Is there a cogent argument that explains why government ought not to offer health insurance?

[athelas]

To get back to the OP topic, the answer is that when people have more insurance, they’ll use more healthcare for decreasing returns. If the government’s picking up the tab, I’ll have filet mignon. What we need to do is align incentives and have higher copays, so that people will internalize the costs of their own healthcare. The perennial complaints about overutilization and insane end-of-life expenses will only grow worse if someone else is paying for it; if patients have to foot an increasing proportion of the bill they will think twice, leading to reduced medical costs.

The one certain consequence of expanding insurance coverage is that it would raise spending. When people have insurance, they use more health services. That’s one reason Obama’s campaign proposal was estimated to cost $1.2 trillion over a decade (the other reason is that the federal government would pick up some costs now paid by others). Indeed, the higher demand for health care might raise costs across the board, increasing both government spending and private premiums.

No doubt the health program that Congress fashions will counter this reality by including some provisions intended to cut costs (“bundled payments” to hospitals, “evidence-based guidelines,” electronic recordkeeping). In the past, scattershot measures have barely affected health spending. What’s needed is a fundamental remaking of the health-care sector – a sweeping “restructuring” – that would overhaul fee-for-service payment and reduce the fragmentation of care.

The place to start would be costly Medicare, the nation’s largest insurance program serving 45 million elderly and disabled. Of course, this would be unpopular, because it would disrupt delivery patterns and reimbursement practices. It’s easier to pretend to be curbing health spending while expanding coverage and spending. Presidents have done that for decades, and it’s why most health industries see “reform” as a good deal.

[Voyager]

@athelas

To get back to the OP topic, the answer is that when people have more insurance, they’ll use more healthcare for decreasing returns. If the government’s picking up the tab, I’ll have filet mignon. What we need to do is align incentives and have higher copays, so that people will internalize the costs of their own healthcare. The perennial complaints about overutilization and insane end-of-life expenses will only grow worse if someone else is paying for it; if patients have to foot an increasing proportion of the bill they will think twice, leading to reduced medical costs.

Your link took me to FaceBook.
I’m sure you’ve heard by now of the New Yorker article about McAllen, Texas. This place has one of the highest healthcare costs in the country. The reason? Not because of poor health - El Paso, with the same demographics and general health, spends half of McAllen. Not because of insurance - McAllen is fairly poor. Not because of malpractice. They’re in Texas with strong anti-malpractice suit laws, and they have a near zero rate of suits, according to a doctor. Not because of high tech - they have the same equipment as El Paso. Not because their care is better. Their hospitals are worse than El Paso. Not because of too many specialists - they actually have fewer than average.

Why then. Overutilization. He gives an example of gallstones. For first time sufferers, pain medicine and a change of diet usually solves the problem, with surgery required only if they recur. In McAllen the patients go right to surgery, and the doctor makes an extra $700.

You think rationing is bad? McAllen can use some, and Gawande notes that states with higher average Medicare costs have better outcomes. He’s a surgeon, btw.

This is the article Obama is reading. They can cut costs in half in McAllen without hurting anything. And our current system isn’t doing it. And I’m sure El Paso could be cheaper also.

[foolsguinea]

@Ruminator

It wouldn’t matter if AMA allowed more doctors. If you kept the intense 12-year educational workload exactly the same, that’s a built-in barrier in itself. If the IQ and 12-year commitment isn’t enough of a barrier, then the tuition costs for 8-years of college is another one. Would eliminating the AMA’s restrictions automatically quadruple the number of doctors? I don’t think so. Do you have a cite that proves otherwise? Even if we had 4x the candidates with the prerequisite IQ and tuition $$$, do we have quadruple the capacity in hospitals to handle and mentor the 3-year residency programs? It’s not just the AMA… the entire chain from medical schools to residencies to medical boards etc has to expand.

THIS THIS SO MUCH.

This is why I’m so disgusted at the political discourse in this country that acts as if rejiggering health insurance will address costs. It’s easy to add customers to insurance rolls, insurance is just a middleman. It’s hard to add more medical services, where the actual shortages are. This is basic economics, & the political system is missing it.

Our country is a man with a bleeding wound, & Congress is a passerby who offers to audit his bank account.

[foolsguinea]

@athelas

To get back to the OP topic, the answer is that when people have more insurance, they’ll use more healthcare for decreasing returns. If the government’s picking up the tab, I’ll have filet mignon. What we need to do is align incentives and have higher copays, so that people will internalize the costs of their own healthcare. The perennial complaints about overutilization and insane end-of-life expenses will only grow worse if someone else is paying for it; if patients have to foot an increasing proportion of the bill they will think twice, leading to reduced medical costs.

I used to think this.

At one point I said that health care should either be completely socialized or third-party payer pools (health insurance) should be completely abolished. But those “solutions” were rooted in pure macro thinking; & the latter concept, at least, has some problems on the micro scale. There’d be a hell of an adjustment when many persons get priced out of circumstantially needed care. (But abolishing insurance won’t happen anyway.)

So then:

What about socialization? Not a full monopoly, but government responsibility for the infrastructure of hospitals, at least. Wouldn’t that help? I think so, but you have to look out for “reinventers of government” who make cuts in short-term spending that hurt the country long-term. (This happened in the 1990’s with a cap on med school enrollments.)

IF the GOP/BlueDogs/DLC could be kept out of power long enough that the new régime has tradition behind it, there’d be hope. Or if they can be convinced to do it themselves & see it gets them votes (an outcome I don’t have much hope for in the case of either the GOP or the DLC).

Unfortunately, the DLC & BlueDogs are dominant right now. We’re going to get a piece of junk.

[foolsguinea]

@Voyager

Your link took me to FaceBook.
I’m sure you’ve heard by now of the New Yorker article about McAllen, Texas. This place has one of the highest healthcare costs in the country. The reason? Not because of poor health - El Paso, with the same demographics and general health, spends half of McAllen. Not because of insurance - McAllen is fairly poor. Not because of malpractice.** They’re in Texas with strong anti-malpractice suit laws, and they have a near zero rate of suits,** according to a doctor. Not because of high tech - they have the same equipment as El Paso. Not because their care is better. Their hospitals are worse than El Paso. Not because of too many specialists - they actually have fewer than average.

**Why then. Overutilization. He gives an example of gallstones. For first time sufferers, pain medicine and a change of diet usually solves the problem, with surgery required only if they recur. In McAllen the patients go right to surgery, and the doctor makes an extra $700. **

You think rationing is bad? McAllen can use some, and Gawande notes that states with higher average Medicare costs have better outcomes. He’s a surgeon, btw.

This is an ethical failure on the part of physicians. I think the lines I have bolded show a (tenuous) link.

I would hope that one aspect of greater competition among physicians would be that there’d more likely be a physician that would offer a cheaper service. But enforcing standards of care somehow would be nice.

[Algher]

@foolsguinea

This is an ethical failure on the part of physicians. I think the lines I have bolded show a (tenuous) link.

I would hope that one aspect of greater competition among physicians would be that there’d more likely be a physician that would offer a cheaper service. But enforcing standards of care somehow would be nice.

It is not necessarily an ethical failure, but instead a difference in procedures. Standards of care are constantly changing and the source of a LOT of arguement.

• Full body health scans, for example. They might find something that you are not aware of. They also give you a nice dose of radiation, increasing your chances of some types of cancers.
• Annual mammograms are another issue of debate right now - what is the chance of detection vs. the increase in radiation.
• Chemo is another cancer technique that does not have great numbers except with certain types of cancer. However, it is regularly used for many cancers.
• Prostate surgery for prostate cancer used to have a barely discernable improvement in life expectancy, in exchange for some pretty negative side effects. This has changed, but for awhile I had already said I would just take pain pills, keep my private parts functional, and die with a month or two of my predicted time regardless.
• Lets talk about the Lap Band and other types of surgeries for weight loss. They are ALL overpriced and unnecessary if the vast majority of people would just eat less and exercise.
• The gall stone example is similar. Can the doc trust the patient to change their diet, stick with it, and just take some pain meds? Does the doc give the patient a choice? Do the patients choose the “easier” path of surgery? Is it ethical for the doc to deny surgery if someone wants it? Is $700 enough to sway a doctor’s behavior?

It is all well and good to claim that we should follow specific, affordable, measures of care. However, we would need to actually agree on those measures, - that ain’t gonna happen.

[smiling_bandit]

@Rumor_Watkins

Remind me again where GlaxoSmithKline, Hoffmann–La Roche, Sanofi-Aventis, Novartis, and AstraZeneca are headquartered? They’re the 3-7th largest pharmaceutical companies in the world. try again.

This is an illogical respoonse and does not answer the question. Many drug companies which are headquartered in Europe are increasingly doing their drug development mostly or wholly in the US (to have better access to the FDA), and are tailoring their investments only to the US market.

It’s not like they have recently been developing medically useful drugs, anyways; they research boner pills, pills for weepy housewives that have nothing better to do but bother everyone about how rough they have it, pills for fat people that refuse to exercise while consuming 3000 calories a day, etc. They’re all lifestyle drugs that don’t cure much of anything but bad habits. (this is somewhat T-I-C, so I don’t need tons of posts calling me insensitive to the needs of depressed people or those with heart disease; point is that socially useful drugs, i.e. the ones that cure ailments, aren’t exactly the drugs that keep the customers coming back to refill the 'scrips)

First off, this is grossly incorrect. You hear about those drugs because they are easily salable and rather public. But they account for only a small amount of drug development in total (though certainly a large part of the market they want).

However, I don’t even have to go that far: my answer is “Who gives a shit?” Quality of life treatments are no worse than any other, and simply because they don’t have the thrill of saving lives is no reason not to have them.

I’m sorry, how much money do we pump into research universities in this country? How much of that gets siphoned off by the “public/private” partnerships that swoop in and cherry-pick the most promising research programs?

Not remotely enough, sir. Not remotely enough. We’d have to pony up tens or hundreds of billionsmore to match, and remember that research universities have no interest in making drugs which are directly useful to people. They are interested in the underlying effects of drugs and how that can potentially be useful in the possible future.

There’s nothing wrong with basic research - I favor more investment here. But it is not and can never be a replacement for direct working development, because their priorities are fundamentally different. In the same way and for the same reasons, you do not see many Comp Sci professors being hired to write production code or manage big corporate projects. Their interests and goals are just too different from a practical working environment, and they frequently encourage the use of very bad code among those they teach.

Finally, who cares if companies “cherry-pick” the most promising programs and bring them to development. Generally, a university works hand in hand quite happily, in exchange for a considerable fee or royalty. Everybody wins!

[quoteNo, the government (i.e. society) pays plenty by awarding patent protection which allows these companies to recover their costs. Extending patent protection has significant costs for society as generic manufacturers aren’t allowed to produce the drug, increasing costs, and thereby costing us money. Not that patent protection isn’t fair, but stop pretending that these companies receive nothing of value even where the state has monopsony power.[/quote]

Except that governments can, often threaten, and frequently do cancel that patent. I would have no trouble shortening the patent period (though only combined with improved and more efficient methods fo testing and bringing drugs to market. This makes for a very tough negotiation.

Once again, however, I do not even have to go that far. governments don’t have to worry about the patent when they are the only purchaser. That is, it becomes a non-issue. After all, the company cannot sell it without dealing with a single-payer, then that payer sets the price no matter.

No, it means advertising. The marginal cost of a pill is about an order of magnitude smaller than a penny.

This is either a damned lie, or you are so ignorant of business, you have no business talking here. Marketing is almost everything about drug development except the direct research. It will include testing fees, much of the hidden manufacturing cost, logistics, overhead for mixed facilities, usually the entire accountancy and finance departments, nearly all management, and much more. Companies are legally required to repot this, and if you are going to post here you ought to know the difference between marketing and advertising. People hostile to drug companies always attempt to confuse the two.

Plus, don’t think that “free samples” are anything but really effective means to ensure that the next time the patient needs a drug, they’ll ask for the same “free” one they got the last time - except that this time it won’t be free.

Really? Because I’ve had more free samples than I’ve actually had paid for drugs, often entirely in lieu of any payment whatsoever. Drug companies often provide these to doctors for their poorer patients (c’est moi). And even if so, the doctor can advise the patient. If the doctor refuses to work right, or the patient is too stupid, well, them’s the breaks. It would happen under any system.

So now we have to suffer higher drug costs (by way of education costs) because the doctors are too damn lazy to stay current on medical knowledge or their initial training was inadequate. Jesus, we may as well create a new civil service job category while we’re at it: doctor-fluffers.

I don’t see how this is a criticism of my position, so I’ll simply say it’s an unfortunate fact. We can deal with the problem, to the degree there is a problem, in a number of far better ways.

[Voyager]

@foolsguinea

This is an ethical failure on the part of physicians. I think the lines I have bolded show a (tenuous) link.

I would hope that one aspect of greater competition among physicians would be that there’d more likely be a physician that would offer a cheaper service. But enforcing standards of care somehow would be nice.

Maybe an ethical lapse - but the doctor is probably doing what the patient wants, and the patient isn’t directly paying. Lots of patients want it to be fixed right now - pain pills and diet changes are slower and tougher on the patient. So there are plenty of reasons to go this way besides the extra money. And the patients aren’t being coerced into it. If it is an ethical lapse, it is a minor one. How about C-sections? They probably do reduce risk - they are also more expensive. Medicine takes a lot of judgment, and it is possible a doctor who doesn’t care about money would make the same decisions.

As for increased competition, how would that work exactly? When I was a kid, 50 years ago, we went to one of the first HMOs. Most doctors were independent, working out of small offices. Today I go to a gigantic group - which has shared access to expensive technology. 100 doctors under one roof reduces competition, but I think that train has left the station. In situations of naturally reduced competition, government regulation might be the best way of getting the benefits of larger groups without some of the disadvantages.

[Voyager]

@Algher

It is all well and good to claim that we should follow specific, affordable, measures of care. However, we would need to actually agree on those measures, - that ain’t gonna happen.

Sure it can happen, if we have rules about paying for evidence-based treatment. If someone wants to pay for a treatment that has been demonstrated to be ineffective, let him, but let’s not have the pool pay.

[Algher]

@Voyager

Sure it can happen, if we have rules about paying for evidence-based treatment. If someone wants to pay for a treatment that has been demonstrated to be ineffective, let him, but let’s not have the pool pay.

Lipo works. So does exercise.
Gall stone surgery works. So does a change in diet.
Chemo sometimes works for a small portion of the population.
C-Sections work very well (and one saved my son’s life - cord was wrapped around his neck).

In each one of these, a judgement call is made by the physician around several possible methods that have positive outcomes - depending on the patient. The patient drives so much of the process. Their willingness to follow the drug regimine. Their willingness to follow the new diet. Their willingness to exercise. The patient’s actions impact what is the best solution.

[gonzomax]

http://www.alternet.org/healthwellness/140918/we’ve_been_trapped_inside_a_bad_health_care_system_so_long%2C_we_don’t_even_know_how_much_we’re_missing_/
We don’t realize what a soul sucking health care system we have until we go somewhere that does not have it. The psychological effects of sweating and worrying about medical coverage is so ingrained into our lives, that we just accept it like unthinking soldiers. It is a demoralizing mentaally restricting system that does psychological harm and financial harm. it is wrong.