Who Decides How Long?
David Lazarus writes in the LA Times of Bob Iritano, who just died of cancer at 51 on Thursday:
Iritano was just a guy who worked his job as an insurance broker every day. He was a husband. He was the father of four kids.Iritano also had terminal cancer. He knew he was going to die. The only question was when.
His insurer, Health Net, decided last year not to cover a life-extending procedure that had worked just a few months earlier. This left Iritano fighting for time -- time to share with his wife, Karen; time to teach his son to throw a football; time to attend a father-daughter school dance with his little girl.
Iritano faced a situation that many others with terminal illnesses or chronic diseases face: What price do you put on a life? How much money and medical resources are too much when it comes to prolonging a doomed existence? Who decides when your time is up?
...In the harsh light of pure statistics, it's clear that we have to do more to bring down healthcare costs and expenditures. One way to do that would be through the efficiencies of extending Medicare to all Americans and more strictly regulating how much can be charged for medical procedures and insurance.
Another would be to limit how much of our healthcare resources should be devoted to, for lack of a more artful term, lost causes.
More to the point, do we really want to spend hundreds of thousands of dollars extending the life of a person with a terminal illness?
For me, Bob Iritano provides a resounding "yes" to that question. And the reason is a simple one: What if it were me? What if it were you?
Couldn't you just bust a gut laughing at "Little House on the Prarie" reruns, when giving old Doc Baker a live chicken had your account paid in full?
Patrick at September 2, 2011 1:19 AM
> What if it were me? What if it were you?
I'd want to know what men have wanted to know since the dawn of time as they responded to the crisis: The value of my resources.
We're all gonna die. (And here's the goofy part: For most of us, it will probably be horrible.) That's not a policy problem, it's just the way the planet goes. (If you don't like that, don't have babies.)
But government and (to a lesser extent) industry & financiers have conspired to hide the prices of healthcare from us. You don't know the street price of a heart bypass... Because even if you're cutting the check out of your own pocket, you're probably being billed for the seven other patients who had no (or lame) insurance.
It's an old melody from me: Americans are better at finding the correct prices for things than anyone in the world... And that includes the Israelis, wink-wink nudge-nudge.
But in this realm —which is about to become crazy-important to the bursting bolus of baby boomers as they slither to the end of the tract– we've blinded ourselves with idiotic fantasies about what it means to be compassionate.
It's gonna hurt.
Crid [CridComment at gmail] at September 2, 2011 1:45 AM
Typical brainless, feel-good thinking. Just look at these two excerpts:
...it's clear that we have to do more to bring down healthcare costs and expenditures...do we really want to spend hundreds of thousands of dollars extending the life of a person with a terminal illness...a resounding "yes"
And his "solution"?
...the efficiencies of extending Medicare to all Americans and more strictly regulating how much can be charged for medical procedures...
What efficiencies would those be? The ones that involve massive bureaucracy? Or the ones that pay so little for medical procedures that many physicians refuse to take Medicare patients?
In a fantasy world, you could pay a buck and cure terminal cancer. In the real world, hard choices have to be made. If someone finds themselves with a terminal disease, with no insurance or assets to cover massively expensive treatment, it's tragic for them as an individual. It is also called "tough luck" or "shit happens". Society cannot afford to pay for heroic treatment. Society - in this case, the US government - is already bankrupt from funding too many feel-good, life-ought-to-be-fair programs.
a_random_guy at September 2, 2011 2:56 AM
> it's tragic for them as an individual.
> It is also called "tough luck" or
> "shit happens".
Darlin'... Honey chile'... Sugarbun...
First of all, I agree with you. M'kay? Full stop: You're right.
But when you say it like that, and make it so personally condescending, no one is going to see your larger point. They're going to think your wife didn't give you weekend sex, so you're just trying to share your personal pain.
We don't know what the price of modern medicine should be, but I can promise you it ain't cheap. The best minds of the last ten generations have been roaring through the difficulties with the best clarity, discipline and warmth that civilization has to offer... This ain't about the village conjurer from three thousand years ago, mixing the eye of a newt into some sassafras mulch and calling it medication. This stuff works, and the people who make it work want and deserve to be well-paid.
"Tough luck" is just not how it works in our society. We don't say 'Children have the right to learn to read when they're white and healthy and live near schools': We say 'Children have the right to learn to read.' It's that same share of our humanity that forbids us from saying 'Some people deserve no medical care.'
That doesn't mean that everyone should get the best. If this stuff is as valuable as I think it is, a large part of a typical person's life is going to be devoted to earning that medical care, as well as some of the care that needy people will receive. It needs to be devoted to creating that wealth. It deserves to be.
It's just that in these years, as with the housing markets, nobody knows the price of anything... You have know idea how much of your working life should be given to this before you think about other things, like earning money to feed and clothe and educate your kids.
When your government says something is too important to put a price on, it becomes worthless.
Good luck selling your home, and good luck preparing for retirement.
Crid [CridComment at gmail] at September 2, 2011 3:50 AM
I'm with random guy, he said what I was just going to.
Every person ever born who had even the smallest modicum of good fortune, had people who loved and cared for them. They had mothers, sons, daughters, wives, husbands...family and friends and many a wonderful thing.
BUT...what of it? Every single one of them over 112 (I think that was the record) Is dead. Death is an absolute inevitability. It will happen, and it will happen to all of us. Some sooner than others, and while that painful loss must be dealt with, we have the unique ability now to prolong our lives somewhat.
However the word "somewhat" is the key here. We can't keep people alive forever. And when someone contracts an illness that is beyond our power to cure, we have to ask ourselves how much we can afford to extend their lives.
The touchy-feely "resounding yes" the author writes of, is a resounding hypocrisy.
Because he's not spending his personal cash to keep this fellow alive. He's talking about spending tax payer dollars on programs that won't cure this man, just keep him going for a little bit longer...and a little bit longer...and a little bit longer...until he dies early anyway.
The cost of this...how it would be paid for, is by stealing from the next generation, and yes, even the generation after that, which would be stuck paying the costs of treating people that died before they were even born, let alone working.
And when the whole edifice finally falls apart, who gets screwed? Why the grandchildren or great grandchildren of this long dead family man whom the author feels so much for. Nobody who enjoys life wants to die. But does anyone deserve to live forever as a burden on the backs of generations that can't argue for themselves because they aren't even born yet?
Hell in the best case scenario for this ignorant and hypocritical author, doctors just stop treating certain kinds of illnesses because they have no way to recoup their costs. Some might do some volunteer work on the side while they treat things they can make a living off of, but nowhere near the need.
If the family and friends of this man wants to keep him alive so much, let them take up a collection and pay for him, that is their right, but damnit I pay enough in taxes for benefits I'll never receive, for people I will never see. Stay the fuck out of my wallet, I have my own family and future to see to.
Robert at September 2, 2011 3:59 AM
"His insurer, Health Net, decided last year not to cover a life-extending procedure that had worked just a few months earlier. This left Iritano fighting for time -- time to share with his wife, Karen; time to teach his son to throw a football; time to attend a father-daughter school dance with his little girl."
He had all this money spent on him once to give him time. I'd have no problem telling him "that's it". Nobody EVER thinks it's their time to go not the impala kicking vainly at the lion bringing it down, and not the terminally ill wanting just a little more time. But unless you're a billionaire, this man has already gotten what anyone could hope for after a terminal diagnosis. No tears here.
momof4 at September 2, 2011 4:34 AM
"But unless you're a billionaire, this man has already gotten what anyone could hope for after a terminal diagnosis. No tears here. "
And that's right? That you have to be a billionaire, to get what people in other countries get with no problem?
I know I don't know the exact treatment this man got, but in my dealings with both the American and Japanese health care systems, I see too much in America that's priced out of reach, just because they can charge that much. $1500 for a few anti-nausea pills? $3,000 for an emergency room visit for a sudden case of pneumonia? There are few countries on earth where health care systems have the balls to charge prices like that. Tough sh*t if you have lousy insurance, and people are USED TO that and see it as normal.
crella at September 2, 2011 4:47 AM
"And that's right? That you have to be a billionaire, to get what people in other countries get with no problem?"
People in other countries may get some care with no problem, but they certainly wouldn't get multiple expensive life-extending noncurative treatments. Nor would they have as good chance of surviving the cancer or whatever as they have here. The US has the best 5 year cancer survival rates in the world.
Is it "right" billionaires can afford more care? That's just a stupid question. Right or not it's a fact the world over (no, regular people in the UK, france, germany, and japan do NOT get the care their billionaires get, either) that the rich can afford more and better of whatever they want. It's not going to change, socialism doesn't work.
momof4 at September 2, 2011 5:16 AM
Crella -
Japan is fucked. They aren't having enough children and grandchildren to pay the bill, and eventually nobody's gonna loan them money, and nobody will get a fucking thing.
This is the part that everyone who thinks healthcare is a right don't seem to understand.
Doctors need to be paid. Medical equipment needs to be bought. Pharmaceuticals need to be paid for.
Unless you want to have a system where all of the above labor for free with a gun at their heads, at some point someone's going to have to say "I'm sorry, there's nothing we can afford to do for you."
And if you want to know why ER costs are what they are in this country, it's because they cannot refuse treatment by law. And again, someone's gotta pay for it. Are you volunteering?
brian at September 2, 2011 5:40 AM
I don't hate my children and grandchildren enough to want to bankrupt them to extend my life a bit if I were in that situation.
MarkD at September 2, 2011 5:54 AM
There is a certain amount of cowardice, and selfishness, to the expectation (assuming that it is indeed the subject's desire), that he be afforded repeated "extensions" on his life from anyone. Insurance company or family or some other entirely.
I am proudly spending my life supporting my household, I will feed my children, house and teach my children, provide what comforts and small pleasures I can for my children, and their mother also, because that is what a man is supposed to do.
And if there should come a day in my life, when I know there are very few of them remaining, whether it is premature or not to old age, I will NOT go from being their pillar of support, the strength and foundation of my house, to being a crushing burden the which they can barely carry until I limp out of this world inevitably anyway.
What cruel and crushing legacy is that to leave behind? What lesson is that to make one's parting gift?
There was a man I read about, who took similar care of his family, and when he was ill and due to die he made the most of his last days, and when he slipped into a coma, the family and his doctor discussed options to extend his life with machines. As fortune had it, he awoke from his coma unexpectedly for a time, and left the decision to him. He refused to be a burden to his wife and children in the latter years of his life, stayed alive long enough to say his farewells, and went, as a poet said, if not in whole, "Quietly into that good night."
The final lesson he left his children, his last example, was meeting his end with courage worthy of emulation.
I'd prefer to emulate that as well quite frankly.
I don't want my children to see me scrambling and desperate to hold on to life for one more brief hour, I wouldn't want to spend my last days struggling to have just a few more last days, when I could be spending it with them. How will they then meet their ends, when those happen in what would hopefully be many years later, and they have children of their own watching their example?
No. As sad as the subject of this article's story is, its just part of life, we don't get to live on the dimes of others forever, we don't get unlimited extensions at cost to everyone else. Getting one extension, several months, is more than any generation before him ever got. And yet we should weep that he could not get more and more and more, no matter the cost?
Hmpf, call me hard hearted if you will, but I cannot muster great empathy for the author's cause.
Robert at September 2, 2011 6:41 AM
I feel much the same way Robert does. I don't want to be a burden on my family either. If I'm diagnosed with some terminal illness, and we've done all we can and there's nothing left to do, then by all means, take me out behind the dumpster and shoot me. I've lived a good life. I haven't done it all, but I've done a lot of it. No regrets here. I've got a living will, I'm an organ donor. Take what you need, burn the rest.
Flynne at September 2, 2011 7:08 AM
What if it were me? What if it were you?
What if it were you and me paying for all that? Oh wait, it is. . .
Rex Little at September 2, 2011 7:20 AM
Crid, you are right, of course. I did put it rather harshly. The thing is: how else are you going to say it? Life is not fair, and all the feel-good spending you can imagine ain't gonna make it so.
Worse, all these feel-good programs make things worse.
Middle-class students from mostly whole families outperforming inner-city spawn of single moms? Institute programs like NCLB, that drag down the performance of the good kids.
Have handicapped people who can't get up the stairs to a hidden-away restaurant? That's ok, ADA will demand impossible renovations, making the restaurant close so that no one else can enjoy it either.
Is someone ill, with inadequate insurance and no assets? That's ok, EMTALA or Medicare or Medicaid or Obamacare will handle it - driving up the cost of health care for everyone else.
Rude and condescending? Probably. That's only because I haven't got a clue-bat big enough to hit these idiots with.
a_random_guy at September 2, 2011 7:22 AM
Or the ones that pay so little for medical procedures that many physicians refuse to take Medicare patients?
At some point it is almost inevitable (if things keep going in the direction they are headed now), physicians will be constrained from refusing to treat Medicare patients.
And that, my friends, is also known as slavery.
gharkness at September 2, 2011 7:22 AM
@gharkness: It's already there with EMTALA and emergency rooms. If a hospital runs an emergency room, they *must* accept and evaluate anyone who comes through the door. If there is even the remotest chance that the person has a real medical issue, they *must* treat it. Read blogs like "Crasspollination" to see what their clients are like.
a_random_guy at September 2, 2011 8:02 AM
Crella part of he reason hethcare products and services in other countires are COMAPRITIVELY cheaper is . . .
1.Higher tax rates
2.Their entire infrasturctuer was rebuilt by american money after WW2
3.Their national defences for the last 60yrs have been provided by american tax payers
4. you have to get tonsilitis 12 times, not over the course of your life, but in one year before being eligable for the 'free' tonsilectomy
lujlp at September 2, 2011 8:22 AM
Also anyone else love the irony of a insurance guy getting 'screwed' over by his own company?
lujlp at September 2, 2011 8:26 AM
... we all pretty much agree that shit happens, that's why people pay for insurance, etc.
Let's zero in on what Crid said:
Ben David at September 2, 2011 8:31 AM
@a_random_guy: yes, I know about the Emergency Room laws - and you are right. Eventually, I can't help but believe this will extend to the individual physician, in his own office.
Heading off to read the Crasspolination blog ...thanks!
gharkness at September 2, 2011 8:52 AM
Why do American healthcare providers charge so much? They're probably lining some CEO's cushy office of customizling a jet for him.
OR
Could it be that out of control medical malpractice liability has priced much of medicine out of our reach?
There are few countries on earth where health care systems are at the mercy of predatory trial lawyers; where the son of a textile worker and a mail carrier can become a multi-millionaire solely on the winnings from multiple medical malpractice and product liability lawsuits.
You're charged exhorbitant rates for aspirin in a hospital because if anything goes wrong, you might sue the hospital for giving you that aspirin.
OR
Could it be that you're paying so much for your medical care because you're supporting people who aren't?
Other countrties with "free" medical care (France, Japan, et al) don't charge at the source because they charge their employed citizens via high income taxes, value-added (hidden) taxes, and other use fees.
Don't kid yourself. Their medical care is just as expensive as ours.
Conan the Grammarian at September 2, 2011 9:06 AM
Hi Amy,
I work for the nonprofit organization Good Days from Chronic Disease Fund. We understand that patient medical expenses have increasingly become unaffordable. Our organization is dedicated to helping chronic disease sufferers with their medical care. http://www.gooddaysfromcdf.org/ We can't do it alone though, our program is driven by donations. Every little bit counts.
Good Days from CDF at September 2, 2011 9:42 AM
I have cronic erections, you have any cute asian vollenteers?
lujlp at September 2, 2011 9:55 AM
This article is like a garden of fallacies about the healthcare market.
a. efficiencies aren't going to reduce costs significantly. Costs are following Says law - supply leads demand. People are spending more because the market is providing new, better, treatments. Humans want to live a long life and die comfortably.
b. artificially lowering costs, through caps, reduces supply and innovation. There is no free lunch.
c. There is no such thing as 'our' healthcare resources. Medicare/aid is a healthcare financing scheme. It doesn't represent healthcare resources or capacity, nor does it comprise the entire market for healthcare or healthcare financing. Marginal patients may command a disproportionate share of healthcare spending within this system, but that doesn't mean that they're depleting healthcare resources.
horace at September 2, 2011 10:02 AM
I agree with Crid that much of the problem with many of our health care issues center on not knowing what things really cost. It seems to me that health insurance should work more like car insurance. A car owner only contacts their insurance company when something catastrophic happens, and pays for general upkeep of the car out of pocket. This has the added benefit of letting repair shops compete for costumers using both price and service incentives.
If people paid out of pocket for “general upkeep” and had insurance for just the big catastrophic things it might help put some sanity back into the system. People forget that is also a huge pain and cost for the doctors to have to deal with all the paperwork associated with billing different insurance companies for every little thing.
This would also make it easier to make end of life decisions too. I am currently dealing with this situation with my mom who has a very aggressive bone cancer (Amy, it actually started with aching bones so I don’t find your previous post far fetched). When a family is dealing with the emotional fallout that surrounds a potentially terminal illness there is not a lot of energy left to also fight through all the medical bureaucracy.
I am faculty in a large research medical center and thus have access to more resources than most to navigate our health care system. However, my frustrating conclusion from spending many hours talking to doctors and billing departments is that no one really knows the true cost of anything because of all the “robbing Peter to pay Paul” stuff going on to balance the books. Making the financial side of medical treatments more straightforward would make many end of life care (and all health care) decisions a lot more straightforward to make.
Mel at September 2, 2011 10:02 AM
It's a sad story. However, I would still rather be fighting it out with my private insuror than with that pack of worthless hyenas who currently work at the post office.
robinintn at September 2, 2011 10:09 AM
I am in the middle of one of these end of life care dilemmas right now. My mother was diagnosed with stage III or IV gastric cancer in June.
She had surgery in July only because there was no good alternative. Statistics seem to indicate that at her age (86) surgery was almost as likely to either kill her outright, or even if she lived reduce her quality of life to the point that it might not be worth living.
Unfortunately there were no good alternatives as a large tumor in the bottom of her stomach was rapidly closing off her entire digestive system.
A skilled surgeon removed the tumor and was able to reconstruct the rest of her stomach, but even then it was touch and go for a while. Her lungs filled with fluid, her hearing deteriorated significantly and a post surgery UTI left her literally out of her mind for a week.
Good news is that she might have several good months left "if" something else doesn't kill her in the meantime.
Bad news is the Oncologist was in her room, a week after surgery (while she was out of her mind) trying to sign her up for radiation and chemotherapy. This is the "standard treatment" for gastric cancer, even though, it has proven to have limited or no benefit particularly in someone her age.
And of course, insurance would pay for it. My mother is WELL insured. :-)
He pretty much had scared her into it because I didn't happen to be there when he came in with his sales pitch however I was able to undo the damage when I talked to her primary care doctor and the surgeon who both agreed, that in her case, chemo and radiation was a very bad idea which would be more likely to kill her outright (or leave her tied to a bed in a nursing home for the duration)
One of the first things to go in elderly and very ill people is their judgment. They are easily influenced by the so called experts, and no doctor who is not an oncologist is going to directly tell a patient or their family members that "doing everything that insurance will pay for" is not always in the patients best interests for either length of life or "quality of life"
Some cancers they have made a lot of progress against. Others not so much, but the doctors always want the patient to have "hope" so most of them don't tell you what your real odds are, or what your remaining life is likely to be like after the radiation and the chemo take their toll on you.
The sad truth is not that some treatments are not covered by insurance, but that so many ineffective or minimally effective ones are.
Isabel1130 at September 2, 2011 10:11 AM
"It's gonna hurt."
Crid, I got a good news.
Go to Facebook and search "Tanya Cleary". She is a 47 year old married woman with two children. She is also known as LS.
You insulted her so many times in the internet for being crazy, I always pictured her as a sad woman with many cats. I was wrong.
Now, go to Facebook and request her to be her friend. Go ahead and do it. Do you want to see more of her or not?
I have a feeling she got more bikini pictures to share with friends only.
Life is going to hurt a lot less.
chang at September 2, 2011 10:11 AM
I read something interesting few weeks ago. About 5 percent of the US population accounts for HALF of this country's total health care expenditures. (http://nihcm.org/images/stories/NIHCM-CostBrief-Email.pdf)
So, basically, we've got some seriously amazing medical technology that lets us treat seriously ill people -- but it's seriously expensive.
As crid said up-thread, "This stuff works, and the people who make it work want and deserve to be well-paid." Problem is, realistically, a lot of people out there won't make enough in a lifetime to pay for the cost of saving (not prolonging, but saving) their own lives.
sofar at September 2, 2011 11:16 AM
It seems to me that health insurance should work more like car insurance.
I agree that would cut costs. However, auto insurance is relatively cheap because it's very different from health insurance in some fundamental ways.
For one thing, auto insurance has coverage limits. If someone crashes into you, depending on their state's requirements, they've probably got $100,000 in bodily injury liability coverage (at most, assuming they're following the law). Meaning the insurance company pays you at MOST 100k, and then can wash its hands of you. These limits keep costs low -- the insurer knows that 100K AT MOST is what they'll have to pay for injuries.
But I health insurance (with the exception of short-term plans) isn't allowed to work that way -- and, I'd argue, for good reason. A lot of hospital bills are much higher than 100k. My cousin was mowed over by a hit-and-run driver. The life-saving surgery, life support while he was in a coma, the reconstruction of two of his limbs, the months of rehab, the seizures that he kept having because of his head injures have led us to jokingly call him the "million dollar man."
He has health insurance through his job, thank goodness, so he was able to get that care, go back to work and not be hundreds of thousands in debt.
For another thing, auto insurance is allowed to total a car (assuming you have collision coverage). In other words, they can say, "It would cost us $5,000 to fix this thing, but it's only worth $1,500. Here, take the $1,500 and scram." You can't total a human.
That said, I do agree with you that having people get high-deductible health insurance (and use it only for the big stuff) would be a step in the right direction. It would still be more expensive than car insurance though, because of the above reasons.
sofar at September 2, 2011 11:26 AM
Got to agree on physicians becoming slave labor eventually. You can only offer someone pennies of reimbursement on a dollar of cost before the system collapses. Unfortunately, the cynic in me thinks that is what The Powers That Be want: a broken system that has been crushed under its own weight that needs to be ‘rescued’ by government fiat.
The following is for conditions that are terminal or with low chance of survival and does not reflect conditions that are otherwise survivable (as in sofar’s story). It is a generalization of the majority of cases I have dealt with and does not reflect unique/rare situations where a ‘miracle cure’ happens.
As for extension of life, I find it almost universal people forget that those last weeks/months are the worst of your life. You are in a hospital or ICU bed, tubes coming out of every orifice (some even created for the purpose of sticking in more tubes), drugs dripping into your veins to keep you alive, maybe a tube down your trachea forcing air into your lungs. It is an ugly and wretched way to die. Your best quality time is when you first find out you are sick. That is your time to quickly weigh the pros/cons of treatment because your quality of life is only going down from there. Do you want to spend your next few months in the hospital or with your family? Either way you will eventually die. Towards the end you are not likely to be having lucid conversations with friends and family, unlikely to be attending any events and definitely not tossing the ball with your child. It is disingenuous to characterize those last weeks as anything other than miserable—both for family and the patient. And extending that time only amounts to extending the suffering—both for family and the patient.
Beware the ghouls masquerading as doctors. As Isabel’s story reflects, we are really good at doing things to patients and not so good at doing things for them. Isabel, I am glad your mom did not get caught up in the medical machine.
Doc Jensen at September 2, 2011 12:35 PM
And when someone contracts an illness that is beyond our power to cure, we have to ask ourselves how much we can afford to extend their lives.
We should also ask ourselves whether it is their lives we are extending, or their deaths.
This word, compassionate - I am not sure it means what many people think it means.
Pirate Jo at September 2, 2011 1:15 PM
Crid,
"Chang, I don't know if you're being funny, but I'd welcome a friend request from Crid, though I doubt he'd offer one. I'd love to see what Crid looks like (I have this snarly curmudgeon pictured)."
LS said her friendship is yours for asking.
Now, kiss and make up.
chang at September 2, 2011 1:20 PM
Amy Alkon
http://www.advicegoddess.com/archives/2011/09/02/who_decides_how.html#comment-2457050">comment from Doc JensenDoc Jensen, I think you're right about where we are, what the intentions are, and where we're going -- "rescue" by government.
My friend Cathy Seipp was very brave when she was suffering from lung cancer. I am not "very brave" when I have a cold. I can't imagine suffering through those last few weeks like people do.
Amy Alkon at September 2, 2011 1:42 PM
> how else are you going to say it?
Like this: When health care is righteously priced, people are going to have to create the wealth to pay for it, whether for themselves or for others.
That's shorter than a tweet.
It's indisputably true.
It's viscerally true; anyone who was taught as a child not to cry for candy at the grocery checkout will recognize the requisite stoicism.
And get this; If all you really want is to kind of do a towel-snap at someone who's being childish, this will work perfectly. A huge percentage of the people on this planet –rich, poor, successful or incompetent, it doesn't matter– are absolutely crushed when they hear it said, out loud, that the cosmos doesn't love them enough to let them ride for free.
This infantile resentment is part of human nature. It's the common thread in all the ugly foreign cultures that we have to deal with... From the I'm-secretly-a-prince fantasies of Europe and Arabia to the Putin-will-take-care-of-me alcoholism of Moscow.
Crid [CridComment at gmail] at September 2, 2011 1:45 PM
"[O]f Moscow" shouldn't be italic. Sorry. Remember that power outage Amy had earlier in the week? It moved up here this morning... To the NICE part of L.A.'s Westside, where decent, hardworking people live... Not like those druggish sexparty beach people where Amy lives. So I'd composed that comment before the computer turned itself off. And Firefox remembered what I'd typed when it woke up! How cool is that? (Pretty fuckin' cool, I'd say!) So I pushed the "Submit" button right away... And the name on that button always makes me feel meek and servile... But that's how it works, OK?!??!?!
So now, lunch having been eaten and the days' non-electric chores having been completed, let's kick Brian's teeth in... Whaddya say? We shouldn't approach this task with a sense of unpleasant obligation at the cusp of a holiday weekend... We don't do it because we have to; we do it because we want to. Truly, it's no sacrifice... It will be fun!
> Japan is fucked.
They've got some bad things going on, but this—
> eventually nobody's gonna loan them
> money, and nobody will get a
> fucking thing.
—is silly. (And beligerent, hangover-tinged obscenities don't help it. See also "lujlp" in these comments and those for the next post.)
Time and again Japan has absorbed terrible blows from within and without, and has responded with tremendous forward progress. Despite few natural resources, their social cohesion has propelled them to the forefront of modernity. They don't have coal, the don't have oil, they don't have a breadbasket like the California Central Valley. What they got is a hundred twenty-five million Japanese people, a blessing to be treasured and relied upon. When these people need resources, they create them or they buy them.
Have you noticed that we haven't yet read any stories about how the March quake has warped Japanese culture or anything like that? It was terrible to see that happen to a nation of friendlies, whatever our disagreements with them. The consequences of a similar tragedy in North Korea, or any number of other states, would have been much worse.
> Doctors need to be paid. Medical equipment
> needs to be bought. Pharmaceuticals need
> to be paid for.
I can't believe my eyes. This counsel, from the motorcycle rider who went without health insurance for most of his adult life, but who was (passively) confident his benefactors would be compensated?
Breathtaking.
Crid [CridComment at gmail] at September 2, 2011 4:22 PM
• Insurance is not flexible.
Health insurance is regulated, manipulated, and distorted in every state. Lobbyists at the state level arrange for their treatments to be covered by insurance, such as accupuncture, chiropracty, and health clubs. Insurance plans differ in total financial coverage, but don't offer ways for the consumer to benefit from choosing an older, cheaper drug. So, everyone picks the new, expensive drug, and the state-standardized insurance plans evolve to universally cover those and to cost more.
Team Obama has mandated that mammograms, birth control for women, and preventive care for women will be "free". This means that premiums will go up for everyone, including 25 year old males, to pay for these "free" services. This preventive care will indeed have some good result, but the overall cost of care (cost of preventive care, minus costs of illness avoided) will go up, so insurance premiums will go up for everyone.
• Insurance is not personal.
Most health insurance is bought by employers for their employees. This is due to tax benefits originally granted to get around wage and price controls during World War II, 65 years ago. Untangle the tax mess, and make all health insurance and useful medical care tax deductible. Then individuals could buy insurance for their long-term benefit, and insurance companies would create a variety of plans to meet individual preferences.
• Medicines are too safe and too expensive.
Drug development is burdened by amazingly bureaucratic rules and huge expenses. The FDA is applying a ridiculous standard of testing and safety. Delays in introducing new drugs have arguably caused more death than the occasional cases where a bad drug side effect has appeared. And, this is in a market where almost any uncontrolled herbal remedy is available to poison the public.
Drug companies, competition, and doctors would quickly decide what level of safety and testing is required in each case. Tell people that the government is not magically protecting them, and they would question all drugs and demand the safety they deem appropriate.
Ironically, without the FDA, snake oil drugs could not claim that they have been suppressed by an establishment that wants expensive drugs and is suppressing inexpensive, "natural" remedies.
• Cost Shifting is Raising Hospital Prices.
The government is saving money on its lavish medical promises by underpaying for services delivered to Medicare and Medicaid patients. Doctors and hospitals react by raising prices in general, and collecting most of their reimbursement from private insurance patients. Private patients look at the prices and conclude that their doctor and hospital are thieves taking advantage of their misery.
The government should be giving vouchers, not specifying reimbursements. The overpromising by politicians will not end well under any plan.
---
These are the problems in our current health care. They are all the result of government control and intervention. Removing that intervention is the way to fix the system. I am not holding my breath.
The free market in healthcare is breaking, and the government is breaking it. Our policy makers have already designed a system of price controls that doesn't work. Their solution is to cover up this failure by blaming "the market". The "market" is short for the freedom of people to produce and cooperate among themselves, always delivering value and achieving efficiencies that government cannot match.
That freedom is what the government has taken and is taking away, in favor of higher hidden taxes and directed rationing. Our leaders have been buying votes with lavish promises of what the government will deliver. Their plan is to put us all in one boat, then make us pay for their promises to prevent the boat from sinking.
Obamacare Bails Out Medicare.
Andrew_M_Garland at September 2, 2011 6:03 PM
Whether or not health care should be a right it acts like an economic good.
Innovation in health care is the best thing for the most people.
Imagine if everyone had gotten universal coverage for leeches in 1792.
Comment Monster at September 2, 2011 6:59 PM
We should also ask ourselves whether it is their lives we are extending, or their deaths
Yes. Fortunately, in my father's final days, a doctor at the hospital helped talk some sense into my sister, who was trying to keep an 89-year-old terminally ill man with prostate cancer, dementia, a pacemaker, a colostomy bag and a permanent supra-public catheter alive at all costs. The doc told my sister he could keep my dad alive for another four months with drugs and dialysis, but Dad was never leaving that hospital alive. Thankfully she finally saw reason.
So to everyone who is insisting that they will not be a burden on their families or society: Get a health care proxy and a living will to back that up. When the time comes, if you are still as brave then as you are now when you are healthy, the choice might not be up to you.
MonicaP at September 2, 2011 7:30 PM
Japan does not have "free medicine" like France. DH pays $150 a month for his health insurance, as his spouse I pay $75. This covers 70% of our medical and dental, we pay a flat 30% for every procedure and medication we receive. We also pay monthly for "kaigo hoken", insurance that kicks in after 75 years old to pay for Home Helpers, housekeeping and assistance in the home for bathing etc., as well as discounts on wheelchairs, canes and things like that.
The huge difference is that prices for each procedure, office visit, and medication is determined by the government, and those prices are the same in every facility across Japan. As a result, X-rays, CTs, MRIs and most medications cost in some cases 1/10 of what they do in the US. A chest X-ray (simple) is $20, an MRI of my lumbar spine was $100 last year. An infusion of Remicade for rheumatoid arthritis is $2,000 vs. the $16,000 it costs in some hospitals in the US.I was shocked to see that 3 or 5 pills (I'm sorry I can't remember the exact number) in one of my father's prescriptions was $1500, vs. $70 here.
We do have a higher tax rate than the US, true. Another thing is that there are two different insurance systems, 'Kokumin' and 'Shakai'. If you are employed by a university, or anywhere outside of white collar type corporate fields you go with the Kokumin insurance and your premiums are like ours (that's what we have), the 'Shakai' or corporate insurance is on a sliding scale based on income.
There are fewer children being born here, true. However the system is changing with the times. Medical care used to be 100% free for those over 75, now they have a co-pay and a base fee when they first go to a facility. The Kaigo hoken system will take some of the burden off the medical sector, as they run hospice and end of life programs, and dementia care programs.
What you will not see is someone being denied treatment like my father was, because it's deemed a poor return on the investment. My father was, according to all medical criteria for the procedure, a candidate for bone cementing. Cancer had invaded two of his lumbar vertebrae and they cracked. The cement, while of course stabilizing the vertebrae, also kills cancer because of the chemical reaction when it hardens. It heats up to a high temperature and effectively kills all the cancer it contacts. We were turned down 'because he's terminal' , and he lived the last months of his life in agony with broken backbones. He wasn't even given a corset. I called his insurance company and the cancer center for weeks.They just weren't going to treat him. While I wouldn't have advocated hugely expensive cancer treatment for him at that stage, I did think it would not have killed any of his health care providers to provide lumbar support so he wasn't in agony.
crella at September 2, 2011 8:23 PM
Crella-- Thanks for that comment. (I trust your Dad found other relief for his pain... Good, legal narcotics are said to be very cheap.)
The thing about Japan is that –like almost every other nation who people want to compare to the United States– her larger security costs are borne almost entirely by the United States... And if they weren't, given her place in history and in geography, we'd be talking about a much different nation, and probably not a more pleasant once, whether judged from within or without.
That's not to complain... We're getting what we want from them. But let's not pretend their health care policy can be read without translation through this fiscal prism. As with most of the modern world, the final signatory for Japan's social contract is the taxpayer of the United States of America.
People are too eager to assume the United States can be run like the nations it shelters... As if Dad can quit his job and move in with his son in the room over the garage to smoke dope and play video games.
Crid [CridComment at gmail] at September 2, 2011 11:05 PM
more pleasant ONE. Damn typoze.
Crid [CridComment at gmail] at September 2, 2011 11:05 PM
"But let's not pretend their health care policy can be read without translation through this fiscal prism. "
True, but do we need all the 'defense' we get from the US? How much of the present forces does Japan want, and how much of it is based on American policy?
crella at September 3, 2011 3:50 AM
Our current foreign policy is a product of the hazards of our previous policy of isolationism.
Problems abroad tended to find their way to our shores. Isolationist policy allowed WWI to break out. Perhaps a more active role wouldn't have prevented it, but it is ludicrous to suggest that the Kaiser wouldn't have given a thought to a nation the size of a continent intervening on behalf of Britain.
Our disinterest in the peace terms after WWI allowed the Allies to impose ridiculously harsh terms on Germany, which ultimately led to a financial meltdown that nation by nation brought us all into the worst depression in the history of Nation States, and perhaps world history entirely, leading to the rise of the Nazi party and WWII.
Isolationist policy brought American troops home after WWI ended, but before we eliminated the Communist threat in Russia, which ended up bringing us a Cold War that very well could have gone Nuclear, several smaller wars that collectively cost around 100,000 American lives and hundreds of thousands of lives in the countries we were fighting. And pitted us against a hostile power whose borders and resources are comparable to our own, eventually gained nuclear weapons, and would actively oppose American policy to this day. (i.e. CHINA)
Isolationist policy allowed Germany to reoccupy the land they'd lost in WWI, and begin a war that destroyed Europe and much of Asia and the pacific and in the end cost over 50 million lives.
The cost of our absence in world affairs again and again has been to see problems come home to roost on our doorstep and draw us, kicking and screaming, into intervening in world affairs.
Power ladies and gentlemen, does that. We are what some in the U.N. have referred to as a "Hyper Power", our only real competition in terms of global influence and the ability to project power beyond its borders is China, which is itself limited by its preference to retain a very dictatorial rule over its own citizens, rather than weaken that by projecting power directly abroad.
Where power comes to roost, that settled place of power will draw the eyes, the envy, or the designs of others. The powers of the world want our influence, economic or military...but they want it on their terms and for their own ends, just as we do theirs as the need occurs. But to gain that there are great lengths to which they are willing to go. The more dire the need, the farther they are willing to go. And when in opposition, they will go to equal lengths to prevent our intervention. Pearl Harbor by way of example, was meant to knock America out of the fight before it began, to buy Japan enough time to finish its primary conflicts, whereupon it was intended that they would seek peace by fighting us to exhaustion thereafter.
Ladies and gentleman I too would much prefer that our nation bow out of foreign affairs that do not directly threaten us, but history shows us that our attempt to close our ears, our eyes, and our borders, allows those threats to fester like open wounds, to grow like gangrene and spread to touch our lives. Yes we must begin to reduce our military presence, the cost is to high, but that only means we must find other methods to influence matters of interest, economic, humanitarian, and yes, saber rattling and even pinpoint assassination or short term bombing to tip the balance.
The only alternative to this is to reduce our power to the point where no nation cares for our opinions or our interests, and if we do that, then it will be we on the receiving end of influence and demands from the powerful. Some would argue in favor of that, since they are what we call total fucking morons that think life is pixie dust and unicorn farts, but grown ups know that the world and politics is not fair, and that only a fool fights fair when his country, and by extension his family and his way of life, are threatened. We must keep the deck stacked in our favor for as many generations as we can, and we can't do that by pretending the world doesn't exist.
Robert at September 3, 2011 4:28 AM
"Crid" if you don’t want me commenting on your comments perhaps you shouldn’t mention me specifically in your comments
My comment on this post about my chronic erections was directly in response to some asshat using Amy's website to solicit donations to their non profit to help those ‘in need’
As for the other thread, I think a little obscenity is called for when dealing with people whose definition of obscene is seeing a womans ankles or cheeks
lujlp at September 3, 2011 5:09 AM
"True, but do we need all the 'defense' we get from the US? How much of the present forces does Japan want, and how much of it is based on American policy? "
It's a symbiotic relationship. There is a very important missile defense installation in Japan. It serves to defend both us and them. Pretty much any North Korean scenario you'd care to name begins with NoKo dropping short-range nukes on Tokyo. Japan isn't going to develop its own missile defense; they simply don't have the economic resources to do it. Never forget that China covets Japan. (So does Russia.) China would love to be able to use NoKo as a plausibly-deniable proxy. The fact that Lil Kim might turn around and bite the hand that feeds him worries Beijing, but not enough to discontinue the policy.
Cousin Dave at September 3, 2011 9:16 AM
Japan's got a population that's getting older, and they aren't having anywhere near enough children to cover the future costs. When you have no realistic possibility of paying your future debts, you get downgraded and people stop loaning you money.
Hence, fucked.
Only to someone who assumes that care can never be refused. You like to make assumptions about what I would do when in a certain position, but I assure you that they are all very, very wrong.
brian at September 3, 2011 9:30 AM
> do we need all the 'defense' we get
> from the US?
Yes. Dave beat me to it, but you're in a baaaad neighborhood, and your needs are profound. (And by the way, did you settle with Russia for the Kurile Islands yet?)
(Also BTW, when you say "we", are you speaking as a Japanese citizen?)
> How much of the present forces does
> Japan want,
Does it matter? Are you paying for them? Do you think the deal works that way?
> and how much of it is based on American policy?
After the Big One, Japan was determined not to be trusted with international defensive power. It's far, far too late in history to get all prissy about these things. By the evening of Dec 7, 1941, this die was cast.
In any case... Do you seriously, seriously contend that Japan has —not just in this troubled year but within any of the last 30 or 40— the wherewithal to compose a defense force sufficient to defend their international interests?
Would you want them to?
________________
How does that bumper sticker go? Get in the station wagon, buckle your seatbelt, and be quiet...
Crid [CridComment at gmail] at September 3, 2011 10:24 AM
I think this man had his priorities right. And if it was me in the same situation, I also wouldn't try to prolong my life a little at considerable expense.
Iconoclast at September 3, 2011 1:45 PM
> You like to make assumptions about what
> I would do when in a certain position
Is there a reason to believe you're an exceptional person in these respects? That you aren't as eager to live, as needful in crisis, and as reliant on your surrounding culture as anyone else?
> but I assure you that they are all very,
> very wrong.
Your assurance has no currency; Insurance has currency. Have you set aside six or maybe seven figures' worth of resources to cover a crisis? Because International Man of Mystery posturing is transparent and irrelevant. Most everyone reading these words has prepared for events with something more than bluster... And we've done so in periods of our financial lives when we'd rather have done something else.
> Only to someone who assumes that care can
> never be refused.
That isn't machismo... It isn't even infantilism... It's just inane. Have we run through these scenarios before? Duzzenmadder... Let's do it again.
You'll be on your motorbike (proudly helmetless, because you're not one of the 'sheeple, man')... Or just walking down the street. You'll crack your skull on the curb. Authorities will take you to the hospital. You'll be unconscious, so doctors will, as required by law, begin an expensive course of treatment. Or, you'll be conscious, and they'll begin an expensive course of treatment, and then... What? —
• Are you going to say 'Golly boys, don't go to any trouble for little ol' me... I'll just crawl out into the parking lot and bleed to death.?
• Are you going to say Go ahead, because you'll eventually get your money?
• Or are you going to rely on the decency, sacrifice, and preparedness of others while you plunge –oh so bitterly– into tremendous debt?
Discussion of this topic deserves coherence to one's personal behavior. (See also: "Raddy & 'The Paying Agent'.") So where exactly do you fit on the continuum?
Whatever... President Obama admires your recalcitrance; he's built a career out of exploiting it.
Crid [CridComment at gmail] at September 3, 2011 3:43 PM
'In any case... Do you seriously, seriously contend that Japan has —not just in this troubled year but within any of the last 30 or 40— the wherewithal to compose a defense force sufficient to defend their international interests?
Would you want them to?'
Given the tendency here for instant decisions pretty much instantly backed up by the populace, no, perhaps not.
We were talking about Japan's health care system being possible in part because the US defends Japan. It seems like too much of a burden for the US, if it benefits only Japan, and so I wondered, who does it benefit most?
The Japanese government does pay $2 billion annually towards the bases, although I don't know what percentage of the total that is.
I shouldn't have put quotes around 'defense'...I know it's a bad neighborhood, and I respect the armed forces :-D On the other hand, I hear about and see the constant complaining of the Japanese against the bases, and have experienced first hand the gawd awful noise levels in Yokohama and Sagamihara from fighter jets and other aircraft. The bases seem to be a thorn in a lot of people's sides. For the average Taro on the street, the noise, accidents and other problems are what come to mind first. I didn't mean that Japan isn't defended, I meant that a whole lot of other problems come along with the package...I have wondered if the number of bases isn't overkill, but no military expert am I. For a place the size of California, the bases take up a lot of room.
But, it is a bad neighborhood :-D
I'm a permanent resident, here 31 years. I can apply for citizenship, but have not.
"China would love to be able to use NoKo as a plausibly-deniable proxy. "
I wouldn't doubt it...
crella at September 4, 2011 1:12 AM
> I can apply for citizenship, but have not.
OK, so about that "we" in "do we need all the 'defense' we get from the US?"...
...That's weird.
Dance with the one who brung ya, OK? (This is the same thing I tell Amy's Canadian commenters who suddenly believe they're from Tennessee, the same way Bieber's fans suddenly believe they're his girlfriend.)
And the one who brung you was the United States. You are, presumably American.
Furthermore, Japan, except for the continuing WWII conflict with Russia over the Kurils, has faced ZERO convincing threats to her borders. Right? We been taking care of business. Two bills a year is peanuts.
I mean, presumably, all the noise and smoke from those nasty, mean aircraft wouldn't be as objectionable if they were Japanese, right? Suddenly, you (in the we sense of the word) might want a whole lot more of them.
Answer carefully: A lot of America's ongoing commitments are subject to review in the times just ahead. And, again, things are going to hurt.
Crid [CridComment at gmail] at September 4, 2011 4:04 PM
Why not 'we'? I presume all those living in the country are defended should Japan be attacked....all of us living here, 'we' all are affected by the bases.
crella at September 4, 2011 5:11 PM
"Like this: When health care is righteously priced, people are going to have to create the wealth to pay for it, whether for themselves or for others.
That's shorter than a tweet.
It's indisputably true."
Gee, Crid. You agree with me, and on more than this one point, however addled you may be about how to handle pensions.
I hope you straighten yourself out sometime. Soon.
Radwaste at September 7, 2011 6:25 PM
Are you buying insurance for yourself and your family not provided through your employer?
Crid [CridComment at gmail] at September 8, 2011 5:40 PM
Crella: Heads up.
Besides, you quite obviously didn't mean "we" as in people who happen to be staying on the islands for the weekend.
Crid [CridComment at gmail] at September 8, 2011 5:41 PM
"OK, so about that "we" in "do we need all the 'defense' we get from the US?"...
...That's weird.
Dance with the one who brung ya, OK? (This is the same thing I tell Amy's Canadian commenters who suddenly believe they're from Tennessee, the same way Bieber's fans suddenly believe they're his girlfriend.)"
"Besides, you quite obviously didn't mean "we" as in people who happen to be staying on the islands for the weekend."
Not being sarcastic, but what's your point about 'we'? I'm certainly not pretending to be Japanese...but I am married to a man from Kobe, have lived here longer than I lived in the US, have cared for and am caring for an in-law with Alzheimer's , my son just married a young lady from Tokyo last year and I have a grandchild up there; I pay hefty taxes, volunteer and am on my neighborhood board (elected last year) so I'm definitely not an ex-pat on a package here for 2-5 years who isn't involved in Japanese society. I'm here for the long term and I'll die here. 'We'.
I was not correct to say 'defense' and perhaps I shouldn't feel pissed about all the bullshit surrounding the bases.It does get tiring, but minimizing the role of US servicemen and women was petty.
My ass isn't grass because of the US bases. Point taken.
Are you asking me about insurance? The type I get is determined by my employer, I pay for it. They make matching contributions on my behalf to the national pension fund (Kokumin nenkin).
crella at September 8, 2011 7:56 PM
Crella- The point about 'we' was that you made it sound like you've gone fully native... No crime, that, what with the husband and the in-laws and all the rest. But even if you have, you would be expected to pick a team. And the only team righteously available is that of the United States, and the peace sheltered by her military. I want people to remember who's who and what's what in a very explicit way.
See more recent comment threads here... Commenter BOTU is obviously a troubled man, but like you he's living in Asia. And he's been made so comfortable by the sacrifice of others that he thinks the world was never very dangerous anyway. This strikes me as grotesquely pathetic.
> Are you asking me about insurance?
No, that was for Raddy.
Crid [CridComment at gmail] at September 9, 2011 1:29 PM
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