The biggest issue facing America

http://lewmoorman.com/the-biggest-issue-facing-america

by lmoorman • 17 years ago

23 39 17 years ago

bokonist2• 17 years ago

The simplest thing to do is pick out the best healthcare system in the world, and then replicate it exactly. So bring in the top officials from Singapore, put them on an independent commission to redesign the healthcare system, and force Congress to pass exactly the plan they come up with.

But coming back to Earth, such a plan could never happen. If you approach the problem from the perspective of a hypothetical policy advisor, there is very little that is both a) politically possible and b) would actually improve the system. Raising the caps on medical school enrollment is an obvious fix that would reduce costs without costing taxpayers anything, but the doctors will try their hardest to block it. A mandate to buy insurance makes sense in theory, but in practice the required level of healthcare to buy gets set way, way, too high, and so a mandate ends up being a huge transfer from citizens to the healthcare industry. There are dozens of other examples. Our system is f*ed up for a reason, and until the political system is reformed, policy reform is impossible.

In reality, healthcare spending will continue to rise until it simply cannot rise further. The spending will be distributed according to political power.

lmoorman4• 17 years ago

Added the link to my list of reading. Looks very interesting. I do share your cynicism that we have no tolerance for real change politically. The charge of socialism meets every single proposal that involves a little more government involvement.

bokonist2• 17 years ago

Lack of government involvement is not the problem with U.S. healthcare. There is government intervention everywhere. My rule of thumb for determining whether an industry is a free market or not, is that I ask the question, "Can I start a business to solve the problem? Or am I legally prevented or constrained from doing so?" In the U.S. I am legally barred from implementing most of my business ideas that would fix the healthcare system, so I do not consider it a free market.

The problem with U.S. politics in general is that it is fractured. Policy is determined by the interplay of powerful, organized factions. Any government intervention gets captured by these factions, and the policy ends up hurting the general interest rather than making things better.

Here is a comment I made a while ago where I explain how American politics works in practice: http://news.ycombinator.com/item?id=557298

anamax5• 17 years ago

> The simplest thing to do is pick out the best healthcare system in the world, and then replicate it exactly. So bring in the top officials from Singapore, put them on an independent commission to redesign the healthcare system, and force Congress to pass exactly the plan they come up with.

You'd have to also replicate the covered population and make sure that there's a "USA" outside paying for drug development and the like.

ibsulon2• 17 years ago

As much as people speak of the drug development problem, how many copies of Viagra do we need? How many more statins? The drugs don't even seem to get better, they just are finding ways to extend patents!

Past that, most of the competition is not in innovation, but rather in marketing.

"The researchers’ estimate is based on the systematic collection of data directly from the industry and doctors during 2004, which shows the U.S. pharmaceutical industry spent 24.4% of the sales dollar on promotion, versus 13.4% for research and development, as a percentage of US domestic sales of US$235.4 billion." -- http://www.sciencedaily.com/releases/2008/01/080105140107.ht...

Finally, the NIH is picking up most of the tab for fundamental research, and as such, it isn't the drug company that is leading innovation. As such, I find the drug development argument hollow.

noonespecial3• 17 years ago

This might actually be a problem that politics just fails monumentally as a tool for fixing. Like trying to repair an MG with a herring.

There will come a time when technology will make it possible to keep someone alive indefinitely so long as you spend exponentially more money to do so. Everyone has been conditioned to think that they deserve the best healthcare regardless of what choices they've made in their lives. They will not accept that someone that has more money lives longer.

The only option is rationing. Either the naked market does it or the government does it. The perceived (and often genuine) inequality of the market practically guarantees that the voting public will demand the latter. This means that someone steps in and essentially decides who lives and dies. Some agency will perform the brutal calculus that decides that a Nobel winning scientist is a better investment to keep alive than a retired truck driver. Historically this has a terrible track record. Anyone willing to wield this power is usually the last person you'd want to actually do so.

Eventually technology will take us through this transitional period into a better time where healthcare, like food, is cheap enough that everyone can have as much as is needed and the only shortages will be caused by politics as is the case for food now.

It seems the best thing we can do as a species is knuckle down and drive through this transitional period as fast as we can. I'm kind of hoping that this current recession produces a few more of the "knuckle down and drive through" types as they seem to be in short supply these days.

lmoorman4• 17 years ago

The GOP has already targeted "rationing" as the evil word of the debate. Any talk of it will be demonized. I still have no clue what the answer is, but you are right, at some point we have to make calls at what point in the exponential cost curve do we say, "it is time to die." that is a tough one.

noonespecial3• 17 years ago

Too true. Especially considering that we ourselves are in many cases not even allowed to make this decision for ourselves.

Right now, I'd settle for just the right to say "I'd like a quadrupal shot of morphine please so that an extended stay in a miserable nursing home won't bankrupt my whole family."

richcollins• 17 years ago

> The only option is rationing

This would be less of a problem if physicians weren't part of a guild that artificially reduces supply.

klein_waffle• 17 years ago

Can we discuss health care without the science fiction and doomsday scenarios?

I realize that the USA is used to looking inward for solutions, but other governments are solving these problems, better, today.

Every discussion I have with Americans about healthcare leads directly to these imagined totalitarian futures, as if "everybody" knew that this was what happens. I don't understand it. Where did you all learn this narrative? Was there some nursery rhyme about the evils of socialized medicine?

furburger3• 17 years ago

Can we discuss health care without the science fiction and doomsday scenarios?

only if you travel back to 1981 before these costs started their long-term snowball

xiaoma• 17 years ago

>Every discussion I have with Americans about healthcare leads directly to these imagined totalitarian futures, as if "everybody" knew that this was what happens. I don't understand it. Where did you all learn this narrative?

Pre-WWII footage of Nazi health programs, Aldous Huxley's Brave New World, the movie Soylent Green and pretty much everything William Gibson has written. We've seen just about every distopian outcome imaginable.

Star Trek counters this to some degree, but it's considered "nerdy".

olefoo2• 17 years ago

As I see it the major problems of our current healthcare regime have very little to do with radical life extension and any perceived unfairness in end-of-life care.

The major problem is that we are in the hands of a criminal syndicate that is structured around extracting money from people when they are at their most weak, vulnerable and uncertain. That this criminal syndicate, which spans the health insurance, legal and financial industries and for which health care is merely the bordello on which the operations cash flow depends; is regarded as a legitimate business is merely one symptom of how corrupt our society really is.

There is an entire industry devoted to extorting money from people under the threat of illness and death. And yet those who run it are considered fine upstanding members of society; always good for a donation to a good cause.

If you go looking it's not too hard to find instances of people who paid in to health insurance for decades, only to be stripped of their coverage when they became ill.

Tying it to jobs makes it even worse, if you know you need medical coverage, you basically can't leave your job; even if it's to start a company that would produce much more value for society than the job left behind.

As it stands now, on average Americans spend twice as much and get worse health outcomes compared to the citizens of any other industrialized nation. It is a disgrace and a crime, and we need to start labeling it a crime and treating it as such.

noonespecial3• 17 years ago

Well said. I actually took as a given that this system will disintegrate very soon. It was unraveling even in the best of times but the current economic conditions have set it up for the final collapse. I was thinking more about the difficult task of deciding what will take its place.

I'd wager that the only people left who don't think that the entire path that money takes between patients and doctors needs to be demolished and started over from scratch are lobbyists.

At this point, the parasites have more or less killed the host. If, in the unlikely event that we Americans make no real progress on this in the next couple of years, projecting out to 2043 and talking about sustainability is entirely moot. We'll have gone banana republic long before it matters.

Edit: Perhaps I over-emphasized the end-of-life part. Got it on the brain a lot these days. The perceived unfairness will permeate the entire system. Just put the Noble laureate and the truck driver in an accident with only enough resources to save one. Who will decide, and how. If they have the power to choose the scientist, they have the power to choose their roommates cousins nephew or a big campaign donor.

Government rationing seems like the best choice. It still sucks. Bummer.

old-gregg• 17 years ago

A friend of mine got physically attacked by an old woman in a supermarket because he was wearing his scrubs. She didn't stop throwing shit at him until security took her away.

cnlwsu• 17 years ago

Hmm, no citations, no real references. The graph is 50% "estimated" from 2005 and pre-estimated values doesn't have the exponential growth thats demonstrated on the graph. Lets also keep in mind the new medicare/medicaid restrictions that is drastically effects what is being paid for by the state and what hospitals are now footing the bill for.

"Social security can be solved" sweet, lets get on that. glad he had some solutions in this article.

why is this on on HN btw?

lmoorman4• 17 years ago

The whole point of the post is I don't have solutions.

Try to refute the point that healthcare is the massive piece of our unfunded liabilities. You can't. Good resource: http://www.pgpf.org/

What I am concerned with is I don't think the coming debate will get very far. We have a visceral fear of change in this arena and it will hurt us.

siegler• 17 years ago

These aren't the forums you're looking for.

You can go about your business.

Move along, move along.

ojbyrne• 17 years ago

I just finished "In Defense of Food." Michael Pollan makes a pretty good case that the health care issue is driven by processed food - causing obesity, type 2 diabetes, high blood pressure and cancer. Essentially if americans ate less processed food (and less food overall), there wouldn't be a healthcare issue.

rarrrrrr• 17 years ago

Absolutely. One of the best things we could do would be changing our farm subsidies away from corn and sugar and instead contribute to many forms of fresh produce.

lionheart2• 17 years ago

Why does the bad trend only start in the Estimated part of the graph?

lmoorman4• 17 years ago

baby boomers hit the 60-80s. and most healthcare costs are in your later years.

lionheart2• 17 years ago

But if the trend hasn't started yet, how can the graph possibly hope to extrapolate it with any degree of accuracy?

patrickg-zill2• 17 years ago

It is a good start, but he doesn't have the detail at the local level to see what is going on - the prices are all over the map and there is no way to rationally determine what is expensive.

I have a weird plan where I pay a percentage of the total cost, but have to pay for everything first and then get reimbursed; but ultimately a more expensive operation ends up costing me more, so it always makes sense to shop around.

As a result, I know all the cash costs for an upcoming outpatient surgery I am having, and whether they offer cash discounts.

The difference between various hospitals and service centers is HUGE, like 5 to 8 times from one place to another.

Imaging center "A" : CT scan $232 ; Chest Xray: $33; EKG: $21

Hospitals "A" and "B" : CT scan >$1000; Xray $185; EKG: > $100

You end up renting the operating room (the surgeon has privileges at 4 different locations):

(new, shiny, modern) Surgery Center "A": $1200 with cash discount

Hospital "A" : no exact price, "range is $7K to $11K, typical is $9500"

Hospital "B" : no exact price, "range is about $7500, cash discount = $5000"

HOW can it even be reasonable that there is such a discrepancy in pricing? For one hospital, the CT scan "interpretation charge" was more than the $232 I spent on the entire scan + interpretation at the imaging place I went to.

(And yes, I used the exact same billing code in discussions with all the medical billing people I talked to.)

patrickg-zill2• 17 years ago

I should add, that I think that part of what is going on with the hospitals, is to make cash payments so cumbersome, that people are herded into the arms of the insurance companies.

furburger3• 17 years ago

some points:

- healthcare is not a business. get over it. the law says you cannot decline emergency care. there is no business model here, any more than there is in running the navy. its a cost.

- you care about public health. meaning, you care if other people are healthy. do you go to the mall or restaurants? if you do, you care if the person next to you has TB. infectous diseases doesn't care about your fully-paid premiums...it matters if other people are also healthy. this once again goes to the fact that healthcare is not a business.

- single payer is the only model that works. or would you prefer to spend another century experimenting with craptastic half-baked business/public hybrids? all health insurance companies must go. the government itself chooses single payer when it needs to run large healthcare plans. the VA, military, federal govt...they all go through single-payer.

- healthcare will be rationed. deal with it. water is rationed. the carpool lane is rationed. bandwidth is rationed. why would healthcare not be rationed?

anamax5• 17 years ago

> water is rationed. ... bandwidth is rationed.

Nope.

I'm pretty sure that I can buy as much water as I want and I know that I can buy as much bandwidth as I want.

LogicHoleFlaw• 17 years ago

I can buy as much water as I want

Try saying that in... Colorado and see how far you get before you get your lights punched out.

Water rights and rationing are serious business.

david9272• 17 years ago

Thanks for banging the drum on this! You're absolutely right. I'm an American who has lived in Germany, Switzerland and now the Czech Republic, and I'm astonished how much better healthcare is over here.

We need to keep banging the drum. America deserves better than this.

The biggest issue facing America

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