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August 04, 2006

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Outstanding post, hilzoy. Delicious...and nutricious!

Nice collection. I am wondering, however, if there's a correlation between diseases and country that could skew these results. Like, I remember reading some years ago that white Australians had very high rates of skin cancer. If Americans are significantly fatter than these other countries, you could imagine disproportionate costs for diabetes, heart disease, and so forth.

I'll look for such data myself later if time allows.

Yay! I am so sick of the oft-repeated myth that Canadians would rather spend $25,000 on gall bladder surgery in the US when they can get for free at home.

Thanks, Hilzoy. You can expect a lot of linking to this piece in the years to come.

OK, so set up a wonderful govt healthcare system funded by people voluntarily joining due to it's wonderfullness. What? You have to _force_ people to pay for your govt program? If given the option, so many people would opt out of the program (and it's payments) to make it unworkable? Everybody walks around in sheer terror of an illness and being left to the tender mercies of Capitalism, but too many would stay outside your system if they are given the option? That's odd.

I don't know, US #1 in effectiveness seems pretty good to me.

Part of our poor showing in terms of life-expectancy, infant mortality, etc., has got to be with the ridiculous lifestyle we live here. When we drink, we drink. When we smoke, we smoke. When we eat, we eat. Moderation means nothing to the average american, AFAICT.

Part of my skepticism stems from my father (a Dr. who makes grand living off the current system so maybe he's biased), who is generally of the opinion that efficacy of preventative care is swamped by people's life-style choices.

Anyway, good post.

I left off all the major Capitalist employers who would pass on buying their employees the cheap (and wonderful) govt program instead of using the bloated and expensive for-profit insurance system, giving up lower costs unnecessarily.

And since the govt program is so wonderfully efficient, no taxpayer subsidies will be needed. The voluntary payments people make to get in will cover everyone. It's magic.

Another part of our poor showing is the poverty and poor health among recent immigrants and migrants, who comprise a fair chunk of the population in the US. This certaily hs something to do with the infant mortality rates.

"Everybody walks around in sheer terror of an illness and being left to the tender mercies of Capitalism, but too many would stay outside your system if they are given the option? That's odd."

It sure is. Thus the force. It's like the War in Iraq. I wouldn't pay for it if the tax system was voluntary. It's only the prospect of jail that convinces me.

You wouldn't believe how odd I feel.

Ugh wrote:

Part of our poor showing in terms of life-expectancy, infant mortality, etc., has got to be with the ridiculous lifestyle we live here.

Jim wrote:
Another part of our poor showing is the poverty and poor health among recent immigrants and migrants, who comprise a fair chunk of the population in the US.

Both of these comments strike me as attempts (I trust unconscious ones) to *not* acknowledge the elephant in the living room: the US has a very large proportion of poor *citizens*, most of whom are non-white.

A useful international comparison I have not seen (but which may be out there) would be health care outcomes for Australian and NZ aboriginals. Are Oz & NZ better able to deliver health care to their underclass than the US is? I don't know.

Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.

Funny, when appropriations time comes up, people receiving care from the VA are suffering and the program needs more money:

America’s Neglected Veterans ...In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics. The number of uninsured veterans has increased by 235,159 since 2000. The proportion of non-elderly veterans who were uninsured rose from 9.9% in 2000 to 11.9% in 2003.

Many of the 1.69 million uninsured veterans in 2003 were effectively barred from VHA care because they had incomes above the eligibility threshold, or because of waiting lists at some VHA facilities, unaffordable co-payments for VHA specialty care, or the lack of VHA facilities in their communities. An additional 3.90 million members of veterans’ households were also uninsured and ineligible for VHA care.

The Medicare program (which covers Americans over age 65) covered virtually all Korean War and World War II veterans. However, 681,808 Vietnam-era veterans were uninsured (8.7% of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during “other eras” (including the Persian Gulf War), 12.1% (999,548) lacked health coverage.

More than one in three veterans under age 25 lacked health coverage, as did one in seven veterans age 25 to 44 and one in ten veterans age 45 to 65.

Many uninsured veterans had major health problems. Less than one-quarter indicated that they were in excellent health; 15.6% had a disabling chronic illness.

A disturbingly high number of veterans reported problems in obtaining needed medical care. ...

Govt 'success' proves the govt deserves more power; govt failure proves the govt needs more power. Nothing can happen that doesn't lead to the conclusion that the govt should have more power. The next quote is even more fun. Note how both VA successes and VA failures are both used to argue in favor of more power going to govt. The original post here used VA 'success' to argue for socialized medicine, this liberal uses VA failures to argue for it:

1.7 Million Veterans Lacked Health Coverage In 2003 ...David U. Himmelstein, M.D., study author and Harvard Medical School Associate Professor, commented: “This administration professes great concern for veterans, but it’s all talk and no action. Since President Bush took office the number of uninsured vets has skyrocketed, and he’s cut VA eligibility, barring hundreds of thousands of veterans from care. Our president has put troops in harm’s way overseas and abandons them and their families once they get home.

“Like other uninsured Americans, most uninsured vets are working people. And uninsured veterans are denied the care they need – turned away because they can’t pay,” said Dr. Steffie Woolhandler, a study author and co-founder of Physicians for a National Health Program. “We need a solution that works for veterans, and for all Americans – national health insurance.”...

Doctor Science - Well, I was thinking of all the pasty, overweight, alcoholic smokers who I grew up with in the midwest. But I suppose a lot of them were poor too.

Dr. Science wrote:
the US has a very large proportion of poor *citizens*, most of whom are non-white.

This statement is false. If we define poor *citizens* as those living under the FPL, then only 40% of poor *citizens* are white according to the 2000 census. If we use 200% of the FPL then it falls to 36%.

Most of the poor are first-generation immigrants or single mothers and their children.

That said, significant discrepancies in health care provision still exist by race, after accounting for income.

Scott: the articles you cite about the VA do not concern "people receiving care from the VA ", as you say, but people who are not. The entire point of those articles is that not all veterans are eligible for VA care. That's an entirely separate issue from whether VA care is good, which is the one I was discussing.

Your series of rhetorical questions are kind of hard to match up with anything anyone is saying. Personally, I think it would be great if US employers were not burdened by health care. It would certainly make them more competitive internationally, while at the same time removing some distortions of the labor market.

I addressed the taxpayer subsidy questions in Andrew's last thread; the basic point was that of course you'd expect taxpayers to have to pay for it -- we now pay for private health insurance, after all, and why should public health insurance be free? However, it turns out that Taiwan was able to go to a single payer system without paying more for health care than it was already paying (while greatly expanding coverage), because the efficiencies introduced by universal coverage saved enough money to make up for the additional costs.

If you don't know why there are efficiencies associated with universal health care, try googling "adverse selection", or else asking nicely.

Scott: the articles you cite about the VA do not concern "people receiving care from the VA ", as you say, but people who are not. The entire point of those articles is that not all veterans are eligible for VA care. That's an entirely separate issue from whether VA care is good, which is the one I was discussing.

Both articles cover people in the VA's area of responsibility. If they help some well by not covering others, that does matter.

the basic point was that of course you'd expect taxpayers to have to pay for it

It's wooooouuuunnnnddddeeeerrrrfuuullll, but still needs taxpayer subsidies.

and why should public health insurance be free

It could be covered by what people pay voluntarily to buy in if it's so damn efficient.

f you don't know why there are efficiencies associated with universal health

You're trying to paint a picture of something so wonderful that only a fool wouldn't want in, yet feel you must mandate people being in it. Sounds like you have no faith in what you're claiming.

Both articles cover people in the VA's area of responsibility. If they help some well by not covering others, that does matter.

The rich are covered in the US and get great healthcare. Does that mean liberals will stop talking about the poor not being covered as failures of the system, on the grounds that since they are outside the system they don't count? That's your argument covering the VA here.

You're trying to paint a picture of something so wonderful that only a fool wouldn't want in, yet feel you must mandate people being in it.

Do you pay taxes, Scott?

Both articles cover people in the VA's area of responsibility. If they help some well by not covering others, that does matter.

Kinda matters on the reasons for the non-coverage, no?

If it's a problem externally imposed, then expanding the program WILL demand more money, but that's not really a problem.

You're not being very clear (to me, at least) in articulating your objections, outside of a very generic rant.

Do you pay taxes, Scott?

Unfortunately, yes. If your program is so wonderful, why shouldn't I be able to opt out, since I clearly would never want to.

If it's a problem externally imposed, then expanding the program WILL demand more money, but that's not really a problem.

Yep, govt failure leads to demands for more money going to govt. Those damn taxpayers, externally imposing restrictions on govt are the cause of govt failure.

The sarcastic tone ain't helping much either, Scott.

The sarcastic tone ain't helping much either, Scott.

It's the only tone you deserve. Anything the govt does that can be spun into success proves it deserves more money and power; any failure too obvious to ignore (or too useful in Congressional testimony) proves it needs more money and the damn taxpayers are externally imposing failure on our poor civil servants.

The poor aren't supposed to be covered by private insurance they don't pay for, therefore you cannot blame our 'private' healthcare system for the care they don't get. They, like uncovered veterans, are outside the system and thus the system isn't responsible.

If your program is so wonderful, why shouldn't I be able to opt out, since I clearly would never want to.

(a) Our system is wonderful. Any Canadian political party who even hints at major change immediately lose popular support.

(b) I would support completely opting out of our system, as long as it was for life, and you could never get back in. When I talk to critics complaining about the system, and I offer that suggestion, they pale visibily and say no, of course they wouldn't want that.

It's the only tone you deserve.

Are you familiar with the posting rules here?

And explain why I shouldn't be allowed to take my healthcare spending out of your pool if it will clearly be so much better than anyone else's. You don't think millions of people will leave your wonderful system if they have the choice, do you? Because a handful of malcontents like me leaving shouldn't hurt your program.

Our system is wonderful. Any Canadian political party who even hints at major change immediately lose popular support.

Is there some reason you'd be afraid if individual Canadians could leave the system?

I would support completely opting out of our system, as long as it was for life, and you could never get back in.

Just like Blue Cross does. Oops, that evil for-profit system doesn't have that broad of a restriction.

What the Klingon Scott says is unimportant so loaded with sarcasm as to be unintelligible, and we do not hear his words.

Okay Scott, I tried, but if you're going to keep trolling, I have no interest in discussion with you. Maybe someone else can pay attention to you for a while.

Here, Jes, this is the person you were trying to argue with the other day, whom you mistook Andrew for.

The sarcastic tone ain't helping much either, Scott.

It's the only tone you deserve.

Conversation on blogs is voluntary. If you feel it is appropriate to express contempt for your interlocuters, you may find that people cease responding to you, on the basis that they may assume you're just a troll, rather than someone interested in honest or semi-respectful discussion.

Dr. Science, you don't have one of these, do you? I wish to know how much I need to worry.

Dr. Science wrote:
the US has a very large proportion of poor *citizens*, most of whom are non-white.

This statement is false. If we define poor *citizens* as those living under the FPL, then only 40% of poor *citizens* are white according to the 2000 census. If we use 200% of the FPL then it falls to 36%.

Um. I having trouble with this statement. If 40% of poor citizens are white, then it the majority of poor citizens are non-white, which would mean most of them.

Most of the poor are

One of the reasons that health-care-by-employer has generally worked in the past is the relatively high percentage of people who are covered. Health care costs hew to the 80/20 rule extremely reliably (I worked as a health underwiter for a number of years; to amuse myself I used to calculate this. I virtually never saw a company of more than 50 people where there was a deviation of more than 5 percent (that is, where the 80% of costs were generated by less than 15% or more than 25% of the employees)). Every time we tried to sell a voluntary opt-in program, it eventually had to be dropped because the sick people would join disproportionately, costs would rise, the program would lose money, rates rise to compensate, the least sick drop off, etc.

Some of the Libertarian arguments in this matter reminded me of a frequent conversation the customer service people would have when someone would try to buy health insurance: "This policy has heart disease excluded! Why would I want it? I've got heart disease, that's the whole reason I want insurance!" "Ma'am/Sir, insurance is to guard against future events." (We had one very nasty individual underwriter who would frequently add "You should have bought insurance before you got sick if you wanted it to cover your heart disease.")

The problem to me has an interesting interaction with game theory and more particularly rationality research. We know that people are not very rational in assessing probabilities of future costs (I think the relief some people feel in having retirement plans comes from recognizing this, being grateful they don't have to consciously consider it). A strict Libertarian might say regarding everybody who doesn't make the correct assessment, "Well, too bad, but that's their problem." Well, maybe it is. But if the end effect is people going bankrupt, for instance, or not being able to afford their children's college costs, then the negative effects extend further than just their misery. The health care costs remain in one way or another--unless we demand payment-on-service in every case, in which case our callousness is going to lead to a kind of society that I at least don't want to live in.

The question is, how do we deal with this general irrationality given that it's not going to disappear? I find some kind of required universal health plan to be the best solution for pragmatic reasons--you have to minimize the effects of antiselection or a plan won't work.

note: I'm not addressing rationing here, which has to be answered in one way or another. There are cases in which you could spend a nearly infinite amount of money keeping people alive for another day, week, month. Obviously we don't want to do that. I suspect some kind of utilitarian calculus is required to figure out the maximum point that a universal plan should be set to serve. (Just as normal health insurance plans used to only go up to $500K, $1M, or $2M. Above that, I think the idea was you're already f---ed, so no reason to drag everybody else down.)

note 2: I'm also ignoring the fact that health care costs rise so dramatically in part because of the cost of new technologies. The inelasticity that many have noted, because most people are willing to pay almost anything they have in order to avoid dying, has a particularly strong interaction with economic complexity (in the sense that Donald Warsh used it in his 1986 book). That also has to be addressed in one way or another.

Neither of these two issues has a critical bearing on the basic question of whether there should be a universal plan or not, though.

Gary--
How come it says it's a melee weapon but then is effective at up to 100 meters? That sounds more like a medium-distance weapon to me.
(Don't throw one at me by way of answer, I'm ducking.)

Phil: Here, Jes, this is the person you were trying to argue with the other day, whom you mistook Andrew for.

Oh no. I've met Scott before on Slacktivist. Charming chap: he makes me wish I had a daughter so that I could forbid her to marry him.

"How come it says it's a melee weapon but then is effective at up to 100 meters?"

Uh, bad judgement?

I don't recall, offhand, if the episode had the Capellans also using them as handheld weapons; I don't recall that they did, but it's conceivably a detail I'm forgetting (I don't think so, but I want to cover my bases).

They were always shown throwing them. So I'd tend to think it's just a bad choice of words at that site. But at least I found the picture. :-)

(Dr. Science was quoting from the episode, specifically Dr. McCoy using a local idiom to insult the visiting Klingon.)

"Charming chap: he makes me wish I had a daughter so that I could forbid her to marry him."

It's the belligerent, in-your-face, "oh yeah, you jerk!" libertarians, who are so very visible, and memorable, who give the sane and sensible ones, like Andrew, or Jim Henley, or Jon Henke, an entirely undeserved bad name.

Funny they don't seem to realize that, but perhaps they reject the notion as collectivist.

Our (aussie) public health system is far from perfect, but it is better than none.

Nice to see you back Gary. I have some twangs of empathy with libertarian positions, but it seems that it has largely become a stalking horse for the right. I think in 30 years, libertarian is going to be as perjorative as anarchist (apologies to Anarch)

"I think in 30 years, libertarian is going to be as perjorative as anarchist (apologies to Anarch)"

No offense intended: pejorative. It's an immensely common error.

I tend to think you're wrong, but who the hell knows where we'll be in 30 years?

Maybe politics will be primarily pro and anti Extropian. I'm sure not going to predict.

Oh, trust me, LJ, it already is. At least if you visit the farther-left blogs.

I didn't see the chart of doctor salaries, malpractice provider revenues, provider insurance company revenues, and drug marketing expenses. Don't these have a lot to do with the differences in costs? My experience is that doctors are not impressed with the notion of being employees in some system, be it a gov't or corporate one. And I recall reading that the AMA functions as a cartel, limiting the amount of practitioners it will allow to join. Anyone know if that's the case?

And no visit to a doctor's office is complete without seeing the immaculately++ groomed and dressed drug company reps with their little carts of samples -- costs of which are passed on, of course. One local group decided to bill the drug reps if they came during office hours: would that it were a more widely adopted idea.

Anecdotally, I had a doctor tell me (his uninsured patient) that he had to clear $300K before he got paid, and his offices were by no means palatial. This was at least 10 years ago.

I have been hung out to dry by insurers multiple times and am currently paying off an $8000 dental repair that wasn't covered, so I feel a distinct lack of sympathy for any argument that says the current system is the best of all possible worlds.

Thanks, Gary.

Phil, just out of curiosity, whose more at fault for the pejorative reading? The far left, or people who use libertarianism as a blunt argumentative club?

I think in 30 years, libertarian is going to be as perjorative as anarchist...

Some of us who don't have "Anarch" in our name have a history with that ideology y'know.

Perjorative? Hang on while I look that up ... uuhhh.. perizzites ... Hey!!

I think there's enough blame to go around, lj. You've got your Glenn Reynoldses and suchlike who put on a libertarian veneer even as they defend every bad choice the Bush administration makes about everything, tainting the word by association; and you've got your committed socialists who turn up their nose at anything which purports to defend market capitalism. (I'm not trying to do any Red-baiting there, btw; I think the people to whom I refer would describe themselves the same way.)

Dr. Science, you don't have one of these, do you? I wish to know how much I need to worry.

No, no -- Vulcan Academy of Sciences, that's me. We're peace-loving people. *pinches fingers together significantly*

"you've got your committed socialists...

I have a problem with committment. For me, it's a flirtation across a crowded room. Sometimes the girl is a capitalist ice cream purveyor and I go for it. Sometimes she's offering shoes and that's fine by me at a certain price. But occasionally I spot a babe across the room who offers me a kidney transplant at subsidized rates, with the collective picking up most the tab.

It all works, more or less. Until my wife finds out and then I admit I was just kidding about that first paragraph. Really, I hate ice cream, I go barefoot, and what's an extra kidney but a burden.

I'm committed to my one and only ideology.

I would support completely opting out of our system, as long as it was for life, and you could never get back in.

Just like Blue Cross does. Oops, that evil for-profit system doesn't have that broad of a restriction.

Look up "pre-existing conditions," Scott, before you tell us how wonderfully tolerant private insurers are about letting people sign up.

"We're peace-loving people."

You can't fool me; I know my Vulcan history. Though if you're truly a follower of Surak, okay. Up a point (avoids obvious joke). Still doesn't mean you can't decide to rationalize, I don't know, supporting the Maquis, or something.

And you people claim you don't lie, but you sure can "exaggerate."

So keep those two fingers away from me, unless you approach with them held together. I gots your number.

Though if you ever get to that seven year point, let me know if you need a friend to help out. For the benefit of inter-species amity, you understand.

Just in case Scott is still hanging around: I was snippy earlier, for which I apologize. That said, I am not trying to paint a picture of anything. I didn't draw any particular conclusions from the data; I just wanted to provide it as a reference point. It shows the US being good in some areas and bad in others. To my mind, it does not show the US getting value for the vastly greater amount we spend per capita. But the post was just data.

Tangenting onto the Libertarian bit: A friend of mine -- sadly recently deceased -- was an avowed libertarian. He used to talk about there being two sorts: The "privatize the sidewalks" ones and the "Sane ones". (Take a guess which side he was on).

About the only thing we EVER agreed on was that the privatize the sidewalk Libertarians were best avoided -- like street preachers and door-to-door salesmen.

Some of us who don't have "Anarch" in our name have a history with that ideology y'know.

And some of us who do don't.

But you have to admit, you are going to that university famed for its rather, well, anarchic approach to student government.

Sonofa...

Enrak wrote:
If we define poor *citizens* as those living under the FPL, then only 40% of poor *citizens* are white according to the 2000 census. If we use 200% of the FPL then it falls to 36%.

That was supposed to say 40% are non-white.

Look up "pre-existing conditions," Scott, before you tell us how wonderfully tolerant private insurers are about letting people sign up.

The post I was responding to didn't limit itself to pre-existing conditions. I read him as saying you couldn't come back no matter what, and that's much more restrictive than private insurers are.

Charming chap: he makes me wish I had a daughter so that I could forbid her to marry him.

As if any daughter you'd raise would be interested in men.

That said, I am not trying to paint a picture of anything. I didn't draw any particular conclusions from the data; I just wanted to provide it as a reference point. It shows the US being good in some areas and bad in others.

You have to admit, the people wanting more money for the VA painted a somewhat less rosy picture of the healthcare veterans are getting, and the people wanting to expand govt healthcare paint a somewhat more rosy picture.

I still don't see why, if 30 million Canadians can create a wonderful system, why you couldn't do it w/ only 30 million Americans. Would only the poor or sick want in, as if no healthy person even wants insurance? What does that say about whether the middle class really wants the govt to take care of it? Why couldn't you get the people the program would need voluntarily?

Scott,

The problem we run into with healthcare (and I speak as someone wholly opposed to nationalized health care) is that if it is limited to those who opt in, we run into a massive adverse selection problem.

Insurance works by pooling risk: by getting a large enough group of people, the company can utilize statistics to determine what costs they will probably incur. The company can then determine premiums based on that data to ensure that, over time, the company can cover insurance claims and still make money. With health insurance, however, the people who tend to think about it are those who need it. When I was working in the civilian sector, I consciously rolled the dice and went without health insurance because my wife and I were both young and healthy, so going without was a reasonable choice given our fiscal situation. Now that I'm a bit older, I'm going to make sure that I get a good health plan when I get out of the service because I am older and I have several conditions that require daily medications. I am not unusual in either of these decisions, which means the insurance companies have to charge much higher premiums in order to cover expenses and still make money. By forcing the young and healthy to purchase insurance, the companies can distribute these costs and reduce individual health care costs.

If the government creates a national plan that people can opt into or out of, it will run into the same problems. This is exacerbated by the fact one can always get emergency care if you need it, so if you're poor or even just short on cash, opting out of the system may be a rational decision.

This is not necessarily to say I favor a mandatory health insurance scheme of any kind, only to point out why, if we're going to create a universal health care plan, everyone is eventually going to have to be included.

Scott wrote:

As if any daughter you'd raise would be interested in men.

That should tell you everything you need to know about Scott.

As if any daughter you'd raise would be interested in men.

I missed that the first time through Scott's comment. While I'll ultimately defer to the more experienced members, I believe that comment is in violation of posting rules.

Scott, you are more than welcome to comment on the facts, ad hominem attacks about a person's personal life go beyond the bounds of civilized discourse and will not be tolerated. Consider this a warning.

[snark]It seems that some people really do want to see poor people dying in the street for lack of health care.[/snark]

Another thing that I'd like to see some numbers on is the savings in administrative costs. I've heard (no verification) that various government programs spend about one third of their budget on bureaucrats whose purpose is to deny care to those who "don't qualify". A universal system would eliminate a lot of administrative costs.

Also, poor people rely on emergency rooms for health care. A universal system would hopefully get the non- emergency patients out of the emergency room. Emergency care is *very* expensive.

As if any daughter you'd raise would be interested in men.

Many people who do not know a lot about homosexuality seem to think so. However, various studies show that that is not the case. Contrary to believe in some circles it is not contagious.

Scott: "As if any daughter you'd raise would be interested in men."

Hello: this is a clear and blatant violation of the posting rules.

Does anyone have any explanation for why VA health care outperforms managed-care and Medicare? What could be the cause of this?

I mean, is it just adverse selection, or is there something more to it?

That was supposed to say 40% are non-white.

Ah. Makes MUCH more sense. Thank yew.

Does anyone have any explanation for why VA health care outperforms managed-care and Medicare? What could be the cause of this?

Yes. Some sort of explanation would be nice, if its only to exclude the VA from the discussion (though I suspect there are some factors that would limit its applicability generally, counterbalanced by other factors that would indeed be useful for the wider discussion).

Andrew: "I missed that the first time through Scott's comment. While I'll ultimately defer to the more experienced members, I believe that comment is in violation of posting rules."

Right you are. (No need to defer ;) )

Scott: You have been warned. Further incivility will get you banned.

Ara: It's in the article. Basically: in addition to the much lower administrative costs (which come from not having to decide who is covered, not being able to try to get the sick to leave the VA's risk pool, etc.), there are also a bunch of innovations that there's a lot more incentive to use given that the VA knows that the people they cover will probably be with them for life. (The simplest example, not an innovation, is prevention: up front costs, benefits down the road. If you know that you will be the insurance company reaping those benefits, you have a much greater incentive to incur the up-front costs than you do if odds are the person you're spending them on will change jobs and be insured by someone else.)

Also, some things (like portable electronic records) that are a lot more efficient to install in a large and integrated system. (Here again, the upfront costs argument applies.)

But the article is quite readable, not that long, and does a better job of explaining why the VA is not both (a life-long, integrated system) and (very efficient) by coincidence, but because the first enables the second.

(Not, of course, that it ensures it. Bad management will destroy anything.)

I read Scott's comment to me, and thought, more or less: "Should I respond? Nah, Scott obviously hasn't realized that the quote I nicked from Hitchhiker's Guide to the Galaxy was actually calling him a Vogon, not a man. What more can I say? Scott does not know where his towel is."

So unhip that it's a wonder his bum doesn't fall off.

So unhip that it's a wonder his bum doesn't fall off.

Gah

ObiWi's anti-spam character recognition thing sucks and causes frequent double posts.

A universal system would hopefully get the non- emergency patients out of the emergency room. Emergency care is *very* expensive.

My experience with the military system was just the opposite. I never got a same day appointment with a doctor-I was often given appointments 2 and 3 days away. This is why we eventually opted to pay more out of pocket and take our children to a civilian pediatrician. Also, I was often encouraged to go to the ER for things that could be handled as non emergent.

Also, one thing I don't care for with Universal or government provided healthcare is the perception that it is "free" care so going to the ER isn't viewed as something that shouldn't be done.

I guess I am just not convinced ER's will get less use, and I actually suspect the use will either stay the same or increase-shoot if I didn't have to pay anything out of pocket for an ER visit, there are times I may have opted for the ER rather than a wait until the next morning for an appointment-that $100 or $50 deductible made me think about whether medical care was emergent or not.

As for the VA-I am curious what they used to gather their criteria. My husband is a disabled veteran. When we lived in North Carolina his care was excellent through the VA. He could get timely appointments, he could get the medications he needed, and he had the same doctor follow him through his care. It was a very good experience.

We live in NH now-and the VA in this area is terrible-terrible to the point that my husband doesn't even use his VA benefits in this way anymore. Appointments are often backed up for months. When we first moved here, he got his first appointment 8 months after he contacted them for one. The same doctor doesn't follow your care-you just get whatever doctor is "on" that day. And even more frustrating is that the VA up here doesn't fully stock its pharmacy. My husband has severe allergies and asthma-the only allergy drug he could get through the VA up here is one he knows he is unable to take. They also couldn't get one of his asthma drugs. He tried both the VA in NH and VT and neither was a good experience and both required more than an hours drive (which would be worth it, if he actually got adequate care).

In the end we just opted out of the VA system, we pay almost $100 a month for his medications each month, and he sees a family doctor and an allergist that is covered on our insurance.

But I have to say that if the standard of care would be that of the VA in NC, I wouldn't be as worried, but I think they failed to include the little out of the way VA hospitals and outpatient clinics-because the standard of care there is worse than what I thought we had with the military-and that wasn't so great either (although in defense of the military system-when he was in the Navy they had not fully switched over the the tri-care system, although it was in its infancy in Norfolk, when we were there, so the system may have improved, but I admit we weren't pleased, and felt more comfortable taking our children to a civilian doctor where they would be followed by the same doctor and we could get same day appointments).

hilzoy sez:

". . . there are also a bunch of innovations that there's a lot more incentive to use given that the VA knows that the people they cover will probably be with them for life. (The simplest example, not an innovation, is prevention: up front costs, benefits down the road. If you know that you will be the insurance company reaping those benefits, you have a much greater incentive to incur the up-front costs than you do if odds are the person you're spending them on will change jobs and be insured by someone else.)"

This is just so, at least according to my experience. When my company first created a "wellness" program to market to its clients, they were charging an additional 1-2% in premium for it. Eventually they dropped the extra premium because there was no reflection in increased costs for it. But such programs were hardly pushed, because the assumption was that for the vast majority of your business, you would only have it for 3 to 5 years, then another insurance company would get it (usually because they were in an acquisition mode, willing to risk losses in order to increase the number of bodies insured. This all has to do with the cyclical nature of insurance, in which insurance companies basically all either gain or lose money each year. Sort of like a boom-and-bust cycle, except in terms of premiums/costs. As I recall two 3 and 7 year cycles with different weighting was the best predictor). Anyways, there was no real impetus to strongly push, for instance, cardiac fitness or anti-smoking programs, because you were unlikely to see the benefits of putting them in place.

The following exchange comes from the "Different Ways Of Looking At It" thread, where the topic of blood pressure came up, but I realized it made more sense to put it here, so here it is:

Hilzoy: "Gary: speaking as a pretty steadily 90/60 gal myself: yikes."

(Hilzoy was responding to my mention of my blood pressure, as measured at the supermarket yesterday, being 215/one-hundred-something [I forget exactly; 140?].)

I was displeased, myself, though it wasn't unusual. A bit unusual given that I'd taken two Clonidine, and been regularly taking it (out of Enalapril; have to both make a new clinic appointment when I have $10 to spare, and get another Enalapril prescription, when I have another $20 to spare), though.

The BP problem goes back decades it's why I ended up not getting my kidney operation back in the mid-Nineties until about seven months later than originally scheduled, because my BP wouldn't come down enough for them to feel safe doing it, combined with the fact that although I had health insurance at the time, it was "managed care" HIP, so each time the operation was postponed, it took another 6-9 weeks to be re-scheduled (all the time during which I had a "renal stent" inserted, which I won't detail, but isn't actually as much fun and kicks as rumor has it).

So when I hear about how universal health care might lead to waits, I think, gosh, that would be terrible.

And now that I have no health insurance at all, well, I'm just convinced that this is the best of all possible systems.

Hmm, wrong thread (now in the right thread).

Gary: eek. Also: "all the time during which I had a "renal stent" inserted, which I won't detail, but isn't actually as much fun and kicks as rumor has it"

-- you mean that if you had health care, this would not necessarily lead you to seek out opportunities to get renal stents inserted? Next you'll be telling me you'd only have colonoscopies when your dictor recommends them, as opposed to on a Friday night, just for kicks.

doctor. doctor. not dictor.

Eye zink mebbe you hat it korrekt der firsten time, hilzoy.

"...you mean that if you had health care, this would not necessarily lead you to seek out opportunities to get renal stents inserted?"

Not being a masochist: not so much.

I'm suddenly overwhelmed with memories I've managed to bury for years. That year was a nightmare. I spent 9 months -- 10.5, if you count post-op -- heavily doped on percocet, because the renal stent -- which is essentially a piece of metal that is, shall we say, inserted up an orifice that is not designed to have anything at all inserted in, let alone a piece of metal -- is, in fact, goddamned painful, which is why I was non-stop doped up on percocet (apparently I don't have as addictive a personality as I'm inclined to think I do, because I actually had no significant problem whatever stopping taking it when it came time; I had a couple of weeks of feeling lousy, like mild flu, and that was that; no big deal at all; I feel a lot worse just about all the time these days) the whole 9+ months I kept getting scheduled to be operated on, and having it postponed.

The postponements weren't just because of high blood pressure, although that was a few times; several other times it was because a higher-priority emergency happened to another patient, and even though I was lying there on the gurney, about to be wheeled into the operating room, having been admitted for surgery, I was bumped, and told to go home, and reschedule, which, as I said, always took about another 6 weeks each time.

And after the initial fun of the kidney stone attacks -- which is as much fun and kicks as rumor has it -- I wound up with the most appallingly worst doctor I've ever had, thanks to HIP (Health Insurance Plan Of NY).

All the other doctors I've ever had in my life have ranged from decent to great, with most being good.

But this one guy, who worked out of the Washington Heights HIP clinic, that I was assigned to see after my initial emergency room stay for the kidney stone attack (which occurred in the offices of the Doubleday Book Clubs, specifically the adjoining offices of my longtime friend, the editor of the Military Book club, and my other friend, for whom I was dropping off work, and expecting to pick up new manuscripts from, Ellen Asher, editor of the Science Fiction Book Club), was unbelievably awful.

My first clue as to this guy was sitting in the waiting area outside his and other doctor's offices at the clinic, and I hear him screaming -- screaming -- at the top of his lungs, at this couple that when they emerged, proved to be in their late eighties. He was bellowing at them about how stupid they were, and why couldn't they follow simple directions, and how he wasn't going to bother seeing them again if they were going to continue to be such idiots, and so on. The old woman was crying as she left -- she had one of those slow, can-barely-walk, shuffles -- and looked shell-shocked, and her equally ancient husband was trying to comfort her, but they were both utterly cowed.

Then I was ushered in to see him (for the first time), and he just snapped at me, and demanded I show him the paperwork I'd brought, don't keep me waiting, I'm busy!

He looks at it, snaps up, then reaches for the phone, and says into it "I have a patient I'm scheduling for immediate emergency [name of procedure] tomorrow: how early can you get him in?" And snaps off other medical jargon I didn't understand.

Then slams the phone down and snarls "be at [hospital] at 6:30 a.m. tomorrow." And pointed to the door.

I started to ask him what was going on, and he starts yelling at me like he did the previous patients: "Goddamnit, I don't have time to waste explaining things to you! Do you want to die!? Fine with me! Get out of here!"

Long story short, I managed to drag some info out of him, since I'm not in my late eighties, and won't take sh*t, particularly when my life is at stake, and I'm being told I have to rush in for emergency surgery (this was late afternoon already) in about 13 hours.

And the long story short on the medical side was that the huge kidney stone (my first clue at the ER had been when I had the X-ray taken, and I heard the technician let out a huge whistle: "What is it?" I asked; "that's the largest goddamned kidney stone I've ever seen in my life!" he said; then: "oops, sorry, I'm not supposed to say anything; ask your doctor." Who, the ER intern, that is, when he saw the x-ray, let out a loud whistle... and admitted it was the largest kidney stone he'd ever....) was in a position where if it shifted just a few millimeters, would block a certain duct, which would cause my kidney to shut down, and kill me within a couple of hours -- unless the stent was inserted.

Anyway, before I left the clinic, I went to the head of it, and complained at length about this asshole doctor, and outlined his style, and made sure that when I came back, I'd never see him again; when I left, I passed his office, and heard him bellowing at some other poor patient.

I gots a zillion more lovely medical anecdotes that I'll spare all, but there's one little tale from the thrilling universe of private health care.

Although let me say that when I, after the stent was inserted, was assigned to a specialty kidney clinic, the doctor I dealt with, who turned out to be the chief doctor of the place, who performed my initial lithotripsy (to which my kidney stone utterly shrugged off, apparently being a kidney stone that had traveled here from planet Krypton, with powers and abilities far beyond those of mere Earth kidney stones), was terrific; I couldn't have asked for better care.

But when I hear scare stories about the terrors awaiting us if we have universal health care: meh, I'm not so worried.

Also: whatever it is, it's pretty much apt to beat no health care at all (I do have access here to the Boulder [poor] People's Clinic, but when I had to have my heart seriously examined, I was referred to Boulder Hospital, and saddled with several thousand dollars worth of bills).

Gary: gosh, that beats, by miles, my story about the person who drew blood from me while smoking a cigar. Also, forgot to put a bandaid or anything on after taking the needle out, so that blood was shooting out of my arm in cheerful little pulses. And me just fifteen.

Generally, my doctors have been quite good. Dentists, however, are another story. I have probably mentioned the one who had somehow come up with the idea that loud music uses the same brain receptors (or whatever) as pain, and so would strap us into headphones playing Mahler at high volume, instead of Novocaine. We kept saying that it hurt. He refused to believe us, and said it was our imagination. I said: imagined pain is as bad as real pain, and if the Novocaine makes it go away, why not use it? For some reason, he was not persuaded.

Just thinking about it makes my teeth hurt.

"Dentists, however, are another story."

You really shouldn't get me started on medical stories.

Dentists. When I first moved to Seattle, and then eventually needed to find a dentist, I naturally asked longtime resident friends for recommendations. Vonda McIntyre told me about this sweet, somewhat elderly woman, whom she said was wonderful.

And, indeed, she was. But getting a little old.

After all the preliminaries, it was determined that I needed to get a couple of cavities filled; basic stuff.

But then they left me alone a long time while the dentist and her aide dealt with other patients, and eventually they came in, and started drilling.

And after a while I made enough noises, that I got them to take apparatus out of my mouth, so I could ask if they couldn't please, you know, use some Novacaine, please (and maybe nitrous oxide, as well?; I'm a suspenders and belt person when it comes to that sort of thing). And she looked at assistant and said "didn't you give him the Novacaine?" And the assistant says: "I thought you gave him the Novacaine."

Much embarrassment, and many apologies followed.

I kept seeing elderly dentist, and she was always fine otherwise, until she retired about a year and a half later.

My main complaint about dentists (last I saw them, which is more than fifteen years ago now, which I desperately have to do something about ASAP, as I've been saying for a while, but never mind) is the same complaint I generally have about any doctor and painkillers; I have great trouble getting them to give me enough nitrous oxide, because I'm very resistant; same as regards painkillers; I'm very resistant, and naturally, they think I'm a Drug-Seeker. No, I just really don't like pain, thanks.

Oh, and the kidney stone, if anyone cares, was about the size of a quarter-and-a-half; not the sort of thing that could come out on its own, which is why I ended up needing the surgery when the lithotripsy (sonically breaking it up; also my first experience with having an epidural).

Typical hospital story (St. Vincents, in this case; the kidney stone ER was St. Lukes-Roosevelt, where my former sweetie once worked, in fact, as a night ER admitting clerk, and, boy, did she have stories -- and, incidentally, if you have an emergency in NYC, that place is far better to go to than Bellevue, but that's a whole 'nother story): when I was admitted, I didn't look closely at my bracelet for about a minute, and then noticed that it said I was "Gary Faber." I pointed this out, but a minute had passed, and it was Too Late. So for the next four days of my stay I was "Gary Faber." Too much trouble to change it, you know.

Then there was when the nurses didn't drain the bag that... oh, never mind, that's too disgusting to tell.

Let's just say that I'm very happy to deal with needles and blood running in and out of me through them, compared to other tubes going in and out of parts of my body. Particularly unnatural drilled holes.

And apologies to all those for whom any of this has been TMI.

This is not a story of healthcare incompetence, and it's not a story of me, but I work with a guy who was walking around with a ruptured appendix for days on end. When he finally got in to see the doctor, they felt around, did an emergency MRI, hustled him into the ICU and...couldn't operate, because he had some pretty large-scale peritonitis. So they put a drain in (actually, they had to do some endoscopic, proactive drainage, the result of which was one or two of the trained professionals performing the procedure had to leave the room suddenly and...well, hurl), put him on some truly potent antibiotics, and told him to go home for a few days. After things cleared up, they went in and removed what was left, cleaned up a bit more, and that was that.

He lived. The guy is a scuba diver, sky-diver, and probably does a few other high-risk activities, and is almost done in by himself.

Also, one thing I don't care for with Universal or government provided healthcare is the perception that it is "free" care so going to the ER isn't viewed as something that shouldn't be done.

The ER is free, true; but then so is the normal doctor. If you go to Casualty (the equivalent of the ER here) you'll wait in line to be seen; if you go to your local doctor you can pick an appointment time.

What happens, in my experience, is the sensible thing - people with urgent problems go to Casualty; people with not-so-urgent problems make doctor's appointments.

Australia has free public health care, but still has a problem with people (particularly men) who do not see the doctor as often as they should. Cost is not the issue - the issue is people feeling uncomfortable about being poked and prodded by doctors.

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