Editore"s Note
Tilting at Windmills

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November 5, 2009

CONSERVATIVES STILL THINK YOU'RE ALREADY OVER-INSURED.... This comes up from time to time, but it's good to see former House Majority Leader Dick Armey (R-Texas), a new ringleader for right-wing activists, state it plainly.

"The largest empirical problem we have in health care today is too many people are too overinsured," he said.

There it is, the right's philosophy on American health care in 17 words. Most of us think the problem with the existing system is that we pay too much, get too little, and leave too many behind. Dick Armey sees the existing system and thinks we'd all be better off with less coverage. Lest anyone think this is unique to Armey, the opposite is true. A few years ago, during Bush's pitch in support of health saving accounts, the LA Times' Peter Gosselin explained, "Most conservatives -- including those in the [Bush] administration -- believe that the root cause of most problems with the nation's healthcare system is that most Americans are over-insured."

Just two months ago, Reps. John Shadegg (R-Ariz.) and Pete Hoekstra (R-Mich.) had an op-ed in the Wall Street Journal making the same case. "When was the last time you asked your doctor how much it would cost for a necessary test or procedure?" they asked, making the case that consumers need more "control ... over their care."

For those with insurance, we visit a physician, and follow his/her recommendations, knowing that insurers and our employers will shoulder most of the costs. If we didn't have that pesky insurance -- if we had more "control" -- we could, you know, haggle and stuff. Think of the savings!

It's all premised on the notion that health insurance encourages medical treatments. If we have coverage, we might get tests and procedures that we wouldn't get if weren't so darned insured. Less coverage means fewer costs.

Josh Marshall recently explained:

The problem is that you go to the doctor and agree to take the tests the doctor recommends. Shadegg and Hoekstra want a system where if your doctor suggests a biopsy for a suspicious lump you think about the pros and cons. Is it worth the money? Do you have the money? How suspicious is the lump anyway? Maybe you get the first one. But not necessarily the follow up scan six months later.

This is the essence of the Republican plan: the fact that you're insured and aren't directly feeling the cost of individual tests and procedures is the problem and getting rid of the insurance concept is the solution.... [T]he problem according to most Republicans in Congress isn't that there's not enough insurance or that it's not good enough. It's that there's too much. The problem is that you have insurance. And good policy will take it away from you.

Dick Armey is only saying explicitly what conservative lawmakers have been arguing for quite a while.

Steve Benen 9:20 AM Permalink | Trackbacks | Comments (45)

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Isn't everyone a multi-millionaire and can pay for care out of pocket? Geez, there's no excuse for not being rich.

Posted by: Conservatroll on November 5, 2009 at 9:22 AM | PERMALINK

So, basically Republicans want each American to be his or her own one-person mini-death panel.

Such mensches.

Posted by: Dave in DC on November 5, 2009 at 9:25 AM | PERMALINK

You and Josh aren't quite right on this, I'm afraid. At least if "This American Life" was accurate in its recent show on health care ("Other People's Money"), the problem isn't about getting two recommended biopsies or one. It's about getting tests that are completely unnecessary according to actual doctors. We ALL do it, it drives costs insanely high, and doctors (apparently) are unwilling to say "don't get this test because it's 99% likely to be a waste of money," because there's a teensy tiny chance they could miss something and get sued, and the patient demands to have all their bases covered. And they do this because, once they're paid in, they never see the cost difference between one test and another.

The show is here, Oct. 16th. It's possibly the most entertaining hour I've spent hearing health care discussed--and contains the single best explanation I've ever heard of how we wound up with crazy employer-based health care in the first place. http://www.thisamericanlife.org/Radio_Archive.aspx

Posted by: Wordboy Dave on November 5, 2009 at 9:28 AM | PERMALINK

This health care debate is getting personal. The other day I visited my doctor. He wants me to get a colonoscopy because I am older now and that is a great thing for anybody over 50. I have one of those crappy high deductible HSA plans. I asked how much the colonoscopy would cost and was told $4,200 or so if everything is OK. The doc charges $700 and the hospital about $3,500.

Do I have symptoms that would indicate I have colon cancer? NO. The doctor says the colon cancer should be a preventable disease. Is it a good idea for somebody my age to be screened? Yes. Is the $4,200 easy to find? No.

Here is my choice, spend $4,200 now and possibly head off cancer or save $4,200 and possibly die from a disease that I watched kill a dear friend just a couple of years ago. Colon cancer is not a pleasant way to go.

Oh, every month my wife and I spend about $1,000 for my crappy high deductible plan.

America, what a country?

Posted by: Ron Byers on November 5, 2009 at 9:31 AM | PERMALINK

Well Wordboy how about substantiating your assertions with some proof. Some doctors say there are too many unneeded tests. Give me a break. Some actual posters at this site say your sitting in your moms basement in your teddy bear jammies pounding on your keyboard.

Posted by: Gandalf` on November 5, 2009 at 9:36 AM | PERMALINK

Steve, you are stuck in a very myopic view of the situation. I see opportunity here. Perhaps Dick is on to something. I suggest Dick be encouraged to explain his perspective and illustrate how the GOP health care bill addresses this over-insured problem. With any luck at all, Dick's tea-bag army will spread the word.

Posted by: Chopin on November 5, 2009 at 9:39 AM | PERMALINK

Sillies, the counterargument should be that we have too many doctors. If there weren't so many doctors using up those millions in insurance premiums, there would be fewer tests and higher charges instead. Can I be republican now?

Posted by: Ruth on November 5, 2009 at 9:45 AM | PERMALINK

Perhaps Dick should voluntarily give up his own overabundance of health care coverage, thereby inspiring all Americans to do the same. Then we can all pray he never needs to have his Galtbladder removed.

Posted by: PattyP on November 5, 2009 at 9:45 AM | PERMALINK

Wordboy hasn't thought it through, although at least he IS having real thoughts.

So long as you think about health care as economics, first and last, you can't understand the problem. Put it this way -- what if you or someone you love, say your child, happened to be one of the 1% who needed that test but didn't get it because, hey, what are the odds?

The "conservative" take looks at those cases (and there are THOUSANDS of 'em, cuz there are 300 million of us), and decides that the problem is malpractice law.

It's not a crazy position, of course. (A Rule -- no position that blames lawyers is ever truly nuts.) Defensive medicine that is motivated by the risk of malpractice suits is expensive.

But -- THINK about it for a second. The purpose of the frigging system is neither to benefit lawyers NOR doctors.

It's about US -- patients.

I used to know a guy who smoked all his life, until cancer finally killed him. He probably paid something like $100k in health insurance premiums, and before he died, he'd run up about $600k in bills.

THAT'S the problem. The malpractice stuff is a distraction cuz the money involved is dwarfed by the cost of NECESSARY care.

There is simply no economic model for private health insurance that allows for it to be profitable, IF it actually provides cradle to grave health care.

That's why "conservatives" insist that there must be something wrong with reality, cuz it doesn't follow their ideological model. The economic concept of a market requires that price and quality competition will produce some equilibrium, in which buyers and sellers agree on what we want and are willing to pay for which can be provided profitably: but that does NOT work for health care.

Contrast the profitable insurance model for cars: everybody HAS to buy car insurance ( a government mandate) in order to drive. But that works to everybody's advantage, because of these things called "accidents", which are called that because no amount of skill can guarantee that your car won't get smashed up. So it is worth paying an insurance company something every month, because if your car IS smashed up, you will save money when they pay for most of the repairs. (Then your premiums go up, but it still...)

Then consider health insurance: with very few statistically insignificant exceptions, before they die, EVERY person will run up health bills that will vastly exceed what they'd paid in premiums. The overwhelming probability for this approaches perfection for older folks, which is why somebody like Dick Armey couldn't get private health insurance: he's too old to make any money for the insurance company.

That he does not regard this as a market failure, is a sign he isn't serious about his own ideology. That he happily allows the taxpayer to cover his health care costs is a sign he's a blatant hypocrite.

If you want to consider health care as economics, e.g., why should employers provide it?, then you have to consider the ACTUAL economics of health insurance for profit. They are very simple -- take money from people who are young and health, and refuse to pay when they get old and sick.

That's not health care.

Posted by: theAmericanist on November 5, 2009 at 9:45 AM | PERMALINK

Lawmakers live in the "Village" where most people are overpaid and overcompensated for their services (e.g. William Kristol).
Their only exposure to people is where these overpaid, pampered, connected people ARE overinsured. Also, aren't they (the lawmakers) over insured?
Their minds are made up, don't try to confuse them with facts. Just because many, many people still have to declare bankruptcy because of medical problems, even though they HAVE insurance, that's not relevant to the Corporate Owned Republicans. Anyway, this talking point is far more "truthy" for the base.

Posted by: BuzzMon on November 5, 2009 at 9:46 AM | PERMALINK

Surely Dick Armey has health insurance for himself and his family. To prove his point, he should give it up. But I'm sure he has very good reasons why HE needs health insurance. It's those "other" people that really just shouldn't have it. For the good of the rest of us.

Posted by: carl on November 5, 2009 at 9:47 AM | PERMALINK

It's a thoroughly idiotic argument and has been discredited. Gladwell wrote an article years ago about the economic ideas underlying the current system, much of which is predicated on conservative ideas. The basic notion is that people are inherently hypochondriacs so that you have to disincent them from going to the doctor too much, hence the deductibles, etc.

The only problem with that, as highlighted above, is that PEOPLE AREN'T DOCTORS. That is, you can sit around and do your own cost/benefit analysis as to whether you think that treatment is "necessary" but at a very obvious point, if a doctor recommends it, he's quite literally doing it for your health - you simply are not qualified to make this "educated consumer" decision that Dick Armey thinks everyone can make. Put another way, if I could determine which tests were necessary and which weren't, I wouldn't need the fucking doctor in the first fucking place. It's that obvious.

That said, there is significant overtreatment. The problem is that patients aren't the best people to judge whether this is the case or not.

Posted by: George on November 5, 2009 at 9:48 AM | PERMALINK

Wordboy, Economics isn't some master science that must be yielded to at all times. It's not even a natural science at all. It's a social science, and not a terribly good one primarily because it refuses to acknowledge to itself that it is not a natural science.

In real life, because you're actually dealing with people and not machines, you're going to end up with waste. The only realistic alternative is to take things out of the hands of patients altogether, but it's unlikely you'll ever manage to pass health reform that says "You can no longer make decisions about your own care."

Nobody likes to admit this, but we have so many malpractice suits because doctors screw up a lot more than they did 20 years ago. They work longer hours, they have to handle more patients, and because they want to keep their income artificially inflated, they prevent reform that would allow minor healthcare to be conducted by other healthcare professionals (who do most of the grunt work anyway) and they prevent individuals with medical degrees from other countries from practicing here.

Basically, doctors brought about the circumstances that causes a wave of malpractice because of their own greed. Now they complain about having to pay out for insurance when they keep screwing up.

Posted by: soullite on November 5, 2009 at 9:58 AM | PERMALINK

Good post.

What is the real issue? for most of us, improving health. What is the issue for conservatives and Libertarians? Making a profit. Recorded dollars of revenue and cost are the primary focus, not health outcomes.

There's too much insurance if you look at the problem as being one of making a profit. Profits are increased by eliminating costs. All payment for health care is "cost." Eliminate insurance and many suppliers of health care will go out of the business, so profits will be increased. That view ignores the real issue most of us think is important in health care, at least when it applies to us. The real issue is improving health.

The primary way of looking at "health care" for other people as far as conservatives are concerned is whether it makes a profit. The actual health outcomes of other people is their own problem.

The conservatives are not interested in improving other people's health, just in making a profit. They'd happily get a defense contract or make some other investment if they thought it would be more profitable because their focus is on a profit-and-loss statement. They have no interest in the actual people behind the dollars of revenue and cost that P&L statement represents.

Just ask the top executives in large companies what their decisions are based on. They'll show you financial statements. All kinds of financial statements. Then ask them what the human costs are behind those reports and they'll almost invariably tell you "I'd have to get more information to answer that."

Posted by: Rick B on November 5, 2009 at 10:00 AM | PERMALINK

Oh, it's worse than that. As George points out, "patients aren't the best people to judge" whether we need to have a television camera on a four foot cable investigate our innards, as noted upthread, and for a lot of us, if that wasn't disincentive enough, paying $4,200 for the privilege might be just enough to put it off. That's Armey's idea that patients would be most cost-conscious if we had to pay ourselves.

Which, in what IS a statistically significant # of cases, would mean a very expensive death: dying of colon cancer over a year or two runs about $1 million.

And it's not insignificant that you DIE, when it's over.

So the HMO model is to have actuaries and MBAs second-guess the doctors -- ordering tests that are at least partially indicated by defensive strategies against malpractice is a part of the problem.

But it's dwarfed by the basic economic dynamics of a for-profit system: having taken your premiums from your early 20s through your 60s, no private insurance company or HMO wants to then actually have to PAY for the very expensive care that you thought (fool that you are) was why you were paying into the system for all those years.

Even the uninsured issue is less than the inevitable costs of dying in our damn near miraculous health care system. Young people who have no insurance are gambling with their lives, but more candidly, with OUR money, in exactly the way a guy driving without insurance poses a risk not only to himself, but to YOU. A guy without insurance totals your car, YOUR insurance company has to pay. (This pisses them off.)

A guy without health insurance gets HIT by a car (or cancer), we have to pay for his care. So we should get pissed off.

The actuaries and MBAs who run our private, for-profit health sector understand this dynamic, and for them it's all about shifting the costs on the taxpayer (viz., Dick Armey) while keeping the revenue streams (and the profits) in private hands (e.g., Dick Armey).

Posted by: theAmericanist on November 5, 2009 at 10:06 AM | PERMALINK

It would be nice if you could actually get health-care providers to tell you the cost of something in advance. I once had to take my son to a specialist at a well-known hospital, and the hospital sent me a nice little brochure a few weeks in advance explaining why it was totally impossible for them to estimate what their services would cost, so don't even ask. How come contractors can give you an estimate, car repair shops can give you an estimate, and even dentists and cosmetic surgeons can give you an estimate, but a hospital can't?

Posted by: acorn on November 5, 2009 at 10:07 AM | PERMALINK

The Republicans’ “uninsurance” plans return control of health care decisions back to the patient, who, in this best of all possible free market worlds, is uniquely able to make the right choice, having rationally and accurately weighed the economic and medical pros and cons.

As a physician, let me give you an example from my clinic of how this works in reality. I recently saw a 6 month old baby who has several medical problems including a congenital heart defect. The latter, prompted the referring physician to order a chromosome analysis. This was a perfectly appropriate test, as this heart malformation is frequently caused by a specific chromosome deletion. The chromosome analysis ruled out the deletion that causes heart malformations.

So far so good. However, 3 of the 50 cells examined had specific chromosome rearrangements that can be seen in a rare, life threatening disease that causes neurodegeneration, immune deficiency and cancer. So we repeated the test - this time, 0 out of 50 cells had the rearrangements.

What to do next? Was the first test a fluke? Or was this a clue to why the child had slightly abnormal immune function in addition to her heart defect. How far should you go to rule out this unlikely, but potentially fatal diagnosis? Children don’t usually develop symptoms of the disease until they are 1 or 2 years of age. So, do we wait and see or do we try to nail down the diagnosis by further laboratory testing? A quick and cheap blood test looking for elevation of a specific protein seen in this disease was equivocal - she tested just barely outside the upper limit of normal. The next steps in testing are an expensive and slow: a molecular analysis of the gene involved and/or a complex evaluation of the child’s cells in the laboratory. Together these tests would cost $5000+ and take six months to complete, just about the time when she might first show symptoms of the neurodegeneration.

So, how far would you go to evaluate this child? She’s too young to have the major symptoms of the disease and it’s a disease that neither her parents or her referring physician has heard of. What’s your tolerance for risk and doubt? Do you feel lucky? As an expert in this area of medicine, I don’t see an obvious choice for these parents. However, the Republicans think you, as a health care consumer in the free market, should have no trouble making the right call, this time and every time.

Posted by: Platypus on November 5, 2009 at 10:08 AM | PERMALINK

Very good point, Americanist. (9:45am)

before they die, EVERY person will run up health bills that will vastly exceed what they'd paid in premiums. The overwhelming probability for this approaches perfection for older folks, which is why somebody like Dick Armey couldn't get private health insurance: he's too old to make any money for the insurance company.

That's why prior to the passage of Medicare no insurance company sold health insurance to anyone over age 65, and most insurance policies were canceled when the insured reached age 65.

That's the health insurance market in action. Insure the healthy and skim the profits, ignore those likely to get sick and push those who are sick under the bus.

Posted by: Rick B on November 5, 2009 at 10:11 AM | PERMALINK

i thought the whole point of health insurance was to provide the necessary care at the necessary time, without having to worry about how much it cost.
silly me.

Posted by: mellowjohn on November 5, 2009 at 10:29 AM | PERMALINK

Shorter Dick Armey: "Don't get sick, but if you do, die quickly." What's to argue about in that characterization?

Posted by: T-Rex on November 5, 2009 at 10:33 AM | PERMALINK

"When was the last time you asked your doctor how much it would cost for a necessary test or procedure?"

That is indeed correctly quoted from the WSJ op-ed, and it's really amazing. If they were asking about unnecessary tests that would be one thing, but they explicitly said "necessary". So are they suggesting that patients should ask about the cost of tests that they actually need to get, and then not get them if they cost too much?

Posted by: DonBoy on November 5, 2009 at 10:33 AM | PERMALINK

If the problem were the separation of patient and payment, then health care costs would be high worldwide, because every advanced nation has a system with this feature.
Instead, our health care costs are 40% higher than any other country on Earth, so something else must be at work.
Ridiculousness aside, Armey's approach is a political non-starter. Eliminating insurance would eliminate insurance companies, and I think they have lobbyists to address that proposal.

Posted by: RZ on November 5, 2009 at 10:40 AM | PERMALINK

"How come contractors can give you an estimate, car repair shops can give you an estimate, and even dentists and cosmetic surgeons can give you an estimate, but a hospital can't?"

Cuz they don't know what's wrong with you, Acorn.

And cuz they don't know what insurance will pay for -- there's a constant negotiation going on OVER your health, between the actuaries and MBAs at the insurer (or HMO), the hospital, and the doctors.

Take the car analogy, again: you're getting lousy gas mileage. So you take it into the shop. Now -- the mechanic realizes immediately that it might just be that your tires are under-inflated, so his first choice is simply to kick 'em. But of course, if he DOES kick your tires, realizes they're soft, and sends you to the airhose (possibly for no charge, like Marcus Welby, Mechanic would have done it), he's breaking the rules set down by his employer, the HMO: everything has to be quantified.

So he writes up the Tire Gauge authorization form. But then he has to check the protocol (this is where the bitching about defensive medicine comes in), because in a small percentage of cases, it's not ONLY under-inflated tires, but something in the engine itself that's causing low gas mileage. So he has to look under the hood -- only real fast, because his employer also requires that he see four cars an hour.

Your tires DO turn out to be soft, but he doesn't much like the look of your dirty old engine -- and at that point, he loses control over his own judgment: it's the actuaries and the MBAs who determine whether it is cost-effective (health care divided by malpractice risk) to check your points, etc.

Meanwhile, your Marcus Welby mechanic might well have noticed that the back tires are softer, and the car sits lower on 'em, than the front ones -- and he might begin to think that maybe you forgot about the cinderblocks you'd put over the rear wheels (like he suggested) for better traction when the snow got so bad last year.

But if he checks THAT, he has to quantify his hunch for his employers, rather than just, you know, pop the trunk. Or even ask you. Cuz if he asks you if you forgot the cinderblocks WITHOUT popping the trunk, that, too, violates his employer's policies AND (so sayeth their lawyers) exposes them to greater legal risk... and they haven't approved his unquantified hunch yet.

See how it isn't the lack of an estimate, but the deadweight of the profit-driven middlemen (and yet NOT, strictly speaking, the malpractice threat) that drives up costs while making the damn thing opaque?

Posted by: theAmericanist on November 5, 2009 at 10:45 AM | PERMALINK

Two reasons why the car insurance model is a very bad one to apply to health insurance, much as conservatives love it:

1. If you can't afford car insurance, you can do without a car and get where you need to go by walking, biking, taking public transit, etc. If you can't afford health insurance, you can't decide to just do without cancer. If you break your leg, you can't decide to not get it set, at least not if you're planning to ever walk again.

2. If you total your car, you can buy a new one. What's the conservative plan if your kid gets cancer -- are you supposed to write that one off, let him/her die, and then go out and buy a new child? We don't live in a fabulous sci-fi future where, if your current body poops out on you, you can just trade it in for another one. Once you die, you're gone. But, as usual, it's easy for conservatives to decide that other people should die for their beliefs but they shouldn't have to (cf Iraq, abortion policy, etc.)

Posted by: Mnemosyne on November 5, 2009 at 10:46 AM | PERMALINK

I didn't "back up" my earlier assertion because I didn't want to blow a lot of space summarizing an argument that took This American Life an hour of interviews to bring together. The problem, as they frame it, however, comes down to this:

1. Patients will ALWAYS demand more tests, because there's no limit to how much we're willing to pay to keep ourselves alive.
2. Drug companies are constantly pushing new minorly-tweaked medicines/procedures (which are insanely expensive by design) to increase their profits, as a way of getting around negotiated caps.
3. Doctors (who ARE overworked and who do have a lot of malpractice as a result, which suggests there ought to be labor laws of some sort) often pass this cost on to the insurance companies because the new drugs are what the patient demands.

I hate to sound like an apologist for the insurance industry, but the This American Life segment makes it clear that there are a number of other pressures at work here, and one reason health care is so expensive is that the drug companies and the insurance companies are in an arms race of money extraction that patients, who aren't experts, are obliged to assume results in the best care.

You can agree or disagree, of course. But if these are the forces at work, I don't want liberal sites (especially Benen and Marshall, who are my two faves) to mischaracterize the conservative approach on one of the few topics where it's possible conservatives are not embarrassingly unhinged for once.

Posted by: Wordboy Dave on November 5, 2009 at 10:58 AM | PERMALINK

RZ said:

Instead, our health care costs are 40% higher than any other country on Earth, so something else must be at work.

My understanding is that our costs are higher because, with a huge market of (by global standards) wealthy Americans, and no government control over health care, this is the only place in the world where all the health care colossi (Big Pharma and Big Insurance especially) have the leeway to squeeze out serious money. When the elephants fight, the grass suffers.

If we went to a government-controlled healthcare system, my suspicion is that the extra costs would start to be more equally shared by other parts of the world. My understanding, of course, could be dead wrong.

Posted by: Wordboy Dave on November 5, 2009 at 11:04 AM | PERMALINK

Americanist, I love your post. The This American Life segment (and I see now I'm a Man of One Book--anyone got others?) used pet insurance to explain not only what's wrong with human health care, but how we might fix it.

Posted by: Wordboy Dave on November 5, 2009 at 11:09 AM | PERMALINK

Alan Grayson explained the conservative position best: Don't get sick and if you do, die quickly.

Posted by: CDW on November 5, 2009 at 11:13 AM | PERMALINK

I agree with Wordboy Dave, sort of. Health care manufacturers make a lot of money in the US.

I disagree however, that our high costs are subsidizing health care elsewhere in the world. Companies make as much as they can whereever they can. If they couldn't make money selling, say MRIs in Munich, they wouldn't sell them there at a loss. They just wouldn't sell them there. That way they would make more dollars in profits while deploying less capital.

Another way to look at the issue: We pay more for services where no cross-border subsidies are possible. For example, we pay doctors more than other countries do, and nothing in the pay of a US doctor subsidizes the pay of a doctor elsewhere.

Posted by: RZ on November 5, 2009 at 11:21 AM | PERMALINK

How long ago did the Big Dick follow that rabbit into that ol rabbit hole ?

Posted by: rbe1 on November 5, 2009 at 11:25 AM | PERMALINK

Regarding the assumption that patients with "ALWAYS" demand more tests. In general I find that my patients don't challenge my recommendations for or against specific tests. In addition, for genetic testing, I've found that there are many more patients who don't want to know their genetic status and decline my recommendations for testing than there are patients who demand genetic tests that are not medically indicated.

Posted by: Platypus on November 5, 2009 at 11:33 AM | PERMALINK

Patients will ALWAYS demand more tests, because there's no limit to how much we're willing to pay to keep ourselves alive.

Who, other than hypochondriacs and possibly people with Munchausen Syndrome, "always" demand more tests?? All the reality-grounded people I know a) dislike going to the doctor; b) hate having invasive, uncomfortable, humiliating medical tests performed; and c) aren't willing to pay out the nose for tests, but rather for treatment, as tests aren't what will save their lives after they become ill.

Now I would certainly prefer tests that will help me avoid getting a condition which requires treatment, and I think most people would agree. Not to mention, diagnostic tests are still cheaper in the long run than treating most life-threatening conditions. If this is really the claim being made by This American Life, they're pretty much bonkers.

Seems to me this problem (which IMO is being blown way out of proportion) could be easily solved by insurers paying for all doctor-recommended tests, and charging the patients for extra, unnecessary tests should they "demand" them. If several doctors can't agree on what's wrong with a patient, then additional tests are warranted. But if a patient sees 3 doctors and has 3 tests, all of which say he or she has colon cancer or something, make the patient pay for more if so desired. The patient obviously is in denial at that point and is desperately seeking anyone who will give a different diagnosis.

Posted by: PattyP on November 5, 2009 at 11:45 AM | PERMALINK

Let me paste a couple of missives together.

The largest empirical problem we have in health care today is too many people are too overinsured, but if you do get sick, die quickly.

Yeah, that works too.

Ruth @ 9:45
Careful there, your heading straight for the tipping point.

Posted by: Kevin on November 5, 2009 at 11:59 AM | PERMALINK

Mnemosyne: the car insurance analogy CONTRASTS the sound profit-motive model for insuring cars, with the unsound profit-motive model for insuring health. Next time, strive to have a point.

Wordboy: you're still not getting it. Try defending "death panels" -- and yeah, I'm serious.

Basically, you and I are neighbors. We both pay the same premiums to the same insurance company for health care -- only you're 25 and healthy, and I'm, say, in my 50s. You COULD get cheap private insurance, or even take the risk to have none at all, cuz the odds are on your side. That's why libertarians don't want you required to buy insurance, and why private companies love to sell it to you.

I can't buy private insurance (unless I already have it), just cuz I'm too old.

So I go see the doctor (who is unusually and probably illegally forthcoming with data), and he tells me, gee, I see here that you've paid a quarter million in premiums over the past 30 years: such a deal for you, cuz in the next THREE years alone, your health care is gonna cost $2 million. (This, btw, is the Blue Cross max.) After that, you're just gonna have to get Wordboy to cover the rest of your costs -- which is the good news, because as long as you can find that $1 million a year, you're gonna live for maybe 20 years -- happy, actually pretty healthy, you'll even be able to work: just don't miss your $1 million a year treatments.

So when I share this good news with you -- I'm gonna live 20 more years! -- and, oh, yeah... you're not sure you like the news as much as I do.

Ah -- but then, your little kid gets sick. When you take him to Platypus, the good doctor recommends $10K worth of tests, which you can't afford.

So you want me to pay for 'em.

Armey's response is to say that I should tell you to stick it, and that YOU should decide, on your own, whether it is worth your kid's life to save the $10 grand. Your car or your kid? And what if he needs a few hundred grand in treatment? Your house or your child?

Well? Still think this is economics?

Now, consider the POLITICS of this mess: not everybody who gets that 'you'll live 20 years with $1 million a year bills' actually likes the choice. F'r instance, James Michener, the novelist, could have easily lived indefinitely hooked up to a dialysis machine, and HE could have actually afforded it -- but he refused, had the machine disconnected, and checked out with class and grace.

But when Democrats proposed that Medicare should reimburse patients who wanted advice on those issues, Republicans shouted "death panels".

If you're serious about these issues, Wordboy: go ahead, DEFEND "death panels".

Cuz that's what you're proposing.

Posted by: theAmericanist on November 5, 2009 at 12:05 PM | PERMALINK

The political answer to this every time it is said should be pointed and personal: will you, Republican believer in the over-insurance myth, give up the insurance you and your family enjoy? Right now? If not, end of argument.

Posted by: Theda Skocpol on November 5, 2009 at 12:20 PM | PERMALINK

Excellent discussion here.

The Americanist--I don't always agree with your postings, but today you're cookin'! Your posts should be spread all over the blogosphere, in editorials on newspapers, etc. Cogent.

I am one of the people who hates going to the doctor, like so many others. I've had a lot of the tests in the past and have no wish to repeat them. For instance, although health profs encourage me to get a colonoscopy (I'm 63), so far I'm resisting that. Hemoccult is good enough for me. If that proves positive, THEN I'll get a colonoscopy.

I've also had bad luck with tests in the past. I had severe pneumonia a couple of years ago, and the docs attempted a bronchoscopy on me. I spent the entire night previous to the test in a state of dread, and I was right to dread it, as I went into bronchospasm and almost died. I can still remember the struggle to breathe and thinking if that was going to be the rest of my life, someone just take me out and shoot me. Fortunately, some albuterol delivered via a C-Pap (the machine used for people with sleep apnea) cleared up the bronchospasm, but it meant two days in ICU (expensive, anyone?).

As a retired medical librarian, I can make some judgment as to whether or not I want to undergo a specific test, and know how to search for the info in the professional literature as well as being able to read and make sense of it. But most laypeople don't have my knowledge base.

And, as others have pointed out, a test costing a couple thou to detect problems early, plus treatment for the early stage, is a lot less expensive than treating the illness after it has progressed.

Posted by: Wolfdaughter on November 5, 2009 at 1:38 PM | PERMALINK

People over profits...That is all!

Posted by: st john on November 5, 2009 at 1:52 PM | PERMALINK

Let's also note that Armey of Dick once told a buddy that he'd get his damned MRI -- either with Medicare or the FEHB plan, I'm guessing -- or he'd sue the doctor.

Hypocrite much?

Posted by: pseudonymous in nc on November 5, 2009 at 3:24 PM | PERMALINK

So they want to go from a free-market to a flea-market system?

Posted by: Forsetti on November 5, 2009 at 3:57 PM | PERMALINK

Some good discussion here... but I'm puzzled why the attack on wordboy. He brought some third party information, posted a link, then later politely summarized.

The cited segments of This American Life were well-researched and documented. The show has a progressive bent, at least in terms of topics covered (very subjectively, it literally moves me to tears on a regular basis, but i'm such a bleeding heart I have to buy clorox by the tanker).

If you just want to beat someone over the head with your own opinion, carry on; we all feel the urge to open up a can of righteous indignation on occasion. If you want to actually learn something, perhaps even to the point of moving to a richer understanding of a tough issue, it's worth taking the time to review some actual research. Anecdotal evidence kills (h/t to SuperCrunchers, by Ian Ayres).

Posted by: JD on November 5, 2009 at 4:37 PM | PERMALINK

"When was the last time you asked your doctor how much it would cost for a necessary test or procedure?"--Shadegg/Hoekstra editorial.

Funny you should ask guys, because that would be last time I went to the doctor, and the time before that. Because in fact the procedure is not covered. I guess that's what "overinsured" means. It means I sit there listening to a doctor tell me it's very important I get this done, and I tell the woman no, I can't.

Posted by: Half Elf on November 5, 2009 at 4:41 PM | PERMALINK

I really would recommend listening to the two This American Life programs on healthcare reform. Sure, the Republican plan is crap (and not even seriously intended). But it is a legitimate problem that insurance disconnects patients from costs. Not only do you, as a patient, not know whether you really need that test, but you have no way of knowing what that test costs or who is paying.

Posted by: The Pop View on November 5, 2009 at 5:27 PM | PERMALINK

Just assigning a "penalty" to something is sufficient to reduce use of it, but not to make use of it frugal. If I give my dog a shock every time he barks that will stop him from barking, but it's not going to make him bark only when there's a stranger breaking into the house or Timmy's trapped in a well.

The problem with making patients more aware of their health care costs (and more accountable for them) is that you're just shocking the dog. A patient generally has no independent understanding of his health situation; his most reliable course is to just parrot what the doctor tells him. Patients are also terminally inept at assessing risk (a $4000 test today, or a 1% chance at a $2M hospital bill and death a few years down the road?)

So, what forces are there for not running unnecessary tests? Well, for one, there's your doctor's judgment. We used to trust that, but according to the Tea-bagger crowd that's not reliable any more. For someone with the most skin in the game, we go directly to the insurance company: they can and do refuse payment of services (although often after the service has already been rendered, so *someone* still has to pay). From the patient's corner of the healthcare triangle, they generally have a reason to avoid tests to begin with: tests are rarely completely comfortable and painless, and more often than not take time out of the patient's day for which he is not getting paid to boot.

If anything, the "accountability" focus needs to shift more towards the doctor and less towards the insurance company. I know my doctor and trust him, and more importantly he knows me and all the details of my health far better than some insurance clerk in Des Moines or or executive in Hartford.

I understand the This American Life argument. It sucks that the one paying for my care has no idea of the specifics of my case beyond the broadest of strokes. I don't think the right solution, though, is to force that accountability on the least informed individual in the whole equation.

Posted by: Tom Dibble on November 5, 2009 at 7:45 PM | PERMALINK

A pathetic observation: ain't it odd that this thread is a more informed debate than the one in Congress or on the national news?

Posted by: theAmericanist on November 6, 2009 at 9:28 AM | PERMALINK

Cool posting, thanks for any information, I'll make this place a regular on my daily time wasting :) time.

Posted by: UK birding on January 14, 2011 at 8:30 AM | PERMALINK



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