Tuesday, June 23, 2009

Who IS that standing there?

I was doing something domestic the other morning while my bride was skimming channels and caught her pause on one of the network morning shows as someone (presumably a GOP talking head) was ranting: "If Obama gets what he wants you will find a government bureaucrat standing between you and your doctor!!"

I had kid lunches to find and breakfast to make, but I still had time to think,
"You smug, self-satisfied son-of-a-bitch, have you ever had a job shitty enough to have had lousy insurance? Because if you had, which I doubt, you insurance-company-donation-fattened hyena, you'd know perfectly well that there already IS a bureaucrat standing between me, and about 89% of the rest of Americans and their doctors. And it's a bureacrat even less objective, less reasonable, and less helpful than one from my government; its the one from my goddam insurance company."
I'm not sure why Obama's people haven't figured out that one of the few things less popular to the average Yank than our government bureaucracy are the meeching, grasping, parsimonious scriveners at our HMOs and insurance companies.

But there's a drum there, and I'm not sure why they don't beat it.

Update 6/23: Maggie Jochild over at Group News Blog gets it:
"They (the GOP and Congressional Dems shilling for the insurance companies) also claim it means a government worker will decide what kind of treatment you get. Well, currently those decisions are being made by cubicle drones for private insurance companies who receive bonuses for denying you care. Your disability and death have no impact on their bottom line. But a "government worker" will have no such incentive to keep you away from necessary treatment, and in the big picture, having more citizens alive and productive is better for the government's bottom line. You tell me which one looks more attractive."


  1. I've got the answer to your rhetorical question, Chief.

    When people think of government, they think of incredibly expensive and not terribly cost-effective programs like defense, education, and space exploration that usually get the job done but frequently using methods we wish they hadn't. Mostly that's okay, defense and education for example SHOULDN'T be run with a profit margin in mind. They are expenses that are part of being a great power and the benefits we acrue from them can't really be measured in dollars.

    I need to tell you that I worked in the health insurance industry for a couple of years and I find your libelous comments about the people who lead insurance companies to be FAR TOO GENTLE to those small-souled, uncompromsing, relentlessly stupid, egomaniacal, snot-nosed TWITS!!!

    Anybody who has worked in an industry other than insurance and falls into those PITS OF INIQUITY known as health insurance companies learns VERY quickly to either become a soulless automaton (not very comfortable, I've tried it) or to flee.

    But back to my main point. Americans don't have that much faith in government. Things never seem to work the way they are supposed to on the first try and always seem to be more expensive than expected.

    Now the Obama crowd are promising to use the powers of government to reduce healthcare expenses (which are WAY out of line and getting worse WAY TOO FAST).

    We all know that Obama really does care and really does intend to get it right but we also know that the bigger the system the easier it is to break it and any healthcare initiative the government passes is going to make the DOD look like really small potatoes (gulp).

    I haven't looked too closely at the proposed plans yet but the costs sound suspiciously low (by a factor of 5-10) and the benefits seem too good to be true. We've heard lots of government proposals that sounded good on paper but didn't work out as expected. Can the US government afford a huge mistake at this time?

    Contrary to what you're probably thinking, I'm actually in favor of doing something. But all I've seen so far are pie-in-the-sky ideas that have no basis in reality and that makes me unwilling to directly support government run healthcare at this time.

  2. P.S. - I posted a message under your "Shocked, Shocked" entry that I'd like to get your response on.

  3. Pluto: every other industrialized nation has some form of national health care. Every one uses that system to control costs better than we do, and none of them has substantially worse patient ourcomes than we do. The bottom line is that government is not worse at medical bureaucracy than any private company and, since it has no profit motive and benefits more from healthy, productive citizens than a 15% bonus for the stockholders, less motive to ration care for financial reasons.

    When you think about it, for-profit insurance and medicine is almost the very definition of insanity. It is a natural monopoly, it is a "commodity" that has no real quantifiable outcome (defone "healthy" in financial terms...). It almost cries out for inflated costs, unnecessary tests, $40 dollar aspirins...

    Fee-for-service medicine and private insurance are dead ends. We need to get that into our heads and move on.

  4. Chief-

    You said, "every other industrialized nation has some form of national health care. "

    There is a big difference between national health care and national health insurance. The former is where the government operates a health care delivery system, and the latter is where the government simply provides (or subsidizes) insurance coverage to pay private providers for health care services.

    The scare mongers cite "rationing" and loss of choice as the typical evils of national health care. Of course, they avoid addressing that some 50 million Americans are "rationed" out of the system, and have no choice other than an emergency room.

    We are in the crisis we are in because health care has become obscenely expensive. Not because it should be, but because all too many people were willing and able to finance, trough the risk and burden spreading of commercial insurance, the endlessly rising cost of health care. But we are reaching the point where this profit driven medical industry has begun to price itself out of the reach of more and more people.

    I did my annual physical at the national health center here. Appointment was one week after requesting same. Doctor interviewed me, gave me the typical hands on check, then drew up the list of blood work. Since I had an upper respiratory infection, she told me to wait 10 days before coming in for bloods, as that could elevate white count, and she didn't want to assume any elevated white count was due to the URI. Gave me a prescription for the URI and scheduled me (herself, in her book)for two weeks hence. Did as she ordered, and finished the exam two weeks later. Total cost - nada, zip, nothing, other than the prescription, which TRICARE reimbursed 75%. If I had Greek insurance, which costs the same as TRICARE for LIFE, the prescription reimbursal would have been 90%.

    BTW, every Wednesday morning, a National Health Care physician comes to our village of 80 folks to conduct office hours. That saves people without a car from taking the bus 8 km to the next village where the doctor has hours three days a week, or 25 km to the island health center.

    I wonder why Greeks have a lower infant mortality rate and longer life expectancy than Americans?

    I will say, however, that the interior decorations in the facilities here are nowhere near as nice as in the states, and the chairs in the waiting rooms are not upholstered.


  5. Chief, Al is getting at what concerns me.

    Turning the US into a healthcare insurer strikes me as very similar to your definition of a natural monopoly and since government tends to be:
    a) somewhat less efficient than business
    b) above all other powers
    I fear that we'd wind up with a HUGE natural monopoly that would eat up the rest of the government in short order.

    I am more in favor of a national healthcare service with rationing. We ration healthcare services in the US right now by making them so expensive that only an ever-shrinking group of people can afford them so some form of merit-based rationing seems to make more sense to me than the current system.

  6. Pluto

    There is actually both national and private health care here. National tends to keep the cost of private way down, for obvious reasons. On an island like ours, private supplements the national. For example, there is a private dermatologist. Costs to have a minor skin lesion removed cryogenicly was 60 Euro, involving three office visits. Private ophthalmologist (MD) complete eye exam is 35 Euro. Find those rates for good care in America if you will. Of course, their waiting rooms will never grace House Beautiful, as is the case in the US.

    Similarly, there is public and private insurance. Since the cost of private care is reasonable, so is insurance. An expat friend pays 90 Euro/month for 90% coverage of private health care if she chooses to go that way.


  7. One of the great victories for the Republican Party in the post-Reagan political cycle is the acceptance by the American people of the "government is evil, government is incompetent" mantra. The logical corollary is that "business," as embodied in good old corporate capitalists, can always be trusted to do a better job than that stupid old government.

    The American people still believe this shit, even after they've collectively lost some ten trillion or so dollars, thanks to the rank incompetence and untrammeled greed of American business interests. Admittedly, government had a slight window of opportunity to try to slow down the corporate and financial trainwreck, but the reality is that government had essentially been denuded, stripped of both competence and authority, and those regulators left who were honest brokers just couldn't keep up.

    Even Pluto buys into the myth. No, Pluto, I don't agree that government is "somewhat less efficient than business." Government has never fucked up the way business did this time around. Yes, government, in the form of venal politicians, was an enabler, but it's pretty clear now that all of those captains of industry didn't have a clue as to what they were doing. Nor did the masters of the universe whiz kids working for them. They were a bunch of fools who enriched themselves while fucking the rest of the world.

    Going back to the Reaganites' victory in fostering the myth of government incompetence, we find ourselves gazing upon a young president who's not as smart as he thinks he is. He, too, has bought the myth that industry is somehow more capable. Plus, of course, he's playing politics. And I will tell you what's going to happen. Mr. Obama is going to fuck this one up. Just as Mr. and Mrs. Clinton did 16 years ago. We are going to continue to stumble along with our current broke-dick system until the whole damned edifice just collapses of its own weight.

    And, no, I am not defending government. But it's pretty clear to me that government is the only solution to the embarrassment that we now call a "health care system."

  8. Publius:

    "But it's pretty clear to me that government is the only solution to the embarrassment that we now call a "health care system."

    Actually for it to become a "system" there can only be one lead agency, and that would have to be government, the only entity in the country that is, at least theoretically, accountable to every last swinging Richard. The unfortunate part is that the medical care (really hard to call it "health" with a straight face) industry is as dysfunctional as the current economy, and for all intents and purposes, a bailout, or the equivalent, is going to be required.

    We have become so seduced by the "business is good, government is bad" mantra, that some 50 million of our fellow citizens have been priced out of medical insurance, with more to come. In relative terms, those of us with TRICARE Standard (75% coverage), for example, are seen as having a near Cadillac level of coverage, while 90% is routine in less developed countries.

    The bill is coming due, and it will fattened by decades of private business excesses and myopia.


  9. So if we put it in the hands of government, taking it out of the hands of the greedy corporate MF'ers, how do we set it up to minimize abuse. Can a system be built that disallows fraud?

  10. wourm: There is, never has been, and never will be a system that disallows fraud in al of human history. We're all human, and the built-in instinct to get something for nothing, to game the system, has been with us since the first australopithecene conned his fellow hominid into climbing up the hill to look for ripe berries while he snuck down to gorge on the ones he already knew were growing in the valley.

    That said, part of the problem with the medical business is the sheer lack of accountability. Right now, for example, there is no systematic or world-wide understanding of, say, how to best treat a back injury. That same proto-human had back problems - comes with bipedal locomotion - and the causes are pretty well understood. And yet there has never - never - been a complete, thorough, statistical study done of 1) symptoms, 2) diagnoses, 3) treatments, and, 4) outcomes. So, in essence, each and every physician starts out from a tiny, localized knowledge base: what she's learned in school and in practice, the advice of other physicians she knows, the PDR and other archived medical references.

    This goes for damn near every other medical treatment and condition. Why on earth would anyone let this happen?

    Simple: there's no money in doing the research. No one gets paid to discover that all that expensive back surgery has a 34% higher chance of additional complications and a 6% lower incidence of patient recovery than, say, physical therapy, weight loss and exercise.

    Businesses do certain things well, things where urgency isn't critical and the customer has the time, and the understanding, to shop intelligently. And where there is a well-regulated competition to keep prices low, quality and variety high.

    Medicine is almost the definition of something that a private market shouldn't do well. Sick and injured people are in a bad position to make rational decisions, there is no way that you can, say, comparison shop for a back surgeon versus a chiroprachter versus a dietician/personal trainer.

    But...no system, whether it's private or public, can be built to lock out fraud. The best you can do is to craft a system that rewards rational decision and intelligent planning and have a watchdog without bias or motive (i.e., NOT a private insurance company, who has a motive to deny any claim it can just to increase its own profitability...) to keep an eye on everyone.

  11. Firstly thanks for the invite here, lots of interesting topics and interesting people.

    Now health is a particular area of interest of mine. Worked for a private hopsital company, a major private health insurer, done some consultancy for a health industry group.

    Now the private health system in Australia is tightly (very) regulated and basically performs as an outlet for those with a few dollars to jump queues for non-critical work.

    Now I did a study (for the health insurance co) and I came up with a 17% difference in efficiency (based on bed days and what is called DRG's) between the private and public system. The public was more efficient. This did not include marketing costs which would have made the private system worse, it was on a comparible to comparible basis of treatment.

    The reasons are slightly more subtle than most people think. True the large beurocracy did actually make better decisions on things like capital investment. An example from the past is MRI/CT/etc machines. At one time (this was years ago) the Victorian State Govt had only half a dozen in strategic locations. But Tasmania, a much smaller State had a greater number in private hospitals in Hoebart. basically there was insane competition for 'machines that go BING'.

    The other reason is only the Govt can negotiate on any like a position of strength with doctors who, if allowed, will (bit like Wall St bankers) rort the system dry. At the pivate health insurer, doctors bled us dry.

    Plus the low (fraction of a %) collection costs as it money is collected through the tax system

    The outcome:

    The US, the only major OECD country not to have a centralised health system pays 15%+ of GDP with very poor health outcomes.

    Look up OECD statistics and then the WHO.

    Cuba actually beats the US on several health stats like infant mortality, and nearly equals it in things like life expectancy (77.1 vs US's 77.3 .. Oz is 80.4) despite only paying $197 p.a. vs the US's $5,274 (2007 stats if I remember).

    How this works in practice? My mother (in the UK) had a heart attack, taken to hospital fixed up, bypass, follow up care, etc ... cost to her ... nothing and she's still around 10 years later.

    My wife, brain anuerism, best (literaly) care in the World, 2 procedures no less. Right as rain now.

    My mother in law (here in Oz), broke her thighbone, straight into hospital, fixed, follow up physio, etc .. cost .. again nothing.

    All this on (in Australia) health costs that are less than a quarter than the US in $ terms.

    Now the US has to have a public health system, mainly to save (increasingly scarce) money. The direct costs are terrible (and a drag on the economy), the indirect costs (of non or poor care) would have to be comparible and obviously an equal drag on the economy.

    Yet there is no technical reason why the US cannot half (yes half) the $ cost of health care and improve outcomes markedly.

  12. OldSkeptic-

    You are spot on. My cousin came to visit. Fell down in the airport and broke her hip. Hailed a taxi, told the driver she thought she broke her hip and her took her to the leading orthopedic public health hospital in Athens. Immediate surgery to pin the break and 11 days in hospital, as the Dr wanted to monitor her until risk of serious complications passed. Total bill = 1200 Euro, and she was a tourist. Bill was for room and board and "supplies" - they gave her a walker and crutches to take with her, for example. Returns to US, and her orthopedic surgeon bills her insurer $5,000 or so for the initial exam to check her into follow up care and rehab. Is there something wrong with this picture.

    BTW, while in the hospital in Athens, they gave her a 100% physical. Standard procedure, as it makes no sense to ignore the whole body when you have a captive audience.

    Unfortunately, the provision of health care in the US is a huge, profit making industry. Even with the 50 million uninsured Americans, none of the major players in health care business is starving. The real fear is not "rationing", "bureaucracy" or "loss of choice". It's loss of profit.