Health Care and Innovation

November 14, 2007 7:05 PM

Creative Destruction: The Best Case Against Universal Health Care.[Via The Mahablog.]
posted by homunculus (82 comments total)

Good article, but I hate it when writers try to confuse me (at first) as to which side they're on. How am I supposed to know if I'm angry or not?
posted by fungible at 7:19 PM on November 14, 2007

Good article. Thanks for sharing. I hope posters take the time to read it before commenting.
posted by wilful at 7:24 PM on November 14, 2007 [1 favorite]

It's a useless non-argument. Insurance providers are just as likely to make the 'not a cure? Forget it.' judgment as the government is. As for choice in insurers, people are overwhelmingly forced by the cost to take whatever comes with their job. Not to mention that insurance companies illegally collude, and everyone knows it.

At the end of the day, you're just letting your employer pick what treatments you can get instead of the government, and your employer (unlike the government) has a vested interest in keeping it cheap.
posted by Mitrovarr at 7:27 PM on November 14, 2007 [3 favorites]

Wait, are you being sarcastic? "The ideal would be to come up with some way of achieving the best of both worlds--paying for innovation when it yields actual benefits, but without neglecting less glitzy, potentially more beneficial forms of health care. And that is precisely what the leading proposals for universal health care seek to do."

That isn't an argument against universal care is it?
posted by oddman at 7:31 PM on November 14, 2007

This isn't a new argument, it certainly isn't the best argument. Universal health care doesn't preclude the possibility of profits, huge profits even, which is the true driver of innovation in America (if the author is to be believed).
posted by jmgorman at 7:31 PM on November 14, 2007

Krugman's summary.
posted by homunculus at 7:36 PM on November 14, 2007

you know, all i really want to universalize is the stuff we're already paying for. which is to say, the tax-payer funded innovation that takes place at the NIH and most universities.

researchers use federal grants to develop new drugs (for example). then they patent the idea and go private. if everything works out, they end up selling a drug that lots of folks can't afford. the same folks whose taxes funded the research. . . .

keep public intellectual property public, me says.
posted by 1-2punch at 7:38 PM on November 14, 2007 [3 favorites]

Pose that argument to people in the ER, let me know if they like it.
posted by tarheelcoxn at 7:39 PM on November 14, 2007

Clearly, Cohn's never heard of Australia, which is too bad, because a lot of medical innovation has been and is happening here, and, despite the last 11 years of Howard government rollbacks on Medicare, universal health coverage is working very well. I never had such doctors in the States as I've had here.
posted by galtr at 7:45 PM on November 14, 2007

The notion that innovation only happens in for-profit systems is a ridiculous conceit that belongs back in the Microsoft vs open-source argument.

One of many possible counter-examples.
posted by rokusan at 7:47 PM on November 14, 2007

In the end, we would probably still spend more than what even the higher-spending countries in Europe pay. And that should be enough, given that the citizens of those countries are not exactly missing out on cutting-edge medical treatments. France and Switzerland--traditionally the two highest spenders--get the newest cancer drugs to their patients with virtually the same speed as the United States does. And, when it comes to cancer radiation equipment, France actually has more per person than we do.

EVERYONE READ THE CONCLUSION BEFORE YOU COMMENT, THANKS.

Good article. Innovation and even -- gasp! -- profits are not impossible under a universal healthcare system.
posted by Avenger at 7:58 PM on November 14, 2007 [2 favorites]

Despite the many, many, many problems in the defense industry (the root of which is probably that too many large companies are playing for a very small number of potential contracts and systems, a problem which would not exist in health care), the legacy of innovation in an industry that is entirely funded by the government is fairly remarkable.

It's a good article. The innovation angle is something that voters must consider, but if stagnant innovation is the best argument against universal health care, there simply are no compelling arguments against it, because it doesn't (have to) hold water.

Confusing positioning of the article though.... where are my soundbites?
posted by socratic at 7:59 PM on November 14, 2007 [1 favorite]

Just to clarify, Cohn in this piece is arguing against the notion that innovation only happens in for profit systems. He claims that this is "the best case against universal health care," but in the end is not convincing. He is for Universal healthcare.

It is a stupid and confusing title, but the piece itself is quite good.
posted by afu at 8:04 PM on November 14, 2007

The great breakthroughs in the history of medicine, from the development of the polio vaccine to the identification of cancer-killing agents, did not take place because a for-profit company saw an opportunity and invested heavily in research. They happened because of scientists toiling in academic settings.

Damn straight.

companies have become exceedingly good at promoting their sales directly to consumers.

This is one great, messed up issue with health that I can't believe is allowed to continue to exist in the US. I was shocked at some deep level when I found out that they're allowed to advertise prescription drugs to the public and tell people to ask their doctor for them - it just seems completely utterly wrong, and bound to end in tragedy. But, I guess people in the US are used to it and don't notice it anymore.

If that practice was banned:

(a) Drugs would be cheaper because drug companies advertising budgets would virtually disappear.
(b) You would see more true innovation because competition would move to how well treatments work rather than how well they sell.

It seems like a fucking no-brainer to me. But then, universal health care seems like a no-brainer - that doesn't mean America is going to adopt it any time soon.
posted by Jimbob at 8:06 PM on November 14, 2007 [5 favorites]

This was an interesting artlcle. Thanks. Although I too suffered from initial outrage, which got confused and ended up eating itself as I read on.
posted by tentacle at 8:20 PM on November 14, 2007

The United States is famously the world leader in medical innovation--in part, it would seem, because we spend like a drunken sailor when it comes to medical care. Today, we devote 16 percent of our gross domestic product to health care, by far the largest proportion of any country in the world. (The highest spending country in Europe, Switzerland, devotes just 12 percent.) That huge, largely uncontrolled spending translates into large profits for health care companies, offering an incentive for them to do research and development--the kind, presumably, that plays a significant role in breakthroughs like DBS. Universal health care would attempt to bring health care costs under control by, among other things, using government's leverage to drive down prices of everything from medical services to drugs and devices. And, if the payoff for something like DBS weren't as big as it is now, who's to say a company would have bothered developing it in the first place?

Where is the incentive to quickly cure or prevent a disease with a high profit attached? High profits translates into expensive treatments of the symptoms. This explains the resistance to stem cell research by the corporate religious lobby, because stem cells just may lead to bypassing prolonged and proprietary treatments that produce huge profits.
posted by Brian B. at 8:25 PM on November 14, 2007 [1 favorite]

"Medtronic, a company that makes the electrodes, says the whole procedure costs between $50,000 and $60,000."

That's what they SAY, is it? Well I suppose we'll just have to trust them and mortgage the house to pay for it. It's my fault for having the bad brain, anyway.
posted by hermitosis at 9:11 PM on November 14, 2007

This was a really good article, thanks. We have been sold a bill of goods by the insurance industry and pharmaceutical companies who play on emotional arguments to people who don't understand the issues. There is literally a mountain of evidence at this point to discredit almost every scare tactic that is used against universal health care.

The chilling of innovation argument is an important one to air out, since it's one of the few aspects of health care that would seem, superficially, to benefit from the market. I am very skeptical myself that there would be *any* fewer people able to access things like DBS. As was said before, I'd rather have my government, which is in theory democracy, make the decision than a for-profit insurance company which was selected by whatever company I am working for that year.

However, I am coming at this from the perspective of a primary care doctor: this discussion about whether we'll get the latest treatments for cancer and Parkinson's seems pretty hollow when less than 50% of us are even getting the basics, which are already *proven* to save lives. I could save way more lives in my town if I just could get a $50 mammogram for everyone who is a candidate for it than if I could give them a new $50,000 cancer treatment. It's encouraging to read that it's possible to do both, and *still* spend less than we are now.
posted by Slarty Bartfast at 9:26 PM on November 14, 2007 [2 favorites]

Jimbob: what's interesting is that this type of direct-to-consumer advertising has only been legal in the US since 1997 (pdf).
posted by zsazsa at 9:28 PM on November 14, 2007

Creative destruction is our middle name, both within our own society and abroad. We tear down the old order every day, from business to science, literature, art, architecture, and cinema to politics and the law. Our enemies have always hated this whirlwind of energy and creativity, which menaces their traditions (whatever they may be) and shames them for their inability to keep pace. Seeing America undo traditional societies, they fear us, for they do not wish to be undone. They cannot feel secure so long as we are there, for our very existence—our existence, not our politics—threatens their legitimacy. They must attack us in order to survive, just as we must destroy them to advance our historic mission. -- Michael Ledeen, in the aftermath of 9/11.

"Creative Destruction" is a favorite theme of neo-conservatives.
posted by empath at 9:45 PM on November 14, 2007 [2 favorites]

Excellent article, homunculus. Jonathan Cohn is one of the smartest people writing about healthcare today, imo, and well worth following.

People who are interested in following the health care debate, policy issues, and the merits or lack thereof of various health plans proposed by presidential candidates might enjoy Health Wonk Review, a bi-weekly carnival gathering some of the best blog posts from health policy wonks. Cohn is an occasional participant, as is Ezra Klein. There are some excellent contributors, both industry observers and participants. (disclosure: I am a participant in this project).
posted by madamjujujive at 10:22 PM on November 14, 2007

Thanks for that link, juju.
posted by homunculus at 10:42 PM on November 14, 2007

Here's a handy list of Paul Krugman's columns on health care over at Devoter.
posted by homunculus at 10:44 PM on November 14, 2007

Given that the US spends approximately 16% of GDP on healthcare, for distinctly middle-of-the-road performance, it seems like a mighty large innovation premium that's being paid, if that's the key defence of US-style policies.
posted by wilful at 11:10 PM on November 14, 2007

Nice article. A wee bit cheeky in the way he set up the straw man before knocking him down, but a good read. Unfortunately, it seems like a good chunk of the commenters (both here and on the original site) didn't make it all the way through before pressing the outrage button.
posted by Jakey at 2:35 AM on November 15, 2007

Even if his straw man was correct, I would be willing to accept a slower pace development for new cures in exchange for everyone having access to the lifesaving drugs and technologies that already exist.
posted by Jatayu das at 3:53 AM on November 15, 2007 [1 favorite]

I'll never get this universal healthcare argument.

1. everyone bitches about the government screwing things up
2. people bitch about raising taxes. How do you think this will be paid?

I rather pay my deductable and go where I want, when I want.

I do agree, however, that the price of pharmaceuticals needs to be better controlled. Sure we have generics, but a dose of Herceptin isn't genetic. That's where we have to figure out cost control.

Maybe if we didn't pay pharma workers (not talking R&D; but marketing) high salaries, this would be a step.
posted by dasheekeejones at 3:59 AM on November 15, 2007

I rather pay my deductable and go where I want, when I want.

Good fucking luck. Under most healthcare insurance, you are limited to going only to in-network providers.
This is a real problem under many private policies where, if you go to an out-of-network provider (like your GP, whom you have been seeing for 20 years, but isn't in-network under your new private policy), you have to pay the full price out-of-pocket...and that cost does not apply to your already astronomical deductible.
posted by Thorzdad at 4:35 AM on November 15, 2007 [1 favorite]

Universal health care doesn't preclude the possibility of profits, huge profits even, which is the true driver of innovation in America (if the author is to be believed).

Except that the author's point is exactly the opposite of that. You have to read the whole thing.

Why do we refer to a "health-care" industry at all? They are insurance companies. The only involvement they have with health care is (very reluctantly) paying for some of it, out of the monstrous profits they make. If they could, they'd disallow payments for everything. The U.S. medical-care consuming population has a giant parasite on its back. Getting rid of that parasite would have to make things cheaper. How can anyone believe that the government would do a worse job than the insurance companies are doing?

John Edwards is threatening Congress's wonderful health care system, trying to force them to give the rest of us something better than what we have.
posted by Kirth Gerson at 5:08 AM on November 15, 2007

If the government can force me to pay for others' healthcare, would it be too much trouble for them to force said others to take better care of themselves in the first place? Specifically, we must lobby for said others to quit smoking, lose weight (~21% BMI), limit their alcohol intake to two drinks per day, cut out the salt, sugar, and saturated fats, and eat a vegetarian diet.

THEN you'll see "our" healthcare costs drop. Thank-you.
posted by ZenMasterThis at 5:10 AM on November 15, 2007

I go to MetaFilter for both my deep and not-so-deep brain stimulation.
posted by caddis at 5:13 AM on November 15, 2007

Oh, and said others must also get regular mandatory, government-monitored exercise.
posted by ZenMasterThis at 5:15 AM on November 15, 2007

Great article, and special thanks for posting it because I would never have bothered looking at The New Republic.

For those of you who can't be bothered to actually read it before spouting off, here, at least read this excerpt:

The development of DBS was one part basic knowledge—an understanding of how Parkinson's works and how the brain responds to electrical stimulation—and one part sheer luck. Profits, on the other hand, had relatively little to do with it. According to Robert Gross, an Emory University neurosurgeon and expert in the field, Benabid had actually approached the companies that already made electrodes for use in treating chronic pain, suggesting they develop a device specifically for Parkinson's. But they declined initially, so Benabid had to use the existing devices and adapt them on his own. "The companies did not lead those advances," Gross says. "They followed them."

In this sense, DBS offers an important window into the way medical innovation actually happens. The great breakthroughs in the history of medicine, from the development of the polio vaccine to the identification of cancer-killing agents, did not take place because a for-profit company saw an opportunity and invested heavily in research. They happened because of scientists toiling in academic settings. "The nice thing about people like me in universities is that the great majority are not motivated by profit," says Cynthia Kenyon, a renowned cancer researcher at the University of California at San Francisco. "If we were, we wouldn't be here." And, while the United States may be the world leader in this sort of research, that's probably not—as critics of universal coverage frequently claim—because of our private insurance system. If anything, it's because of the federal government.

The single biggest source of medical research funding, not just in the United States but in the entire world, is the National Institutes of Health (NIH): Last year, it spent more than $28 billion on research, accounting for about one-third of the total dollars spent on medical research and development in this country (and half the money spent at universities). The majority of that money pays for the kind of basic research that might someday unlock cures for killer diseases like Alzheimer's, aids, and cancer. No other country has an institution that matches the NIH in scale. And that is probably the primary explanation for why so many of the intellectual breakthroughs in medical science happen here.

Thank you.
posted by languagehat at 5:29 AM on November 15, 2007 [2 favorites]

Health fascism! What a solution! Thank you so much for your insight into How Things Oughta Work, ZMT!
posted by grubi at 5:45 AM on November 15, 2007

Insurance providers are just as likely to make the 'not a cure? Forget it.' judgment as the government is.

Straw Man. It's also demonstrably false. Governments take the long view on health care, while Insurance companies (tend to) take the short view.

1. everyone bitches about the government screwing things up
2. people bitch about raising taxes. How do you think this will be paid?

1. we have proof government is better at health care than private companies. better, in this case, means

a. they cover more.
b. they pay quicker.
c. they do it cheaper.
d. they innovate more (NIH)

2. if i don't have to pay for my health insurance (10K a year) but instead need to pay 6-8K more in taxes, then i'm saving 2K a year. taxes get raised by insurance premiums GO AWAY.

Health insurance would get so much cheaper so quickly in two ways: 1. easy to work with insurance, that is, collect payment and verify eligibility and 2. medical malpractice would virtually go away. why sue for damages when it would get paid for anyway? and as for punitive damages, i would trade my rights for punitive damages for universal healthcare in a heartbeat if i could be assured of some kind of system of tracking bad doctors.

I rather pay my deductable and go where I want, when I want.

so for that to be true you can't have an HMO...your stuck with a PPO or an a la carte program. if you're on universal healthcare, you can still go where you want when you're sick.
posted by taumeson at 6:29 AM on November 15, 2007

This article is confusing, is he for or against UHC?
posted by Mastercheddaar at 6:32 AM on November 15, 2007

If the government can force me to pay for others' healthcare, would it be too much trouble for them to force said others to take better care of themselves in the first place? Specifically, we must lobby for said others to quit smoking, lose weight (~21% BMI), limit their alcohol intake to two drinks per day, cut out the salt, sugar, and saturated fats, and eat a vegetarian diet.

THEN you'll see "our" healthcare costs drop. Thank-you.

while we're at it, we should lobby for people to stop fighting wars so we don't have to pay 1.2-1.8 trillion dollars for NOTHING.

in other words, good luck with that. i'll take what i can get. :)

Health fascism! What a solution! Thank you so much for your insight into How Things Oughta Work, ZMT!

yeah, i shouldn't feed this troll, but i should mention that the system we have NOW is more akin to fascism than a universal health care system would. only what we have now has plentiful collusion and racketeering thrown in for good measure.
posted by taumeson at 6:32 AM on November 15, 2007

Pose that argument to people in the ER, let me know if they like it.

and finally, by making it so that poor people don't have to worry about coverage, they won't overburden our current ER system looking for indigent/charity care for minor ailments!

by increasing the pool of urgent care centers and nurse practitioners we can offer vastly more care to more people at lower costs while increasing the level of care and attention to those who need it (trauma victims).
posted by taumeson at 6:45 AM on November 15, 2007

Time and time again I see people commenting on how obvious the idea of "universal" healthcare is, on how they can't believe America hasn't got it, and on how stupid Americans must be for not getting it.

But healthcare is complex, and minds likely greater than yours have weighed up both sides of the debate. So if you think it's simple, I would respectfully suggest that you are missing something.
posted by hoverboards don't work on water at 7:27 AM on November 15, 2007

No - many Americans are missing something: decent healthcare.

The principles of "life, liberty and the purfuit of happineff" seem obvious now, but they weren't always so. It took progress and thought to create institutions and systems of government that were capable of upholding those principles.

I feel that health care is something that needs to be added to the list. It's time.

In UHC (aka a single-payer system) there still can be many opportunities for profitable participation by the private sector. But they have no business controlling the delivery or access to health care.
posted by Artful Codger at 8:01 AM on November 15, 2007

My quetion is - how DID Kinsley pay for it, anyway? Because I'll tell you right now that here in our wonderful current system, no way would my insurer pay for such a "non-cure."
posted by kgasmart at 8:07 AM on November 15, 2007 [1 favorite]

hoverboards,
Changing an existing complex system without catastrophic downtimes is the complex part. Your healthcare situation can plausibly get even to the point where everyone agrees that this new model X would be better, but still we can't change our system, because trying to change it would crash it. Insurance companies are a nasty tumor, but devising an operation that wouldn't kill the patient is difficult. Still the tumor is a bad thing. Good luck, I'd still suggest having that operation sooner than later.

(In Magic Republic we're having a nurses strike, which will probably kill some patients, and even when everyone agrees that they really should be paid more. It just is so difficult to give 20% raise to one underpaid sectors without raising similar needs in other underpaid sectors. The change is the hardest part, even if the result would be ok for all.)
posted by Free word order! at 8:25 AM on November 15, 2007

Hoverboards wrote: But healthcare is complex, and minds likely greater than yours have weighed up both sides of the debate. So if you think it's simple, I would respectfully suggest that you are missing something.

You know, with all due respect, saying that "healthcare is a controversial issue, therefore anyone who has strong opinions about healthcare is ignorant" is a pretty stupid thing to say.
posted by Avenger at 8:26 AM on November 15, 2007

... minds likely greater than yours have weighed up both sides of the debate.

No, that would be Congress. Highly unlikely that those minds are greater than ours.
posted by Kirth Gerson at 8:30 AM on November 15, 2007

I don't think that's the best argument against single-payer universal health care. (And I'd like to make the point that the huge number of UHC proposals we're seeing coming out the states show that UHC != single payer in every instance.)

I think an instructive example of the potential dangers of a single-payer system can be seen in Medicaid. (That's the insurance for poor people, not old people.) It's very nice that Europe has such great systems for agreeing to what should be covered based on things like--well, you know, science--but a glance at Medicaid shows that ain't necessarily the way it's going to work here. Health care--and PARTICULARLY health care for women--is very politicized in this country. Would a single-payer system cover abortion? Would it cover birth control for non-married women? Are we going to treat AIDS for people who got it through a preventable channel (e.g., unprotected sex rather than a blood transfusion)? Who decides?

It's also easy to see U.S. legislators might start proposing things like making fat people wait longer for a doctor's visit (it'll encourage them to lose weight, see, if they have to "pay" for being fat). Or proposing that people who smoke should not having access to care until they go through a smoking-cessation program. Or not covering STD treatments for gay people.

Say what you will about the evil insurance companies, but I know that my insurance covers abortions, and the pill. They don't do it because they're really nice, or because they just really really believe that women can't be equal without control of their fertility. They do it because they know they'd have a very hard time competing for enrollees if they refused to cover the 2nd most common surgical procedure in the US, and one of the most common prescriptions. They do it because they know that I, and many other women, would be out the door (or complaining loudly to HR at our companies) if they didn't cover it. Consumer pressure can be a beautiful thing.

There are some ways in which comparisons to the European system of healthcare coverage is instructive, but it's also worth considering the ways in which the US is fundamentally different. The politicization of all sorts of health issues--from women's fertility to conditions associated with being overweight (diabetes, heart disease)--is totally different here. I wish that people's health wasn't viewed as some messed-up barometer of people's fundamental morality or character, but it is in this country, and ignoring that fact in the push to insure everyone seems very, very dangerous to me.
posted by iminurmefi at 9:14 AM on November 15, 2007

If the government can force me to pay for others' healthcare, would it be too much trouble for them to force said others to take better care of themselves in the first place?

I'd settle for the government to stop forcing me to pay for other people's deaths.
posted by homunculus at 9:17 AM on November 15, 2007 [1 favorite]

For the record, I'm against being forced to pay for the wars, too.
posted by ZenMasterThis at 9:35 AM on November 15, 2007

No, that would be Congress. Highly unlikely that those minds are greater than ours.

More likely they're on the take.
posted by kirkaracha at 10:03 AM on November 15, 2007

Well - that, too.
posted by Kirth Gerson at 10:24 AM on November 15, 2007

For the record, I'm against being forced to pay for the wars, too.

Noted.
posted by homunculus at 10:56 AM on November 15, 2007

ZenMasterThis: First, what are you saying? People with lung cancer, heart disease, and alcoholism don't deserve health care? Second, you're already paying for someone else's health care and that's the de facto way of getting health care in the US—how do you think private insurance works? That is, of course, unless you can pay for it out of pocket (ha!).
Well, you could always go to medical school and be your own doctor. That's about the same cost as a medical catastrophe, right?

iminurmefi: I do understand the concern about politicizing health and illness (see above), but I do have to ask how this could be worse than what we have now? At this point, if you're uninsured and obese, a smoker, a drinker, etc, getting affordable health insurance is pretty damn hard. Fuck it if you contract HIV or some other chronic illness—just go off and die, or pray that you find an employer with a generous insurance plan. These illnesses don't even get the chance of rising to moral/public health issues, because, first and foremost for insurance companies, these are financial issues—and financial risks. Hell, I have a manageable case of epilepsy, and I'm terrified about what I'm going to do when my health insurance runs out in two months. And epilepsy hasn't been a controversial illness in the Western world since the Middle Ages, as far as I can tell.

With universal health care, at the very least we get some political discourse about what is covered and what isn't (and, indirectly, a say in it.) And I would thin imagine that the discourse would be different from the that surrounding Medicaid. At the very least, we would be talking about "our" health coverage, not the coverage for "them" (i.e. the poor, other countries' foreign aid, etc). That's already a big political distinction.

And a question for the MeFi in general: how politically viable is it really, in the age of high fructose corn syrup, to discriminate against obesity in the context of a universal health care plan? That'll be a quick way of creating a new and angry voting bloc.
posted by Weebot at 1:10 PM on November 15, 2007

Ack, hit post instead of preview. Oh well.
posted by Weebot at 1:22 PM on November 15, 2007

Would it cover birth control for non-married women? Are we going to treat AIDS for people who got it through a preventable channel (e.g., unprotected sex rather than a blood transfusion)? Who decides?

These discussions have already occurred. Yes, all Medicaid systems I am aware of pay for birth control. Nearly all HIV care is currently paid through Medicaid, Medicare, and Ryan White grants.

It's also easy to see U.S. legislators might start proposing things like making fat people wait longer for a doctor's visit (it'll encourage them to lose weight, see, if they have to "pay" for being fat). Or proposing that people who smoke should not having access to care until they go through a smoking-cessation program.

Well, we'll see about whether those positions would be politically tenable, but in the meantime you'd prefer a situation where smokers and obese people (who are way over-represented among the working poor) never see a doctor or even hear from a health professional about how their obesity and smoking is directly affecting them.

Say what you will about the evil insurance companies, but I know that my insurance covers abortions, and the pill.

Seriously? I contract with 12 different insurance plans. I have never seen one that pays for elective terminations. I do not believe that on paper or in practice that delivery of privately funded health care is free from bias or politics. What I do know, is that in the current market based system, neither doctors nor patients have much say in what is being covered, only those people who stand to profit. I honestly do not understand how in 2007 someone could be so naive about how the almighty market doesn't quite fix every problem in society.
posted by Slarty Bartfast at 1:29 PM on November 15, 2007

Weebot--what I'm trying to point out is that in some ways it's limiting to look at it as a strictly binary problem of better under the current system vs. better under a single-payer system. I mean, those are not the only two options for expanding coverage, and I hate that the progressive discourse automatically seems to assume that the only way to achieve universal coverage is with a single-payer system.

Yes, a single-payer system would likely be better for people who are currently uninsured. However, it may be worse for people who are currently insured, particularly those with uteruses. I think it's worth weighing those things when we think about expanding coverage--if we expand it, who is worse off, and how can we limit that? Are certain groups going to be systematically worse off? If there's anything the current system should have taught us by now, it's that once you have the system set up in a certain way it's incredibly difficult to shift it. I want to expand coverage, but I'm leery of the idea that just as long as everyone's insured everything else will be fine, or we'll work out the details later.

I'm pretty progressive--in fact, on many counts waaaay to the left of most people I know on more than a few issues--but I just have a hard time believing that I'd be better off in a situation where the medical treatments available to me are determined by the will of majority (yes, this would be the same populace in many states that has said it's a-ok for pharmacists to refuse to provide contraceptives or plan b when she looks slutty; the same populace that has voted to outlaw abortion in a number of states and has decided that abortions *may* be okay for rich women to pay for but not for poor women; and hell, the same populace that elected W). I'm progressive, but I don't think profit is evil, and I'd sure as hell prefer to pick and choose my (well-regulated) insurance company rather than be forced to a Medicaid-type program.

I'm never quite sure of how to respond to people like Slarty who say I'm naive in thinking that competition and choice is not all bad, yet themselves display this trust that the government will make the right decision in all cases. Or that the government will respond to the will of the people, which of course will be just, and do the right thing. (Strangely, the ones that seem to espouse this view most often seem to be white men.) I don't think insurance companies love me, but I do think they love my money (of course! they're greedy bastards), and I think in most ways companies are a lot more responsive to pressure than the federal government is.

So on balance I'm less "rah rah free market rawks!" and more "oh sweet jesus, the federal government already is trying to screw with my woman parts, I don't want them to have the opportunity to do it more."
posted by iminurmefi at 2:18 PM on November 15, 2007

Although I do have to thank Slarty for pointing out that I was naively assuming that my insurance's explanation of coverage included "pregnancy termination," which does not necessarily imply it covers elective termination. Definitely going to follow up on that one (although god willing I won't ever need it), 'cause you definitely don't want to wait until you need it to find out it's not covered.
posted by iminurmefi at 2:20 PM on November 15, 2007

ZenMasterThis points out precisely why this is hard in the US. Some right wing goojob who professes small government, low taxes, leave my shit alone, blah, blah, blah will show their true colors in wanting to essentially control how everybody else (well, those who differ from them) live their lives and they will use the incredible power of the government health care system to do it. You think abortion and birth control will get any funding?
posted by caddis at 2:32 PM on November 15, 2007

iminurmefi: First, I'm would not agree with you that the insurance-industry is well-regulated. The impression I got from Cohn's book was the opposite, and anecdotally my family has a battle-scarred history with Health Net and its refusal to comply with ERISA laws.

Anyway, you're setting up a false dilemma, since, even in single-payer nations, universal health care does not mean that private health insurance cannot exist (also note that I didn't use the term single-payer in my first post). They aren't mutually exclusive. In fact, Clinton is taking great pains to show that; she even titled her plan the "American Health Choices Plan." So even if it were to come to pass and they offered Medicaid-style coverage, you'd probably be able to keep your insurance company. I sure as hell wouldn't, though. Not that I can.
posted by Weebot at 3:41 PM on November 15, 2007

I don't know what is the percentage of people who have real choice when selecting health insurance plans, but I would estimate it is not high. Is that (very small) competitive force worth the downsides that are well established: A- Health insurance companies only pay for what is cost effective in the short term while your actual health is a long term concern. B- There is an enormous amount of redundancy and waste in the bureaucracy required to administer the system C- 45 million people cannot afford what insurance companies charge, in addition to the 30 million or so that are already being funded by your state government.

I guess it comes down to a judgement. I do not believe that the very small amount of choice that a few consumers have really exerts that much effect on the industry and I do believe that there are theoretically ways that we could use our representative government (now maybe I'm being naive) to safeguard your right to birth control.
posted by Slarty Bartfast at 3:50 PM on November 15, 2007

If the government can force me to pay for others' healthcare.

America spend about the same amount of tax payers money on health care, per person, as other countries. (Actually, a fair bit more than places like Australia were that money gets you pretty good coverage rather than nothing).

It's just that on top of that they need a bunch of private spending to actually get health care.

Ouch.

(No idea what nationmaster is, but I've looked at the numbers before in other sources and come to the same conclusion).

I think medication costs are interesting, the way it works in Australia is through the PBS. Drug companies are free to sell drugs in Australia at any price they wish. On top of that, through the PBS, the Australian Government buys many drugs and sells them to the public for a flat price of about 30AUD. Now since they are buying in bulk they have a strong bargaining position, and they set their buy price based on the actual demonstrated benefit of the new drug, and how it compares to competing treatments. Drug companies are free to ignore that price and attempt to sell direct, but Australians are used to paying 30AUD, so that doesn't tend to work too well.

Incidentally, any time you see a bunch of stories on the current affairs programs about some battling mum dying because the evil government won't put some hail mary drug on the PBS (usually because the drug company wants a higher price), you can bet that there is a marketing company somewhere in the background pulling the strings, it's a dirty business.
posted by markr at 3:57 PM on November 15, 2007

First, what are you saying?

I'm saying that a lot (70% according to a surgeon general's report that I can't seem to locate at the moment) of healthcare spending in the US is to treat conditions attributable to bad lifestyle choices: smoking, drinking, over-eating, eating bad food, and not exercising.

I was joking of course about government-coerced programs to make people live healthier lifestyles, but answer me this:

1) If someone else has a right to free healthcare at taxpayers' expense, why shouldn't taxpayers have a right to see the highest return on their public healthcare dollar, that is, on people who choose to live healthy lifestyles?*

2) If someone else has a right to healthcare at taxpayers' expense, why shouldn't the person benefiting from that right then have a moral obligation to take better care of him/herself through prevention?

Basically, I'm saying that I'm against socializing the risks while privatizing the rewards (to individuals) of unhealthy lifestyle choices.


*(Including those who live healthy lifestyles who have congenital issues or just plain bad luck.)
posted by ZenMasterThis at 4:53 PM on November 15, 2007

If someone else has a right to free healthcare at taxpayers' expense, why shouldn't taxpayers have a right to see the highest return on their public healthcare dollar

That's easy.

Because the first thing is a sensible use of government funds in a way that's virtually certainly Pareto-superior to the status quo, and the second thing is tyrannical micromanagement of people's lives in defiance of even the most trivial notions of liberty.
posted by ROU_Xenophobe at 5:17 PM on November 15, 2007

ROU: you left out a bit...

that is, on people who choose to live healthy lifestyles?*

Where's the tyrannical micromanagement, exactly?
posted by ZenMasterThis at 5:21 PM on November 15, 2007

In making people do all of the various things that constitute living a healthy lifestyle. Your comment doesn't make sense in any other context.
posted by ROU_Xenophobe at 6:06 PM on November 15, 2007

I can't argue with that...
posted by ZenMasterThis at 7:07 PM on November 15, 2007

I do think it's highly amusing that many of the same people who go 'OMG! The government spends money like a drunken sailor!' in any other argument will immediately reverse to 'OMG! The government will crush your freedoms in their relentless push to save money!' when the subject of universal healthcare comes up.
posted by Mitrovarr at 7:16 PM on November 15, 2007 [2 favorites]

If someone else has a right to free healthcare at taxpayers' expense, why shouldn't taxpayers have a right to see the highest return on their public healthcare dollar

That's why we should tax cigarettes at about 100% per pack and give tax CREDITS for gym membership.
posted by Brian B. at 7:18 PM on November 15, 2007

If someone else has a right to free healthcare at taxpayers' expense...

Who exactly are these people who have the right to this hypothetical health care system; who will, for their entire lives never pay taxes and never be taxpayers (therefore making their health care truely free); and who will still seemingly get every benefit of a universal health care system?

I'm not being facetious. I want to know. I can think of a few answers, but none of them are exactly significant populations, populations where it would be politically tenable to deny benefits, or populations where the conventional wisdom that they don't pay taxes is even true.
posted by Weebot at 7:38 PM on November 15, 2007

"Good fucking luck. Under most healthcare insurance, you are limited to going only to in-network providers.
This is a real problem under many private policies where, if you go to an out-of-network provider (like your GP, whom you have been seeing for 20 years, but isn't in-network under your new private policy), you have to pay the full price out-of-pocket...and that cost does not apply to your already astronomical deductible."

Um, no actuall you're not. What you are describing is HMO not a PPO with choice deductable. In network 90% coverage. Out of network, 80% coverage. You can't assume that ALL coverage works the same either. When I worked for financial services, I had a major insurer coverage where copays were the norm (and it was a PPO). Now I work FOR the major insurer, and my insurance is a PPO with the 90% vs 80% in-network/out of network coverage.

Seeing that surgeries rack into the thousands (septoplasty--$17k for a 20 min surgery; my father w/ cardiac issues and 5 days in the hospital? How's $65k). I rather pay my 90%, reach my $2k deductable, get $75 out of each paycheck to cover it and STFU. It's better than having zero coverage.
posted by dasheekeejones at 3:35 AM on November 16, 2007

Who exactly are these people who have the right to this hypothetical health care system; who will, for their entire lives never pay taxes and never be taxpayers (therefore making their health care truely free); and who will still seemingly get every benefit of a universal health care system?

Furries. The fucking furries.
posted by ROU_Xenophobe at 5:14 AM on November 16, 2007 [1 favorite]

Medicare for all.
posted by Brian B. at 6:37 AM on November 16, 2007

Since when does UHC preclude doctors working private practices doing procedures not covered by standard healthcare? There will still be the same amount of research and high tech procedures as there are now. There will always be a demand for advanced medical procedures which will not be provided by UHC.
posted by JJ86 at 8:34 AM on November 16, 2007

And Why Not Take Away Congress's Health Care?
posted by homunculus at 1:38 PM on November 16, 2007

Bush Vetoes NIH Budget And Open Access Bill
posted by homunculus at 11:07 PM on November 16, 2007

It’s Not Just the Uninsured
posted by homunculus at 3:13 PM on November 17, 2007

What do the uninsured in America do when they need health care? Some turn to a volunteer medical group that was set up to provide free services in third world countries.
posted by homunculus at 10:57 AM on November 18, 2007

That's the insurance for poor people, not old people.) It's very nice that Europe has such great systems for agreeing to what should be covered based on things like--well, you know, science--but a glance at Medicaid shows that ain't necessarily the way it's going to work here.

Medicaid's problems stem from a chronic lack of funding. Fuck poor people, we need to pay for wars and old people.

Medicaid is actually paid for by a few different programs, all of which are "medicaid" (like how "welfare" is actually HUD + food stamps/WIC + etc.) These programs get consistently cut.

Furthermore, the money is given directly to the states, who they set up their medicaid programs. There are basically 50 different payers, and this causes problems for billing software developers (aherm) and doctor's offices with out of state patients (I think).

The money isn't used for nation-sized initiatives like lowering the unwanted pregnancy rate or HIV education.
posted by taumeson at 8:46 AM on November 21, 2007

Giuliani, McCain, and Thompson advocate tax-incentives for buying health insurance. Their plans do not address the reality that Giuliani, McCain, and Thompson could not buy health insurance as individuals.
posted by Kirth Gerson at 8:57 AM on November 21, 2007

That is one of the biggest problems in health care today, and you are right, none of their plans address the issue. Just try forcing the plans to take all customers, like auto insurance in some states, and see what bloody hell the insurers will raise about how it will drive them out of business and bankrupt them, and the politicians nod in agreement because it is better to bankrupt individuals who happen to get sick than to bankrupt a business.
posted by caddis at 9:12 AM on November 21, 2007

Republicans are trying to make the insurance and healthcare industries more money (being on their short list of friends, with big oil and defense). This is the essentially the absurdity of the right-wing position in society. If we are made poor from health costs and insurance, then we can't afford anything else, and the demand economy collapses by way of its industrial corruption.

Until there is universal health insurance, there is no ethical way for society to enforce the licensing of doctors or limit patient access to needed pharmaceuticals. It should be a free for all for the consumer as long as the industry profits and helps bankrupt others from disease.
posted by Brian B. at 9:59 AM on November 22, 2007

Bush Vetoes Kids Health Insurance Bill
posted by homunculus at 9:37 PM on December 12, 2007

You can't assume that ALL coverage works the same either. When I worked for financial services, I had a major insurer coverage where copays were the norm (and it was a PPO). Now I work FOR the major insurer, and my insurance is a PPO with the 90% vs 80% in-network/out of network coverage.

Good for you!
I was describing the sort of private coverage that average families can actually (though barely) afford. The PPO plans you describe are enormously expensive wet-dreams for large numbers of working families.
posted by Thorzdad at 11:35 AM on December 13, 2007

Conservative Christmas hypocrisy
posted by homunculus at 11:00 PM on December 13, 2007