healthcare the safe way?

June 21, 2009 8:32 AM

How Safeway Is Cutting Health-Care Costs- "At Safeway we believe that well-designed health-care reform, utilizing market-based solutions, can ultimately reduce our nation's health-care bill by 40%. The key to achieving these savings is health-care plans that reward healthy behavior... 70% of all health-care costs are the direct result of behavior... 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable." [1,2] cf. Wyden's Third Way & Healthcare CEOs Shoot Themselves in the Foot

BONUS

• Obama: Health Care Reform as the Key to Our Fiscal Future
• Obama: If You Like Your Doctor, You Can Keep Your Doctor [cf.]
• OMB: Debating Health Care
• Health Care Rationing Rhetoric Overlooks Reality - "The choice isn't between rationing and not rationing. It's between rationing well and rationing badly." [more]
• More from Gawande on controlling healthcare costs

previously...

posted by kliuless (130 comments total)

I may be missing something, but obesity and rape really aren't in the same category of acts of violence. Good tagline, bad for discussion.

Maybe my assumptions are off here, but doesn't obesity come from eating more than your body burns off? There are already labels on every store-bought food item labels the contents, but people still over-eat. I may be way off-base, but the no "S" diet seems like it would speak to FDA Commissioner David Kessler's notion of avoiding things that are laden with sugar, fat, and salt. Don't eat snacks, sweets, and don't take seconds, except on Saturday, Sunday and special days (holidays, birthdays, etc). That, or stick with Hara Hachi Bu, eating until you are 80 percent full.
posted by filthy light thief at 8:56 AM on June 21

One doctor's view, published in the Wall Street Journal (and surprisingly nuanced for having been published there).
posted by jedicus at 8:58 AM on June 21 [4 favorites has favorites]

I fear that the meat of this article will be ignored in favor of the usual tedious argument about obesity. Metafilter, please prove me wrong.
posted by Afroblanco at 8:58 AM on June 21

The funny thing about rationing health care is that a) people already do it, since health care is so expensive, and b) that's probably kind of your whole problem right there.
posted by Sys Rq at 9:04 AM on June 21

This is just awesome. If government attempts to implement sweeping public health changes, in the interest of the nation's health, it's socialism. When a corporation attempts to implement the same kind of changes, in the interest of keeping their costs down, you get a glowing op-ed in the Wall Street Journal. Now, which system is it that gives the insured person more choice?
posted by Slarty Bartfast at 9:05 AM on June 21 [32 favorites has favorites]

and more than 90% of obesity is preventable.

Not as long as Safeway keeps selling those yummy pies and cakes.
posted by birdherder at 9:10 AM on June 21 [10 favorites has favorites]

it wouldn't be an american health plan if someone wasn't trying to shove the costs of it onto someone else - that's the way everything in our government seems to operate these days - let the other guy pay for it

the definition of the other guy is usually dependent on ideological justifications and self-righteous indignation, the goal being to find a minority that the majority can exploit, either because they have too much money, or because they "deserve" less, or both

_____ should pay more because they ______ is the number one theme of our political culture, left and right

no wonder we haven't solved problems like this
posted by pyramid termite at 9:13 AM on June 21 [2 favorites has favorites]

The article jedicus linked is really great and rings very true to this doctor.
posted by Slarty Bartfast at 9:13 AM on June 21

Life insurance decreases your premiums if you don't smoke, why shouldn't health insurance?
posted by furtive at 9:16 AM on June 21

If government attempts to implement sweeping public health changes, in the interest of the nation's health, it's socialism. When a corporation attempts to implement the same kind of changes, in the interest of keeping their costs down, you get a glowing op-ed in the Wall Street Journal.

Except that if our government tried to replicate Safeway's plan, it would be called Libertarianism. As tempting as it it is for an anti-Universal wonk like me to support a tax reform that levies more against fat people and sweet-toothed diabetics, even *I recognize that the educational playing field is not remotely level enough for such a solution.
posted by njbradburn at 9:21 AM on June 21

Look, if I'm going to be force to pay for others' healthcare, why should those others be forced to take better care of themselves?

Or aren't I supposed to think of it that way?
posted by ZenMasterThis at 9:21 AM on June 21 [2 favorites has favorites]

From the WSJ link: But if your preventive strategy is medical, if it involves us, if it consists of screening, finding medical conditions early, shaking the bushes for high cholesterols

Wait, high cholesterols come from bushes? Or they hide in bushes? Doctor, are you suggesting people who are, ahem, shorn would have lower cholesterol? Methinks the barber was just invited back into medicine.

I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone.

And that makes medicine different from the automotive industry, or gardeners? A dollar spent is a dollar passed along the line anywhere. The problem with this "communal drinking trough" that is money spent on medicine is that there are a lot of mouths getting between the money and the medicine.

I don't understand why the Obama administration doesn't want to make healthcare a government-run entity. Bureaucracy already stymies the system, so why not trade out the convoluted insurance system with something government-run? I know there is a lot more to it than swap A for B, and with that, I'll be spending a good while reading more.
posted by filthy light thief at 9:22 AM on June 21

Several times now I've started to write an article about our love for "Gotcha!" moments, such as the final scene of the most famous Twilight Zone episode ever, Time Enough at Last.

Our society is filled with preventable obscenities like the cancer patient whose coverage is cancelled because of the long-forgotten acne prescription, the single mother fined two million dollars for sharing a few songs, TV shows which invite us to take pleasure in our fellow citizens' discomfort as they are marooned, eat bugs, betray and endure betrayal in pursuit of a prize, or are chased by cops and rendered into handcuffs as a winking voice reminds us that these lowlife scumbags are innocent until proven guilty.

And of course there is our health "care" system. In Sicko Michael Moore notes that the difference between cultures that have fixed this problem, such as France, and ours is a pervasive sense that we focus on "me" instead of "we," that those other cultures feel a sense of collective belonging that we reject.

And I think this is close to the core of everything that is wrong with modern culture, both in the US and in those places where we have exported our bad habits through the pervasiveness of our corporate structures, our media, and our wars of conquest.

When you strip everything else away, we like seeing other people get screwed. We like it because it makes us feel superior and safe at the same time, because of course we rugged individuals watching Cops would never do the dumbass things that get you a starring role.

Until we figure out how to fix this, I fear the rest will just continue to spiral into obnoxiousness.
posted by localroger at 9:24 AM on June 21 [66 favorites has favorites]

Safeway preaching about being healthy with an anti-obesity message is kinda like your local crack dealer talking about the virtues of a drug-free lifestyle.

Fuck you, asshole, fuck you.
posted by hal_c_on at 9:25 AM on June 21 [2 favorites has favorites]

I look forward to hearing about how Safeway is opening hundreds of new stores in low-income inner-city neighborhoods, then stocking them with plenty of fresh produce.
posted by box at 9:27 AM on June 21 [29 favorites has favorites]

Look, if I'm going to be force to pay for others' healthcare, why should those others be forced to take better care of themselves?

If i have to pay for someone elses baby to be born or someones skiing accident or car accident or STD, you should have to pay for any choices i may make. we're all in this together. let's not simpfy and sound bite this issue to death and blame each other for everyone's sins. we ALL make choices.
posted by brandz at 9:32 AM on June 21 [13 favorites has favorites]

Good for Safeway for trying to reduce their own healthcare costs. But it does seem to me that, if Safeway were REALLY devoted to decreasing "our nations' healthcare costs", they would apply market forces thusly:

1) Stop selling cigarettes. If they're bad for your employees, they're bad for everyone.

2) Reengineer your grocery store aisles so the food that has the best nutritional value is at eye level, and put the products which are the worst for the nation's health either in difficult to access places or stop carrying them altogether. Those shelves are very carefully studied and engineered to promote the sales of the most "addicting" foods, which also happen to be the highest-profit sales items for companies. Change those, and you change people's shopping habits.

3) Offer well-presented, live in-store full-day-long cooking demonstrations showing how to feed a family of four a nourishing meal for $10. Make these impossible to avoid while in the store so anyone who walks in the doors will have to at least confront the notion that there are food choices which they may not be making.

I could go on with these examples, but it is clear to me that he is not talking about truly reshaping the way our nation eats. He is instead talking about punishing low-wage employees for making the exact bad choices which are available to them. (This MeFi thread is related.)

And can someone, ANYONE, please find a way to stop hanging out the canard of "tax breaks means health care is affordable?" If, as Senator Wyden stipulates, a family of four pays $13K in a year for health insurance, then it becomes quickly clear that, even if they government gives them that full amount "back" in tax credits, when your family only earns $30K in a year, you're simply not going to buy that health insurance, because the choice quickly becomes housing vs healthcare, or food vs healthcare.

We have to go to a system in which people are NOT purchasing their healthcare outright, and where those who cannot afford it are not having the stick dangled in front of them that "if you buy it, we will pay you back." You could offer to pay me back for a brand new BMW sports coupe, but if I can't pay for it in the first place, the purchase will never be made.
posted by hippybear at 9:35 AM on June 21 [36 favorites has favorites]

Look, if I'm going to be force to pay for others' healthcare, why should those others be forced to take better care of themselves?

Because they have a property interest in their own body; there's no property that's more uniquely theirs. If society chooses to provide a health-care service for that property, that's fine, but that's society's choice. It's a gift; it doesn't get to include behavior-controlling strings.

You can't abrogate someone's personal rights by giving them gifts. If you want to offer universal health coverage, that's fine. But you gain no authority to then force people to comply with your view of how they should behave.
posted by Malor at 9:40 AM on June 21 [11 favorites has favorites]

The reason you are not going to have a government-run health care pass the Senate is because it will be devastating for this country, Senator Lindsey Graham said. The last thing in the world I think that Democrats and Republicans will do at the end of the day is create a government-run health care system.
posted by ornate insect at 9:41 AM on June 21

Percent of spending vs. life expectancy. The US spends 5-7% more on healthcare, yet has the lowest life expectancy. It's also the only developed country running a capitalistic healthcare system.
posted by five fresh fish at 9:41 AM on June 21 [1 favorite has favorites]

a dollar spent on medical care is a dollar of income for someone.

The point there, I think, is just to point out that we should be wary of preventive care (as opposed to preventive actions by patients, such as quitting smoking) because preventive care is ultimately about spending money to save money and that money spent is income for some healthcare provider. The upshot of that is that putting a lot of money into preventive care runs the very real risk of actually driving up costs as the doctors and hospitals performing the preventive care push for more and more preventive care out of self interest.

A point I don't know if he made or not, is that a lot of defensive medicine, which definitely drives up healthcare costs in the US, for example, could easily be justified as 'preventive care.' Defensive medicine is bad in that it is motivated or justified by saying 'oh, I'm just ordering this test to stave off a lawsuit' but the doctor also often stands to gain materially from the questionably necessary test. It's a carrot and stick that leads to higher costs and the use of money that would be more efficiently spent elsewhere. Shifting the justification to 'oh, I'm just ordering this test as a preventative measure' doesn't change the reality, only the rationalization.

The other problem is that spending money to save money can often backfire. After all, you're still spending money, just in the hopes that it may save down the line. Many a person has gone broke from all the money he or she saved at sales, as the saying goes.

why not trade out the convoluted insurance system with something government-run?

The concern with a completely government-run system is that it then becomes trivial for patients and wealthy interest groups like the AMA to push for voting more and more money into the system. The article points out that real, definite savings comes from actually cutting or controlling spending, and once the entire healthcare system is tied to the will of the electorate that may become very hard indeed. Or maybe it won't, but it's something to guard against.

Of course, a public option is different. That is basically just a price floor on health insurance, which I think is fine, so long as it doesn't use the power of deficit spending to become a loss leader that bankrupts private insurance companies.
posted by jedicus at 9:43 AM on June 21 [1 favorite has favorites]

It's a gift

It's a right.
posted by ornate insect at 9:46 AM on June 21 [17 favorites has favorites]

Look, if I'm going to be force to pay for others' healthcare

no, you're paying for a civilization that takes care of people's health
posted by pyramid termite at 9:46 AM on June 21 [31 favorites has favorites]

It seems to me that from a cost-benefit perspective massive and sustained investment health would make great sense.
Let's get the hurf-durf nonsense out of the way first:
Americans are fat for structural reasons and that is the beginning and end of it. The main difference between the average fat American and the average thin American is that the fat people don't tolerate the sedentary lifestyle and appalling diet of the US as well as the thin ones.
Of course (genes notwithstanding) most fat people could be thin, But given the environment that exists - And it is a given, none of us can magically change the whole culture and macrostructure of the food industry - it is just not realistic to expect substantial numbers of people to be able to do that.

The fools who natter on about 'free will' and 'personal responsibility' as if they were some kind of talismans are nothing more than latter-day mystics. They believe in a magical world that is radically at odds with observable reality. As if willpower is some kind of panacea!
Should we do away with child labour laws, just because really motivated children will still manage to get an education? The very idea is absurd. It is very clear, if you create the kind of environment that the US is (and the UK for that matter) YOU WILL GET FAT PEOPLE. The evidence is rather difficult to miss, what?

Listen. When I said that the environment was a given? I lied. For an individual that is mostly true, but we have invented this wonderful thing called society. Through the alchemy of rationally considered, democratically made policy, we can make changes to our environment. We can say, let's make P.E. a real priority in schools. Let's give tax incentives for gym memberships. I bet you think that public nutrition education is ridiculous don't you? Surely, you think - Every fucker knows what a normal portion looks like. No, my overstuffed little muffins, many Americans (and British again) are at least a generation removed from instinctively knowing that.

So I say:
First of all, this is not a substitute for universal coverage, it is in addition to it.

Present your demands to your representatives:
- A black iron gym on every corner
- Better P.E. in the schools
- Marg bar Archer Daniels Midland Regulatory pressure on the food industry
posted by atrazine at 9:46 AM on June 21 [19 favorites has favorites]

The current upsurge in obesity is poorly understood at the moment. Assuming it's purely a "lifestyle choice" is probably a mistake.

Note Kristie Allie and Oprah - both are millionaires with access to the best personal trainers and private chefs. Both have seen their weight yo-yo wildly, as chronicled mercilessly at the Supermarket checkout - and here's something interesting: Kristie Allie didn't have this problem until she deliberately became overweight for a role. She assumed she would be able to just lose the weight afterward, and keep it off... and she was wrong.

To put this sort of reward system in place is asinine, as it does not treat obesity or tobacco addiction as diseases that require treatment, but as some sort of social faux pas, like eating peas off the knife or something.
posted by Slap*Happy at 9:53 AM on June 21 [4 favorites has favorites]

I eats my peas with honey
I's done it all my life
It makes them taste quite funny
but it keeps them on my knife.
posted by hippybear at 9:56 AM on June 21 [3 favorites has favorites]

[Stupid fight-starter first comment removed. Please don't do that.]
posted by cortex at 10:06 AM on June 21

I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone.

You know, once you have a phrase like that in your journal, you're really more of a magazine. In my domain, you have about a 50/50 mix of articles and advertisements for filters and stainless steel plumbing and you keep calling me asking if I want your other magazines on subjects that I have no interest in.
posted by Kid Charlemagne at 10:07 AM on June 21

When a corporation attempts to implement the same kind of changes, in the interest of keeping their costs down, you get a glowing op-ed in the Wall Street Journal.

What are you talking about? The CEO of Safeway wrote the "glowing op-ed". Of course he's going to sugarcoat it.

I get the fact that anti-corporation is a theme here. But you make legitimate arguments against corporatism look moronic with ignorant, snappy one-liner comments like yours. It's not a race to come up with pithy comments around here.
posted by SeizeTheDay at 10:12 AM on June 21

A few things to consider about public health care.

Private collectivized health insurance discriminates against preexisting conditions and selects those with least risk in order to keep costs low and maintain profits for itself, essentially causing the problem of having uninsured in the first place.

There are questionable ethics in making a profit from disease anyway. Essentially it amounts to taking many people's life savings during a life emergency, causing 60% of the bankruptcies. Interestingly, the best hospitals rated annually by USN&WR are usually non-profit over 90% of the time.

A common lie about prescription drugs is that they must be rationed to keep prices high in order to fund more research. However, the marginal costs of manufacturing drugs at maximum production often amounts to pennies per pill, and if these were sold to government agencies at cost and distributed on a need basis, it would save billions in taxpayer dollars (those who helped fund original related research, and who protect the special marketing rights to make those huge profits). It would be the cost of doing business in the first place if we had any business sense.

The last thing to consider about public health care is the money already spent with no price control. The US taxpayer already spends about 41% of each health care dollar, but has little say in pricing, and is happily price gouged as the sucker in the deal. A modest proposal would be to automatically pay 50% of every health related bill and begin freezing prices immediately. We can worry about the details of the health care debate later.
posted by Brian B. at 10:14 AM on June 21 [3 favorites has favorites]

I dunno, Slap*Happy... I was driving through an affluent east coast neighborhood the other day just as a middle school was letting out. A lot of the kids were walking home. A good third of them were obese. Does anyone here remember there only used to be one fat kid in school? One. And it was glandular.

I shudder to think what's going to happen to the healthcare system when these fat little buggers grow up to be morbidly obese adults with all the associated maladies.

Why are so many children obese all of a sudden? Methinks it has something to do with the shrinking outdoor play radius. Less physical activity is certainly a major lifestyle alteration, if not a choice.

You're supposed to be able to eat ridiculous amounts of stupid food when you're a kid because you run around all day and jump rope and climb trees and go swimming and play pick-up sports.
posted by TheGoldenOne at 10:14 AM on June 21 [1 favorite has favorites]

Eh, this is kinda basic stuff, and Safeway shouldn't really been seen as a bunch of geniuses for implementing it. I'm not entirely against this idea of health insurance, assuming that you're using an insurance model of paying for health care in the first place. But there are a few things worth noting:

1) The cost of the health care system in the US is not that of health care treatment. The same levels of disease can undoubtedly be well treated at a far lower cost in a differently designed system. Throwing the book at patients for costs they have no power over seems unfair.

2) There's a moral problem as the person seeking insurance has the incentive to lie about their situation, and the insurer cannot be sure that they are issuing insurance based on good information. While BMI and cholesterol may well be subjective (though usefulness is another matter), smoking, alcohol intake, and so on, are all things that can be denied or downplayed by the insuree.

3) So-called 'lifestyle choices' are too complex to put down to personal responsibility. Poverty is the main cause of health inequalities (as per the Black Report), meaning that those most needing health care are those least able to afford the increased insurance costs.

Leading on from point 3, perhaps if Safeway progressively raised their wages at the bottom they would find (after some lag) that their insurance costs would decrease. If all employers concentrated on better lower-end wages rather than how to cover health care costs it would lead to a better long term outcome throughout the US.
posted by Sova at 10:15 AM on June 21

MetaFilter: a race to come up with pithy comments
posted by hippybear at 10:17 AM on June 21 [1 favorite has favorites]

But cortex, now the second makes no sense.
posted by gerryblog at 10:18 AM on June 21

Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable
At least 95% of all pregnancies are preventable, but I'll bet Safeway isn't encouraging/rewarding their female employees from having babies. Because it's perfectly acceptable to tell an overweight person "Hey, tubbo, lose some weight" but not a high school sophomore or a single mom who already has three in diapers to "keep your legs together" (or use a condom or a diaphragm, but the only 100% way to not get pregnant is to not have sex, of course).
posted by Oriole Adams at 10:19 AM on June 21

There's a moral problem as the person seeking insurance has the incentive to lie about their situation, and the insurer cannot be sure that they are issuing insurance based on good information.

people can be tested for tobacco and alcohol intake the same way they're tested for drugs, so lying isn't going to work

just to be clear, i don't like that idea
posted by pyramid termite at 10:30 AM on June 21

But cortex, now the second makes no sense.

Which is the main reason I left a comment. Carry on!
posted by cortex at 10:31 AM on June 21

please find a way to stop hanging out the canard of "tax breaks means health care is affordable?"

How about "tax breaks raised rents and home prices?". That's the theory of the "All-Devouring Rent", which correlates well with my life experience.

A common lie about prescription drugs is that they must be rationed to keep prices high in order to fund more research

One glance at GSK's SEC filings shows that the bulk of its spending goes to administrative overheads, marketing, and profit. R&D is ~1/4th of SG&A and profit put together.
posted by @troy at 10:33 AM on June 21 [2 favorites has favorites]

people can be tested for tobacco and alcohol intake the same way they're tested for drugs, so lying isn't going to work

but tobacco and alcohol are legal products, which we pay taxes on. i'm not even going to address the idiocy of drug testing.
posted by brandz at 10:33 AM on June 21

But you make legitimate arguments against corporatism look moronic with ignorant, snappy one-liner comments like yours. It's not a race to come up with pithy comments around here.

I actually know far more about this subject than I think you can imagine. I am a physician that is worked in public health for almost 20 years. My moronic argument was to make the point that any real discussion of the real change that needs to happen is poisoned by people like the Wall Street Journal talking about how the government is incapable of fixing the system. But then a corporation, one that peddles cigarettes and Fritos no less, argues for some of the same kind of social engineering, and they get showcased in a national publication. People with real lifetime experience on public policy with real ideas get shut out of the discussion and then some dipshit CEO who wants to preserve his profits comes along -- in my bizarro world view, people like this shouldn't even get to participate in the discussion.

Anyway, it's my first father's day, my family is trying to get me out the door to go to brunch and I don't have time for yet another heated health care debate, but fuck you very much sir.
posted by Slarty Bartfast at 10:34 AM on June 21 [22 favorites has favorites]

Methinks it has something to do with the shrinking outdoor play radius

yeah, skateboarding on a game console vs the real thing. I had to bike a mile to Junior High every day, and when skates got cool thirty years ago I skated all over the south half of the city for a summer.
posted by @troy at 10:37 AM on June 21

Well, here's the first question: Is Safeway going to pay for gym memberships?

Because the sad truth is that even with the price breaks, at supermarket wages, a gym membership can be a luxury. Sure, you can get places for around $40/month, which isn't too bad, except when you're choosing between that and a bus pass to get to work in the first place, or medication, or a couple of weeks of groceries, or a lot of things $40 can cover.

And of course, then being locked into the 6-12 month contract gyms put you into, assuming you are going to keep that oh-so-stable supermarket job.

Here's the second question: Is Safeway going to pay for trainers?

The most unhealthy folks are the ones most likely to get injured when they first start exercising - they're usually dealing with a fun mix of lack of neuromuscular coordination, being out of touch with their own body's limits, as well as weakness the stabilizing muscles they'll need to develop.

Nothing preventative like blowing your ankle, knee or shoulder and being out of work 2-3 weeks, right?

Finally, while it would make sense on a meritocracy basis if someone's health only affected them, but the reality is that it can easily come around to affecting me when other people don't get checked for swine flu, have untreated STDs, don't take the medication that prevents their schizophrenic attacks, passes out on the freeway while driving and any number of possible things that could get me hurt or the people I care about.

So yeah, I'll pay for that.
posted by yeloson at 10:37 AM on June 21 [2 favorites has favorites]

Can someone explain what ought to be a relatively simple point to me? As a doctor, I still have trouble understanding how preventative care plays any role in reducing the cost of care. Is there data that really supports that in the long term? Don't get me wrong, I'm all for preventative care and I think it's the most efficacious way to get people living longer and improve overall quality of life. But isn't that guy that was going to have a massive heart attack at 60 who now takes 6 medications a day for the rest of his life, has regular tests to monitor his status, does so for an extra 20 years, and then gets dementia and requires rather expensive elder care before likely costing an arm and a leg in end-of-life ICU care for recurrent pneumonias -- isn't that guy still going to cost a boat load of money in the long run, and aren't we just going to have more of him with our improved preventative care?

It seems like the focus on preventative care is a straw man in the argument of cost containment. In the short term, sure it saves insurers in the current system cash because they can reasonably expect their members to stay healthier while on the plan and then leave the plan and become the government's problem anyway on Medicare. That's why it makes great financial sense for Safeway to do this, but they ain't doing us a favor, I assure you. In the long-term we're still going to be paying. Greater focus on preventative care will give us more bang for our buck, but cutting costs has nothing to do with that. It has to do with setting limits on what we are willing to pay for when it comes to non-preventative care. Our obsession with trying to keep people with terminal conditions alive for that extra month even if it costs a million dollars and that month is spent in an ICU has not changed. It will require a wholesale cultural reevaluation of how we see groing old and the end of life before those costs go down, and in that regard, preventative care may just be a distraction.
posted by drpynchon at 10:39 AM on June 21 [13 favorites has favorites]

I can't fault honest efforts, private or otherwise, to encourage better health habits.

I was more interested in reading this WSJ article linked to by jedicus. At first, I thought he was skating around key issues, til finally he wrote:

We may not like it, but the only way a government can control costs is by wielding great purchasing power to get concessions on the price of drugs, physician fees, and hospital services; the only way they can control administrative costs is by providing a simplified service, yes, the Medicare model (with a 3% overhead), and not allowing private insurance to cherry-pick patients (some of them operating with 30% overheads, the cost passed on to you).

He's got the central issue right, but omits mentioning the biggest cost factor: the fact that all the current corporate players in healthcare are siphoning off healthcare dollars for profits, and their decisions are geared to benefit shareholders, not clients.

Companies must make profits, sure, but a private insurance regime is very seldom efficient - look what car insurance does to the cost of body repair, for example. So the very biggest cost saving will come from removing profit-taking from the administrative layer. A single-payer system will also be more effective in negotiating prices, of course.

All the rights we currently enjoy as citizens require government protection. All of those rights were at one time controversial, but we got over it, and now consider them within the proper role of government to provide. I think it's about time for the US to consider adding healthcare as a right.
posted by Artful Codger at 10:47 AM on June 21 [10 favorites has favorites]

but tobacco and alcohol are legal products, which we pay taxes on.

it doesn't matter - i know of one company in my state that actually tests people for tobacco usage as they don't want users working for them

i think that firing people for tobacco use should be against the law, but so far it isn't in my state
posted by pyramid termite at 10:48 AM on June 21

I look forward to hearing about how Safeway is opening hundreds of new stores in low-income inner-city neighborhoods, then stocking them with plenty of fresh produce.

Not that I want to defend Slaveway, but I used to live a block away from one located in a poor, high-crime, minority neighbourhood, and while they did an amazing job at never having enough employees on shift to handle the checkout duties (but always had 4 security guards walking around!), their produce was actually pretty good, well stocked, and reasonably priced. I've been to a few in other low-income areas in the US and again, good produce. So I don't think you can really blame them for shoving junk food at inner-city shoppers over healthy food.
posted by cmonkey at 10:55 AM on June 21 [1 favorite has favorites]

also, let's remember that it's smokers who just incurred a big tax increase to expand SCHIP. it could be argued that smokers are in fact paying a disprportionate share of taxes. let's face it, government is addicted on tax dollars from smokers, but if you use the product they rant and rant and demagogue the issue.
posted by brandz at 10:55 AM on June 21

Consider also the need of society to have immediacy in all things, including diagnostic information. Will you as a consumer trust your physician to offer a diagnosis without myriad expensive tests up front? I generally can expect anyone over sixty to be completely fine with clinical guidance, and pretty much anyone under 50 or with an income above average to expect any and all diagnostic lab and imaging studies to be performed to establish all the things that are not causing their backache/headache/fatigue/weight gain/abdominal discomfort/change in stooling habits/occasional nosebleeds/ADD symptoms. Perhaps a slight exaggeration, but a new paradigm of trust needs to be developed that doctors can trust that they won't be sued if the diagnosis is found to be dire three weeks after trying something conservative. No one likes the sound of that. And they'll like it less and less if Primary Care takes another pay cut and the only people you can find to make these front-line calls are trained on the beaches of Grenada and Haiti.

But yes, count me as someone that desperately wants a public option. We ought to be able to save billions just by intervening in routine illness earlier. If you come see me on the public plan and I catch your pneumonia earlier, it costs about 100 bucks to pay me and give you a course of antibiotics instead of 20K for six days in the hospital. What it won't do is give me any way to screen you for prostate cancer or elevated cholesterol, necessarily, but you need to start somewhere.
posted by docpops at 11:00 AM on June 21 [6 favorites has favorites]

Our obsession with trying to keep people with terminal conditions alive for that extra month even if it costs a million dollars and that month is spent in an ICU has not changed. It will require a wholesale cultural reevaluation of how we see groing old and the end of life before those costs go down, and in that regard, preventative care may just be a distraction.

Yeah. You're a doctor so you know this. There is only one real way to get health care costs significantly lower: deciding that at some point you have to put the really old and really sick people out on the metaphorical ice floe. We don't do that; usually we spend and spend and spend to prolong someone's life as long as possible, even if we can just eke out another week or two.

The problem is that the money you've just spent keeping that kid (or grandparent or whoever) alive for a few extra crappy, disease-filled weeks is money that you now can't spend curing ten other kids of treatable diseases and giving them many decades of life. You've traded decades of health for a bunch of people away for a few crappy weeks for one person.

That's just a fact. But it's easy to say so when it's somebody else's family member being denied the $70,000 treatment to extend her life by 5 weeks and not so easy when it's your kid being denied the same thing and you're told that, yeah, we could give you a few more weeks with your daughter but it's not cost effective so she's going to die tomorrow instead of next month.

I don't have a good answer. We should spend the money on the 10 people rather than the 1, but I sure don't know how we do that. Certainly I'm not sure I could deny treatment to a parent or keep myself from demanding treatment for a loved one on principle.
posted by Justinian at 11:06 AM on June 21 [5 favorites has favorites]

Can someone explain what ought to be a relatively simple point to me? As a doctor, I still have trouble understanding how preventative care plays any role in reducing the cost of care. Is there data that really supports that in the long term?

Sure, a few years ago I recall a junior manager was told to roll out the stats for part of the NHS public health scheme. He calculated that the cost of one person giving up smoking (taking into account the cost of all the people who received help but didn't stop) was less than 20% of the typical terminal condition/end of life care given to somebody dying from a smoking related illness. Undoubtedly that person would still receive medical care at the end of their life, but many other causes of death are less costly (supposedly dying from lung cancer or COPD is particularly nasty and drawn out). Added into this the benefit gained from extra life years, fewer sick days, less ongoing chronic care just for the one person, and it's a very clear net benefit. Given that many of those who are helped to stop smoking but relapse end up with both reduced tobacco intake and continue their attempts to stop smoking, means that it's money well spent.

I think, that perhaps doctors have trouble understanding the benefits of preventative care because by the time they get to intervene, most conditions already require medical treatment and therefore have a large cost.
posted by Sova at 11:08 AM on June 21 [3 favorites has favorites]

Sova: But you've cherry picked the condition with the single greatest benefit for preventative medicine. Now do the same thing for high blood pressure and you come to a very different conclusion since some dude dropping dead of a heart attack at 54 is cheap while giving him beta blockers and keeping him alive to die of bowel cancer at 74 is expensive.

(This is NOT an argument against preventative care. I'm just taking issue with looking at only smoking since it's atypical).
posted by Justinian at 11:15 AM on June 21 [1 favorite has favorites]

The problem with trying to run health insurance like life insurance is the social gradient in health: the richest people are the healthiest and being low in SES-- even before you get to smoking, drinking, drugs and poor eating-- doubles to triples your risk of cardiovascular disease and death from the vast majority of causes in general.

This is true even in countries *with* national health care-- it has to do with the physiology of being a low status mammal in a situation where low control over important facets of life is common.

So, if you think you are going cut health costs by incentivizing low wage workers to change their behaviors, well, you may have some reduction, but you aren't going to see the massive reductions you are looking for because the stress of being poor in a rich society *in itself* raises cholesterol and blood pressure. In fact, insuring a rich smoker is cheaper than insuring a poor one because the risk of lung cancer *even amongst smokers* follows the social gradient.

Of course, if we started talking about reducing economic inequality in order to improve health (which, the low inequality countries show can be done-- they have greater life expectancy, lower infant mortality, etc.), then we'd really get called socialists.
posted by Maias at 11:16 AM on June 21 [4 favorites has favorites]

As a doctor, I still have trouble understanding how preventative care plays any role in reducing the cost of care.

Compare what you charge for a 15 minute consultation with what the ER or Urgent Care Clinic charges for a visit. There's an order of magnitude difference. Preventing a health condition from exploding into a medical emergency is a great way to bring down healthcare costs as a whole.
posted by Slap*Happy at 11:19 AM on June 21 [2 favorites has favorites]

The Cost Conundrum: What a Texas town can teach us about health care

New Yorker article that is very interesting and relevant to this discussion! Basically: Rising health care costs can be attributed to the capitalist instinct in health care trickling down to doctors: more tests! more procedures! Solution: peer review in hospitals and removing the $$$ motive on the doctor level.

I don't know much about this but hey it's a good read anyhow.
posted by wemayfreeze at 11:24 AM on June 21 [1 favorite has favorites]

Anybody here have HIV?

I hope you have a Canadian visa handy, since your condition is "preventable", after all.
posted by Avenger at 11:25 AM on June 21 [4 favorites has favorites]

Justinian - my own experience would disagree. Smokers don't really seem to create too much burden in the long run, which isn't to say we don't save a ton keeping the habit from getting started. But a better way to look at prevention is to consider what the prevented issue leads to.

Hypertension is the foundation for everything. Control blood pressure - really control it, like 110/70 instead of giving up after two drugs and 140/90 - and you reduce or eliminate the odds of strokes and their godawful costs, dementia, congestive heart failure, renal disease, heart disease. The list is pretty endless. And we have a ton of safe, easily tolerated pills that will do this even if patients don't try on their end but simply can agree to treat the condition.

Same for obesity. People who are obese simply kill us when it comes to their care because the things they suffer from are nebulous and have costly, ill-defined care required to help them. The clear issue is diabetes, which makes a couple drugs for a smokers emphysema look like penny candy. But less well-defined is the other stuff. The three weeks it takes to recover, off work, from a simple slip at home, or a 5 mile an hour rear-end collision that leads to twelve weeks of lost work and chronic debility and physical therapy that is really nothing more than a really half-assed trip to the gym for anyone else, or the two-week post-op stay from an infection that started in their pannus after a routine appendectomy, or the endless visits and prescriptions for pain, for fatigue, for depression, for the missed cancer in their pelvis, for the lack of preventative care because of embarassment over being seen naked, or the recurrent cellulitis that starts in the ankles from poor blood flow to the skin because of the massive hydrostatic forces created by three hundred pound of upstream weight.
posted by docpops at 11:28 AM on June 21 [4 favorites has favorites]

All the rights we currently enjoy as citizens require government protection. All of those rights were at one time controversial, but we got over it, and now consider them within the proper role of government to provide. I think it's about time for the US to consider adding healthcare as a right.

Part of the problem here is how it's become increasingly fashionable to paint government as the enemy and the corporation as the family friend that can do no wrong. Quite frankly I think most Americans want their lives governed completely by corporations in some kind of libertarian Snow Crash future and I am strongly starting to suspect that's where the future is headed. I don't think any of this can be undone without some sort of paradigm shift that vastly expands the quality and accessibility of education and reins in the anti-intellectualism that's become endemic in our culture. Only then will we be able to have the universal health care system we deserve. Short of war or some other groundbreaking change, I don't see that happening and all we'll get is just another version of healthcare that funnels money upward differently.
posted by crapmatic at 11:30 AM on June 21 [4 favorites has favorites]

Sova: But you've cherry picked the condition with the single greatest benefit for preventative medicine. Now do the same thing for high blood pressure and you come to a very different conclusion since some dude dropping dead of a heart attack at 54 is cheap while giving him beta blockers and keeping him alive to die of bowel cancer at 74 is expensive.

Actually, I haven't cherry-picked, smoking is the thing I know most about because I used to work in that area so was surrounded with the figures and arguments (though I was only an admin).

The choice you give about high blood pressure is skewed between a (supposedly) cheap death and expensive intervention. But healthy eating/activity campaigns from an early age plus better food manufacturer regulations probably have a very low cost per person compared with treatment decades later. I don't have the figures though, so I can't make the case.
posted by Sova at 11:36 AM on June 21

I actually know far more about this subject than I think you can imagine. I am a physician that is worked in public health for almost 20 years. My moronic argument was to make the point that any real discussion of the real change that needs to happen is poisoned by people like the Wall Street Journal talking about how the government is incapable of fixing the system. But then a corporation, one that peddles cigarettes and Fritos no less, argues for some of the same kind of social engineering, and they get showcased in a national publication. People with real lifetime experience on public policy with real ideas get shut out of the discussion and then some dipshit CEO who wants to preserve his profits comes along -- in my bizarro world view, people like this shouldn't even get to participate in the discussion.

Anyway, it's my first father's day, my family is trying to get me out the door to go to brunch and I don't have time for yet another heated health care debate, but fuck you very much sir.

Thanks for writing this.
posted by Blazecock Pileon at 11:39 AM on June 21

My insurance company would reimburse me ($20 a month, IIRC) for a gym membership. The problem is that only one gym in my area could be used for part of the reimbursement, because it has an electronic check-in system. They need to know I actually go twice a week to qualify for the reimbursement, you see.

The problem is that the gym that actually offers this is easily double, if not more, than the gym I used to go to. Meaning the membership would cost me even more, even after the reimbursement.
posted by Talanvor at 11:39 AM on June 21 [2 favorites has favorites]

Keep in mind the quick death (cheap) is the exception. Most people live through it (stroke,MI) thanks to modern interventions. But the next thirty years suck. And cost a fortune.
posted by docpops at 11:40 AM on June 21

Tell me again why having a government bureaucrat standing between me and my care is worse than a Safeway bureaucrat doing the same thing?
posted by l33tpolicywonk at 11:46 AM on June 21 [1 favorite has favorites]

Compare what you charge for a 15 minute consultation with what the ER or Urgent Care Clinic charges for a visit. There's an order of magnitude difference. Preventing a health condition from exploding into a medical emergency is a great way to bring down healthcare costs as a whole.

My point is that in many cases you aren't really preventing those emergent episodes per se. On a per person basis you may simply be delaying them. "Preventative" care may be an accurate descriptor in the short term, but in the long-term it may be a misnomer. On a per person level, my suspicion is that for some patients this approach may save money over the course of their lives, but for others it may well not. No amount of preventative care is going to prevent death. And I simply don't know if there's strong evidence that on an epidemiological/societal level it really does save cash. Perhaps as sova suggests, for smoking cessation it makes fiscal sense, and I can see for example, how stroke prevention is fiscally smart, but that may not extend to other preventative care. Preventing catastrophic events that lead to chronic debilitation requiring lots of financial and human support may be fiscally prudent, while preventing catastrophic events that lead directly to death may not be so. When such events fail to occur, people will invariable die of "old age," which may be quite expensive in my mind. I'm going to have to read more about this, but my suspicion is that the data is pretty back-of-the-envelope. It's still a great idea and of substantial benefit to focus on "prevention" but I'm not convinced about the fiscal impact this has. I suppose if people are living longer, healthier lives, one could further argue that they are being more productive and paying into the system. But this seems to be a much more murky issue than some paint it to be, distracting from rather obvious wasteful medical spending that has nothing to do with preventing illness and everything to do with our refusal to let our 90-year-old nana go to hospice.
posted by drpynchon at 11:49 AM on June 21 [2 favorites has favorites]

crapmatic is exactly right, and it ties very neatly in with Dr. Kessler's ideas, linked to above. We've been brainwashed through advertising and social engineering to crave simple choices (even when those choices are too overwhelmingly numerous for the human psyche to deal with), to substitute personal brand identification for taste and style, and to believe that anyone who does not participate in this overwhelming sea of manufactured "need" as socially apostate. (You cannot imagine the kind of shit I used to take from my coworkers because I will not shop at WalMart. Hard to believe this was a point of contention with them, but it was. This is one small example of how much of a hold corporations have over the public.) Especially here in the US, this becomes a "fish don't know they are swimming in water" problem, because it is so overwhelmingly pervasive that most participate without realizing what is happening.

We could undo a lot of this with an aggressive media literacy campaign, a public, universal AdBusters-type campaign designed to undo the hold that corporations try to exert upon our populace. It would require the same level of research and guile as has been put into the last fifty years of the enslaving messages. I don't believe it would take the same number of years to undo the damage, because the unweaving of an illusion takes much less time than the creation of one.

But yes, I agree completely. Until we can somehow break the hold that corporations have over us, we will only continue to have our lives and our health ground into numbers in bank accounts instead of being allowed to live fruitful, healthy lives of our own choosing. Sadly, I cannot see this happening without direct government intervention in our media, because as corporations grow ever larger, their divested interests begin to create synergy. If you sell products that make people unhealthy, and then sell products to cure those unhealthy people, you will be shooting yourself in the foot if you discontinue the one product, because it creates the market for the second.
posted by hippybear at 11:52 AM on June 21

one that peddles cigarettes and Fritos no less

could somebody please explain to me how not selling cigarettes or fritos at a chain supermarket will have any meanigful impact on cost or policy in healthcare. i can just go down the street to the next chain store and buy said products. i say red herring.
posted by brandz at 11:52 AM on June 21

So I don't think you can really blame them for shoving junk food at inner-city shoppers over healthy food.

Kudos to Safeway for having supermarkets in inner-city neighborhoods, and you're right that they do have some (the one that comes to my mind first is the Safeway in downtown San Leandro, CA, which is close to BART and almost as close to some of the grittiest areas of East Oakland), but they want to make a profit like any other supermarket, and what they are most interested in selling is not produce, but processed food that will fly off the shelves. I have no answer to what would make a supermarket more willing to sell healthy food, but that is the reality, whether the supermarket is located in an inner-city neighborhood or not. If I don't blame supermarkets for that, who do I blame?
posted by blucevalo at 11:53 AM on June 21

Slarty, behind your rhetorical bullshit, I've yet to hear a real argument. You want to silence those CEOs who are ultimately responsible for healthcare decisions for tens of millions in the US; meanwhile, your own organization, the AMA, has come out against a public insurance plan.

And quite frankly, telling me to fuck off, and then running out of the conversation is just childish. Stand up for what you're saying, and stick around, or I repeat my original criticism: your pithy comment is just a drive-by troll.
posted by SeizeTheDay at 11:54 AM on June 21 [2 favorites has favorites]

could somebody please explain to me how not selling cigarettes or fritos at a chain supermarket will have any meanigful impact on cost or policy in healthcare. i can just go down the street to the next chain store and buy said products. i say red herring.

The point is not that Safeway should not sell cigarettes or Fritos. The point is that they raise the issue of preventive health-care reform options in their internal documents and then aggressively sell products that defeat preventive health-care reform options. The fact that all other chain stores do precisely the same thing makes their preventive health-care reform arguments sound even more absurd.
posted by blucevalo at 11:57 AM on June 21 [1 favorite has favorites]

could somebody please explain to me how not selling cigarettes or fritos at a chain supermarket will have any meanigful impact on cost or policy in healthcare.

I think it's less a point about the actual impact on healthcare not selling those products would have, and more about the hypocrisy of an organization which will continue to offer to the public exactly the products which they are discouraging their employees from using.
posted by hippybear at 11:57 AM on June 21

Or, on non-preview... what bluecevalo said.
posted by hippybear at 11:58 AM on June 21

As a doctor, I still have trouble understanding how preventative care plays any role in reducing the cost of care. Is there data that really supports that in the long term?

It depends on what you mean by "preventative care." Within the American health care system, this usually is shorthand for screening tests and treating conditions earlier (and sometimes starting to treat what would have been borderline cases, like treating pre-diabetes when before you wouldn't do anything until someone actually had diabetes). The empirical evidence is pretty clear that this isn't cost saving, just the same way that you don't really "save" money when you buy something on sale--whether it's still worth it, even at the higher cost, is debatable, but in any case it's usually adding net costs to the system, because the cost of screening is usually pretty high for each case you actually catch, and the additional cost of treating that person for decades might end up to be about the same amount as you would spend treating an acute event if they ended up in the hospital untreated. (Not arguing that screening tests are bad, just that anyone arguing for more of them should be making their argument on the grounds of health alone, not cost savings.)

If you broaden "preventative care" to include public health measures, and specifically the types of low-cost interventions that are delivered outside of the medical system, you can start to see net savings. As I recall from a WHO publication a few years back, one of the health measures with the highest ROI is installing speed bumps and stop signs in urban areas. I would be unsurprised to find that spending money to reform our agricultural system (fewer subsidies to high-fructose corn syrup and more to vegetables) and our transportation policies (fewer freeways, more walkable communities) would actually save more money in the health system that it would cost. That's (unfortunately) not really a part of the political conversation around health care reform right now, though.

A really interesting article on what health care reform actually means in terms of improving the nation's health just came out a few days ago, and touches on a lot of this.
posted by iminurmefi at 11:58 AM on June 21 [3 favorites has favorites]

eek! blucevalo. bad me. apologies.
posted by hippybear at 11:58 AM on June 21

The company my husband works for (not Safeway) has a very similar program. (Probably not coincidentally, they are also self insured). Its called "Healthy Lifestyles" and its a huge pain in the ass. To call it "voluntary" is to stretch the limits of that word, since if you don't participate your premiums don't go down ... they simply fail to go up. Also, many, many employees have concerns about exactly how private their health info is, since anyone in HR or payroll can basically tell what's wrong with you simply by the amount of the premium you pay. We're also subjected to these moronic "health coaching" sessions four times a year where you're required to talk with a "health coach" (ie: college student sitting in a call center in Des Moines) about what your current health issues are and how you'd like to combat them. Of course, no one ever tells the truth since these coaches are not doctors and no once can see that there is any legal guarantee of privacy.

In October, I broke my knee quite seriously when a driver ran a red light and crashed into my scooter. I was in the hospital for two nights and on nearly complete bedrest for another five weeks. I developed DVT as a result of the surgery. Now the "healthy lifestyles" program is bombarding me with letters and calls that say "We notice you broke a bone, perhaps you need more calcium in your diet or need to have a bone scan. Osteoporosis can be serious for women over 40" and we had to jump through all sorts of hoops to keep our insurance rates at the same amount because the DVT put me in a different risk category, and because I gained weight while on bedrest.

No one I know who is in the program is healthier. If anything, the pressure on employees to hit all the markers for the program is causing them more stress, and I know of great employees who have left the company in large part because they now needed to find insurance elsewhere, because they do not want to disclose health issues to The Company and risk a lack of confidentiality.
posted by anastasiav at 12:00 PM on June 21 [10 favorites has favorites]

I would be unsurprised to find that spending money to reform our agricultural system (fewer subsidies to high-fructose corn syrup and more to vegetables) and our transportation policies (fewer freeways, more walkable communities) would actually save more money in the health system that it would cost. That's (unfortunately) not really a part of the political conversation around health care reform right now, though.

It's a great idea, but could you actually prove it...unfortunately I think ideas like these make sense in theory, and seem reasonable, but beyond anecdotes, no one can be sure, which is why they can't be implemented without significant political cost.
posted by SeizeTheDay at 12:01 PM on June 21

This thread should be archived for future generations so that they can see why it's a bad idea to let libertarians near anything important.
posted by hamida2242 at 12:01 PM on June 21 [14 favorites has favorites]

drpynchon
Have you seen "The Biggest Loser?" Those people go from needing 10 medications to one or none. Assume that each medication costs $30 a month. Get a fat man to lose weight and how much are you saving him and his health insurance provider?

Have you seen how often people go to the doctor? How about getting people to actually come in for regular check ups? Maybe your cold stays a cold and doesn't become pneumonia. Maybe listening to your doctor's advice, maybe taking a damn sick day, lets your system recover enough that you don't end up bedridden and missing work or in the hospital and using up all those expensive drugs and fluids.

Maybe your allergies don't turn into a sinus infection (with the need for an antibiotic) because you got a comparatively cheap pill or spray that lets you go outdoors and play with your kids and maybe not be so sedentary which makes you fat which means you've got to get all kinds of pills which means...

Maybe if you feel that you can call a doctor and just complain about some general badness you're feeling, the doctor can diagnosis your condition now instead of later when your arteries are really blocked or the diabetes is full-blown.

Preventative care can save a lot of money, but you're right in the end we all die and deciding how long to keep someone on that edge alive is some costly math, but if we got some of this other shit under control, maybe the money wouldn't hurt as much.
posted by BeReasonable at 12:06 PM on June 21 [1 favorite has favorites]

aggressively sell products

how exactly do they 'aggressively sell?' i realize they don't necessarily practice what they preach, but i also don't think they 'aggressively' sell anything. they sell what people buy, just like any other store or business. maybe they also shouldn't sell butter and soda and ice cream and red meat and frozen pizza.
posted by brandz at 12:14 PM on June 21

maybe taking a damn sick day, lets your system recover enough

This assumes, of course, that your employer gives you sick days. A friend was recently fired from his job because he lost consciousness while driving to work and elected to go to the ER rather than to work. He was within the first 30 days of his employment and was summarily let go.

It also assumes, of course, that you have the cash on hand for the $30 - $40 copay the doctor is going to charge.
posted by anastasiav at 12:17 PM on June 21 [2 favorites has favorites]

brandz: End-cap displays or right-inside-the-door stacks of products are aggressive selling. As is television advertising mentioning specific products which can be bought at a certain chain. As are the placement of the same product in multiple locations throughout the store so the items can be viewed in different "contexts" within the shopping environment. As is the placement of products on shelves with eye-level products being the ones the store seeks to promote over other brands, which are placed either above head level or on the bottom shelf.

Seriously? This was nearly eponysterical.
posted by hippybear at 12:20 PM on June 21

Tell me again why having a government bureaucrat standing between me and my care is worse than a Safeway bureaucrat doing the same thing?

Well, there /are/ other grocery stores to work for. Changing governments is a more . . . involved . . . task.

But since we're talking theoreticals, theoretically changing things with one's vote is more efficient than changing things with one's feet.
posted by @troy at 12:23 PM on June 21

I don't know about you guys but I'd much rather have tens of millions of people without health care than running the risk of paying slightly higher taxes. It could be the 1918 flu out there for all I care- what, do you think I'm going to downgrade to a 42" television? Besides, I eat only the freshest healthy food from the boutique grocery store and I don't smoke like all those idiots.

No serious health problem could ever happen to me, and if it did, I wouldn't get denied by the insurance company because I work hard for a corporation and other corporations like & respect that about me. I know people think all they care about is money (and good on 'em too, for the sake of my mutual fund!) but when someone like me who didn't deserve to get sick comes along, they'll do the right thing. They'll take care of me.
posted by hamida2242 at 12:28 PM on June 21 [5 favorites has favorites]

End-cap displays or right-inside-the-door stacks of products are aggressive selling.

well, the supermarkets i go to (east coast here) don't have end displays of bacon or butter or ice cream or cigarettes or red meat. those products are sold in particular sections (refrigerator, frozen, front of the store). i think you don't like what people choose to buy and consume.
posted by brandz at 12:30 PM on June 21

Regarding the idea that obese people= 300 or more pounds and rarely move

I am obese according to BMI. I'm concerned a program like this could depend on oversimplified things like BMI to raise or lower rates. That's sad since I lift weights (which adds poundage)and have worked out hard for 4-6 hours a week for years.

In fact in order to be overweight, I need to lose 30 pounds. In order to be a normal weight, I'd have to be weigh as much as I id as when I was 14 (in the 120s at 5'6 height). Family and friends would become very concerned.

I don't believe companies' know enough about fitness and health to intrude or advise on health matters. Anastasiav, you're story is a good example of what I worry about.
posted by Freecola at 12:33 PM on June 21 [1 favorite has favorites]

I am fairly certain that products beyond the minimal list that you mention are doing equal if not greater harm to the public health. The endless quantities of corn-based snack foods are displayed in multiple locations in the Safeway we have in our town here, and I know from experience that these are not random, store-based decisions but are dictated from a corporate level. The 3 to 5 locations where one can quickly grab HFCS soda are also fairly standard, nationwide. Perhaps you are seeking to draw me into an argument about what products people SHOULD purchase, but I am discussing actual current practice, not theoretical banning of products. Please, visit a local Safeway (if they have them in your area) and take a good look at where things are located within the store and how that impacts what you see and what you put in your basket. Until then, you're talking red meat, and I'm talking entire store layout.
posted by hippybear at 12:37 PM on June 21

Of course, If we had universal, single payer health care, safeway's health care costs would go to zero. Just like companies in most of the rest of the developed world. And that would be fantastic for safeway's shareholders. But it would mean higher taxes for the CEO and the board, so obviously they're opposed to it...
posted by delmoi at 12:49 PM on June 21 [3 favorites has favorites]

I understand your point about obesity Freecola, I was just turned down for a life insurance policy because I'm a 6 footer at 300 lbs. Apparently I may die at any minute and so am a poor risk.

I don't feel deathly ill, and my doctor just told me to lay off the soft drinks and junk food...
posted by BeReasonable at 12:49 PM on June 21

wemayfreeze, I haven't read the New Yorker article, but your summary brings up a couple of issues. There are multiple reasons why doctors order too many tests, and they have to be addressed. Many complain that they do it for fear of being sued, and while reform on the legal end may be a big Republican talking point, it really does need to be factored into the equation.

Another thing that I rarely see discussed, is the issue of financial transparency. When I go to a clinic, I have no idea how much a test or procedure is going to cost. Why shouldn't I be told, for example, that my liver biopsy is going to be $1200? Most of the time, people find out about costs only afterwards, and don't have any way of making informed choices. If Hospital A does infant delivery for $5000 and Hospital B does it for $10,000, shouldn't I be able to make that choice before I'm in the delivery room?
posted by CheeseDigestsAll at 12:58 PM on June 21 [6 favorites has favorites]

hippybear -- no worries. You made the point better than I did.
posted by blucevalo at 1:00 PM on June 21

I tend to miss end cap displays entirely, even when they are things I am looking for and want. Wonder why that is.

"We have heard from dozens of employees who lost weight, lowered their blood-pressure and cholesterol levels, and are enjoying better health because of this program."

Dozens, ey? How many people are employed at Safeway?

In the past year, two out of some twenty people in my department have had what are clearly cardiac events- neither has taken this as a wakeup call. Small sampling, granted, but still, illustrative. People self select for healthy living and neither money nor fear nor just feeling better seems likely to change that. The fortune five hundred company we toil for tries to encourage living right in a half baked kind of way, but the admirably well equipped company gym is seriously under- utilized and the staff there begs Us Happy Few to remember to sign in so as to justify the place's existance and not have it be removed in yet another round of budget cuts. Not all take advantage of the free annual physical nor even the intranet Fun Quiz that takes a bit of doing but cuts off a hundred dollars from your health insurance. Much water, many horses, few drinkers.

we like seeing other people get screwed

We, who? I ask because you cite the French as an example of a people who have fixed the problem of health coverage and who have a culture of we. Trust me, the French are plenty happy to see other people get screwed, and depending on circs, their culture of we can be pretty circumscribed. Schadenfreude long predates America as a word and as a failing. Hell, it isn't even an English word, much less American. (Off topic, granted, but you had a lot of favorites and though I agree with the statement, I can't see it as peculiar to our time and place. Please consider broadening the scope of your article, and best of luck with it.)
posted by IndigoJones at 1:02 PM on June 21

Of course, If we had universal, single payer health care, safeway's health care costs would go to zero. Just like companies in most of the rest of the developed world.
posted by delmoi at 3:49 PM

Not really. Here in Canada, I pay $350/month for each of my single employees and 1k for each family health/dental plan. This covers all the medical costs which are not paid for by the government.

I also just found this recent story about our biggest grocery chain (who also provides benefits).
posted by gman at 1:13 PM on June 21 [2 favorites has favorites]

Slarty, behind your rhetorical bullshit, I've yet to hear a real argument.

Who's the troll here? Almost everything you've said here hasn't been an opinion about this issue, it's been an attack on me. My first comment above was really about the irony of a business-centric publication apparently endorsing social engineering. I don't owe you an argument about what I think should be done to fix healthcare, but I have made plenty of them here on the blue in the past, feel free to look them up.

You want to silence those CEOs who are ultimately responsible for healthcare decisions for tens of millions in the US;

These people are already way over represented in the debate. There is literally no data in the public health literature that these kinds of programs generate cost savings or improved health outcomes and it is amusing to me when these kind of half-assed ideas get thrown around as though they are going to save the system. Just like any other issue in medicine, I pay attention to people who have researched and published impartial findings. These people exist yet when politicians talk about them, they are shouted down as socialists.

meanwhile, your own organization, the AMA, has come out against a public insurance plan.

15% of doctors belong to the AMA. I have never met a primary care physician who belongs to the AMA. They've stood in the way of reform for way too long and they exist solely to represent the business interests of specialists. Their number one issue shouldn't be malpractice reform, it should be protecting patients' access to care.
posted by Slarty Bartfast at 1:17 PM on June 21 [12 favorites has favorites]

Look, if I'm going to be force to pay for others' healthcare

This attitude will be a big sticking point in America.

Will the public option in healthcare reform cover abortions? If so, you haven't seen craziness yet.
posted by Brandon Blatcher at 1:26 PM on June 21 [3 favorites has favorites]

I think there's only one thing you need to know about health care: every other developed nation has universal health care, and it works better than American health care.

To argue against universal health care is, then, to argue that America can't do what other countries have done.

And I really don't believe that can be true.
posted by five fresh fish at 1:26 PM on June 21 [5 favorites has favorites]

IndigoJones -- I didn't cite the French, Micheal Moore did. And obviously some of the things I mention, like reality TV, are popular in those other places too. So no, the problem isn't uniquely American, but I think America is unique in how fully and horrifically we have embraced the idea that it is not just OK but virtuous to laugh at people whose lives have been destroyed because they "should have known better."

We do have records of cultures that didn't seem to act this way. Most of them were overrun and destroyed during the era of Western imperial conquest.

The reason I don't ever seem to get more than a few paragraphs into that article, other than the fact that the place I'd normally have published it has gone to shit, is that I don't honestly think it can be solved, which means I am living in hell and my species is ultimately doomed to extinction. So I close the word processor and surf metafilter instead.
posted by localroger at 1:27 PM on June 21 [1 favorite has favorites]

When you look at a map of which countries have universal health care and which do not you would think it would give Christians the heebie jeebies to see a lot of those countries we are presently lumped in with.
posted by notreally at 2:11 PM on June 21 [2 favorites has favorites]

Here in Canada, I pay $350/month for each of my single employees and 1k for each family health/dental plan. This covers all the medical costs which are not paid for by the government.

gman, do you mean you pay $350 a month toward OHIP and $1000 a (month? year?) for supplemental dental, etc., from a private company like Manulife? I've been trying to figure out what I pay for Ontario health coverage via federal and provincial taxes, and what portion employers put in.
posted by maudlin at 2:21 PM on June 21

I pay $350 for each single employee I have and about 1k for each employee with a family. This goes to Great West Life to cover all the crap which the government does not i.e. dental, prescriptions, etc.

As for OHIP premiums, here is the provincial chart. And here is how employer contributions (EHT) work. Federally, I have no idea.
posted by gman at 3:01 PM on June 21

Obama May Lack Votes for Health-Care, Feinstein Says (also noted here)
Obama's healthcare push on rocky road in Congress
posted by ornate insect at 3:02 PM on June 21

Can someone explain what ought to be a relatively simple point to me? As a doctor, I still have trouble understanding how preventative care plays any role in reducing the cost of care.

To make this a little too personal: My father's cancer treatments would have been a lot cheaper if a colonoscopy had managed to catch it before it metastasized. Probably cheap enough to let 1,000 other people have colonoscopies that didn't have colon cancer. Maybe more-it depends on how long he'll be on chemo.
posted by dinty_moore at 3:06 PM on June 21 [1 favorite has favorites]

maudlin - Sorry. Those numbers (350/1000) are per month, and I believe they take total costs for the previous year and tack on like 15% "administrative charges".
posted by gman at 3:14 PM on June 21

If you don't think capitalism is fucking evil at its core, then let corporate insurance companies run the health care system. Profit before people is so lovely.

My opinion, for what it's worth: If you are quicker to attack people's "lifestyle choices" than you are to question the suitability of profit in the health care "industry", you are fighting the wrong enemy.

Our current system is broken and unsustainable. Period.
posted by Benny Andajetz at 3:36 PM on June 21 [7 favorites has favorites]

--The Health Reform We Need & Are Not Getting
--Costs are keeping patients from care: copayments rise as families struggle
posted by ornate insect at 4:00 PM on June 21

To make this a little too personal: My father's cancer treatments would have been a lot cheaper if a colonoscopy had managed to catch it before it metastasized. Probably cheap enough to let 1,000 other people have colonoscopies that didn't have colon cancer. Maybe more-it depends on how long he'll be on chemo.

I think people are misunderstanding drpynchon's point. He clearly realizes that preventative care saves money in the short term. He's saying, and I can see how this would work, that in the long term you're just pushing back the major outlays of money.

Say you detect someone's skin cancer early. Great! Otherwise it would have cost a ton of money and then killed them. So you save money right now. But instead of dying from skin cancer they have a stroke in 7 years and need expensive long term treatment and care. Or they get in a car accident and are paralyzed and need expensive long term treatment and care. Or they just get really, really old and lots of stuff starts not quite working right and they need, you guessed it, long term expensive care.

Everybody dies of something. Even people we "save money" on now by treating them early. Eventually something gets missed and it isn't clear that something is, on the average, cheaper than what would have killed them now.

The argument isn't that we shouldn't do everything we can to prevent people from getting sick; it's that from a strictly financial standpoint something is going to eventually kill you and that thing is likely to cause a lot of medical bills. So we may just be shifting the big payments down the road.

drpynchon says he'd like to see studies to evaluate this. So would I, actually. as it's a good point. Is preventing the heart attack now but paying for the liver cancer later really cheaper? Keeping the diabetes in check now but paying for the heart attack later? And so on. Again, speaking only on a financial level.
posted by Justinian at 4:09 PM on June 21 [1 favorite has favorites]

When you look at a map of which countries have universal health care and which do not you would think it would give Christians the heebie jeebies to see a lot of those countries we are presently lumped in with.

It should give everyone who thinks they're living in a first-world nation the heebie-jeebies.
posted by five fresh fish at 4:13 PM on June 21

To argue against universal health care is, then, to argue that America can't do what other countries have done.

And to the CEO who wrote this misguided, self-serving article, please note: the English have lifestyles just as unhealthy as Americans, as do Canadians and they both manage to spend less on health care per capita and get better outcomes.

The issue IMO is that to improve the stats on the overall system you need to fix the worst off - this is why middle America has no interest in the plan. It only helps poor people. Many, many Americans are OVER insured - they get too much treatment for problems that are small while many others go without any care at all. And the people who have insurance like it that way.

The notion that it has to do with preventable conditions is nonsense proved with simple empirical evidence from any other Western nation.
posted by GuyZero at 4:13 PM on June 21

In Poll, Wide Support for Government-Run Health

Reform Theater
posted by homunculus at 4:26 PM on June 21

The argument isn't that we shouldn't do everything we can to prevent people from getting sick; it's that from a strictly financial standpoint something is going to eventually kill you and that thing is likely to cause a lot of medical bills. So we may just be shifting the big payments down the road.

Maybe we need to understand cost effectiveness as an ratio instead: life expectancy/$. Otherwise, the most cost effective route is no health care at all. And while there is, and probably should be, a discussion about how much money we should spend for a few weeks with no real quality of life, I don't think anyone is willing to put a price cap on decades of health.
posted by dinty_moore at 4:47 PM on June 21 [1 favorite has favorites]

Here's another chart that illustrates the problem.
posted by five fresh fish at 5:30 PM on June 21

Life insurance decreases your premiums if you don't smoke, why shouldn't health insurance?

How about a combination of single-payer health insurance and higher taxes on cigarettes?
posted by oaf at 5:38 PM on June 21

Is preventing the heart attack now but paying for the liver cancer later really cheaper?

I don't see this as very different than maintaining a car or a wooden patio to upkeep its value. The major differences would be that the younger disease victim is probably employed and paying their way through life, and that's a hidden cost to take into account. Their body's are tougher and more resilient, and so the earlier the diseases really begin to change them, the longer they will probably endure them.
posted by Brian B. at 5:50 PM on June 21

These people are already way over represented in the debate. There is literally no data in the public health literature that these kinds of programs generate cost savings or improved health outcomes and it is amusing to me when these kind of half-assed ideas get thrown around as though they are going to save the system. Just like any other issue in medicine, I pay attention to people who have researched and published impartial findings. These people exist yet when politicians talk about them, they are shouted down as socialists.

Thank you for contributing your valuable perspective to Metafilter.
posted by Blazecock Pileon at 7:09 PM on June 21

At least 95% of all pregnancies are preventable, but I'll bet Safeway isn't encouraging/rewarding their female employees from having babies. Because it's perfectly acceptable to tell an overweight person "Hey, tubbo, lose some weight" but not a high school sophomore or a single mom who already has three in diapers to "keep your legs together" (or use a condom or a diaphragm, but the only 100% way to not get pregnant is to not have sex, of course).

Wow, it's defending the obese by demeaning women!

Yes, that's right; women never have kids with a partner who later leaves, making a good choice catastrophic; women never have trouble paying for or getting access to birth control; women never have kids and then lose their jobs or have health problems; women never get coerced into pregnancy by a controlling spouse; women just get pregnant because they're stupid bitches!

And since birth control sometimes fails, even the ones who try, poor dears, not to be stupid shouldn't have sex anyway, because being the child-bearing sex means that you forfeit all sexual pleasure and freedom until menopause, amirite! Because otherwise, they are a horrible burden on society and the cause of all our modern problems up to and including overcrowded prisons, crying babies in the theater while you're watching The Hangover, and endemic poverty. Probably obesity too. Too bad their employers and the public can't shame and demean them more openly to defend society from their horrible menace!

Have I correctly summarized your gist?
posted by emjaybee at 7:51 PM on June 21

Quick note about this:

Because the sad truth is that even with the price breaks, at supermarket wages, a gym membership can be a luxury.

Even free, a gym membership can be a luxury, because time is also a finite resource, especially when you're raising kids and working hard.
posted by davejay at 8:13 PM on June 21

As a large group of people, we should have the resources available to provide a baseline of food, housing and health care coverage for everyone in the group. It might not be the best food (you can live on rice, beans, fruits and vegetables, right?) or housing (you'll have to have roommates, or a house that's very small for the size of your family) or health care coverage (your glasses are going to have to last you two years, your fillings will be clearly visible, your hospital stays will be very, very brief) but it's better than letting people starve/be homeless/die from curable things.

However, doing any of this as a group requires keeping associated costs extremely low, which means someone's profit will be hurt, which means some part of the group will be unhappy. And when you have the choice between powerless poor people being hurt or powerful wealthy people being hurt...well, the powerful wealthy people have more power to stop being hurt.

It would be better if nobody had to get hurt, but that's not going to happen. And so, regardless of the outcome, expect it to be ugly. And so it has been, and so it will be. Where we come out at the end will probably attempt to hurt nobody, and so will be flawed, but perhaps it will be enough.
posted by davejay at 8:21 PM on June 21 [1 favorite has favorites]

drpynchon: " still have trouble understanding how preventative care plays any role in reducing the cost of care. Is there data that really supports that in the long term?"

The problem is quite complex, and the cost/benefit varies for different populations. When you consider the effects of preventing obesity and smoking in people...

Lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and “healthy-living” persons (defined as non smokers with a body mass index between 18.5 and 25) ... Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers . Obese individuals held an intermediate position.

posted by meehawl at 9:47 PM on June 21 [2 favorites has favorites]

So you nay-saying guys are basically saying the obese and smokers should just go die already, so as to not cost you anything.
posted by five fresh fish at 11:09 PM on June 21

Even with the libertarians this has been a remarkably civil and informative thread, and might be archived as an example of that. Thanks all.
posted by carping demon at 11:43 PM on June 21

gman: "maudlin - Sorry. Those numbers (350/1000) are per month, and I believe they take total costs for the previous year and tack on like 15% "administrative charges"."

This seems like, well, a lot. Especially for something supplemental. Is this typical for Canada? What sort of thing is it used for?
posted by alexei at 1:26 AM on June 22

So you nay-saying guys are basically saying the obese and smokers should just go die already, so as to not cost you anything.

Reading comprehension: It's what's for dinner!

I believe people are saying that preventative care should not be looked at as a particularly good cost-savings measure but rather only as a good in and of itself. That still makes it good, it just makes a good thing that doesn't necessarily save you a lot of money in the long term.
posted by Justinian at 7:19 AM on June 22 [1 favorite has favorites]

Speaking of reading comprehension, how do you figure that your "that still makes it good" makes you a nay-saying guy?
posted by five fresh fish at 9:16 AM on June 22

How many people in the thread are saying that preventative care is a bad thing, rather than something that is good but good specifically in certain ways?
posted by Justinian at 9:19 AM on June 22

Part of the problem here is how it's become increasingly fashionable to paint government as the enemy and the corporation as the family friend that can do no wrong.

Part of the problem here is how it's become increasingly fashionable to paint the corporation as the enemy and government as the family friend that can do no wrong.
posted by ZenMasterThis at 9:47 AM on June 22

It looks like you're right. I mistook the hostility in this thread for something it isn't.
posted by five fresh fish at 9:59 AM on June 22

Part of the problem here is how it's become increasingly fashionable to paint government as the enemy and the corporation as the family friend that can do no wrong.

Part of the problem here is how it's become increasingly fashionable to paint the corporation as the enemy and government as the family friend that can do no wrong.

I believe that a government would likely be more friendly to the general populace than a corporation. Common sense dictates that an organization which only has the mandate to "maximize shareholder profit" is going to shortchange anyone and anything that isn't a shareholder in pursuit of that goal. Government, at least, has some amount of accountability to the masses, even if it isn't necessarily always exercised in the proper way. Corporations, on the other hand, have demonstrated repeatedly their willingness to take any steps necessary to do the expedient thing, not the correct thing.

(All this looks prettier in my mind than it does in practice, I will admit.)
posted by hippybear at 10:30 AM on June 22

Part of the problem here is how it's become increasingly fashionable to paint the corporation as the enemy and government as the family friend that can do no wrong.

In this case, it's not widgets - it's people's lives. Three insurance company CEOs flatly refusing to disown the practice of recission pretty much sums up the corporate approach.

And our government is specifically charged with promoting the general welfare. Handing over health care lock,stock and barrel to private companies is dereliction of duty, as far as I'm concerned.
posted by Benny Andajetz at 10:36 AM on June 22 [1 favorite has favorites]

And our government is specifically charged with promoting the general welfare. Handing over health care lock,stock and barrel to private companies is dereliction of duty

This. Thank you. Perfectly stated.
posted by hippybear at 1:56 PM on June 22

Insurers Revoke Policies To Avoid Paying High Costs
posted by homunculus at 3:47 PM on June 22

Game, set and match, bro. No room for reasonable people to disagree here. No way the general welfare clause was ever interpreted as a limitation on the power of the United States Congress to use its powers of taxing and spending. Nope. I surrender.
posted by ZenMasterThis at 4:53 PM on June 22

ZenMasterThis:

I understand your point, and your frustration. I really do. But the private sector is not holding up their end of the bargain. We've made the "market-driven" approach practically a fetish over the last thirty five years, and the middle- and lower-classes have gotten hosed.

The government has to be the arbitrator. If the private sector insists on insuring its well-being at the expense of the public, then they have to cede their right to call all their own shots.

Whether you like it or not, the common good has to be a consideration for a functioning and sustainable society.
posted by Benny Andajetz at 6:33 PM on June 22

all corporations in the u.s. exist solely under public charter. at some point we should remind them of this.
posted by yesster at 8:29 PM on June 22