View 799 Tuesday, November 19, 2013
“Transparency and the rule of law will be the touchstones of this presidency.”
President Barack Obama, January 31, 2009
Christians to Beirut. Alawites to the grave.
Syrian Freedom Fighters
What we have now is all we will ever have.
Conservationist motto
If you like your health plan, you can keep your health plan.
Barrack Obama, famously.
I’ve just (1600) had a wisdom tooth removed after it suddenly sprouted pains; fortunately without complications, but I am to take it easy for a couple of days.
Health Care Discussion:
This continues a long discussion about health care insurance and the Affordable Health Care Act. My correspondent is a Northwestern physician part owner of a clinic and far more devoted to individual health care than to politics. He’s also a good guy.
Before launching into a discussion of some of the points raised on Dr. Pournelle’s web site, I’d like to make the point that I’m not an expert in health care economics and Jerry has asked me to discuss the ACA as a supporter of it. I’m not an ardent supporter, but I believe that discussion is how we come to agreement or improvement and I would argue that discussion about how we change the US healthcare system is needed.
Personally, I agree that there is much flawed with ACA, but it is acting as catalyst for discussion. For the purposes of this discussion I am attempting to put aside my cynicism about politics and motives.
I’m convinced that healthcare in the US needs to change. I’m less sure that the ACA is the solution to that change, but it is the solution we are currently discussing as a nation and it has some merit.
Does Healthcare in the US need to change?
Let me start by discussing the belief that the US has the "best" healthcare system in the world. There are many metrics used to analyze a countries health care systems. Many of them suggest that the US is not anywhere near the top in most metrics. For the sake of simplicity lets look at three of them:
http://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems
We can go look at the original document at http://www.who.int/en/ or we can use the Wikipedia overview. In brief, in this document, the US ranks 50th in life expectancy, we are at or close to the worst in heart and lung disease, sexually transmitted diseases, pregnancies in adolescents, homicides, and disability. We spent more per capita than any other country on the list in 2011 to reach 50th place.
All of that is horrible news. We can argue that the WHO is biased and unfair, of course and look for other studies:
http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries
In this overview the US spends the most on health care on a relative cost basis with the worst outcome. and ranks 46th among studied countries.
If we look a the Commonwealth Fund report on how the performance of the US health care system compares internationally http://www.commonwealthfund.org/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx?page=all We find that we rank last among the 7 nations studied in the report despite being the most expensive. Here is a brief overview with quality measures. http://www.commonwealthfund.org/usr_doc/site_docs/slideshows/MirrorMirror/MirrorMirror.html
Quality is a hard thing to measure and I’d agree with Dr. Lewis (https://www.jerrypournelle.com/chaosmanor/?page_id=1074 ) that we have "the most advanced care in the world is available here." I’m less certain that we deliver that advanced care to everyone that needs it nor that our costs for that delivery are the best and I think an argument can be made that numerous countries do a better job than we do at delivering advanced care. All that said, we do a reasonable job for many people, albeit at a high cost.
While there are numerous metrics to compare health care between and among countries, by many measures the US does poorly. We can, and often do, deliver superb care. The discussion about how we make care better needs to continue and, again, if the ACA focuses attention on health care, that is a good thing.
Who should we cover and who pays for it?
I’ll break this into two parts:
Part 1) Jerry Pournelle asks "…why I am expected to pay for someone else’s misfortunes."
Part 2) Should every procedure be available to everyone at all times?
Part 1) Jerry Pournelle asks "…why I am expected to pay for someone else’s misfortunes."
Part of the answer is that you already pay. You directly pay for Medicaid and state, county, and municipal medical care. Indeed, we average 8,508 per capita in healthcare expenses (OECD 2013) and we spend almost 5000 per capita on health care in public expenditure per year (OECD 2013). If we look at the public expenditure per capita and compare it to the top 12 countries in the world, we spend the second most of any country (trailing only Norway).
So if we look at 2011 data from the OECD 2013 report we are spending MORE in public dollars than all but ONE of the countries who have "universal" health care.
So we spend more privately and more in public funds. By one measure, you are paying more now just in public funds than some countries pay for all of their public care.
Thus one reason why you might pay for "someone else’s misfortune" is if it reduced the overall cost of health care to you in the long run or if it provided a huge benefit to society of 100 billion/year. (https://docs.google.com/viewer?url=http%3A%2F%2Fwww.whitehouse.gov%2Fassets%2Fdocuments%2FCEA_Health_Care_Report.pdf)
Will the ACA reduce the amount of expenditure? The goal of the ACA is to expand coverage, to improve quality of care and reduce health care expenditure. That is the hope and the promise of the ACA and the area where I fear we have work to do as a nation. The cynical view says "of course not, all government policy costs more than what it replaces." That is certainly true if we don’t discuss this and keep after it. I’d argue, perhaps with way too much optimism, that we need to do better.
At the risk of being labeled "paternalistic" or a "liberal" many, many of the insurance plans I see are awful. The common response to that is "well, the user picked it and they knew what they were doing and they face the consequences of their actions." Well, of course, unless of course the insurance plan was written in gobblygook and the insurance company mislead you or if the insurance company denied you coverage because a pre-existing condition or if the patient is on a very limited income.
Part 2) Should every procedure be available to everyone at all times?
This is a very difficult question and one which is far beyond the scope of a few lines on a blog. The easy answer and the one by which most of us in practice is that the same care should be available to everyone regardless of income. However, the discussion is very difficult. If, for example, it costs 300,000 to extend life by an average of 10 minutes, should we do it? How about if it extends life by 4 weeks? A year? Who decides? Does it matter if its Dick Cheney or Bill Gates?
Should a 4 pack a day smoker with severe lung disease and a high Childs-Pugh score (bad liver disease) be offered Coronary Bypass if his life expectancy in one year is calculated to be 35%? Again, who decides? If society has limited resources, how does society decide how to use them? There are never infinite resources and the current system doesn’t provide guidelines for physicians. This is an absolutely critical discussion and one which can’t be allowed to degenerate into naive discussions of "death panels". Is there money in ANY country to pay for everything for everyone? I agree that if you can pay for it out of pocket, who cares. However paying for it out of pocket is beyond most of us. So how do we decide?
Can the ACA work? The idea, as I see it, was to improve insurance coverage by expanding Medicaid and by setting up insurance exchanges where people without access to affordable insurance can buy standardized policies and might be able to get a subsidy to help defray the cost of the the policy. This has a somewhat hidden benefit in that such a system would not tie insurance to a job and let people switch jobs. Because insurance is usually more expensive for a small company than for a large company, small companies are often less likely to provide insurance for employees. The exchanges don’t eliminate the gap between employees and individuals but the tax break that companies get is mirrored by the subsidy for the individual. One concern about ACA was that it would force insurance companies to only cover the very ill, the ACA put in place a penalty for the uninsured. (The employer penalty has been delayed).
Jerry and many others have suggested that this increase of insured will increase the use of health care and thus drive up spending. This is valid and the ACA attempts to slow the growth of health care costs. This, to me, is where we need to focus a lot of attention.
Can it work? I’ve no idea, as yet.
One of my long term friends, a very conservative neurosurgeon, is watching my posts on your site. He said to me "you are both brave and foolish" given the venom about the ACA. He agrees, however, that we need to discuss these topics..really they are NOT discussed outside of medicine. Who decides about who gets what health care? How do we decide?
Northwestern Physician
I continue to raise the more fundamental question, to what are people entitled by reason of citizenship, or, lately, sheer residence legal or not? Your father lay with your mother, and you now claim a portion of my goods and earnings to pay for your health care although you and I have no relationship other than you live a few miles away in a part of the city I seldom visit. Why should I pay that?
Now of course I am often exhorted to act as my brother’s keeper, and reminded of my obligations to those who have few to none of the goods of fortune and are in need. That, however, is a religions, not a political obligation, and seems ironic when made by those who say that a state court cannot hang a copy of the Ten Commandments in the courtroom (although apparently a pagan statue of the goddess Justice is all right). Laws such as local Sunday closing laws passed ostensibly for economic have been struck down because it was found that the “real” motivation for their passage was religious; surely laws confiscating property – “taking a bit from the haves to give it to the have-nots who need it so much” – have no greater validity?
And yet: as Burke said, for a man to love his country, his country ought to be lovely; and few would call lovely a place where the needs of the poor are not considered. Of course that then leads us to the question of the deserving vs. the undeserving poor. How much does society owe Alfred Doolittle? More to the point, how much do you owe him?
Defending the Affordable Care Act on economic grounds fails: the effect of the Act, f it worked exactly as planned, would be to require the young and healthy to pay roughly the same premiums as the older and less healthy. To compensate for this confiscation, as many as possible will receive subsidies. To pay for those subsidies the government will have either to raise taxes or borrow money. Raising taxes means once again that someone productive will have to pay more to support someone unproductive, and raises the question of how much do the productive owe the unproductive? As to borrowing money, this simply puts the burden of supporting the sick and elderly on those coming after them – a transfer of money from the young and healthy to the elderly. Of course it may have the effect of transferring the burden to Chinese bankers if the government can’t continue this pyramid scheme, but there is always the hope that Moore’s Law will so increase productivity that we can support the unproductive in a style to which they would like to be accustomed. We seem to be well on the way to that.
Note that while the Affordable Care Act seems to be an insurance pool, so did the Social Security Act; but over time the Social Security System was jiggered to allow disability payments to people who had never in their lives paid anything into the system. After all , it had collected more money that was paid out, and here was this pool of money, why not give some to the have-nots who need it so much? I suspect the Affordable Care Act system will never produce even a temporary surplus: health care costs will rise to exceed income, just as education costs always rise to exceed revenue available. The Affordable Care Act begins with subsidies to be paid by various manipulations, but the revenue sources such as taxes on medical equipment such as crutches and hypodermic needles are vulnerable to political pleading – while other subsidies come from cuts in previous subsidies. None of this increases productivity or reduces demand.
As a beneficiary of the old system – Kaiser paid out a lot of money for my 30 days of hard radiation treatment with frequent tests, all this after a number of high quality people tried to figure out what to do with an inoperable lump – I am hardly going to denounce it. But I can make the case that I paid into a medical insurance account for most of my life, and I paid into Social Security through the Self Employment tax for many decades and in fact still do. This worked like insurance. The affordable Care Act creates a class of entitlement without much in the way of obligation. It does not do so very efficiently.
I agree that the system we have needs reform, but I am not at all sure that the right way to go is through government. I keep remembering Tocqueville on the difference between America and Europe: America did things through what he called “the associations” and which we now seem to call Non Government Organizations. Whatever one calls them, they have been very effective and a lot more efficient than government. They might still be if government did not attempt to drive many of them out of business.
We will continue this another time. We are certainly agreed that what we have needs reform. I contend that the Affordable Care Act is doomed to economic failure and will need many fixes long after the exchange problems are solved.
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Subject: The unasked question
Jerry, you’ve been asking why you should be taxed to provide health care to the undeserving poor, but I think there’s a question that needs to be answered first: "Why should the government help the undeserving poor?"
Now, I’d like to point out that I’m surviving right now on Social Security and VA benefits. However, I did spend most of my adult life working and paying into Social Security, and I did serve a hitch in Uncle Sam’s Navy, including spending about 7 months in Tonkin Gulf back in ’72, so I think it’s safe to say I’ve earned what I’m getting now.
However, what I’d like to know is why healthy men and women who have never worked a day in their lives and wouldn’t know what a paycheck was if they saw one should have their bills, healthcare and otherwise, paid for by society. I’m not saying that they shouldn’t; after all, there is such a thing as charity, and unlike Ebenezer Scrooge, I’m not suggesting that they be sent to either prison nor a workhouse. I’m just asking why it’s the government’s job, because unless it is, there’s no justification for taxing anybody to provide compulsory charity.
Charity is voluntary giving, i.e. the work of NGO’s, also known as associations. By definition it is not charity if I vote to send a tax collector to take money from Bill Gates in order to support you, or from you to support the homeless man who sleeps under the bridge on Laurel Canyon. I may be my brother’s keeper, but that is a religious obligation, not one I can impose on my next door neighbor.
In particular, should I pay for a heart transplant for a 55 year old massively obese man who has smoked all his life? Perhaps if he is my brother or my neighbor, but how do I justify sending the tax collector to you for an involuntary contribution.
The Affordable Care Act in effect requires those who consume the least health care to pay insurance premiums close to the premiums of those who consume the most health care; then it adjusts that by subsidies to those who are paying too much (but this is of course means tested). It also borrows money to accomplish this. The result is that the young and healthy are charged wither immediately or with debts that must be paid. Of course some will never be productive and will never pay anything – so the productive and those who will be productive in future are being charged to pay for the health care of today’s elderly and sick.
Now I can understand trying to nationalize the whole system and being done with it; there could be a number of efficiencies introduced that way, including free medical education for those qualified who want to become physicians. (And those who want to opt out of the national system would then get to pay some of their education costs before they could become concierge doctors…)
This sums up a lot about CO2:
The nearly 400 ppm of CO2 in our atmosphere constitutes a (currently) fixed number of molecules of the gas.
If you were standing on Mars you would have significantly more CO2 (and nothing else) above you than on Earth. So one would expect that the “greenhouse” effect would be much more intense even after accounting for the r**2 problem. So why is the temperature so much colder?. Turns out that the radiation effectiveness has already been used up. You are witnessing a radiation absorption effect similar to Zeno’s Paradox. Each increment of gas increase has much less effect on the ability to adsorb energy. By the time you reach 20 ppm you have absorbed just about all the energy in the radiation impinging on the Earth. (or emitted from it). Increasing to 1000 ppm would have almost zero change in the amount of energy adsorbed.
As you note , is only the water vapor that does the real work; a much wider adsorption band (as well as much greater concentration). And the clouds that result from the water vapor greatly complicate the solution. Some clouds increase energy adsorption, some decrease it. In fact the problems are so great that the AGW crowd just ignore them when they build their models. Their models are fine for their idealized planet, but it is not Earth. So their conclusions do not apply here. (sort of like the start of a physics problem – “Imagine a spherical cow …”
The Ice Ball Earth scenarios require a CO2 concentration of 20% CO2 (vs. current .04%) to stop the advancing glaciers.
Could we survive those conditions; No, we give out at 4% CO2 because of poisoning effects (I have been in 2% CO2 for long periods). The plants on the other hand would love it. Of course they would not be a green mass over everything, they would just find some other limiting nutrient. (Greenhouse growers try to have high CO2 by adding CO2(1000 ppm is about as much as they can afford) but in the 45 seconds it takes a mass of air to travel the 100 foot length of a greenhouse (cooling times) the air drops from 1000 ppm to 300 (the point at which some plants stop growing from lack of CO2)
Earl
Thanks. My general view is that a long open ended experiment on increased CO2 in the atmosphere has dangers I’d prefer not to risk, but that’s for another time. Our current CO2 reduction programs have great costs including political; fortunately technology is making energy cheaper; the lower energy costs raise productivity and economic growth, which is about the only way out of our current economic problems – problems exacerbated by the tendency of people to be generous with other people’s money.
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For those with a musical interest:
http://www.thisiscolossal.com/2013/11/viola-organista/
Freedom is not free. Free men are not equal. Equal men are not free.
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