Short-term memory

[nancylebov]

The failure mode for government-supported health care which concerns me is that paying for medical care can't help but affect what sort of care gets supplied. I don't fear cost-cutting death panels so much as unpredictable moralism. It's been mere months since most of the people who support a major revision were very angry about the Bush administration making abortion harder to get-- and the Bush administration had a lot less leverage than will be available in a more centralized system. The people you like will not necessarily be in charge forever.

However, Americans have a crazy streak. As nearly as I can tell, the American character has two primary components: It's better to do something, and it's important to be a good person. Thought and kindness are permitted, but they're optional.

This doesn't mean change is necessarily a bad idea. The current system is horrendous and medical care as a right has worked pretty well in other countries. The risk might be acceptable, but I wish the people who support the government guaranteeing health care took the risk seriously.

My nightmare is a medical system where care is withheld if the patient is "non-compliant"-- this could mean not losing weight when ordered to, or not taking prescribed drugs because in one is "self-non-prescribing" because one has the delusion that one is entitled to judge which side effects are tolerable.

But really, the particular way things could go wrong is not predictable because fits of moralism are pretty random. So far as I know, there isn't a rights system built into proposals for medical care, and feedback is by way of pressure groups. This seems pretty fragile.

Comments

[nellorat.livejournal.com]

I need to learn more about what is being proposed-- One protective mechanism would be if a person got some choice in which local doctors to go to. This still could be bad in rural areas without as many alternatives, but I would think that just as it is hard but not impossible to find fat-accepting physicians now, it would be possible to find physicians who would understand some patient approaches instead of branding them "non-compliant," if we were free to shop around.

I can kind-of understand noncompliance being an issue: I know someone who just decides she'll cut back her blood-pressure meds, believing she doesn't need as much, on no evidence that I can see. OTOH, most doctors feel any compliance is usually better than none. I think that person's doctor finally booted hir, but it took a while.

[autopope.livejournal.com]

Point of information for you:

I am in the NHS in the UK. I'm currently with a fund-holding group practice of GPs (i.e. independent but funded by the NHS on the basis of the number of patients on their rolls). If I don't like the GP I'm seeing I can ask to see another GP in the practice. And if I don't like any of them, I am perfectly free to look around for another practice, as long as I'm within its catchment area, and sign on (if they've got room to take on patients). I don't have to worry about what HMO or insurance company they're with -- I just walk into reception, ask "are you taking on new patients?", and give them my details and the ID of my old surgery so they can fetch my medical records.

It is possible to get booted from an NHS practice, but it generally takes abusive or violent behaviour towards the staff.

[anton-p-nym.livejournal.com]

In Canada's single-payer system, doctor choice is entirely left to the patient. (Potentially making it even more flexible than the US's HMO system, which restricts doctor choice according to which doctors and clinics have service arrangements with your insurance provider.) If you don't like your doctor, you can always look for another... the only difficulty being that some regions are underserviced, but that's the case in many other systems.

-- Steve's frankly baffled at the vitriol in American health care debates, and the astonishing level of blinkering that happens in US policy debates.

PS: The major problems with health care in Canada come from perceived underfunding... as noted elsewhere, if Canada spent as much per-capita on health care as the US every Canadian would be using MRIs to measure shoe sizes.

[mama-hogswatch.livejournal.com]

I don't fear cost-cutting death panels so much as unpredictable moralism.

Amen. This is exactly where I get scared.

[autopope.livejournal.com]

My nightmare is a medical system where care is withheld if the patient is "non-compliant"-- this could mean not losing weight when ordered to, or not taking prescribed drugs because in one is "self-non-prescribing" because one has the delusion that one is entitled to judge which side effects are tolerable.

In practice -- as those of us who live with government-funded single-payer systems know -- messing with a GFSP system rapidly becomes a political "third rail" once the voters realize how useful it is to them. Withdrawl of treatment is very nearly impossible, once it is available. And nobody wants their healthcare provider to cut them off. The issue you raise actually comes up regularly in the UK ... and gets shouted down (and no politician in their right mind will go near it with a barge-pole: there are no votes there, and lots of grief).

Anyway, you guys already have a system where care can be withheld if the patient is "non-compliant" in one very odd direction -- i.e. not coughing up money on demand.

[chickenfeet2003.livejournal.com]

I wouldn't overestimate the degree of state control in state funded health care systems. It's nigh impossible to coerce physicians (individually or collectively) so as long as the patient has the option to swap physicians there isn't a big issue with state imposed 'moralism'. There's probably more of a problem with individual physicians (nurses, pharmacists) trying to impose their values on patients but, again, as long as the patient can switch providers it's manageable.

[glenmarshall.livejournal.com]

There are a number of things that need to be fixed for US healthcare, so dwelling on the fringes is not helpful. This is especially true about things that would harm people. Specifically, it is politically extremely unlikely that necessary care would be withheld - ever. We need to focus on real issues.

Americans tend to view physicians as some sort of gods with the power of life-or-death, and with a malevolent tendency at that. I don't know where that unnatural fear arises. Physicians are professionals, some more capable than others, but medicine is still more art than science. Bad outcomes happen. You cannot legislate that fact away, but suing doctors for imperfect outcomes is not acceptable. We need to remove the cost of unreasoned liability from the system.

One very costly part of healthcare is the under-served populations. The most obvious direct cost is over-utilization of hospital ER services for non-emergency illnesses. A less obvious, but quite common, cost is voluntary medical identity theft, e.g., lending one's Medicaid card to a neighbor so they can get free care. There are lots of issues that drive the under-served population medical costs but, bottom line, we are already paying for the costs in uncontrollable ways. It would be nice if there were some controls so they could get adequate care at lower cost.

We need to rein-in pharmacological cost. There has been a shift toward the use of drugs versus more costly treatment, but the cost of drugs has not been adequately dealt with. That, by the way, is the main reason for patient non-compliance: they cannot afford the drugs.

We also need to increase the use of information technology. Currently, only 2-3% of healthcare revenue is spent on IT. In the manufacturing sector it is 10-15%. 60% of hospital costs is in nursing staff, and half their time is spent in information handling. If we increased the use of IT to ease that burden, the cost of hospitalization could decrease by about 25%.

If the ambulatory care setting, a single-payor insurance system would reduce costs by 30% or more, just by removing administrative overhead costs that are not benefiting patients.

And so on...

[womzilla.livejournal.com]

There are doctors who have refused to treat symptom X (which can be exacerbated by weight) until the patient loses weight, even though there are treatments which will ameliorate symptom X without weight loss. So Nancy's worry isn't coming completely out of nowhere.

The real question is, is a government-managed health care system more or less likely to indulge in this type of behavior than the profit-driven, functional monopoly system that most Americans have now?

[enegim.livejournal.com]

Yes, exactly. (You beat me to it.) Nancy, it sounds like you're assuming that the moralism and rationing you fear would happen under state control but do not happen with private and for-profit providers; in my experience, the latter assumption is entirely unrealistic.

[nancylebov.livejournal.com]

No, I'm concerned that a more centralized system could make it a lot worse.

[tomscud.livejournal.com]

In addition to other comments, I don't really see government being restrained from getting in individuals' faces now, from the drug war to smoking bans to various mandatory safety-device rules. (And I'm not sure all of those rules are a bad thing, either; I've lived long enough in third-world countries to be happy that I can assume every car will have a working seat belt for whatever seat I'm in). There's already some momentum building towards eg. labeling and maybe banning fatty foods; I don't know that UHC of whatever kind will make much of a difference either way.

[madfilkentist]

It's inevitable that government funding implies governmental limits on what you get. Whatever system exists, there are limits. The existing system is corporatist (not free-market); there are tax pressures, among others, for people to get their medical care paid for by insurance, and it's actually mandatory in Massachusetts. But at least there are various insurance companies competing with each other, and buying one own's insurance is an option. The limit is set by whoever is paying. Government-managed and subsidized insurance would set its own limits, while leaving people fewer options. Calling the agencies that set these limits "death panels" is serious hyperbole, but the limits will exist.

The government doesn't like people opting out of the system. It makes life extremely difficult for doctors who want to opt out of Medicare; as I understand it, they have to opt out completely or not at all. Once the government gets its hands seriously into medical insurance, the economic distance between patient and doctor, which is already far too wide, will become even wider.

[autopope.livejournal.com]

It's inevitable that government funding implies governmental limits on what you get.

Except government funding doesn't preclude private funding.

Here in the UK, we have private health insurance alongside the NHS. But around 90% of us don't bother with it -- we consider the state-funded system to be more than adequate for our needs.

The nearest thing to a "death panel" you get in the UK is NICE, the National Institute for Clinical Excellence, which makes decisions not on individual cases, but on what treatments the NHS will pay for. And? Surprise: the horror stories all seem to involve highly experimental cancer treatments that cost upwards of £100,000 and give, at best, a couple of extra months to folks with fatal illnesses. NICE figure the money is better spent where it can buy real quality of life -- organ transplants, slightly less expensive treatments for other otherwise-fatal cancers, that sort of thing. And despite that, they've got discretion to make exceptions on compassionate grounds.

Whereas the private sector US system has death panels by the truckload -- non-medically-qualified insurance industry executives who have a financial incentive to find reasons to deny care to their customers.

[eye-of-a-cat.livejournal.com]

But, don't you guys have health insurance systems with things like lifetime/annual caps on coverage now? That's totally alien to the kind of system we have (I'm in the UK); there's no sense of 'Your chronic illness is costing us a fortune, so we'll cover one more x-ray for you and then that's your lot.' Medical care is determined on a case-by-case basis by medical need, not by ability to pay.

The government doesn't like people opting out of the system.

Not the case here. The government has no problem with people buying private health insurance; why would they? If someone goes private, that's one fewer person the public system needs to cover.

[sethg]

A friend of mine has a son with hemophilia who gets regular infusions of clotting factor, and the health insurance policy's lifetime cap is a real issue for them. The irony of it is, the father works for an insurance company (although not one that provides health insurance).

[anton-p-nym.livejournal.com]

Government-managed and subsidized insurance would set its own limits, while leaving people fewer options.

Demonstratably false in many systems world-wide, if you're implying that government health insurance limits treatment options.

Arguably false if you're implying that a public option will reduce coverage options, in that the current HMO system tends to result in cartel behaviour and that coverage plans are so baroque and opaque that policy-holders are rarely making completely informed decisions about their coverage. (And often don't have much in the way of choice of providers, seeing that the bulk of policies are group policies through their employers and not individual policies selected by consumers.) The Swiss and French systems, for instance, offer much more transparency and superior coverage to the current American system with their mixes of public and private insurance.

-- Steve is once again struck by an oddity of the US health care debate; proponents for a public option point to concrete examples, while opponents use hypothetical cases to illustrate their objections.

[avram]

Libertarians like to fancy themselves economists, and you know what the definition of an economist is? Someone who sees something working in practice and wonders if it will work in theory.

worries and concerns

[purplemoonwoman.livejournal.com]

The worries and concerns you bring up are real. We have to deal with them all the time. I know I do - I'm a fat chick. I just went to the doctor yesterday and was told I have a skin infection BECAUSE I'M FAT. Oh, yeah. My bad. I keep forgetting thin people don't get skin infections.

However, one fact we keep forgetting is that here in America we are more likely to be the victims of this type of prejudice and all its associated evil in the ABSCENCE of government. Left to their own, private institutions discriminate on nearly every possible front - gender, sexuality, skin tone, weight, race, religion, you-name-it.

But, the problems still remain and they are problems we already deal with. We already have to fight for fair health care now. The difference is that the people we are fighting against are under NO OBLIGATION to provide fair and equal treatment - not really. They are private companies who have the right to toss homeless people on the streets - LITERALLY - without even removing catheters or IV bags. They found SEVERAL hospitals doing this in LA and it was uncovered by the fact that they actually found one homeless guy crawling down the side walk dragging his colostomy bag and wearing only a hospital gown. The poor old guy was so out of it, he couldn't even remember which hospital he had been in. IT took the police weeks to track it down. AND, then, the police said there was nothing that they could do about it. The hospital had broken no laws.

This is sad. Really. Very sad. 20 - 30 million people in this country have ZERO access to medical care that they need. On top of the obvious moral and ethical dilema this presents us with, there is also the tremendous cost of "on-the-spot" emergency care provided that has not been planned for and no money has been set aside to deal with.

We are already paying for indigent care and we aren't getting our money's worth. It is incredibly expensive. It is paid for out of taxes that we already pay. The difference is that we do not get any benefit from this ourselves, the money is spent haphazardly, the poor still get crappy medical care, and even doctors end up on the rough end of the stick. Our ER departments across the country are stuffed full of people who could be seen elsewhere to get a prescription for antibiotics or other minor care and then those who are truly in emergency situations are left waiting hours for life saving procedures.

So, I guess the part that really ticks me off is that insurance companies really do suck. They get to cover only what they want to cover. WE don't get a say in it at all and we have no choice but to pay. We don't get a vote. We don't get to say "this procedure should be covered" or "this one should not be covered." Insurance companies are evil, blood-sucking punks and they are getting away with murder.

Something - really - something must be done.

[subnumine.livejournal.com]

paying for medical care can't help but affect what sort of care gets supplied.

Quite so; and that's true now. Admittedly, we rarely - not never- have to worry about the morality of insurance companies (the catty remarks I'd rather leave to you), but we do have to worry about some pointy-haired bureaucrat deciding that some form of care isn't cost-effective for the insurer, which will reduce the demand for it so much that the care will have much less supply.

This is one reason to support the public option - competition by genuinely non-profit insurance - over regulation, which seems to be what the Blue Dogs would substitute for it.

[richardthinks.livejournal.com]

Regarding the NHS in the UK: what Autopope said. Except... there seems to be a general consensus in the UK about a whole slew of social issues, which are battlegrounds in the US. Just because there is a system that appears to work reasonably in one place, does not mean such a system will be adopted in another. So I would be worried, and I'd fight and claw and get my voice heard, because you can't rely on the existing systems to make new, workable, livable systems.

It would be awfully nice to actually have some data - a proposal of some kind - to react to, though, rather than the current echo-chamber of idiots.

[autopope.livejournal.com]

there seems to be a general consensus in the UK about a whole slew of social issues, which are battlegrounds in the US

Yes. For example, around 15% of the population are opposed to abortion, while 70-80% are pro-abortion and around 50-60% are pro abortion on demand (a rather more inclusive category). Female contraceptive pills/injections are free on the NHS (although for many years condoms weren't; AIUI condoms became available on prescription relatively recently). Opiates are controlled but used in medicine -- indeed, diacetyl morphine, aka diamorphine (or Heroin™ as you probably call it) is routinely carried in ambulances for treating heart attacks (it's a good coronary vasodilator and anxiolytic, as well as a potent analgesic).

I'm willing to bet that even if Obama somehow judo-throws the Senate into passing a tax funded system, it won't cover abortions. Or gender reassignment surgery. And there'll be other differences.

[bradhicks.livejournal.com]

I understand your worry, but does it help allay your fears if I remind you that Medicare was signed into law in 1965, and in the intervening 44 years, even during the Reagan and Bush the Younger administrations, and during the equally sanctimonious the other way Carter administration, nothing like the scenario you describe ever happened?

In one form or another national health systems have existed in other countries since World War II, and none of them have failed in that particular way, either. The closest thing to that that I can think of is that doctors in the UK and in France are being offered cash incentives for every patient they persuade to quit smoking and for every patient they persuade to lose weight and for every patient they persuade to show up for regular checkups, but still, they are explicitly not given any power to compel, any power to coerce.

To assume that something that hasn't happened across multiple examples running simultaneously for two generations is a common enough failure mode to make special plans for now seems to me to be counter-intuitive. I can't make a case against fixing a problem that kills 18,000 people a year now on the basis of such a demonstrably implausible hypothetical.

[chomiji]

That was a very useful link. Thanks!

my experience

[tahkhleet.livejournal.com]

In Canada, I have never seen or heard of anyone getting dinged that way except in small and basically reasonable ways. I complained of back pain when I was 230, the doctor said "you're too heavy, lose some weight, I'm not sending you to a surgeon or ostreopath when this is self inflicted and not life threatening (emphasis added). I have heard of people with all manner of self inflicted conditions get care if their lives are in danger. Transfolk who get surgery for GRS from inept surgeons to save money are still treated for the complications of those surgeries. (Which is why BC, AB, and ON cover the surgery: its less expensive than suicide rates, depression beds at the psych hospitals, lost taxes through lost income and medical patch up work fixing amateur docs' mistakes.)

You might say its profoundly immoral to let someone experience discomfort if you could do anything about it, but my perspective is we have our hands full keeping people alive. If the system was healthily in the black, I'd take exception to this. But it's not. Until it is, self remediable discomfort will have to be remedied by the individual. ( I am not clear if there is a risk of how they treat cases of the "severe chronic pain through own actions". I haven't heard of it though.)

I mean, in a private system, you won't get covered for self inflicted conditions either, you know. If you want to get care for stuff like that, you'd have to pay for it yourself at market rates _anyway_. I don't see how the gov't system leaves anyone worse off.

[landley.livejournal.com]

> My nightmare is a medical system where care is withheld if the patient is "non-compliant".

Why do people keep saying "care will be withheld" when we're talking about _payment_ being withheld?

Right now we have tens of millions of uninsured people, who have no medical coverage. Care isn't withheld from them when they show up at emergency rooms, get treated, and go home. They then get huge bills they can't pay and their credit rating is trashed, but for a lot of 'em this isn't anything new. (And ask any medical professional: they're SWAMPED with this, all the time.)

Yes the current status quo sucks, but if they're bleeding or having a heart attack, a hospital generally isn't going to turn them away (if nothing else, for fear of big lawsuits). Even when the hospital has to then pass that cost on to the people who _can_ pay.

Now some right-wing nutballs are saying that because we propose to change how all this is paid for, suddenly we're going to start withholding actual _care_ from people, even when doing so is life threatening. And that if you're uninsured now, the new situation might somehow be _worse_.

Sheesh, today health insurance won't pay for optional cosmetic surgery, and state insurance wouldn't either, so paying for procedures out of your own pocket will _always_ be an option. Don't confuse "we won't pay for it" with "we forbid this procedure from being performed under any circumstances" (Which is currently the FDA's job anyway, by the way. That would be nothing new.)

Sheesh, when I see idiots complaining how they don't trust the government to run medicare (WHO DO YOU THINK RUNS IT NOW?), or who have no IDEA how easy it currently is to become uninsurable for life with any number of chronic conditions (including ones where they'll slap your employer with a million dollar annual fee for the extra risk of covering you, until said employer either finds an excuse to fire you or goes under)...

It's not just "not thinking straight", it's also "unclear on the status quo". Before you start flailing in terror about the unknown, take a good hard look at the _known_. The baby boomers born in 1945 hit 65 next year. The medical system is about to MELT DOWN. Add up medicare, medicaid, and the veterans administration and they're the second largest budget item after "everything we spend on defense combined". (And those two together add up to 48% of the total budget for 2009. And that's TODAY. The numbers going forward get worse.)

Go read this:

http://bradhicks.livejournal.com/432173.html

And while you're at it, read this:

http://bradhicks.livejournal.com/432458.html

THEN be afraid.

Rob