[Winstonm]

kenberg, on 2013-November-15, 12:33, said:

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.

Hi, Ken,

Having read most of your posts on different WC subjects, I seem to remember in your history that your own personal choices of doctors have not always worked out for the best and you have had to change doctors on occasion. What I hear you say with "personal choice" is that you want to retain the ability to change providers. I'm not so certain that isn't possible in NHS systems, but I haven't lived under that type of care. I am fairly certain that in an NHS you are not required to use only a specific doctor.

[Trinidad]

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

Free choice is an issue.

Ken, what do you want to chose? And what makes you think that this choice is gone in a government based system?

Family physician?
Seems like a good idea to be able to chose your "every day doctor". Of course, this is possible in a government run system.

Your ER?
Usually this is guided by whatever hospital you can get to fastest. You are free to chose the first ER in a government run system.

Specialist treatments?
You will usually chose the specialist together with your family physician. Most patients wouldn't know who would be the best oncologist in the neighborhood anyway, but if you have a preference, that won't be a problem. And -more importantly- the government will take this out of your hands: All oncologists will be excellent.

Very specialist treatments?
Your local specialist will tell you what hospital is specialized in that "reverse gamma introtherapy" that could be suited for you. So, if you have a rare condition, they will refer you to Prof. Smith in that hospital many miles away.

All these choices are readily available in the government run health care systems that I have had the pleasure of going through (a lot in Sweden and a little bit in Finland).

Only in the USA I have lived in a situation where I had no freedom at all to chose my doctor or my hospital, because my health insurance would cover only one health center and one hospital, because they had contracts with them and not with any others.

In a government run system, the government "has contracts" with every hospital. Do you think that the government cares whether you go to hospital A that they pay for or hospital Z that they pay for? They really don't care whether you go to Dr. O'Malley at St. Mary's or to Dr. Jones at General. Only free market insurance companies care about such things.

Rik

[kenberg]

Winston, yes, after I moved a few years ago I found it challenging to get to the right doctors.

Rik, you have the idea of what I am talking about.

An example. Warning to the queasy, I am about to discuss medical issues. We moved maybe seven years ago, I got a new doc. I also git a new urologist to keep tabs on my aging prostate, although it's just aging, not seriously screwed up. I was not liking either of these new guys much. I had some pain, I went in to the doc. His wife, the nurse, thought it might be a kidney stone. The doc said no, not a kidney stone, I had Devil's Claw, a problem with no treatment. A month or so later i was in the hospital with a serious kidney stone issue that had to be handled by going inside, the details of which I don't want to recite and you don't want to hear. The doc at the hospital said he would send the results to my urologist, I asked if he would be my urologist, he said yes. That was that for the urologist. It took me a little more time to find myself a new gp but I now have one that I am very happy with. In both cases the transaction amounted to "Will you take me on as a patient? "Yes". Actually, for the gp it was slightly more complex, it is a group practice and I started with someone else who left, but that's a detail.

Another example. It seems maybe self-indulgent to talk about all of this but I see no other way to really get my views across. In July a year ago I had, I guess, a mini-stroke. The "I guess" is because it does not, at least if you are lucky, leave much of trace. But we set out to find out what is going on. Initially I took referrals from my gp, but then I started going beyond that. Well, it appears that I will live. But there are some things to keep track of. About two weeks ago I had an MRI at Johns Hopkins. It's amazing technology. I was in the tube for a good half hour. The result was a motion picture MRI where you can watch the blood flowing around in the brain. Properly flowing around, I am happy to say. It takes a little leg work and perhaps some persistence to get this sort of care, but I am delighted to have it.

I wish everyone could have the care I have, but there are only so many top level doctors and only so much technology available. Here is the problem: It would be nice if we could say "Ken needs this so he gets it" or "Ken doesn't need this so he doesn't get it" but the situation is that until we put Ken in the tube, we don't know if Ken needs it. If we wait until we are sure that Ken needs it, it's too late. Well, I would like to live, preferably not as a vegetable, so I want us to find out. Uncertainty is the rule, not the exception. There was this time when I went into the emergency room and said "I hope I am wasting your time". It turned out that I was wasting their time, but when I walked in I was not at all sure of that.


So now to Obamacare. I hope for the best for it. When Obama got it passed, I saw it as something mostly for other people. Despite assurances to the contrary, I figured it would cost me something in taxes or premiums or something, but that's ok if it works. I think the bottom line is that he had better make damn sure that it does work. "Trust me, it will work" is wearing thin.

[blackshoe]

Cthulhu D, on 2013-November-15, 05:50, said:

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.

Life is risk. It is impossible to eliminate all risk. So? Should we just give up and die in the maternity ward?

When "medical professionals" made the decisions, it was rarely necessary for government to step in with "hard legislative requirements", professional ethics handled the job just fine. Problem today is that it's not medical professionals making the decisions, it's some bean counter in an office somewhere far removed from the blood and gore.

[Cthulhu D]

Zelandakh, on 2013-November-15, 11:01, said:

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.

Japan benefits from extremely high population densities - as does Singapore for example. The more you can centralise things, the easier it is to cut costs. Singapore also screws poor people. Japanese people have very low rates of smoking and eat exceptionally healthy diets. By comparison, the US, UK, Australia and the Dutch are about as fat as each other. It's not a hugely helpful comparison so I don't go there.

With Australia, we pay roughly $300 dollars more per person per year (~10%) on a PPP basis. The numbers are slightly distorted because the most recent UK numbers are more up to date than the Australian numbers and healthcare costs go up in real terms year on year - more in Australia than the UK because the UK has better cost containment measures, so it's probably a bit more than that. When we look at what we get for those dollars, the UK also has better coverage than the Australian system (because dentistry is partly included in the NHS), and we score worse on every dimension (quality of care, patient satisfaction etc) according to the WHO except being 'patient centric', and having better population health outcomes, though those outcomes are probably nothing to do with the healthcare system.

Quote

When "medical professionals" made the decisions, it was rarely necessary for government to step in with "hard legislative requirements", professional ethics handled the job just fine. Problem today is that it's not medical professionals making the decisions, it's some bean counter in an office somewhere far removed from the blood and gore.

That's the US health insurance industry, yup. One of the biggest problems with it - you guys have more administrative costs (both in raw terms and as a proportion of spend!) due to proliferation of administrative overhead in the 'efficent' private sector. The UK public sector healthcare system has a much better ratio of tail (administrative staff) to teeth (carers) than the US! If that's what you want, a single payer 'no cost' to patient approach where the doctor doesn't have to consider your insurance or who is paying and can just jump in with both boots is probably the most effective.

Quote

Another example. It seems maybe self-indulgent to talk about all of this but I see no other way to really get my views across. In July a year ago I had, I guess, a mini-stroke. The "I guess" is because it does not, at least if you are lucky, leave much of trace. But we set out to find out what is going on. Initially I took referrals from my gp, but then I started going beyond that. Well, it appears that I will live. But there are some things to keep track of. About two weeks ago I had an MRI at Johns Hopkins. It's amazing technology. I was in the tube for a good half hour. The result was a motion picture MRI where you can watch the blood flowing around in the brain. Properly flowing around, I am happy to say. It takes a little leg work and perhaps some persistence to get this sort of care, but I am delighted to have it.

I appreciate this may come as a surprise, but in the socialist state of Australia I can do all those things you can too, including choosing my own GP and specialists (a right I have exercised!). Just it costs 50% less than what you get, and we rate higher on 'quality of care' than the US according to the WHO. Hope that gives some perspective.

[Trinidad]

kenberg, on 2013-November-15, 14:41, said:

Rik, you have the idea of what I am talking about.
[free choice issues]

These free choice issues are typical for a market approach. After all, you want to do the choosing and the insurer has to do the paying, whoever you choose. Since there are price differences, the bean counters will have a problem with your choosing.

In a government run system, the doctors are all employed by the same system. The system makes sure that their quality is good. There are no price differences, all the doctors are payed a government salary. Sure, the system has bean counters too, but they don't care what doctor you choose, because the price tags are the same.

It is really funny, but in a sense a government run system is more market like than a market approach: The price of the doctors and treatments is based on the exchange of information. Because "the system" has the necessary knowledge, the prices of treatments are kept under control.

In a market system, a doctor can ask whatever he wants. Unfortunately, the patients don't have access to the information needed to assess whether this doctor is worth this price. Ironically, they will be drawn to the doctor with the Porsche rather than the one with the Toyota, because the guy with the Porsche must be good.

I have a friend who used to work in the perfume industry. There, prices are not determined by manufacturing or development costs, or supply and demand, but by emotions. They are set in a market segment. The manufacturer would sell less if he would lower the price, since the price creates the image of quality. While the health care market is certainly not as extreme as the perfume market, it does have emotional components that strongly influence the price. (Imagine how much the costs for perfume would drop if there would be a government run perfume service. All perfumes would be a quarter per bottle.)

Rik

[kenberg]

From Rik

Quote

In a government run system, the doctors are all employed by the same system. The system makes sure that their quality is good.

This is pretty close to getting at my concerns. In ant profession the skill of the practitioners varies. At the local grocery store all lf the cashiers are "good", they would not keep their jobs if they were not. I still sometimes choose one line rather than another because of who is behind the counter.

To put it another way I see the phrase "The system makes sure that their quality is good" as asserting something that experience shows is never really true, not with doctors, not with anything. And I am not just speaking of the once in a lifetime exception. Not all cab drivers are good. Not all plumbers are good.

I think that it is not only well-known but also true (not the same thing at all) that the very wealthy often come to the States for treatment. A friend who had some issues similar to mine had to wait for his surgery while his doc operated on some oil prince. Earlier in this thread, mikeh, who probably is not an oil prince, spoke of plans to bring his wife here from Canada. It turned out he didn't need to, but plans were made. These arrivals do not just take pot luck on who does the treatment.

I also am not an oil prince, but I also think some docs are better than others and I want my say. It may be that, as in Lake Woebegone, all the doctors are above average. I want better.

I think my real answer to both you and to Cthu is that to the extent that the system you advocate gives free choice, I say great. This feature is very important to me. I believe that it is very important to many others, and I think it is precisely this issue, rather than some devotion to Ayn Rand, that fuels some skepticism about the ACA. The ACA is very complex, if it were not complex, the website would be working. We take it a bit on faith (some have more faith then others) that individual choice will be preserved. I think a good part of what's driving the flap over "If you like your insurance you can keep it" is that this faith is fading. The proverbial Christian Scientist with appendicitis comes to mind.

In the last fifteen months or so I have spent more time on medical issues than in my entire previous seventy-three years. Much more. Before this flurry of activity I had already dumped the idiots I was seeing after I first moved here, so that was not an issue.But still there were many decisions. Most problems were bureaucratic in nature, and Medicare was the most opaque. I have managed, but when the government wasn't involved it was easier.

It is my hope that we get this right, and I think that there is cause for concern.

[kenberg]

Fwiw, here is a "Howzit playing" incident. I was chatting with a guy in his thirties. He is in good health, he is not particularly interested in politics, he is single, he does not have health insurance. I asked him about the ACA. He plans to ignore it. His view is that he doesn't need health insurance right now. As for the fine, he figures that they are so screwed up it will be years before they ever figure out who is supposed to pay a fine and he will deal with it then. I was asking him because I was curious (or nosy, if you prefer) about how he saw this, and I did not offer advice. In fact, I can see his point of view but whether I agree or don't agree, it's his choice. I have no idea how widespread this approach is.

[Winstonm]

I feel to an extent that I am being offered a Hobson's choice. I have never been a huge supporter of President Obama because I have felt he is too inexperienced, too conciliatory, and too conservative on some issues. At the same time, any failure of his on policy issues gives ammunition to the whackos running the show on the right side of the isle, so I am compelled to support Obama's agenda when I do not particularly like it.

In different times, or if he had the political muscle of LBJ, Obama could have been a terrific President. I am afraid at this point that his showing is so middle-of-the-road blah that he would be hurting the Democratic Party in normal times, and the only reason he is not is because of the Hobson's choice created by the out-of-control wingnuts on the other side of the aisle.

The ACA is such an agenda item. I never liked it because it did not go far enough, and, IMO, does not really go to the problem that needs solved: rising costs. The ACA solution to rising costs is to add a larger group of healthier people to the insurance pool - and that idea should either: a, lower costs for insurance or b, increase insurance companies' profits - but what it does not help is the administrative cost of services, which is the biggest flaw of market-based healthcare. Adding the young and healthy to the insurance pool helps with insurance and, by spreading the risk among a larger, healthier number, should lower insurance premiums over time.

That action does not do anything to improve the quality of physicians, quality of care, costs of care among different hospitals and physicians, etc., etc.

To me, it is sad that we cannot seem to get past the cowboy mentality and start acting like a nation of adults.

[y66]

kenberg, on 2013-November-16, 07:25, said:

Fwiw, here is a "Howzit playing" incident. I was chatting with a guy in his thirties. He is in good health, he is not particularly interested in politics, he is single, he does not have health insurance. I asked him about the ACA. He plans to ignore it. His view is that he doesn't need health insurance right now. As for the fine, he figures that they are so screwed up it will be years before they ever figure out who is supposed to pay a fine and he will deal with it then. I was asking him because I was curious (or nosy, if you prefer) about how he saw this, and I did not offer advice. In fact, I can see his point of view but whether I agree or don't agree, it's his choice. I have no idea how widespread this approach is.

It seems reasonable to bet the system won’t catch up with him anytime soon. Depending on insurance costs and psychic returns from risk seeking behavior, maybe it's rational to self insure against potential catastrophic loss. I'm guessing his decision model assumes he's the only one who will bear the costs of his risk taking and that he has never survived a game of road chicken.

[Trinidad]

kenberg, on 2013-November-16, 06:41, said:

From Rik

Trinidad, on 2013-November-16, 01:04, said:

In a government run system, the doctors are all employed by the same system. The system makes sure that their quality is good.

This is pretty close to getting at my concerns. In ant profession the skill of the practitioners varies.

That is true, but regulation can cut off the lower part of the distribution. This increases the average and decreases the variation.

And the regulator specifically targets quality in the form of meeting the patient's needs (rather than quality in the form of profit generating capability).

BTW, I think (or better: I know) that it would be an illusion to think that the USA would switch to a government run health care system in the near future. In this thread we have two discussions. One is about Obamacare. The other about whether a government run health care system is better (and for some whether it would even be possible). I have some ideas about Obamacare, but since I don't live in the USA right now (and I am not American either) I can't claim that I know any details.

However, I do have experience with living with government run health care and market-insurance run health care. In my experience, government run health care is clearly better: it is more efficient, reducing the costs, as well as the patient's worries and paperwork.

But government run universal health care is not fit or every country. It requires that society basically has the same view on health care. You can only do something together if people basically agree on what should be done together. Given that, I think it is impossible to implement something remotely close to government run universal health care in the USA.

Rik

[blackshoe]

Some comments:

On administrative costs: an example. When I graduated from high school (1965) the paperwork required to obtain a construction permit for a nuclear power plant stacked to about my height. By the time I got my M.S. in nuclear engineering ten years later, the paperwork filled a 10 by 10 by 10 room. And the cost of building such a plant increased about tenfold. All of this increase was due to government mandates.

On the political spectrum: it is not one dimensional. It's at least three dimensional, and probably more. In some ways it has as many dimensions as there are voters. Jerry Pournelle wrote his doctoral thesis in political science on this in 1964.

On "wingnuts": Right side, left side or other, there are "wingnuts" everywhere. People should stop trying to imply that their "side" doesn't have any.

[Winstonm]

Unfortunately, wingnut is descriptive only of the far, far right wing in the U.S.

"Wingnut" refers to the person completely closed to any viewpoints other than ideologically based beliefs. The progressive mindset is such that it is impossible for this definition to apply - the very definition of progressive is a willingness and openness to changing opinion and beliefs as new facts and ideas are presented.

[blackshoe]

Uh, huh. Right. Sure.

[kenberg]

Trinidad, on 2013-November-16, 11:47, said:

But government run universal health care is not fit or every country. It requires that society basically has the same view on health care. You can only do something together if people basically agree on what should be done together. Given that, I think it is impossible to implement something remotely close to government run universal health care in the USA.

We do seem to be having a bit of a problem these days with the e pluribus unum concept.

[Winstonm]

I think this link is pertinent to this discussion as to me the health providers should be asked what system would be best. If the healthcare professionals are in favor of single payer, then what groups are opposed and for what reasons?

Quote

Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs. Patients would no longer face financial barriers to care such as co-pays and deductibles, and would regain free choice of doctor and hospital. Doctors would regain autonomy over patient care

[ArtK78]

blackshoe, on 2013-November-16, 17:10, said:

Uh, huh. Right. Sure.

Nice comeback.

[FM75]

At this point.. the "Whatever happened to journalism" part of this topic seems to be either a) historical artifact, or b) never relevant.

Thread drift alert!!

We have beat the freedom of the individual to choose versus the right of government to choose to death. A few Europeans and Euro wannabes have chimed in how much better their system is.

So here is the chance to show how savvy you really are. (Challenge.)

Predict the endgame. Obama (semi-)caved on his promise that you could keep your insurance. Now (if the states and insurance companies play nice with him), you can keep you insurance (for only one more year).

Prediction is hard, especially about the future. So there is a good chance your predictions will be wrong. But make them anyway.

1) What percentage of the people (like my self-employed friend, and others who got policy cancellations because their policy was not PPACA compliant), will be allowed to retain the health insurance policy that they chose and paid for?
2) If they are allowed, will that same policy be available in 2015, 2016, ...? (Note. Obama and co did not promise they could keep it for only one year...)
3) With the president having a majority approval rating in only one demographic - blacks, be able to control his party in either house of congress for the rest of his term?
4) How many states agree to let the insurance companies provide policies that are not compliant with federal law - based on Obama's plea?
5) Where (if) states do, will the insurance companies allow their customers to continue their policies?
6) With Congress's ratings at a very significant, if not all time low, how many incumbents will lose seats when they are next up for re-election?
7) If he continues to blame Republicans (not the Tea Party) for the problems, how many Democrats will distance themselves from him? Which ones?
8) How many people will enroll in Obamacare via the Federal websites by 3-1-2014? How many will enroll by the same date on Federal and states web-sites?
9) How many people will be charged by the IRS to pay a "TAX' for not enrolling for the 2014 tax year?
10) 2015?

Ten questions. All requiring an answer of yes or no, a count, or a percentage. (Exception - the follow-on question in 7.)

Good luck. Prediction is hard....Give it your best shot.

[kenberg]

You forgot to ask "Which starlet that I have never before heard of will become famous for doing something stupid?". Your list is long but let me take a couple of my own choosing.
(I'll go a. and b. to distinguish from your numbering)

a. I predict that the Obama fix of the canceled policy problem will need a fix, perhaps a major fix.
b. I predict that all fines will be waived through 2014 for not signing up for the ACA.

My thinking for a. comes from putting myself in the place of the state person who has to authorize the change. It is not clear that it is legally sound. I, in my hypotehtitcal role as state regulator, would not be willing to authorize this on the basis of Obama's assurances. My job is (as regulator) to see that the laws are followed and if this all crashes, I don't want to sound like a ten year old "Barry told me to throw the rock". I would want my own legal advice, it will take time, and results may vary. Of course a state regulator, when he seeks legal advice, can stack the deck either way to get the advice he wants. That's true of the president also. But I am hopiong, or guessing, that a fair number of regulators take their jobs seriously. They will not want to approve this until they are confident it will stand up.

As to b., I mentioned above a guy I talked to that plans to just ignore the ACA. (This gets at some of your other questions as well.) I doubt that he can do this for all that long, but for next year I think the defense will be "You want to fine me for not using a website tthat isn't working? I don't think so." I was listening to an interview with a supporter of the ACA. He was asked "Given what we have heard about problems with security, would you put your own personal data up there?" He replied that he would first want to check into what progress had been made in security. I think the answer of the man in the street will be a more simple "No". I know more than a few people (mistly but not all in my age group) who are not much comfortable putting anything on the web, even if they knew how. They will not be putting stuff up on a hard to use possibly insecure website. This had to be rolled out with competence if the desire was to have everyman use it with confidence.Or even just use it.

[c_corgi]

FM75, on 2013-November-17, 00:40, said:

...
3) With the president having a majority approval rating in only one demographic - blacks, be able to control his party in either house of congress for the rest of his term?
...

Perhaps this question should be rephrased: at the moment it seems to imply that the ethnicity of a president's support can compromise the validity of his mandate.

I have no idea what would be plausible answers to your questions, but they seem to be more to do with the condition of the US than with healthcare provision. The answers would likely point to the conclusion "If I were to implement an efficient and fit-for-purpose healthcare system, I wouldn't wish to start from where the US is now". But Obama doesn't have much choice where to start from.