Tuesday, July 19, 2011

I Guess it's How You Look at It?

State of Illinois legislators are fuming because the stricter rules they have put in place for proving Medicare eligibility have been rejected by the Feds. Their legislators say it is necessary to prevent fraud and to lessen the burden on an already overloaded budget.

State Representative Patti Bellock, a Republican who helped craft the reform package, didn't mince words when describing how overloaded she believed the state's Medicaid rolls are.

"Fifty percent of all births in Illinois (are) on Medicaid," Bellock said, according to ISN. "One out of every three children in Illinois is on Medicaid, and one out of every five Illinoisans is on Medicaid."

Is Rep Bellock's "non-minced words" directed at the people receiving Medicare benefits, or at the state of the society in Illinois that results in these large portions of the population having to fall back on public assistance to receive medical care? Add the 2008-2009 uninsured to the numbers she is quoting, and roughly 35% of her state's population is either uninsured or on publicly assisted insurance. And, if you wade through that Kaiser data, you will find that 58% of the uninsured are employed full time, as are 54% of the Medicaid beneficiaries. We are talking about working people. I Guess it's How You Look at It?

Note that Rep Bellock does not seem to be expressing concern that 1/3 of the children in her state are from families that cannot afford "private health insurance", and that perhaps that's an indicator of other deprivations suffered by the young in her state. I Guess it's How You Look at It?

So, is it about "budget issues", or people? It sure as hell isn't about "those people getting jobs and getting off the welfare rolls, as only 55% of the population has employer sponsored coverage, and if you factor out government employees, the private sector is not doing anything truly significant to give access to health care benefits to the population. I Guess it's How You Look at It?

Does the US spend double the per capita amount of other nations for health care, or do we charge double? Indeed, if you look at it from a charges basis, we charge 3 to 4 times more for most medical treatments and supplies than anywhere else in the world, yet our most common health indicators are lower. I Guess it's How You Look at It?

What leaves me cold, is that the generally expressed viewpoint tends to judge poorly those who must rely on public assistance for the cost of their medical services, yet the data shows that on a societal level, we have priced health care out of the reach of a significant portion of the population. I Guess it's How You Look at It?

Sadly, the sub-texts in the medical insurance debate seem to make it sound as if a small, lazy, segment of the population is over burdening the public coffers. I would offer that a large, bloated, greedy insurance and medical care provider industry is slowly, but surely bleeding everybody's coffers. I Guess it's How You Look at It?


  1. The entire "Reagan Revolution" was about ensuring that the conversation would always be about lazy poor people and darkies meeching off the public rather than lazy rich corporate execs and bankers sucking off the public tit...while merrily making money. Goldwater's people had tried that, but it wasn't until the Eighties that the Great Communicator managed to run the con. Now most of our political class has internalized that notion to the point where it's nearly impossible to get the point across that most of those "undeserving" poor people are poor for a reason...and the reason isn't because they're lazy, stupid, or criminal.

    Great post here (http://pandagon.net/index.php/site/comments/people_on_the_public_dole_living_in_denial) about how this has worked so perfectly that people define whether they're "on a government program" by their perception of their social class rather than whether or not they're actually getting a bennie from the government!

    Her concluding graf is so good at discussing what you pointed out, Al, that I need to quote it here in toto:

    "The obvious result of this is that Republican voters are supporting ideas they clearly don't understand, because their prejudices are preventing them from thinking clearly. So you see a lot of conservatives raving online about how we don't need to raise the debt ceiling, and they're thinking, "We've borrowed enough money to pay for the liquor and cigarettes for an undifferientiated hoarde of dark-skinned layabouts. Screw 'em. They should get a job and spend their own money." This is wrong on many levels, and liberals tend to focus on the most obvious wrongness of it---the classism and the racism and the total lack of empathy and the broad stereotyping that has no basis in people's realities---but there's another level of wrongness here that is driving this entire debt ceiling fiasco. And that's the assumption that the main role of government is to tax well-off people and hand it out to people who have less. The government actually does very little of this. If anything, they tax well-off people and then give it right back to them in credits, deductions, subsidized loans, etc. in order to to make their lives easier and more secure. And that's after all the money that's spent just running the country and of course the untouchable defense program. The amount of taxation that goes to redistribution of wealth is measely. It's certainly not enough to get the people who depend on it on a road out of poverty, unlike middle class subsidies that really do help middle class people start accumulating social capital and wealth at an early age that pays off their entire lives."


  2. I always find it ironic that "real" health reform would probably get the job done across the board. One need look no further than WHO's stats: http://apps.who.int/ghodata/.

    The problem is a large swath of the American population doesn't seem to want it. People voted these nuts into office in droves. Personally I chalk this up to ignorance of the facts and an irrational fear of the big, bad unmentionable, highly un-American S word (it rhymes with "shmocialism").

    The right has simply done a bang-up job of severing the debate from reality--a winning strategy apparently as it has left sweeping cuts as the only politically viable solution.

  3. ""One out of every three children in Illinois is on Medicaid,..."

    IMHO three out of three should be covered. The crime is that every child in America should be covered by Medicare. They certainly rate it more than geezers like me. With the high cost of end-of-life care, why not spend those dollars on beginning of life for all. No means testing, all under 18 should be eligible.

  4. Chief-

    I find it interesting that some folks I know who work for firms that are 100% dependent on DOD contracts call themselves "private sector employees", and most rail against "feeding at the welfare trough." Yet, for many, their jobs were done by uniformed military or civil servants just 5 or 10 years ago.

    But then, we have seen the Tea Party Seniors demanding that Medicare be protected from a "government takeover".

    Our populace is out of touch with reality, and demanding sweeping policy decisions on their day dreams and fantasies.

    Is it any wonder WASF?

  5. Al-

    Great thread. No answers, sorry . . .


    "The problem is a large swath of the American population doesn't seem to want it. . ."

    Why? What is it that we all see, that they don't?

  6. I am constantly surprised by the American voter.

    Things that seem to be no-brainers (like universal health care and universal decent quality education for kids) seem to create great controversy for the "typical" voter.

    Other things like spending huge quantities of money on foreign adventures are simply accepted as the price of being "the greatest country on earth".

  7. Here's a perfect example of the sort of guy who would think that poor kids getting sick rather than having "his" taxes go to pay for their medicine is a good idea. This turned up on my Facebook in regards to some sort of House of Reps foofaraw over this ridiculous "cut, cap, and balance" snake oil currently being hawked by the GOP raree show.

    This individual, who defines himself as a "conservative", says;

    "I happen to be all for revisiting the revenue side, unlike some of the "extremists" in the House GOP. Most of the Bowles-Simpson recommendations appeal to me, even if it will cost this 'greedy' Capitalist more money. And as for health care being a 'right'... sounds great in theory, but if health care is a right, then someone has a right to something I and millions of other individuals and companies have acquired after years of study and sacrifice. I'm very sorry, but in our current economic system, that would be called theft. If you deny the medical community the right to price their products and services in a free market (something M'care as it currently stands does), then who will be next? Is food, shelter, and clothing a "right", the way free speech, freedom of religion and freedom of assembly are rights as the Founders understood them? If yes, then 'freedom from want' is a right (h/t FDR), and all goods and services should be regulated and distributed by the State. In my lexicon, that's called Socialism and if that's what the Left is calling for, by all means let them call it what it is and fight for it. None of this is to suggest that there isn't a place for government assisting people in need, and the typical straw man argument from the left that the (R) plan is intent on doing just that is at once insulting and destructive to a rational debate."

  8. OF course, the problem is that the very notion that medical care is a "free market" is nonsense. Do you go in to the doc, listen to her spiel, and say "Well, gee, Doc, that's an interesting proposal, but the nice people over at Surgery R' Us just quoted me a liver transplant for $80,000 less than you are asking. How about you give me the transplant for $235,000 and throw in a nice set of whitewalls, too?"

    Put it that way and it sounds silly, doesn't it? And yet, that's what this boob and millions like him actually believe. And trying to change his mind? Forget it.

    Nope - I'm afraid that I'm with Andy on that it's going to take a real crash, a real hard landing, to change anything. But what I don't agree with him is that the change is going to be good. Instead, I think it's going to find us our Lenin, or our Franco, or our Napoleon, and we're going to be very, very sorry...

  9. seydlitz - a great question.

    I think it all goes back to how the issue is framed. An obvious example is of course how the GOP spat the word "socialism" when the debate was at its height--as if you could draw a direct line from a universal system of healthcare to the gulag.

    I hate to play elitist but I think it boils down to plain old ignorance (willful or otherwise).

    As Ael says the absurd belief in American exceptionalism is still going strong among the average voter. People don't see the statistical reality staring them in the face because they don't even bother to look for it. They're not interested in alternatives like the Japanese system (publicly funded to cap costs, but privately administered), or acknowledging the fact that a universal system of care and private insurance are not by any means mutually exclusive (many Europeans supplement their basic coverage with private insurance). They don't care because they're convinced America always knows best.

    Like the Chief I'm deeply pessimistic on this. The economic reality is that in lieu of substantive reform there are going to have to be broad cuts, triggering--in his words--"a real hard landing." Sooner or later there's going to be a shrill wake-up call, and I too have little faith we will learn the right lessons.

  10. The Tea Party/GOP has been able to shape the argument to look as if large gobs of money were coming out of middle and low income taxpayers to pay for these "lazy" people who end up needing public assistance. In reality, middle and low income Americans pay a very small amount in taxes and of that small amount, an infinitesimal amount goes to actual lazy people. (Unless you're counting our congressional salaries)
    I worked with a guy who at least admitted he was a Libertarian. He also acknowledged that, on the surface, Tea Partiers are Libertarians. His salary was probably around $50k/year and as he was single, I'm sure he paid a fair chunk of it in taxes. But not that much. Still he complained.
    The other thing that worries me is that when Dick Cheney, Karl Rove and Rupert Murdoch own the US, what will they do with it? Enslave the idiots that let them take it? There will be no economy left as all the wealth will be held by their cadre. I really don't think they realize what they power grab is doing.

  11. Sadly, we are a more of a nation of "believers" than "thinkers". I don't know how else to describe the intellectual fiber of American society. The "Know Nothings" throw out statements unsupported or actually refuted by fact or experience, and it is accepted without any further rational inquiry, with large segments of the population accepting that which reinforces their "beliefs", rather than exercise a bit of mental examination.

    Some of this might well be a result of the "Age of Enlightenment", when knowledge was seen as good, and thus, absolute knowledge is seen as the ultimate good. Heaven forbid someone might say, "I really don't know". or "There are complexities involved". Unfortunately, all too many confuse "belief" with "knowledge". But then, simply taking something on faith is intellectually easier than actually having to understand it.

    Thus, while the far right may view the poor as lazy, what about their basic, imbedded intellectual sloth? They let the Bachmanns and Palins make their wild statements and then accept them as if they had come to the conclusions themselves. Who is robbing our nation of more treasure, the poor or the Know Nothings?

  12. This country became a plutocracy a while back, we just didn't recognize it.

    The plutocracy is only interested in making itself as comfortable as possible, frequently at the expense of the rest of the country.

    This isn't a giant conspiracy in my opinion, it is merely the logical result of several thousand REALLY rich people spending money to gain influence in Washington for the last 40 years. One of the surprising things about politicians is that once they are bought, they stay bought and keep delivering benefits for decades.

    Another dirty little secret is that the Republicans recognized this first and re-oriented themselves to take advantage of it but the Democrats are now maneuvering themselves to get a decent piece of the action as well. Don't look to the Tea Party to save us from this trend as they are a Republican experiment in plutocracy that got out of control.

    The two most interesting things about the situation are:
    1. The plutocrats don't seem to recognize their overwhelming victory in American politics and keep pushing for ever more ridiculous policies. It is quite likely that they will overplay their hand at some point and that could end very badly for everybody.

    2. The American public's willingness to go along with said policies. I'm sure that a lot of this is smart advertising (particularly in the false choices department, "Give up your rights unless you want to let the terrorists win"). Again, I suspect that their willingness to do this is deteriorating and at some point there's going to be a bad ending to this experiment but I can't see it coming right now.

  13. to all,
    I'm not right or left, i hope.
    But this question/thread is a basic one right now.We must answer what gov't is/isn't-step one.
    Then we must define rights AND responsibilities of the citizenry.
    I don't live in an ivory tower and came from poverty/immigrant stock.
    Now here's my sticking points.Attack if you will.
    -in my county we have migrants sending millions a month to Mexico and they usually are on medicaid. This is a fact b/c we see it with our own eyes.
    -Our locals won't work in the fields like the Mexicans, but they also get Medicaid/wic/housing subsidized etc.Fact.
    -What % of the 1/3 on medicaid is in unwed /single mother homes? Having kids w/o a declared/known father is a cottage industry in my county.It beats unemployment i reckon.
    I have total sympathy for the kids that we all love when they are fetus's , but generally ignore as actual human beings.
    We /i live with poverty all around me, but must ask -wtf? Where is the reality, cause i really don't know.
    We have a higher std rate than Ghana.
    I don't live in Portugal or Greece ,i don't cruise country clubs and play golf.
    I LIVE IN/AROUND AND RUBBING UP ON THE POVERTY AND MORAL BANKRUPTCY .of our system, and i surely don't know the answers, but we sure as fuck better start defing the proper questions, and this ain't gonna happen any time too soon.
    Read my post-on RAW called Rodeo cowboy and this is the kind of guy my miserable neighbors elect to represent us in Congress. Let's also throw Rubio into the mix.Also remember that we elected Jeb. How can any of this be explained other than saying that we live in the twilight zone? These guys are not reflective of reality.
    How/why i don't know but it's stultifying to experience, and you're gonna say-move. This geographical escape doesn't change the music sheet.
    How do you solve problems like people using their entire SS check to buy lotto tickets?
    Someone sent me hate mail last week and told me to get the fuck outta town and go 1000 miles north, which means go back to Cleveland. Great idea but what is less fucked in Ohio? We are in systemic decline.
    The answers should follow if we can only ask the right questions.I do not believe in hope and all the other eyewash words.

  14. To all,
    correction-the RAW article is RODEO CLOWN.
    What i guess i was trying to say is that knee jerk liberalisn isn't the answer any more than right wing screed.
    Have a nice day out there.

  15. jim --

    "How do you solve problems like people using their entire SS check to buy lotto tickets?"

    An important point. Sadly I don't think there is a realistic way to prevent this other than cutting social welfare programs entirely.

    So long as there's a system people are going to try and game it (and succeed at that). The cost of the resources and administrative infrastructure needed to effectively police the system would probably outweigh any benefits from dumping the dead weight--granted that's pure speculation on my part.

    I too would be interested in seeing detailed stats though as I have no idea what the numbers actually are...

  16. jim

    in FL, 6% of the population is Medicaid with dependent children. 25% of the population is unemployed with dependent children.

    In IL, the rates are both 14% of the population.

    Single, unemployed mothers aren't the root of Medicaid cost problems.

  17. Ok, time for me to be the curmudgeon:

    I always find it ironic that "real" health reform would probably get the job done across the board.

    What's "real" health care reform? I might humbly suggest that there isn't a single definition (eye of the beholder and all that) of "real" health care reform - in fact opinion varies widely and those opinions translate into political preferences and those political preferences are diverse to a sufficient extent to prevent formation of a political consensus which, in turn, prevents reform.


    Why? What is it that we all see, that they don't?

    Or, to put it another way, what is it that they all see that you don't? Maybe this has something to do with it?


    Here's a perfect example of the sort of guy who would think that poor kids getting sick rather than having "his" taxes go to pay for their medicine is a good idea.

    Well, as Al pointed out in his post, we here in the USA spend 2-3 times the amount of money on healthcare than most other countries do and despite that we are underachievers in several important health care metrics. In light of that fact, how do you think, for example, French taxpayers would act if they had to pay three times what they are currently paying for, at best, roughly equivalent service? In short our healthcare problem isn't a revenue problem or a problem where the US taxpayer isn't willing to pony up the goods to provide health care. Indeed we are willing to pony up 2-3 times what everyone else pays. The problem is we are getting incredibly shitty value for our money so you can count me in as another one of “them” who thinks that dumping more money into the growing health care black hole isn’t such a great idea. There is no level of taxation that can keep up with current and historic growth rates.

    Just to be clear I've said "on the record" here for a few years now that I think taxes in this country need to go up for pretty much everyone and that repealing the Bush & Obama tax cuts is a good place to start, but "stingy American" arguments don't make much sense to me when it comes to health care because we are spending a shit-load of money.

    And I would hasten to add that the problem is only getting worse since Medicare and Medicaid costs are currently increasing at 8-9% per year. With an economy that's growing under 2% a year there is no level of taxation that can keep up with that level of growth.

  18. (cont)


    I hate to play elitist but I think it boils down to plain old ignorance (willful or otherwise).

    Well I'm definitely an elitist - something I'm not afraid to admit - but I think you may want to consider alternative explanations before declaring that people who see issues differently than you are doing so out of ignorance of your enlightened position.

    They don't care because they're convinced America always knows best.

    Are you sure about that statement? Maybe they "don't care" because they are generally happy with their health care (see above) except for how much it costs, which is an attitude that's been pretty consistent for a couple of decades.


    The Tea Party/GOP has been able to shape the argument to look as if large gobs of money were coming out of middle and low income taxpayers to pay for these "lazy" people who end up needing public assistance.

    Serious question here - do you know where the money from your state and local government actually comes from and actually goes? I'll use Illinois as an example since that's the topic of Al's post and I don't know where you live. Or you can look at the official Illinois budget summary and see that 45% of the budget is spent on "...Human Services and Healhcare and Family Services - which include Medicaid, other medical assistance, income support, child and community care programs and other health and social services..." How much of that 45% comes from the middle and lower classes? Turns out it’s quite a bit.

    A lot of bad policy chickens are coming home to roost in Illinois. It's quite a bit more complicated than suggesting that the GoP and Tea Partiers are baddies who hate the poor, particularly in reference to what is essentially a one-party state like Illinois. I'm no fan of the GoP but it seems to be a bit of a stretch to lay Illinois problems at their feet when the state has been a Democratic bastion for decades and remains so today. Illinois didn’t get into its present circumstances overnight.

    The other thing that worries me is that when Dick Cheney, Karl Rove and Rupert Murdoch own the US, what will they do with it?

    Sorry, but can I have some of what you’re smoking? The great and frustrating thing about the US is that it is about impossible to “take it over.” Our population is too diverse, power is too decentralized and our political system isn’t amenable to a small cabal controlling the puppet strings.


    Single, unemployed mothers aren't the root of Medicaid cost problems.

    You are right of course – IMO the problems are systemic and sadly our country isn’t dealing with it systemically, choosing instead to focus on the margins and on outdated ideological non-solutions. All I can say is that the chickens are on their way home and unsustainable practices can’t, by definition, last. At an 8-9% growth rate Medicare & Medicaid costs will double in under a decade. What state budget could possibly withstand that? On the federal side, costs are going to climb from ~$750 billion to $1.5 trillion in less than 10 years. How are we going to pay for that?


  19. Andy-

    The hunt for a health care whipping boy, as you seem to point out, has never really focused on the industry itself.

    The Gallop Poll is interesting, but it flies in the face of virtually every metric of health care in general use in the world at large. For double the per capita cost, we are no where near the "best" in life expectancy, accessibility, infant mortality, and the like. Of course, what do the respondents in the poll have to compare the US health care to? Our son, who had great fears that Obama would institute "Socialized Medicine, Europe Style", was amazed that he could see a National Health Service doctor here with a 15 minute wait to address what appeared to be a sinus infection and flu symptoms. He admitted that he would have to make an appointment, typically two days out, through his "excellent" company health plan. He was further amazed at how thorough the exam was and that the blood test results were back in 20 mins. At least for that level of medical care, our 'socialized medicine" was, in his view, better than what he receives in the US, and cost him nothing.

    And, before anyone says, "That's why Greece is broke", government health care payments, per capita, are 1/3rd that of US government spending per capita. It's not a significant contributor to the current debt crisis.

  20. Andy--

    When I talk about "real reform" I am talking specifically about reigning in costs for this reason:

    "we here in the USA spend 2-3 times the amount of money on healthcare than most other countries do and despite that we are underachievers in several important health care metrics"

    There's nothing wrong with anyone being happy with their healthcare the way it is quality-wise, the problem is we can't afford to maintain the current system.

    So to my mind there are essentially two options:

    1) Cut government programs/support or implement a voucher system a la Paul Ryan, which could force a kind of market correction.

    2) Reform the system structurally to cap costs, which I am comfortable saying, based on every study and statistical data set I have ever seen, requires some system of government-managed care.

    I admit both strategies could work--morally/philosophically I prefer the latter, and I think pretty much the rest of the developed world has shown it works. If the wealthy really want private insurance they can still purchase it, just like they do all over Europe.

    Option 1 unsettles me because every time I think about it I get chills remembering Greenspan's shtick about how markets do a great job of regulating themselves other than in notably rare exceptions such as 2008.

    I understand the alternative viewpoint of "I can afford quality health insurance now and probably always will be able to, don't raise my taxes," but I'm pretty comfortable labelling that one ignorant.

    I'm open to evidence cuts would prompt a market correction, if it exists. Unfortunately that's simply not how this issue is framed in popular debate (e.g. "cuts would ultimately drive costs down and make quality care cheaper for all").

    In the end though this is all academic: you'll only ever mobilize enough popular support for cuts, and the economic reality is something has to be done.

    But yeah, my comment about hating to play elitist was stupid.

  21. Interesting comments. One of the (increasingly) few things that make me happy to live in the UK is the comprehensive health care offered by the NHS. I hope this doesn't seem for most like a ramble off at a tangent, I find the comparison of systems the most useful way to critique.

    Watching the debate in the US played over here is difficult for many here to get their head around, how most of your countrymen/women believe something more efficient, cheaper & (gasp) fairer isn't in their best interests.

    I reflect on the development of the NHS though and notice that it was not the logical conclusion of carefully reasoned debate amongst all classes. It really came about through a radical Labour govt in the immediate aftermath of WW2, the second of two catastrophic wars, both within many of the nation's citizens lifetimes. Unlike the UK the US did not have to mobolize the whole nation for war; it is easier for a nation like the UK to accept central state control when it is already used to it.

    It is a common misperception that the NHS is some statist structure, there is in fact a few internal markets built into the system, competing hospitals and GP practices. Perhaps these do improve services for patients and perhaps they don't, but all are still free for the patients.

    It's far from a panacea and there is lots more to do. Care for the elderly had been highlighted as inadequate, this lies largely in the private sector. Questions are being asked how to make it fairer and more uniform, questions asking inevitably whether care homes can function effectively in the private sector (they can of course, it's just some cost-cutting, profit making companies have been caught, very publicly, with being negligent).

    A lot of similar anxieties and concerns as in the US but different questions, answers, and political climate.

  22. Andy: "How we pay for that" is how most other industrialized nations do it; you make health care a centralized system and ration care based - not the way we do it, by personal wealth - but by relative effectiveness.

    So things like annual check-ups, well-baby care, prenatal care, screenings for early-detectible illnesses like prostate cancer or breast cancer are damn near universal and effectively free. More costly treatments, like transplants, are hard to get and expensive when you do get them. Some treatments, like the incredibly costly end-of-life care (with Grandma ending up on a ventilator for her last six months) are essentially impossible to get.

    Physicians are paid a salary, instead of getting fees by the service. And those services are extensively regulated and peer-reviewed for effectiveness (rather than revenue generation) as a means of screening out treatments that cost the heavens and the earth and have a very low success rate.

    Obviously, this is going to be bad for some people. If you have a rare, difficult-to-treat, low-survival-rate disease...you're gonna be out of luck unless you or mom and dad are very wealthy and able to pay for the out-of-pocket costs for the spendy treatments.

    But the overall effect will be what it has been for pretty much every other industrial nation; a much higher return for the cost and a generally healthier population.

    Now...the BIG question to my mind is, rather...will we have an economy capable of producing the jobs needed to sustain even that relatively lower-cost system. And I frankly don't have the answer for that. The former "70% consumer spending/15% financial sector/15% everything else" economy we had pre-2008 was clearly unsustainable. But I honestly have no idea what can and will replace it. What I fear is...nothing. And so we will become an increasingly polarized society with a shrinking middle class, a shrinking elite based in things like finance, law, and medicine, and a growing flattened proletarian base of people who are either on the dole or within inches of it.

    And that prospect, frankly, terrifies me - it's a prescription for a tyranny of some sort. It's Third World, and I'm not mentally redy to join the Zimbabwes and Burmas of the world yet...

  23. I do not see how the US can address health care by simple "adjustments" and modifications of the current practices. It is, indeed, a "market based" industry, and the reason that costs are out of control is that there has simply been enough money chasing medical services to allow prices to rise insanely.

    Further, the pricing structure is irrational, in that providers charge amazingly different rates for the same service, based upon who is paying, and in the end, establish "list prices" that are, for all intents and purposes, astronomical. The actual payment for an indigent patient receiving emergency room care is typically significantly higher than that of an insured person.

    IMO (can't even begin to call it "humble"), the only cure is collapse, followed by nationalization. There is no way in hell the general public would support a nationalizing without collapse to motivate them. In the main, since they have no basis for comparison, the masses really thing we have a good thing going, even though is it grotesquely overpriced and underperforming. What they see is beautiful facilities, excellent interior decoration, nice elevator music and professionally tended rented plants.

    How grotesque is it? Read Part II!

  24. Part II-

    Our Grotesque Health Care Industry.

    OK, this is anecdotal, but since it pertains to a major medical center's POLICY, it rises above simple anecdote.

    Last year, while a group of us were touring Tuscany by Vespa, one of our riders had a mishap. He went to the local National Health Care facility, where he was x-rayed and seen by a physician. Diagnosis was fractured ankle, and more serious, extensive fracturing and damage to shoulder. Physician said that he could either be treated in Italy (free) or stabilized in casts and return to US. Patient asks what the treatment would be, and Dr says that ankle is simple reduction and cast, but shoulder damage is significant, and that there are two possibilities. 1) Wires, screws and pins or 2) replace some of the bone and joint. Dr would do the joint replacement rather take the lower probability of success route of wires, screws and pins. Too high a chance of having to do it all over again with wires approach he says.

    Patient and wife discuss it and decide that since their coverage is via Stanford Medical Center, they would prefer to have it done there. Dr puts patient in casts and off they go, with x-rays and Italian Dr's notes, translated into English.

    Patient arrives home and calls Stanford to make orthopedic appointment. Stanford asks why, and he says, "Fractures from accident". Stanford says, "Go directly to the emergency room". Patient tells person on phone that he has already received "emergency room" treatment in Italy, and Dr in Italy told him to make an appointment with Orthopedic surgeon. He is told that Stanford orthodpedic surgeons can only receive patients suffering fractures through emergency room. Request to speak to supervisor returns same answer. Tries a direct call to one of the orthopedic Drs and office tells him the same. "Hospital policy that Dr must obey."

    So, he goes to Emergency room, where a couple of x-rays are taken, along with his $2,000 deductable. Since he's already in a cast, appointment is two days away. At appointment, Dr says that there are two ways to handle the shoulder (same as Italian Dr) and says he will do the wires, screws and pins. Patient mentions what Italian Dr said, and Stanford Dr says, "It would be very difficult to get your insurance to cover the joint replacement, as there is at least 50% chance of success with screws, etc."

    Long story short, 7 months after wires and screws, patient, after continuous suffering, was approved for bone and joint replacement. Another $2,000 deductable down the drain, as well as his 20% co-pay.

    Again, while anecdotal, this guy was put through unnecessary pain and expense as a result of POLICY, not the skill level of the available care.

  25. Single, unemployed mothers aren't the root of Medicaid cost problems.

    Nor are folk gaming the system for gov't benefits that they don't qualify for the biggest problems Florida has.

    Florida US Rep Cliff Stearns:

    Obscure Florida Republican Congressman Cliff Stearns tacked on a provision to the 9/11 compensation law that mandates all the tens of thousands of heroic firefighters (the ones Republicans love to use in over-produced campaign ads during elections when they could win or lose the House) be compared to the database of suspected terrorists. Worse yet, any of the responders who are not compared to the database of suspected terrorists would be barred from getting treatment for the numerous, worsening ailments that the James Zadroga 9/11 Health And Compensation Law was passed to address.

    Florida US Rep and drummed out of the military Allen "You're no Lady" West.

    Florida US Rep John Mica:

    With negotiations at a stalemate, the chairman of the House Transportation and Infrastructure Committee, Rep. John Mica, R-Fla., introduced a bill last week to extend the FAA's operating authority for the 21st time. Previous extensions had been routine, but this time Mica added a provision eliminating federal subsidies for airline service to 13 rural airports.

    One of the airports is in Ely, Nev., home state of Senate Democratic leader Harry Reid. Another is in Morgantown, W.Va., which is in the home state of Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, which has primary jurisdiction over FAA legislation. A third is in Glendive, Mont., the home state of Senate Finance Committee Chairman Max Baucus, who has jurisdiction over the aviation tax portions of the bill.

    Total cost savings would be about $8.5 million, lawmakers said.

    In a letter delivered to Mica late Tuesday, Rockefeller accused the GOP lawmaker of inserting the airport provision into the extension bill in retaliation for senators' refusal to accept the labor provision.

    "Your attempt to punish the Senate by hurting small-community air service has backfired. This language only guarantees that the Senate will reject the FAA extension," Rockefeller said. Unless the House lawmakers agree to remove the airport language, they risk a shutdown of the FAA, he said.

    Plus Florida Governor and ex-con Scott who nobody likes that well.

    Not to worry too much about your state, jim. My US Rep Huelskamp voted to eliminate federal farm aid in a summer where more than half of Kansas' wheat crop was eliminated with our drought/heat wave and now corn, beans and silage are burning up. Say goodbye to your Fritos.

    And Governor Brownback who is spending scarce state funds ( goin to legal cronies of his ) to defend the state in court against lawsuits brought against the state for establishing an unreasonable set of regs for abortion clinics in the KC KS area and just a couple days' time for them to prepare to be inspected under the new regs.

    White collar malfeasance: So very much harmful to society at large but so very much more likely to never be prosecuted or punished.

  26. Oh, one more group of mangy grubbing rascals sucking poor old Uncle Sam dry and stealing the rest of us blind with their thieving and criminal, cheating ways.


    {Extreme sarcasm, in case it flew past you.}

    The very fact that such things are being said, and allowed to be said by the present president, just like other issues before us now, like the Big 3 Social Security, Medicare and Medicaid, means that serious people are seriously working to cut or limit these programs.



  27. I'm going to play devil's advocate here for a minute:

    Chief: "Andy: "How we pay for that" is how most other industrialized nations do it; you make health care a centralized system and ration care based - not the way we do it, by personal wealth - but by relative effectiveness."

    Chief, that's one solution. There's thousands of possible solutions. For example, we could just continue down the road we are currently going.

    Long-term net effect: The top 1% of have the world's best healthcare and have an average life expectancy of 115-120. The bottom 40% have no healthcare and their life expectancy drops to 55-60.

    Why would we go with your expensive and demanding solution when the current US healthcare solution is nearly ideal from the viewpoint of the relatively few people who own the government?

  28. BB: Closing the airports that serve your political opposition is small-minded, mean, and very cleaver in a small-minded sort of way. I wonder what the Democrats will do in retaliation.

  29. Al,
    I'm just trying to make the point that we have systemic problems.
    I'm not only cmting on medicaid, but the entire system. Like, you know,SSI for chilrens with unknown fathers. And this is another problem b/c a society cannot punish the offspring for the parents behavior, but why do we allow the bullshit of putting FATHER UNKNOWN on birth certificates. Why do we pay for raising these kids?
    Whyt don't we force people to list the suspects , if they can't name whoever did the shoot and scoot.
    But this is less important than why our policies encourage this behavior. And we are in agreement that every one should have health coverage, but as always it's a question of who pays.
    This is why we need to determine what government entails.
    If someone is too irresponsible that they can't identify the father of their heaven sent load then how can they be responsible voters?
    It's a circular question.

  30. Pluto,
    My constant theme is America first and isolationism. This means that we pay for arcane things like health care and social programs by ELIMINATING WAR BUDGETS,elective wars/invasions and all that shit.
    Of course nobody agrees but back to the Brown Univ study placing the cost of wars since only 9-11 at +/- 4 trillion.Now that's a lot of aspirin and tetracycline.That'd keep an entire SF group drip free.
    The 4 trillion$ is about 25 % of the figure that our leadership are wrapped into destructive balls over.
    We are building nations abroad while disassembling our nation here in the Homeland.
    It's all such a gordian knot that absolutely NO ONE can get a handle on it. For example- can anyone out there even conceptualize 4 trillion$ let alone 12 Tril$?? Can anyone even visualize a billion$??! If we can't even understand the reality how can we do fuck all to move forward?
    Oh i know,audacity and hope. BTW BB that was sarcasm, imagine that.
    As for abortion and Kansas.
    The only reason Kansas is making abortions so hard to get is simply to keep generations of selective inbreeding safely rolling along.
    Abortion should be applauded in todays scenario.
    I'd favor paying for abortions to cut welfare/social costs.

  31. Good comments!


    I don't really disagree with anything you said. I'm also for fundamental reform and I don't really care what form it takes as long as it's able to control costs and is consistent with good public health.


    Yeah, your anecdote isn't isolated - in my experience those kinds of required "referrals" are very common. For instance, I had melanoma a few years back and so I have to see a dermatologist yearly to check for additional cancers. Whenever we move, I have to make an appt with a GP in order to get a referral to see the dermatologist. Even in the tricare system the various regions don't talk to each other and I have to go through the same hoops everytime.

    Over the 4th of July weekend my daughter had some lower abdominal pain which was located right where an appendicitis would be. We were at the in-laws, so we went to the local ER where they decided to do a CT scan. That was inconclusive because they screwed up and couldn't image that area (that's another story - let's just say that they should have known it wasn't possible to get a 7 year old to drink two quarts of the nasty contrast liquid). So they decided to transfer her to the local children's hospital. After a couple of hours and an ambulance ride we end up at the Children's ER where we spend a couple of hours and are seen by the pediatric surgeon. He says he's pretty sure it's not appendicitis (a conclusion I reached hours ago since my kids pain had stopped) but they wanted to keep her overnight just in case. So we get admitted to the regular hospital. It's now 3am.

    The most frustrating thing for me with that whole episode is that I had to answer the same questions literally about 20 times. Every doctor and every nurse would come in, ask about the patient history along with the same series of questions about the pain etc. I finally got irate (it was 3am and we'd been doing this for 12 hours) and asked some poor nurse why she had to ask me the same questions and "don't you people write anything down?"

    The whole incident gave me very mixed feelings. On the one hand I think that if my daughter did have appendicitis, she would have been well taken care of, but on the other hand, the process was so painful and needlessly bureaucratic and complicated that it just reminded my how much I want to avoid ER's. And who knows what this episode cost?

    I do not see how the US can address health care by simple "adjustments" and modifications of the current practices. It is, indeed, a "market based" industry, and the reason that costs are out of control is that there has simply been enough money chasing medical services to allow prices to rise insanely.

    I agree with the first sentence, but I don't think health care is currently a "market" at all. It's a Frankenstein hybrid consisting of the private and public health care industries, state and federal government regulations and incentives on both providers and insurers, along with employers and the private insurance industry. There's very little competition anywhere - people usually don't have a choice of insurers and insurers usually don't have much leverage over providers since they are usually conglomerates who control most of the care in a particular area. Not that I think competition is necessarily the solution but neither is it the problem IMO.

    I do agree that I think the whole system will have to collapse before reform comes in. Given our state and federal finances, that could be soon - definitely within my lifetime.

    On that score IMO any reform needs to get rid of fee-for-service and needs to get employers out of the health-care business. I'm not sold on any particular payment model, but right now I think capitation has the fewest downsides.

  32. Andy--

    Just wanted to show I'd looked at both sides. I felt we were pretty much saying the same thing, too.

    I agree this has been a very interesting thread to follow.

  33. Andy: My understanding is that right after WW2 the New Deal Dems wanted to try a British-style national health but were warned that they would be demagogued on it...so the answer they came up with was to torque the tax code so as to encourage employers to give workers a "pay raise" in the form of health insurance. Employer-provided health care was already in place in some large companies, so this was seen as a workable compromise.

    So the current system is the bastard child of political expedience. I'm shocked, shocked!

    One thing that bugs me is that we keep circling the drain on this subject - not health care, per se, but the overall "WTF is our malfunction?" regarding the overall state of the nation. And everybody has lots of good ideas...but the answer nearly always is "This wouldn't fly politically". So our problems seem to be largely self-inflicted, and, as always, those sorts of wounds are the least tractable.

    But re: medical anecdote. Having worked inside the system somewhat, I can tell you that there are two huge distortions in it. The first is that the internal communication in the medical industry in the U.S. is tremendously poor. And this applies to everything from patient notes to treatment techniques. Very, very little has been done, and spent, to improve the methods that date to the end of the Victorian period. So docs and nurses still write notes on paper, those notes are often not updated, the system of shift change handover is unchanged from the 1890s...its ridiculous, and largely because there is no money in better efficiency for the hospitals and clinics. It also, BTW, is a major player in the misadministrations and other hospital errors that have put the U.S. way up there in terms of clinically-created injuries, a very underreported fact of U.S. medical care.

    Another aspect of this is that very few U.S. physicians have any idea what the most effective treatments for the illnesses or injuries they encounter. Data collection and reporting on treatments vs. successful outcomes in this country is virtually unknown - hence Al's story of the screws and wires. What we DO know is that most physicians treat based on what they were taught by their mentors in school and what their local associates do. So improved outcomes from other places are VERY slow in working their way into the system, if ever.

    And the other factor is the huge fear of litigation, which tends to produce defensive medicine and the sorts of cast-in-stone procedures you and Al describe. So long as the procedure is followed, and the procedure has been vetted by the hospital's attorneys, the chances of losing in court are lessened, and that's WAY more important than patient comfort or successful treatment - at least to the sort of people who actually RUN the medical facilities. Add to that the various financial incentives for certain types of treatments and you have a truly nasty combination...

  34. Andy: On that score IMO any reform needs to get rid of fee-for-service and needs to get employers out of the health-care business.

    Fee for service by private providers is not a problem in countries where there is a robust national health care system with which to compete. Our private physicians on our island charge about 1/4th what a US physician charges. Consequently, private health insurance here costs a pittance compared to the US, and is typically no more than a 20% co-pay for any and all services, medicine and supplies.

    Yes, employer provided health coverage was a major contributor. That's probably one market force that is so often overlooked. Pass the cost of health care off to the customers, and not worry about it until it starts to really crimp the bottom line.

    Our system is irrational. Princeton economics professor Uwe Reinhardt, speaking recently before the Senate Finance Committee, said of Duke University's 900-bed hospital: "We have 900 billing clerks at Duke. I'm not sure we have a nurse per bed, but we have a billing clerk per bed. It's obscene."

    Also from Reinhardt:

    My wife, May, called up the Princeton hospital and asked what a normal delivery would cost. She got nowhere. I called about a colonoscopy and got the same runaround. So I asked a guy at New Jersey Blue Cross. He just roared. "Are you serious? We pay 50 prices. We pay every hospital a different price. We pay the same hospital five different prices."

    I asked, "Are they public? Can I look them up?" The answer was, "No. That's proprietary." Imagine if a bunch of people were blindfolded, shoved into Macy's, and told to shop prudently.

    So much for the right wing's claims that we must protect "consumer choice".

    Is there any wonder WASF?

  35. Chief,

    That's pretty much correct. Businesses used it to attract employees and, at the time, the cost was marginal. The tax benefits were - and continue to be - a huge driver. You may remember that "company" cars used to be quite common and the reason was the same - the car was a tax-free benefit.

    You're also right that doctors are way behind the times. Al can probably speak to this better than I, but aviation adopted checklists for pilots a long time ago and the safety and other benefits were clear an substantial. There's a small but growing movement to get doctors to adopt checklists as well, but there's a lot of resistance.


    Sure, fee for service works in some other countries, but it's obviously broken here. I don't think it can be rescued personally.

    Do you remember the so-called "death panels" idiocy? That was actually a pay increase for doctors, not death panels at all. It was a measure inserted into the health care law to make end-of-life counseling a billable expense for Medicare. In other words, it was a measure that would have paid doctors extra for something they were already doing (or should have been doing). There have been thousands of similar measures inserted to bills over the years since Medicare was created and healthcare has thus been deconstructed to such an extent into billable "proceedures" that pretty soon we will get charged when a doctor passes gas. Unless there is some method to control that, the provider lobby can continue to have Congress give it pay increases.

    Yes, employer provided health coverage was a major contributor. That's probably one market force that is so often overlooked. Pass the cost of health care off to the customers, and not worry about it until it starts to really crimp the bottom line.

    That and what you describe about 50 different prices for the same thing is why there isn't a market in health care. For a market you need price discovery. For a market you need choice. With the current system there is neither.

    I think conservatives often mistake "market" for "private." Just because something is private doesn't mean there is a market. Many conservatives seem all too happy to let government pick winners and losers and promotes the big established players.

  36. And again, I'm not saying that "market" solutions are the way to go with health care - as I've said before I'm not ideologically or otherwise invested in any particular solution. I'm simply saying that market failure isn't the problem since a market doesn't exist, or is so twisted as to be a Frankenstein.

  37. Andy: I'm simply saying that market failure isn't the problem since a market doesn't exist, or is so twisted as to be a Frankenstein.

    The second clause hits the nail on the head. There was a "market", but it was between the providers and insurers, and it has very little to do with health care delivery to patients. Thus, the "End of Life Counseling" crap. Allows the Dr to bill one more item during a consultation, or as a separate consultation. It's not about delivering care, but identifying more billable items with that care. And, as we all know, there are hundreds, no thousands of numeric codes to identify every element that is billable, and armies of billing clerks to convert your office visit into the codes necessary to collect on as many items as possible.

  38. There is a great NPR podcast linked to here that explains some of the crazyness of the billing/coding system. Listen if you get a chance.

  39. One of the things that many European systems have is a national physicians board that collects data regarding treatments and outcomes. This information is available to physicians country-wide (and, now, presumable EU-wide) that allows physicians to evaluate the success rate for various treatments.

    My understanding is that this has been fiercely resisted here, probably for the reasons you point out, Al and Andy; treatments are looked on as "revenue generators", and finding out that your biggest profit-maker might be a worthless load of shite would hit the providers right where it hurt most...

  40. Andy, no, I don't believe Cheney, Rove and Murdoch are part of a secret cabal. Twas simply a metaphor for the less than 1% that own the bulk of the wealth. I'm wondering what the breaking point is where the lower income people will snap? Is there a point when that disparity in wealth will collapse the economy? Will it take a revolt?

    As for where the money is coming from, it's certainly not coming from my taxes. Last year, I paid almost nothing in federal taxes due to child credits, education credits and energy credits. As for the state, I paid, but it wasn't an onerous burden. I have to believe that those making half of what I make are paying even less. I easily paid 4x to car insurance and health insurance than in taxes. No, even still, you can't convince me that lower income people are holding the lions share of that burden.

  41. Andy-

    After some reflection, I would offer that there is, indeed, a "market" aspect to the US medical industry. The billions spent in medical marketing and advertizing, something unheard of in most nations, tells us that the providers are not only trying to sell their services, but much of their focus is on stimulating demand.

    And, when you have a moment, Google "Medical Marketing Consultants" and be prepared to see a huge industry with firms poised to help you:

    - Build and manage your ongoing doctor referral program.
    - Develop your website and Internet marketing strategy, including search engine optimization and pay-per-click advertising.
    - Manage your social media marketing.
    - Create branded brochures and other marketing materials.
    - If you want to advertise, our healthcare advertising agency can create your ads and buy your media.
    - Train your staff about how to convert phone inquiries to visitors and how to create a patient experience that will generate positive word of mouth.
    - Build your reputation with free press through our expert healthcare public relations people

    This same firm offers:

    A target audience selection and a demographic analysis so you understand who your best patients are and where new patients will come from

    A Positioning and statement that will guide your subsequent creative efforts. It will answer the question, "Why you?" so that you stand out from your competition and give patients a compelling reason to choose you.

    I wonder if the poor among us qualify as "best patients"?

    Come on, folks, with crap like this, is there any doubt WASF? Medical providers pay for this crap, it becomes a "cost of business" and ends up in the price of the "fee for service". The industry deserves to collapse.

  42. Andy, I was just discussing this with my wife. The medical system was screwed up when the first health insurance policy was sold. Necessary healthcare should be socialized. There should be no need for marketing, competition or any of the business oriented crap that exists today. Right there, the medical malpractice insanity will go away.
    Sure, sell elective health care. Want a nose job, be willing to pay. Liposuction, botox, you name it. There's a huge market there and the vultures can have it. Take the business out of running a regular (non-elective) medical practice and make it about medicine.
    It will also create a better doctor. Anyone willing to work in medicine where it doesn't automatically mean beaucoup bucks will be more dedicated to Hippocrates as well.

  43. Look up "Mayo Clinic". Solution there to fee-for-service, and it's worked for 80-some years.