(no subject)

[winterbadger]

Thanks to blueingenue for a link to an excellent article in the Atlantic about healthcare. In particular, the author highlights one of my greatest reservations about the discussion of *insurance reform* now going on:

...fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system-—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.

We need health *delivery* reform as well as health *process* reform and health *insurance* reform.

Edited to fix link error.

Comments

[winterbadger]

You're not listening to the argument, and I'm getting really tired of your naysaying. If you're not going to comment productively, please don't feel you need to comment.

[schizokitty.livejournal.com]

This may be so, but for the millions of people with no health care at all, I would wager that any improvement is a huge step forward. Let's at least get everyone covered; then we can start chipping away at the structural/ideological problems.

[winterbadger]

But the problem is that if we simply get everyone coverage with the current system, we will reach a national crisis *much* sooner, and whatever public option gets set up (if any) will quickly become bankrupt. No one will actually be better off, and some people will be worse off.

Economic systems are dynamic; you can't simply change one factor and have all the rest stay the same. If you expand the number of people receiving services and don't change the cost of the services, you will need to find drastically more money from somewhere. It won't come from the government, because people won't wear tax increases. So it will have to come from employers (meaning jobs, or at least salaries, will be cut) or from the people themselves. The people currently in need have no extra money (which is why they are in need) which will mean the extra money needs to come from those already insured.

And the one thing that's clear so far is that a system that negatively affects those *currently* enrolled is DOA.

So we really *have* to come up with a program that cuts systemic costs, or nothing will be changed. Not just health *insurance* but health care *itself* needs to be made more efficient than it is now in the US.

[sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[schizokitty.livejournal.com]

Ah, that'll teach me to reply too fast: I misunderstood the heart of your point. I did not, in fact, read the entire article you linked to, but focused on "insurance-based, employment-centered, administratively complex", mainly considering the unwieldiness of the current system, not the underlying costs themselves. You are right in that, of course.

"[T]he extra money needs to come from those already insured": ah, yes. This will always be true. If the money comes from taxes rather than employers, the rich(er) will always pay more to support the poor(er). That's how we pay for national parks, national defense, medicare, and, on a more local level, police, fire departments, schools, etc. Oh, sure, there are plenty of people who don't want to pay for any of those things, but they're in the minority. But when you've got a country this big, how else can you do it? If you let those without drown every time they break a leg or their house catches fire, what do you think happens to our society overall? Productivity? Competitiveness? What kills me is that the actual anti-healthcare nuts seem to think that everything acts in isolation. Why should they -- upstanding, hardworking, moral, "real American" folk -- pay for some poor loser who can't find full-time work with health benefits? Because that "loser" might repair the roads you drive on, make the clothes you wear, or do any of the thousands of other jobs that, in the words of the inimitable Mike Rowe, "make civilised life possible for the rest of us." I mean, not even bringing Common Humanity into the equation, doesn't a machine run better when all the parts are in good repair?

Augh. Sorry. That turned into a rant, but these selfish "I don't want to help anyone else if actually costs me something" assholes drive me crazy. To return to the point of my comment: I will endeavour, in future, to be more certain of the point I'm arguing before I set fingers to keyboard. ^_^;

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[winterbadger]

But my point is that I think the question of who pays for it is a red herring. Yes, sometimes we need to suck it up and help out those who have less. And I think our generation desperately needs a filmmaker who can make that point as effectively as Frank Capra made it in the 30s and 40s.

But in this case, we *have* to get costs under control. Our medical establishments are practicing medicine VERY inefficiently, and the administration systems are handling the paperwork VERY badly, and those MUST be fixed.

They have to be fixed first of all because it's an immense waste of money that we simply can't afford. That waste is why we spend so much more, proportionately than other countries who get better health outcomes.

But if we fix those problems, even a small portion of the money that's saved would almost certainly pay for the expansion in coverage we need, if combined with real competition in the insurance industry, instead of the near-monopoly that American businesses all dream of while they talk about "free markets".

The problem that the article points out (read it--it's good! :-) is that if we think we have trouble getting insurance companies to compete, we ain't seen nothing yet if the next stage is getting doctors to adopt best practices. Doctors don't *like* being told that they need to change the way they do things; they are not used to being challenged about anything.

The only person I've ever heard say they thought the NHS was a bad idea (not "it could be done better" or "they need to fund it more" but actually "it sucks and it should never have been done") was my great-aunt. Who was, predictably, a doctor. Doctors like to be in control. And that's a big problem we're going to face in reforming healthcare. They've been treated like little princes and princesses by drug companies and insurance companies for decades, and they need to be brought down to earth.

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[schizokitty.livejournal.com]

Uncle! ^_^

Seriously, though, I think the problem is that I got off topic and in the end we were talking about two different things: you about the mechanics and economics of the situation and me about social attitudes. I wasn't paying close enough attention to what you were saying and just got off on a rant. Sorry. ;-P

I have read the article now, though, and I'm not sure either of our opinions is completely in line with the author's intent. ^_^

But the problem is that if we simply get everyone coverage with the current system, we will reach a national crisis *much* sooner, and whatever public option gets set up (if any) will quickly become bankrupt. No one will actually be better off, and some people will be worse off.

I didn't get this impression from the article. It might be a logical extension IF no more progress is made once/if national health care is instated, but it doesn't seem to me that the author is against the Obama Administration's reform, fearing that everything would immediately collapse too quickly to fix. He even agrees that many of the provisions would alleviate some of the current system's problems. His point is reform can't stop with there. He acknowledges, too, that really fixing our system will take a long time -- a generation, perhaps -- time that will undoubtedly be spent in tweaking the system.

He even points out that consumer-driven care is creeping into the system already, with HSAs, discount clinics, and competition for services not usually covered by traditional insurance. Our plan, in fact, is based on an HSA, and the unused portion is carried forward every year.

Economic systems are dynamic; you can't simply change one factor and have all the rest stay the same.

I wasn't suggesting that. I was thinking that we should move forward as much as we can, now, and hammer out the details once we've gained a foothold. I expect I am being too naïve, but it seems to me that passing a national health bill will provide a huge ideological victory. The trouble, of course, will be getting the government to evolve the system, and there I think you certainly have cause for concern, but if we can get moving at all, I think that's a good thing. Of course, I may be wrong; that's always a possibility. ^_^;

[...]if we think we have trouble getting insurance companies to compete, we ain't seen nothing yet if the next stage is getting doctors to adopt best practices. Doctors don't *like* being told that they need to change the way they do things; they are not used to being challenged about anything.

I don't think that's Mr. Goldhill's ultimate conclusion. He admits that doctors are resistant to change, but goes on on the same page to say that they are no more the villains than any other one of the health care players -- as you say, it's the system that's fucked. I know that doctors can be arrogant and stubborn, but judging from this article if they do have competition thrust upon 'em, as it were, they'd learn to adapt quickly enough. >;-)

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[winterbadger]

You don't have to apologise for your rants, especially as I usually agree with them. :-)

It might be a logical extension IF no more progress is made once/if national health care is instated

Well, national health care is *never* going to be instated, not in this country, not in our lifetime. But we might get some sort of national health policy, if we're lucky, out of this Congress.

And "if no more progress is made" is *exactly* what I'm afraid is going to be the result of this single-minded public discussion and debate over *insurance* reform. I think whether or not anything meaningful gets passed this year (and I think that's still up in the air), that will be IT for health care reform during this president's term. It makes no sense (to me), but that's how Washington seems to work.

it doesn't seem to me that the author is against the Obama Administration's reform

I didn't think he was either; if I suggested that, I misspoke. My point (and, I think, his) is that *just* doing insurance reform isn't enough.

His point is reform can't stop with there.

And that's my point too.

I entirely agree with Sullvan when he says

"...fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform."

I wasn't suggesting that. I was thinking that we should move forward as much as we can, now, and hammer out the details once we've gained a foothold.

But my impression is that public policy doesn't work like that. You don't agree on general principles and then work out the details later. For something to be enacted by Congress, it has to be hammered out to a certain level of detail *before* it gets voted on.

My point, as originally stated and continually maintained :-) is that we need to make serious progress on all of these areas (coverage, administration, and delivery) at the same time, or the situation will get worse, not better. And I agree with Sullivan, we need *systemic* change, not a reorganisation of the current system.

[doctors] are no more the villains than any other one of the health care players -- as you say, it's the system that's fucked

But systems don't just rise out of nowhere, created by no one and accountable to no one. They are created, albeit over time, by people, and adjusted for the benefit of people. So far, the system has been almost exclusively designed and adjusted for the benefit of insurance companies, pharmaceutical companies, and the medical profession.

Not villains? I think I would debate that. When health professionals won't do something simple like following a checklist that makes sure they execute basic safety procedures, and as a result thousands of patients die who probably wouldn't if they had? I don't just call those people villains, I call them murderers.

Sullivan agrees with you. He says "They all want to serve patients well." I don't believe that at all. I think *some* of them want to serve patients, but I think most of them want to serve themselves and their careers. And even the ones who want to serve patients are not willing to compromise over simple things because they are too invested in their professional self-image to accept that someoen else might have a better idea than they, to listen to anyone but themselves.

I know that doctors can be arrogant and stubborn, but judging from this article if they do have competition thrust upon 'em, as it were, they'd learn to adapt quickly enough

You say that is if somehow someone is going to force them to change. I am not at all convinced that this is the case. All three of the entities I mention (insurance companies, pharmaceutical companies, and the medical profession) have much more influence over Congress and a much more powerful voice in the public debate than patients do.

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[schizokitty.livejournal.com]

Hmmm, I believe that we are mostly on the same page; it's just looks like you're much more pessimistic than I. ^_^

I just want to clarify a couple things I may not have communicated well:

I didn't say that doctors can't be villains (or that there were no villains at all): I said that the author believes no one group is more to blame than any of the others. Get human nature together in that large and complex a system, and there will be plenty of opportunity for villainy. As for "most of them want to serve themselves and their careers," we'll just have to disagree on that. Obviously there are plenty who don't care much for the patient, just as there are plenty of business people who don't give a shit about any sort of customer, but in my experience it's hardly been "most." Most -- not all, but most -- of the doctors I've seen have been honest and seem to genuinely care about my health; some even go out of their way to avoid extra charges, by having me call in my progress instead of scheduling an appointment, or by reimbursing me for a mistake (such as my optometrist, who absorbed the cost of new lenses when she found she'd prescribed too strong a correction and who waived a test fee because her assistant hadn't told me the test wasn't covered by my insurance).

"[H]ave competition thrust upon 'em": I actually wasn't thinking of regulations at that moment, more of market forces, with the rise of discount clinics and HSAs, as mentioned and elaborated on by the author. (Not to mention opening Angie's List to reviews of doctors, which I think will help by allowing people to choose their care providers based on more information.) In fact, the author gives examples of such competition/adjustment already happening, such as the Lasik surgery case he mentions on page 4. Whether this trend will continue or not, I don't know, but if it does I think that when doctors see their bottom line endangered they'll find a way to stay competitive. ^_^

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[winterbadger]

some even go out of their way to avoid extra charges, by having me call in my progress instead of scheduling an appointment, or by reimbursing me for a mistake

I have NEVER had a doctor (or other health service person, like an optometrist) do either of those things. Ever. And I've seen quite a number of doctors.

I actually wasn't thinking of regulations at that moment, more of market forces, with the rise of discount clinics and HSAs, as mentioned and elaborated on by the author.

Except that I don't see these things changing the cost structure or medical practices of most doctors, from what I can see. Doctors are so overbooked now that discount clinics (which are only going to handle minor stuff anyway) aren't probably going to have much effect on their bottom line. And HSAs--IMO a nasty little trap that a lot of people are going to regret getting involved with IMO--I don't see having that much impact of doctor's practices either.

(Not to mention opening Angie's List to reviews of doctors, which I think will help by allowing people to choose their care providers based on more information.)

Except that this doesn't really affect most people's *costs* (other than being something else they have to pay for), as the trump card will still be what fee structure the doctor works out with the insurance company. Angie's List (which is a real pain to use, from experience, as they don't provide any metadata about doctors--like what practice they belong to, or what insurance they take, so you have to do more work to collate them with other sources, and the data they do have is very poorly managed and presented) is only going to help you decide which of whatever doctors you can go to you might want to use, but it doesn't allow patients to choose among doctors based on price, as that is beyond a patient's control, unless they are outside the insurance system altogether, in which case they're screwed.

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[schizokitty.livejournal.com]

I'm sorry you've had such trouble with doctors, but not everyone has/does (e.g., me). There are good ones out there.

Well, I've given my opinions, you've given yours, and I don't think we're going to change each other's minds. ^_^ Pax?

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[winterbadger]

I didn't see it as a fight, just an exchange of ideas. :-)

There certainly are good doctors out there, but I think our standards of "good" are different. To me, a good doctor is one who is skillful, experienced, and polite. My preference is for one who explains his/her process of diagnosis and options for treatment, but I realise that isn't everyone's preference--some people would rather just be told what the doc thinks is up and what he/she thinks the best solution to it is.

I don't think a doctor is bad because they don't go out of their way to reduce the cost of their services to me--that seems an unreasonable expectation. But I do think that the economic incentives for doctors need to be restructured, I don't think the current system is going to do that, and I do think that a lot of doctors will fight changes that mean they get less income. That's just human nature.

Re: [sorry for the double-post -- I wanted this to be a reply, not a stand-alone comment]

[blueingenue.livejournal.com]

(Not to mention opening Angie's List to reviews of doctors, which I think will help by allowing people to choose their care providers based on more information.)

Interestingly enough, the next Atlantic has an article about how the market for rating systems has expanded and how it will help consumers waste less time researching and making decisions.

[schizokitty.livejournal.com]

My standards for "good" are not different from yours. I always ask what's going on, what the options are, how the doctor arrived at the conclusion s/he did, etc. I'm quite nosy, in fact. I simply used the particular examples I did because we had been talking a lot about money.

I didn't see it as a fight, just an exchange of ideas. :-)

You're so cute when you're delusional. >;-)