" ROBERT COYNE, Mattoon

Healthcare is a mess. Congresss plans will worsen it. We need reform the opposite way."""""


WOW!!! Robert!....glad you've seen the final proposal, can you share all the details with us? Thanks!! "

" http://www.markfiore.com/political/reform-madness "

" The Post-Dispatch has a wonderful editorial this morning starting off (sarcastically) with:
"Thousands of angry protesters turned out at town hall meetings in Hillsboro, Cape Giardeau and across the country this week. The had come to pledge their unstinting support for the world's 37th best-performing health care system. ........
The protestors vowed to protect a system that is, hands down, the worlds most expensive.
........
Yet in apples-to-apples comparison, it produces lower average life expectancy and higher infant mortality rates than most other developed nations and performs poorly on many other important measures.
That is in large part because it is the most unequal system in any industrialized country.
.........
There is plenty of room for reasoned debate about the details. But opponents are relying instead on wild exaggerations and outright falsehoods in their increasingly hysterical attacks." "

" With all due respect, sir, are you nuts?

You state that "routine medical care and end of life care are best covered by savings." What about those -- the majority of Americans -- who are struggling just to pay the rent or mortgage, utilities, and to keep food on the table? Many Americans are living paycheck to paycheck and simply don't have $100 - $200 for that routine visit. If they must pay it all out of pocket, they will skip routine or preventive care, and will even skip going to the doctor when their health problems are still in the early stages when they are most treatable. They will ignore symptoms and tough out the pain, until their health problems are too huge to ignore. Then the treatment they'll need is very expensive, and if they have no money to pay, the hospital is stuck with the bill and we'll all pay, through higher bills for everyone.

And end-of-life care? Statistically, healthcare costs in a person's last year of life are more costly than much of the care expenses for the rest of their lives. How do we pay this out of pocket?

And for your ridiculous claim of "do away with the need for a prescription; if I know what I want give it to me" -- are you SERIOUS? What gives you the medical expertise to know that what you want is the right treatment for your condition? What you want may kill you. That's why we leave it in the hands of medical professionals to know what medicine is appropriate. "

" We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.

Harry Truman, November 19, 1945 in his Special Message to the Congress Recommending a Comprehensive Health Program "

" We have a higher infant mortality because we try to save more of the at risk babies that come along. More attempts are made in this country to save those premies and at sickly children. That is a fact. I do not understand the post about below average life span. Haven't seen that, but could be true with the heavy, out of shape people. When we were in Europe, those people are definately more trim. "

" hahvahd,

Im a health nut, but not otherwise nuts; I just didnt have space (within the 400-word limit for letters) to make my argument at anything like the ideal or perhaps necessary length. Ill try to flesh it out here. Oh, and thanks for taking this seriously, if only in an oppositional way.

In asserting that most people would be unable to pay for healthcare out of pocket, you are assuming, falsely, that the paychecks and the medical bills would be what they are now. But actually, if my recommendations were implemented, the take-home pay would be higher and the healthcare prices much lower. Lets take each in turn.

Start with your pay, and for the moment lets ignore wealth redistribution. Lets also ignore the tax advantage of employer-provided insurance, because as I said in the letter, that could and should be extended equally to other ways of paying for healthcare, to any extent thought appropriate; all the preference for on-the-job plans does is distort the market, drive peoples choices into a form that apart from the tax angle would be inefficient, and thus for society as a whole _is_ inefficient. (I dont say that all job-based insurance is wrong; certainly I dont mean to forbid it. There are some real advantages to it, namely centralization of the paperwork in a single outfit that already does plenty of that, a natural affinity group, and some assurance that everyone in the pool is at least minimally healthy, enough to work. Sometimes its right and sometimes its not. The tax break dragoons people into it even when its wrong.) In other words, lets contemplate a straightforward insurance scheme, with no legal (political) gimmicks. Then the employees collectively, thus the average employees, are paying the full cost of those insurance premiums. (Some may do better, of course, but then others must do worse.) Not the company; its just a conduit, and doesnt pay a penny, except maybe in some transitional period during which everything else is fixed by contract or you havent had time to search for another job. Because the employer doesnt care whether you get your compensation in cash or health insurance or some other benefit; all it cares about is its total compensation cost, how much money its out because youre on the payroll. Whatever its paying in premiums it would be just as happy to pay you directly instead, in extra cash salary. And it would have to to keep you on board, because you, too, are lookiing at the total value of your package, and divvying it up differently among cash and benefits doesnt change the basic bargaining position. If you have insurance on the job (or any other benefit), your cash pay is lower than it would otherwise be, by the amount of those premiums. (If you didnt realize this, its because your employer, your union, and your political leaders all prefer that you dont realize it. They want you to think youre getting something for nothing, from their generosity or fighting spirit). The premiums cover not only the healthcare expenses the insurer expects to have to pay out, but also their administrative expenses and their profit. So on average you inevitably get back less in claims than you paid in premiums. This may be acceptable if its real insurance, against risk, that is against huge fluctuations in claims according to your medical luck; for then in return for paying a little more on average you eliminate the chance of having to pay a lot more if youre unlucky. As a typical individual, your finances are relatively illiquid and your subjective preferences, your utility function, highly nonlinear; e.g. at a certain point in outlays you lose the house or have to direct Junior to a cheaper college. So a deal with the insurance company, with its greater liquidity, may be advantageous for you both; in effect you are renting their liquidity for a fee. But when you cover what is not a risk but a typical, routine, average, predictable, expectable expense, so that what you get back in claims will be more or less what everyone expected, with little variation, there is no such gain from the deal. With no risk and no resulting need for liquidity involved, you are paying the insurer that excess amount for nothing. Every year you pay a premium and almost every year get back a substantial but nevertheless smaller amount, and whatever variations there are from year to year are too small to take you out of the linear zone and make you want to consider anything but the average, which is a loss. If you could stop paying those premiums and have that cash in hand instead, you could use part of it to pay the doctors bills and still have left over, still in your pocket, the amount that didnt go to the insurance companys staff and suppliers and shareholders. So you would be better able to pay for healthcare than under the broad-coverage, pseudo-insurance plan.

If the pseudo-insurance plan is not a private one but Medicare, or some new government plan, the argument above goes through pretty much unchanged, except that now you are paying in the form of taxes. In particular, dont let anyone tell you that you only pay half (or whatever) of the premiums/taxes and your company pays the rest; whatever the official incidence, in reality you are paying it all, on exactly the same argument as before; the legal technicalities may have some effect on taxes, but apart from that the employer-share notion is just another deceptive gimmick by the politicians. However, there is one additional effect when we deal with a government plan, and it makes things even worse than with a private one. This is that Medicare, like its parent Social Socurity, is something very close to a Ponzi scheme, on a scale Bernie Madoff never dreamed of. Current taxes are not saved and invested in real assets producing real income that will be used to pay the eventual claims; instead, the taxes are used to pay current claims, and any excess (but already nowadays there isnt any) to fill some of the hole in this years general federal budget; this years taxpayers are dependent, for payment of their future claims, on the programs and the governments future taxing ability. What keeps it from being a complete, typical Ponzi scheme is that when its this large and long-term, that supply of new investors really does tend to grow. But basically only as fast as the economy grows. The maximum sustainable virtual interest rate that you are getting on your investment is only the rate of growth of GDP, and in the long run this is always less than genuine interest rates on genuine investments, such as a private insurer would rely on. So to make up for that lack of investment income, you will pay Medicare more in taxes than you would pay a private insurer in premiums (in a properly competitive market) for the same coverage.

Turn now to the providers side, the prices charged for healthcare. First of all, the insurance company isnt the only one awash in paperwork; first the providers back office has to fill out all those claim forms. This costs considerably more than sending you an old fashioned, informal but intelligible bill, in English instead of codes. The fee reflects this. The combination of third-party payment with complex, coded, unintelligible billing also makes it easy for providers to cheat -- and they do. Most hospital bills contain errors, usually in the hospitals favor: They charge for procedures that were never done, charge twice for the same procedure, upcode diseases and treatments to something more paying, and so on. The hospitals get away with this, and know they will, because they know most patients wont bother checking the bill carefully, because the patient isnt paying much of it. The typical division is that Medicare pays 4/5, the secondary insurer pays 4/5 of whats left, and that leaves the patient to pay at most 1/25, if the provider even bothers to bill it, which many dont. Thats not enough to make it worthwhile for the patient and his family to keep careful track of everything that is done to him, learn the codes and definitions, hunker down and study the bill, and fight the hospital over questionable charges. Then there are the charges that are performed only because theyre insured. This, of course, is especially bad if the provider is psychiatric (more power over the patient than most doctors) or the patient is a child (less autonomy than an adult), and when its both, look out. About twenty years ago there was a scandal over psych wards that were advertising to the parents of teenagers to the following effect: Going on vacation? Dont want to leave your teen alone at home, and dont know what to do with him? No problem! Commit him to our psych ward. We can always diagnose something or other. Well house and feed and supervise him for the few weeks youre gone, and your insurance will pay for it all, or if it only pays part we wont bother you about the rest, wont cost you a penny, cheapest babysitter in town. Thats an extreme case, but lesser versions are far from uncommon. Plenty of beds are filled and inpatient treatments provided until the patient miraculously recovers enough to go home just as the insurance runs out. And let me mention an example from my own experience running interference for a relative who was in the hospital diagnosed with a tumor in the brain. The doctors didnt know whether it was primary or secondary, or if secondary where it came from. They thought it was probably originally prostate cancer, and if so they would want to suppress his androgens. So one wanted to jab a bunch of biopsy needles into his prostate. This, of course, would be very painful, plus have the potential to spread the cancer more if it existed, plus a negative result would not be at all conclusive since they might simply have poked the wrong places. And he was an old, tired man with little need for a sex drive and probably not that much longer to live anyway, so there seemed to me little downside to just bypassing the biopsy and starting the therapy without it, just in case. And the doctors eventually did agree to this, but meanwhile they explained: The biopsy is the gold standard for convincing the insurance people he has the disease and needs the treatment. In other words, they werent practicing medicine, they were practicing insurance, tailoring their ways to the pressures of insurance rather than medical considerations.

But the most important effect of a medical economy in which insurance is dominant is that it makes nonsense of the standard insurance language about how much theyll pay, and makes the issue of how much to pay insoluble. A patient paying out of pocket has some sense of how much hes willing to pay at a maximum, and in many cases he can shop around for doctors and take their prices into consideration (among other things) in deciding who to go to. This puts a certain constraint on how much a doctor can charge; what the traffic will bear may not be much. But an insurer has no such (legitimate) subjective sense of how much this probable amount of extra health is worth, and patients tend to get upset if the insurer tries to choose their doctors for them. So insurers have to do it a different way. The usual provision is that they will pay an amount described as some combination of ordinary, customary, reasonable, and similar vague words, and what this basically boils down to is what this and other doctors typically charge. Which was fine as long as most patients paid out of pocket, because those fees then established the standard. If a few people are insured, the insurer looks at the cash side of the market and knows what to do. But once cash becomes rare and insurance the dominant form of healthcare financing, the system comes loose from its moorings. Now providers can raise prices as much as they like, so long as enough of them do it more or less together to constitute something that can be called ordinary, for then the insurance will have to pay. The skys the limit, and the premiums reflect it, but people cannot opt out without losing the tax break, and Medicare is even more compulsory, so the federal subsidies are really going right through to the providers in the form of higher prices, leaving patients, especially the uninsured, worse off than ever. It is precisely the overwhelming presence of insurance (and Medicare) that makes exhorbitant healthcare prices possible. (Much the same has happened in higher education: As the federal government gave or subsidized more and more aid to students, tuition went up and up, because students could now afford to pay more.) If most people were un(pseudo)insured, providers would not be able to charge more than most people could afford; anyone who tried would have no patients. Prices would come way down, and that combined with the extra money in the savings account that you didnt waste on the pseudoinsurance company would enable you to pay cash with plenty to spare.

If you dont believe that, look at history. Let me cite some figures I ran into recently on the Internet; I havent checked these out, and Im not sure how reliable the source is, but I assume these are fairly correct. In the early 1950s, you could have a baby delivered (by an obstetrician) for $30. Weve had much inflation since then, so in todays dollars that would be about $250. Just about anyone could afford that, or at least anyone who could afford to bring up a child and who had had about eight months notice to start saving. The price today is astonishingly higher, not uncommonly $25,000, in other words 100 times as much. This is not because the procedure is 100 times better. The basic event, after all, is natural and age-old; infant mortality and maternal mortality are not 100 times lower; in no plausible sense is the new version 100 times more valuable to the average patient. And even in luxury markets where people are willing to pay an arm and a leg for the very best, simply to have the very best, the price spread is seldom that big. A Rolls-Royce does not cost 100 times as much as a Yugo; dinner at a 3-star restaurant does not cost 100 times as much as dinner at the Family Diner; a Stradivarius does not cost 100 times as much as a minimally-professional-quality violin by a respectable modern maker. So if its not quality, what happened? Insurance happened. Employer-provided insurance was invented as a way to evade wage controls in the World War II era, and then survived afterward because of the tax advantage, so in the early 50s it existed but it was not yet dominant or pervasive. As time went on it became so. Then the federal government got its feet wet with the VA hospitals; these were originally supposed to be for service-related injuries, but the vets kept demanding more from them, and everyone sympathized with that Greatest Generation that had done so much for us all, so soon the VA hospitals were general hospitals for vets every medical need. And the result was predictable: cost overruns, stifling bureaucracy and red tape, morale in the pits, and a series of scandals right up to the present, even at the flagship Defense hospitals. Congress didnt learn anything. Next we got Medicare and Medicaid. And prices havent looked back since; theres been no stopping em.

If theres one knockdown argument for why we need radical reform, its Medicare. A train wreck fast approaching. The unfunded promises amount to several years worth of GDP; there is no way that will ever be financed. At todays prices, Medicare is doomed, and when the crash comes, the bankruptcy becomes visible to all, the people who didnt buy much private insurance and didnt save much because they believed the politicians promises and thought Medicare would take care of their medical needs are going to be suddenly crushed, and many will die, or worse. The only thing that can save Medicare and those trusting retirees is a dramatic drop in healthcare prices, well below what the projections are based on. But as Ive explained, Medicare itself, and the mindset that goes with it, are largely responsible for those high prices. So its Catch 22. And Congresss response? More of the same. They regard this catastrophe, Medicare, as a model to be expanded and emulated; they want to enroll more of us in Medicaid.

Getting back to hospitals for a miscellaneous moment, Medicare isnt the only bad law they must deal with and pay for somehow. How do you think Michelle Obama, a lawyer, got a lucrative job as a hospital administrator? Its because hospitals are already so strangled in red tape and regulations that hospital administration is as much about regulatory compliance as about providing services to patients. We had a local example just recently: Carle wanted to establish a new clinic, but needed regulatory approval to do so; Sarah Bush didnt want them to do it, because it would be competition; both sides spent resources on lobbying and legalism that would have been better spent on patients. It all goes into the hospitals charges, legitimately or not. Meanwhile, Congresss main idea for how to lessen prices is fiat: Just command them to be lower. Canute might as well have stayed home. Well, actually its not quite as bad as it might sound on first hearing, because to the extent the prices are arbitrarily high from the big pot of money available to pay them, as described above, simple refusal to pay more than a fixed amount really could cut them. But how much? Whats the right price? Government officials have no more idea than insurance company officials, and indeed will do worse for reasons Ill get to soon. So while its not quite a ghastly idea, its still pretty bad. And now Congress seems to think that the way to lower prices is to make every provider or its lawyers read and try to understand another 1000-page statute plus however many thousands of pages of regulations will go with it.

But that cost is the least of my worries. Whats really scary in the fact that all the bills seem to be (aiming for) about 1000 pages long is that it means they are planning a nearly complete federal takeover of the healthcare system. Because it wouldnt take nearly that much statutory verbiage to leave the choices to us. The reason the bills have to be that long is that Congress wants to make, or authorize bureaucrats to make, innumerable decisions that would otherwise be ours, have always been ours, and should be ours. Oh, it wont be officially a single payer plan, at least not yet; the insurance companies will still be around, but only to do the paperwork and collect some profits (and of course for show), after all the real decisions have been made in Washington. Oh, and I am not reassured when someone assures us that such-and-so isnt in the bill. One must look also at the logic and dynamics inherent in the new system; at the spirit of the law as well as its letter. Once some things are done, others follow almost inevitably; because they become necessary or rhetorically easy or the next political target, and theres no turning back, once the old ways and supports and institutions have been destroyed. If its not in this years bill it will be in nexts, or in five or ten years. And the problem in Congresss plans is not in the details; its in the concepts and the assumptions and the goals. In these more essential ways, all the versions seem to be more or less the same, and they are wrong, and disastrous, and no angel in the details can make up for that.

But I digress; lets get back to the main line. I have been assuming every tub on its own bottom, but maybe thats too strong and unrealistic an assumption. Ive argued that healthcare would be much more affordable under my regime than under the present one, but of course that doesnt prove that it would be affordable for everyone. There might still be some people too poor to pay for their healthcare, by any route. Maybe what you meant, what you want, is that these people should be subsidized, have their healthcare paid for by other people. My first reaction is that even if so, that should be the last step in the reform, not the first. We have very little idea just what the figures will be, how many people will need such assistance; my own feeling is that it will probably be very few. Certainly it will be _relatively_ few if we wait and see; doing it as part of the initial package, guided by todays prices, guarantees that this aspect of the program will be massive. And the difference matters, a lot, because the whole idea has serious problems, and while they may be theoretically the same regardless of size, in practical terms a problem involving a small number of people and small sums of money tends to be a small problem, not worth worrying about very much, as it just doesnt seem to make much difference what you do, while problems in a program involving many millions of people and many billions of dollars cannot be waved off easily.

The most fundamental objection is that redistribution of wealth is generally a lousy idea, because it destroys social solidarity and channels resources wastefully into politics. If I am going to have to pay for your quintuple bypass, then I would be better off if you were dead. Thats not going to bring us together; its going to raise hostilities. (What brings us together is the free market, the world of voluntary transactions and relationships, because in that world, nearly everyone is either in some other line of business than yours, in which case he is a potential supplier or customer or complement of some sort, and anyway no threat, or in the same business as you, a competitor, in which case you have economic reasons for opposition but emotionally your many similarities in situations and life histories and problems and political needs and social position will tend to make you think of each other as One Of Us and keep you more or less friendly or allied; there is thus hardly anyone who is a natural enemy.) Even redistribution via government may be OK if the payers themselves, at least as a group, favor it; if you are getting your free bypass from a bunch of us because we all know what a great person that hahvahd is and we are using the government because we dont quite trust each other and want to guard against free riders among ourselves, then no one is likely to object seriously. But the problem becomes acute when the payees are numerous or otherwise powerful enough to vote themselves money out of other peoples pockets against the payers wills. Because then the payers feel wronged, feel like victims, and they may be right; this sort of thing is often little better than legalized robbery. So they hate, and they fight back. They too can organize politically, and they must to protect themselves against further depredations, and while theyre at it they might as well satisfy their longing for revenge. And if they cant get revenge, especially if they cant even protect themselves from their original despoilers, they will be tempted to take it out on some third group even weaker than themselves, get something out of them so as at least to break even on the whole. So the third group is dragged in and does the same, and on it goes. Politics ceases to be about coordinating organized collective action for the general good, and becomes a high-stakes and vicious struggle for power, in which the only questions anyone really cares much about are Whose Ox, and Whose Side Are You On, which party are you in. Which is about what we see today. So, descending from the general to our particular issue, it does matter how many people are getting subsidies. If its only a few, thats not going to cost Mr. Payer very much, so while he may object on principle hes unlikely to get very upset, especially as the recipients are so few (and poor) as to have obviously very little political power, meaning they are no threat; they must be getting their benefit because most people agree they should. In such a case, the particulars of the case (such as the widespread visceral sense of healthcare as a necessity and a merit good) may outweigh the presumption against redistribution and justify the subsidy. But if the recipients are numerous, the program expensive, then the payers are out enough money to care, and the payees look lke a voting bloc and make the division and tension between the two groups seem real and important, and all the ill effects are set in motion. So the presumption is at its strongest, and the redistributive impulse should not overcome it, especially since the large-scale subsidy is probably unnecessary. So lets try my way first, and if it proves not quite adequate for all, Ill be glad to talk about the sympathy business later.

Another important reason to be wary of subsidizing health insurance specially is that its so narrow, even for health purposes. Doctoring and drugs are not all there is to health, or even the main thing. Wouldnt Mrs. Poors health be better if she could eat a better (and more expensive) diet? If she had more money generally and thus less of that unhealthy financial stress and even more unhealthy resulting marital stress? Wouldnt Juniors health improve if the family could move to a better neighborhood where he could go outside and play without being beaten up? So why limit the Poors (if they want their subsidy) to the kinds of health approaches health insurance will pay for? If were going to help support them, mightnt a more general strategy be better?

And thirdly there is the issue of what level of government is best for the job. Even if medical care should be subsidized, why specifically by a federal program of coverage rather than, say, the Township Supervisor, who in Illinois is responsible for administering General Assistance, which is mostly about medical needs. Isnt he likely to understand the situation better? Im not saying the feds couldnt possibly be right, but it seems far from obvious to me that they are. My guess is it depends on things like the distribution of doctors and hospitals around the country (thus the degree of local competition) after theyve adjusted to their new, lower incomes. Things very hard to predict yet. So I say again, dont rush into redistributional efforts as if that were the main thing; its not. And if its anyones real main goal, it shouldnt be. Start by bringing down costs, using my methods (and others along similar lines that I didnt have room to mention). Then wait a few years, till the dust settles. Then, if theres still an apparent need for federal subsidies, itll be time to talk about it.

The worst aspect of subsidies, my worst nightmare, is that they give the government an excuse to regulate our everyday lives. Because lifestyle has much to do with health, and if other people are paying for my healthcare, how long will it be before they want to reduce those costs theyre bearing by forcing me to do things the way they regard as most healthful? And when it comes to deciding what is or isnt healthful, the governments record has been abysmal; they typically get it wrong because they typically base their recommendations on political pressures. I have visions of being forced to do things I believe (but Im a minority view) are terribly bad for my health, because thats government orders. Weve already lost a lot of liberties, and this would be a great big nail in the coffin. Most things are only money, but this is our bodies, our lives. I want governments sticky fingers off, but once theyre paying for it, I dont believe that will be possible to maintain for very long. Another reason to keep the subsidies small and late.

The argument for preventive care sounds plausible _a priori_, but empirically is very questionable. There is strikingly little evidence that a big investment in preventive care will pay for itself; on the whole, the strategy is just not nearly as effective as you might think offhand, or as politicians want you to think because its such a politically attractive solution. Thats not to say that no preventive efforts are right; my guess is that probably a few are. But only a few, and for now its still hard to know what they are. The real answer to your point, however, is simply that there is no conflict between it and my approach. The core of my plan (on the insurance side), remember, is freedom of policy writing, with the insured and the insurer able to write the policy any way they can agree on, the insured trying to tailor it to his personal beliefs about healthcare and the insurer trying to fill every available and profitable niche. There is nothing to stop them from including in the coverage such preventive efforts as the insurer believes will more than pay for themselves. And they will do it, because otherwise, exactly as you say, the insured will be tempted to speculate against them, avoid the preventive practice for which he would have to pay because he knows that if he gets worse and needs elaborate care the insurer will pay for that. By covering the prevention, the policy can induce him to behave better, get the prevention he should, and thus reduce overall costs; and this gain can be split between the two of them, making both happy. So these few types of profitable prevention become exceptions to the rule of thumb that routine care should not be insured. But notice that they are exceptions only in extension, not in principle. They are not there because the insured wants more coverage, thinks more coverage is better (the attitude I am criticizing), but because the insurer wants equal or similar coverage of alternatives between which there is an important tradeoff. And because these profitable preventions are probably so few, the rule of thumb remains generally and normally correct; and the exceptions prove the rule, by having their very special and different justification, confirming that some such is required.

There will be various insurance companies competing, and it is in each ones interest to know, to find out, which preventions are worth it and which arent, because that enables them to write their policies better. With all that research, and with selection for the companies that get it right, we can expect, in time, a fairly good understanding of these matters. But it will not be static. Each of these decisions is a tradeoff between two moving targets: The details of, or knowledge about, both the prevention and the serious illness and treatment its trying to prevent may change with time, and the balance between them may tip, either way. So items will come and go from the correct list of profitable preventions, and insurers must try to keep up. But they have good reason to, and few or no constraints on their speed and flexibility in adjusting to new knowledge; indeed, because the list of covered preventions is not something the insured wanted but merely something he agreed to to keep the insurer happy by getting the preventions they want him to, they can probably even insert in the policy a provision allowing them to change the list in the middle of the policy term. So Id expect pretty good tracking of the latest information. Now contrast the alternative system in which the federal government prescribes the policy, or the preventive-care part of it. There is no way Congress can write this into law right now; we just dont know enough. And even if they could, they shouldnt, because the legislative process is far too slow and unwieldy to cope with the necessary future changes in a timely way. So they will have to leave the writing of the list to some agency. But even an agency is very slow and rigid compared to a private company. They have to do all sorts of studies (but theyre only one outfit rather than many, so they may not do them very well), and publish a proposed rule, and wait a while for public comments, and publish again, and even then they do not have direct contact or any direct relationship with policyholders and may not be able to affect their behavior as well as the local insurance agent could. And even if they _could_ do it well, they have no incentive to. In Washington, status does not derive from success at the nominal mission, but from budget and staff size. A top bureaucrat may very well be able to improve his social life and career prospects by making his agency inefficient. Most government agencies are inefficient and sclerotic and, well, bureaucratic. Optimal preventive care will flourish better in an open market than in a governement-guided system. (The unwieldiness and perverse incentives, at least, apply also to the issue about what lower price by fiat is the right lower price by fiat. Again, these numbers will be often changing, so Congress will have to leave it to an agency, which will be almost as hard pressed to keep up, and have no great desire to anyway, even if the task were possible, which its not.)

End of life care. The same ideas as above, just with larger numbers. But there is a vital extra feature: End of life care, like pregnancy or cosmetic surgery, is mostly a matter of choice, of lifestyle and deathstyle. Yes, there is some luck and unpredictability involved in the details (and you should be able to insure this), but by and large, the length and cost of this kind of care depend mostly on how long and heroically you want to be kept alive. And since you know this long ahead of time, whatever your tastes you should save enough to pay for them. My own attitude is the extreme one: I dont want any end of life care. When I get into a terminal situation (as opposed to a temporary, acute ordeal leading to recovery and a more or less normal life), and when I get into a condition requiring serious, expensive care, that will almost surely mean that I am no longer able, and will never again be able, either to enjoy myself or accomplish anything, and at that point I will have no reason to live, and I will kill myself. And you are correct that end of life care is a large fraction of the total cost of heatlthcare in this country. So if I could buy insurance that didnt cover it, I could halve my premiums on that choice alone. But at present no insurer is allowed even to take a Living Will into account, much less write it into the policy. Why should I be required to subsidize the life-is-sacred crowd?

On drugs without a prescription: Yes, Im serious, very serious, deadly serious. Lets take the strongest case for the legal requirement of a prescription: antibiotics. Strongest becuase misuse of antibiotics can result in antibiotic-resistant microbes that may then infect other people, menacing the public health rather than merely the health of the user. So in principle there might be something to be said for an antibiotics exception to my rule. (There should probably be another for drugs well suited to murdering people.) Yet in America today, antibiotics are so routinely used in food animals, so that we get constant low doses in our meat, that I doubt its worth it to control direct human use. More important for our purposes, the supposed control hardly is. The fact is that antibiotics are grossly overprescribed. An amazingly large fraction of the prescriptions are for colds, flu, and other viral infections, on which antibiotics have absolutely no effect. Yet doctors continue to hand out scripts for them. Similarly for childrens ear infections; these are often bacterial so the antibiotics can and typically do kill the bugs, or most of them, and bring short-term relief; yet empirically, this treatment increases the likelihood of recurrences, so that the kid would probably be better off without. Doctors routinely prescribe it anyway. Why? Because patients (or their parents) demand it, or obviously want it; they dont feel theyve had their moneys worth, had proper respect, unless they go off with a script. And if they cant get it, theyll find a more satisfying doctor. Note the perverse reults of the prescription requirement here. Under my rule, a patient who really wanted a drug his doctor advised against could simply buy it, and then if the results were poor, he would be inclined to go back to his old doctor and pay more attention to his advice. But under the present system, he has to go instead to another doctor, with whom he might hit it off, and then even if he gets disillusioned with Doctor Two he will probably be embarrassed to go back to Doctor One after that sort of disloyalty. So Doctor One doesnt want to risk it; he writes the script. The gatekeeper function of doctors is expensive but ineffective.

Theyre not good on the other side, either: A prescription does not mean the drug is even vaguely safe. Doctors simply dont know very much about drugs; they are not at all the experts you imagine. Somebody recently did a survey test of drug prescribers (MDs, PAs, and APNs). The response rate was distressingly low, and the people who chose to respond were presumably the ones who thought they knew this stuff, so the results should be better than in the general prescribing population. But they were dismal. The test consisted of 14 questions on drug pairs, their interactions and hazards. On average, people got only 6 right. Of the four really dangerous interactions, the average responder identified only one. And these were not obscure drugs or minor risks, but common ones and major risks, in one case potentially lethal. If you want knowledgeable advice on drugs, youre usually better off with a pharmacist than a doctor. But pharmacists (in most states) are not allowed to prescribe.

The distinction between prescription and OTC drugs is artificial and money-based anyway. Have you noticed the way drugs that were too dangerous to be used except by prescription somehow become safe enough to be changed to OTC once the patent runs out and the generic competition heats up? The maker is simply doing, at each stage, what is most profitable. But they do have one legitimate concern in my system: fear of lawsuits for ill effects from misused drugs. But there is a simple fix. Provide that the maker can still classify drugs as prescription, and then if you get it without one and your experience goes bad and you sue, you are held to the same standard of care and expertise as a doctor of the sort who would typically prescribe the drug.

The chief effect of the present system is to delude people into thinking drugs are safe. The OTC ones are safe because theyre OTC, and that must mean theyre safe, right? The prescription ones are safe because the doctor prescribed them, right? But the truth is that there is no such thing as a safe drug. The annual American death toll from drugs runs to six figures. People would be a great deal safer if they understood that every drug is dangerous, that the government will not and cannot protect you, and that every time you go into a drugstore or even the drug aisle at the supermarket you are taking your life in your hands and had better know exactly what youre doing. The change I recommend would make this point much clearer.

Nothing in my freer system would prevent you from getting a prescription from your doctor if you want that advice, and he could perfectly well put it in writing for you to give to the druggist to minimize garbles (though they happen, often, because prescriptions are written so poorly). You just wouldnt have to. You could get advice from anyone you wanted, anyone you trusted. There is a great deal of information available to the general public. There are print and email newsletters, many of them free, and discussion boards and support groups and Medline and the Cochrane reports and all sorts of stuff. And most importantly, if the FDA were gutted as I propose, you would be able to contact the maker of your possible drug (or, probably more importantly, of your more natural substance) and cross-examine them; or if youre not up to doing that personally, the expert commentators would be doing it for you, or you could have a friend or relation do it. And if the sellers people refused to answer, you could infer that they must have something to hide, because surely they would provide good answers if they had any. But in the present regime, you cannot draw any such advserse inference, because legally theyre not allowed to answer. Even a truthful and candid response to a direct and specific question could get them put out of business.. So you cant find out anything. Which makes it harder and more dangerous for you to use your own judgment, do anything but follow the orthodox prescription. Which is why the FDA does it.

But its my life, my body. Im the one whose vital interests are most at stake. And no doctor nowadays has the time to bone up on my particular disease as thoroughly as I would. So my attitude is that while doctors may be very useful as advisers and technicians, in the end I want the right to make the call, make my own decision, as the principal. Sure, this may be dangerous, even fatal. But the fact that something is dangerous is no reason to ban it or even to regulate it. Lots of good things are dangerous. In the crunch, I have more faith in my own judgment than in any doctors. Certainly more than in the FDA; I have so little faith in them that if I knew nothing about an issue except what they said, I would be inclined to believe the opposite. I want the right to back my own judgment and live or die by the result.

Safety doesnt come from regulation; it comes from information, which develops best in a free play of ideas and experiment. If each of us does as he thinks best, then the ones who get it right will live and the ones who get it wrong will die, and soon enough well know which is which and we can all start doing it right and stop dying. Whereas when the government decrees for everyone what to do, and they get it wrong, we all die, and we go right on dying, because theres no self-correcting mechanism. And when it comes to health, government gets it wrong very often.

Quite apart from their economic follies, Congresss reform plans are doomed from the start by their false assumption that there is one obviously best form of healthcare, namely the orthodox MD style, that everyone wants it, and that the only problem is to finance it. Actually, healthcare is riven by vigorous, vehement, often vicious disagreements between various schools of healing. A good system, a free system, allows each his taste. A government-controlled system will decide for everyone what is to be covered and what not. What should be decided first by personal preference and then by science and practical success with peoples health will instead by decided by politics, even more than it is at present. And the political struggle will get even sharper and nastier. Because Congress does not understand any of this, they think the problem is about healthcare financing. But the real problem includes also, and more importantly, healthcare itself. Solve that and the financing problem will half solve itself. Ignore that and no amount of tinkering with the financial end will get us anywhere. "

" Now THAT'S a manifesto! "

" what a waste of bandwidth.. "

" Mr Coyne said: "A government-controlled system will decide for everyone what is to be covered and what not."

My health policy says: Well, actually I have about 25 pages of what they will and will not cover, AND only the charges that THEY feel are customary or average for the area which is NEVER the full amount we are billed IF preapproval has been approved by some unnamed commssion of strangers and not my doctor. Our current system already "decides for everyone what is to be covered and what not". So, please explain the difference because this is one Faux Noise talking point that has absolutely no teeth and yet it keeps getting repeated over and over and over. "

" GOP leader chuch grassly and his priorities:

GRASSLEY: Certainly not. And I told the president that a week ago Thursday and I told Max Baucus that over a period of three or four months, so Im not telling you anything new. In fact, let me build on what you said and why I say that I wouldnt be. Im negotiating for Republicans and if I cant negotiate something that gets more than four Republicans, Im not a very good representative of my party. And secondly, were talking about health care, thats life or death for every American and were talking about one sixth of the economy.


gee chuck if it's life or death and 1/6 of the economy......should it come first and not second to the "party of no?" see chuck, that's why the gap is suddenly widening with people with any brains wanting this reform ASAP. "

" Now we know why they have a 400 word limit. "

" HOLY COW!

Eat ya heart out, Mike P!
LOL!
:-) "

" Becky,

I dont know what other people have in mind when they make similar-sounding statements, so Im just going to speak for myself.

Essentially, its a matter of degree. I entirely agree with you that the current system already deprives us of appropriate control over our healthcare and healthcare coverage, vesting too many decisions in those faceless committees or whoever. Thats one reason Im proposing radical reform. But as bad as it is, it could get a lot worse, and it will if anything like what were hearing about is enacted. Because those plans accept and perpetuate and encourage and enlarge and aggravate the very features of the current system that cause the problem. But my proposal, reform in the opposite direction, attacks those features and will minimize the problem (though it cannot be completely eliminated). The big contrast I was trying to make is not between government control and the present system but between government control and my system. Thats why I ended the passage you quote from with the qualification that theyll be determining coverage for everybody even more than now.

Unfortunately, explaining how this works may be a little lengthy, again, because Im not sure what you mostly have in mind. There are two aspects or stages of determining coverage. First, someone has to decide what the policy covers in the abstract, or in other words what the policy itself is to say, what its language is to be. This is what I was talking about in the paragraph you quote from. What I had in mind was questions like, Are you covered if you go for a midwife instead of an obstetrician? An acupuncturist? An Ayurveda practitioner? An M.D. in Rumania, using methods American doctors frown on? -- and what about the airfare and the motel room across from the hospital? And so on. In my scheme there might be also a more detailed checklist of conditions and treatments to be included or not. There is also the question of how much they will pay. Everything, or 80% or 50% or what. And the deductible. Basically the 25 pages you speak of. And then at the second stage, somebody has to decide whether and how your particular condition and treatment fit into the policy categories. Have you sufficiently proven you have the disease to justify the treatment? And what is the appropriate price for these services? It sounds like your personal grievance is about this second aspect. Also, you didnt say how you acquired your policy, what kind of insurance it is. So I have to deal with several cases and variants.

If you want maximum control, pay cash. That way its just you and the doctor, with no third-party payer to second-guess you. (At present, the medical Establishment can second-guess your doctor and corral you, but under my proposals that would change.) Next best is individual insurance. The insurer will supervise the medical decisions to cut down on the chance of your suckering them, but cannot be arbitrary or often wrong, because you have a direct and voluntary relationship with them. When they mess up, you can call them and squawk. And their ability to keep you as a customer depends on your satisfaction, and their ability to attract new customers depends on their reputation for being reasonable about claims. So its something of a hassle, and there will be the inevitable frictions, like when the provider and the insurer disagree about what is customary, each naturally in its own favor; but on the whole it shouldnt be too terrible. (In particular, it shouldnt be as bad as casualty insurance has become recently, because health claims happen much more often than casualty ones, so the satisfaction and rep effects are faster and stronger.) If you have group insurance through some voluntary group of likeminded people, maybe largely in it for the insurance, thats an intermediate case, not quite as good. And the worst is employer-provided insurance. Because now you cant personally yell at the insurance people, and they know you cant individually opt out and get another company. Everything has to go through the middleman, the employer. Which at best makes for delays and garbles and excuses. And this is only one, minor piece of your total employment relationship, and you are only one among many employees, so neither you nor the employer is likely to do anything drastic over your quarrel with the insurer, and the insurer knows it. To make it even worse, because employees are not involved in choosing the insurer they have no reason to study insurance company reputations, and people typically assume theyre not going to get sick, and dont think about it much or take it much into account in their employment decisions. So the employer is tempted to pick an insurer on other grounds, like sheer low bid, ignoring the claims atmosphere because those problems will develop only later. So if the insurer wrongs you, you dont have much practical recourse. And likewise if you mess with them, since they cant drop you individually; so in fear of that, they will trust less and supervise more and crack down harder. All very unpleasant.

With that in mind, look at the politicians plans. They all embrace the idea and goal of coverage; the assumption is that it is best to maximize insurance and minimize cash. The details vary, but basically they want to pressure us to have insurance, make it costlier than it is now (if only in unachieved subsidies) to do without. In fact, those pressures are going to have to be, or become, irresistibly strong. Because one thing all the negotiators seem to agree on is forbidding insurance companies to deny coverage or charge higher premiums because of a pre-existing condition. And that rule cant work without an individual mandate or the equivalent. Because if people can opt out, then healthy people will do so until they get diagnosed with a serious condition that will require expensive treatment, and at that point, and only then, they will sign up, at the same rates as if they didnt have any such problem, thus saving all the premiums for the years they went without. This adverse selection cant be allowed, so insurance will have to be compulsory. And as between types of insurance, all the politicians seem to agree that employer-provided is best and to be encouraged, through various pressures against failing to provide it. This may be partly to minimize the previous problem (individuals strategically doing without), but cannot solve it entirely unless employer coverage is universally mandatory, which is probably impractical. So we will get the semi-mandates on both sides. From the point of view of claims hassles, how much coverage you actually get in practice how easily, these preferences and pressures are utterly perverse, an inverted scale in which the worse is preferred to the better. Your grievances against insurance companies will become more grievous and less avoidable.

For me, however, the more serious issue is with the first stage, the policy provisions. These are already far too standardized, partly owing to legal mandates (which I want to repeal), and there is too little competition among insurance companies, largely owing to the way the industry is dominated by employer insurance. Because in any large group of people like that, their idiosyncrasies wash out in the averages; there is less difference between two large groups than between two individuals, and thus less room for niche companies with inventive policies. And anyone with minority tastes is out of luck in employer insurance, which is naturally designed for the more typical people. Both these problems will only get worse as employer insurance is further favored. In addition, the government itself will have to impose more mandates, amounting almost to writing the policies. Because you cant subidize something without specifying what exactly qualifies for the subsidy; otherwise there will be fake policies that do nothing but collect the subsidy. And you cant mandate or twist arms into coverage by employer or of individual without specifying what exactly is required. Sure enough, the most detailed, best known of the plans looks forward to forbidding, starting in a few years, any new insurance that doesnt conform to a particular federally-drafted model policy. At this point I must point out that there is a link, a tradeoff, between the two stages of coverage, through the payment fraction. The less of the charges the insurance pays, the higher your co-pay, the more inclined the claims adjusters will be to trust you, take your word for things, because they will figure you are paying so much of your own money for this whatever that you wouldnt be doing it unless it were really right and necessary; whereas if they are paying almost everything, they must worry that its not really necessary or a good idea and you are doing it only because it is almost free to you, and so they must ride herd on you. So by going for a higher co-pay you can improve your claims experience. Obviously this tradeoff depends on many factors, including your finances, your relationship with your doctor, and the insurance companys reputation. Different people will want different choices. And again the march toward employer insurance will interfere. And the government policy-writing will make it worse. Because they do have to limit these choices; otherwise well see insurance with zero payouts and 100% co-pays, in other words fake insurance, to evade the other mandates. To stay far away from this, the government is likely to mandate quite a high figure, based on what seems typical, and again those with minority preferences, who want lower, suffer.

Worst of all is the plight of the minority healing method or school, and those who want it. What kinds of healing are covered is one of those many things that must be federally controlled, because were not going to subsidize voodoo. And even if it didnt have to be, the government wants to control these things and will take any excuse to do so. This playing field is already tilted steeply, but at least there have been some escape hatches. Insurance has not been entirely standardized, and in recent years there has actually been some movement toward policies covering alternative medicine. If you cant find a policy you like, there has been for at least some (without employer plans) the ability to go without insurance and use the money to pay cash for your favorite methods, which tend to be cheap. And there is at least some competition between states and their regulatory regimes; if you cant stand yours, you can at least think seriously about moving. But the New Plan will increase the prevalence of employer plans, hike the costs of opting out of insurance, and centralize the rules so that moving to another state wont do it, youd have to move out of the country, which is much harder. So well all have to pay for the federally favored methods whether we use them or not, which will make it very costly to use any others and have to pay for those also. Their use will diminish, and so will the pace of their development and improvement through practice and experience and research, therefore they will become even less competitive with time. The federal government will have a stranglehold on healing methods, able to choose which ones prosper and which ones are destroyed. They will make those decisions according to political pressures and favoritism. And we know who will win, namely the same people who win now, because nothing will have changed in the political balance of power. We will all be at the mercy of the big drug companies. "

" 1. "First, someone has to decide what the policy covers in the abstract, or in other words what the policy itself is to say, what its language is to be"

With a universal, one policy language, we would all know exactly what was in it.

2. "Because then the payers feel wronged, feel like victims, and they may be right; this sort of thing is often little better than legalized robbery"

We are already paying for the uninsured through higher premiums, taxes and medical bills. And, the uninsured's medical expenses are usually 100 times higher because their only option is to use emergency rooms for treatments that they could have gotten from a doctor's office visit.

3. "If I am going to have to pay for your quintuple bypass, then I would be better off if you were dead"

You already do pay for it Mr. Coyne. Eliminating the profit drive and unnecessary middle man and transferring those billions to actual healthcare instead of mansions and limos would cover those who are less fortunate and getting their bypass anyway. "

" "we will all be at the mercy of the big drug companies"


Not if I can help it. "

" I, like many people who post here don't read epic essays like those posted by mr coyne.

robert you may have some legitimate points, but if you can't say it in a few paragraphs, don't bother. "

" He's worried about a 1000 page bill then writes a 1000 page post!?!? "

" Here's how the debate goes on cable TV:

Right-Winger (to Left-Winger): "YOU HATE AMERICA! YOU WANT TO HUG TERRORISTS! YOU WANT TO KILL MY GRANDMA AND SET FIRE TO MY SPECIAL NEEDS BABY! YOU WANT TO DESTROY AMERICA AND TAKE AWAY ALL OUR FREEDOMS AND TURN AMERICA INTO SOVIET RUSSIA!!!"

Left-Winger (to Right-Winger): "That kind of hatemongering is un-American."

Right-Winger (to Left-Winger): "WHAT?!?! YOU JUST CALLED ME 'UN-AMERICAN'!!!"

Left-Winger: "No, I didn't, I "

Right-Winger (to Left-Winger): "YES YOU DID! YOU CALLED ME UN-AMERICAN! YOU DON'T RESPECT FREEDOM OF SPEECH UNLESS IT'S FROM YOUR SIDE! YOU HATE AMERICA! I DEMAND AN APOLOGY FROM YOU, AND ALL LIBERALS AND DEMOCRATS MUST MAKE FORMAL STATEMENTS DISTANCING THEMSELVES FROM YOU!"

Host: "Thank you both for coming on, very exciting. Coming up next..." "

" Mr Coyne, please-


try to keep each post under 6000 words...... "

" TheQuestion, you really need a vacation or something! "

" father bob et al.,

If I could say it briefly, I would. Believe me, I don't enjoy staying up till all hours trying to hold up my end of the discussion. But some things can only be explained at length, at least to an audience that cannot be assumed to have the necessary background. Economics is often counterintuitive, because our brains are designed for gathering, hunting, scavenging, and swinging in the treetops, not for a large-scale trade-based society. If I can go step by step, methodically and exhaustively, I can hope to make each step in the logic small and simple and palatable, and thus make the conclusion studiously plausible. When I skipped all that and merely asserted and alluded and sketched, I was asked whether I was serious and whether I was nuts. This stuff does not come natural or easy.

If you'd just been seated on a jury, would you go to the judge and say, "Now I don't want to spend a week listening to all that examination of witnesses and documents in evidence nonsense; just have each side state its case in a couple of minutes, and then we'll decide"? If you were elected to the U.S. Senate, would you want to change the rules to eliminate extended speeches and allow only one-minutes? If your chld just started high school calculus, have you refused to splurge for the textbook and told the kid to make other plans for that slot starting next week, because the teacher should be able to explain all the important bits in a few classes? Of course, average citizens don't feel as much responsibility as jurors or senators, or have as much personal stake as students -- this is one of the problems of democracy. But if you've got time to hang out on virtual street corners and jeer at passersby, you've got time to read something serious. You could learn something. "People with brains" usually do read stuff, more than a few paragraphs.

If you don't want to I can't make you. (My posts don't have the force of law.) I know that not everyone here will read what I write. But some may, just not you. Whereas if I don't write it, no one can read it. So I hope enough people will read it to be worth the effort. The average American spends hours every day watching TV. Is it too much for me to hope that some significant number of people might be willing to spend maybe ten minutes reading about the hottest issue facing the country?

Thomas Jefferson once argued that a certain farm implement must have been introduced first in America, because it bore a strong resemblance to and had probably been suggested by something described in Homer, and "Only American farmers read Homer." And in those days, he was right, they did. (Now there's an epic!) As late as the mid-19th century, Lincoln could and did give long, detailed, thorough, lawyerly speeches (to a general audience), and he succeeded with them, he was admired for them. We've lost that now, and this is a big reason for our troubles. You'd better hope there's some spark left for people like me to revive. "

" Becky,

>With a universal, one policy language, we would all know exactly what was in it.
Even assuming so (heroically), you wouldn't have any _choice_ about what was in it. Unless your healthcare philosophy, your death philosophy, your family-size preference or philosophy, your sensitivity to pain, your genetically weak organs, your financial situation, your extended family, and your social network are all just about average and typical, the one policy language decided by the federal government will not be what you really need or want, will not be as good for you as what you could get in a more open market. Think of food. Why make people read all those complicated labels (if they care what's in it and whether it's good for them)? Would you prefer to find, when you go to the commissary (run by the commissar), that theres only one, standardized breakfast, one lunch, and one dinner to be bought? And that the breakfast consists of 50% high fructose corn syrup, 40% trans fat, and 10% artificial flavors and colors, because that's what the most powerful players in the industry lobbied the government into prescribing? Or how about clothes. You don't want to have to spend time choosing among that bewildering variety of clothes, and have to read labels to see what it's made of and how to take care of it and who designed it and where it was made, and have to worry that somebody else's outfit might better made or more stylish, now do you? So just wear this uniform, we've even fancied it up with this Red Star.

And the universal policy will have the worst possible case of the problem I mentioned in the original letter: When you as a voter, through your representatives in Congress, decide how much healthcare to pay for (whether in taxes or as premiums for the only permissible policy), you will be conscious of the costs, you will not be willing to pay unlimited amounts for every conceivable incremental or cutting-edge treatment, but then when you as a patient decide whether to go to the doctor for the ticklish throat, or whether to have the MRI for the mysterious ailment, you will think of it all as nearly free, because for you at this point it will be. So people individually will always be demanding more healthcare than the system collectively is capable of providing. In fact, even if the money could somehow, miraculously be found (Are you imagining that taxes are for other people?), the professionals couldn't. There's already a shortage of doctors in many places, and of nurses almost everywhere; a sudden influx of the newly covered would break the system. So healthcare will have to be rationed. Traditionally, single-payer nations have done this mostly by waiting time -- That's why Canadians come across the border to get their healthcare in the U.S. Something like it has been popular in the U.S., too, because of our overcoverage; that's why the doctor is on too tight a schedule to listen to you. But of course it can also be done by human decision. The faceless committee will be bigger and busier than ever, and you won't be able to escape it by switching companies. And if they don't like your race or your political viewpoint, are you going to be able to prove that? Oh, and the death panels aren't imaginary, aren't just something dreamed up out of thin air for political purposes. There was a scandal recently in Britain when the relevant agency decided that a guy couldn't get treatment because at his age they weren't going to spend more than I think it was $22,000 on him, it wasn't worth it. And in this country, also recently, two NIH experts opined in print that one really must weigh costs and benefits in making these decisions. And once those costs are collectively and involuntarily borne, they're right. Once the rest of us are paying for your end of life care, how long do you think it can be before we start wondering whether you're worth it? And again, I don't care if it's not in the bills in Congress; it's hardly escapable in the logic of the plans.

>We are already paying for the uninsured....expenses are usually 100 times higher because their only option is to use >emergency rooms for treatments that they could have gotten from a doctor's office visit.
This is indeed a problem, but it comes from more of those bad laws I want to repeal (but didn't have space to mention in the original letter). The laws requiring hospitals to take all comers in medical need should be relaxed, so that emergency rooms can be reserved for genuine emergencies. For those, we do need a law requiring them to take you in first and worry about money later, because in a genuine emergency there isn't time to negotiate anything or prove your ability to pay. But when they discover that you don't have an emergency at all, just something that you should set up an office visit for, or should have earlier, they should be able to turn you away, and bill you for their valuable time that you wasted. People would learn this soon enough and stop doing it. And under my system, they would be able to afford the office visit.

Incidentally, the current illicit tactic is not always a matter of financial necessity. The most extreme version happens near the Mexican border, where pregnant Mexican women cross the border and head for the nearest American hospital to have the baby delivered. The hospital has to do it, and the illegal alien gets not only the elaborate obstetrics that she'll never pay for but also birthright citizenship for the baby. Obviously, obstetrics is almost never an emergency, short of sudden premature labor, in which case one would hardly be reacting with a border crossing.

>You already do pay for [other people's quintuple bypasses]
True, but again, that's because the present system is lousy. A bypass is one of those common, expensive treatments that I would never want, except maybe in an absolute emergency, if I am having a heart attack or just had one. For the mere "ticking time bomb," it's not a good idea. The heart can regrow new blood vessels, do its own bypass. And meanwhile, there are ways of cleaning out gunked arteries throughout the body, which is important since the problem always extends beyond the coronaries. Surgeons do bypasses at the drop of a hat because they're hugely profitable, not because they're medically appropriate. So I would love to be able to get insurance that excludes (most) bypasses. But I can't.

>Eliminating the profit drive and unnecessary middle man and transferring those billions to actual healthcare instead >of mansions and limos would cover those who are less fortunate
You seem to have a backwards notion of economic causation. No company does or can say to itself, "Gee, it'd be nice to make an extra billion in profit this quarter, so let's pay our suppliers half a billion less and charge our customers half a billion more." If they tried that, they'd have no supplies and no customers and they'd be out of buiness and in bankruptcy court in no time. In any productive process, the prices of both the inputs and the output are determined largely by the surrounding economy, "the market," based on how valuable the inputs would be if used for other purposes instead, and how valuable the outputs are to the customers, given whatever ability they have to get substitutes from elsewhere. The profit (or loss) is whatever is left over after the subtraction. If it's large, that means the economy was out of whack, prices were out of whack, such that there was an opportunity to buy cheap things and convert them into something much more valuable to people, and the company has found and seized upon this opportunity, with the effect of making society richer. Normally, the profit will gradually diminish as competitors enter the market. Big Insurance may well be able to prevent that by corrupting the insurance regulators into making it nearly impossible for new companies to enter. But that is a matter of too much regulation, not too little. "Eliminating the profit drive" does not "transfer" wealth anywhere, because the wealth does not yet exist; it comes into existence _as_ the profit. If there's no profit (allowed), there's no reason for anyone to figure out what kinds of production would be profitable (i.e. increase the total value of things), or to engage in the process even if they know what it is. Similarly, few people in a capitalist society get mansions and limos by being useless; they get paid that much for doing something valuable to the company, necessary for the productive, profitable process. If they can't get their reward, they won't do the work, and the process won't happen, the valuable output will remain hypothetical.

Incidentally, I believe that my proposals, if implemented, would bust the insurance industry wide open. Not only would there be room for many more "niche" companies, but the center, the mainstream of the market would shift dramatically, and with it the knowledge and skills and connections needed to succeed. The current dominant companies would lose their advantages and I suspect many of them would be hard pressed to survive. Plenty of mansions and limos would go under the hammer. And the new, more numerous people wouldn't have such a hold on the regulators, either, so whatever unfairness there is in that quarter would decline, too.

Frankly, what you seem to want is socialism. (Sorry, The Question, but if this sort of thing is said too often, it's partly because it's too often true. When someone urges, in reference to a huge sector of the economy, eliminating all consumer or producer choice in favor of a one-size-fits-all determined by the government, and further decries and proposes to eliminate "the profit drive," apparently as such, what can you call it but socialism?) It's been tried, and it doesn't work -- Ask anyone in Eastern Europe. In this system, the mansions are called dachas, the limos are black and don't stop for you in the crosswalk, and all of us here on these boards are targets for the bullet in the back of the head in the bassement of the Lubyanka. "

" Medicare and Social Security are that awful socialism at work, Robert. Ask elderly Americans if they'd like to see them ended because of your theoretical antipathy to their existence. "

" At a Barney Frank town hall meeting in Dartmouth, MA, a constituent asked, "Why are you supporting this Nazi policy?"
Frank responded, "On what planet do you spend most of your time?" He then called her approach "vile, contemptible nonsense." He closed by saying: "Trying to have a conversation with you would be like arguing with a dining room table."
About time. Let the morons have it with both barrels, Dems. "

" Mr. Coyne,

You state that government run healthcare would dictate to it's patients what care and from whom they would recieve. Well, I beg to differ. My mother just died of cancer. The doctors let her decide what treatments she may want or not want. The medical staff made sure she was as comfortable as possible. If she was in too much pain she could go to Sarah Bush and they took care of her and when SHE decided she was well enough to leave, they let her go home and set up, basically, a hospital room at her home with visiting nurses and hospice. She was taken care of with utmost care and all of the decisions were hers, after the doctors explained to her all of her options. And after all of this wonderful medical advice and treatment, guess who her "insurance" was....medicare!!! So you constantly repeating that the government would control all aspects and decisions is unfounded and purely ignorant of the facts. My mother could not have received any better care, and probably worse with private insurance due to their many "regulations and limitations" on their policies. The most fascinating thing about most of the people who are against universal coverage are already on a government controlled plan....medicare. "

" Robert Coyne, I've never seen such arrogance! You want health care designed around YOUR wants (what makes you the person to decide what's right for me?) -- and some of those wants are, at best, medically questionable (such as wanting to do away with the need for all prescriptions and just let the patient go in and tell the pharmacist what they want/need, as you wrote in your first letter, or your desire to ban most if not all heart bypasses because YOU'D never want one).

And it is the epitome of arrogance to basically tell us that "you hunter-gatherers don't have the mind to comprehend this complex subject unless I spout off about it for an hour." Believe it or not, some of us have evolved and can actually discuss them hard-thinkin' subjects without bein' all con-fuzed, and we can do it without yer fancy (and inefficient, needlessly wordy) phrasin'. "

" Hahvahd wrote on Aug 19, 2009 8:17 AM:
"And it is the epitome of arrogance to basically tell us that "you hunter-gatherers don't have the mind to comprehend this complex subject unless I spout off about it for an hour." Believe it or not, some of us have evolved and can actually discuss them hard-thinkin' subjects without bein' all con-fuzed, and we can do it without yer fancy (and inefficient, needlessly wordy) phrasin'.


Great Post!!!.....i read the first two sentences of his reply to my post and came to the same conclusion. a narcissist at the very least. more impressed with himself and his thoughts on anything than to have a relevant debate. leave him to his essays. "

" When I come to Coyne's posts, I'm thankful my mouse has a WHEEL which lets me literally run over them. "

" Becky,

>My mother just died of cancer.
(My condolences, of course.) This is the most important fact in your post: Your mother _died_ of her cancer. This is typical when cancer patients are treated with orthodox methods. After half a century and many billions of dollars of federal research money for a "War on Cancer," the cancer death rate has hardly budged. Nor have the standard treatments changed much; there have been minor improvements, but basically the big three of surgery, cytotoxic chemotherapy, and ionizing radiation are the same as when the War started. And it doesn't work. There are ten or a dozen particular kinds of cancer, all rare, for which these methods do work pretty well and can be advised. But for all the common cancers, surgery may be necessary or useful to minimize the immediate threat but is not reliably sufficient by itself, and chemo and radiation are ineffective, even counterproductive, and have horrible side effects, but are nevertheless routinely recommended. The cases of "spontaneous remission" almost always are of patients who used "alternative" methods, and especially if they didn't first wreck their bodies with the orthodox ones. Cancer is a very serious illness, against which even the greatest healers may fail, so I am not telling you that if your mother had been better treated she would have lived. But I think it very possible, far better than an outside chance, something more like an even chance.
>The doctors let her decide what treatments she may want or not want ... after the doctors explained to her all of her >options
I doubt that very much. Did they explain to her all those alternative-medicine options? Did they tell her, or you, about hyperthermia? IV vitamin C? Low-dose chemo with insulin potentiation? Graviola? And there are many more cancer cures, with new ones coming out all the time. Did anyone tell the two of you to contact Ralph Moss for his latest advice? Did anyone offer to pursue these approaches if your mother wished to? No, of course not, because these methods are illegal in this country; more open-minded doctors would be risking their careers, their licenses, even their freedom. So don't blame the doctors; they probably didn't even know about these options, because it would be imprudent for them even to inquire into such matters. A doctor who looked into one of these treatments would either find that it doesn't work, it was a flash in the pan, in which case he has wasted his time, which is precious, or he would find that it does work, in which case he has put himself into the horrible dilemma of either practicing it and suffering the legal consequences or keeping his mouth shut but now with a guilty conscience for betraying his patient. Best to keep his mind shut from the start. The fault lies with the system, the legal and professional regime, and my first recommendation for reform addresses this. Had my plan been adopted before your mother got very sick, she might be alive and well today.

>at her home with visiting nurses and hospice
I can't be sure, of course, but most visiting nurses, at least the ones from the Visiting Nurses Association, are unpaid volunteers. Your mother may have gotten her wonderful care more from the kindness and generosity of a segment of the nursing profession than from Medicare. As for the lesser caretakers involved in home hospice-type care (and maybe the nurses, if I'm guessing wrong), I have the impression that Medicare only pays for the narrowly medical services. Most dying people also require help with daily living. Your mother was lucky: She had you. Had no loyal daughter been available, your mother would have needed a Home Health Aide or at least a homemaker. And I don't think Medicare pays for those, so she would have been out of luck unless she had private Long Term Care insurance. (Incidentally, LTC policies are always written in a way that for anyone with common sense sounds nuts. This is because they have to be that way to qualify for yet another special tax break. But explaining would take us too far afield.)

Notice that your mother's decision to spend her last months at home saved Medicare a ton of money. She wasn't trying to occupy an expensive hospital bed; she was paying for her own real estate, far from the fancy equipment, and you were contributing services for free. Her preferences and Medicare's interests aligned, with no occasion for conflict. Similarly, when she needed to go to the hospital for the occasional bout of acute pain, it sounds like she left soon enough, as soon as she felt better, so she never ran up against Medicare's time limits for hospital stays. In short, your mother was very lucky. And anyway, a sample of one doesn't prove much.

But let's assume that you are completely right about the facts and their short-term interpretation: Medicare was perfect not only for your mother but for everyone enrolled and in need. That would simply explain how they have been digging themselves so deep into the financial hole, in such an unsustainable way. Every Ponzi scheme looks wonderful in the early days; that's what sucks the suckers in. Social Security was a glorious windfall for the first retirees on it, who collected SS payments without ever having had time to pay much in employment taxes; the problem comes later, when the whole political folly is dumped on the generation that pays employment taxes all its life and then suddenly and unexpectedly collects nothing because the system went bust as they retired. If your mother had been an early investor with Madoff, but died before the crash, and you and the other heirs had different ideas and took the money out in time, would you now be singing praises of Madoff for doing so well for your mom?
Medicare did OK as long as it had the demographic wind at its back, with the Boom generation supporting a relatively small generation of elderly. But already by now, just recently, that's changed -- as it was bound to do some day -- , and it will only get much worse as time goes on. Meanwhile, since the Medicare figures are fixed by politics rather than by any intelligible principle, and because the gray lobby is so powerful, government has been generous to them. Your mother died while the dying was good. But it can't go on that way for the whole big picture. A community activist can organize his little community to fight politically for gains at the expense of other communities, of which there are many; but when he becomes president and is supposed to try to represent _all_ the people, with no outsiders to defeat, it gets much tougher.

If you don't want to see this, then have I got a deal for you! Come to the Coyne Casino, and play roulette, betting each time on 35 numbers. See, you won your first three plays, so why not triple the stakes? And you can play blackjack, too, doubling up each time you lose; after all, you're almost sure to win eventually. If you judge everything entirely by raw experience, you will fall for such things, and you will regret it in the end. To understand in advance, in time to avoid them, that these are bad moves, you need theory. "

" Hahvahd,

>You want health care designed around YOUR wants (what makes you the person to decide what's right for me?)
I'm not trying to decide what's right for you. Certainly I want a system that meets my needs, but not to the exclusion or impairment of yours. In my system, I get what I want and you get what you want. In fact, you would certainly get your preferences much better, more closely, than I would mine, because the market would attend more to the more typical and numerous type of person than to outliers like me. It is you who are trying to decide what's right for me. But when we are allowed only such choices as are politically approved, and especially in the extreme (Becky) plan of one single policy for all, then we have to fight politically over what those terms are, with the stakes life and death. The unpleasantness on this thread will become everlasting. In my plan, we don't have to fight, there's nothing to fight over, because it's all decided individually, each to his taste.
.>your desire to ban most if not all heart bypasses because YOU'D never want one
Again, you are misrepresenting what I've said. I don't want to "ban" bypasses, I just don't want to have to pay for something I don't believe in and will never use. If you believe in bypasses and think you might want one, you should be able to buy a policy that covers them, and pay premiums accordingly.

>some of [your] wants are, at best, medically questionable (such as wanting to do away with the need for all >prescriptions
One of my main points is that most things in medicine are questionable; that's one reason I want decisions made by the principal, the patient, rather than by second and third and fourth parties the patient doesn't trust. I've argued the prescription issue at length, and you haven't deigned to respond to anything I said; you simply repeat your bare opinion. But I won't complain, because this gives me the chance to add an extra point, a couple of examples of when needing to go to the doctor for a prescription seems just ridiculous. Back when, I got athlete's foot (with complications), and the dermatologist prescribed a prescription cream, which did the trick. But of course athlete's foot is a hardy little fungus, and eventually there was a recurrence. By that time, I had moved away. Luckily, by that time the drug had gone OTC and I simply bought it, and it worked again. Which was extremely likely, because obviously this was far more likely to be a recurrence of the same old strain than something entirely new and independent. And if it hadn't worked, I would have realized that soon enough, and could try something else, maybe including going to a doctor. But if my initial infection had been earlier in the patent period, so that the drug was still prescription-only at the second need, I would have been forced to go to a doctor for nothing but the legal script. Second case: precautionary measures against possible future needs, especially public health emergencies. There are a number of prescription drugs I would like to keep on hand just in case. That way I won't need to waste any time if the time comes. Besides, in a pandemic or other emergency, half the doctors themselves will be out of action sick, and the remainder will be overwhelmed; that's no time to see a doctor. At present, I don't have the medical problem, so there's nothing to diagnose, and I do have plenty of time to research the matter as much as I like, to figure out what I want. But the law won't let me just buy it; I'd have to try to locate a sympathetic doctor and schedule a visit just to try to convince him that my wish is acceptable policy -- for it's hardly a medical decision at all.

In fact, the whole issue of whether to require a prescription is not a medical issue, not anything that could be medically right or wrong or questionable. And my plan would not deprive you of your prescriptions; as I've explained, you could still get a prescription just as easily as now, if you want one. The only thing my plan deprives you of is the law -- and the resulting comforting social reassurance that every other layman is as incapable as you of making drug decisions. And similarly, your imagining that I want to ban bypasses and decide what's good for you is rather an amazing feat of misreading. I suspect you are confusing medical need with political cravings. If what you really want, really "need," is political victory, enactment (or at least preservation) of your political agenda, that being something your heart is set on and vital for your emotional equilibrium, then of course any political opposition will feel like an attempt to deprive you of something. But that's the only thing I want to deprive you of.

By the way, the U.S. did not require prescriptions till some time in the 1950s, and many nations still don't. This is one of those things that after a while just come to seem so "natural" that people forget anything else is possible and any suggestion of change seems "nuts." Sort of like racial segregation.

>Believe it or not, some of us have evolved and can actually discuss them hard-thinkin' subjects without bein' all con->fuzed
Then why haven't you done it, why don't you do it? And why have you and others here made so many statements so clearly wrong as to show unmistakably that you _do not_ understand these things? Yes, in principle it's possible that you might; adaptation isn't everything, and there are lots of things the human brain can do for no direct evolutionary reason beyond that its abilities include some very general. But _a priori_ there is no reason to presume so. When it comes to something so outside the EEA, your intuitions may well be systematically wrong, just as they are about physics and statistics. The only way you could legitimately feel confident about your economic first thoughts would be to have ample experience with thinking such matters through technically and expertly and discovering that sure enough, your final conclusions always seem to match your initial impressions. Obviously you haven't done this.

What you are really saying is that your feelings and intuitions and other first-reaction or that-sounds-right thoughts are sacrosanct, incorrigible in the philosophical sense, because they are the ultimate standard or the only thing. Expertise or even analysis or extended logical thought of any sort is impossible or forbidden. This is a juvenile epistemology, which unfortunately lingers in some people. I hope you evolve in good time to realize that Medicare won't be there for you when you need it.

>Robert Coyne, I've never seen such arrogance! ... And it is the epitome of arrogance
I haven't claimed any authority or asked you to take what I say on faith. Ive spelled out every step in my thinking, in excruciating detail, so as to bring you up to speed on the necessary bits of background expertise and enable us all to discuss the matter sensibly, on its merits, on more or less equal terms. If there were errors in my reasoning you could have pointed them out. You haven't No one here has. My entire argument stands unrefuted and practically unchallenged, except for _being_ an argument. Meanwhile, you demand that I accept your off-the-cuff, uninformed, intuitive, fifth-hand bare assertions as sacred and unchallengeable. As I've explained, you also project onto me your own wish to control other people's lives. And then you call _me_ arrogant?!

Hahvahd, despite your handle you have a bad case of intellectual envy and resentment, just as Becky suffers from financial envy and resentment. Both are vicious, in both senses of the word. Unfortunately, neither I nor your doctor knows any cure. And your political leaders certainly won't cure you; they have built their careers on such vices.

>yer fancy (and inefficient, needlessly wordy) phrasin'.
Yes, I'm sure I've committed some such faults. I'm posting first drafts, because in this informal, somewhat fast paced, and evanescent medium, I don't think the improvements in style from editing would justify the time and effort. Have I written anything so badly phrased that you had real trouble figuring out what I meant? You haven't mentioned anything.

I apologize for posting these responses so late. I really had to get my sleep, or I might soon have needed healthcare myself. "

" Hahvahd,

(Oops. I forgot this in my previous post.)

Have you noticed the inconsistency between your attitude toward my posts and your attitude toward prescriptions? When it comes to discussion on this board, you don't believe there is any such thing as expertise or knowledge, you want everyone to regard your opinions as as good as anyone's, even when they're not. But when I say I want to be allowed to use my own judgment about drugs, you think that shouldn't be allowed, you believe only a doctor can make such decisions well enough to be permitted to.

I think the difference is that superiority in a certified professional, who can be thought of as different and incomparable, isn't as threatening to your self-esteem as superiority in a formal peer. Plus, of course, you're more willing to concede ignorance when it threatens your life or health. You really need the doctor; you don't need to learn anything from political talk. "

" Countries that have universal health care for their citizens:

Afghanistan*, Argentina, Austria, Australia, Belgium, Brazil, Canada, Chile, China, Cuba, Costa Rica, Cyprus, Denmark, Finland, France, Germany, Greece, Iraq*, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Oman, Portugal, Russia, Saudi Arabia, Spain, Sweden, South Korea, Sri Lanka, Ukraine and the United Kingdom

There are only three lacking universal health coverage. The other two happen to be Mexico and Turkey, which have the excuse of being poorer than the rest (and until the onset of the world economic crisis, Mexico was on the way to providing healthcare to all of its citizens). The third, of course, is us.

Are you trying to say Mr. Coyne that you are more brilliant than the rest of the world's minds put together? Oh, my bad....of course you are. "

" No, Mr. Coyne, I do not suffer from intellectual envy; I am merely annoyed by narcissists who speak as though they are ultimate authorities -- yet with offering any evidence of their credentials on the subject. You've written quite a bit, but where-oh-where is any evidence to support your claims, other than the fact that Robert Coyne, the self-appointed genius, has posted them. You're spouting THEORY, nothing that has actually been put into practice. And your theory, for all the volumes you have spoken, lacks substance. The mere length of your argument, sir, does not mean it is a valid one. And your insults -- to Becky, to father bob, to me, for example -- seem, quite frankly, rather transparent attempts to merely belittle anyone who doesn't share your high opinion of yourself.

I'm sure this will bring about yet another lenghty essay in reply, but I won't be reading it. You haven't provided anything convincing in the 100,000 words you've already posted, so why should I assume your next post will somehow be your breakthrough moment. And before you assume that I'm some sort of stupid troll who can't wade through long works, I'll let you know that I'm a professor of literature who has read thousands of long works and appreciated their intellectual challenges, their beauty, their passion. The difference between War and Peace or Moby Dick and the drivel you spew forth, however, is that the former have compelling observations to make but the latter is merely the vomit poured forth from a wannabee prophet. Good day to you, sir. "

" Oops -- I needed to proofread. My bad. Of course, I meant to say that Mr. Coyne's argument is WITHOUT substance. (Volume is not the same thing as substance, Rob.) "

" LOL Good one Cog. "

" Mr. Coyne,

Just because there is no limit to the comments section doesn't mean you should be allowed to go on and on and on and on and on.

Geez Louise! Got Succinct? "