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September 17, 2008

Health Care "Crisis": Is It Largely Fictitious?

Robert Samuelson has an interesting piece in Newsweek on health care costs:

Unless you've been living in the Himalayas, you know that huge numbers of Americans—46 million last year, or almost one in seven of us—lack health insurance. By impressive majorities, Americans regard this as a moral stain. At the Democratic National Convention, Sen. Ted Kennedy echoed the view of many that health care is a "right" that demands universal insurance. This is a completely understandable view and one that is, I think, utterly wrong. Take note, Barack Obama and John McCain.

Whoever wins should put health care at the top of his agenda. But the central problem is not improving coverage. It's controlling costs. In 1960, health care accounted for $1 of every $20 spent in the U.S. economy; now that's $1 of every $6, and the Congressional Budget Office projects that it could be $1 of every $4 by 2025. Ponder that: a quarter of the U.S. economy devoted to health care. Would we be better off? Probably not. Countless studies have shown that many diagnostic tests, surgeries and medical devices are either ineffective or unneeded. "More expensive care," notes CBO director Peter Orszag, "does not always mean better care."

Greater health spending should not have the first moral claim on our wealth, because its relentless expansion is slowly crowding out other national needs. For government, higher health costs threaten other programs—schools, roads, defense, scientific research—and put upward pressure on taxes. For workers, increasingly expensive insurance depresses take-home pay, as employers funnel more compensation dollars into coverage. There's also a massive and undesirable income transfer from the young to the old, accomplished through taxes and the cross-subsidies of private insurance, because the old are the biggest users of medical care.

Equality-in-Care-with-text.jpgIt is widely assumed that health care, like most aspects of American life, shamefully shortchanges the poor. This is less true than it seems. Glance at the adjacent table. It comes from economist Gary Burtless of the Brookings Institution and is based on a government survey of health spending. Burtless was understandably astonished when he assembled these data: they show that, on average, annual health spending per person—from all private and government sources—is equal for the poorest and the richest Americans. In 2003, it was $4,477 for the poorest fifth and $4,451 for the richest.

Probably in no other area, notes Burtless, is spending so equal—not in housing, clothes, transportation or anything. Why is this? One reason: government already insures more than a quarter of the population, including many of the poor. Medicare covers the elderly; Medicaid, many of the poor and their children; SCHIP (State Children's Health Insurance Program), more children. Another reason, I suspect, stems from the skewing of health spending toward the very sick and dying; 10 percent of patients account for two thirds of spending. People in this unfortunate group, regardless of income, get thrust onto a conveyor belt of costly care: long hospital stays, many tests, therapies and surgeries.

That includes the uninsured. In 2008, their care will cost about $86 billion, estimates a study for the Kaiser Family Foundation. The uninsured pay about $30 billion themselves; the rest is uncompensated. Of course, no sane person wants to be without health insurance, and the uninsured receive less care and, by some studies, suffer abnormally high death rates. But other studies suggest only minor disadvantages for the uninsured. One study compared the insured and uninsured after the onset of a chronic illness—say, heart disease or diabetes. Outcomes differed little. Here are the results. After about six months, 20.4 percent of the insured and 20.9 percent of the uninsured judged themselves "better"; 32.2 percent of the insured and 35.2 percent of the uninsured rated themselves "worse." The rest saw no change.

These results are not only counterintuitive, but undermine the "we need nationalized health care now" mantra.

Military personnel live with socialized medicine. The Walter Reed scandal is an object lesson in what happens when government takes over medical care, and it's not pretty. By and large, the military actually does a fairly good job of providing urgent health care to military personnel and their dependents, but this is largely due to the dedication of the people working the system.

The system itself is massive, slow, and riddled with wasteful redundancy and inefficiencies. Its various parts cannot communicate effectively with each other and patients must often wait for routine medical care that private patients can obtain immediately.

I couldn't wait until my civilian employer provided me with my own health care: I left the military medical system and never looked back. Now I get immediate access to affordable health care without frustrating delays and the byzantine bureaucracy that plagues the military medical system. I can get the prescriptions I need without having to have my doctor's recommendations reviewed by a screening board.

I am never told the pharmacy won't carry my medication for another two years, only to find out they've had it in stock all the time.

What political demagoguery so often masks is a fundamental misunderstanding of how subsidizing people's lifestyle choices blurs the critical connection between cause and effect, dangerously encouraging destructive and irresponsible behavior that both harms the individual in question and impacts society at large:

The trouble with casting medical-care as a "right" is that this ignores how open-ended the "right" should be and how fulfilling it might compromise other "rights" and needs. What makes people healthy or unhealthy are personal habits, good or bad (diet, exercise, alcohol and drug use); genetic makeup, lucky or unlucky, and age. Health care, no matter how lavishly provided, can only partially compensate for these individual differences.

There is a basic moral and political dilemma that most Americans refuse to acknowledge. What we all want for ourselves and our families—access to unlimited care paid for by someone else—may be ruinous for us as a society. Sensible limits must somehow be imposed. The crying need now is not to insure all the uninsured. This would be expensive (an additional $123 billion a year, estimates the Kaiser study) and would provide modest health gains at best. Two fifths of the uninsured are young (19 to 34) and relatively healthy. The compelling need now is to limit the runaway increases in spending that make private and government insurance more expensive and may not deliver significant health improvements.

After nearly 50 years of a War on Poverty that has not only failed to defeat poverty but has arguably decimated the black family, perhaps we should examine the unintended consequences of yet another massive entitlement program and look, before we leap.

Posted by Cassandra at September 17, 2008 07:47 AM

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'health care is a "right"' ... Yes, I've heard this numerous times from the folks who advocate "free" government socialized heath care. When I ask them why they would want their medical experience to be run with the same charm as the department of motor vehicles and the bureaucracy of the VA medical system (prove you're sick) they usually reply because everyone needs health care ... well everyone needs food, should the government seize the farms and processing plants and dictate what and how much you get eat so that everyone gets their fair share ... everyone needs a place to live, should the government seize all the property in the country and dictate where you can live, how many rooms etc.

Posted by: Frodo at September 17, 2008 01:08 PM

"Right" is a very specific word to me. You have a "right" to life, liberty, property UNTIL your exercise of those rights infringes upon another without their consent. In other words, I can swing my fist, but my right to do so stops at your nose.

The problem with a "right" to healthcare is that it infringes upon others BY DEFINITION. You are taking away time from that doctor and hospital staff, without recompense. You are taking away the money (property) of taxpayers to pay for the services of the hospital. You cannot have a "right" to someone else's life or property. That's fundamental to the whole concept of rights.

Posted by: MikeD at September 17, 2008 01:25 PM

There's also a massive and undesirable income transfer from the young to the old, accomplished through taxes and the cross-subsidies of private insurance, because the old are the biggest users of medical care.

I hate this argument because it looks at health care as a snapshot. What if you look at it longitudinally? With the exception of about 12 months when I was 21, I've had health insurance literally my whole life: first from my parents, then through college, then through work, now as an individual. If I receive medical care now and my insurance company pays, am I being subsidized by the insurance premiums of more-healthy people or am I being paid out of the money I've invested in health care over lo, these many years?

Another reason, I suspect, stems from the skewing of health spending toward the very sick and dying; 10 percent of patients account for two thirds of spending. People in this unfortunate group, regardless of income, get thrust onto a conveyor belt of costly care: long hospital stays, many tests, therapies and surgeries.

So what is the answer? To let them die? And, if so, who decides that? Samuelson seems to be sort of mixing up private insurance with public policy: if private insurers want to cover everything for even dying people that increases the societal cost of health care just as much as if government did it. So should the government be telling private health insurers to just let some people die? Or, if not that, should the government continue to shield some health insurance companies (like HMOs) from lawsuits designed to force them to cover uncertain treatments?

It sounds perfectly reasonable to say limit costs by getting rid of unnecessary tests and dubious treatments but who decides what tests are unnecessary and what treatments are dubious? The government? Private insurers? Some combination of the two?

We're getting into treacherous waters as soon as we start talking about making "reasonable" cuts in pointless health care spending. You can take a look at two Junkfood Science posts (here and here) to see where this can go. She is talking about government-run agencies but if we're going to talk society-wide spending on health care then we're going to have to look at limiting care even when provided by private insurers.

I don't know what the solution is but I think Samuelson - who I respect very much - is being overly facile in this article. Or perhaps it's that while his data is extremely useful in framing the debate he seems cavalier about the magnitude of the "moral" dimension.

Furthermore, I think his analysis that the uninsured may ultimately not do any worse than the insured in terms of health outcomes ignores two factors. First, the extent to which lacking health insurance may mean low-level ailments that affect quality of life rather than life itself do not get addressed. Second, the level of anxiety among the uninsured. It may be that in life-threatening situations they can get care but knowing that a bad case of the flu can be an economic nightmare does not do much for one's peace of mind.

I've thought about this and tried to write about this and in the end I suspect the problem of health care may be intractable.

Posted by: Elise at September 17, 2008 01:26 PM

I still think there are lots of uninsured families. For one thing, unless you're working for a company that provides those benefits, you cannot afford health insurance. Premiums will run about $15,000 a year. (Ask anyone going to college, or in grad school.)

The other side of the coin is, if you thing health care is expensive now, just wait till it's free.

And when it's free - as JunkFoodScience hints at - it will be rationed. Just look at Canada and Britain.

Posted by: ZZMike at September 17, 2008 03:14 PM

The entire health care system is so massive that I get tired just thinking about trying to comprehend it, so I don't really even know how to decide what a good system would be.

I do know I get annoyed with the people who say we need "affordable" health care. How do we decide what "affordable" is? Because it seems to me, if you're employed and it's partially employer subsidized, it would be hard to claim it's not affordable.

Many individual plans seem affordable to me. I often wonder, if you can't afford $50 a month for health care, is it that you can't afford it, or don't want to put your money there?

I'm not being flip about that, $50 bucks a month is hard for me to come up with, too, but I would consider it a good investment in catostrophic care.

Who gets to put a dollar amount on what is affordable?

Posted by: April at September 17, 2008 03:15 PM

Well, we didn't have health insurance for the first 2 or 3 years we were married - not until my husband graduated from college and joined the Marine Corps.

I couldn't afford it on my salary even when I went to work. It was just too expensive. But we were young and healthy and assumed the risk. Also we found a pediatrician who did not charge us very much for office visits, knowing that we had no insurance.

We paid cash for the delivery of our first child. And I mean cash - as in we paid by check -- up front.

Posted by: Cass at September 17, 2008 04:32 PM

I don't know, Elise.

When my boys were growing up, we went to the doctor approximately 25% as much as everyone else we knew. Their medical jackets at the dispensary were so thin the doctors kept asking me if part had gotten lost. It hadn't. They just didn't go to the doctor all that often.

My kids still got sick.

It is just that I didn't rush off to the doctor every time they got the sniffles. Guess what? They got just fine on good old Tincture of Time. And in fact my kids never got complications of colds, something I have always attributed to the fact that they were almost never put on antibiotics.

I usually resorted first to home remedies like a hot compress or decongestants or steam for mild earaches and head colds, and they went away. If I saw some alarming symptom that they weren't healing, THEN they went to the doctor. But just for a mild earache? No way.

My kids both inherited my husband's genes as well as mine. All the kids in his family had short eustacian tubes and frequent ear infections. I tried to treat this proactively by making sure they got plenty of sleep and the air in their rooms was kept fairly moist in the winter. That really made a huge difference - every time I forgot to do it, they got sick.

When I started getting migraines, they peered into my left eyeball and decided I had a brain tumor. I had an MRI. That was an egregious waste of taxpayer money.

We do a lot of things just because we can, and the more they are subsidized, the more the "can" factor increases and wants become needs.

Posted by: Cass at September 17, 2008 04:42 PM

I'll tell you another driving factor behind the cost of medicine: malpractice insurance. These poor doctors order so many tests because idiot patients sue the daylights out of them for no real reason. They have to test for everything under the sun just to preclude the possibility of a lawsuit b/c they didn't rule out some rare condition. So sometimes common sense flies out the window.

Posted by: Cass at September 17, 2008 04:46 PM

That was a bit strong.

Sorry. I'm feeling crabby today.

Posted by: Cass at September 17, 2008 04:47 PM

You have a right to as much health care as you can afford.

You have a right, if you wish, to join with other like-minded people in a cost-sharing agreement to avoid crushing expense to any given inidividual(s): it's called insurance.

You may have the ability to arrange for the government to force other people into such cost-sharing agreements, but that is not a right. It is an immorality, for it amounts to theft.

Everyone has talked for many years about the ultimate demise of retirement on someone else's dime; this is much larger, much worse.

Posted by: socialism_is_error at September 17, 2008 04:49 PM

My first two children were paid for with cash also. The first cost $1800 and the second was $2500. (circa 1975)

The third, 6 years later cost us $25, as we were insured by one of the first HMOs and my employer paid 100% of my premium. We didn't get bills, we didn't get EOBs or have anything to do with filing claims.

My first grandchild cost around $22,000, paid by 80% insurance coverage provided by an employer who charged the family $200/mo premiums.(2004) Their premiums, deductible, and copay for one year is much more than both my first children cost.

"Life" costs more at the beginning and end than in between.

Posted by: Donna B. at September 17, 2008 05:14 PM

"Premiums will run about $15,000 a year."
ZZMike, send me an email if you would like a quote on health coverage. My son-in-law sells insurance. You might be startled to discover how affordable good individual coverage can be.

Posted by: bthun at September 17, 2008 05:42 PM

Cassandra, I do agree that malpractice insurance/lawsuits may be driving up the cost of health care. Certainly, anecdotal evidence indicates that although I haven't seen (or, admittedly, looked for) a study on it. I would be amenable to a proposal to cap damages for malpractice. In return, I'd like absolute transparency from doctors, labs, hospitals, and other health care providers with regard to lawsuits filed, complaints made, and patient outcomes.

I'm sure there are people who run to the doctor too often but I'm not sure how many there are. Maybe it's different if you're panicky about kids but in general I don't think people like going to doctors and having tests. At least I don't so I find it hard to believe a lot of other people do. On the other hand, people like all kinds of strange things (like liver) so maybe...

When I started getting migraines, they peered into my left eyeball and decided I had a brain tumor. I had an MRI. That was an egregious waste of taxpayer money.

Yes because you didn't have a brain tumor. If the doctor was just covering himself, ordering the MRI was a bad call. But if he actually saw something, ordering the MRI was a good call. I participate in a health board for a very mild condition that shares symptoms with some more serious conditions. Every so often someone pops up with the information that they finally, finally convinced their doctor to do a test and - guess what - they don't have the mild condition, they have one of the serious ones.

I'd really like to see a study on some of the big HMOs over the years. They were formed with idea they would cut the fat from health care by eliminating unnecessary tests and procedures. They've been around long enough so they should have done that. What's been happening with their members' health care costs? Are they going up like everyone else's or has restricting access to needless medical care kept costs down? Then, in order to really test Samuelson's idea that "the runaway increases in spending ... make private and government insurance more expensive and may not deliver significant health improvements" we'd also have to compare HMO patient outcomes with the outcomes of patients in traditional health insurance plans. (Surely someone has done something like this.)

SIE said:

You have a right to as much health care as you can afford.

Are you willing to let people who cannot afford - or decide not to buy - any insurance die when they need medical treatment? What about their kids? I'm not being outrageous here. That's a big part of the argument for some type of mandatory health insurance: we as a society will not let people die for lack of health insurance. Since we're going to have to ante up for them when they get sick, shouldn't we force them to pay whatever they can for health insurance before they get sick?

This is why the Obama health insurance plan made no sense: no requirement to buy health insurance but a guarantee you could get it whenever you needed it with no penalty for waiting to buy until you got sick. I kept wanting to hand him a dictionary open to the word "insurance".

Okay, shutting up now. I could easily write another 10,000 words on this so maybe I've finally been inspired to do the writing on health insurance I've been meaning to do for months. Thanks, Cassandra.

Posted by: Elise at September 17, 2008 05:54 PM

"I would be amenable to a proposal to cap damages for malpractice. In return, I'd like absolute transparency from doctors, labs, hospitals, and other health care providers with regard to lawsuits filed, complaints made, and patient outcomes. "
Georgia legislated such a cap without the attending transparency.

While I appreciate your sentiment Elise, I'd rather see transparency, as you suggest, along with a lawsuit provision that forces the loser pay for the costs of litigation. I think I made a similar comment at Grim's a few moments ago.

IMHO, that is a simple solution that does not deprive anyone of their day in court. IOW, If a p!$$ poor excuse of a medical professional, who by hook or crook has managed to fly below the radar of the AMA for any length of time, ruins someone's life through carelessness, neglect or they are simply unqualified/inept, I'd rather allow the the injured party their day in court, free from some arbitrary limit imposed by... gob'ment representatives?!

I suppose that it's just a fear on my part of that good old one size fits all legislated solution for something that can be a case of life and death or grievous harm to a person who placed their life and health in the hands of a person/organization.

My two cents.

Ok, so does this admission mean that I have to surrender my Platinum Conservative Membership in the Fraternal Order of Huns?

Posted by: bt_shakin'-the-intern-boss_hun at September 17, 2008 06:12 PM

Bthun -
The AMA protects their own, like any good union.

If they were more concerned with protecting the ethics and standing of the profession and policed themselves better (acting more like a trade guild than a union), there wouldn't be as much mal-practice. That's what is called 'root cause analysis'. IMHO.


If something becomes too expensive, the supply must be too small.
If a commodity disappears, it may be too cheap, or frankly undesirable.
So if medical care is "too expensive", is it disappearing or is the supply too small?

There is, of course, a third (unthinkable!)alternative, and that is that the game is rigged to promote high prices, even though the 'supply' of medical care may be adequate.

This is somewhat analogous to the cost of gasoline.
Everybody is sure there is plenty of oil to make into gasoline, so why is the price so high? Perhaps because enough of the key producers (Russia and the OPEC states) have connived to raise the world price to expropriation levels.
In fact, there is now little excess capacity of oil production in the world, with demand rising, so oil producers can create a priced market wherever and whenever they can leverage the price.

Similarly, medical service 'providers' (and that includes insurance companies), can leverage the price, to create the notion of a scarcity of supply. This is done by disconnecting supply from demand. With many people using Medicare/Medicaid/Employer supplied health insurance, most of us have little real grasp of the cost of most medical procedures and examinations.
Thus demand grows ever larger (it's cheap!), with supply lagging because of the disconnect between users and payers. And benefits managers of companies wonder why their group rates keep going up every year? They are in on the racket, it just hasn't quite dawned on most of them yet.

Reconnect the users (that's you and me, citizens) with the real cost of medical care (yeah, good luck with that), and the medical care inflation rate will slow down tremendously.

How we do that (politically) is a mystery to me.

I know all the 'free market' answers, but our friendly neighborhood Congress is not about to go down that path. The political tendency is to give more to the citizen of the welfare state, not to take away, or make him (or her) face reality. The notion of personal responsibility in the US of A is going the way of an unbiased press and the passenger pigeon.

Like somebody said, if you think medical care is expensive now, just wait until it's free.

Posted by: Don Brouhaha at September 17, 2008 06:39 PM

Mr. Brouhaha,

I wish you were mistaken. Sadly I must admit that you are spot on in your comments beginning with the AMA right on through Congress clutching for more power and control and the masses seeking more gimme's.

But I still think consumer/market driven solutions based upon readily available data, ala some sort of Consumer Medical Reports data ought to get the ship moving in the right direction. A nudge here, a shove there...

Lawdy, Lawdy! Please give me anything but mo gub'ment in mah life!

Posted by: bt_shakin'-the-intern-boss_hun at September 17, 2008 06:58 PM

I'd rather see transparency, as you suggest, along with a lawsuit provision that forces the loser pay for the costs of litigation.

If I understand correctly, that's how the law works in Britain. I have the impression it tends to have an extremely chilling effect on lawsuits especially when an individual is thinking about suing a large company. That's not necessarily a bad thing but it may be a consequence of your plan.

When I talk about capping malpractice, I envision actual damages assessed realistically. If a doctor's incompetence leaves someone needing care for the rest of his life, the damages should set up a fund to provide that care. I would then cap pain and suffering, mental anguish type damages at either some percentage of actual damages or some flat amount.

You guys are talking about this at Grim's, too? I think that's too confusing for me.

Posted by: Elise at September 17, 2008 07:05 PM

"Are you willing to let people who cannot afford - or decide not to buy - any insurance die when they need medical treatment? What about their kids? I'm not being outrageous here."


Of course you aren't being outrageous. It's a serious and complex business and no one can deal with it all in a few paragraphs.

First off, insurance in general should be aimed at preventing catastrophic loss, not splitting every dollar one spends. The idea is to stay out of the poorhouse, not to get a discount every time one visits an MD (those who expect the latter should pay accordingly). Deductibles should be substantial (how substantial is a secondary debate) and co-payments should cease. Manifestly, premiums would immediately be reduced; additionally, the costs would be driven down by the re-institution of competition. If one has to pay the full freight for common services like bi-annual physical screenings, not only is one likely to more critically evaluate the frequency of same but one can also shop for services, since the providers, freed from one-size-fits-all fees for these services, can compete for patients.

Why should I see an MD for a routine physical when a trained nurse-practitioner can do it, referring me to an MD only when something questionable is found? In such an environment, less expensive provider-types could establish their own practices for the bulk of common services, an obvious potential for reduction of cost over-all.

Just a beginning to a very complex debate.

As to your questions about the incapable and the unwilling, I would be surprised, given the generosity of our people, if charitable resources could not be found to supply premium payments for those, although one might propose that a re-direction of the money presently aimed at Medicare might suffice. Just another detail for examination.

Have at me.

Posted by: socialism_is_error at September 17, 2008 08:17 PM

Last weekend, I saw a broadcast on C-Span of Newt Gingrich speaking at morning session for a group of delegates at the Republican convention from early in September.
Newt was pretty humorous in parts, but he did mention something that he was part of, which was a promotion of "best practices" in health care, where the emphasis was on finding best medical practices at the lowest cost, all over the country. And then telling other people how it was done. He made a few brief comparisons with some low cost "best practices" versus standard practices and costs.
Worth considering, IMHO.

Posted by: Don Brouhaha at September 17, 2008 08:40 PM

Growing up, the American taxpayer took care of my healthcare, as my dad was active duty Army since before my parents got married until he retired in '91. I wasn't taken to the doctor for every little cough or whatever. I guess Daddy retired before Tricare became the way of things.

I probably had a gap in coverage after graduating college and starting my first "real" job later that same year, but I didn't have an health issues. Had coverage through that first job, then the job I moved to Arkansas for. Then, I got the job that allowed me to move back to Texas. I guess I should have asked more questions beside "is health insurance available?"...

That small business' "health insurance" would have cost me over $400 a month. And that was just for me - I have no family to try and insure. When I decided to go back to school (just a few months after starting that job), I became eligible to get health insurance through the group student health insurance offered through the university. My premium for that was something like $80/month, which was equivalent to what I'd been paying in Arkansas (which I'll discuss later). The policy ran August-August. I knew I'd be graduating in December, but I would be allowed to have that policy active through the end of the plan year, which I took advantage of.

I assumed that would carry me through until I got a teaching job and I had benefits. Well, things haven't quite worked out that way. I've now been uninsured (again) for just over a year. Two years ago, after a medical procedure, the doctor said I should have another in two years. Well, here I am, two years later, without health insurance. I might be able to tell the doctor "I can't pay for this", and they'd direct me to some program to have someone else pay for it, but it's really no one's fault but my own that I am where I am right now. I've not completely given up on a teaching job for this year (believe it or not, I just got a call today for an interview next week), but if all that falls through, I have to do something to get myself covered. But, I don't plan on having the taxpayer pay for my medical care. I might be uninsured and not in a position to "self-insure", but I don't think it's a "right" that should be guaranteed by the government.

Now, back to that job in Arkansas. When I first started, I don't recall what the insurance provider was, but it was affordable and met my needs. Somewhere along the line, my employer decided to go the "self-insured" route. All the participating employees would pay or premiums, and that is where everyone's "insured share" would be paid out of. Premiums went up every year. The poor guy who had been tasked within the company, when he would talk to all us employees about the changes, would say "we had a bad plan year"... Enough women have babies, or people have other surgeries, in a given year, and to cover that, everyone's premiums went up the next year. That, and some of the plan options went away, too. I'm not sure the total number of employees, or how many dependents were covered, but it could only have been in the hundreds.

Now, comparing someone who has to pay for it through private insurance and out-of-pocket vs. someone who is covered by Medicaid/Medicare: I am the second of 21 grandchildren. So, I have lots of cousins. Several - siblings - live here in Austin. The oldest is married, and he and his wife are comfortable. They have private insurance. Their oldest, who is 2, was premature (it was a risky pregnancy - their first child was stillborn), and seems he's had to go to the doctor for things that aren't just a case of the sniffles. They had another baby who will be 1 year old in about a month. The youngest brother, who is also married, isn't so well off (I'm sure it had a lot to do with the fact that his now-wife was still 17 when he got her pregnant, and they met while working at Pizza Hut). The wife of the oldest brother told me that the wife of the youngest brother didn't understand why they didn't take their son (who was the only one at the time) to the dentist - they took their daughter. What you need to understand is, that daughter just turned 3 this summer, and her dental visits were being paid for by you and me. Oh, and I just found out that she (this wife of the youngest brother) is pregnant with their third child. So, looks like you and I and everyone else will be helping to pay for even more health care for that little branch of my family tree... My point being, it costs my cousin and his wife - who don't make a lot of money - nothing to take their children to the dentist to have teeth cared for that are going to be falling out in a few years anyway, so they take full advantage of it. The cousin and his wife who DO have to pay something out of their pocket are a little more discriminatory in their health care usage...

Sorry about being so verbose...

Posted by: Miss Ladybug at September 17, 2008 08:50 PM

I haven't had insurance since 1988. My medical expenses per year run less than $400. I did have a lip resection due to an accident in 3: $5000 total. In 2005 I had a very major illness that the medical system would have used to usher me to a kidney transplant. I found a better way that cost $200 every 3 months for blood work and involved diet and exercise, no oddball stuff just nutritious food. Kidneys are currently at 98% efficiency. Guess I didn't need that transplant after all.

I make plenty of money to have insurance but the car insurance covers me if I'm beat up in wreck so why bother with medical? I put the money in investments instead.

Of course I'm weird, I wouldn't do traditional treatment anyway. Our medicine is fabulous at rebuilding things that have been beat-up or worn out, but awful at curing disease and providing a good quality life afterward.

Posted by: Samantha West at September 17, 2008 10:10 PM


I hate it when I post in a hurry. "Military personal"? What the heck is that? Some sort of dating service for lovelorn sailors? :p

I never cease to be amazed at my own ability to overlook typos and mistakes when I'm preoccupied. Multitasking will be the death of me yet.

Posted by: Cass at September 17, 2008 10:25 PM

Dating services for military personnel? There are several out there...

Posted by: Miss Ladybug at September 17, 2008 11:32 PM

"I hate it when I post in a hurry. "Military personal"? What the heck is that? Some sort of dating service for lovelorn sailors? :p"
Always wondered if that service should have been covered as part of a holistic health plan back when I was a swab... =8^}
"I never cease to be amazed at my own ability to overlook typos and mistakes when I'm preoccupied. Multitasking will be the death of me yet."
Your villainous readership must know of the lesson in forgiving, let they what is without typo, cast the first bottle of whiteout, or something like that.

Posted by: bt_shakin'-the-intern-boss_hun at September 18, 2008 07:23 AM

Lest they, bthun?


Posted by: Miss Ladybug at September 18, 2008 09:27 AM

Lest they what, Miss L? ;)

Posted by: socialism_is_error at September 18, 2008 10:13 AM

Miss LB,

Why bless yor pea-pickin' heart! Ya'll done fergot whar I's from? Er is yu makin' funo tha way I tawk? =;^}

Posted by: bthun at September 18, 2008 10:23 AM

Yu ain't got above yer raisin', son, that's shore enuf. ;)

Posted by: socialism_is_error at September 18, 2008 10:31 AM

(This is the point in these threads where I always feel like the vinegary substitute teacher walking into the classroom full of light-hearted students and arriving with a thud.)

SIE - I don't have a problem with anything you've said. The idea of health insurance only to prevent catastrophic loss is certainly a valid one. However, I do see two issues we have to deal with. First, "catastrophic" is different for someone with an income of $25,000 a year than it is for someone with that famous income of $125,000 per year. So if premiums go up as the definition of catastrophic goes down, the poorer you are the higher your premium. So we have to figure out how to account for that.

Second, if you buy the idea that regular preventive care keeps health care costs down in the long-run (an issue in and of itself), would a catastrophe-only policy result in less well off people not getting, say, regular checkups for themselves and their children and thereby ultimately using up more of our health dollars by letting little problems turn into big ones?

Posted by: Elise at September 18, 2008 11:23 AM

Universal healthcare is frightening.

My father is a highschool teacher and was when I was growing up. Depending on the school district we lived in we had plans that cost $100 per visit for preventative care with no prescription coverage and plans where everything was free.

No matter the plan we made it work. You saved up money and put it aside incase you might have to visit the doctor's unexpectedly.

People need to plan ahead and make decisions. If you can't afford health care premiums or deductibles how about cancelling your cell phones, internet, cable tv and any other extras you have. Then are you a little closer to the monthly amount needed?

There are already government programs in place for many who truly can't pay and are below the poverty line. The government shouldn't have to provide free healthcare for those who live their daily lives with anything more than basic food and shelter.

Why should my healthy family that isn't overweight, eats healthy foods and exercises be required to pay for your diabetes medication or heart disease issues? With national health care no one will have accountablity. Everyone can stuff themselves with fast food and someone else can pay for their problems.

Even in Eurpose where healthcare is difficult and rationed the people weigh less and live healthier lifestyles. Can you imagine Americans on a plan like this? We think Americans have a lack of restraint and can't get up of the sofa now, just wait.

Posted by: Ana at September 18, 2008 12:27 PM

Sorry, that's suppose to be Europe not Eurpose!

Posted by: Ana at September 18, 2008 12:30 PM

"(This is the point in these threads where I always feel like the vinegary substitute teacher walking into the classroom full of light-hearted students and arriving with a thud.)"


No need for such feelings; one thing I like about this place as well as Grim's and others is that the people can discuss things seriously while occasionally taking breaks to have fun.


I recognize that premiums go up as one's chosen catastrophic threshhold goes down; however, the premiums for any given situation are bound to be less than those where the benefit kicks in right from the start. It's just like choosing a higher deductible for your auto insurance.

The real point is that, if you have to pay the however-many first dollars, you may decide to be a little more careful about your own behavior. Of course, this idea is rooted in the basic conservative view that people should not be dealt with as dependent children, unless one intends to promote and preserve that state-of-being.

A health savings accounts (HSA) is pretty much what I'm describing here. If you read the entry, you will notice that opponents of this type of plan basically are whining about not being able to force the participation of people who don't want the program in order to subsidize those who do want it - something I made general comment about earlier.

What gives most people problems in this area, I believe, is the unconscious acceptance of the idea that we have to settle every problem down to the last case, regardless of the marginal cost; in fact, it is a consequence of our "government of laws, not men". The law demands perfection. The economic realities don't allow perfection.

We cannot continue to keep people alive for a couple extra weeks or months for hundreds-of-thousands or even millions of dollars taken from others, money that could have been used to handle the sorts of situations you have asked about, e.g., children in low-income households. Thus, I extend my model by suggesting an upper bound for benefits (details to be hashed out) beyond which the individual resumes responsibility for the cost. Premiums would reflect the choice of this limit just as they do the choice of deductible. It would then be the free choice of the individual, subject to his lot in life, as to just how much his life is worth.

We can't continue as we are.

Posted by: socialism_is_error at September 18, 2008 02:46 PM

SIE said: "You have a right to as much health care as you can afford."

I don't think there are any good arguments against that. In the Old Days of our grandfathers, that system worked well. Doctors made "house calls" (for you younger folks, you called him up, told him the problem, and he came right to your house with his little black bag. [It was almost invariably "he".]

When he was done, the bone set, or the baby delivered, the pills left, he'd send you a bill for $25 or so. Not too long before that, you'd repay him with a few chickens or a pig.

If you couldn't pay, he probably wouldn't come back.

Nowadays, as most of you point out, doctors aren't the problem, lawyers are the problem. Like John Edwards, who made his considerable fortune suing doctors in the South for malpractice - whether they were guilty or not was beside the point. He could convince any jury that his poor suffering client was due a million $$ or so (of which he got the usual 25% or so share).

Malpractice premiums are one of the top 3 or 4 - if not #1 - expenses doctors have to pay.

From a 2005 news article (search for 'malpractice premiums'):

Average premiums:
Specialty         DC    Maryland    Virginia
General surgery $69,270  $64,919     $56,163
Ob-gyn          $139528  $143477     $85297

Posted by: ZZMike at September 18, 2008 03:04 PM

The other problem with malpractice cases can be the jury feels sorry for the plaintiff and figures "well, that's why doctors have insurance, so let the insurance company pay." Actual fault be damned.

Posted by: MikeD at September 18, 2008 03:27 PM

Not to mention that the jury doesn't consider the cumulative effect of many such awards on their own future costs and premiums.

Posted by: socialism_is_error at September 18, 2008 04:03 PM

I think that the most important issue this year is health care and that it should be a much bigger part of the political discussion. I work for Boldmouth Inc. and have had the privilege of working for the Divided We Fail sponsored film competition at UCLA that is highlighting this issue. It is called Stolen Dreams and everyone, regardless of their political views, should check it out.

The website is http://www.stolendreams.com

Posted by: Katie at September 19, 2008 11:57 AM

FWIW, while I agree that malpractice premiums are an issue, they are not the most important issue in health care costs or health insurance premiums. And while I agree that malpractice verdicts can be outrageous and Edwards was responsbile for many of them (and he and the attorney that referred him the case probably received 40% - not 25%), most (by a large number) med mal trials end in defense verdicts. Many carriers are willing to try them.

Posted by: KJ at September 19, 2008 04:42 PM

I'm glad to know that; however, the expenses of litigation still weigh on the defendant and, thus, the public.

I have long wished, as bthun suggested, that the loser in a civil suit pay all costs. In fact, I would go further and make plaintiff's counsel liable for a percentage in the interest of governing the "class-action" suit. With these sorts of changes, people would be more hesitant to engage in nonsense suits.

Sure as the sunrise, the whining would ensue about the "little guy facing the legal hordes of the huge, evil corporation." I say bunk. If the little guy *and* his counsel are really certain a legitimate wrong can be proven, they should trust a jury of peers to agree.

Posted by: socialism_is_error at September 19, 2008 06:15 PM

I have friends tell me all the time they believe they can't afford medical insurance (not even the kind with a high deductible that's available for a couple hundred dollars a month if you get it before you're diagnosed with a major disease). But they can afford computers, TVs, cable, internet connections, cell phones, restaurants, second cars, and houses bigger than they need, not to mention tons of other things that weren't "necessities of life" 50 years ago (like AC), so why are they "necessities" now? And how did we come to believe all these things are more necessary than medical care?

It seems to me that much more medical care is available now than used to be the case. There are treatments for untold numbers of conditions that people used to just suffer with or die from. (Transplants, joint replacements, by-pass surgery, cancer treatments.) Now that the treatments are available, it's very, very hard to imagine doing without them. But as a result, the higher level of medical care costs a greater percentage of the GDP. Yet we don't believe we have to set aside a much higher percentage of each family's income for it.

Posted by: Texan99 at September 19, 2008 11:21 PM

"And how did we come to believe all these things are more necessary than medical care?"
Odd isn't it? Alas, it is what passes for logic these days.

Priorities... Your mileage will vary.

Posted by: bt_Dr.-House?-paging-Dr.-House_hun at September 20, 2008 10:39 AM

According to Samuelson, there is no crisis as far as people not getting health care. That is, even though a large number of people don’t have health insurance, health spending is virtually equal across income quartiles. There are contradictory studies on whether health outcomes differ for the insured versus the uninsured.

The crisis instead is that health care spending is eating up more and more of our GDP which is squeezing out other desirable purchases.

Samuelson believes “30 percent of Medicare spending may go to unneeded services that do not enhance recipients' well-being”. He believes that if we can alter how Medicare works we can reshape the health care industry. Specifically he wants to Medicare to “encourage more electronic record-keeping, better case management, fewer dubious tests and procedures, and a fairer sharing of costs between the young and the old.” I’d like to see specifics on what he means by case management and how the plan to make cost-sharing more fair will work but in principle I have no argument with any of this.

Samuelson seems to believe in general that ineffective and unneeded “diagnostic tests, surgeries and medical devices” account for the rise in the percentage of GDP consumed by health care spending. I believe it is equally plausible to hypothesize that - to put it as simply as possible - people who 50 years ago would simply have died can now be cured or at least kept alive for an extended period. It’s much cheaper to die than it is to receive long-term treatment for heart disease, cancer, AIDS, and other illnesses that were previously a death sentence.

Samuelson contradicts himself. At one point he says that unlimited care paid for by someone else poses a moral (and political) dilemma. Yet he concludes his article by - as I said above - talking about administrative changes to Medicare to limit waste. There is no moral issue involved in limiting waste.

I believe what Samuelson is skirting around is the moral issue not of limiting waste but of limiting care. Back in the 1980s Oregon figured out how much money they had to spend on their health care program for the uninsured. They printed off lists of all procedures, rank-ordered by effectiveness. Treating pneumonia was the most effective: give antibiotics to someone with pneumonia and you had (at that time) a better than 90% chance of curing them. Oregon also figured out how much each procedure would cost and estimated how many of each procedure was likely to be needed by the people they were insuring. This gave them an extended cost for each procedure. They kept a running total of estimated costs as they went down the list from most effective to least effective. When they hit the amount of money they had to spend on health care, they drew a line. Procedures above the line they would pay for; below the line they would not.

All this stuck in my memory because after Oregon did this there were news reports of a young woman in the state health insurance program begging the legislature to change the rules. Her young son needed a liver transplant or he would die. The transplant for someone in her son’s circumstances had less than a 25% chance of succeeding. That was well below the line.

I do not necessarily think that Oregon did the wrong thing. There is a certain appeal to a health care plan for poorer people providing only proven treatments and leaving more uncertain approaches to private insurance plans. The rich then become guinea pigs. However, if we are going to make those kinds of decisions about Medicare and Medicaid, we need to be upfront about what we’re doing.

In addition to the issue of limiting care based on effectiveness, there is also the issue of limiting care based on characteristics of the patient. Not providing liver transplants to alcoholics seems like only common sense. What about diabetes care for people who are overweight? For people whose weight is fine but who eat too many sweets? Too many fruits? What if you just suspect they eat too many fruits but you’re not sure? What about carpal tunnel surgery for bloggers? Or for anyone who works at a keyboard - shouldn’t they have been smart enough to wear a brace? To echo some of the ugliest writing I’ve seen in this election cycle, what about people who give birth to a child with a birth defect that they knew about before the birth? Some people are already arguing that since the parents could have aborted the child, we shouldn’t have to pay to take care of him. What about a heart transplant for someone who is 90? 80? 70? 65? What about a hip replacement for someone who is 75? What about aggressive medical treatment - say, for heart problems - for someone with advanced Alzheimer’s?

These are not just questions that apply to government-run health care plans. Private health care plans contain pools of people, too, with varying habits and genetics. There have already been stories that private health care plans want to refuse to pay for some procedures for diabetics who the companies believe have not been careful enough about their diet.

As for some type of national health insurance, my question at this point is, “Why is this an issue at the national level? Why not leave it at the state level?” I believe Democrats want this considered at the national level because, well, they want everything considered at the national level. I believe Republicans want this considered at the national level because they want to pass legislation that will allow people to buy health insurance across state lines. Not, I cynically suspect, because they think it will be better for consumers but because it will allow insurance companies to ignore all state regulations on who must be covered, what must be covered (drive-by mastectomies, anyone?), and how much can be charged. What that means, of course, is that all the fights that have occurred in the states over forcing companies to offer insurance to everyone and over covering problems like mental health and over limiting rate differentials based on age and preexisting condition will be re-fought at the national level. That doesn’t sound like small national government to me.

Even if we want some national level involvement in health insurance, maybe we’re going way overboard here. If the problem is that people cannot afford health insurance, the solution may be to figure out a way to subsidize them, not to create a whole new system for them. And even that seems like it would be better handled at the state level; health care is a heck of a lot more expensive in New Jersey than it is in Alabama. Why should a taxpayer in Alabama subsidize a patient in New Jersey? Isn’t that just another kind of wealth transfer, from poorer states to richer ones?

That would seem to just leave us with the people who cannot get health insurance. I’d like to know how many of those there really are.

Posted by: Elise at September 20, 2008 03:25 PM


1. I'm not seeing where Samuelson contradicts himself.

You are saying that you dispute the study he cites, but that is not evidence that he is wrong; merely that you find his evidence unconvincing. The way to refute his evidence is to present evidence in refutation of the study Samuelson presented. Then we can compare and contrast. I'm not able to do that from your argument.

2. There are other possible explanations for the rich and poor spending the same amount on health care. It is possible that the rich are being overserved (due to better overall health, their health care costs may consist largely of maintenance and elective procedures) while the poor may be underserved (due to worse overall health, their health care expenditures may consist largely of non-elective/serious medical procedures which in fact don't suffice to keep them in good health despite the fact that they spend the same as wealthy folks).

Neither of these things are something we can tell from the study cited, though. And neither of them address self-destructive, irresponsible, and most of all VOLUNTARY behaviors that it's not necessarily fair to ask taxpayers to pay for. Further incenting those behaviors by subsidizing them via a public health system is arguably not in the best interests of the poor for many reasons, not the least of which being the example of nations which already have a public health system demonstrate that the quality and quantity of health services declines when they are not paid for by a competitive market system.

All we're really doing here is substituting one kind of "unfairness" (that some people are poor/unhealthy) for another (I am going to take your money to pay for someone else's bad luck/poor choices and there's nothing you can do about it).

Posted by: Cass at September 22, 2008 12:48 PM

I apologize Cassandra. Usually I write something long and stream of consciousness then distill just the take-aways for a comment. In my last comment, I dumped all the long and soc stuff and even as I was doing it I worried it was not going to be comprehensible.

I don't dispute Samuelson's study of the amount spent and he himself says different studies have found different outcomes for insured and uninsured. Where I believe he contradicted himself was in stating that Americans need to face up to the moral aspects of health care but then recommending (in his last paragraph) changes to Medicare - and by extension the entire health system - that focused solely on reducing waste.

My point was that there is no moral issue involved in reducing waste and Samuelson was skirting the moral issue that does arise when you talk about limiting care either based on success rate of procedures or based on characteristics and/or behavior of patients.

Posted by: Elise at September 22, 2008 02:52 PM

Never apologize, woman! :)

I will always come back on an argument if I think I see a weakness in it. However, many times my own arguments are not exactly bullet proof! I love your comments and am just thrilled to have you participating. I've just been way too busy lately and haven't been able to keep up with comments.

Posted by: Cass at September 22, 2008 03:48 PM

Never apologize, woman! :)

Okay. Just remember you said that down the road. :)

Posted by: Elise at September 23, 2008 04:06 PM

I know this post is dead as a doornail (doorknob?) but this is where a link to the following article seems to go:

Two stories from Arizona

It's a look at two contrary movements in health care: the movement by insurance companies to force medical personnel who contract with them to only see patients covered by insurance versus the movement for a Freedom of Choice in Health Care Act.

Posted by: Elise at October 3, 2008 08:23 PM