GoRight - corph Sparring Challenge
Recently, our own GoRight challenged my to a sparring match. It was part of a subthread that I instigated by lamenting that, essentially, Republicans suck . We both caught a bit of grief from B Rational about being hyperpartisan and biased, which resulted interestingly enough in our both attacking the purplebar, with I calling him a mealy-mouthed Broderite and GoRight attacking his condescension.
So anyway, I accept. My line of thinking wouldn't be very persuasive if I didn't think I could flatten GoRight in a straight up debate. He challenged me to pick any topic. I think I'll go with healthcare, and not because I have any expertise in the area (I'm a nuclear safety engineer). Mainly because Medicare and Medicaid already dominate the budgets. Here's my general position statement:
Universal healthcare, ideally with a single payer (the Federal Government), is a worthy objective and would be better than the current system or anything Republicans have proposed in the past thirty years.
I will expand on this argument upon request depending on where the thread takes us.
I would like to suggest that GoRight and myself make alternating comments responding to this original post. Anyone who wants to jump in can make nested comments. There are no rules of discourse; I assume that if either of us goes heavy on the fallacies, others will call us out.
- corph's blog
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Comments :
I accept, of course. :)
But I do think we need some ground rules on the discourse if we are to consider this an actual debate rather than a mudslinging match. Both you and I should restrict ourselves to honest substantive content devoid of name calling or other silly taunts. I agree with your back and forth format. Our debate shall occur at the first level of comments. Discussion of these points should be restricted to sub-threads off of those first level comments. Others are asked to NOT make any first level comments and restrict themselves to the sub-threads.
In the subthreads I invite others to comment on the substance and the quality of the points being made in the corresponding first level comment. corh and I can provide clarifications and responses to others in these sub-threads but in the spirit of our debate, any new substantive points should only be made at the first level back and forth comments.
Agreed?
Since a debate of this sort will require time to research various aspects of the topic I expect that this will have to occur in a slow and deliberate pace over a week or two, or until there is nothing left to say. We will mutually declare an end at some appropriate time at which point we can ask our fellow SCs to take off their partisan caps and vote to declare a "winner" in the sense of who they believe made the most compelling argument.
Agreed?
Since you opened with a high-level general statement, let me counter with an equally high-level general statement and lob things back into your side of the court:
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4GoRight, a link for you
Thought you might find this interesting, from the New York Times
:
Emphasis mine. :)
We are the environment. There is no distinction. What we do to the earth we do to ourselves. —David Suzuki
Gee, thanks SL! :)
An excellent article. I think you may have finally convinced me that things can be true and misleading!*
But even IF I accept that premise as true, who is it that is making these misleading statements? Hmmm.
It's a good article either way.
-------------------------------------------
* (Not really.)
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Agree to both points.
I'm glad we've come straight to the shortcomings of other industrialized countries with single payer systems. I of course will concede that problems such as long lines and waiting lists exist in Canada and Britain, and are worse than in the US. I also know that in some extreme cases Canada was forced to send patients to the US for cancer treatments.
But I believe those problems are manageable, and even if they never improve, those problems are dwarfed by American ones.
As with most unsexy government programs and instititions, you only hear about the horror stories without any perspective on scale or scope. Canada and Britain have good healthcare, and it's free [edit: by "free" I mean publicly-funded with no out of pocket expenses for basic services]; You will get your emergency heart surgery when you need it, and there is no five-digit bill coming in the mail, no claims representatives to hassle you and no mountains of paperwork to fill out. The psychological effect of not having to worry about going bankrupt while fighting an ilness cannot be ignored either.
As for being "starved for cash", I would argue that any healthcare system is starved for cash, including the US's, because healthcare is an insatiable money pit. There is no end to worthwile research and treatment expenses where human health is concerned. The issue is how best to allocate what limited resources are available, through taxes, premiums, co-pays and out of pocket expenses.
And that's where the single-payer systems win hands down, despite (or maybe because of) their lack of profit motive and other inherent inefficiencies. You would think that a big government-funded beaurocracy would have higher overhead costs than a private healthcare provider, but it's well-documented that it's quite the opposite. With a public system, there is no point in trying to deny or pass on costs, which saves adminstrative resources. With a public system, there is an inherent incentive to focus preventive measures that save far more money in the long run. With a public system, doctors can focus on the patient's health without worrying about what services he can collect for.
The fundamental flaw in the US's more market-based approach is that healthcare is not used like a commodity or ordinary service. Healthy people (other than hypochondriacs) won't go to the doctor when they don't need to even if it's free, because it's an uncomfortable inconvenience. Conversely, sick people are most often willing to pay almost anything to get better, which distorts supply and demand principles. The nature of healthcare means that by and large, publicly-funded system works best for the overall health and well-being of the population: rich and poor have access to the same quality of service, and the same opportunity to persue life, liberty and happiness.
Of course, comparing our system to single-payer ones and getting there from our current situation are two different debates. What is clear to me, however, is that a single-payer system is vastly superior in terms of the value to the patient for all but the very richest citizens.
OK, here's my response.
Let me begin by referring our readers to two articles that I found very helpful in the preparation of this reply:
(1) Inequities in socialized health care
(2) Health care in Canada: Different, but not necessarily better
Well, this is a good start then. See we have found some common ground already.
Well, personally I am not so sure that these problems are "manageable." To think so seems naive to me. The UK's National Health Service was created in 1948 and shows no signs of having them under control. Why do you believe that after 60 years the UK is still struggling with these problems and yet you baldly assert that the US can manage them? I so no reason to believe that our bureaucrats are any smarter than theirs in this regard. If other US Governmental agencies are an example of the efficiency we can expect then I will require a little more convincing on this point.
Just consider the situation in Canada:
A 4 year wait to get you foot operated on. That's quite a wait by anyone's standards, I think.
My opponent then goes on to write:
Well, let us test that assertion. From the UK we have the following:
And from Canada we have:
Having to remortgage your home, paying taxes, paying premiums, and STILL paying 30% for things that insurance covers in other countries really doesn't sound that free to me.
My oppenent then claims:
But a little reading reveals stories like this:
Apparently this applies to neurosurgeries and high-risk pregnancies as well. If the US moves to this style of healthcare, who will be there for us to run to in these situations? There is no viable answer as far as I can see.
Next my opponent dives into the issue of costs to the patient:
How would our friends to the north respond?
I'm not sure that I would count this as a major differentiator in the grand scheme. Bankrupt is bankrupt as far as I can tell.
Next we move onto the allocation of resources:
There is some validity to this argument. Clearly there is no end to the need and so the question is how best to allocate the limited resources available. In response I will raise the following points:
(1) I believe that the best means of determining the "best" allocation of such resources is a free market based on supply and demand. The US economy is a great example of this at work. Even in our current depressed state we are still the envy of the world economically speaking. There is no government bureaucracy that is going to centrally manage the allocation of locally delivered services as well as the free market does. The fall of the Soviet Union is a testiment to this. Centrally managed resource allocations on a large scale do not work. I see no reason the same will not be true of healthcare, even with it's special characteristics in terms of being a commodity.
(2) Within a system where the patient has no out of pocket expenses they have no incentive to not seek healthcare when it is not really needed or simpler alternatives exist. As a reault demand skyrockets and the availability of services remains fixed. The result? The rationing and waiting lists discussed above. The US system is superior in two respects here: first each patient has an incentive to only seek care when it is truly needed, and second if demand in some area increases the market can easily adapt because entrepeneurs will seek to fill the gaps out of profit motive. If the waiting time to get an MRI goes up, private MRI services will crop up without any need for a governmental bureaucracy to get involved. In fact, the market is so good at it that it evens fills the gap in those other countries too
.
I think we have a fundamental disagreement here. The free market system, which is inherently driven by the profit motive, is the most efficient means of resource allocation ever yet devised. It is inherently distributed in its decision making and infinitely adaptable in its responses. No government run program can match it.
I'm going to need some convincing on this point. Show me the data. In and apples to apples comparison in terms of both quality and timeliness of care, I don't believe that you will be able to demonstrate this. One reason is that you will be hard pressed to even find a single payer system that provides the level of quality and timeliness of healthcare that the US system does today.
The US system likewise has its counterparts to this concept. They are called Health Maintenance Organizations (HMOs). We also have healthcare networks whose focus is on driving out costs. The result? The same thing we see in the single payer systems which artificially cap the costs of procedures rather than letting the market determine the best price: doctors drop out of the system because that can't run a practice under the centrally managed constraints.
This, of course, creates shortages of qualified practitioners:
In short, I don't see how turning the entire country into one single giant HMO is going to produce a better result. Doing the same thing but only on a larger scale just isn't going to work. It doesn't work here. And it doesn't work in Canada or the UK.
I fundamentally disagree. These forces don't "distorts supply and demand principles", these forces ARE the supply and demand principles at work. The demand for healthcare services is driven by the people who are sick. That's basically what you are saying here. Personally, I don't find that the least bit surprising. The market's reaction? It focuses its resources on addressing the needs of the people with needs and in direct proportion to what those needs are. Shifts in resources are completely automatic based on the relative demands (and therefore profit opportunities). Competition keeps the costs at a sustainable level in a global sense across all of the resources being utilized.
Even this doesn't appear to pan out, at least in Canada:
I have argued that a single payer healthcare system will result in a lower quality of care for the patient. As an illustration of this point consider the following examples from the UK, a system that has had 60 years mature:
In closing if the US goes the way of Canada and the UK there is no reason to expect that we would fare any better. But once we become them, where else will we turn to in order to meet the needs not addressed by our own system? Today the US is the safety valve for Canada and the UK. If we adopt their system there will be no safety valve and when the pressure builds, the system will simply explode with catastrophic consequences for the patients.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4I wonder if Magilson
is still worried we're "getting personal".
I now see why it took you a while to respond. Congratulations for looking all that stuff up (unless you just copy-pasted from one or two aggregate sources
).
My response below, coming soon.
I looked up a couple ...
But mostly just followed the references from the American Thinker one. I had some others that didn't make it into the text.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4The role of insurance?
I would disagree with the superior nature of these points with regards to our current system and think a solid argument "for" our current system must account for the distorting affects of medical insurance in these two areas.
Our current system does NOT incentivize people to seek care only if needed: if one has insurance, with a simple $20 copayment, one is in fact encouraged to run to the doctor for anything troublesome. A minor sprain, a child bumping his head, a sore throat or cough -- our current system encourages overuse of expensive medical resources (Xrays, MRIs, specialists, etc) or of potentially damaging treatments (antibiotics, estrogen therapy, nearly universal prescription of cholesterol drugs, etc.).
Which leads into the second point: you are correct, entrepreneuers have indeed filled the gap out of profit motives. Insurance companies, by incentivizing the wrong behavior, have made it possible for doctors to charge more because of increased demand, have encouraged doctors to prescribe more, which in turn enriches drug manufacturers, who then charge more because demand is up, whose increased fees justify increased premiums, etc.
I don't necessarily disagree.
But your observation only illustrates why are current system in superior to the one my opponent is advocating. For example, if a low out of pocket payment like $20 causes people to go to the doctor more than they need is a $0 out of pocket going to make that effect better, or worse? I argue worse.
Thus if we want to give people a reason to pause, we need to increase the out of pocket expenses not decrease decrease them as my opponent's plan would do. Clearly his plan is moving in the wrong direction, and therefore on the continuum of options our current system must be at least marginally better.
Now, you could try to argue that $20 might as well be $0 so where's the difference? This argument is only valid for the upper levels of the income brackets. For the truly poor? $20 is not insignificant. Who are the largest portion of the population? Lower and middle class. Who are the ones with the poorest health and therefore the greatest need for care? The lower class. So while it may not seem like a lot to you and me, I would argue that the $20 copay is actually significant to those in the poorest health and thus it really does act to incentivize fewer visits to the doctor. Certainly it does more than $0 would within that same population.
I suppose that the solution might be some sort of progressive copayment scheme. The higher your income the higher your copays. That way everyone gets an incentive.
This isn't actually true. Doctors are making less, not more, under the current scheme. That's why there is a shortage of general practitioners and an increase of specialist. Specialists can charge more.
With HMOs and POS Networks the doctors agree to accept whatever the network provider agrees to pay for various services. He/she may charge whatever they like but the bill will be reduced to whatever the insurance company deems reasonable and customary within their network.
I recently had to change doctors (well a couple of years ago). The reason? My old doctor had decided to drop out of my insurance carrier's network and she cited the fact that she couldn't afford to provide care on what they were offering as her reason.
HMOs and POS Networks clearly have an incentive to keep the costs down. The better they do that the better their profit margin for that year. They can't just arbitrarily raise their copays and/or fees because people would simply switch to their competitors. Again, profit motive is want causes entrepeneurs to fill a resource gap but competition is what keeps them from raising prices to arbitrary levels. If they raise their prices too high some other more hungry entrepeneur will set up shop and eat his lunch.
While it is true that increase patient demand will increase the number of presscriptions, that doesn't necessarily mean that doctors prescribe more per patient (i.e. at a higher rate per patient). As for the increased demand for drugs raising the prices I actually don't think that the drug companies (well the generics would be an exception) use demand-based pricing. They would be much smarter to use value based pricing. In other words to set the price at what the drug is worth to the patient rather than what the market would set the price at. They can get away with this because they hold the patents. They are the sole supplier for their drugs ... until the patents run out and the generics move in. Once the competition (i.e. generics) show up what happens to the price of a given drug? It drops like a rock. *
There is no doubt that the increased demand will raise prices for things that don't have patent protection because these things can only rely on market-based pricing. The increasing expense to the average doctor will obviously be passed along. Among other things these increased costs are due to new advances in techologies. These too will benefit from patent protections and thus can use value-based pricing rather than market-based pricing. The same argument about recouping sunk costs within the 20 year windows applies here as well.
This effect inevitably raises the prices of treatment. If a company develops a new imaging technology that is superior to all other existing technologies what are they going to charge for it? Less than their competition? Why? They have a superior product so they can charge a premium above the going rate. But of course everyone wants to use the superior technology because, well, it could quite literally save their lives relative to the competition. People place a lot of value on their lives so they are will to pay a lot for the best care available.
So why is the US system better than my comeptitors proposal with respect to this? In the US system can actually accomodate and support both technologies in parallel. People who can afford it can use the newer technology and people who can't can still get access to the older technology. Does that suck? At any instant in time yea, it sucks to be poor. But the reality is that the rich end up subsidizing the development of the new treatments and technologies and over time these become more affordable. The system allows for the introduction of new technology over time.
In a single payer system this won't be the case. In a single payer system everyone is going to demand the same level of care. The poor want to have access to the same technologies as the rich. This is, of course, only natural. But this puts the bureaucracy into a bit of a bind given that they have fixed resources. They can opt for the newer more expensive technology and ration access, or they can opt for the older technology and reduce the quality of care. Either option is worse for the patient, IMHO. This situation also disincentivizes research and development to find newer and better technologies and treatments. If a new technology is deemed too expensive the bureaucrats will opt to stay with the old technology and so there is no profit in doing the reasearch. If on the other hand, the cost of the new technology is comparable to the old why bother to develop it at all? Sure there is the altruistic motive of helping people, but that is not the same level of motivation as a healthy profit margin would be.
So, again, I would argue that the US system is superior because it encourages the development of better treatments which will improve the quality of care for the patient, and over time everyone reaps the benefits of the newer technologies because prices will inevitably drop (when the patents run out if nothing else).
-------------------------------------------------------------
* Now, lest you read this and think that the drug companies are greedy heartless bastards consider for a moment the huge cost of research and developement that goes into each drug that actually makes it to market (not to mention the ones that don't). They have 20 years to recoup their already sunk costs and make a little profit before the generics are allowed to undercut them. Clinical and other trials don't come cheap and not all drugs even provide a paybeack because they get canned in the trial phase.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Good job, you're really getting into it. Fact is you've already
won this deal. America has the finest health care in the world hands down. No one except the densest of liberal democrats would refute that.
The worst thing for people who want excellent affordable health care is the government being in charge!
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
The worst thing for
people who want excellent health care is for your health to be in the hands of those who profit the most from you being sick. The sicker you are the more money they make.
I'm only half stupid
Run that by Robert Gibbs then get back to us.
nt.
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
Thanks for settling it
with a platitude and a toss-off. I'm appropriately chastened and will start working on being less dense now.
Oh good, win win then.
And maybe check in with some folks in the UK too before you start an argument you can't win.
You do know they have limitations now on who gets what medicines, right?
For instance the government in its infinite wisdom has done the math, and in England you have the Government Rationing Body, and they have decided women with advanced breast cancer and patients with stomach cancer will no longer receive the most expensive and effective medicines.
Period.
Forgive me, but if I have a problem, no matter what the last hack says, give me the good shit ok. Maybe thats why so many Brits and Cnucks leave to be treated abroad?
*BTW-If you consider what I posted previously and elicited your response a platitude, you really should get out more.
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
This is a good argument
...against a nationalized healthcare system like the UK has. But corph is suggesting a single-payer system, which is significantly different. You'd be better off looking at problems with France's system if you want to argue against corph's idea.
We are the environment. There is no distinction. What we do to the earth we do to ourselves. —David Suzuki
I assume corph will make his own points ...
but could you please elaborate on what you think is unique about corph's proposal? I haven't seen enough to differentiate it either way.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Vive la France!
I wouldn't say it is unique, but I don't think he is proposing a UK-style system. This is not exactly my area of expertise, but from what I do know:
The UK system is not simply single payer, it is single operator. The government owns the health care facilities and delivers health care services. It really is socialized medicine, and thus problems like what Centinel brings up can occur.
France is decidedly not socialized medicine. I guess it is more like socialized insurance. Everyone has it, and it automatically pays for something like 70% of your health care bills - more if you are really sick. But there are still private insurance companies, which most people have (through their employer, just like the US currently), that can pick up the rest of the bill. It seems to work quite well. I am sure there are some problems with it, but nothing is perfect. And the impression I get is that the French system is significantly closer to perfect than the US system.
I don't know about corph, but France would definitely be the model I would be looking at most closely if I were setting out to redesign the US health care system.
We are the environment. There is no distinction. What we do to the earth we do to ourselves. —David Suzuki
So if there are multiple payers ...
how is this an example of a single payer system?
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Modified single payer?
I don't really know what the various terms officially mean, but I guess you could call this a single payer system in that everyone is covered by a single payer - the government. It just happens to also have supplemental private insurance allowed.
We are the environment. There is no distinction. What we do to the earth we do to ourselves. —David Suzuki
Well there is a giant leap between talking about
providing national health care, and a national health insurance to be certain. I think more Americans would be comfortable with a simple government insurance program where they could still pick their doctor, etc.
Here is a good piece on the French model
.
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
GR you better reread what you wrote
" But the reality is that the rich end up subsidizing the development of the new treatments and technologies and over time these become more affordable."
What is this........ privatizing taxes, in essence asking the rich to subsidize research for private corporations so the unwealthy can benefit later?
Wow! So you are saying you trust the business heads who are seeking to profit from health care research and development to ask the wealthy to pay more for the greater good so the rest of us at some future point in time can receive a cheaper benefit.
At the rate health care costs are going up yearly, at what future date in time should we plan on just giving the insurance companies our whole paycheck, so they can continue this marvelous research and development work that will someday benefit all of us?
I'm only half stupid
Sorry, it's just the truth.
"But the reality is that the rich end up subsidizing the development of the new treatments and technologies and over time these become more affordable."
This in no way implies that the rich are being altruistic, quite the opposite. They are simply buying the best healthcare available even though the poor cannot afford it (theoretically speaking). But healthcare equipment is no different than big screen TVs in this sense. They start out as uber expensive toys for the rich and then the prices come down.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4They are being forced to pay
The rich are being forced by for profit health care providers to pay for the poor. I agree there is no altruistic intent. It's a tyranny upon the rich. Much like you claim taxes are, only in this case the benefit is solely for business. The rich are paying most of the health care costs. The lower middle class are becoming poorer because of health care costs.
Do you realize that what you are saying is that only the rich can afford health care?
I'm only half stupid
Do you realize that what you
Not quite. What I am saying is that only the rich can afford the bleeding edge healthcare. The poor can still afford the standard treatments of today. In fact, when the new bleeding edge technology comes out the price for the old treatment drops. So even then the poor get a break.
But the point is in a single payer system where they have to pick between one technology or the other, the truly expensive bleeding edge research (which might provide significant benefits down the road) simply won't be done. In that sense medical advances are stalled and everyone loses.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4What you are saying
essentially is that you think it is fair for the rich to pay to invest in medical research and you are equating research to mean health care. Disengenious. Why not let researchers compete on the open market to develop the best product to sell to the health care companies?
The rich in any country can afford bleeding edge health care, so this is hardly a newsflash.
If there is a market for a cure, there will be those that seek to find it. Are you saying in this case that competition among researchers won't provide the best medicine? That researchers need to be housed under the umbrella of health care?
Did the rich pay extra for health care to find a cure for polio.
Essentially what you are advocating is a 'tax' on the rich, redirected into insurance companies, because you are claiming that would be a good 'investment' into medical research.
I don't see how this solves any of our health care problems at all. It just puts a greater burden on the rich, with the vague notion that at some point in the future there might be a cost benefit for the less rich. So far the results of this type of thinking have been the continuing rise of health care costs to the point of the absurd.
What you are doing is turning doctors into walking salesman for medical supplies and drugs, that you expect the rich to pay for. It has little to do with actual health care and lots to do with 'for profit'.
I'm only half stupid
Huh?
I am not being disingenuous in any way here. I think you have a fundamental misunderstanding of what I am saying. First of all, I am not saying anything about the "rich paying to invest in medical research", as in they put their capital into R&D firms.
What I am saying is that in a free market system, it is the profit motive that will drive entreneurs to invest in the R&D required to make medical advances and that such R&D is hugely expensive so, to recoup the sunk costs associated with the R&D the initial prices for access to the new technoloigies will necessarily be high.
When I say the rich are subsidizing the R&D for medical advances what I am saying is that the rich are the only ones who will be able to (initially) afford access to the new technologies, and therefore they are indirectly paying the entrepeneurs so that they can recoup the sunk costs and make a little profit. If the rich weren't willing to pay for these newer treatments there would be no profit motive and the enterpeneurs simply wouldn't invest in the R&D.
Now the motive of the rich who are indirectly footing the bill here is not a profit motive. Their motive is to obtain the best possible care and treatment. They have a self-serving motive here, but they also have the deep pockets to afford it. They are paying for what they perceive to be the increased benefit to themselves, not because it will help others. But ultimately their paying does end up helping others after the prices drop and these new treatments become available to the poorer parts of society.
Note also that this system automatically gives the most sound and time-tested technologies and treatments to the poor. The rich are the ones to become the "general population guinea pigs" for these new treatments. Even after all the clinical trials some new treatments and drugs have unforeseen side-effects and are ultimately pulled from the market
.* So the rich end up taking the bad with the good in all of this. To some small degree that does ameliorate the purported disparity in fairness between the rich and the poor in this context.
I am saying nothing of the sort. In fact, I am saying exactly the opposite. In my example the R&D investments made by independent entrepeneurs is exactly the free market that you speak of.
Sorry but this does not hold up. A "tax" is something that people are forced to pay. No one is forcing these people to pay for these expensive treatments. They are doing so out of their own free will and ability to pay, and they are NOT viewing this as an "investment" of any kind. They are viewing it as buying the best possible care available.
I have proposed no solutions to anything. I am merely describing our existing system as it already operates today and demonstrating why even the current system is superior to what my opponent is proposing.
It doesn't put a burden on anyone. Everyone involved is free to make their own decisions based on their own personal circumstances and ability to pay. Under a single payer system they have no such freedom.
It is undeniably true that the current costs of healthcare are increasing. I have provided an explanation for why that is and why it is inevitable. It is also an artifact of the fact that we have better care available and on a more timely basis than the alternative my oppenent is proposing as seen in actual real-world implmentations of his proposal (or as close as we can get if there is some nuance I have missed in what he is actually proposing).
I am not turning anyone into anything. I am merely describing how medical advances are effectively funded in our current system and articulating why, even with all its faults, it is still superior to a single-payer alternative and I have backed up my claims with real-world examples.
----------------------------------------
* I offer the Vioxx example merely to illustrate that these types of things do happen, not because I am claiming that this is a prime example of my point. I don't know enough about the specifics of the Vioxx case either way to make that claim. But if Vioxx was actually an uber expensive drug (I don't know) then I would argue that it was a good example of what I am talking about. Only the rich would have been using it, roughly speaking.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4I followed your links.
They are essentially lists of shortcomings of the Canadian and British systems, not comparative studies with the US one. And the conclusion of the second one was that "things are just different - not necessarily better or worse". And the "safety valve" metaphor is weak. If the US were not there, Canada would face enough political pressure to pony up the dough. There would be no "explosion".
The iffy-sounding data point in your first link is "more than 400" Canadians have been sent south for emergency heart surgeries since 2003. And the article was published in 2009. So, that's less than 100 a year. OK, bad. The Canadian and Ontario governments should probably open a few more ORs. In the meantime, the US has 45 million uninsured. Where do they go for heart surgery? They either go bankrupt or to the ER, where they're stabilized and sent home to die. Then there's the self-employed underinsured with their 1500$/month premiums or high deductibles or copays or whatever. It not only represents a huge health risk, it kills the competitiveness of all those small business whose taxes people on the right are always so worried about raising.
I noticed you didn't respond to the excess paperwork argument: basically that there is a huge perverse incentive for any private insurer to do anything they can to avoid paying what they call "medical losses". This results in 31%
of your healthcare dollar going to administrative costs, vs. 17% in Canada. Yes, I know, Krugman. But I couldn't find anyone who puts it better than he does. He does source pretty well and has some credibility on the matter.
I'm not going to post as many links as you did, only those with the macro data that I believe can make the larger point. Here's the money quote from the same article:
See that? The US government, despite providing far less coverage than Canada, spends more per citizen on healthcare! I wish I could have put this at the end (I'm trying to follow your order). As Add Canada's life expectancy and infant mortality numbers wiping the floor with the US's, and I believe this debate should be over.
As for the larger argument you make later:
I find that very simplistic. Supply and demand forces work great for making iPods. They have mixed results with things like highway construction and public transit, bad results for healthcare and we don't even attempt it with national defense (Blackwater notwithstanding). We, as a society, are not willing to accept rich kids getting any kind of expensive therapy they want while the poor kids get sent home to die. We've tried to patch up the discrepencies with things like Medicaid and SCHIP, but the public-private resulting mess hasn't fully addressed the problem, while causing skyrocketing administrative expenses as mentioned above.
I'll respond to this in two parts, because I think you're dead wrong on the first part and you make a good point on the second:
1. Patients don't need incentives not to seek healthcare. If you're not sick, you usually don't go to the doctor. Demand might go up if people want worthwhile healthcare such as cancer screenings and periodic checkups, but that's a good thing because those save money in the long run. In the US, the underinsured ignore their symptoms until they become catastrophic, resulting in loss of quality of life and huge medical expenses.
2. It is true that the US has plenty of MRIs, the epitome of expensive medical equipment that can make you a fast buck. But recall that MRIs are a diagnostic tool, not a treatment one. The difference is that people almost never need emergency MRIs (say within the next few days), which makes the demand for them more elastic. I will concede that there are certain areas in healthcare where supply and demand forces work better than others. My solution, however, would be to convince Canada and Britain simply to either buy more of them, or find more cost-effective diagnosis methods.
One final point: I'm not suggesting the US adopt the Canadian or British model as is. They have the same legacy inefficiencies (read: electronic medical records) the US system does, and they're too reactive in allocating resources. According to many, both France and Germany have preferable systems to the Anglo ones. The one thing they all have in common is that they're all largely single-payer.
Thanks.
I'll mull this over for a while and get you a response. It most likely won't be until AFTER tax day, though, I need to get those done first. :(
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Good, I don't want
to have to declare vitory by default
Ehh?
Wrong, we might want to let doctors who are trying to diagnose, and patients who are suffering from potentially serious things like - brain tumors, blood clots, nerve damage, etc, etc, etc!
In America they are seen and treated quickly, can you imagine having a serious painful injury and having to wait for days to be seen for an MRI, ouch.
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
Almost never
He did say almost never, not never. The only hard numbers I can find are here
: looks like about 3% of MRIs in this study were emergency MRIs. I'm sure there are quite a few more that are "semi-emergency," but I don't think it changes corph's basic point about elasticity of demand.
We are the environment. There is no distinction. What we do to the earth we do to ourselves. —David Suzuki
Well your link ref's ER room ordered MRI's
I do not have any hard and fast data at hand, I will ask my Dad, he is an Oncologist and owns a couple MRI machines in his radiology practice offices. Just being around the offices and working part time for him from time to time over the years, many of the scan orders are placed on an expedited basis.
ER's ordering MRI's is something I do not remember hearing about much in the offices, probably because when someone is experiencing dizziness, or their sight is fuzzy, or the many symptoms an MRI can help diagnose, they go to their primary care doctor, that however does not mean the case is not an emergency.
When someone comes in on regular basis, and finds out they have some terminal or serious illness, it's an emergency.
So I think your link is very misleading, and does not show how many "critical" MRI's are done on a time critical basis.
Congrats on the opportunity to be of service here at SC! ;-)
Great Spirits Have Always Encountered Violent Opposition From Mediocre Minds...~ A. Einstein
Which is going to do a better job of reacting to ...
changes in demand for services like MRIs? The capitalist free market where the almighty dollar is king, or a government run bureacracy where keeping costs under fixed budgets is king?
When demand exceeds the capacity of the government budget what do they do?
The free market has no such budget constraints and it is self-regulating in terms of supply. If demand exceeds supply newcomers will fill the gap. If demand drops off the supply will shrink automatically to match as unprofitable businesses are shut down. The free market is a beautiful thing to behold under these circumstances.
There is no way a government run system can match it in terms of over-all efficiency across all the variables involved in something as complex as healthcare. The fact that private MRI providers are in Canada at all suggests that this is true.
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Well, I have let this sit far too long.
But I let myself get distracted of late, as you might well know. :)
I won't address everything in your last post at this time, but just to get the ball rolling again let me highlight a few points from a link provided by SL above, as well as a few specific replies of my own.
This is, of course, speculation on both our parts but I claim that the weight of the evidence is at least leaning my way slightly. Consider the following points:
We know for a fact that Canadians are relying on the US for things that their system does not cover.
Using the Canadian system as a real-world example of a state run healthcare system, we have no reason to believe that the same would not be true under a US government managed system.
If the US system stops covering the procedures in question there is currently no known alternative to fill the gap.
I submit that based on the available evidence it is nothing more than wishful thinking on your part to suggest that there would not be "an explosion." Clearly something would have to give and I fear it would be the quality and the timeliness of the care as we see with existing systems in the UK and Canada.
If you are advocating for some alternative form of government managed healthcare, such as from France or Germany, then we will have to explore that in all due time.
I think you misunderstand the significance of this statistic. The issue at hand is not a lack of ORs, the issue at hand is that these people can't get the life saving procedures in Canada at all as far as I can tell. To reiterate a quote from above:
So unless I am mistaken here the only treatment being offered in Canada is the clot-busting drugs, and if those fail they have no other alternatives available in Canada. That's why they have to turn to the US. Building more ORs won't address the problem.
From the link so kindly provided by SL above, we find that this statistic is actually true but misleading as SL would say.
From the text we learn that this number includes:
... about 10 million residents who are not American citizens. Many are illegal immigrants. Even if we had national health insurance, they would probably not be covered.
... it counts millions of the poor who are eligible for Medicaid but have not yet applied. These individuals, who are healthier, on average, than those who are enrolled, could always apply if they ever needed significant medical care. They are uninsured in name only.
... 18 million of the uninsured have annual household income of more than $50,000, which puts them in the top half of the income distribution. About a quarter of the uninsured have been offered employer-provided insurance but declined coverage.
The article then concludes:
Next I would like to addres the following:
I would indeed like to thank you for pointing out this statistic. Let me run this past you again only now you can apply my point of view to it: even with our current system the US Government is ALREADY spending more per citizen on healthcare and you ADMIT that they are providing far less coverage than Canada.
Color me confused. Does this statistic not directly support my contention above that we have no reason to believe that a US government run system would be better than a Canadian one? You appear to have provided an existing statistic that suggests that the US government would be far less efficient than Canada rather than more. Right? And in fact this is already true.
Kudos on the nice rhetorical flourish there, but let us return to the article SL provided:
Moving on further we have:
This is merely an assertion on your part. While it may sound nice I would ask you to back this up with some sound evidence. What data do you have to support the bald assertion that market forces have bad results for healthcare? While we may be paying more for our healthcare than other countries we are also getting better care in terms of quality and timeliness of service. That doesn't come cheap.
My dad who ran his own business had a sign that read:
That sign pretty much sums up the situation for healthcare too. Obviously I think that we as a society are better off picking option #1.
Fine, I can accept this. But this is a choice that they make, right? They are under insured in most cases by choice because they refuse their employer sponsored healthcare to try and save a buck in their healthy years ... or at least in the years that statistically should be their healthy years.
Sure, for some people that gamble bites them in the arse. Don't expect me to have sympathy for people who are making bad choices. Don't expect me and my family to have to suffer with inferior and untimely healthcare to cover people who are their own worst enemies. Remember that, per the statistic cited above, most of these people are in the upper 50% of income earners.
The truly poor who can't even afford healthcare? They are already eligible for governmental insurance through Medicaid so changing the system won't change their situation at all.
Two points. First I think that this response is a bit disingenuous from the perspective that I only used the MRI as a representative example, my point is broader than merely diagnotic aids. Second, I disagree that people don't need emergency MRIs. That is just silly on its face. Are you saying that ERs don't send people to get MRIs? Of course they do.
And if we didn't have these secondary providers to send the non-emergency cases to the result would be that the overloaded hospital resources would be even more overloaded and this will either result in what? Lower quality of healthcare and/or waiting times to get the necessary diagnostics performed.
But your point about the elasticity of the demand is a good one. But I submit that the free-market provides a far more elsatic supply option that does any government run bureaucracy. Matching the level of supply closely to the level of demand is the very epitome of efficiency. The government managed systems have already demonstrated this fact. That's why they have private MRI facilities in Canada.
With all due respect, do you honestly believe that either the UK or the Canadian governments are NOT already trying to do just that? Of course they are. That's why they refuse to pay for expensive leading edge treatments and find themselves managing budgets for scarce diagnostic resources. X-rays are a mature and proven diagnostic tool, but they are not a substitute for an MRI. If they were we wouldn't even be buying MRIs.
Well OK then. Can we at least rule out Canadian and UK style solutions as being inferior to our own as they stand today? And that unless you can demonstrate some reasonable solution to the shortcomings of those systems which will have a high probability of success that we should view those options as off the table for discussion at this point?
As for the French and German models I don't know enough to comment either way. So at this point I am going to throw the ball back into your court. Please highlight for us the benfits that these other models have over our current system
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Before I reply at length
let me clarify my position on
NO. I maintain that both the Canadian and British systems, while far from optimal, are highly superior to the US one. I would be happy to make the argument in terms of Quality-Adjusted Life Years (QALYs) per dollar spent, if you would accept that as the most important efficiency measure.
Why would we do that?
Well, I don't mean any disrespect but from my perspective I have shown lots of evidence to the contrary as well as provided evidence that suggests your purported statistical measures (i.e. life expectancy and infant mortality rate) aren't a true reflection of the quality of the healthcare system. So I am left wondering, what else do you have?
As we have seen already, raw statistics like this are inadequate to capture the complexities of the issue. Why would this be any different than using the Infant Mortality rate or the Life Expectancy figures which have already been shown to have no meaningful relationship to judging the quality of the healthcare system.
But hey, its your time, spend it making whatever case you want. :)
The problem with using statistics like this is that it is akin to what people in the agriculture industry would term a Herd Health mentality. In a herd health mindset your don't make health related decisions based on the individuals, but rather based on what is best for the herd as a whole. So, for example, you end up sacrificing individual benefits in favor of maintaining the best overall herd. When an individual cow comes down with something you may decide to just euthanize that individual to prevent the spread of whatever to the rest of the herd.
Now obviously I am not suggesting that nationalized healthcare is actually going to have a euthanasia program, but the mentality is the same. Sacrifice the benefits to the individual in favor of benefits to the herd as a whole. One example from the UK system might be things like the decision to not pay for treatment of someone's eye unless they were already blind in the other. This is a result of the herd health mentality. How so? Because the decision was made based on the need to spend those healthcare dollars where you get the most bang for the buck.
Making a decision like that, and that decision was not some hypothetical it actually happened, makes total sense if your goal is to maximize things just like "Quality-Adjusted Life Years (QALYs) per dollar spent." Don't pay to fix an old geezer's first eye because that money is better spent on the younger people where the benefit will acrue over a longer period of time.
Personally I don't find a system where bureaucrats are making those decisions for us to be acceptable. From a tax payer's perspective that might make sense, but it sucks to be the old geezer. Especially to be an old geezer who has already paid into the system his entire life only to be tossed out on the curb when he finally needs help.
In this example are you in favor of paying to fix the old geezer's eye or do you prefer to maximize some impersonal statistic?
I'm the Bugs Bunny of Swords Crossed!
-4 Strongly Disagree - 0 Meh - Strongly Agree +4Apologies for the delay
This is kind of turning into a marathon, length-wise.
Canada has all the expensive treatment facilities (not talking about research) the US does, just not enough of them. Because they run their system on the cheap and because it's difficult to patch up shortcomings without committing to long-term liabilites. Right now it's simpler and cheaper for Canada to send 400 heart patients to the US, and foot the bill. If that ever becomes 400,000 either US hospitals will stop accepting them or it will bust Canada's healthcare budget. But that's not happening because by and large Canada's system can handle the load. Incidentally, have you wondered how many Americans move themselves or their business to Canada to take advantage of universal healthcare? Toyota did.
As for the 45 million figure, I can accept the illegal aliens number not being insured anyway. But NOT people who don't apply or those who make over 50 grand. There are at least, what, 30 million poeple left? Under a single-payer system there is no means testing and no one needs to apply for coverage at all. Those things do not improve quality of care and only add to administrative costs. Sure, maybe some of these people are lazy or could pay out of pocket, but that's no excuse for people not having coverage. I would wager plenty more are simply confused about or too poor to get properly insured. Why does the US system have to be so complex? Pretty much everyone wants to be covered for whatever they're going to come down with. They do not want to use the medical system anymore than they have to. Few healthy individuals will gripe overmuch about sick people driving up their own payments a little.
Oh, and not every employer offers decent coverage, if they offer any at all. Ask Wal-Mart employees with chronic conditions about their wonderful coverage. Or a mom-and-pop shop owner in Vermont about how fair his premiums are.
Here's my only link this time, but it's a good one: A Semmelweis-like probe
into the causes of Medicare outlay disparity between two Texas counties. It doesn't address the single payer / public option directly, but it argue extremely convincingly that the profit motive does considerable harm to the healthcare industry. This suggests you can't run healthcare like a traditional business, and would suggest your fast, cheap, and quality 2oo3 model does not hold up to scrutiny. The US is not paying a premium for fast, quality healthcare in most cases. It is wasting patient's time with claim forms and denials, putting profit before quality of care and wasting money on nonessential lucrative treatments.
You have no answer to my points about underinsured increasing costs by ignoring symptoms other than to say they may have deserved it? I can't accept that. It's more expensive and harmful to wait for catastrophic systems to develop. And when dealing with things like outbreaks, it becomes more than a matter of personal responsibility.
Healthcare is expensive and will most likely get increasingly so, no matter how the system is structured. Costs need to be controlled, any reserving the best treatment for the rich or federal employees while letting the masses fend for themselves is, I'm convinced, both a losing moral and electoral strategy. I know you probably wouldn't argue in favor of that explicitly, but that's where the current system is trending.
Tell ya what: support Kennedy's public option as a means to demonstrate how wrong I am, and maybe we can agree on some benchmarks for a few years down the road. Then we'll ultimately see who'se right.