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How Health Care Reform Is Sort of Like a Costco Membership

May 15th, 2009 . by economistmom

costco-cards

In today’s Wall Street Journal, the President’s budget director, Peter Orszag, explains that the fiscal challenges facing the U.S. government are almost entirely driven by the rise in health care costs, so that the best way to get the math right (to bring government spending more in line with government revenues) is to pursue major health-care reform.  But Peter’s not talking about reform that would reduce spending by reducing access to subsidized health care; he’s talking about expanding coverage and saving money at the same time.  How does this work?  As Peter explains:

The good news is that there appear to be significant opportunities to reduce health-care costs over time without impairing the quality of care or outcomes. In health care, unlike in other sectors, higher quality currently seems to be associated with lower cost — not the opposite…

How can we move toward a high-quality, lower-cost system? There are four key steps: 1) health information technology, because we can’t improve what we don’t measure; 2) more research into what works and what doesn’t, so doctors don’t recommend treatments that don’t improve health; 3) prevention and wellness, so that people do the things that keep them healthy and avoid costs associated with health risks such as smoking and obesity; and 4) changes in financial incentives for providers so that they are incentivized rather than penalized for delivering high-quality care.

Already, the administration has taken important steps in all four of these areas…

But more must be done. To transform our health-care system so that it improves efficiency and increases value, we need to undertake comprehensive health-care reform, and the president is committed to getting that done this year. Once we do, we will put the nation on a sustainable fiscal path and build a new foundation for our economy for generations to come.

But wait–more, for less?  There are lots of skeptical fiscal policy experts out there, as New York Times columnist David Brooks points out:

[W]hat exactly is the president proposing to help him realize hundreds of billions of dollars a year in savings?

Obama aides talk about “game-changers.” These include improving health information technology, expanding wellness programs, expanding preventive medicine, changing reimbursement policies so hospitals are penalized for poor outcomes and instituting comparative effectiveness measures.

Nearly everybody believes these are good ideas. The first problem is that most experts, with a notable exception of David Cutler of Harvard, don’t believe they will produce much in the way of cost savings over the next 10 years…

The second problem is that nobody is sure that they will ever produce significant savings. The Congressional Budget Office can’t really project savings because there’s no hard evidence they will produce any and no way to measure how much. Some experts believe they will work, but John Sheils of the Lewin Group, a health care policy research company, speaks for many others. He likes the ideas but adds, “There’s nothing that does much to control costs.”…

…and there’s even some nay-saying, or at least back-pedaling, among the very same health care leaders who the President claimed pledged to cut $2 trillion in health care spending, according to a report by Robert Pear which also appeared in today’s New York Times (emphasis added):

After meeting with six major health care organizations, Mr. Obama hailed their cost-cutting promise as historic.

“These groups are voluntarily coming together to make an unprecedented commitment,” Mr. Obama said. “Over the next 10 years, from 2010 to 2019, they are pledging to cut the rate of growth of national health care spending by 1.5 percentage points each year — an amount that’s equal to over $2 trillion.”

Health care leaders who attended the meeting have a different interpretation. They say they agreed to slow health spending in a more gradual way and did not pledge specific year-by-year cuts.

The Washington office of the American Hospital Association sent a bulletin to its state and local affiliates to “clarify several points” about the White House meeting.

In the bulletin, Richard J. Pollack, the executive vice president of the hospital association, said: “The A.H.A. did not commit to support the ‘Obama health plan’ or budget. No such reform plan exists at this time.”

Moreover, Mr. Pollack wrote, “The groups did not support reducing the rate of health spending by 1.5 percentage points annually.”

He and other health care executives said they had agreed to squeeze health spending so the annual rate of growth would eventually be 1.5 percentage points lower.

The promise of cost savings through major health care reform which includes expanded coverage is oddly (or EconomistMom-ly) similar to the promise of saving money on the family budget by getting a membership to Costco.  How so?

  • A membership to Costco requires an up-front investment of the annual membership fee for the privilege of shopping there and the potential to reap savings in the future so that your investment (membership) will ideally pay for itself.
  • What exactly you are buying the right to in terms of future shopping options is uncertain at the time you pay the membership fee; you don’t know exactly what goods will be available for purchase at Costco over the next year, how stable the selection will be once you find some things you indeed like to purchase, or how great the prices will be compared to the prices at other stores (which don’t require a membership fee).
  • Whether you actually save money from your Costco membership depends on how you view/use your Costco option.  Will you buy things you would have bought at a more expensive store anyway?  Will you buy only what you need and not have to waste any, given the humongous sizes of the things one must put up with at Costco?  Or might you end up buying things you would not otherwise have bought?  In other words, will the Costco membership actually expand your consumption possibilities, rather than help to constrain, restrain, or ration them?  (When one “has to spend money to save money,” which side wins?)
  • If  you prove disciplined enough with your family budget and that Costco card (buying from Costco only those things you would have bought anyway from other stores), how much of your family budget is actually able to benefit from the Costco savings?  What are the tradeoffs in terms of selection/product variety and convenience?  Do I often choose the more expensive retail option anyway, because I’d rather pay more and get it more quickly and easily, and get bundles of goods better tailored to my short-term (as opposed to multi-year) consumption needs?  (Yes, and I’m sure there are other moms out there who’ve been stuck with a hundred bags of fruit snacks or dozens of boxes of mac and cheese that their kids have tired of long before you’ve gotten through consuming them…)  And would I be willing to have the Costco membership work to help me save more money if it required that I give up the option of shopping at the more convenient but more expensive stores?  (No.)
  • My family’s had our Costco membership for about 15 years now (it began as a “Price Club” membership); why, we’re even “Executive” members now.  If you asked me now whether I’ve saved money on net for our family budget by having had the membership and spent the thousands of dollars each year there, I’m not sure what the answer would be (yes or no), and I’m not sure how I’d begin to quantify that even if I had kept track of all my Costco purchases.

So the promise of health care cost savings from health care reform is quite a bit like the promise of family budget savings from a Costco membership.  It’s certainly good to have lower-cost options available to us.  But we don’t know exactly what we’ll be able to buy with those options in the future, we don’t yet understand what tradeoffs we’ll face, and we certainly have no guarantees we’ll end up making better choices just because we’re faced with better options.  I certainly wouldn’t take any presumed future savings from my Costco membership and go use it to buy a new car–even through Costco.

20 Responses to “How Health Care Reform Is Sort of Like a Costco Membership”

  1. comment number 1 by: Tim

    There’s one serious problem with this argument. I can opt out of becoming a member of Costco. I can choose my insurance provider now, with a private system.

    The government won’t allow me to opt out of their retirement plan, and if you ever get your way, they won’t let me opt out of their health care plan, either.

    It boggles my mind that someone with your level of intelligence cannot grasp that MORE entitlement cannot be the solution to a country that has far too much of it already, with promises that it cannot afford to pay.

  2. comment number 2 by: Brooks

    Tim,

    If you’re going to be snarky, at least work on your reading comprehension skills. The point of the post is one of skepticism and uncertainty regarding the existence/magnitude of net savings from the changes advocated by the Obama Administration, in response to Orszag’s claims.

    If I may borrow your phrasing, it “boggles my mind” that people can get as snarky as you just did on the basis of an obvious, complete misunderstanding (on your part).

  3. comment number 3 by: Phil

    Hey Tim… Just because someone might disagree with parts of your argument does not mean they cannot grasp it. Your ability to persuade with good logic is really hampered by your snarky tone.

    I like this comparison and think it could be taken further. If anything could bankrupt America, it’s healthcare, so I’d love to look for more ways to save.

  4. comment number 4 by: Brooks

    Interesting analogy (Costco). And given that the Administration’s policies involve not only upfront investments in systems, preventive care, etc., but also, as you note, expansion of coverage, perhaps your equation for net savings from Costco membership should include your buying me a membership, too*.

    * Granted, an imperfect addition to the analogy, because of the relationship between the cost of healthcare for the uninsured and costs for those with insurance, and due to the relationship between private healthcare costs and public (mainly Medicare & Medicaid).

    On a related note, I am eagerly awaiting The Concord Coalition Series on Healthcare and Medicare http://www.concordcoalition.org/medicare/concord-coalition-series-health-care-and-medicare . I look forward to reading Issue #1 this weekend http://www.concordcoalition.org/issue-briefs/2009/0515/nations-health-care-conundrum-where-do-we-go-here

    There is a large faction that contends (or at least implies) that we can adequately mitigate our long-term fiscal imbalance via net savings from painless healthcare “reform”, combined with taxing “the rich”, cutting Defense and eliminating “waste-fraud-abuse-yadda-yadda”, and therefore, the argument goes, there is no need for any significant sacrifice. If they are wrong — as I suspect they are — it is important that those with the relevant expertise and credibility inform and demonstrate to the public (via analysis based on assumptions that are widely acceptable among experts) that such measures, while perhaps beneficial, are inadequate, and that further measures involving actual sacrifice are needed to avoid greater pain later.

  5. comment number 5 by: Jason Seligman

    Like Brooks and Phil I have an issue with Tom’s response but it is not tone related. My concern is the presumption of choice under the current private insurance system. Let’s all remember that most people who have private insurance gain it through employment, and options are limited to those available though the particular employer. That does not allow much in the way of market competition.

    When you couple the inflexibility of the composite product (Health Insurance | Occupation and Employer) with the evolution of health insurance offerings at most employers you quickly realize that over time one may wind up with a very different insurance plan than one initially agreed to, even if initial job selection was made in solely in response to the health insurance offering. (Which of course is exactly what workers do in the labor market, err, I mean “health insurance market”)

    But, the greater concern I have these days is with change in what the “I” in Insurance really implies. It is more and more frequent to observe policies that have lifetime maximum benefits, or even yearly maximum benefits (as I learned my dental “plan” does this past week — $1,200 a year (*)). You see in the private market it is increasingly rare for the “I” in insurance to stand for Indemnity, rather, it stands for Individual. “I” am the residual claimant of larger catastrophic care in our competitive private system. Insurance indeed. Costco cards look good by comparison—at least the discount works all year round — a co-pay lower than 100 percent sounds pretty good right now.

    As for the grand partnership, I am more than a little unimpressed by the results of these decades health care initiatives. I do hope the administration is a bit more imaginative than the recycled proposals of the Clinton and Bush years. For whatever and however many reasons they have not provided either improved care or lower costs. I applaud the Obama administration for listening to the proposals from industry, but we do not have time for kabuki theatrics and false starts. Two twice elected administrations (that is sixteen years) later, it is time to move on.

    Attention Health Insurance Industry, a lot has changed since 1994. fewer Americans are happy with their healthcare. Those that remain happy with their personal coverage are more likely aware of the challenges besieging parents, friends, colleagues, and subordinates. Heath care should not be a gateway to bankruptcy. Health is a public good and deserves to be acknowledged as one. Institutions and labor force dynamics together have created a system plagued by misinformation, administrative bureaucracy, supply shortages and the mismatch of preventative and acute care consumption. Let’s not dither over the 1.5 percent let’s focus on the bigger picture—the promise of private markets is failing the nation’s health and finances.

    (*)-seems the best time to have a dental emergency is roughly November under my plan, that way you can spread costs over 2 calendar years.

  6. comment number 6 by: Anandakos

    Single payer. Single payer. Single payer.

    Let people go to any doctor or facility they wish; charge premiums for the coverage to help defray its costs, but provide truly low-income people with financial assistance to pay them; levy somewhat progressive co-pays for all procedures, but ensure that everyone has most of the cost covered; allow purchase of pharmaceuticals through non-public sources but legislate a maximum wholesale price 110% of the highest price in any other OECD country; allow a parallel “non-covered condition” system to exist for things like plastic surgery but forbid third-parties from “insuring” patients in it — you want it, you buy it; compensate the doctors in the covered conditions system generously, with rewards for better than average outcomes; compensate health care facilities in the covered conditions under a formula which assumes “not-for-profit” operation — allowing of course for facility and equipment upgrades and bonuses for staff for above average weighted outcomes but no rake off for third parties; publish age, gender, and ethnicity weighted outcome statistics for all members of the covered conditions system; provide nearly full Federal tuition assistance for medical and nursing education to qualified candidates, with loan forgiveness at specified working milestones in the covered conditions system; and refuse to pay for heroic intervention when a group of three doctors chosen by the patient in advance or by family members agree that the intervention is pointless. Do allow a self-paid system for people or families who wish to waste their money on pointless care, but again forbid third-parties from “insuring” patients in it.

    A system much resembling this is the only possible way to save money in the system.

    Health insurers are vultures feasting on the rotting bodies of America’s frightened, vulnerable citizens.

  7. comment number 7 by: Anandakos

    “pointless end of life care”

  8. comment number 8 by: Diana

    I share your skepticism about the relationship between expanding coverage and reducing total costs. I think the real point of health reform should be improving quality, accountability, and value for money. Nobody can say with certainty today what the optimal level of total health care spending in the economy should be 10 or 20 or 30 years from now. However, we are more likely to make the correct tradeoffs between health care and everything else if we can develop a better understanding of the relationship between what and how we spend on health care and what we get in return for that spending.

  9. comment number 9 by: Brooks

    Anandakos,

    Since you mention “pointless end of life care”, I just want to make a point that I think some may not realize or appreciate.

    First let me say that I agree that we must, as a society and as individuals, give serious thought to how much we want to spend on “end of life” care for ourselves, our loved ones, and others in our society. A great amount is spent, and obviously resources are finite and we should consider trade-offs, and then try to align our policy and individual choices with our values and priorities. So I’m not knocking you for raising that important point.

    Now on to my comment about “end of life care”.

    “End of life” is an (very) educated guess based on statistics combined with whatever is known about the individual patient. Not only is “end of life” often not clearly defined (Is it an X% chance of providing Y additional months/years with Z “quality” of life?), but it the period of incremental time and incremental “quality” time (”quality” itself individual and subjective) is probabilistic, and is only really precisely determined as “end of life” for the individual after the fact.

    When my mother was diagnosed with Stage 4 lung cancer the odds very much against her living — with the help (I assume) of chemotherapy, radiology, and other care throughout her struggle — anywhere near the additional three and a half years that she did with the quality of life (in objective terms and her own subjective experience) that she had for most of that time. Was all or part of that care what should be defined as “end of life” care? Should she have been denied coverage for some or all of that care?

    I do not ask these questions rhetorically, let alone snarkily. These are important questions. I’m just saying we need to think it through. And no need to respond per my personal example above (I wouldn’t want that to inhibit frank discussion — I only discussed it because I happen, unfortunately, to have some personal experience and perhaps insight with this matter). You can respond in general terms or with hypothetical examples, etc.

  10. comment number 10 by: Jim Glass

    I’d like to consider “Costco-model” national health care by looking at the national health care systems we already have, Medicare and Medicaid, and seeing how we’d have to change them to get to a Costco model. Then maybe we’d get some idea of the real-world practical challenges involved.

    (I can provide only one link in this comment system, sorry.)

    Medicare’s inefficiency is pretty well documented….

    We find that states with higher Medicare spending have lower-quality care. This negative relationship may be driven by the use of intensive, costly care that crowds out the use of more effective care… [Katherine Baicker, Dartmouth]
    ~~~
    we find that a large component of Medicare expenditures … nearly 20 percent of total Medicare expenditures — appears to provide no benefit in terms of survival, nor is it likely that this extra spending improves the quality of life.

    … etc. etc. Medicare has a lot of fraud and semi-fraud problems in supply purchasing and the like too … but its inefficiency and fraud issues don’t match Medicaid’s from coast to coast

    Of $34 billion annually spent by the Medi-Cal program for health care for some 7 million poor Californians, state officials estimate that as much as 40 percent, or nearly $14 billion, is stolen in fraud.

    Note well, that’s not 40% spent “inefficiently” — that’s 40% “stolen in fraud” [LA Daily News]
    The same figure applies 3,000 miles away in New York State — 40% going to fraud and what investigators call “legal fraud”, practices that appear fraudulent on their face but happen not to be against the law the way it is written, what Tammany Hall famously used to call “legal graft”….

    New York Medicaid fraud … “It’s like a honey pot,” said John M. Meekins, a former senior Medicaid fraud prosecutor in Albany who said he grew increasingly disillusioned before he retired in 2003. “It truly is. That is what they use it for.”

    James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal. “So we’re talking about 40 percent of all claims …” [NY Times]

    That’s a good long way from Costo Care! Why all the distance ?

    Well, when crusader Elliot Sptizer was NYS attorney general he notoriously made political hay by prosecuting Wall Street, which wasn’t his jurisdiction (there’s the SEC and Feds for that) while totally ignoring Medicaid fraud, which explicitly was his responsibility. When he got called on it, he answered: “But the legislature gave me no budget line to do it”. And he was correct.

    Not only that, when Medicaid fraud started becoming a local issue, due to things like the Times story quoted above, the state legislature voted to — get this(!) — prohibit further investigations of Medicate fraud! Yes, in the face of admitted widespread fraud, the states legislators voted to ban investigations of the fraud!

    Why, oh why, would responsible elected officials ever do such a thing???

    The answer is easy: (1) Every single elected official who is seen to be denying medical benefits to the needy (indeed to be prosecuting the poor-and-needy over their medical care) can only lose votes for it. No politician is ever going to gain votes for that!; plus (2) The legislators get major campaign contributions and electoral support from providers of medical services (from unions to doctors to medical suppliers to CEOs) who do not want any new “crackdown” rules on the money they get from the govt, whether they are honest are not.

    The political incentives in play and their result are overwhelming and obvious: The politicians support wasteful-to-fraudulent expenditures because it is good for them … there is near-zero political incentive the other way (much less for Costco efficiency!) … with the resulting real-world government-provided results, that we see before our eyes and which are reported in newspapers and academic studies.

    Now I don’t see how Orszag’s ideas do a dang thing about any of this — but I would very much like to be proven wrong. So here’s a modest proposal:

    Following the injunction of the Hippocratic oath, “First do no harm”, before expanding the government’s control over the nation’s health care in search of “efficiency savings”, let’s see if the government can first attain those savings in its existing programs that it already runs, Medicare and Medicaid!

    Let’s have President Obama name Orszag “Czar of Improved Medical Efficiency and Health Care Outcomes” (the government always needs a Czar for such challenges). Have him chair a IME&HCO Commission that will select a “top 15″ list of efficiency improvements to impose on Medicare and Medicaid a year from now — specifically starting with all those “reverse cost-benefit correlation” Medicare procedures and Medicaid fraud. Face it, there’s so much “low hanging fruit” the payoff can be huge … if he can do it.

    But my wager is, when he takes his proposals to Congress and the state legislatures for them to enact, they are going to say: “No”. Because every citizen and health care provider who will lose something being received now will be furious at the elected politician responsible for the loss, and will rise to politically punish that politician and all his cohorts. While the politicians who vote to impose those loses on their constituents will get no political reward from anybody. And how the politicians will respond to that mismatch of incentives is obvious.

    In other words, the situation will be exactly as it is now, and the politicians will continue to act exactly as they have until now in creating this mess, for exactly the same reasons.

    Prove me wrong! Run this test! If I’m wrong, the payoff will be huge. (I want to be wrong!) If I’m right we’ll all learn that the problems with the national health system are not the technocrat reasons Orszag gives, “lack of electronic recordkeeping” and the rest, but the politics and incentives of it, and that Orszag’s ideal is just a technocrat’s pipe dream.

    But please, please, run the test before committing the entire nation to a national health care system that is promised and sold as “Costco-model health care” but which turns out to be Tammany Hall-model health care.

    A footnote anecdote about an attempt here in NYC to provide a real Costo-model health care program….

    In a case that’s become locally semi-famous, Dr. John Muney offered his patients a full range or office medical procedures “everything from mammograms to mole removal” at clinics operating across the city, for a flat rate of $79 per month, with unlimited visits and a $10 co-pay. His program was targeted at the uninsured and cost far below the local going rates for insurance, “normal” office visits, etc. The Costco model!

    Can you guess what happened? Of course … the state closed him down — because he was charging too little.

    The state ruled that flat-rate provision of services is “insurance” (tell that to the phone company) and he wasn’t a licensed insurer. Moreover, even as an insurer his rates were illegally anti-competitively low (yes, the “low prices are anti-competitive” argument again) because state insurance law requires insurers to cover a host of special and elective procedures that Dr. Muney’s clinics don’t provide, increasing regulated insurance premiums far above his $79 “premium”, making it illegally low.

    Dr. Muney appealed, lost, was forced to drop his plan and charge higher “competitive” rates per procedure.

    So the “Costo model” provision of medical care is explicitly illegal at least in New York State.

    I leave it as an exercise to figure out the political incentives operating in this case.

    If anyone can figure out a way to reverse them so that NYS politicians will want to provide Costco-model health care, all suggestions will be gratefully accepted!

    But until someone comes up with such ideas — and someone tests them and shows they work in our existing Medicare and Medicaid systems — I’m going to remain pretty darn skeptical about ever seeing anything remotely like Costco-model health care in a politically administered health care system.

    Tammany Hall-care will continue to remain much more likely, IMHO.

  11. comment number 11 by: Tim

    I’m still waiting for a single example of efficient government investment even on a small scale. There are examples, but they are few and specific. The inefficiency of government owned and planned economic activity is well documented over the entire historical record for which we have data.

    Governments are good at killing people and breaking stuff, but even private contractors have shown that they can even take on this government monopoly in recent years. UPS and FedEx have done a damn good job of competing with the United States Postal Service, even with the heavy burden of taxes that the USPS never pays, especially on fuel.

    The only logical conclusion is that removing the “market” from health care completely can only cause more damage. Currently, a very small proportion of the cost of health care is borne by consumers. Shrinking that proportion to near-zero in an attempt to provide universal coverage (and doing so without limits on its consumption) can never respond to the tragedy of the commons argument that surely follows any such debate.

  12. comment number 12 by: Anandakos

    Brooks,

    Thanks for the lack of an attack in your post. When I said “pointless end of life care” I did NOT mean treating people who are alert and have a will to live (granted, that’s a subjective evaluation) just because their illness is normally terminal.

    What I mean are interventions such as the automatic treatment of an advanced Alzheimer’s patient with pneumonia. If the family of the patient is willing to let her or him go, why should the health care system stand in the way of a natural end of life?

    I understand that doctors and nurses form relationships with their patients, and nobody likes to say “I’m whipped”. If another series of Keflex beats the bug the doctor gets to feel successful and that she or he has served the patient well.

    But has she or he really?

    You stated in your post that your mother had a better quality of life than doctors — and probably she herself — expected. No one would want to deprive someone of that sort of care. But we need to have a national discussion about the care we provide — force on? — seriously debilitated people will little to no prospect of recovery of independence.

  13. comment number 13 by: Anandakos

    Jim Glass,

    Your arguments are depressingly accurate. Even though all of the other advanced economies have relatively efficient and functional public health systems, here in America we really DO have the Tammany Hall pitfall. It could sink the system.

    However, I think that the problems are not so much a problem with single-payer health care as they are with our “first-past-the-post” electoral system.

    Because incumbency provides enormous opportunities for indirect patronage, it to use Rod Blagojevich’s immortal words suitably censored it is “a frakking valuable thing”. People are hugely willing to buy access to the holder of that valuable thing.

    Since the ostensible “progressive” party (the Democrats) are about 99 and 44/100 percent as bad as the “conservative” party (the Republicans) on this, we can’t just “vote the rascals out”. All we get is a set of rascals from a different demographic.

    The only way to solve the problem is to pay for elections ourselves. There are dozens of specific ideas for ways of doing it, but the bottom line is that we need publicly funded elections with effective supports for independent minded candidates who go against the two-party orthodoxy.

  14. comment number 14 by: Anandakos

    A follow up to may last post. Along with public funding we should also have Instant Run-Off Voting so that independent minded people bucking the party duopoly have a chance to win.

    I consider myself a progressive, but I’d be very happy for secular, sober and non-racist Libertarians (NOT tin-foil hat Libertarian anarchists) to win some elections. The way the current Republican party is structured the religious folks and the KKK wing dominate things. The small government message is completely eviscerated by the “we need to sniff your underwear to be sure you are a virgin” and the “club the homies” types.

  15. comment number 15 by: Josh Uy

    Well I’ll add my 2 cents. As a geriatrician that deals with end of life care daily, I would say that by having physicians spend about 15 more minutes with patients to help determine goals, many many ER visits, hospitalizations and ICU admissions could be avoided because the patient doesn’t want it anyway (if only someone were to ask). I’ve seen many patients intubated/hospitalized etc when everyone standing around says, “he wouldn’t have wanted this.”

    As a family doc (before I became a geriatrician), it’s always amusing to me when people try to analyze/fix the health care system by deconstructing it into a couple of key factors that need to be fixed (tech, prevention). It’s like trying to make a great tasting cake by just thinking about the ingredients and not how it is put together. Right now, most care is delivered and packaged by the shrinking workforce of primary care docs. So once we think about health care as a sum of abstract parts, any discussion also needs to include how things will work/look different from a provider’s perspective and a patients perspective to keep it realistic.

  16. comment number 16 by: Brooks

    Anandakos,

    Thanks for your reply, which shows how important distinctions of categories and definitions are in discussing this difficult general issue of morality/ethics and economics.

    The kind of “pointless end of life” care to which you refer, while still at least sometimes involving difficult choices, is at the less difficult end of the spectrum, particularly when speaking either of forcing upon a patient, against the wishes of the patient (or family, if the patient is incapacitated and has not formally indicated a preference) treatment with extremely low potential benefit to the patient. Even if cost were not an issue I would oppose, on the grounds of individual rights, forcing such treatment upon a patient.

    Moving along the spectrum in the more difficult direction would be the same situation but with the patient (or patient’s family) wishing to get such treatment. Obviously a big gray area of costs, benefits, probabilities, contingencies, etc. and all the related questions of ethics, morality and economics (And as cold as the latter — considering the “economics” — may sound in this context, it is indeed a moral imperative to consider how the funds could otherwise be used, what benefit or reduction of suffering could be achieved via those other uses, etc.).

    We do, indeed, need to have (more of) a national discussion of these questions as we shape healthcare policy.

  17. comment number 17 by: Brooks

    Anandakos,

    Although I, too, dislike some of the social policy positions of the Republican “base”, it is both unfair and counter-productive of you to throw around labels like “KKK” so loosely and broadly. Just my suggestion, for whatever you think it’s worth.

    On a separate matter, I, too, strongly support at least mostly public funding of elections. It should be voluntary (to avoid First Amendment issues), but so attractive in terms of matching ratio and spending limit (adjustable as necessary to match a candidate who opts out) that there would be little incentive or advantage to opting out. And the max individual contribution should be within the reach of most Americans — e.g., a couple of hundred dollars. Such a system would be the best investment taxpayers could ever make, given the savings from elimination of subsidies, special tax breaks, import quotas, favorable regs and policies, etc., that are payback to campaign contributors. And it would be nice, as well, to move closer to de facto one-person, one vote.

  18. comment number 18 by: Anandakos

    Brooks,

    I like your version a lot. As I said, there are lots of competing ideas out there about HOW to do it. Yours has a nice balance between preserving genuine taxpayer involvement in the process and limiting options to buy the system. Assuming we can get it by the skeptics (and figure out a way to avoid some of the obnoxious gaming of the system that Portland has encountered), I hope whatever evolves is quite like what you’ve outlined.

    Sorry about the KKK phrase. You’re right about it being overbroad, but I grew up in Oklahoma with lots of otherwise very nice people who are unconscious of how completely they assume the worst of black people. Most would never don a sheet but it’s pretty sickening the jokes that get passed around.

    And the sad truth is that there were lots of people at those rallies whose dislike of the President goes well beyond his policies. Distilled into a word, he’s way too “uppity”.

    By the way, I do understand that many black people are skeptical about making real friendships with whites, too. It’s partly a cultural thing; most people prefer to be with people with whom they share the same taste in music, conversation, and activities. But there’s another reason, as well: they’ve been hurt too often by the sort of unconscious racism that everybody over 40 from that part of the country has — including me; I screw up sometimes, too, and it really embarrasses me. (Not saying the embarrassment is as bad as the hurt; no sympathy asked or deserved).

  19. comment number 19 by: Anandakos

    P.S. No, not really “everybody”; just 90% of the privileged race.

  20. comment number 20 by: Brooks

    Anandakos,

    Another benefit of mostly public funding of campaigns is less readily evident, but still very important. Beyond the direct benefits I mentioned (budget savings, consumer savings, more de facto democracy, etc.), another benefit would be a higher level of trust in government that would be conducive to public acceptance of the kind of major sacrifices (on both tax and spending sides) that we need in order to start making serious progress toward adequately addressing our long-term fiscal imbalance.

    As long as there is broad resistance to such sacrifices, fiscal responsibility will be a net political loser for politicians and they won’t support such measures. And one source of resistance to such sacrifices is a general mistrust of the politicians — suspicion that any such call for sacrifice would represent politicians calling for sacrifice by the “little people” so that powerful segments or “special interests” can gain or at least avoid sacrifice. Some will say things like “Why should anyone get less in Social Security benefits just so that the bankers can get all the taxpayers money instead?” Others will say things like “Why should I pay more in taxes just so the politicians can dole more out to special interests?” Etc., etc.

    So I view (mostly) public funding of campaigns as conducive to the achievement of fiscal responsibility, and to achieving it sooner rather than later, which would translate into lower ultimate costs to the American people.