So Much for Stirring the Pot

>> Monday, June 15, 2009

The problem, of course, with trying to stir up controversy is that you need mindless gullible folks who think with their emotions, respond from their gut with kneejerk vehemence in order to do it right. To the best of my knowledge, I don't have any readers like that and, if I do, they don't generally show up in my comments.

Since my readers are overwhelmingly intelligent and thoughtful, they gave courteous considered answers that made sense, which, although not adding to the controversy, does make for a much more pleasant conversation.

Now, the Mother and I spoke of many other things regarding healthcare reform. I'm going to include many of them and I won't be making a distinction between ideas she had and ones I had. That's not entirely fair to her, of course, so I encourage you to assume the ideas you like are hers and the ones you don't are mine. That ought to even things out nicely. That and she is encouraged to jump in if I've misrepresented her views in any way.

The Mother and I address this problem from different directions. I don't know that we are looking for different results (though I suspect we have different levels of confidence that anything appreciable will be done to address it any time soon), but we are seeing it from different sides. I am looking as a patient, as a citizen, where prices appear ungodly high and, though I have good insurance that reduces it drastically (a) the costs are still very high for a quite healthy family - aside from the high cost of the insurance itself - and (b) I know personally half a dozen families devastated by the high cost of medical care for a loved one. And that's aside from the millions in this country who have no protection. Not only are they not cared for in a way that could preclude serious maladies, because they have no insurance, medical care when they have serious conditions are much more costly and still fall on us to pay - in medical costs for those costs absorbed by hospitals (and higher insurance premiums and copays as a result) and in higher taxes.

The Mother (paraphrasing from our conversations) doesn't see a way to reduce costs without making some serious changes to how we do things. Cost reduction must include (some of these are mine):

  • Reducing outlay for the care of those who have no chance of survival and no quality of life - to what degree, well, there's a debate (as I discussed yesterday). This includes limiting care for those who will not help themselves.
  • Tort reform to limit malpractice to a reasonable level and assure that cases are not tried that are not based on solid fact. Malpractice insurance, even for successful doctors, is outrageous and, believe me, that increases the cost for all of us. Don't think that the fact that we have the highest healthcare costs is completely unrelated to our rampant litigiousness. Even clearly baseless lawsuits can be expensive because the one suing is not held responsible for the costs (something I'm all behind).
  • Administrative costs. Most doctor's offices have more staff to deal with (often fight with) insurance companies/medicare/medicaid and submit 18 kagillion different forms in triplicate to get reimbursement often months later. Money spent on administration goes into fees for service and money not spent on nurses or other medical support.
  • Doing something about the high cost of medical education. Most doctors don't get to practice until they're practically in their thirties. That's a long time to live without a viable income aside from what can be hundreds of thousands of student loans. Doctors are a huge boon to any society, but the exigencies of becoming a doctor forces a certain level of greed on them just to survive and recover. It makes sense to provide some sort of subsidization, especially to encourage doctors to go into some of the less lucrative but undermanned subprofessions.
Now, the Mother is scared to death that a public option will be like Medicare, which, in her (and other doctors she knows' opinion) starves doctors for fees, reduces fees willy nilly whenever funds are cut without rhyme or reason. Clearly, there are other doctors who agree and, at least a handful who do not. I don't know what it's really like, whether it's an inherent problem with the system, whether the recent privatization is a factor, whether this is a side effect of having a vehemently anti-medicare faction in the government (either dominating Congress or the White House or both) since 1980 (with the exception of 2 years). Possibly, it is a factor of all three, but what I can say is that there is a significant potential for a public option to be mismanaged due to the political winds that blow and suck in Washington, because of factions that actively want it to fail will work to ensure it's failure, because a long term program is always struggling in an environment that changes the budgetary rules every year.

But, here's the thing, there are powers that very much want to have a viable healthcare system, one that doesn't leave huge swathes of the populace at a disadvantage, powers that want the right healthcare for everyone. They know very well that an option that doesn't work is more hindrance than a help toward their goal. It is very much in their interest (and surely the rest of our interest) to find an option that works because I believe very much that it's possible. The industrialized world beyond our borders is proof positive in my opinion that it can exist (and I find it every bit as compelling as the evidence of vaccination's great good).

In healthcare reform, in my opinion, involves several medical things and several nonmedical things. It's about reducing cost, preferably by removing as much from the equation as possible that isn't medical (and yes, that can include health insurance, but also administrative costs, protection against unreasonable lawsuits), while (a) improving care by reducing unnecessary errors (I'm of course for electronic records) and penalties for excessive secondary infections or surgical botching, and (b) providing care to everyone in a reasonable way, which, in my opinion, would also reduce costs associated with nonemergency medical care in an emergency setting, and reducing the burden of preventable disease. The cost of a mammogram is far less than the cost of treating stage 4 breast cancer, but people without insurance are going to end up with the latter if they can't afford the former.

It is about reducing the overall cost, but I don't see it, if it can be done intelligently, reducing the burden on the citizens because we're already paying for all those that don't care until its too late, by those who can't afford it, and, of course, for billions of dollars in profit to the health insurance "industry". Big pharma is a whole other topic, of course. I want to see a big change in where the money's going: to doctors and medical practicioners instead of lawyers and insurance companies - if we can do it, doctors won't go broke and we'll pay less than we did before. For better care.

Tomorrow, I'm going to postulate one way I could see doing it. So, if you feel like arguing, get ready. Or practice on this post. :)


  • The Mother

    That pretty much sums it up. No complaints here.

  • Stephanie B

    I do strive for accuracy. Not saying I always manage it, but I try.

  • Aron Sora

    Could preventing health problems be cheaper then solving them? Would it be easier for a doctor to do a quick 10 min check up every two weeks rather then spend 20 hours operating on a huge problem? Could the personal trainer reduce health care costs in this nation. If doctors gave a diet instead of pills, would this be better?

    I'm North Korea and you two are the US and Russia, I'm playing wit fire here but this discussion still has some life to it. Plus I get to work on my debating skills at the expense of my skin. (Don't hurt me, I don't really have nukes)

  • Aron Sora

    I'm sorry if my comment on Sunday's post is illogical.

  • Richard Perkins

    The double edged sword of big pharma and a health industry fueled by a fundamentally capitalist social structure: If we cut profits for medical industry we might be able to reduce health care costs without penalizing health care practitioners or reducing the quality of care for the most of the patients. The trade-off is that big profits in the field of medical technology attract big investments, fund big research budgets, and pave the way for great leaps forward in medical treatment. (Of course they also line the pockets of every middle man along the path but if you want an omelet...)
    In the long run, will this curb the rapid growth of healing state of the art that the western world has enjoyed over the last 2-3 decades? I can't answer that with my murky crystal ball. If I was more motivated I could probably do some research into new drug or groundbreaking medical practice releases per unit time broken in nations with expensive but intensely capitalist medical systems compared to socialized medical schemes. It would be enlightening, if anyone knows of someone who has already done such an analysis.
    Of course this doesn't even consider the prohibitively high impact of liability and administrative costs on American health care that Stephanie and Mother have already pointed out so eloquently.
    I just wanted to bring up another consideration, to add another dimension to this multidimensional challenge we face.
    There are no easy problems... just easy (and usually wrong)solutions. ;-)

  • Stephanie B

    Aron, of course preventive care is cheaper than treating a serious condition. I alluded to it so you'll have to pick a different country, perhaps one with universal healthcare. Perhaps you can sneer at us from France.


    Richard, many industrialized nations have had universal healthcare/socialized medicine for decades, yet they are often involved in medical breakthroughs (France was one of the biggies, if I remember, involved in AIDS research). Clearly it can be done and they have the health stats to prove it. We have examples of many different options, but to say it can't work defies logic to me. It does work. It has worked and it's working now. We don't have to start from scratch.

    One thing we do need, though, is a government committed to it. Half-baked plans and politically mealy-mouthed, poorly executed semi-solutions are likely to be worse than nothing.

  • David

    I will offer a dour view of health care. America is becoming a poorer nation. We have to lower our standard of living to compete with India and China. Does China worry about their health care costs? The result of this global competition is America will have a lower our standard of living. It has already started. We don’t have speculative bubbles (housing, stock market) to goose our incomes. This means that the medical field will be forced to take a haircut. A very big one, because we don’t have the money anymore. Rich doctors will be less rich, along with the rest of us. Which is fine with me.

  • Stephanie B

    That's one reason I think healthcare reform is necessary today. There are good doctors, not out to get rich, just out to make a living like the rest of us, who want to help people get well. I've met a few.

    However, it's hard to think of a doctor you've spent 20 minutes with who charged $180 for the time as someone on your side, as someone who hasn't gouged you and your insurance (if you're lucky enough to have it). If prices continue to rise, I suspect their will be a backlash against doctors and, as I think we've noted, this is more than just doctors trying to get rich.

    Though I agree it feels like it sometimes.

  • Richard Perkins

    Stephanie - You're right about semi-solutions, without a doubt. One other factor I overlooked before about the evils/benefits of big pharma: we no longer really have national economies or national markets. Instead we live in a world economy where everything is connected. So even if a big pharma company is based in a nation with universal health care and does their R&D in that economic environment, they still have huge capitalist markets to sell their products in (like us).

    Case in point: We lived in Australia for two years where we enjoyed a wonderful universal health care system. We have an asthmatic cat (don't ask) who takes fluticasone daily. Oz medicare didn't cover our cat, so we were paying for the inhalers at the unsubsidized market price. Our prescription cost for that drug (branded Flonase in Australia) was just over $50. Now that we're back in the US, we pay nearly $200 for the same drug (branded Flovent here). We're unemployed and uninsured here in the US, so again we're paying the market price.

    Granted prices do fluctuate over the course of 2 years, but we were buying Flovent in the US prior to moving to Australia for a little over $100 in 2006. (We were insured then, but the cat wasn't so it's still an apples to apples comparison) Now in 2009 it costs twice as much here and still costs the same in Oz. Same drug (fluticasone proprionate), same company (Glaxo Smith Kline based in UK), same dosage, different market.

    What's the point? Big pharma companies with deep pockets can afford to lay out lavish sums of money on R&D for exotic wonder drugs. They can also afford to sell those product in socialized markets for minimal profit, because capitalist markets (like us) will pay more, especially if they can market their new wonder drug directly to the patient, bypassing those pesky doctors (sorry Mother)

    Sigh. I guess it would be difficult to find conclusive data on whether capitalist healthcare systems promote or hinder expensive healthcare technology development better or worse than socialized medical systems. The markets are too entangled to decouple. Unless we ran an experiment where we shut down all the capitalist healthcare markets... hmm anyone up for an experiment?

  • Stephanie B

    The problem is that we'd have to depend on the drug companies for that answer and they have a vested interest in the profit margin.

    There are other motivations for advance besides riches. Perhaps we might find research would focus more on saving lives and less on acne treatment if profit wasn't as much of an incentive.

    I've read of older medicines that have great potential in helping disease in third world nations, but, since there's no profit margin, they aren't pursued. Perhaps, if we funded some research on merit instead of profit, we could do even better.

  • Richard Perkins

    Stephanie - True. Sadly, human nature is such that few things motivate more reliably than greed or self defense.

    To play devil's advocate, where would the money come from to fund research focused on saving lives instead of profit? Human decency is its own reward, but you can't eat it, and you certainly can't retire comfortably off it's dividends.

    I'm not really as callous as these arguments sound. But I am jaded enough to know that the masses of humanity vote (in aggregate) with their pocket books. Follow the money. The fastest way to change the world is to make it profitable for someone to do so.

    Unfortunately, many of our current crises (health care, energy, climate) clearly demonstrate that the fastest doesn't mean the best.

    Nice trading insights with you.

  • Stephanie B

    So we keep being told.

    The problem is, changing the world on a profit motive, doesn't make it better. Instead of helping people, they are almost always just a way to further concentrate the money among a few.

    There are organizations that do tremendous things world wide without a profit motive, Red Cross, WHO, even the Bill Gates, Habitat for Humanity, Doctors Without Borders. Even the efforts to put affordable computers into the hands of every child. In the long run, the changes we make for the right reasons are the ones that make the world better.

    In my opinion.

  • Relax Max

    I am offended by the opening paragraph of this post. Although I am a regular reader of your blog, I am pretty mindless and gullible. I will thank you not to lump us all together.

  • Stephanie B

    In the future, I'll point out the intelligence and courtesy of my readership...and Relax Max.

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