Wednesday, August 19, 2009

Death panels, said the executor

Really, huh? A public health care option equates to death panels, right? Well, I have news for you.

A reasonable set of routine blood tests, which can easily save your life, costs about $800.

That's just the routine diagnostics. If you don't have insurance, then probably you can't afford $800 in utterly basic tests every year. And actually, the tests could cost you more because you may have to pay another $200 or so for a doctor to prescribe them for you.

Compare the $800 to the minimum wage, or to the median salary, or to the median rent, or to the median mortgage payment. Can you afford that? Do you have a family? How would you like to multiply that by 4? If you get all frisky when your taxes are raised by 1%, how should you react when you have to pay e.g.: 5% of your salary in health care? Bonus points if the AMT prevents you from deducting the medical expenses of a large family.

So, $800 a year, per person, and hopefully everybody is still healthy. What if you actually get sick? And what if, like ~50 million people in this country*, you do not have health insurance? Thus, $800 for basic tests is, effectively, a death sentence --- and never mind the insured who are denied the care they urgently need to avoid death. Of course, this situation is compoundedly sick because it is often presented as if it were the patient's fault to begin with.

A couple years ago, I had a bad case of barotrauma after a flight to Buenos Aires. I went to one of my favorite private hospital's ER in pain, semi deaf, and with fever. I had no insurance in Argentina. Before I was done paying for the ER visit, I had a specialist standing next to me, waiting to wisk me away into the examination room. Not even 3 minutes had gone by. How much did the whole hospital experience cost me? $20.

Death panels? Really? Come on, what planet do you come from? Public option or not, I do not think the average garbage we hear every day about health care has anything to do with reality.

* BTW, ~50 million is far more than the number of illegal aliens to whom we gladly and quite purposefully pay salaries we cannot legally offer, so knock it off with the xenophobia and muster the courage to look in the mirror already.

PS: see what I mean?


PS2: we can definitely do better...

15 comments:

cremes said...

Please tell me that you understand that the $800 is also paying for 1) those without insurance, 2) to make up for losses incurred by handling Medicaid/Medicare due to a lack of proper pricing signal.

Also, please tell me you understand that in Argentina it may have cost you $20 but it cost someone (those taxpayers) quite a bit more than that.

You are a smart guy and I've enjoyed your books so I know you are capable of critical thinking. A basic economics text will make it clear that any public option will become the *only* option since the government would not bend to the market's pricing signals. This would lead to price fixing which anyone who can remember as far back as Nixon will recall leads to rationing and shortages.

"Death panel" may be hyperbolic but it cuts to the heart of the issue. There will be a bureaucrat who has never examined you or understands your condition who may decide if you are worthy of treatment (by age, potential productivity to the state, risk factors such as alcoholism, etc).

I'm 36, healthy, pay $150 a month for a Health Savings account ($2500 deductible) and I see no reason to spend $800 a year for "routine" blood tests. Implying that anyone would view yearly blood tests as reasonable does not make sense. Perhaps when I hit 45 (or older) I'll have a different view. By then my HSA could/should have quite a bit of $$ in it unless it gets wiped out by a new law.

Andrés said...

Cremes, in general terms I find the notion of health being *so much* of a business a bit repulsive. The term "rationing" should be defined in terms of "you can't afford it", and "shortages" should be understood as "50 million people without health insurance".

I think we tend to talk so much about money that we (the people that do well enough to spend time writing in blogs instead of having 3 jobs) lose sight of the quite numerous 50% of the population under the wealth median.

carbon said...

Andrés, the term "rationing" should be understood as "you can't have it under the government program because 1) you'll have to wait a long time (indefinitely?) or 2) you don't deserve it." The long wait is due to the fact that there are *always* finite resources available whether they are dollars or people.

Today, under our current system, people wait. To "jump the line" costs $$. That's a signal. If a lot of folks are paying up to jump a line, that tells the market to produce more of that (more radiologists, more pediatricians, more MRI machines, etc).

And let's not forget that the 42 million uninsured include tens of millions who choose not to insure themselves.
http://tinyurl.com/rl42w

(Perhaps that source is biased. Let's find several and debate their merits.)

I admit there are millions who would like insurance but really can't afford it. Let's say for argument's sake there is 40 million of them. Why not produce a program to help out those 40 million instead of a program to take over the health insurance of 350 million?

Take a look at a talk given my a British PM just a few days ago. It's 3 parts and lasts 30 minutes total. He has some interesting things to say about their health services organization.

http://tinyurl.com/nle72x

Lastly, please point me to any existing government program that delivers good service on or under budget to hundreds of millions of Americans. You can't. It doesn't exist. Why we would want a central government which has *never* succeeded in running an entitlement program within budget to take over 10+ percent of our economy is mind boggling to me. Historical precedent supports my rational fear that they will fail at running the health system too.

James Foster said...

Death Panels provides some background on how the government might exercise its discretion to limit coverage to "reasonable and necessary" expenses. As the article notes, Britain generally refuses to cover medical treatments that cost more than $35,000 per year of life saved.

Andrés said...

Carbon,

> I admit there are millions who would like insurance but really can't afford it.

Wonderful, we agree. So what are we actually doing, today, about them? Effectively, we ration or short their service (meaning they do not get what they need) because they cannot afford it.

This sets a dangerous precedent because it equates "deserves to live" with "has money". Now, over the last years, the real purchasing power of most people has fallen. This means that, over time, more and more people fall under the category of "does not deserve to live". Perhaps today we feel some sense of "superiority", but the (bogus) grounds for that are going away.

Now, we can talk about this from a political POV all we want. After all, the comments I heard so far seem to mimick a news show and avoid talking about people. However, at the end of the day, our action (and inaction) leads to more unnecessary deaths. I find this very disturbing. Just because the uninsured are minority does not mean the majority can simply say things like "health care is too expensive, so cut out the uninsured further so it lowers my bill". To me, pushing those kind of arguments in press conferences is a clear sign of money being more important than life.

> Why we would want a central government which has *never* succeeded in running an entitlement program within budget to take over 10+ percent of our economy is mind boggling to me.

Hey, we elect those guys into office, therefore we are to blame. Stop assigning responsibility to abstract entities such as "government".

> Historical precedent supports my rational fear that they will fail at running the health system too.

But what about those who run for-profit corporations? Is their performance any better, really? How about private companies that manage retirement funds? Have they done any better than government managed funds? The most obvious difference I see is that those who manage the private entitlement companies run similar losses, but at least their management earns a fantastic salary to deliver essentially the same results. And guess who bails them out when they fail...

Andrés said...

James,

> As the article notes, Britain generally refuses to cover medical treatments that cost more than $35,000 per year of life saved.

So, basically, have any serious health problem and you might as well die already.

On the one hand, for those that are uninsured, it would be considerably better than the *nothing* they have now. On the other hand, private insurance companies do that kind of stuff here (even if indirectly) when policies have limits so that patients do not receive the care they need to live.

See, at the bottom of this is the assumption that "caring for person X is worth at most Y". Who should decide that? You could say "somebody I elect should decide", at least you can choose. Or you could say "a private company should decide", even though the kind of abuse that results is obvious.

Regardless of who chooses, what happens when somebody decides that any of your loved ones (or yourself) should die because the patient is not worth that much in insurance premiums and copayments anyway? Then what? Should you tamely subject to "only rich people deserve to live"?

In the end, it's the wrong question. So, I'd rather stop asking that question and have health care for everybody without (the currently obscene level of) profit entering into the equation. I don't necessarily care the precise way in which the resulting improvement is managed, as long as it results in better care for everybody.

cremes said...

Weird how my second comment showed up as "carbon" when it should have been "cremes." I'll break this comment into two to avoid the 4k char limit...

> This sets a dangerous precedent because it equates "deserves to live" with "has money". Now, over the last years, the real purchasing power of most people has fallen.

Andrés, I am all for helping people. I *really* am. I have personally helped over a dozen people in my lifetime. This was *my* choice. I gave them aid, wrote them a check, etc.

Now here's the difference. I know you can pick this out because I will highlight it so it can't be missed. I *chose* to help them.

Government ("we the people") can never *choose* to help anyone. As soon as government is involved, deadly force is automatically part of the equation. Government *cannot* be compassionate and help people. Don't believe me?

Skip paying your taxes and see how far you get. You will end up in jail or dead. Government power comes from the barrel of a gun. It always has and will. Sorry, perhaps that sounds too much like the nightly news or a partisan commentator? That "abstract entity" will jail you. I won't get thrown off topic though by this transparent attempt to change the subject.

At the end of the day, people have *no right* to health care. You have a few inalienable rights. Air; defense of yourself; your square of land if it doesn't belong to someone else. Precious few others. I am not sorry if I don't sound compassionate because when it comes to government power, I am *NOT*. I don't trust the government ("we the people" again).

> This means that, over time, more and more people fall under the category of "does not deserve to live".

Then please encourage politicians to push for deflation. That will increase the average Joe's purchasing power. Forget the side effects; this is apparently an "economics free" zone.


You may petition and vote for your view of things. Feel free to pay the government extra to provide for your fellow citizens. Prepare to be opposed by me and others who do not agree with ceding that much power and authority to an entity (again, government) that has shown such poor capacity.

So we agree that millions don't have insurance. What do we do about them? What is your idea? Do you have one other than to destroy the current system and replace it with one unlikely to work? If you think it *will* work, explain why. Use any worldwide example for a similar population and geographic size that the same or similar idea has already worked.

BTW, thanks for providing a reasonable forum to discuss these topics. While it is clear I don't agree with you, I certainly don't think you are evil or stupid. I hope you can say the same for me. If not, explain.

cremes said...

(Continuation of earlier response...)

> But what about those who run for-profit corporations? Is their performance any better, really?

Yes, their performance is vastly better. I can easily point to 500 companies that made a profit this past year. That is, they brought in more money than they paid out. Can you do the same for any government? When was the last time the government turned a profit 2 quarters in a row? (To make this easier, let's assume a profit can be gained if a quarterly deficit is under 10% of that government's budget.) You can't because no state or federal government has accomplished a feat that THOUSANDS of private entities accomplish each quarter.

> How about private companies that manage retirement funds? Have they done any better than government managed funds?

Yes, private companies have produced much better gains than government. Not all of them, but their win percentage is quite a bit better than any state or federal government. Our Treasury is now auctioning off our country's debt at a rate of $400 BILLION per quarter. It used to be that we would auction that entire amount in a single year. We now auction that amount 4 times per year. Yeah, they are great stewards of our money and are making it grow. :-\

Just what is your stance here? Do you endorse the current health care plan? Do you have any reservations? Quit sniping our comments and present your critique or endorsement so we know where you stand. Please.

cremes said...

Andrés said:

> In the end, it's the wrong question. So, I'd rather stop asking that question and have health care for everybody without (the currently obscene level of) profit entering into the equation. I don't necessarily care the precise way in which the resulting improvement is managed, as long as it results in better care for everybody.

How do you provide incentives to people or government to provide this level of service and care? Without a profit motive (whether it is given in dollars or in esteem), will this work? Please provide an example where similar incentives have already supplanted the capitalist system to support at least 10+ million people in a similar endeavor without rationing or poor service.

Andrés said...

Cremes,

That's a lot of material, so I'll try to summarize.

> As soon as government is involved, deadly force is automatically part of the equation.

I'd blur the distinction between government and other companies as far as deadly force is concerned. If you look at much more mundane cases like Argentina, you can see both tend to be on the same boat. So, actually we don't disagree. However, I don't think that distinction helps the most.

What I think is most telling is that there are people with first and last names behind those abstract entities we call "government", "corporations", etc. Thus, the fingers of blame belong to people, to *us* and *our* society that allows all these excesses to occur.

Therefore, I think we do ourselves a disservice when we discuss things like public or private option, death panel or not death panel etc when, at least as far as health care is concerned, people die for no good reason. To me, that statement trumps other attempts at rationalization to explain why we are in the mess we are right now. The real problem, to me, is that our pack/mob mentality we picked up from our arbitrary culture is effectively working against us. And we even think it does us a favor.

> At the end of the day, people have *no right* to health care.

I'd rather disagree with this.

> Then please encourage politicians to push for deflation. That will increase the average Joe's purchasing power. Forget the side effects; this is apparently an "economics free" zone.

I don't think you can have a sane system when you can create money out of thin air. On top of that, we still like to believe the money thus creates is worth more than human lives. Thus the discussion we're having with regards to health care.

(... more...)

Andrés said...

> You may petition and vote for your view of things. Feel free to pay the government extra to provide for your fellow citizens. Prepare to be opposed by me and others who do not agree with ceding that much power and authority to an entity (again, government) that has shown such poor capacity.

As far as health care is concerned, I do not think insurance companies have a good track record either. Quite frankly, it's clear that a few contributions can put government on the side of corporations. So, really, there's only one side to this.

Now, besides all this, in our system somebody has to pay. The matter is pay for what.

> So we agree that millions don't have insurance. What do we do about them?

A couple ideas... actually improve education so that they can have a more productive life, so that they can earn a better salary, so that they can afford health care.

Even if you will not do that (after all, the powers that be actually benefit from a "dumber" population that can be taught to consume without bounds), I still think the responsibility to care for one another cannot be waived --- even if it is for the most pragmatic reason that I'd rather treat e.g.: hepatitis A in those that prepare my food (which, without meaning disrespect, are frequently employed illegally).

>> But what about those who run for-profit corporations? Is their performance any better, really?

> Yes, their performance is vastly better. I can easily point to 500 companies that made a profit this past year. That is, they brought in more money than they paid out.

The comment I responded to referred to entitlement programs. I do not think that private retirement companies turned in significantly better results than government retirement programs (which, BTW, are typically managed by private companies anyway).

With that said,

> Can you do the same for any government?

In general terms, I do not think our system of fiat money is one where everybody, or even most, *can* turn in a profit even if they want to. Money is created out of thin air and we have to pay interest on it with money. Thus, clearly, the debt cannot be repaid.

> Our Treasury is now auctioning off our country's debt at a rate of $400 BILLION per quarter.

I am not arguing that... but, to me, it's a consequence of the large scale setup of the system. To me, one of the consequences is that we talk about health care in terms of where we draw the line between those that live and those that die. I do not think anybody is worthy of such a throne... there's laws that punish both intentional and negligent death.

> Just what is your stance here? Do you endorse the current health care plan? Do you have any reservations? Quit sniping our comments and present your critique or endorsement so we know where you stand. Please.

I would like a significantly better society in which we do not have to take for granted that money is worth more than life.

> How do you provide incentives to people or government to provide this level of service and care? Without a profit motive (whether it is given in dollars or in esteem), will this work?

See, I think this question exemplifies our apparent belief that money is everything. Why cannot we do something other than for money? And, while in general terms I wouldn't object to turning in a profit for providing good service, I do not think the goal should be profit above everything else (including the long term sustainability of our planet, for example).

So, to make the story short... I think we can continue arguing about local defects in our system, but none of that will remedy (what I think are) the inherent flaws of how we value things. Thus, to answer your question of what to do, I'd disagree with the notion that money is everything, and act accordingly. For example...

... enough with justifying death by negligence or omission, already...

cremes said...

> > At the end of the day, people have *no right* to health care.

> I'd rather disagree with this.

This is our core disagreement. If you believe it is a right as defined under our system of laws, then you believe that the government may use deadly force to protect that right.

Let's forget for the moment that "government" is made up of people. It is far outside the core issue and deserves a discussion all of its own. For this discussion it is a red herring.

Regarding rights, I have never seen "health care" argued as a natural right up until this last century. Unlike other natural rights (speech, defense, etc) all of those rights may be exercised solely by the individual without external help. Health care as a "right" would be putting another person into bondage to you (doctor, nurse, surgeon, etc) since most individuals don't have the capability of exercising this "right" without dependency. That isn't a right; it's a justification for slavery.

> I don't think you can have a sane system when you can create money out of thin air.

Glad to hear this. You also recognize our fiat money will eventually fail (it's failing now).

> On top of that, we still like to believe the money thus creates is worth more than human lives.

I see how you reach this conclusion but I think you are mistaken. By my measure, money is a representation of life. It represents education and toil to get the money. We "spend" our lives in pursuit of it. To vote for policies that give away money is tantamount to giving away people's labor (i.e. their life). This doesn't kill obviously, but it certainly isn't good.

> > How do you provide incentives to people or government to provide this level of service and care? Without a profit motive (whether it is given in dollars or in esteem), will this work?

> See, I think this question exemplifies our apparent belief that money is everything. Why cannot we do something other than for money? And, while in general terms I wouldn't object to turning in a profit for providing good service, I do not think the goal should be profit above everything else.

I see that I was not clear. For one, I did mention "esteem" as a potential payment. That is a large motivator for some people. But really, it *does* come down to money. I'm not saying folks need to get rich doing nursing (or whatever) but they certainly cannot do it for free. You can't eat, own a home, buy a car, go on vacation, etc. I don't think you are saying people should work for free but it isn't clear to me from the context. There must be some compensation (dollars, praise for those who don't need the money) or the system literally won't work.

Andrés said...

Cremes,

It looks like we also disagree on a number of other things, such as "let's forget government is made of people" and (seemingly) "government can use deadly force [for anything, basically] (in the sense that it's both reasonable and justifiable)".

Oh well. I am happy with "we disagree" and that's about as much energy I want to spend discussing this right now.

Andres.

cremes said...

> Oh well. I am happy with "we disagree" and that's about as much energy I want to spend discussing this right now.

Yeah, I'm tired of it too.

Looking forward to your latest book. I'm mostly a ruby guy but I have found many Smalltalk ideas and techniques translate rather well. Good luck with finishing up your latest opus.

Andrés said...

See, the good thing is that we don't have to kill each other over a disagreement :).

> Looking forward to your latest book. I'm mostly a ruby guy but I have found many Smalltalk ideas and techniques translate rather well. Good luck with finishing up your latest opus.

Thank you! I hope you like the book. In the introduction, there's an email address for feedback. Let me know how it goes!

Andres.