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"Access To A Waiting List Is Not Access To Health Care"


It seems so simple. Just give everyone health insurance! But, forgetting about who pays (wanna be taxed like the French?), think about who gets served, and how slowwwwwly. Michael Tanner and Michael Cannon of the Cato Institute write in the LA Times about "Universal health care's dirty little secrets":

AS THEY TACK left and right state by state, the Democratic presidential contenders can't agree on much. But one cause they all support — along with Republicans such as former Massachusetts Gov. Mitt Romney and California's own Gov. Arnold Schwarzenegger — is universal health coverage. And all of them are wrong.

What these politicians and many other Americans fail to understand is that there's a big difference between universal coverage and actual access to medical care.

Simply saying that people have health insurance is meaningless. Many countries provide universal insurance but deny critical procedures to patients who need them. Britain's Department of Health reported in 2006 that at any given time, nearly 900,000 Britons are waiting for admission to National Health Service hospitals, and shortages force the cancellation of more than 50,000 operations each year. In Sweden, the wait for heart surgery can be as long as 25 weeks, and the average wait for hip replacement surgery is more than a year. Many of these individuals suffer chronic pain, and judging by the numbers, some will probably die awaiting treatment.

...Supporters of universal coverage fear that people without health insurance will be denied the healthcare they need. Of course, all Americans already have access to at least emergency care. Hospitals are legally obligated to provide care regardless of ability to pay, and although physicians do not face the same legal requirements, we do not hear of many who are willing to deny treatment because a patient lacks insurance.

You may think it is self-evident that the uninsured may forgo preventive care or receive a lower quality of care. And yet, in reviewing all the academic literature on the subject, Helen Levy of the University of Michigan's Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago, were unable to establish a "causal relationship" between health insurance and better health. Believe it or not, there is "no evidence," Levy and Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health. Similarly, a study published in the New England Journal of Medicine last year found that, although far too many Americans were not receiving the appropriate standard of care, "health insurance status was largely unrelated to the quality of care."

photo by Gregg Sutter

Posted by aalkon at April 6, 2007 7:24 PM



question: the shopping carts. um. not getting the connection.

Posted by: André-Tascha at April 6, 2007 6:10 AM

They're lined up, it's grim, reminded me of a waiting room in a free clinic or something.

Posted by: Amy Alkon at April 6, 2007 6:26 AM

ahhhh... I get it now.

Posted by: André-Tascha at April 6, 2007 6:41 AM

That last part makes me glad not to be a doctor. What would it be like to be told by society that your work was so important that you were forbidden to charge people for it? It's like that woman earlier in the week who said abortions should "absolutely free" or words to that effect. I'm not sure she ever thought it through to the extent that everyone was going to have to pay a little because some people couldn't supervise their own underpants, and she certainly never thought about what it would be for people who thought abortion was morally reprehensible to compelled to invest in it.

There are an awful lot of people who think that if everybody just holds hands and wrinkles their brow, or if we all just hold our breath, of if Hillary Clinton does some paperwork, that valuable things can appear out of nowhere. Amy hates religion, but this seems to be the new kind of magical thinking that replaces belief in deities.

Posted by: Crid at April 6, 2007 6:54 AM

I might've posted this in the comments before, but my old boyfriend, who does liver transplants in a major Manhattan hospital, makes $30/hr. for Medicaid patients. He said, "That won't even pay the hourly rate for my plumber!"

Posted by: Amy Alkon at April 6, 2007 7:16 AM

PS And Crid, "magical thinking" when it comes to economics and social policy is quite terrifying.

Posted by: Amy Alkon at April 6, 2007 7:25 AM

Of course Americans will be willing to be taxed at the same rate as the French...


Seriously, v. interesting. And I completely agree on the magical thinking. As I've said before, I think the real division in humanity is between those who "need" some sort of faith-based structure, and those who don't. I'm in the former category, which is why I'll be at church later today; Amy is in the latter category. The problem is the people who need the faith-based system but don't want to put up with the specific rigors of a religion with rules...and so they instead approach the environment, health policy, whatever with a faith-based approach and seek to impose rules with a zealotry with which the Inquisitors would be able to find common ground.

One thing I'm wondering about the U. Chicago study, my experience, people with health problems and those past a certain age are far more willing to make sacrifices in order to obtain and keep health insurance (plus, Medicare kicks in just as the health-care-heavy years are really ramping up), whereas the young and/or very healthy are less willing to do so. I'm wondering if part of the reason for the findings of that survey is that the people without insurance, on average, just have fewer health problems to begin with.

Posted by: marion at April 6, 2007 8:03 AM

Well, my day job is as a surgical clinic admin and I just finished renegotiating several contracts only to have congress push back medicare payments again. All healthcare payments are predicated on what medicare pays, so HMO, PPO, EPOS, doesn't matter--all providers are taking a hit.

Universal HC is a concept, but I'm afraid it's not a well thought out reality for the US. Why? Because we have way too many players making a profit. Insurance companies have a stranglehold on everything from what percentage they'll pay the doctor to what they demand from him in terms of Malpractice insurance. And it's not only insurers, it's the healthcare industry where middle managers are making hundreds of thousands in yearly income and bonuses.

Doctors are lucky these days to break over 115k if they run a solo practice, never mind that they're the ones in the mosh pit making decisions that affect the lives of his patients and working 70 -80 hour weeks.

And that's where I find Schwarzenegger's plan offensive. They're planning an extra tax on doctors to stay in business. But did you know that the analysts are predicting that there will be NO solo practitioners left in ten years? Why? Because of the rising costs of doing business (personnel, rent, malpractice, practice technologies, supplies) and the decreasing revenues. And that's where docs have to go into alternate revenue services.

Want to know WHY your family practitioner is more skilled at skin peels rather than taking care of a wounds (which they routinely send out to surgeons now --hey! wound care use to be the domain of the GP)? Because skin peels are a cash deal. They can do those and charge you $1000 bucks. They take care of a wound, they probably do it for $30. Or let me tell you about the cancer patients who needs an operation with a plastic surgeon in attendance.....only the contracted PS was too busy doing nose jobs, so we had to refer he whole thing out to USC. So there goes the 'art' from healing.

Oh, I could go on. Even with the patients who have no money, but then you find out they just bought the 52" Vizio at Costco.

So the bottom line is this: Is healthcare a priority with the masses?

I really don't think it is. They only get pissed when it affects them personally. And then they forget once they get well.

Posted by: k at April 6, 2007 8:33 AM

"Supporters of universal coverage fear that people without health insurance will be denied the healthcare they need."

A fallacy. No one is denied services. The real problem is that public clinics are overwhelmed and hospitals are being used instead of clinical visits.

And there are plenty of MD's who take on indigent patients and later have to write off unpaid bills after services were rendered.

I resent this smear campaign by politicians that make MD's the cause of all healthcare woes. And I think it's time someone called it just that. Smearing, and I've heard it from both Repubs and Dems alike.

Tell you what, next time you get into a car crash, just ask to be delivered to he US Congress.

Posted by: k at April 6, 2007 8:41 AM

"Even with the patients who have no money, but then you find out they just bought the 52" Vizio at Costco."

Which brings up another point that I, the heartless capitalist, gets irritated about. I certainly agree that people who are otherwise careful with money shouldn't have to declare bankruptcy because a family member gets cancer and needs lots of skilled treatment to stay alive. Health insurance, I think, should make people bear more of the cost of things such as my visits to the allergists, but then kick in fully at the high end, just like car insurance. HOWEVER, I really don't think it's a bad thing if people have to take money that they would, say, have otherwise spent on 52-inch TVs, or dinners out, or vacations, and spend it on health care. As I said, call me heartless. For one thing, people don't value free/low-cost things highly - basic human nature. I'd whine internally if I couldn't buy fun software because I was spending more to visit the allergist for my (non-life-threatening) allergies or the neurologist for my (non-life-threatening) migraines, because I'm a self-centered human being, but I'd either suck it up and make the sacrifice, or I'd get the software and suffer through the sinus/migraine headaches with over-the-counter stuff. (Horrors!)

We generally accept that those over the poverty line will need to spend a not-insignificant part of their income on food, shelter, and sufficient clothing - all necessary for life. But mention medicine, and you've got a percentage of people who believe that it should be provided for "free." When people complain to me that health costs have been rising rapidly, I point out that the amount of new technology and drugs has also been rising rapidly, as has the demand of Americans for said sophisticated treatments. We SHOULD be paying more for health care now as a percentage of income than we did in the 1960s, because health care DOES more now. Hell, there have been significant changes since the early 1990s - one reason for the drop in murder rates is that ERs have gotten much, much better about pulling people through following extreme trauma. The drugs that magically take away my migraines and the physician knowledge needed to prescribe them did not exist 20, 10 or even 5 years ago. We ask doctors, hospitals, drugs, devices and the system in general to do far more now than in the past. That's going to cost SOMEONE more somewhere, whether it be paid via taxes or directly. If we really want to keep a tight lock on health costs, we're going to have to accept more sacrifices on not just the amount of health care available, but also on the sheer level of things that it can ameliorate/cure. Which - call me naive and jingoistic - is another reason I just don't see a single-payer system working in the U.S., because Americans generally *aren't* willing to accept those limits on *anything*. Which I, for one, think is a good thing and ultimately benefits not just us, but the world...but which is, at some point, going to require some new solutions to health spending issues.

Posted by: marion at April 6, 2007 8:51 AM

Heh. I'm not sure exactly what to think about this. One the one hand, I was inclined to support Arnold's Romney-style plan to mandate a basic level of health insurance for people, because I thought it would make health care work better for us all - not just the poor people who don't have insurance. Two things stuck out for me as benefits: the possibility of de-coupling jobs from health insurance (which is good for people who work for themselves, are entrepreneurs, etc.), and that by getting more people some decent coverage, our emergency care system would work better.

Right now, emergency room care - unless you're bleeding out of your eyes - can take hours, mostly because of all of the uninsured people who use it for primary care. Most of these people don't pay their bills, either, which makes emergency rooms big money losers; not surprisingly, many hospitals are just choosing to close their emergency rooms. This is bad for the insured, too! If you're in an accident somewhere on one of the south L.A. freeways, how long is it going to take for an ambulance to get you to Harbor (I think that's the closest emergency room)?

I was unaware of k's point above that the governor's plan taxes doctors (which seems weird).

But in essence, we already have de facto universal coverage, just provided via a single component of the health care system - which is not surprisingly suffering as a result. Maybe the California plan isn't a good one (I'd be shocked, shocked! if our legislature got their shit together and wrote a good bill), but the concept seems like a good one. If we expand the pool of people being insured, doesn't risk go down, and don't more people pay what they should? Does this qualify as "magical thinking"?

Posted by: justin case at April 6, 2007 9:12 AM

My most recent experience with the health care system (Cathy in and out of Cedars, and then spending her last days there) is that the nurses, especially, are saints. My own experiences at Kaiser is that the nurses are very nice. But, when you have a serious illness, it makes all the difference that people care about what they do. And it's a tough, dirty, emotionally taxing job. There were a number of times I almost cried (I never did -- because that's the last thing a cancer patient needs, some healthy person weeping their ass off) at the level of care she got from an occupational therapist or a nurse. Now that my life is getting back to normal a little (I still have about 100 e-mails to answer from people who need advice...bear with me, I'll get to all of you), I have to send them thank you notes on the 8th floor south and 4th floor north nursing stations at Cedars. If you know anybody who's a nurse -- thank them.

Posted by: Amy Alkon at April 6, 2007 9:15 AM

If we expand the pool of people being insured, doesn't risk go down, and don't more people pay what they should? Does this qualify as "magical thinking"?

It does if you think the money will just come out of the ether; ie, if you "expand the pool" by forcing the rest of us to pay through our taxes.

Posted by: Amy Alkon at April 6, 2007 9:23 AM

What Amy said.

Justin, how does insuring people reduce risks? There some fundamental causal thang in your comment that I'm not getting. Let's say 2 out of 10 people are going to get really sick next year. So that would be the risk. How does insurance change it? Insurance merely spreads risk, which is not the same thing. Socialist plans do so irresponsibly.

Posted by: Crid at April 6, 2007 9:47 AM

Much of the problem with discussing access to medical care is that medical care has a moral component to it that most capitalist enterprises do not. However it is just as susceptible to market forces as anything else.

If you put price controls on ANYTHING you will either get shortages, loss of quality or both.

Posted by: winston at April 6, 2007 9:49 AM

The key question is - why is medical care so expensive and it's getting more and more expensive? Yes, the doctors can do better today due to newer technologies - but why should it cost less? It's not like our computers, telephones, televisions and the like is more expensive because they are much better than in the past. What's so different about the healthcare?

Posted by: gringo at April 6, 2007 10:05 AM

Posted by: Hasan at April 6, 2007 10:27 AM

It does if you think the money will just come out of the ether; ie, if you "expand the pool" by forcing the rest of us to pay through our taxes.

Doesn't this statement assume that your private insurance and taxes aren't paying for these people already?

Here's a hypothetical:

Assume you need surgery, and because you've got good insurance, your bill is 50k. Which Kaiser pays, and the possibility of which has been carefully priced into your premiums by their actuaries. Now someone else, with no insurance, gets the same treatment, but can't pay. The hospital still has to come up with the money for its expenses, which it does by billing people who CAN pay at higher rates.

Because of the moral component that Winston mentioned above, the uninsured do get lifesaving care, and the insured end up paying for a good bit of it out of our premiums. We also pay for it in taxes, when governments bail out struggling hospitals. So it seems like we pay regardless.

Crid - I gotta run and don't have enough time to get into a response in detail. I don't think I worded things clearly. My point was that the purpose of insurance is to pool risk. As an individual, risk remains constant, but it only has a minor effect in terms of the risk of a big pool of people.

Posted by: justin case at April 6, 2007 10:28 AM

Wanna know how people become Republican? Decent people are bludgeoned with their own decency: Democrats tell them things like "Look Bub, you're going to have to pay for us ANYWAY..."

Posted by: Crid at April 6, 2007 10:35 AM

"It's not like our computers, telephones, televisions and the like is more expensive because they are much better than in the past."

Zuh? All those things are cheaper as time passes.

Posted by: Hasan at April 6, 2007 11:14 AM

The key question is - why is medical care so expensive and it's getting more and more expensive?

I'm guessing you haven't been paying attention. Not only do patients encourage doctors to expend every effort to find the cause for their discomfort, the legal system penalizes them for not doing so. Imagine what would happen to your car mechanic if he had to appear just twice in court for not fixing the noise in your dashboard.

And there is an element of self-fulfilling prophecy in this issue. A doctor guarding against malpractice must - that's must - generate income to pay for the insurance and legal fees. Guess where the income comes from?

Posted by: Radwaste at April 6, 2007 11:55 AM

Lately, we've had a group of people who are risky in terms of receiving payments. Most people think it's the truly poor, but it isn't.

It's the self employed, middle class who have no insurance and can't bring themselves to go to a County run facility but try to set foot in our solo practice thinking we'll 'cut them a deal.' What they understand is our 'deal' is straight cash at the standard MediCare rate, which by the way, doesn't even cover our expenses. But then they still have to negotiate with the hospitals, labs and other attending MD's.

The other liability are PPO patients who do NOT have their $2500 deductible saved. I've had patients say, "Oh, I'll pay you $10/ a month," to which I refuse. We don't do their surgery in increments." So pay me. Find a credit card, dig into your savings, have a fund raising party. I have rent, employees and insurance to pay, and $10/ month isn't going to cut it.

The problem is that the politicians are trying to keep the upper hand in dictating a system in which they have NO experience. Here's my suggestion: we take away the automatic benefits from all senators and congress reps. We make them pay for their benefits just like everyone else. We put them into an HMO ... a really shitty one, with long authorization times. And we let them suffer along with everyone else.


Posted by: k at April 6, 2007 1:52 PM

"What's so different about the healthcare?"

Well, for one thing, the production of health care requires higher and higher levels of human involvement and specialized training. The things you're talking about require some human involvement to manufacture, and occasionally to repair, but that's it. You can make computers with no college education and sometimes with minimal training - the same is NOT true for medicine. In fact, the trend is in the other direction. I have a relative who was a radiologist. When he entered his field, they used X-rays, and well, not much more. When he left, he had to be an expert in CAT scans, PET scans, MRIs, you name it - and many, many more of them were being done, for many more reasons.

Technological products, on the other hand, are benefiting from the cheap labor available in other countries. You can theoretically outsource your health care out as well. I've known of people who have gone to South Africa for in vitro fertilization, but, y'know, you could head to India for that angioplasty or China for that tumor removal. You could likely get those procedures done in those places for a fraction of the cost you'd pay in the U.S., even factoring in the cost of the flight, if you plan well enough. You might well be able to get your insurance to cover it - insurance companies LOVE to pay less. Good luck with that!

However, here's another way of thinking of it. A VCR and a desktop computer are both far cheaper today, in nominal and effective dollars, than they were 20 years ago. But I'm willing to be whoever wrote this post has a whole lot of gadgets that he/she didn't have before. A DVD player. A relatively new TV. Cable TV, likely with a DVR. Internet - and high-speed Internet, to boot. An MP3 player. Etc. All in all, you spend a lot of money on things that few people even dreamed of 20 years ago. It's just that no one's ever told you that those things should be free, so you don't expect to be given them at a discount. Plus, multiply that effect by about, oh, 20 to get the real impact of the growth of health care services. We're generally living much longer in the West these days than 30 or even 20 years ago - and the older we get, the more our health needs rise, exponentially.

k, $10 a month? People expect to pay more than that for a TV. Or a car. Or, well, just about anything beyond a couch on installment. Yeesh.

Posted by: marion at April 6, 2007 3:56 PM

If healthcare were a priority, people wouldn't walk in with ten year olds with gall stones. I wouldn't have people walking in the door after 40 years of body neglect with obesity, wondering why their blood pressure is up. Like I said before, the average American doesn't give a shit unless they're sick. And then they forget when they get better or they just sue.

We're in the mess now part and parcel because people (MBA's and that sordied monster the MD/MBA) have tried to play a gambling game when it comes to controlling costs. However, each person has unique needs, whereas one person recovering from a surgical operation might sail through, another might have complications and require more intensive after care. So it's a crapshoot, and a company's first obligation isn't to provide a comprehensive quality health coverage, no, it's to make a profit for insurance shareholders AND down the line, the owners of the IPA's aka "large medical corporations.") Believe me, the doctors and patients are at the end of the receiving line of this gravy train.

And yes, who on this board hasn't self diagnosed and decided they need an antibiotic? An MRI? A different painkiller? So in a way, our own insistence is pushing the price up as well. And when people don't get what they want? Well, the often threaten to sue.

I figure I'm as qualified as Nancy Pelosi or The Arnold or my congressman Ed Royce who tried to blow me off a few years ago at a town hall meeting to come up with a suggestion. So here's mine: everything that isn't surgery that would require a hospitalization stay is straight cash.

Believe or not, you can get your hernia fixed at a day surgery clinic for 2500 or less. That's less than a Vizio, less than a Mac. We get rid of HMO's altogether: there's way too much waste and bureaucracy in that. We get rid of IPA's... even more waste in those. We make people take care of themselves for ailments like colds. We help them manage their chronic conditions that are treatable pharmaceutically, but they pay cash for all of it.

If they require surgery or they have stroke, cancer or a major trauma or a chronic condition like kidney failure or anything else life threatening that requires constant care or anything for mental health under the DSMIV, we have insurance for this.

But everything else? cash, cash, cash. Because that's how you pay your plumber, your contractor and every one else. Cash, darlin', or gimme that Vizio and your BMW in exchange for care of that snotty nose.

Posted by: k at April 6, 2007 5:37 PM

This controversy has gone on a long time and will for a while yet.

For those who denigrate Canadian style Medicare - you don't know what you're talking about. I'm a Canuck and have never known anything else. Like my compatriots, any asshole who thinks I would put up with the shit of a U.S. style schmozzle is going to have the fight if his life putting it over.

k comes close to understanding the difference best.Medical providers currently have to track hundreds of 'plans' with exemptions for different circumstances and NONE WANT TO PAY. It's an accounting/billing nightmare that is eating up the bucks and wasting resources at an unbelievable rate.
If you do pay cash you will be charged at multiples of the going rate for insured patients !
Single payer means an end to that.
Industry realizes that heritage contracts that land healthcare providing at the employers' doors is something that not so much was planned as just happened : and is both undesirable and unsustainable. Reserving care beyond essentials to a secondary tier becomes another opportunity to fuck things up by lobbying, etc.

I don't have a stake in this conversation. I've checked on threads at Ezra Kleins' personal blog and Kevin Drum's Political Animal many times. The consensus is clear.

The way things are doesn't work and is economically unsustainable. Crazily enough, covering everyone regardless is much cheaper.
BTW Medical doctors have provided an eye opener or six about the state of affairs. There's nothing like getting the opinions of those involved - which is why you can find doctors' groups supporting the idea.

Posted by: opit at April 6, 2007 8:00 PM

What little I recall, the original form of insurance (dating back to the shipping of goods across the ocean) had to fulfill a number of criteria in order to be paid. Although I do not remember all of them, two stood out as quite practical: the accident had to cause a catastrophic loss and said loss was an ‘act of god’. The idea and intent are solid: you pay your money and if one shipment of grain went bad it was your loss; however, if five of your ships sank in a storm you would not be so financially devastated. Unfortunately, to many who have insurance, health care is treated as a prepaid ‘buffet’ in which one is to load the plate as heavily as possible to get more than your money’s worth. To those without insurance, they have no incentive to limit health care expenditures for they care less for the bill than the paper it is printed upon. Even worse, we have become a society that just can’t say ‘no’. I have personally had to deal with families with their 90 year old grandma with uncontrolled diabetes, hypertension, COPD and advanced dementia who is intubated and on extensive ‘life support’ (high doses of blood pressure medications and high oxygen concentrations) who tell me to do ‘everything possible’. Insurance will balk at the 10,000$/year medication that keeps leukemia in check but will Medicaid/Medicare will merrily pay the $1,000,000+ bill for a liver transplant for a patient who has been on disability for 5-10 years and will continue so for the remainder of their life. Sorry, I don’t have the answers. But unfortunately (or fortunately), this system will not be able to sustain itself much longer before it breaks.

Posted by: Doc Jensen at April 6, 2007 9:53 PM

Newsflash --It's late, I'm a little snockered, and I'm packing for a trip next week. And I didn't get home from the clinic until 8 p.m. So here's my final snarky deal.

I've found a wonderful way to fulfill our clinic's capitalistic needs with the art of healing. And it's as easy as tossing it into a cart.

I will sell prepaid operations (surgeon's fees only) at Costco. I'll sell a $2000 hemorrhoid package that will be bundled with the 52" Vizio for those slobs who can't get off the sofa.

And a $2500 gallbladder bundle to go with the high fat foods sold there too.

Of course, I'll offer anesthesia packages too. Oh hell, I'll even sell throw in a free donut with the hemmorroid package, and a six-pack of metamucil with the gallbladder package.

Gawd, I love this country.

Posted by: k at April 7, 2007 1:03 AM

Here in Australia, we have a universal health insurance system (Medicare) and the Pharmaceutical Benefits Scheme. The latter caps the price of drugs listed on the PBS, however the cost is growing fast.

Medicare covers treatment for most things in a public hospital. Nice idea, but the reality is far from nice. I have relatives who do not have private health insurance who face waits of years (yes, years) for relatively simple procedures. In the meantime, they suffer.

Those who have the wisdom to take out private health insuance (a basic policy can be had for $600/annum up to about $2,000 per year for the top of the range policies) obtain treatment much more quickly.

Amazingly, only about 40% of people take out private health insurance. Meanwhile, people are happily paying stunning amounts for basic houses, spending vast amounts on thing to go in those houses, and spending more than ever on entertainment. All of those things they buy will typically be insured and yet so few people insure their health. It makes one wonder how seriously people value access to health care.

As with all things health-related, when the government pays (well, everyone pays, but few have the wit to realise they are paying) the amount of health services available is subject to political games.

There is no perfect solution. Everyone wants all the treatment they have to prolong their lives or ease their pain, but few have the means to pay for all they want. The unwillingness of people to pay more directly for their care shows that maybe it isn't all that important to them unless it's "free."

Posted by: E-girl at April 7, 2007 1:12 AM

It makes one wonder how seriously people value access to health care.

You bring up a very good point. There are some people in this country who are denied insurance. But I think there are a good many who mewl on about the benefits of "universal health care" but, for now, put their money into other areas...and I'm not talking the basics.

Posted by: Amy Alkon at April 7, 2007 1:23 AM

Funny thing -- I was at the doctor's office today, and I didn't see anybody in the waiting room who seemed to be there for the fun of it. There were people with painful ailments, and the seriously chronic emphysema patients, and a diabetic or two. But to the right wingers, this is a load of people taking advantage of insurance or medicare. I see it as people with physical conditions that prudence suggests ought to be seen by a professional. One other story: While I was there, one of the doctors was asking the nurses about whether the lab would do some sort of test because, as he explained, "None of the allergists will take medicare." He wanted to take care of the patient and was trying to work within a system that was inadequate in this particular way.

This Cato Institute exercise in propaganda uses an old trick: Set up the strawman of long waits for care and compare it to the upper tier of care available to people with full-coverage employment-based insurance. The fact that this system is increasingly decaying is never mentioned; the fact that it is probably unsustainable under any conceivable future is never mentioned. And lastly, the thought that if we spent exactly what we as a nation are now spending on health care but did it the way France or Germany do, we could already have excellent universal coverage. Try taking the thirty percent or so that now goes to paper pushing and apply it to real care, and see what you get.

I strongly agree that certain conditions should be handled rapidly (surgery on certain tumors, for example), but this is something that we are capable of achieving, and probably better than we do now.

I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. They point out that people enduring a major emergency have emergency room care available to them. They ignore the following, among other things: The same people don't generally have routine preventive care available in anywhere near the same availability; emergency rooms are closing left and right due to the "unfunded mandate" nature of what they do; the same people don't get appropriate followup care in many instances; that there would be a considerable fraction of emergency room cases that could have been prevented, and certainly a large number of such cases that could be treated at a lower level except for the barriers to entry that the system erects.

One other point that isn't being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (ie: what we did in the '70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician. (Getting doctors to practice in rural communities is a chronic problem, but connecting rural service to tuition coverage would help quite a bit.)

Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity. Of course it has both elements, but the Cato approach is to ignore one completely. Try this calculation: Suppose every doctor was employed by the government or by Kaiser or by a megacorporation and paid $200,000 guaranteed. For the 300,000 or so doctors in the country, the total comes to sixty billion dollars a year -- a tiny fraction of what the country as a whole pays out in medical care. Make that a sliding scale that starts at a hundred thousand and goes up to three hundred thousand, and it doesn't change the total very much. Add a hundred thousand new doctors to the mix and pay them an average of 150,000 dollars each, and it adds another fifteen billion dollars to the total, basically a drop in the bucket for the total. If we want to calculate the total cost for those doctors to run traditional private practices, we might double or perhaps triple those numbers, again a cost total well within the current expenditures. Notice that every practicing physician pretty much has to pay for the equivalent of a full-time person just to do billing; imagine that wasted salary and effort being freed up.

Posted by: Bob G at April 7, 2007 2:19 AM

I got insurance cuz of all you people. Since I'm healthy & young it was really cheap. It's less than I spend in a weekend. I feel good about myself, like a responsible human being.

Posted by: PurplePen at April 7, 2007 5:27 PM

"The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity."

Huh? Frankly, if you had any experience with running a medical practice, you'd know that doctors aren't competing to make the most money. They're just trying to break even.

In terms of provider services, the major money makers are insurance companies and after that "medical groups" with large bureaucracies, which subcontract from the insurers to provide services for their subscribers, especially in the case of HMO plans.

In other words: Employer or subscriber buys insurance from Blue Cross. Blue Cross then subcontracts with "Gold Coast IPA or Gold Coast Medical Group" which takes a substantial percentage before it pays its primary care physicians. After that, the specialists are paid an even smaller percentage. And that's how your insurance dollars are trickled.

I think that you put way too much emphasis on trying to make this a "right wing" "left wing" issue. As far as I'm concerned, both sides are wrong, both have no real experience in the trenches.

Our real dilemma is this: we're trying to provide a public service for low cost, but all the other factors are private. The supply manufacturers, the landlords, the insurance companies that all charge for malpractice, the CEO's and the CFO's and all of the middle management. They AREN'T lowering their costs. Yet, they've demanded repeatedly for over thirty years, that doctor take a lower reimbursements.

Billers will always exist, as will verifications and authorizations, especially in a self-contained business. They'll watch every penny as they do now.
So billing? It might get outsourced to India, but it'll still be around. But the big diff is this: the billers of today are already obsolete. Most don't have the skills to keep up with the computer technology. So that doctor with the lone biller doing receivables and billing will soon find herself out of a job. It's all being outsourced to companies with the money to focus on billing technologies.

I'm really glad the poster from Oz wrote in. And the Canadian. My friends in Oz have been great recipients of their health system, however, they note that even they have bought private insurance. And we also know that the system in the UK has teetered on insolvency, and that they're outsourcing to India for heart operations. That's just fact. Whether it's good or bad, depends on what you want.

I really do think that we have to look at the inherent differences in our business and public sectors before we all leap on a blanket policy that ALL UHP are the same and will work over here. They aren't. And what works in Sweden, Oz, the UK and Canada, isn't necessarily going to fly here.

But we have to do something. Right now, everyone's losing, except for a very select group called CEO's.

Posted by: k at April 7, 2007 11:08 PM

That's fucking fantastic, Purple.

"The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity."

Why should doctors spend grueling years and piles of money training if they're going to make $30/hr, just to name my friend's example?

Oh...the "government" is going to pay them. Who do you think pays the government to pay them? Furthermore, in nationalized health care, you wait your ass off for care.

Posted by: Amy Alkon at April 8, 2007 12:45 AM

I would like to respond to the Canuck and anyone who buys into the hype that the Canadian system "costs less". Sure, the government releases budgetary figures that make it appear that it costs less per capita than what the United States pays. Well, I lived for a year in Canada. During that time, I was paid a solid middle class salary of $60k. However, my tax liability almost doubled. Combined national and Ontario income tax was near half my salary. On top of that, I've paid 15% in sales tax. Also, the cost of gasoline included more than 50% of taxes. Compare that to my U.S. employer's $4500/year health insurance premium. If it costs so much less to pay for universal coverage, why did it cost a middle class guy like me so much?

Posted by: mishu at April 8, 2007 9:23 AM

Amy: First of all, I didn't say that the government is going to pay the doctors, only that somebody paying every doctor in the USA $300,000 a year would only run up a tab of $90 billion a year. Compared to the nearly two trillion dollars a year (ie: something in excess of fifteen hundred billion dollars and less than two thousand billion dollars) this country pays out in total, that is a small fraction. It doesn't matter to me whether it is Kaiser, my insurance company, or the U.S. treasury. It's just a number intended to give people an idea of how skewed the current system actually is, considering how little it would cost the population as a whole to pay every single working doctor a princely salary.

I know quite a few doctors, and I don't know many working for thirty dollars an hour. Plugging a few numbers into my hand calculator, and taking a realistic number for specialist annual income of $250,000, it works out that your doctor friends are either working 24 hours a day, 365 days a year, or that they are making less than the average for a specialist. The numbers are lower for non-specialty work, but few entering docs limit themselves at that level. In short, any licensed physician working in normal practice is making lots more than that amount. It is not uncommon for busy specialists to fill their offices with patients, see five or more in an hour, and bill several hundred dollars for each hour they work. Figuring an overhead of 60 percent, that means that specialists collect at least a couple of hundred dollars an hour during normal practice. Again, I concede that there are exceptions, but the question for me as a patient, bill payer, and amateur policy analyst is how all this money fits into our average national income.

One point I made is that covering the tuition fees for medical students (as the English do, for example) pays back many-fold, because entering level doctors don't have that debt load to repay. Again, calculating the costs for paying 30,000 a year tuition for 15,000 medical students comes to a little over $400 million a year, which is half a drop in the bucket -- it is about two percent of the NIH research funding budget, just to take one example. Even doubling that level of funding (paying for food, lodging, books, and a used car) still leaves it cheap in terms of the societal advantages it confers. Curiously, the government already pays out a lot more than this amount to cover scholarships for PhD students and researcher salaries, so why not extend it to the medical side of the equation?

And finally, you ask why doctors should spend grueling years training if they are only going to make $30 an hour? I agree that were this the case, we would see fewer applicants to medical schools, but my answer is twofold: First, it isn't the case. Second, people apply to medical schools for various reasons, one of which is income, one of which is the associated prestige and social status, and one of which is the desire to assist the sick. I doubt that medical school slots would go unfilled even if we expanded the number of entry positions and even if college students came to understand that they would be solidly middle class but not fabulously wealthy should they be accepted and finish the course. The English system produces some amazingly good doctors, even though the entering students' expectations regarding income and social status are less under their system than over here. The same holds for France and Germany. It also held here in the U.S. back when physician income was high but not astronomical.

In short, the crunch on physician payments by the medical insurance companies came in response to the necessity to control costs during the 1990s, and the insurance companies managed to manipulate the system so their profits would increase at the expense of physicians, patients, and the economy as a whole. The current system is unsustainable, and something has to be done. With all due respect, pointing out that other systems which control their overall costs often do so by rationing some aspects of care does not excuse our own pitiful excuse for a system. We also ration care by rationing access to insurance; some of that rationing is at the level of total refusal to insure (nothing you have said deals with that problem) and some of that rationing occurs at the level of setting premiums so high that only middle income earners can afford them.

Posted by: Bob G at April 8, 2007 1:59 PM

I know quite a few doctors, and I don't know many working for thirty dollars an hour.

How many you know is immaterial. That's what a medicaid liver transplant pays per hour at a major Manhattan hospital. This for somebody at the top of the profession, who went to a great school, etc., etc.

Clearly, you think socialism is a system that works. I go to France often, and I'll tell you, people do not have incentive to work very hard because they don't see the results from their labor like they do in a capitalist country. Socialism is irrational and stupid, and anti-progress.

Posted by: Amy Alkon at April 8, 2007 2:28 PM

Amy: This reminds me of the discussion of men wearing thongs, except the roles are reversed. I simply pointed out that the average gross adjusted income for medical specialists in this country is about a quarter of a million dollars a year (family practitioners about 100k less), and that's just the average. That's certainly way above $30 an hour. I was responding to your earlier remark which did not limit itself to one kind of payment plan that is (1) generally considered to be inadequate even by the legislators who oversee it and (2) not the main source of income for the general run of medical specialists anyway and (3) likely a small part of the work and income of the people in question. Or to put it bluntly, I responded to your remark and you changed the terms of discussion on me. So let's try this one:

In the research group that I work in we sometimes see advertisements for medical specialists. One ad we recently ran across guaranteed a minimum annual income of $450,000 for a urologist willing to resettle in North Carolina. Additional perks included access to country clubs and riding stables and an academic appointment at a prestigious medical plant if the doctor so desired. Apparently this sort of offer is not all that rare. it's certainly a nice deal for a young doctor just getting out of residency.

I simply point out that our system is misfiring already and it is getting worse even for the employed middle class who have the best deal so far. You misinterpret that as me thinking that "socialism is a system that works." If you think that France is a socialist country then we have a different definition of the word, and if you think that the U.S. has a better medical system for the lower 50% of the population than France does for its comparable half, then I suspect we are reading different studies. I don't apply any strong ideology to this question -- certainly nothing stronger than a general propensity towards freedom and open markets moderated by enough regulation to protect the public from excesses -- but I don't see how an authoritarian free market ideology helps us find a solution to the current mess. I spend a lot of time in northern Italy, and I don't see a population that is less healthy than our own. I do know that doctors in training over there complain about the lack of residency positions and lack of paid physician spots in the more desirable locations. I don't know of anyone who proposes the same system for the U.S. On the other hand, France and Italy spend considerably less per capita than the U.S., and they manage to cover their entire populations. If the U.S. maintains its current level of per capita spending, we ought to be able to cover everybody even better (in terms of waiting lists) than those other countries.

I don't usually re-respond like this, but you chose to pick up on my words, hence more words from me. I do have one observation about this site and your work: You are entertaining because you are cleverly insulting to some of your petitioners. You can be very funny, particularly when you hold to your area of expertise. When you try to argue economics, you are stepping out on thinner ice. For example your remark "how many you know is immaterial" is exactly wrong. Doctors in this country don't work for $30 an hour, even if hospitals and some of their medical staff are forced to take a loss on some procedures due to the irrationality of our system. I already pointed out that emergency rooms are closing here in Los Angeles due to the laws that cause them to run at huge losses. That system is more socialist than anything I have said, and I still haven't seen you give a cogent response. Don't worry, I don't have one either, except to reconsider the whole way we do things.

There is a great debate going on right now that is being covered much better by Kevin Drum over at When General Motors and midwestern farmers and half the people getting by in the bigger cities are hurting, something is going to happen. The only question is what. Since I have already typed a lot of words on this topic, I shall resist further comment and leave the last word to you.

Posted by: Bob G at April 8, 2007 6:25 PM

The comments on the men wearing thongs question are, for the most part, extraordinarily annoying to me. Here's the link:

In short: I presented the facts: Heterosexual women tend to think ill of men who wear thongs. Thus, if you are a heterosexual man looking for a heterosexual woman, you will narrow your chances of finding one if you wear a thong. You may choose to wear a thong anyway. I really don't care whether you do or you don't, I'm simply presenting the facts. I explained them there, over and over (apparently the men who wear thongs tend to wear them so tight they cut off the circulation to their brains), yet the men posting on that column rail against me as if I invented the way women tend to feel.

Your comments, in general, are too long and boring for me to read. In the future, unless you find me too insullllting to revisit (booohooo!), try to follow Crid's lead. He's always interesting to read, even when he's telling me I don't know shit about something.

And I'll repeat, as your thong must be too tight for you to process this: Doctors -- specifically one I know very, very well -- DO work for $30 an hour, and while staying up all night performing liver transplants.

Emergency rooms in Los Angeles are plagued by selfish assholes who use them for their medical care because they gamble and don't have health insurance. I have to do a little digging on a specific case of that -- but thanks for reminding me.

Posted by: Amy Alkon at April 8, 2007 8:35 PM

authoritarian free market ideology

Now, that's a non-sequitor.

On the other hand, France and Italy spend considerably less per capita than the U.S., and they manage to cover their entire populations


Corporate Individual VAT
Italy 33% 23%-43% 20%
France 33.33% 10%-48.09% 19.6%


Posted by: mishu at April 9, 2007 11:51 AM

car by cheapest insurance >cheapest car insurance rates

Posted by: cheapest insurance and car at May 11, 2007 7:36 AM

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