I am intruiged by libertarian ideas, I am considering them.

You know that just makes my heart go all aflutter.

I feel that your idealogy correctly asseses many of the problems with Government Interference, yet completely ignores the benefits.

I don’t ignore the benefits; I recognized that there are definitely benefits to be found when the government interferes. However, for me, the question is whether or not, on balance, the benefits outweigh the costs/detriments/loss of freedom that also go along with government interference. And I find that often they do not. The problem is that many times when someone analyzes government action, they only see the good (because it’s usually so obvious) and don’t consider the other side of the equation (because that’s harder to see or extrapolate). If you read my Cash for Clunkers post, you’ll note that my argument there was not that nothing was accomplished by spending billions of taxpayer dollars, but that the negatives far outweighed the positives.

Some balance is needed. In health care, this balance needs to be correctly struck, sadly I don’t see that happening.

I completely agree with that statement, but I suspect the balance you think is necessary is probably different than the balance I’d propose.

I read the study you referenced and sent to me a while ago and feel as if I agree with its conclusion.

Yes, this is the study that found that the health care systems around the world (Canada, Great Britain, etc.) that are often touted as models for how we should approach heath care reform are not all they are cracked up to be and have just as many (or more) problems as we have in the U.S. For those following along, it can be found here: The Grass Is Not Always Greener

In reading other sources it seems that the Japanese get a lot of bang for the buck with their single payer, private provider combination. The Government enforces reasonable price controls in that situation.

Can you post a link to that?

Just as Obama’s numbers can be deflated to show that “only” 12.5 million people you feel aren’t covered- (by the way including people who are already covered but aren’t covered because they don’t know they can be covered is disengenous- try collecting on that PEL Grant you could have had that you didn’t apply for)

I don’t feel I’m being disingenuous at all and I don’t think your analogy is valid. In the case of the PEL grant, I assume you mean that you don’t apply for it and it is lost to you forever. That is not the case with those who are eligible for government health care programs for the poor. My point was that they can’t be included in the total number of uninsured if you are using that number as a case for reforming the system to cover more people because they are already covered by a government program. As I explained in the post, sometimes they are not aware the program is there to help them and sometimes they are aware of it and simply wait until they need it before they sign up. What percentage falls into each category I can’t say, but the fact remains that they can get health care if they need it, and many often do when the need arises, but are still counted as “uninsured” which is misleading. In other words, we don’t have to overhaul the health care system to take care of these people; we already have programs to help them. Of course, I could also make the argument that the fact that some don’t know that help is out there is just another example of the government not doing a good job.

I am sure that if all 350 million people in the United States had to use their health insurance tomorrow- the numbers of dissatisfied would increase exponentially. In fact many citizens discover, only when it is necessary, that they are not covered in the ways they assumed they were by their health insurance.

I assume you’re talking about a situation where those people have to use their health insurance for some major illness, because almost everyone with health insurance already uses it to some extent. That was a major point of my article – that we conflate the two types of situations that health insurance is used for, routine medical care and catastrophic medical care, and we need to stop doing that if we want to come up with intelligent solutions. To address your point though, it would be interesting to see if there are any studies on what percentage of patients that need their insurance to cover a major illness have trouble getting their insurance to cover them and why. Until I see some hard numbers, I’m going to reserve judgment on whether a large number of people have such problems. Certainly we hear anecdotal stories about this happening, but I wonder if it’s just a case of “shark attack” reporting or if it’s really a major problem.

I did some research on Medical Bankruptcies and their is distortion on both sides of the issue- however I thought this study was meaningful and balanced.

Thanks for taking the time to research and actually post a link to back up your opinion.

This study finds that 27% of bankruptcies are the result of primarily medical debts. This is lower than advocated of single payer would like- however it is enough for me. What in your estimation should we do about this? Is it acceptable that an unexpected illness should destroy people financially?

I think it’s sad when any unforeseen situation causes people serious financial hardship, but I don’t necessarily think that means the government has to step in and make everyone whole. If that were the case, there would be no end to what we would be obligated to help people with. And the fact that someone has to declare bankruptcy doesn’t necessarily mean that they are destroyed financially. Certainly, bankruptcy is not a desirable thing, but it is called bankruptcy protection for a reason. It’s there to help people who get into severe financial difficulties from losing everything they have. Sure, they may have to downsize, cut back, and live a more austere life, but that doesn’t mean they’re on the street begging for food. Many people declare bankruptcy and then emerge perfectly fine a few years later. Let’s also not forget that even when medical debt is a contributing factor to the bankruptcy, the previous accumulation of consumer debt is much more of a factor, and this is something of their own doing based on their life choices. Yet they get a large portion of that debt forgiven as well. What I’m saying is that, while I don’t wish it on anyone, having to declare bankruptcy is not the end of the world as it’s often made out to be. And, yes, I do think it is acceptable that everyone else not be forced to help out in this situation; though I do hope that friends, family and other voluntary means of assistance becomes available.

Additionally, it seems to me that some of your analogies are flawed.
1) No one shops for services when their appendix is exploding.

I never suggested that they do. Again, you are confusing my argument about market forces at work in the case of routine or non-emergency medical care (when you have time to shop around) with an example of emergency medical care.

A friend of ours recently went into the emergency room for what he thought was the flu- turns out it was divurticulitis. Four days later he was released with a $50,000 bill for services. His options are bankruptcy or a life of indebted servitude. I am looking forward to reading what reforms you might suggest that would alleviate this problem.

I’d be curious to know if your friend had insurance, if not, why not, and if he applied for charity care (almost every hospital has this option, you can do it after the fact, and your bill is written off). Also, did he have surgery? This seems like a long hospital stay and high bill for this diagnosis. Without knowing the facts of this situation, I can’t render an opinion on what reforms, if any, are necessary. For example, if much of the bill is due to defensive medicine, then there are specific reforms for that problem that I’d advocate. Likewise, if he didn’t have insurance because of a pre-existing condition, another set of reforms would take care of that problem. Without more information, I’d simply be shooting in the dark if I were to suggest that I have some solution to offer. What I think you’re suggesting is that someone had an unfortunate situation and because of that we need to fix a broken system. I don’t necessarily think that’s the best way to make public policy. Sometimes life just sucks and we can’t fix everything that’s wrong in the world by big government intervention. I will however offer what I think are some sensible steps we can take – in my upcoming post – and you can let me know if they would have been helpful in your friend’s case. By the way, I’d be curious to know how much of this bill you think your friend should be obligated to pay and how you might determine that.

The for profit model of health care is a failure.

This was brought up by someone else in the comments of my previous post, and I’ll reiterate what I said there. I really don’t know what you mean by the “for profit model”. Do you mean that people who work in the health care arena shouldn’t be paid? That their pay should be limited? Who gets to decide that? If someone wanted to limit your pay (or profits) in your chosen field I don’t think you’d look very kindly on that. Do you really want your doctor to have less incentive to rise to the top of his profession? Do you really want those companies that come up with all the new treatment and diagnosis protocols to have less incentive to do so? I don’t. I want them to make as much profit as they can, because that is what drives them to keep finding new and better ways to treat disease and extend our lives. So “profit” is good. I visited the Soviet Union when it was still in existence and I can tell you first hand that in a system where no one can make a legal profit and everyone works for the state, there is little incentive for anyone to do a good job or innovate. That’s why the Soviet Union is now a footnote in history.

We do not run for profit Fire Departments or Police Forces and there are very good reasons not to do so.

Again, I don’t think this is a good analogy and on top of that, you’re actually incorrect about this. You can’t compare heath care to fighting fires or the police powers of the state. In the case of Fire Departments, we’re talking about an emergency service that has one job, to extinguish fires. This is a very limited task, nothing like the huge, complex system that provides our heath care and is one sixth of our economy. Second, in cases where the fire department has been privatized, the service is often better and less expensive than the public service. See this article and this one. In fact, more towns and cities probably don’t go this route because Fire Departments tend to be highly unionized and would put up great opposition to going with a private option. Finally, there is little public pressure to privatize fire services because the cost of public fire service is not a large portion of each year’s taxes paid.

As for the police, the main reason that we don’t do this for profit is the potential abuse that can occur when you mix the police power (the ability to use force against the citizenry) with a profit motive. The police are given a very special task in our society and we cede them certain powers that we don’t want vested in the public at large – again, not at all analogous to providing health care.

When we insure our cars or houses … The human body is in no way analogous to these material assets.

I think you may have missed my point here or maybe I’m missing your point. Insuring against a catastrophic loss is the purpose of insurance. It is a hedge against the risk that something will happen that we can’t afford to pay for, whether that’s cancer or our house burning down. Certainly there are differences in how this works in practice. For example, the cost of rebuilding our house is a fixed cost, treatment for cancer generally isn’t. This is another reason why health insurance companies, as opposed to fire insurance companies, have such a difficult time containing costs and sometimes resort to what can be seen as unfair measures to hold the line on expenses. My argument is that we should be concentrating on catastrophic health insurance rather than insurance for routine care. Medical care for catastrophic events is where virtually all of our health care problems lie.

A single payer system, with reasonable price controls, maintaining private doctors of your choosing, is the simplest and most effecient way to clean up the mess that is our medical system. It would work, it does work elsewhere…

I completely disagree and the study I sent you (the one you said you agreed with the conclusion) shows that single payer systems have just as many, although often different, problems than the system we currently have. Single payer systems may cover everyone, but there is usually rationing of care, limits on provider compensation and/or long wait times for treatment. Furthermore, the overall quality of care for the most advanced treatments or most serious illnesses is less than in our “for profit” system. Plus, taxes are often very high to pay for all this and sometimes even that isn’t enough. Germany, which has a single payer system is $14 billion in the hole. Again, this is one of those tradeoff situations. If you want to cover everyone, then you have to be willing to give up something in the process and that is usually access and quality of care. I don’t think this is what the vast majority of our citizens want. And don’t forget, you’re talking about doing all this to fix a problem that affects about 4% of the population. I think there are better solutions.

As long as you brought it up though, we actually do have a single payer system here in the U.S. It’s called Medicare and Medicaid. Both those programs have serious flaws including rampant fraud and escalating costs. But the biggest problem is that one of the ways the government tries to keep costs down is to pay providers less than the amount needed to provide the services. This results in significant cost shifting to those of us who are not covered by these programs. It is another reason why our health insurance and costs for medical care are higher than they would otherwise be. And if you expand these programs to include everyone, then there’s no one left to shift the cost to. You’d have to either increase taxes significantly or risk pushing huge numbers of health care providers out of the field and seriously decreasing the quality of care as well as disincentivizing the creation of new, cutting edge treatments. Again, I’m not saying our system doesn’t have major problems, just that I don’t think going to a single payer system is the answer, especially one that covers routine care.

Finally, I just don’t understand the philosophy that suggests we shouldn’t all be personally responsible for paying for our own routine health care. It is something we should all budget into the cost of living, along with food, clothing, housing, etc. For some reason though, when it comes to health care, a large part of the population just doesn’t want to pay for it out of their own pocket – they want someone else to pay for them. Yet these same people have no problem buying big screen HD TVs, ipods, x-boxes, Dish Network, or a new car every few years. What if, instead of just giving lip service to the importance of health care, we actually put paying for our own routine care near the top of our personal responsibility list? Perhaps then there would be some money left over in the insurance pool to pay for those that are seriously ill and really can’t afford to pay for treatment.

…but entrenched interests would lose their businesses and way of life. Of course they will fight this type of reform.

I’m not sure if you mean health insurance companies, but they actually like some of what the government is proposing. Their objection is that it doesn’t go far enough in forcing everyone to buy their product. When the insurance lobby criticized the Senate Finance Committee bill, it wasn’t because they opposed reform; it was because they felt the penalty for not buying insurance wasn’t big enough. Again, this is what happens when the government uses its power to mandate something – special interests line up to get as big a piece of the pie as they can.

Now we will get the worst of both worlds- government interference and subsidy over a for profit infrastructure that will increase complexity and cost while enriching the few. You and I agree that is a bad prescription for medicine.

Amen.

In a effort to facilitate our communication regarding health care, I submit some frameworks to help clarify different perspectives.

Imagine (or actually draw on a piece of paper) a plus sign:
1. In the upper left (UL) is Individual-Internal.
2. In the lower left (LL) is Collective-Internal.
3. In the upper right (UR) is the Individual-External.
4. In the lower right (LR) is the Collective-External.

These four quadrants help account for the information and knowledge we currently have and allow room for new information and knowledge that could be discovered. THE IMPORTANT THING IS, all of these are true AND partial. No quadrant is more important than another.

UL or “I” Space holds the space for the attitudes, values, states of mind, dreams, feelings, emotions, desires, needs, beliefs of a person. These are not tangible objects in the world, but internal ‘realities’ that have been felt, experienced or observed by the person.

LL or “WE” Space holds the space for the cultural understandings, agreements, morals, shared reasons, and so on of groups of people (i.e. our family, our neighborhood, our congregation, our school, our community, our country, our planet.) These are not tangible objects in the world, but internal agreements/disagreements about how ‘we’ understand each other.

UR or “IT” Space holds the space for the objects and behavior demonstrated by them. What an atom is, a molecule, a cell, an organism, a human body are all ‘it’ spaces. How people or objects behave objectively are all part of this space (i.e. diet, exercise, physical actions; objective science, biology, physiology, physics, etc.)

LR or “ITS” Space holds the space for the systems, networks, infrastructures that make up the world in which we live. How the food I ate for breakfast got to my grocery store, where it was grown, under what political, economic, and social conditions it was grown and transported are all examples of the ‘its’ space.

ABSOLUTISM

One thing to keep in mind as we debate health care is that most of us tend to focus on one or two of the quadrants most of the time. I may tend to focus on my own internal state of mind, thoughts, feelings and personal experiences MORE than I tend to focus on the greater community of which I am a part. While this is common, to completely exclude all other quadrants from my perspective, is to be absolutist.

LEVEL/LINE FALLACY

Another thing to consider is that confusion arises when one equates a particular level of an entire line, with the entire line itself. For instance, if I have a bad experience with an immature or under-skilled doctor, I might then equate ALL doctors as immature or under-skilled or worse. Or, if I think that my particular moral development (What should I do?) is a certain way, I may think that the entire level or spectrum of moral development is exactly the way I experience AND that anyone higher or lower than me in that line is wrong.

PRE/POST FALLACY

Taking moral development as an example, we sometimes mistakenly assume that a similar response means the same thing. Taken from Integral Spirituality by Ken Wilber:

“…during the student protests against the Vietnam War…students all claimed that they were protesting the war because it was immoral. Tests of moral development found that some of the students were indeed quite morally developed. In some studies, many of the protesters were saying ‘No!’ to a war they felt was wrong, and moreover, they were doing so from post-conventional levels of moral cognition using worldcentric reasoning. But many of the war protesters were pre-conventional, and they were saying ‘No!’ from an egocentric narcissitic level: basically, go [bleep] yourself, nobody tells me what to do!”

He goes on to say that basically, the conventional attitude at the time was that the war was morally right, but both the pre-conventional and post-conventional student protesters were against it, but for entirely different reasons.

It’s my hope that above material will help us all as we dig to the deepest levels and search across the greatest span of what it means to be healthy, as a person (UL and UR), as a family and nation (LL)…AND…how we are able to access to the information, services, and facilities (LR) that are made available.

I personally find it instructive to embrace the notion that doctors are practicing a medical ART. Where science is usually associated with the UR (objective, quantifiable, behavioral) art is usually associated with the LL (interpretation, shared understanding and meaning.) Therefore the most highly skilled in the profession are BOTH artists AND scientists. And I’ll gladly pay more to the doctor or health care provider who is “BOTH, AND” than to the one who is “EITHER, OR.”

-Ponder East

I am intruiged by libertarian ideas, I am considering them. I feel that your idealogy correctly asseses many of the problems with Government Interference, yet completely ignores the benefits. Some balance is needed. In health care, this balance needs to be correctly struck, sadly I don’t see that happening.

I read the study you referenced and sent to me a while ago and feel as if I agree with its conclusion. Many ways to skin the cat- the most effecient being a mixture of Government and private control. In reading other sources it seems that the Japanese get a lot of bang for the buck with their single payer, private provider combination. The Government enforces reasonable price controls in that situation.

Just as Obama’s numbers can be deflated to show that “only” 12.5 million people you feel aren’t covered- (by the way including people who are already covered but aren’t covered because they don’t know they can be covered is disengenous- try collecting on that PEL Grant you could have had that you didn’t apply for) I am sure that if all 350 million people in the United States had to use their health insurance tomorrow- the numbers of dissatisfied would increase exponentially. In fact many citizens discover, only when it is necessary, that they are not covered in the ways they assumed they were by their health insurance.

I did some research on Medical Bankruptcies and their is distortion on both sides of the issue- however I thought this study was meaningful and balanced.

http://www.aei.org/docLib/20060719_MedicalBillsAndBankruptcy.pdf

Coclusion:
“We do not find support for the view that medical debts are the leading cause of bankruptcy filings. In fact, households who are most likely to file are those with primarily other forms of debt, such as credit card or car debts, who also incur medical debts. Altogether, a 10 percent increase in debts of these households would cause bankruptcy filings to go up by 36 percent on average. A 10 percent increase in debts of households with primarily medical debts would cause filings to go up by 27 percent on average.”

What this suggests is that most people are riding along carrying credit card debt and managing. However when the medical bills come due- there is no getting out from under them. This study finds that 27% of bankruptcies are the result of primarily medical debts. This is lower than advocated of single payer would like- however it is enough for me. What in your estimation should we do about this? Is it acceptable that an unexpected illness should destroy people financially?

Additionally, it seems to me that some of your analogies are flawed.

1) No one shops for services when their appendix is exploding. A friend of ours recently went into the emergency room for what he thought was the flu- turns out it was divurticulitis. Four days later he was released with a $50,000 bill for services. His options are bankruptcy or a life of indebted servitude. I am looking forward to reading what reforms you might suggest that would alleviate this problem.

2) In a for profit system, the incentives for health are perverse, unless they are turned on their head and health care systems are rewarded for the health of their patients. Even then, this leads to rationing of care to appear more successful etc… The for profit model of health care is a failure. Controlling the cost, while providing quality care, should be the task. We do not run for profit Fire Departments or Police Forces and there are very good reasons not to do so.

2) When we insure our cars or houses we are insuring something we have chosen to buy. That initial investment is made with longevity in view and we have choices. “If I buy a Honda, I’ll pay less in maintenance.” “If I buy a Kia I’ll have a 10 year bumper to bumper warranty.” Most of us are able to unload our vehicle or home to someone else when they deteriorate beyond our liking. The companies that make these products have a huge incentive to limit your out of pocket expenses over the course of ownership. You could also choose to walk, ride the bus, or live in an apartment to avoid these costs all together. The human body is in no way analogous to these material assets.

A single payer system, with reasonable price controls, maintaining private doctors of your choosing, is the simplest and most effecient way to clean up the mess that is our medical system. It would work, it does work elsewhere, but entrenched interests would lose their businesses and way of life. Of course they will fight this type of reform. As I see it, they won this battle before it ever began. Now we will get the worst of both worlds- government interference and subsidy over a for profit unfrastructure that will increase complexity and cost while enriching the few. You and I agree that is a bad prescription for medicine.