perfidy

Malpractice insurance rates are out of control, in general. They are devastating to individual doctors, particularly in disciplines that have been rendered high-risk by tort law (such as obstetrics). But malpractice insurance only accounts for 2% of overall spending! This says to me that there are two _very distinct_ problems to be dealt with. The first is solving the malpractice issue, in a reasonable way. Solving that will in NO WAY solve the overall problem with the costs of health care, but it does open up the number of providers.

We must then focus on humane means of cost controls in the system. Right now, the system is being run for the benefit of drug companies and health insurance companies.

If procedure A costs $25 per treatment and saves a life with probability of 90%, somebody MUST choose it over procedure B costing $2500 per treatment that saves lives with a probability of 92%. Each B we authorize means 100 people cannot get A. This painful decision is simply NOT MADE in American medicine in any formal way. It is made informally thousands of times each day, as children and adults die from lack of preventative treatments, from not having insurance.

Patton, you (and virtually every American I meet) are under the mistaken impression that the wealthy of this country pay a large percentage of their income in taxes. This is simply not true. Total federal tax burden ranges from about 16% for the very poor to about 40% for the very rich. There's a little bubble in the 150-250k range that pops up briefly over 40%. Most middle class people pay somewhere around 25-30%. You call that _confiscatory_? I call it the deal of the century, relative to every other country on the planet. Wealthy people in this country pay at most 10-15% more than their middle class counterparts.

Market mechanics operate differently in health care. In other countries, rational decisions are made with respect to financial resources. Unlike here, where a doctor can be sued for not prescribing the very latest and greatest and most expensive drug for a given condition, socialized medical systems have drug approval lists. Expensive drugs don't make it on the list, 'cause the money is better spent elsewhere, period. You want some crazy expensive treatment, you can pay for it yourself, but you're not going to make everyone else suffer.

A week or two ago I heard a story on the radio about an enterprising group of care providers in the south. They decided to focus their practice _entirely_ on the uninsured; in doing so, they were able to _cut_ their rates by 50%. No paperwork to deal with! Cash on the barrelhead...

Having basic medical research in the hands of private corporations just seems stupid to me. They're only going to investigate things that can give them short-term gain. And they're private entities that are incredibly vulnerable in the tort system. Governments can't be sued for the research they do, and rightly so.

Not to turn this into a debate solely about the high cost of healthcare, but there is a serious problem locally in MD where they are running out of doctors to provide quality healthcare because they are being squeezed out by high medical malpractice insurance premiums. Neither party is high on Tort Reform on the political agenda. Personally, I'd like to be able to get treated at my alma mater by a doctor I trust. But I'm not sure they will be there in 5 years because it might get too expensive for them to practice in MD.

Patton, I'm not sure what you mean that progressivity has been built into the global system so that Americans support the healthcare of others. Please elaborate, because I can't think of any ready examples, short of us participating in WHO and UN medical initiatives. Unless of course you mean Bill Gates' money and how MS sucks the lifeblood of folks with licensing fees.... Or do you mean the way the drug patenting process means that large drug companies have only about 7-10 years of inflated pricing to recoup all their R&D costs and continue to research into other drugs? Because I don't see the direct connection at all.

Your first point, about "no trivial solutions", is a given: it was imprecise for me to have used that phrase. What I should have said was "Holy shit! If we do in the US what is done elsewhere, everything elsewhere is likely to be forced to change, too."

Or words to that effect. My discussion the other day centered on illness as a public matter, much like bridge building, post offices, and defence are public matters. Within limits, I fell for it, because it makes sense. The limts, however, are the bitch of the matter, in that the proportion of illnesses that meets the criteria of being public concern is rather small, and it's hard as all hell to control delivery.

When delivery is constricted, you end up with absurdities like the gentleman who had to go to India to save 95% on his heart valve operation. And, at the risk of turning this into a market based medicine screed, there are two reasons it's cheaper in India, neither of which is primarily litigation or malpractice insurance related.

Reason 1: Private health insurance in the US has skewed the market beyond recognition, and if he'd been insured, the man needing the heart valve would have been charged much less, since the bill would have gone to his insurance company and that company has cartel-like powers in the medical market. Just the nature of the beast, and an ugly nature it is. Doctors and hospitals routinely write off 50-75% of their bills when paid by insurance, and yes, that means that their bills are prima facie too damned high to represent reality in the case of a single patient. But they don't measure viability on an individual patient basis, they do so on their entire patient base. Uninsured patients are the wild card and indigent uninsured patients are the double wild card. Clearly, an argument can be made for intervention in that utterly retarded market. And a form of socialized medicine is one of the possible arguments.

Reason 2: The global medical market operates on much the same dynamic as the local markets in the US, and like the Durham NC market in which the gentleman had to opt for India to get his problem solved. Some places are more expensive, sometimes disgustingly so, specifically because other places are quite reasonably priced. Remember those cheap drugs in Canada that everyone wants the US to be allowed to reimport? It's like a water balloon, in that a squeeze one place results in a bulge elsewhere. Some form of socialized medicine in the US will have the effect of raising costs almost everywhere outside the US, while lowering them here. I'm OK, conceptually, with that price shifting, but I wonder if everyone else is. I'm a bit more iffy on the long-term systemic result of efforts to make price go down here without affecting them elsewhere.

And, to wrap this up before I waste all the space on your web server, there's a common thread between the medical market and the concepts of equality and fairness. (That's what I found so intriguing about the basis for your original posting) Most conservatives don't actually think in terms of "low taxes for the rich are good", they actually think that low taxes are good and that there isn't a valid case to be made that, at the margin, taxes should be confiscatory. I don't know anyone who thinks that a flat tax is either workable or required. I know lots of people who think that a simpler tax system, which does the job of funding what needs to be funded without trying to engineer peoples' actions via the tax code, is a good thing.

Should the rich pay more? Of course - even in the extreme case of a flat tax, they do. Building progressivity into the system, to excess, is demonstrably bad, however.

How do I know this? Look at the US medical system, and see if you can tell me that progressivity hasn't been built into the global healthcare market, in such a way that the citizens of the US pay more so that citizens elsewhere can pay less.

Patton, well shucks, why doesn't Congress in this country let the largest buyer of prescription drugs actually allow Medicare and Medicaid to EFFING NEGOTIATE PRICES?!?! That's what happens in Canada and that's why folks are flocking their for prescriptions and flu vaccines.

Oh boy... I'm about to give myself a stroke here. At least this will remind me which way I'm going to vote tomorrow morning when the polls open at *gasp* 6am. I'm headed out at 5:30am with a thermos of hot tea to wait with my new neighbors. I'm excited!

Good grief! I saw your comment (the "hee-hee" comment) Mapgirl, and got corn-fused. Which was bad, considering the fact I couldn't figure out how Ross was voting, but I just assumed he'd become a citizen.

Embarrassment abounds. But eventually, when this comment stream is overrun with spam (like so many others here recently), my silly oversight will be hidden.

Patton, report those spammed posts to the Ministers (mainly Buckethead and/or Johno) so they can be removed.

I'm the other ranting liberal around here so it's easy to be confused. I'm actually laughing because it's pretty funny.

Did you remember to vote?

On further review by the replay official, I can't for the life of me figure out just why I thought your earlier "stroke" post was from the esteemed Mr. Judson. I'm normally better off at polite details than that.

I'll send a representative sample of the 40 or 50 spams to the lads, so that they can either deal with them or ignore them. On second thought, perhaps I won't. Ignoring might be best; they only come from old posts to which I've responded, and they're easily stopped by my unsubscribing to further notifications.

Did I remember to vote? No - that's tomorrow, silly. I know, because I got a call from the helpful folks at the RNC on it. They thought I was a Latino/black GLBT anti-war pro-tax pro-choice gun-hater, but I appreciated the help anyway.

Patton... hee hee. I think you meant to address that last post to me, Mapgirl. You know, the one with a vagina at this Ministry... I could be the "Mini-skirted Minister" if they let me...

Can't vote. I can sure as hell pay taxes, though, and that's why I rant pretty continuously about them ;)

When it comes to taxation, it's really all about the curves...what I find is that when a person understands what the curves _really_ look like, versus what they may think they look like, their attitude about taxation changes quite a bit.

Anecdotal analysis doesn't really work for fiscal policy.

Ms. Mapgirl has certain means of persuasion not available to the Ministers, including a rather unfairly brilliant command of the English language and the pattern language of mini-skirts. ;)

Ross:

That's a big part of the problem, and I'm right there with you: Of COURSE we should effing negotiate the prices.

All we have to do is realize that if prices are negotiated lower here, they're going to be higher elsewhere, otherwise, we're going to chase capital out of Big Pharma. No free lunch, and all that.

Please don't have a stroke, and I hope your wait to vote is short.

Mapgirl: the primary subsidy the US provides to the rest of the world, particularly that portion with socialized medicine, is on the drugs front. We pay excessive prices because the drug makers can't get those prices in other markets. Malpractice, as Ross said, isn't a huge part of the price, but it sure does affect the supply, as both of you have noted.

Ross: I don't think that the rich pay a huge percentage of their income in taxes, certainly nothing like the 90% marginal ratest that existed 30 years ago. But what I'd like to see is a simpler system, without all the hoops and tricks that don't have a thing to do with gathering money to run the government removed. If rates are somewhat higher on the upper end (i.e. a bit of progressivity), then so be it.

I don't think a case can be made that we can solve all problems by taxing the hell out of the rich, because they'll either find a way to avoid it, put their capital and effort to other, possibly less beneficial uses, or both. I'm no fan of a broad, generalized view of the world that says "From each, according to his abilities, to each according to his needs." (Note: my view on that sounds a lot more extreme than it is; please feel free not to react to the words I've chosen)

This ain't a friggin' church, in other words, and a tax system that reaches vastly different results of confiscation based on how successful someone isn't radically different than charging higher prices at the grocery store based on what kind of car someone drives. That strikes me as neither equal nor fair. And that's what we're talking about here, isn't it?

p.s. medical malpractice rates in states that have enacted tort reform are, on average, about 17% lower...

There are no trivial solutions to the problems in the medical system in the US. Market forces are a sacred cow here; any implication that "the market" can be outperformed by other organizational mechanisms is soundly denounced. Political posturing aside, the facts are simple. The US spends _multiples_ of what other countries spend, per capita. Statistical indicators (length of life etc) measured over the same populations show no advantage for the American system, despite that the fact that its participating patients pay dramatically more. Administrative overhead in the Canadian system is around 6%, and overhead in the American system is over %30.

So where is all that money going? Only 2% of all medical spending is routed into malpractice insurance, so that's not it (I don't deny that malpractice is not a huge problem in certain specialities -- it is).

What the American public is unwilling to face is that they have developed a system that has no cost controls. I describe it as a death spiral because various mechanisms combine and aggravate problems in the others.

The bottom line is that medical care gets done better, elsewhere. I read recently about a construction worker from New York who flew to India to have life-saving heart surgery done, as a medical tourist. A US hospital told him he'd have to pay $50,000 as a down payment, and that the surgery could cost up to $250,000. Contracting with a high-end boutique hospital in India, he was flown over, brought to the hospital, and had the surgery expertly performed by top physicians, many of whom trained in America. The cost to him, for saving his own life? Around $10,000, including airfare.

I never thought globalization would apply to medicine, but there it is. You'll see much more of this in the future, as the spiraling cost of medicine knocks more and more "regular folks" out of the system, and they search for alternatives. The people at the top will, as always, be perfectly fine.

On the tests: Equality means that a law is applied without special casing. Fairness tests whether that law advantages or disadvantages any party; it is relatively subjective.

What politics boil down to are goals, and means of achieving them. Taxation is the laboratory for this. Arguments about taxes can go around and around. Most "conservatives" think lower taxes for the rich are a good idea. The _stated_ goal for these lower taxes is that they "help the poor and middle class" by creating jobs. We have 25 years of history that show it just _doesn't happen_. The effect of lowering taxes on the rich is that they are _raised_ on the poor, and rich people get _dramatically_ richer.

Faced with the dissolution of the primary justification for lower taxes for the rich, your average conservative is _still_ for those tax decreases. Why? Because taxing the rich isn't "fair". Push a little farther, and you invariably get the "flat tax" proposal, in which our embattled conservative states that he just wants a simpler taxation system, where everybody pays the same rate. Fine, I say -- what about the negative effects of doubling or tripling the taxation on the poor and lower middle class? Flat taxers really don't want to talk about that, or if they do, they happily point out that the first $X of income will be tax free. Ah -- so we're not really talking about flat taxes, are we? Now we're back into a curve, and we're only talking about where the control points on the curve are, and what the curve looks like.

I think the reason conservatives vote for policies that _hurt them_ is that they are somehow convinced that one day they'll be "rich", and be the beneficiaries of those policies. It is ironic that their support for these policies generally results in higher taxes for the poor and middle class (the rise in social security taxes is a key manifestation), and reduces the savings rates (capital development) that can truly lead to movement up the income scales.

Ross:

Greetings - long time, no read.

Funny thing happened the other day: I had a several-hour face-to-face discussion with a guy who made a good argument for a form of socialized medicine similar to that of Canada, and he made some good points. They're points that, if I scanned your prior comments on the matter, might match up in some ways with what you've said in the past. I'm not yet convinced that the "death spiral of the medical system" can be trivially solved without having other dire effects (about which I won't bore you right now), but I'm open-minded and interested in the matter, and don't disagree that it's a matter for concern.

I'm curious about your larger point - the "three tests". I think I'm clear on the "tellin' other people what to do". How do you (specific you, rather than generic) measure equality and fairness? In opportunities, outcomes, or something else? What is the basis for a decision on these matters which you so eloquently agitate?