to be used when, God forbid, you need additional money for that new hip or heart, or Final Days. Your choice; it can be rolled over to your heirs, if you choose to shuffle off your mortal coil.

But that's another topic. . .

Actually, that is a valid assumption if you're one of the people with a decent health insurance plan.

The problem is that lots of people assume they're one of the lucky ones with decent health insurance and discover too late that they aren't. Even employer-based insurance only lasts while you're employed. If you can't work because of your illness, bye-bye health insurance. Disability insurance will only take you so far once you're paying list price for everything.

It is possible that many of them will be forced onto a public plan if one exists, and it is possible that this public plan will be less likely to fund expensive procedures with not-very-high success rates or less impact on longevity or quality of life than private plans are. We know this is possible because we see that it is true in other countries, such as Canada.

It is also possible -- and is, in fact, far more likely -- that their current insurance company will refuse to pay for that expensive procedure.

That's the issue. In these arguments, people are pretending that we do not have rationed health care in this country, so any rationing by a public plan will be something new and different. The fact is that our health care is already rationed -- it's just rationed using different criteria than the ones Canada uses.

I agree that years of scare tactics have convinced people that they'll lose what little coverage they have now, because some people have been convinced that the insurance they have right now is the best they can do. I also agree that some people have very good policies with iron-clad guarantees that mean medical bills will never bankrupt them who would lose out under a public plan. I just think there are far fewer of those people than you think and that, as with the 25% of Americans who are convinced they're in the top 1% of earners, a lot of people are vastly overestimating how good their coverage actually is.

How about the mere part that I don't really have insurance if I don't have my insurance card on my person. Or if I travel outside of my home town to see my mother. Or if... Any one of a million basic things.

Argh.

And Megan McArdle deserves your attention...why? She's an idiot and a hack and the publication she works for is increasingly irrelevant. You probably do more for her stature by de-bunking her gibberish than by completely ignoring her as the drooling nitwit that she is. But that's just my opinion.

It's quite obvious that Republicans have completely forgotten about the existence of Medicare. Apparently, our government has never had anything to do with healthcare until Obama came into office with his Islamofascist Socialism.

To be clear, I respect and admire Hilzoy's work. Maybe I just feel sorry for her because she has to deal with the likes of Megan.

Another thing to remember, but often confused or tricked up (dep. on who is talking): the true "cost" of moving to a system is the cost of *changing* to it, not the total cost. IOW, we take the cost of "public option" or whatever, minus the cost of the current system to people, and that's the number you use. Aren't the big figures like "one trillion dollars" that people toss around, based on the false accounting of using the raw and not the net cost?

As a sufferer of a genetic bone disease who is on disability and Medicare and is far overdue for two hip replacements (as well as shoulders), and also as a member of an extended family who are veritable mass consumers of joint replacements, one might think/hope that I'd have a great deal of relevant information to provide regarding the hip replacements portion of this conversation. Unfortunately, I don't.

I will say, however, that the most striking thing to me about hip replacements—the oldest and most well-understood and conventional joint replacements—is just how variable the procedures are. My relatives have seen huge differences in outcomes after having vastly different procedures by, apparently, surgeons of vastly varying competence. The greatest concern is easily what surgeon one chooses, and how to determine his competency.

It may well be that the best of these surgeons and procedures are cutting-edge (pardon the pun) medicine that the US is notably proficient at providing. But it also may well be that this variability is the result of far too much incoherence in our system because of the general lack of efficacy evaluation and standards.

And it also points to the probable fact that determining just how competent a given national healthcare system is at replacing hips is a difficult, not simple, process.

At any rate, Hilzoy's essential argument is correct. The greatest variability in health within my extended family with regard to our disease has been the quality of our insurance and, particularly, whether we have any at all. There are more confounding difficulties in my case than just this, but that I've more-often-than-not in the past had no health insurance whatsoever plays the largest role in why, today, my health is much worse than average in my family even though the intrinsic severity of the disease is relatively better than average. My sister had one of her hips replaced via charity, as the above commenter's brother did. This is very rare. Usually, those of us in chronic pain and barely able to walk have no recourse at all except to (as I eventually did) give up on being able to work and go on Social Security Disability in order to gain Medicare. This is surely very economically counter-productive—I'd rather find some way of working *and* having the health insurance that I require.

Glad someone brought up hip replacement. My paternal grandmother, 80 and still chugging along in Norway, stopped chugging last year. A trip to the doctor determined that she needed a new hip.

Problem was, she was old and wasn't employed, so she'd have to wait. A year or more. She was told that there were other patients ahead of her - younger and/or still working.

The pain got so bad that she decided to come to the U.S. for the procedure. Her kids and grandkids pooled together and paid for it. The worst part was the flight from Oslo. Everything else went smoothly.

Is this anecdotal data? Yes, but it should give one pause that a government health care plan is going to be some sort of panacea. In the end, the government isn't going to simply pay for every procedure without question. Sooner or later (I'm betting sooner), budget constraints will force the government to start making choices on what health care they will provide/pay for and what they won't.

The evidence on the rest of the industrial worlds's healthcare systems is already in. They live longer than us on average.

Please point to a peer-reviewed study that shows this is causation and not correlation.

Neonatal intensive care is more useful than intensive care for someone diagnosed with lung cancer. I don't agree with trying to save extremely premature deliveries, but if I had a choice, I would choose that over extending the suffering of someone who suffers from a near terminal disease.

Our health system hates letting people die with dignity, or even allowing them to get effective pain treatment, and the result is extreme medical costs for a few weeks or months of additional pain, not life, just pain.

"Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans. -- M. McArdle

Not for me, it wouldn't be. What would worry me the most is that my employer would cut a deal with a private insurer and refuse to contribute the same amount to the public one. So that, if I chose the Public O, I'd have to pay much more, than if I stayed with the employer-chosen one, however crappy that might be. And I *know* about about public-crappy (from childhood, teens and early twenties spent in commie Poland) as well as private-crappy (the latter getting progressively crappier as well as more expensive every year, while my husband's place place of employment is searching for ever cheaper options).

As for the quality of "extraordinary" care... It so happened that, in 2005/2006, two of my friends got breast cancer, within a couple of months of one another. One was in UK, the other -- well insured -- in US. What a *difference* a single letter -- K or S -- makes...

My friend in US had to drive herself to chemo once a month and sit, in her car, in the parking lot, until the worst nausea wore off and she could drive herself home (her husband is legally blind and cannot drive). My friend in UK had a nurse come to her house to administer the chemo and the nurse sat with her until the worst effects wore off, or the friend's husband came home from work.

Once the lumps were reduced, both friends had lumpectomies, in a hospital. My friend in US spent 2 days in the hospital, in a double room. Her insurance covered most of the cost, so her co-pay was under $2K. My friend in UK bought a supplemental insurance, so as to have a single room. She spent a week in the hospital, and her out of pocket expenses -- for the supplemental -- were around $2K.

Both of my friends are still with us and thriving, but my friend in US no longer has insurance; should a recurrence happen, she's out in the cold.

So, Ms McArdle can jump on the sharp edge of my skinny Polack butt with her arguments and comparisons. She's all "at sea", without even an ice-floe to support her, regarding the situation.

Is this anecdotal data? Yes, but it should give one pause that a government health care plan is going to be some sort of panacea. In the end, the government isn't going to simply pay for every procedure without question. Sooner or later (I'm betting sooner), budget constraints will force the government to start making choices on what health care they will provide/pay for and what they won't.

It was asserted by a guest on Bill Moyer's excellent program a month or two ago that, for less than the amount of money we currently spend on health care, we could perform every useful medical intervention on all patients in the United States. We spend more money figuring out if we should deny care and practicing defensive medicine than we do actually treating patients.

And, you know, even once we get to the point where we do have to ration or deny public funding of crazy expensive treatments, the rich will end up getting them and the poor will do without. Same as now, except everyone would be getting good basic care.

"If not, you're relying on the assumption that the people you're imagining actually have health insurance. In this context, that's not a valid assumption."

And that statement applys to almost everyone arguing against universal health insurance. They have insurance. They want to protect their privilege. They ignore that fact that they don't have to give up their insurance in order for other's to have coverage under an universal government sponsered plan.

Yes, but it should give one pause that a government health care plan is going to be some sort of panacea. In the end, the government isn't going to simply pay for every procedure without question. Sooner or later (I'm betting sooner), budget constraints will force the government to start making choices on what health care they will provide/pay for and what they won't.

Which is precisely hilzoy's point, no? Government health care is no different from private health care in this resepct. Private health insurers are already making exactly these sorts of decisions. There is no shortage of anecdotes of private health care in this country restricting health care based upon their own financial bottom line. Some they simply refuse to cover. Some they do cover but refuse certain procedures. Some they simply find technical reasons to drop when they begin costing more than their premiums. One can argue whether or not this is a better system. But it won't be an intellectually honest argument if the pro-US system doesn't acknowledge that private health insurance is already guilty of all the ills of which they accuse public systems. This is the entire point of the post.

If you think we don't ration hip replacements in the U.S., watch this video:
http://www.prescriptionforchange.org/video.html?bcpid=1767981878&bclid=1551048397&bctid=1549643949

Can anyone tell me why Farrah Fawcett travelled to Germany for some experimental cancer treatment instead of staying in L.A.? I know it happened because I watched her special a few months ago. According to Megan, she should have gotten more novel cancer treatment here.

Oh, hell, USAmericans are going to India to get stem cell treatments for their spinal cord injuries (with extraordinary, though limited, success).

Perhaps someone can flesh this out in more detail, but I seem to recall a few years back that Oregon came up with a plan which worked something like this:

We're going to determine how much money we can set aside for a health insurance plan (including state funds and premium pay-ins) which first creates a special panel of experts.

The experts convened and reviewed a huge list of medical tests and procedures. Might sound daunting, but such systems essentially exist anyway since private insurance companies need a system they can refer to to identify a hip replacement, ringworm or psoriasis.

They then prioritized those items based largely on their cost and their relative benefit to the population as a whole, or the individual. Thus, an operation for someone aged 45 might be rated higher than the same operation for someone 85. Or it might be rated higher in terms of need and benefit so that cosmetic surgery in the wake of a disfiguring incident would get a better rating than something to make you look more like Michael Jackson.

the end result was a list that went up to procedure/treatment/test xxy and if you needed procedures from a to xxy the system would generally pay them, but if it was xxz and beyond YOU got to pay for it if you wanted it.

Seemed to be a pretty good system, but as I recall the outcome, somehow the feds got involved in it and barred the state from carrying through. Am I getting the vapors?

Another problem for the United States when compared with Western Europe is the very low population densities in large parts of the West and Alaska. When your largest city has a population of less than say 100,000 (Fargo, North Dakota) there are going to be a lot of extreme medical conditions that occur so infrequently that the local doctors or surgeons have no experience in treating them. And with extreme surgical procedures, experience is almost everything (however, some surgeons are crap).

For example, a over ten years ago, I suffered an Acute Type A Aortic Dissection and was treated successfully in an NHS hospital a few miles away where the surgeons performed a fair number of elective repairs a year and a small number of emergency repairs a year. After leaving hospital, I looked into what my chances were compared with elsewhere and I came across a number of cases from the more remote parts of the western United States where the outcome had been death. In one case, it was because the triage nurse had never seen a case previously, in another case, from Montana, the patient had to be flown down to Houston for the nearest surgical team experienced in performing the repair, the patient expired in the plane.

So while the major cities and large conurbations may cope with extreme cases as well as or better than Europe a lot of people living in the more remote parts of the US are screwed, as they say.

Brent, Shsssh, we don't want the wingers to hear the truth. Health care is rationed. It doesn't matter who is paying the bills, it is rationed. The argument is a total red herring.

What private insurance companies are spending paying lobbyists over $1.5 million a day to stop is the introduction of real competition in the market place. The public option threatens to introduce real competition in the private insurance market. They like their regional monopolies.

As Paul Krugman points out, it's interesting that opponents of "government run health care" like to recite the fact that hip replacements are done much more speedily in the US than in Canada, and they use this as evidence that the US system is superior. And they ignore the fact that most US hip replacements are paid for by... Medicare! And I suspect that the (also government-run) VA system may be in 2nd or 3rd place.

http://www.photius.com/rankings/healthy_life_table2.html

To Al: Here is a link to a World Health Organization study comparing healthy life expectancies. The WHO reports are the standard for comparing care and costs in the world. The U.S. ranks below all of those havens of socialized medicine. We also spend more money to do it.

Yes, McArdle is a rightwing idealogue and rightwing arguments about healthcare deliberately ignore and exclude
the 50,000,000 uninsured. For conservatives they do not exist. They - the core problem - are assumed
away. McArdle assumes she would have insurance because she is too weak and cowardly to actually confront the
issue.

McArdle's assertion "Since private systems have so far found it virtually impossible to deny many treatments for long" is plainly false.

Some private plans, for example, limit payments to hospitals for procedures (that is other than room and board) to small amounts (recall NY Times article about people with insurance who were bankrupted by health care expenses). McArdle's claim about private insurance is simply false.

Her assertion that employers will stop providing insurance is based on ignoring the play or pay provision -- that is the employer mandate for firms with more than 25 employees.

Astonishnly her case for private insurance is her claim that the elderly get better care in the USA, that is praise of medicare not private insurance. Even if true, it would say nothing about private insurance.

She is not writing about actual health care in Europe, not writing about private insurance in the USA and not writing about the proposed reform. Her post has, basically, no link to reality.

A lady in my church turned 100 last year. A week later she fell in the lobby and had to have a hip replacement. She had a good outcome and was walking with a walker within 2 months. Another 2 months later she fell and broke the other hip. She was 100.5 by then. She got the second replacement as well and is doing fine. Medicare did it all. No rationing and no refusals.

Another thing - private insurance may or may not turn down procedures, but when they do allow an expensive procedure, they turn around and raise the employer's rates so high that the employer raises the co-pays of all employees. Then when a downturn comes in the business cycle, the insurance user usually gets laid off. Anyone 55 or older is the first out the door.

My brother and his wife work for a major health insurance company. When it came time for them to cut staff, the employee who recently recovered from cancer was the first out the door.

I guess Conservatives don't care about anyone but themselves if they have insurance.

I'll give you one good example of rationing that goes on already. I have migraines for which I have a prescription for medication that works very well. I have insurance. I mail in my prescriptions to the service associated with my insurance where they provide a 90 day supply, usually for a single co-pay (as opposed to paying monthly). I usually get 3 boxes of pills (8 per box) for my $50 co-pay. When I refilled, I got 2 boxes for the 90-day period for the same co-pay. When I refilled again, I got 1 box for the same $50.

I called the company to find out why the supply keeps diminishing. They told me that I "exceeded the limitation" for that drug. I asked if the limitation was medical or the result of cost containment. They told me that I could get the next 12 pills for another $50 after a couple of weeks.

For those of you who are counting, that is about $8.25 per pill and if I get one headache, it uses 2 pills. Then, as is common for migraines, the next day a rebound headache occurs. So, I have to worry that if I suffer enough migraines that I use up the 8 pills in 30 days, that leaves 60 days where I must suffer, because the insurance company decided that it will only allow so many pills. If you have ever had a migraine, you know that this not only is cruel, but unnecesary.

The pain got so bad that she decided to come to the U.S. for the procedure. Her kids and grandkids pooled together and paid for it. The worst part was the flight from Oslo. Everything else went smoothly.

So the difference between you and the two posters in the thread whose family members had to wait over a year to get a charity procedure is that your family had enough money to pool together to help your grandmother out.

Again: rationing by who can pay. Your grandmother got her hip replacement because she could pay for it out of pocket, while other people who needed one equally as badly had to wait over a year because they could not pay for it out of pocket. What we're arguing about is how we're going to ration care, not suddenly adopting a rationing policy. We already ration healthcare. The only difference is that we pay private companies a premium to do the rationing instead of having the government do it.

About Oregon: it wasn't the federal government that did it in -- there was a federal snafu, but it was worked out. It was, instead, The One Big Reason why doing health insurance by states won't work: the legal requirement (in most states) to balance the budget. When there's a recession, tax revenues go down while demand for services goes up, stuff has to be cut, and in this case, it torpedoed the Oregon Health Plan. (iirc.)

A few interesting wrinkles: they started out asking people how much they valued this or that procedure, combined that info with the cost, and came up with treatment prioritizations. I can't remember the exact example, but something like appendectomies ranked below something like tooth capping, because the latter is so cheap. Moral of story: when people have to value things, and those valuations are going to be multiplied, so that the difference between valuing a tooth capping at .11% of a year of life and at .12% of a year of life makes a big difference, this is a silly procedure to use. (They fixed this quickly.)

Also: the idea was supposedly that they were going to draw a line at a certain point: above the line, things get paid for, below the line, not. (Where a given procedure was on this spectrum depended on value for money.) But -- oops! -- it was so popular that very few things ended up below the line.

That didn't keep it from getting eviscerated when the economy went south, though.

Megan McArdle:Econ = Mike Tyson:Astrophysics

If you haven't yet, I urge you to take the time to read this diary at Daily Kos

How I lost my health insurance at the hairstylists

It's exactly what Always Hopeful @ 11:40 mentions.

Just like the diarist, you never know when something is going to hit until it does. I had a smudge on my glasses I thought, only to realize when I went to wipe my glasses that it was a smudge on my eye. That was a Sat. last year. On Monday I went to the eye doctor. He had me at the hospital the next day and I was admitted on Wed. It was diagnosed as a first attack of MS.

Here in Japan, I'm completely covered and costs are limited for certain diseases like MS. I had an MRI last Sat. and paid $100 for it. Unfortunately, given the US situation, how can I ever move back? It'd bankrupt me and my family.

Of course my Swedish friend thinks medical costs in Japan are too high. (That's the Swedish friend who is Korean by birth but adopted by a Swedish woman and now married to a fellow Swede--all those pure genes, you know. Those who've read Steve's post below will get it.)

For those who argue against single payer universal health care (or any public option) because it will lead to rationing -- We already have rationed health care.

Most insurance plans max out a $1 million. Once you reach that limit, they don't pay anymore. A serious illness, a bout with cancer, a long term chronic condition, an accident -- $1 million dollars doesn't go very far. For example, after Christopher Reeve was stabilized following the accident that left him a quadriplegic, it cost about $455,000/year to maintain his life.

If your physician says you need an MRI, he will typically have to get pre-authorization from the insurance company to refer you. The insurance company may or may not go along with it.

That's rationed health care.

If you want chemical dependency treatment, they limit your number of inpatient days that they'll pay for.

That's rationed health care.

The reason insurance companies don't want to compete with a public option plan is that they're afraid that they can't compete with a non-profit. By "can't compete", I mean they can't sustain their obscene profit margins. I don't mind a company making an honest profit. I do mind an insurance company CEO taking home $100 million in salary and stock options.

The fact is, we already have rationed health care.

Look up medical tourism on wiki, if you don't know what it means.

Whoever would have thought that Americans would, routinely, have to go to the other side of the world to get necessary surgery affordably?

Need coronary bypass, or a hip or knee replacement, but don't have insurance or enough money? Go to India where it's a fraction of what it costs in the US.

That's where it's heading anyway with employer-provided health care:

http://www.nytimes.com/2006/10/11/business/worldbusiness/11health.html

Thank heaven for unions!

I put it to you that there may indeed be a difference in America for extreme medicine (high cost, low efficacy, low cost efficiency).

A well connected person can put a call in to a Congressman and suddenly the denied claim will be miraculously covered. Insurance companies like to keep those kinds of guys happy.

Perhaps I'm being unfair. Such corruption may be commonplace overseas as well, in which case, the commies STILL beat us. Helping the proles as well as the overlords.

What you don't get to do is act as though the fate that would befall a 99 year old who needs a pacemaker (in the imaginary world in which no one has Medicare) is a horrible new scourge that Obama's plan would introduce into the world. Or, in short: you don't get to ignore the existence of the uninsured. (Or the underinsured, or those whose private plans deny them care.)

But, hilzoy, if McArdle had to be intellectually honest and / or well informed, she couldn't continue to post the half-baked glibertarian claptrap that, against all reason, made her bones as a blogger.

Not to mention the disparity in the quality of individual health maintenance that exists between Americans & Europeans. Casual observation suggest that many middle age + Americans continue lifestyle debauchery by over eating, eating poor foods, smoking/drinking excessively, low-no exercise etc. etal. These folks expect the pills and procedures to be at their fingertips (the ones that can afford decent insurance). This lifestyle choice is defined in several other demographic groups of our culture, and has helped evolve the craven phama industry, and all of the specialty medicine that has developed around this needy population. I do not know to what extent this phenomenon exists, but I do know it impacts the economic and political aspects of the health industry, and may become more evident as this health care fight unfolds. Just another little detail with larger repercussions then one might believe.

Something strange about RepuG views - St Ronny started the "Get Government Off Your Backs", meaning "Cut Regulations". This has become a mantra for the right. They complain that government regulations and red tape are stifling business, both large and small, across the land. Yet, they refuse to accept a single payer system which will eliminate employer involvement in the system, freeing up countless dollars to be spent in far more productive ways.

An obvious point that mcardle ignores and that undercuts her whole argument is that employers are going to have to pay no matter what. If they don't pay directly into an insurance policy for their employees, then they'll have to pay into a pot that pays for the public option. So the only way they would have any incentive to drop insurance is if the penalties for screwing over their employees were a lot cheaper than private insurance companies charge for premiums. And since the purpose of the public option is to provide actual competition for the insurance cartel, that would be a good thing.

Seriously discussing a McArdle article is like considering the historical implications of a 3-year-olds finger painting.

Could we at least have a blog post every once in a while about how someone so obviously wrong and insane writes regular articles for the Atlantic? Or maybe you could tell us the beltway politics / social circle that gives Megan so much more credibility than she is warrants? There is an interesting story here, but it has nothing to do with anything this Randian strumpet puts under her byline.

Jon Reyerson totally missed the boat. In Norway there is only the government plan. Otherwise his grandmother could have gotten her hip replaced at her own expense there instead of having to go to the US. The plan under discussion here is primarily private with a public option for those who don't qualify for a private option.

Shag missed the point by claiming that mcardle may be right that employers will drop private insurance in order to pay into the public option. As long as the private insurers are willing to do their job, they should be able to compete, don't you think?

Al, jr. says that it just might be correlation that the US has worse outcomes healthwise than any other industrialized country. Please.

"But it won't be an intellectually honest argument if the pro-US system doesn't acknowledge that private health insurance is already guilty of all the ills of which they accuse public systems."

Good for you, brent. It doesn't get any clearer than that, and the retards can't continue to claim rationing without being the worst kinds of hypocrites.

Megan McArdle:Econ = Mike Tyson:Astrophysics

LOL, I was trying to think of the best way to summarize McArdle's complete ignorance on this topic and others where she passes herself off as some sort of expert.
A whole lot of baseless assertions, sprinkled heavily with GOP talking points and disinformation, and you've got your standard McArdle piece of hackery.
Does she provide any data to back up anything she says in this piece? And I'm supposed to take her seriously...why?

"Doing something extraordinary there is often not possible for the overwhelming majority of citizens, though that depends on what, and in what system."

This is just a lie. For example, the son of an English colleague of mine sustained a horrible complex fracture in his leg while playing rugby. He needed multiple surgeries and extended physical therapy. All paid for by the NHS. No squabbles with insurers. Full recovery. That was an extraordinary event, and the care for it was provided without any fuss.

Why bother arguing with a liar?

Doing something moderately ordinary here is a hassle. Doing something extraordinary there is often not possible for the overwhelming majority of citizens...

Also not possible for, not an overwhelming majority, but a significant minority (one in six, right?) HERE!!! Hilzoy is right, you don't get to ignore the existence of the uninsured. And I love that "hip replacement" is always the example. Since almost ALL persons receiving hip replacements in the U.S. are already in (horrors!) single-payer system.

Just don't let the government get its hands on my Medicare!!!

Sooner or later (I'm betting sooner), budget constraints will force the government to start making choices on what health care they will provide/pay for and what they won't.

========================

Right now, not in some imaginary sooner-or-later world where you can bet on when it might hypothetically take place, executive compensation constraints "force" the insurance companies to make choices on what health care they will pay for and what they won't.

It's the best system in the worruld, if you're Ed Hanway. Not so good if you're Average Joe, and pretty damn scary if you're in the 15% or so who have no insurance and so don't have to worry about what the insurance companies will choose. They've already chosen, and you lose.

Three years ago I was a well paid government functionary with gold-plated health insurance, 400+ hours of paid sick leave banked, and on a glide path to a more than comfortable retirement on a combination of a 60% pension, about 30% income replacement via Social Security, and a paid off house.

And then boom! I was maneuvered in a way that forced me to resign that not only lost me those 400+ hours but also ineligible for unemployment, without health insurance but with too many assets to qualify for medicaid, but with two or three pre-existing medical conditions. That is over the course of two weeks I was reduced from McArdle style cocooning to a pretty stark reality.

Well shit happens and you got to suck it up. I have been living on my equity and now have to sell my house. Oh well, it was too big for me anyway, I would be satisfied to live in a studio apartment again. All I really need is a place to plug in the mircro-wave and a high speed internet connection. Materially I could get by being a clerk in a used book store or office help in a small professional firm. Or maybe as a courier. I don't live to work, I work to pay the bills.

But in the world we live in I can't afford to downsize via any job that does not provide health care. I have medical bills right now that I am deferring until I sell the house, and even at that declined the health treatments recommended by the doctor. But after that I am basically stuck for the 13 years until I qualify for Medicare.

If we had a public health care system I could spend my days in some bland clerical or retail job and devote my nights and weekends to reading, writing and blogging. But as it is I am forced to shoot for more challenging, higher compensated employment which more likely than not will require a motorized commute. So while I would love to be living the life of a struggling writer, with a tiny room to sleep in, and days spent with with a laptop or at the library, at my age and with my medical conditions I can't afford to be a member of the working poor, I have to continue to target a comfortable perch in the middle class just so that I have access to a doctor when needed.

When you think about it that is kind of a perverse system that won't allow you to reduce your material footprint without you having to make some pre-arrangements to maintain medical coverage. Want to quit your job and write the Great American Novel? Well tough shit, no can do. Want to pursue a career as an independent artist? Better find a spouse with a health care plan. Well that sucks.

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