Brent Nyitray
Fairlington Blade
Let the mutherfuker burn!
jnc4p
Kevin S. Willis
Michigoose
lmsinca
markinaustin
Arcanaut
novahockey
quarterback
ScottC
yellojkt”[E]nd of life is where a huge chunk of our health care dollars are spent. We could probably take a big chunk out of our deficit if we made inroads there even if we left the rest of health care alone.” H/T NoVAHockey, et al.
What kinds of inroads? So why aren’t we doing something about this? What should we do about this? Is it in fact a slippery slope?
I know something about the personal reasons for end-of-life-decisions, as do others here, and they are not always against the economic interests of society. But sometimes they are and maybe should be. My sister is probably a classic example. After her diagnosis with a rare blood disorder, she far exceeded (by 5+ years) life expectation . . . with excellent quality of life but very high Medicare cost. Her last six months, as treatments became less effective and more debilitating in and of themselves, her quality of life decreased significantly and she made the decision to go with grace and dignity. She made that decision at the right time IMHO. I admire her both for her tenacity and survival instinct as well as her uncomplaining departure. And I agree with a comment by lms to the effect that many people facing such decisions at some point have no hesitation about refusing further treatment if their families do not influence (or outright make) the decision.
I don’t perceive my sister’s situation to be at all unique and maybe it’s quite common. So how does this work out? What are the documented economics of end-of-life health care costs in the overall scheme of things? I’ve got the “touchy feely” part of this, but the societal economics of it are waaaay far out of my area of expertise. Help! Can we in fact arrive at a solution that is both compassionate and economically feasible?
Filed under: healthcare |
All Things in Moderation 
It's a tough nut to crack isn't it? Here's one of the things that bugs me about all of this. I've been paying for insurance in one way or another almost my whole life, different insurance companies and different circumstances. Let's see, I've had three children, only one delivery which was paid for via insurance, three minor surgeries, all three as out patients and a yearly check up for years. I've spent a total of two nights in a hospital since having my tonsils out at age 6 and that was only because they weren't ready to send me home without my baby and she wasn't quite ready to go yet.My point is, here I (or employers) have given all this money to insurance companies but as it's not a centralized money pool, such as medicare, even though I've given to them as well, once I hit 65 it's like starting over and by then I'm that much older and facing some form of terminal disease in the next 20 to 30 years if not sooner. So, I took care of myself, never over used the medical system, paid a lot of money over the years for peace of mind and protection against calamity, and I and you are still probably going to end up spending more on my health care at the end of my life than I paid into via Medicare. I know for some this will be a testament for some form of HSA or other but I actually see it as a testament for a central agency that we pay into from cradle to grave via either a premium or tax. That probably seems somewhat simplistic but why does it have to be more complicated?Okie, your sister was a brave woman and lucky to have you around to share the experience.
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Trying to judge when medical treatments have hit the point of diminishing return or are actively exacerbating the situation is a tough, tough call. I hope to never be in that position. My heart goes out to anybody who is.
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Okie- All worthy questions. I will try and piece some numbers together, but by one estimate, "about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life."At least when I am refering to end of life decisions I am generally not talking about chemo or radiation etc. I am thinking more about ventilators and feeding tubes as treatments. At the same time I completely recognize these are incredibly personal decisions and hard to generalize. My father died of ALS when I was 13 and he was 40. He was on a feeding tube for several months before he died and I would not have traded any single one of those dies I got to spend with him. He died in his sleep so we were fortunate in that we never had to decide whether to put him on a ventilator. But it would have been an incredibly difficult decision to make. I'm not suggesting the government intervene more than it already has. I think it should be easier both for patients to express and document their end of life decisions "DNR, no vent, no feeding tube" etc and for hospitals and physicians to carry out those wishes.
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Thank you for posting this. I think it illustrates exactly why, as lms wrote, this is such a tough nut to crack. and the biggest issue is this: treatments "became less effective and more debilitating in and of themselves, her quality of life decreased" I tend to think of this in the terms ashot described: feeding tubes and ventilators that are being used not as treatment that eventually can be discontinued, but as indefinite replacements for normal functions. lms also makes an interesting point that at 65, we all start over. i think this is worth exploring in more depth. I've posted this before but will do so again (and add to the link dump). It's frontline special on end-of-life care. http://www.pbs.org/wgbh/pages/frontline/facing-death/
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If I understand the "starting over" point, I think it is partly based on the misconception that nothing is received of economic value from insurance that is paid for but not fully "used" over a period of time. In reality, insurance was provided. This may not be satisfying to someone like lms in what is (I think) her ultimate belief that a single payer system putting everyone in a single "pool" is the ideal solution, but I do think it is a misconception to say we pay for insurance and don't receive a benefit.
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"I know for some this will be a testament for some form of HSA or other but I actually see it as a testament for a central agency that we pay into from cradle to grave via either a premium or tax. That probably seems somewhat simplistic but why does it have to be more complicated?"Or it's a testament to having your own private health insurance that you pay for yourself from cradle to grave, and you simply get a voucher to help off set the cost once you hit retirement age. No reason health insurance should be any different from home owners or auto insurance.
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"If I understand the "starting over" point, I think it is partly based on the misconception that nothing is received of economic value from insurance that is paid for but not fully "used" over a period of time."Yep, knowing that the maximum amount I will owe if I need surgery or get sick is "$x" frees money up to spend on other things. lmsinca's comments would be echoed by me with respect to car insurance since I have never been in an accident or had my car stolen. Getting back to end of life care, the link I posted refers to a link NoVa previously shared at the PL to the Dartmouth Atlas study which showed wide regional varation in end of life costs. It seems very odd to me that there would be such a large variation. There are also variation in costs of treating many different conditions. Maybe technology like electronic health records (EHRs), health information exchanges and patient portals can shrink these variations a bit, but physicians not wanting to have their independence taken away (see NoVa's comments yesterday) means variation will always exist.
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Private insurance just has to get their customers over the line and into Medicare. There is no real incentive for them to push long-term preventative measures.
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"Yep, knowing that the maximum amount I will owe if I need surgery or get sick is "$x" frees money up to spend on other things."This is actually one of the biggest flaws in Medicare and was brought up by people in focus groups. The coinsurance aspect is theoretically unlimited.
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No qb, I didn't say there was no economic value to insurance, I specifically stated that it provided peace of mind and protection against calamity. What I mean is, if there were a central pool of risk and money that we all paid into and followed us into end of life, the money we've paid would be spread out over our entire lives. It would also protect and provide for those who, for whatever reason, have more costly health issues throughout their lives or don't just slip away peacefully in their sleep once they retire.
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"This is actually one of the biggest flaws in Medicare and was brought up by people in focus groups. The coinsurance aspect is theoretically unlimited."Even were it isn't unlimited it is often difficult to determine what the maximum amount is. I like to think I'm smart and I'm having difficulty figuring out how what my max out of pocket would be in my firm's plan (we're switching since my wife is going to stay at home with my son after he is born).
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*were* should be *where* in my second paragraph.
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jnc4p,I was propogandaized by the Michael Moore and think single-payer is the way to go, but that is a utopian dream. Under the system we do have, we should ditch direct employer purchasing of insurance and make private insurance portable and mandatory (yes the dreaded Romney mandate). If and only then could we transition to a voucher program. I just don't trust the Norquists of the world to adequately fund such a system.
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Good morning, everyone.A quick note to whomever said yesterday that I'm not bitchy. Au contraire! If I could only edit my mouth even half as often as I edit my written comments, I'd be a lot happier. Trust me on this. Ask MrJS or my caregivers.To the topic…these are my personal observations and I have no links to back any of this up. My dad was in advertising, I was in marketing, and my last employer before going on disability was one of the 4-5 mega-advertising conglomerates. So looking at things from an advertising or marketing perspective is an ingrained habit. We are a country of inventors, of pushing the boundaries of our frontiers. In general, we do it well. What we do less well is deal with the consequences of pushing those boundaries.Two frontiers, health care/medicine and marketing/advertising, have converged. We can extend life, but it comes with a price tag. We're also more sophisticated at convincing consumers that their lives will be measurably improved if they purchase a particular product or service. Somewhere in all this, life itself has become something of a product. More of it is better, less of it is bad. Big medicine has been very adept over the years at getting funding for more research/products that allow us to consume more life and avoid the ultimate anti-product, death.The consequences of pushing these boundaries, however, are becoming a strain on our economy and our national dialogue. We don't have a framework for resolving the issues.
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"If and only then could we transition to a voucher program. I just don't trust the Norquists of the world to adequately fund such a system. "Correct. You can't do vouchers for Medicare as a stand alone program without unifying the overall health insurance market. Or in other words combine Paul Ryan's voucher approach to Medicare & Medicaid with Wyden-Bennett.Healthy Americans Act
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Ashot: "My father died of ALS when I was 13 and he was 40. "I think there is a material difference between heroic measures against impossible odds when the patient is 40 and the children in their teens than when the patient is 70 or 80 or 90 and the children fully grown adults, perhaps with their own children. Or, the equation in regards to end of life care shouldn't just be about end-of-life, but the circumstances (especially the age) of the person receiving care. qb: " I do think it is a misconception to say we pay for insurance and don't receive a benefit."I pay a lot for insurance, but I receive a benefit in excess of what I pay (given that, in most cases, I would have to pay full retail price which, thanks to 3rd party payer for 50 years, is highly inflated, in my opinion).
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I never get the full benefit of my premium contributions and I am perfectly fine with that. I am certain my wife is getting back and then some. That is why we use insurance to spread risks.
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"I think there is a material difference between heroic measures against impossible odds when the patient is 40 and the children in their teens than when the patient is 70 or 80 or 90 and the children fully grown adults, perhaps with their own children."I agree, but that is easy to say in a vacuum and not so easy to say when it's your 70, 80 or 90 year old family member or loved one.
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"I was in marketing, and my last employer before going on disability was one of the 4-5 mega-advertising conglomerates. So looking at things from an advertising or marketing perspective is an ingrained habit."I used to be in graphic design and marketing. I did a lot of package designs, my first ten years out of college. And ad campaigns. Now I do databases for a public school system. I cannot tell you how much I prefer my current job to my former job. I understand looking at things from an advertising or marketing perspective (especially commercials, marketing, package designs, end caps, and sales presentation; I always feel like people are trying to fool me, a former magician, with simple card tricks). If you spent the majority of your career in marketing, you have my sympathy. 😉 That being said, life may be a product, but I think the equation that more life is better and bad is worse is natural. As long as I'm enjoying my life, watching my children (and perhaps one day grandchildren) grow up, I'd want to keep on living. If science could make me immortal (and, hopefully, avoid much of the population problems that will ensue from scientific immortality) , I'd be for having a vastly extended life. Immobile and in constant pain, not so much.
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The slippery slope of factoring age and life circumstances into medical care decisions leads to death panels and ice floes. It has to be done with care and sympathy. The problem is that we are already capable of doing more than we should but you can't put those genies back in the bottle.
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Re: "death panels" . . . assuming the system allows private insurance to remain in place, particularly supplemental insurance, I've never understood what's wrong with rationing government provided healthcare. In fact, if you're going to have universal healthcare, you'd have to have cost containment. You do that by rationing procedures based on cost/benefit analysis. Then, individuals purchase supplemental insurance. One can argue against single payer, but why limiting that care and having the private insurance market fill the gap would be a bad thing is beyond me. As well as providing some care, counseling and preparation for individuals with terminal illness . . . I kind of like Krugman on death panels. "We should have them! We need them!" Understanding, of course, that they wouldn't really be death panels, just a limit on what the government would pay for in regards to healthcare services.
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"I agree, but that is easy to say in a vacuum and not so easy to say when it's your 70, 80 or 90 year old family member or loved one."I know, and it has been, for me. But it's still a materially different thing. I'm 42, I've got young children–I'd want them to go heroic and do the ventilators and what not, right now, if it came to that. I have a hard time imagining myself being in that same position when I was 80 (unless we were talking scientific miracles at the other end of it). Or, put another way, I do not have a DNR now, but will when I'm in my 70s. Speaking of which, living wills and DNRs etc are a very good idea, and that way our loved ones don't have to worry about making the "right" decision if we're incapacitated or on life support.
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Kevin:I've never understood what's wrong with rationing government provided healthcare.Not only is there nothing wrong with it, it is an unavidable fact of reality. We should have far greater rationing of government provided care than already exists.As I said on PL a long time ago during the ACA debates, if the government is going to get into the health care business using my tax dollars, not only don't I mind death panels, I demand them.
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Kevin- The funny thing with all the death panel talk is that it came from the ACA wanting to pay doctors for having conversations about living wills, advance directives, DNRs etc. and not really from rationing. Scott- "if the government is going to get into the health care business"If??If?? That ship has sailed, eh? 😉 I do agree with you about needing death panels and rationing and perhaps more importantly we need to be able to talk about that sort of thing without politicians demogoguing them.
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The "death panel" meme during the health care debate was one of the most cynical political ploys I've seen in a long time. I thought it prevented us from getting a better bill that could have had bi-partisan support and input. Most of us knew we weren't going to get single payer or even a public option, but we definitely should have gotten better reform, IMO.
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ashot:and perhaps more importantly we need to be able to talk about that sort of thing without politicians demogoguing them.That's kind of like saying we need to be able to swim in shark infested waters without getting eaten. You don't want to get eaten? Don't swim with sharks. You don't want health care issues politicized and demagogued? Then don't involve the government.Which, BYW, is precisely my preference.
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BYW=BTW
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lmsinca: "and perhaps more importantly we need to be able to talk about that sort of thing without politicians demogoguing them"Well, when all such decisions are finally made by super-intelligent robots, I'm sure that will happen. 😛
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Kev…those were ashot's words. And I like my shark analogy better. 😉
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"The "death panel" meme during the health care debate was one of the most cynical political ploys I've seen in a long time. I thought it prevented us from getting a better bill that could have had bi-partisan support and input. Most of us knew we weren't going to get single payer or even a public option, but we definitely should have gotten better reform, IMO."Here's why we didn't get better reform from the Congress, and it's not about death panels:"The permanent class stays in power because it positions itself between two deep troughs: the money spent by the government and the money spent by big companies to secure decisions from government that help them make more money."Some of Sarah Palin's Ideas Cross the Political Divide
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I've posted a new blurb and a question.
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Scott, when the majority want something that is not forbidden by the Constitution, they can get it. So when Ashot says "that ship already sailed", a libertarian can open with "let's go back to port." But a banker could also offer other suggestions about efficiency while letting us know he preferred no government involvement whatsoever. At least that is how I do labor negotiations. I wish there were no NLRB and that the union would go away, but there is and it won't, so I have to deal with it.I know you intend to post on the value of unbending principles, but none of us will think you have bent your principles if you offer your expertise to make an unprincipled political system work in a more principled manner, so long as you give us the caveat "if I were forced to compromise I would seek these positions as more virtuous".
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jncI realize what else happened in the health care debate re the collusion between government, insurance industry, pharmaceuticals etc. but I still contend the "death panel" meme was destructive. And, SP may be addressing crony capitalism now, but her ship has already sailed also.
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"but I still contend the "death panel" meme was destructive."Death panels were a distraction. The real destruction was behind the scenes.Sick and WrongThis is the primary reason I'm on the libertarian side of the fence. The more you centralize power and decision making, the more you corrupt it.
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My "ship has sailed" comment was less aimed at the idea that we can remove government from health care and more aimed at the fact that using "if" seemed to imply that we had yet to reach the point where Scott was demand death panels.
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jncLike you I read everything Taibbi puts out. I think he's an exemplary reporter and doesn't pull any punches. Unlike you however, I could never be a libertarian. We don't have very good politicians anymore but it doesn't mean the ideas of progressives or conservatives are all bad, we never get to find out. Do you somehow think there's even a remote possibility that we could go back and capture some libertarian fantasy world where the government stays out of the people's business except for roads and defense? I prefer to deal with the world we actually live in. That's not to say I don't agree with some libertarian ideas, I do. But I also believe in the common and firmly believe we are a better country in the grand scheme of things because of it.
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"Do you somehow think there's even a remote possibility that we could go back and capture some libertarian fantasy world where the government stays out of the people's business except for roads and defense?"Hope and Change.
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Mark:Scott, when the majority want something that is not forbidden by the Constitution, they can get it.And, with the right justices on the bench, sometimes even when it is forbidden. 😉…but none of us will think you have bent your principles if you offer your expertise to make an unprincipled political system work in a more principled manner, so long as you give us the caveat "if I were forced to compromise I would seek these positions as more virtuous".I understand what you are saying, and in other contexts perhaps I can do so. But in the context of health care, the goals being sought are simply mutually exclusive and constradictory. How does one advise on how best to achieve impossible ends? They want more and better health care for more people than already get it, but they want to spend less for it. They want systemically "efficient" use of resources, but they embrace the emotionalism of decision making that is the exact opposite of systemic efficiency. The decry the corruption of government with corporate money, and yet want to give the government even more power to decide winners and losers, thus inviting even more corruption.It's like trying to advise someone on the best way to get a twin sized sheet to cover each corner of a king sized bed. The only sensible advice I can think to offer is to get rid of the sheet and get buy different one.
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"world where the government stays out of the people's business except for roads and defense?"more seriously, i view libertarianism as more of a guiding principle than an endpoint. whereas the default seems to be "gov will do it/needs to do it" i'm hopeful we can change that. but i don't think that means we end up w/ a miniarchy
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Hope and Changelol, what a bunch of suckersI agree NoVA, the solutions are never in purity.
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"It's like trying to advise someone on the best way to get a twin sized sheet to cover each corner of a king sized bed."So in this analogy, lmsinca and I are the idiots trying to fit a tiny sheet on a big bed?
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"Do you somehow think there's even a remote possibility that we could go back and capture some libertarian fantasy world where the government stays out of the people's business except for roads and defense?"Here's the real choice as Ezra notes:"There's no free-market solution for the health-care system, at least not insofar as "free-market solution" means the government stays out of it. In a free market, people who are sick, or have previously been sick, can't get health-care insurance. Many, many more can't afford it. And a solution that leads to 40 percent of the country being uninsured is no solution at all.The two eventual choices here are A) government monopoly, like Medicare-for-All, or B) government-structured market, like the Wyden-Bennett Healthy Americans Act, or the system we see in Switzerland."The health-care system will always need the governmentPaul Ryan also notes that government has a role as well in a market based system:"You need to define what insurance is. I agree with that."Rep. Paul Ryan: 'Rationing happens today! The question is who will do it?'The big problem with single payer is the distortions that happen when government participates in a market that it also regulates.
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BTW, if you haven't read Ezra's interviews with Paul Ryan, I highly recommend them. Probably the best discussion of the various approaches to health care reform. I fundamentally agree with these observations:"Ezra Klein: But private insurance is growing that quickly as well. And this question of underpayment is doctors and hospitals making less than they expect to make. What you’re talking about, bringing Medicare spending down very sharply, is even more vulnerable to that critique. You do it on the patient side, not the provider side, but they will feel they’re getting vouchers that aren’t generous enough to keep up with health-care costs.Paul Ryan: So what I’m saying is that rather than having government ration care to manage decline, let’s take those market signals that work in every sector of the economy to reduce cost and improve competition. I got Lasik in 2000. That’s a cash surgery. It cost me $2,000 an eye. Since then, it’s been revolutionized three times and now costs $800 an eye. This sector isn’t immune from free-market principles.Ezra Klein: The Lasik thing is interesting because it gets to the question of whether health care is a market. When I think of getting Lasik, or buying a television, I can walk out of the store. That’s what gives me as a consumer my power in the market. But if I have chest pains and my doctor prescribes a bypass, how do I walk out of the store?Paul Ryan: In Milwaukee, the price of bypass ranges from $47,000 to $100,000. Nobody knows where to go for quality, or the prices. So wouldn’t it be good for the prices and quality metrics to be publicized? And let people make a decision. There’ll always be some level of co-pay or deductible or co-insurance that’s going to push people towards the best value. Then, when you have those chest pains and you’re being rushed in the ambulance, you’ll be rushed to a hospital that’s all along been competing for business and has been improved by that process. You’ll get better health care than you otherwise would. That’s how you improve the system.Ezra Klein: You’re arguing that the benefits of competition accrue, and so even if you don’t choose at the moment of emergency, there’s still an effect from a higher-functioning market.Paul Ryan: Absolutely. I don’t know anything about cars. I look at Consumer Reports and their ratings. What matters is that someone who knows about cars went and figured this out. The car company is competing for the really tough customer who goes under the hood. I’m not saying every American has to be that consumer. But enough people have to so the rest of us can benefit."Rep. Paul Ryan: 'Rationing happens today! The question is who will do it?'
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ashot:So in this analogy, lmsinca and I are the idiots trying to fit a tiny sheet on a big bed?I didn't call anyone an idiot, nor did I mean to imply such a thing. The analogy was meant to convey information about me, not anyone else. Having said that, I don't know enough about your views on health care to know whether you are trying to achieve the contradictory goals I pointed out. I do think, after many long and contentious discussions, that lms is. (This will come as no surprise to her, I don't think.) But she is of course not alone. There is a huge constituency in the nation, perhaps even a majority of people, who think they can be achieved. I think they are all wrong, but that doesn't mean I think they are "idiots".
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"I didn't call anyone an idiot, nor did I mean to imply such a thing."I didn't say you called anyone an idiot. But in your analogy, you're the one providing advice to the person (lmsinca)trying to put the tiny sheet on the big bed. You may not call that person an idiot, but it doesn't reflect a whole lot of respect for them or what they are doing. Anyway, "They want more and better health care for more people than already get it, but they want to spend less for it."I do want more people to have insurance and I do want better care. However, better care in many instances would involve less intervention and less money spent on care. This is the idea behind a variety of pilot projects currently going on, including ACOs. I don't know about spending less for it overall, but I think we there are ways to improve the current system (post-ACA) that would provide care to more people at about the same cost as the old system (pre-ACA). Ideally, I would like to see a pilot program of sorts where a state or a few states de-couple employment and insurance and go with they Wyden-Bennet approach. I also understand that federal involvement in health care makes such a program impossible.
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Scott: "They want more and better health care for more people than already get it, but they want to spend less for it."It's my believe that there is only one way this is possible, and that's through technological innovation. Perhaps some policy changes regarding drug patents, but everything else would have to be innovation. Which cannot be mandated, or done by decree.
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"I didn't say you called anyone an idiot. But in your analogy, you're the one providing advice to the person (lmsinca)trying to put the tiny sheet on the big bed. You may not call that person an idiot, but it doesn't reflect a whole lot of respect for them or what they are doing. "While this may be true, I often use metaphors to express what I'm saying in ways that make more sense. Usually, the metaphors exaggerate for the point of clarity. If the initial thing I'm trying to describe in metaphor was obvious (and thus, anyone not seeing my point simply not as smart as me), then I wouldn't need the metaphor. 😉
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Kevin:I definitely agree.
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jnc- The issues of transparency or lack thereof also impacts what were discussing earlier about knowing what your out of pocket expenses will be. It sure would have been nice to know how much my wife and I could expect to pay for the birth of our son.
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Kevin- "It's my believe that there is only one way this is possible, and that's through technological innovation."Can I ask on what this belief is based?
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ashot:I didn't say you called anyone an idiot. True, you didn't say it. But the clear implication of your protestations was (and is) that I did imply it. I hope now you have been disabused of that notion. You may not call that person an idiot, but it doesn't reflect a whole lot of respect for them or what they are doing.Like I said, I was trying to convey information about my actions, not anyone else's. I suppose I could have come up with a more complex analogy where a genius was trying to accomplish multiple goals via an intricate process but was ultimately doomed to failure because the various goals all required mutually exclusive actions that would act to the detriment of other goals, all of which I could see but for some reason this well-intentioned and completely capable genius couldn't. But the purpose of an analogy is to simplify, not complicate, things. Again, it was not intended to be a refelction on anyone but me.Ideally, I would like to see a pilot program of sorts where a state or a few states de-couple employment and insurance and go with they Wyden-Bennet approach.I wouldn't object to such a thing at all.
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"genius[es were] trying to accomplish multiple goals via an intricate process but was ultimately doomed to failure because the various goals all required mutually exclusive actions that would act to the detriment of other goals,"ladies and gentleman, idiots of all ages, i give you the American health care system.
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How flattering to be the subject of so many posts, lol. Scott hasn't exactly portrayed my opinions re health care reform adequately but that doesn't really matter. I'm willing to explore almost any avenue that provides access to health care, at least on a basic level to all Americans. I don't think we need more health care per person, more often than not we could use a little less. I wish the cost of actual health care services were more transparent and I think most of us now have enough skin in the game via rising premiums and cost sharing to make better decisions if we had that opportunity. I don't believe people with pre-existing conditions should automatically be left out of the market because of such. I also believe the largest risk and money pool the better. I don't particularly care if it's a government program, a non-profit insurance program, or some form of co-op that accomplishes these goals or even if it's on a state by state basis. I also agree with people who think employers need to exit the health insurance industry as it has totally screwed up both the incentives and the delivery of health care.How we get there is open for debate in my opinion but I think we're all wasting a lot of money via insurance premiums and over indulgent doctors that could be put to better use in a lifetime commitment to health services for everyone. I don't expect it to be free or even subsidized, except for the very poorest or sickest among us.
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NoVA:ladies and gentleman, idiots of all ages, i give you the American health care system. You read my mind as I wrote that!
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Wyden-Bennett was a better, smaller idea and it had bipartisan sponsorship. Why it was not "the plan" is beyond me, but the esteemed "shrink" believes it was scrapped to please the insurance lobby. NoVAH?Scott, thanks for the explanation. I believe there are avenues for better care, cheaper, as I have suggested, based on market principles. Increase the supply of providers. Encourage clinic care. These can be affected by federal tax policies and the subsidization of student loans by forgiveness to health care pros who will agree to work in clinic care for a few years. Not expensive or overwhelming as a burden. Has to lower cost by increased supply and increased efficiency.
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lms:I also agree with people who think employers need to exit the health insurance industry as it has totally screwed up both the incentives and the delivery of health care.Welcome to the dark side! This is something that I argued for at length way back when, and I could never get you to agree, except insofar as your desired single payer/public option would, by default, eliminate employer participation. I always thought you perceived it as an unimportant issue.
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"Like I said, I was trying to convey information about my actions, not anyone else's."It seems that I interpret your posts in a rather harsh light, so I'm going to try and take a step back from doing so in the future.I thought you would be fine with the pilot program idea. I'm all for trying various solutions and seeing what works. While we disagree on many things in this area, we all agree that the current system is a problem.
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What I was actually arguing scott was that if employer based health care was receiving subsidies then everyone should receive subsidies. All or nothing. I actually prefer nothing now especially as so many employers are already shrinking their exposure to the cost of health care. I think the best way to get true reform is for all of us to be in the same boat so to speak.
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And contrary to popular opinion I have a very dark side, my favorite series is "Dexter". I am absolutely fascinated by serial killers, lol.
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IIRC, the criticism of Wyden-Bennett from the left was no public option and the unions weren't happy about the change in tax status in insurance. the unions were a big no. Obama came out against it as "too radical" i don't recall specific AHIP opposition but i can find out easily. from the right it was "it's private plans in name only, OMG man the barricades!" but i think that was fairly subdued. I'm going off recollection here, so I can dig up some stuff to verify that. i have access to trade press archives that would likely get into the nitty-gritty. it's a great compromise in my opinion: government guarantees coverage, individuals in charge their own plans. portable. enough to please everyone, so i think it was a simple "if they like it, it must be bad." this is why we can't have nice things.
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lmsinca- Given your interest in serial kilers have you read Bill James' book Popular Crime: Reflections on the Celebration of Violence?He is the guy who wrote the famous baseball book "Moneyball", but I read mixed things about the book.
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NoVAH, thanks. I look fwd to more. So you and I could have passed W-B if we were the S and HoR respectively. We are better than they, obviously.
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I haven't read it ashot, but I have a long list of books I have read, including some documentary type court cases. I have always been interested in the criminal mind. Originally, I wanted to do what shrink does for a living but in 1972, with a one year old and divorced already, I had no money for med school, or time really. Went on to get my master's instead so I could get to work.
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ashot:It seems that I interpret your posts in a rather harsh light, so I'm going to try and take a step back from doing so in the future.Rest assured that, while I definitely think some people are idiots (including mutual acquaintences from PL), none of them are posting here. If it seems I have slammed someone here as mentally deficient, it's almost a certainty that I haven't expressed myself well.I thought you would be fine with the pilot program idea.You'll find that my objections to government intervention will dwindle significantly as the number of people captured by the intervention shrinks. I once wote at length at PL about why, and perhaps I shoud replicate it here at some point, but I am fine with states undertaking schemes that I would object to vociferously at the federal level.Mark…perhaps this is the kind of suggestion you were talking about? (…he said with revelation in his voice.)
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I actually like WB as a compromise as well you guys.
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"If it seems I have slammed someone here as mentally deficient, it's almost a certainty that I haven't expressed myself well."The purpose of me pointing that out was not that I actually think lmsinca and I are idiots. It was more to bring to your attention how you express yourself. Like I said, for whatever reason, I tend to interpret your posts in a negative light when clearly your intentions are otherwise. I actually used to feel that way about QBs post, but only rarely does he raise my ire. So maybe it's simply that you and I have had fewer interactions.I'm not at all surprised that you would be OK with states doing something, but oppose the federal government doing the same thing. I think often your viewpoint, and those who you agree with,is inappropriately viewed as anti-government when at the worst it's anti-federal government and a more fair description would be neither of those.
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very cursory search shows the following history: Dems criticized Wyden's plan for its reliance on the private marketplace and unions hated the tax change. health care community (read insurers and hospitals) wanted stronger mandates to make sure coverage is comprehensive. house R's split on mandate and debating whether to embrace a plan or come up with their own.
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Wyden-Bennett was the preferred solution for most of the pundits as well such as Ezra Klein and David Brooks. Paul Ryan said he could work with it as well.
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"The purpose of me pointing that out was not that I actually think lmsinca and I are idiots."oops I mean not that you actually think lmsinca and I are idiots.
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ashot:oopsI was pondering that.lms:I think the best way to get true reform is for all of us to be in the same boat so to speak. The best way to remove employers from being insurance providers is to change the tax code.
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scottI was referring to the demand for reform.
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OT: I'm in meetings most of tomorrow and I'm out of town after that. catch you all next week.
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Bye, NoVA, I'm gone over the weekend to Utah myself. Have a good one and we'll see you next week.
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Thanks all for your informative opinions, insights and (especially) links. It's been a long and grueling work day for me and I'm too tired to really absorb them tonight but will be examining and mulling more closely tomorrow or next day.Safe travel to NoVA and to lms as well although I assume we will hear from lms before the weekend.
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I'm late on this one, but have a couple of thoughts. First off, I think it is inappropriate to think of health insurance as a pension (as in you should get out what you pay in, with interest). Excepting a 4 year period when I lived in England, I've been paying for car insurance for 25 years. The only time I ever took anything out of it was when I hit a deer crossing a road in NE Utah.I'm also mindful about my father and my (deceased) father-in-law. My suegro (FIL) died suddenly at age 65. He'd been complaining of some intestinal issues. They thought he had diverticulitus. Turns out that he had metastatic cancer and he never made it out of the operating room. It was heart breaking as we were visiting the next month with his six month old twin grandsons. My guess is that his healthcare costs largely consisted of one expensive and ultimately futile surgery.My dad has chronic obstructive pulmonary disease (COPD). It's a legacy of being a smoker. He was born in '37 and so was good and hooked by the time that the hazards of smoking became clear. I'd say his health started to deteriorate when we were married. He had a health scare when we were married in Costa Rica (had better care there than when returning via Texas). It's been a gradual decay of his health, though it seems to have stabilized the last year or so. He's on full time oxygen now, but is doing OK. Clearly, my dad has had a helluva lot more money expended on his healthcare than my suegro. So far, it's been worth it IMHO. If and when the time comes for him, as it will for many of us, we'll make those hard decisions.One more thought. Match on a bonfire, but I can't resist it. Life expectancy in Costa Rica is 79.1 years, one year longer than in the U.S. Fraction of GDP spent on healthcare in Costa Rica is 9.3% vs. 14.6% in the U.S. Whatever one thinks of the solution, we're not doing it right.BBBB
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