[mike777]

 Cthulhu D, on 2013-November-14, 16:56, said:

The conditions for a free market are well known. By definition it includes the ability to make rational decisions to select between a range of competing products (you know.. some sort of market). How do you make rational decisions when you are unconscious?

Please tell me how you propose to resolve this critical issue in free market delivery of healthcare - patient decision making while the patient is unconscious. I look forward to it. Then we can talk about how head injuries impair rational decision making!

there are many possible solutions when you are out of it and in need of health care. examples are living wills or guardianships or families step in. all allow for rational if possible imperfect decisions. anyway...the point is if you believe the government owning all of the health care system and taking away the profit motive leads to a more productive, innovate system. Winston argues in favor of nationalization. I think blackshoe is against the govt owning the health care system.

Clearly Winston and many others start from a point of trust that the govt can and will do better, blackshoe seems to start from a point of general distrust.

[Winstonm]

 mike777, on 2013-November-14, 13:33, said:

The President just changed the law, not sure he has that power but that is what we have.

Again if you want to nationalize health care industry at the very least define it and measure it. I note no other country has nationalized the health care industry despite people saying so. The UK and Canada does not run with just a single payer.

If I understand Winston's point if we take away the profit motive and put the economic and political power over the health care system in a few powerful hands it will be more productive, innovative, and efficient. But at least define that system and how we are going to measure it. Inote even if we expand medicare that does not cover or eliminate the for profit sector or even cover much of the system.

Side note, Winston we have much more regulation than 30 years ago, much more, not less. Whatever the faults of market based health care it is not a lack of regulation.
In any event I still stick with my prediction that millions and millions will benefit from ACA.

Hi, Mike,

Just curiour. You have repeated a claim that we have more regulation than 30 years ago - but I don't see specifics. For sake of argument, let's say 1984 can be counted as 30 years ago. That would be during Reagan's 8-year term. Can you point out where we have more regulation now than then?

Also, you are placing words into my mouth. I did not argue that a single payer system would be anything other than more efficient. It could be as productive and innovative but that depends of how those metrics are measured and the people involved in healthcare.

Free market advocates seem to assume that only profit can motivate - but that is quite a narrow perspective that cannot be assumed to be universally true.

[blackshoe]

 mike777, on 2013-November-14, 17:10, said:

I think blackshoe is against the govt owning the health care system.

That's a fair assessment. I'm not convinced, and nothing I've seen here justifies, to me, any trust that government intervention is the right answer.

 mike777, on 2013-November-14, 17:10, said:

blackshoe seems to start from a point of general distrust.

This much is true.

[kenberg]

I think the discussion about free market medical care is pretty much a dead end, but I am not so sure that it is an impossibility. Solving the problem of the unconscious accident victi seems pretty easy. You need advance planning, just as we now have for planing what to do near the end of life when we become incapable of making a decision. Of course we would have to cluster the options, an individual list of what to dos would be almost infinite, and probably some of it would be done by transferring decision making to someone else, but I doubt the problems are insurmountable.

I guess I'll bring in my age again. In the 1940s, it was simple. You got sick, you called a doctor, he treated you, you paid him. My first daughter was born in 1961. It's a long time back, but I am pretty certain that's how it went then. The child was born, you got a bill, you paid it. Pretty much a free market approach. Maybe not exactly, but close. I don't remember what was done with unconscious accident victims back then, but I wouldn't be surprised to learn that some family member had to step forward and assume responsibility before extensive treatment was performed. In around 1945 i took a tumble, my father took me to an emergency room, they wouldn't treat me until he went back to the house and brought some evidence that he could pay for the treatment. But I was not hurt all that badly, if I were in bad shape they might have acted before they were sure that they would be paid, I don't know.

At any rate, free market medical care would be possible, at least sort of. But that's far from saying that it would be desirable.

It is fundamental that medical care has become much more complex, and much more expensive than in earlier years. The results are now so much better, there is so much more that can be done, that modern healthcare really has to be thought of as a different entity than what we had when I was young. It's for these reasons that I don't think it is now all that viable to run health care as a free market enterprise.

[mike777]

As Ken points out if his dad cannot pay anymore then we need to find other people to pay for the old or sick or poor.


I am worried that posters under 35 wont pay for people such as me or Ken or Winston.


Free capital markets have a solution, think free.....one that we older may not desire as Ken points out.

"At any rate, free market medical care would be possible, at least sort of. But that's far from saying that it would be desirable.'

[HighLow21]

 blackshoe, on 2013-November-14, 16:29, said:

I'm not at all sure this generalization is true. Government intervention seems to be the "go to" solution, for a lot of people, for many, if not most, if not all, ills. Seems to me they're operating with blinders on.

To be fair, so are the people who insist that government can never be even part of the solution to a problem.

I've said that I prefer a free market solution. Others insist "that doesn't work". How do they know, since it's never been tried? Let the government do it? I'm sorry, I don't trust governments.

Free market solutions break down for products like insurance in general, and health insurance specifically. And in terms of trusting governments--I think when it comes to protecting your rights, they're going to do a far better job than insurance companies will.

[mike777]

 HighLow21, on 2013-November-15, 04:03, said:

Free market solutions break down for products like insurance in general, and health insurance specifically. And in terms of trusting governments--I think when it comes to protecting your rights, they're going to do a far better job than insurance companies will.

High low makes important points.....no proof but important points

Please note his most important points...the usa govt protects your rights more than private profit companies

we keep coming back to same point...black shoe does not , in general trust govt.....high low and others trust

[Cthulhu D]

 kenberg, on 2013-November-14, 21:23, said:

I think the discussion about free market medical care is pretty much a dead end, but I am not so sure that it is an impossibility. Solving the problem of the unconscious accident victi seems pretty easy. You need advance planning, just as we now have for planing what to do near the end of life when we become incapable of making a decision. Of course we would have to cluster the options, an individual list of what to dos would be almost infinite, and probably some of it would be done by transferring decision making to someone else, but I doubt the problems are insurmountable.

That assumes you can reliably ID the accident victim, and access his living will or whatever prior to commencing treatment. The reality is when you have an emergency situation you cannot wait around, you have to dive in and you have no practical way of IDing him prior to commencing treatment.

The problems are insurmountable - even if you'd let your insurance company tattoo you with exactly what treatments you are eligible for, the tattoo may become disfigured during the accident, and what happens when your care plan is revised next year - do you get a new tattoo? I imagine after 10 years you might be running out of space to tattoo you. If the decisions are outsourced to a third party, do you really want the paramedics trying to get someone on the phone before they commence immediate life saving treatment when you have 30 seconds to live when they make the call. What happens if after 45 seconds your care is authorised? If you'd prefer being chipped with some sort of ID (this is a non starter, but whatever), what happens if the chip is damaged? Or they have an equipment malfunction? Do they just not treat you?

This is a widely considered problem (it even has a name in the medical profession but I cannot remember what it is - the naked patient problem?) and there are no good solutions, that is why there is a hard legislative requirement that emergency treatment be given by medical professionals if you need it, regardless of your perceived capacity to pay.

[mike777]

one possible partial solution is headless.


headless body parts clones as spare parts. ethics another issue.

this is what science is going for.....many don't know but this is stem cells are about. stem cells grow body parts.

again impede innovation... if the government owns all of health care they make these choices. I repeat government owns all not just part of care


health care is more much more than your local doc.

[helene_t]

I think this issue about unconscious emergency room patients is a distraction. It is an extreme situation and even if the general procedures wouldn't be adequate in such cases, some special clause could be made for such cases.

I think a more important issue is that physicians are simply not going to deny necessary treatment to patients that are unable to pay, or whose parents don't find it worthwhile to pay. People can opt out of cosmetic dental treatment or speedy treatment of non-urgent issues. You can't opt out of coverage of essentials. You might think that you have enough savings to cover yourself so you don't need insurance. But even then, if you suddenly lose your savings and subsequently need treatment, you are going to get it. Directly or indirectly, the taxpayers or those with insurance are going to pay your bill. Libertarians might think it shouldn't be that way but then again, some people might have preferred the Earth to be flat. It's no use arguing with reality.

[mike777]

 helene_t, on 2013-November-15, 06:04, said:

I think this issue about unconscious emergency room patients is a distraction. It is an extreme situation and even if the general procedures wouldn't be adequate in such cases, some special clause could be made for such cases.

I think a more important issue is that physicians are simply not going to deny necessary treatment to patients that are unable to pay, or whose parents don't find it worthwhile to pay. People can opt out of cosmetic dental treatment or speedy treatment of non-urgent issues. You can't opt out of coverage of essentials. You might think that you have enough savings to cover yourself so you don't need insurance. But even then, if you suddenly lose your savings and subsequently need treatment, you are going to get it. Directly or indirectly, the taxpayers or those with insurance are going to pay your bill. Libertarians might think it shouldn't be that way but then again, some people might have preferred the Earth to be flat. It's no use arguing with reality.

Yes you are right.

posters under 35 are going to pay for those of us old or sick or poor.


btw I do know docs that give up and don't treat patients......I meet many


I think people seem to think they don't exist. They have many other options to make money or stay at home make babies.

Most women over 35 don't want to pay for old guys despite bridge forums

[kenberg]

The way to solve a problem that cannot be solved perfectly is to solve it as well as you can and move on. The naked patient problem, if that's what it is called. admits a solution that will work in almost all cases. Of course it won't work all the time, but nothing works all the time. If we wanted to run healthcare on a basis that would highly resemble a free market, we could do it. It would have some drawbacks, and my guess is that the naked patient problem would be only a small part of the drawbacks. At any rate, there really is no chance in hell, and I think Blackie agrees with this, that we will be switching to such an approach so the argument is for theoretical purposes only.

It's more useful, I think, to try to examine approaches that we might actually adopt. We have been working under a confusing jumble of plans.We are adding in the ACA. We who try, with at best modest success, to keep up somewhat with events are trying to understand the consequences. We might even hope to have a bit of a say in the consequences. The game may well go in favor of those who do the best job of understanding the real concerns of many people and addressing them competently and honestly.

Free choice is an issue. In medical treatment it's a big issue ( most of us are non-naked patients) . This sometimes plays out in discussions as free market. I don't regard them as the same at all, but as government assumes a larger role in medical care, it is definitely an issue of concern. When I was young the Golden Rule was explained to me as "He who has the gold makes the rules". It would be naive to think that an increasing role for government will not result in increased control by government. So we should pay attention and try to get it right. Start with, because it is close at hand, the flap over keeping your policy if you are happy with it. Or maybe you can't. Or, as of today, maybe you can. Maybe it depends on the state you live in. Or on some congressional alternative. Or on Obama's mood. Or something. Well, this won't affect me directly . Or I think that it won't. But now that I am reaching an age where doctors play a larger role in my life, I find myself making difficult medical choices. It is very important to me that I can continue to exercise choice not only in the treatment that is provided but in who provides it, where it is provided, when it is provided, and so on. I am hoping that this will not be undermined by the gov's increasing role. As far as I can see, at least in the short run, my freedom of choice will not be affected by the ACA. But it is an issue I try to pay attention to, and the rather massive incompetence of the roll-out of the ACA makes me very uneasy. I have come to associate incompetence with inflexibility. If you can jam someone into a corner and tell them to stay there, they might not notice how badly you are running the show.


Reagan has often been mentioned on this thread.
Reagan did not win elections by courting the Ayn Rand vote, he went out and got a lot of Democratic votes.He did this by understanding the concerns of blue collar working adults rather than by telling them what their concerns should be. Both Republicans and Democrats could learn from this. No one read Ay Rand where I grew up (I tried once but I was the neighborhood weirdo and anyway I quickly dumped the idea). They didn't read Adam Smith either. My mother subscribed to The Ladies Home Journal, my father to Popular Mechanics, I read Tarzan. It's true that I read Edmund Burke, Jean-Paul Sartre, Jeremy Bentham and many others when I was in college (please, no quiz on what I recall), but I didn't let it affect my vote. I voted for JFK like any good Dem. I never gave ten seconds of thought to serving in the Peace Corps though. And I voted for Carter in 1980 and Mondale in 1984. I might not have dome the latter if I thought he had a snowball's chance of winning.

Anyway, I think there is an opportunity here for someone to step forward and get this right.

[Cthulhu D]

 kenberg, on 2013-November-15, 07:33, said:

Free choice is an issue. In medical treatment it's a big issue ( most of us are non-naked patients) . This sometimes plays out in discussions as free market. I don't regard them as the same at all, but as government assumes a larger role in medical care, it is definitely an issue of concern. When I was young the Golden Rule was explained to me as "He who has the gold makes the rules".

[...]
Anyway, I think there is an opportunity here for someone to step forward and get this right.

Is it? Why is choice important? Surely what we're shooting for in a healthcare system is these three things

1) Health outcomes (the most important bit)
2) Patient satisfaction
3) Lowest cost (Cost can be considered in public/government and private/individual costs)

And when designing a system you want to have some sort of balance between the three. Now that we've all accepted that government intervention is required to correct a market failure, then the only question is what is the best model for that intervention. The question has been answered and someone has stepped up. Depending on how much you want to pay, and if you want to outsource operation of the actual delivery of healthcare, the four archtypical models are of:

A) France (Expensive/Best, though still 2/3rds the cost of the what the US pays). Government provides a (high) base level of service to everyone, you may purchase supplemental insurance via your employer.
B) Canada (Outsourced operation, somewhat expensive than the UK for the same quality of service). Government provides a base level of service, additional care may be purchased outside of the state system. System is operated by private providers.
C) The UK (Cheapest, same quality of care as the other options, lower patient satisfaction than France). Government provides a base level of service, additional care may be purchased outside of the state system. System is operated by public providers.
D) The US, with a free market purchasing model, outsourced provision and multiple payers. It's very expensive - over 3 times as expensive per capita than the UK system, delivers the lowest patient satisfaction and doesn't exceed the UK on healthcare outcomes.

Finland, best overall model, may not scale as the population is smaller, so I've gone with larger arch-typical examples.

Clearly, the US has the worst system currently. You're paying a huge amount more in private costs, and almost the same in public costs (OK a bit lower, but it's like $100 dollars per person per year, ask everyone in the US if they'd pay $100 dollar a year to go on medicare from birth!) and not getting scoring higher in any of our assessment categories (outcomes and satisfaction) over the UK, so we can safely discard the free market approach upfront - it just doesn't work. The UK literally delivers Medicare type coverage to it's entire population with pretty much what the US spends on over 65s and medicaid recipients due to the economies of scale and positive externalities of preventative and primary care that can be captured by the single provider. The US is paying all this extra cash to deliver the same outcomes and worst patient satisfaction. It truly is a joke - the direct cost savings from getting it to the NHS are something in excess of $650 billion that could be redirected to productive investments, thus spurring the US economy. Other 'free market' models like Australia have the same problems, but we have more of a single payer system so costs are controlled more - but we still pay more for no better patient satisfaction or healthcare outcomes, so it is a bum deal.

Once we've ditched the free market model as non functional, we can hone in on how exactly the government should control healthcare - should it run public institutions, or should it outsource it? Outsourced care is more expensive, because it appears their are minimal competitive advantages to be gained, the publicly owned/operated models (UK, Finnland, etc) are cheaper than the privately owned models (canada, Australia) on a per capita basis. It doesn't seem to drive increased patient satisfaction either, so we're spending more money but not scoring better on our outcomes.

OK so far we can see that we want a publically operated single pay model - this is the most efficent. The next question is, what's the tradeoff between patient satisfaction and price? Well, it appears from the French vs UK experience (and for example, the Estonians excellent but centralised system vs anyone else) that what drives patient satisfaction is decentralised service delivery and integrated ancillary services that don't have demonstrable clinical benefits, for example the french offer stuff like accupuncture and massage services. However, these things all cost dollars - the concentration of service delivery enables improved economies of scale, but there is a clear tradeoff - the more you provide localised services, the more $$$$ you are on the hook for.

So at the end of the day, you're going with a single payer, publically operated system, and you can then select where you sit on the 'cost' slider by adjusting the 'centralisation' slider. If you want the 'assurance' of the private sector running things, you can click that box and add 20% to the cost to manage their profit margins and the increased cost of capital for private institutions vs the government.

It's a solved problem really, the problem is you guys keep wanting to expand the free marketness, when that has been shown time and time again to increase healthcare costs for zero benefits. Single payer is what works, I honestly do not understand why it's even slightly controversial.

[kenberg]

The above is a fine illustration of what I was saying about how Reagan won Democratic votes. I say that choice is imprtant to me. The reply is that it shouldn't be. Well, it is.

[Cthulhu D]

 kenberg, on 2013-November-15, 08:35, said:

The above is a fine illustration of what I was saying about how Reagan won Democratic votes. I say that choice is imprtant to me. The reply is that it shouldn't be. Well, it is.

So you're literally okay with setting $650 billion dollars a year on fire to create the freedom to choose from a range of inferior products? I'll make an analogy

You are hungry. You can either have a good quality apple that I select for 10 cents, or pay $10 and pick your own apple from a range of poor quality apples. How can the utility of the choice possibly outweigh the utility of the cost saving, especially given that you get a worse apple regardless of the freedom to choose!

Really if choice mattered, why is the US (which has the most choice) so dissastified with its own health system? I'll give you a hint, its because real people as opposed to randian superheros find the 'here's our best treatment and the government is gonna cover the tab for you' message way more comforting than 'you can select from a range of medical professionals and treatment options that may or may not be covered by insurance, and you can only find out after treatment. Also we wan that copay in advance'

This post has been edited by Cthulhu D: 2013-November-15, 09:16

[Winstonm]

 mike777, on 2013-November-15, 06:14, said:

Yes you are right.

posters under 35 are going to pay for those of us old or sick or poor.


btw I do know docs that give up and don't treat patients......I meet many


I think people seem to think they don't exist. They have many other options to make money or stay at home make babies.

Most women over 35 don't want to pay for old guys despite bridge forums

If you truly believe a "Welfare Queen" class of women exists, I feel sorry for you. You are trapped inside an ideological bubble - I was, too, for many years - so I know how difficult it is to change that basic structure.

[kenberg]

Quote

Really if choice mattered, why is the US (which has the most choice) so dissastified with its own health system?

At a personal level (I mentioned this earlier) I am fine with the current system. My support for the ACA is based on a belief, well founded or not, that it will improve matters for a large number of people who are now in difficult circumstances. I am hoping the good effects of the ACA do not come at the expense of what I like about the current system.

Generally I am cautious about saying what is best for others. I figure that they are better placed than I am to say what they need or want. But of course politics involves choices that affect other people and so I try my best on this. I am not at all cautious about saying what is important to me. I could, I suppose, write out some of my reasons. Quite possibly you would find them inadequate. This would not change my mind as to their importance to me.

I don't regard myself as stubborn and I don't think others do. I listen, I can negotiate and I can cooperate. But I have never seen any reason why someone else should choose what is important to me.

Many years back I was in a political discussion with a far more liberal friend. I was expressing reservations about a proposal for something where I lacked any personal experience. My friend told me I was going at this wrong: "A true liberal knows how society should be run on Mars". He was, of course, joking. I think.

Anyway, I like to be able to choose, and this outranks cost in my personal priority schedule. I do recognize that at the national level, as opposed to my own personal level, cost is important. And no doubt it could become very important to me at a personal level if my personal costs rose greatly. I hope a way can be found to accommodate the cost problem at the national level while doing minimal, or no, damage to my sense of what is important for me.

My guess is that I am far from unique with my attitude here, and I do think this presents an opportunity for advancement for those seeking to represent us.

[Winstonm]

 kenberg, on 2013-November-15, 08:35, said:

The above is a fine illustration of what I was saying about how Reagan won Democratic votes. I say that choice is imprtant to me. The reply is that it shouldn't be. Well, it is.

To a large extent, elections are about framing and selling ideas. The more simplistic the idea, the easier it is to frame and present. In single-payer healthcare, what needs to be framed and presented well is the idea that quality healthcare should be available to everyone, that it is not about personal choice but about a country working together to take care of each other.

Framing is what Bill Clinton was so adept at doing: and framing in such a way as to make opposition sound cruel, evil, and heartless, for example, that you were either for feeding children of were in favor of letting children starve.

[Zelandakh]

 Cthulhu D, on 2013-November-15, 08:12, said:

Other 'free market' models like Australia have the same problems, but we have more of a single payer system so costs are controlled more - but we still pay more for no better patient satisfaction or healthcare outcomes, so it is a bum deal.

Can you explain this point a little more. The last numbers I saw had the Australian system paying roughly the same as the UK (~8.5% of GDP) and life expectancies there are amongst the lowest in the world so I guess the system cannot be that bad. Are there some caveats hidden amongst the statistics to make the UK model so much better? The costs in Japan are even lower and the life expectancy even higher so I am surprised noone has brought their healthcare system into focus (not that I know how it works there). Of course, Japan has a somewhat different diet which might contribute something beyond the simple numbers.

[kenberg]

 Winstonm, on 2013-November-15, 09:41, said:

To a large extent, elections are about framing and selling ideas. The more simplistic the idea, the easier it is to frame and present. In single-payer healthcare, what needs to be framed and presented well is the idea that quality healthcare should be available to everyone, that it is not about personal choice but about a country working together to take care of each other.

It may not fly well if framed this way. Do a thought experiment. Suppose that Americans were polled:
Is it more important to you that we preserve personal choice or that we all work together to take care of each other?
I bet that personal choice would win in a landslide.

I am hoping that personal choice can be preserved while we also make progress in taking care of those in bad circumstances. It is not easy to do, but if it costs me some cash to do it I am up for giving it a shot. If it costs me by sharply reducing my personal choice, I am not.

I could hope, perhaps naively, that Obama had figured how to do what has to be done for others in a way that would cost me only in the pocketbook. It's beginning to look less and less like he has thought it all through very accurately.