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Jay Lake
Date: 2010-07-29 05:27
Subject: [culture] The politics of American healthcare
Security: Public
Tags:cancer, culture, health, healthcare, politics
Having a bit of a discussion on Facebook with my friend Bryan Schmidt. We don't agree on much politically, but we manage to get along just fine, and remain happily civil when we get into political interchanges. My response to his remarks from overnight was such that I've decided to promote it to a blog post.

Jay, I have a friend in England who hs been denied surgery by their public healthcare several times for surgery the govt claims is non-essential but his doctor says is. In fact more than one doctor because he got multiple opinions hoping to influence the govt decision.

Unlimited government healthcare can be great stuff.

As the case may be, though I'd hardly describe the UK system as "unlimited" anything. I'll point out also that no system is perfect, but the UK has the virtue of nearly universal coverage without significant compromise in social outcomes measured by infant mortality, average life expectancy, etc., where in many cases their system provides superior outcomes to the American system.

Also, though you did not raise this point as such, I'd like to highlight the fact that many Americans don't understand the difference between "single payer" and "single provider" systems. This is largely because the GOP, the AMA and the insurance industry have spent the years since WWII throwing up a deliberate cloud of confusion about "socialized medicine" in order to short-circuit any reasonable discussion of these concepts.

The UK has a single provider system. Canada has a single payer system. In the US, the VA medical system is an example of single provider. Medicare is an example of single payer. Oddly, most people in both those systems like them quite a bit, and would be appalled to discover they are victims of socialized medicine.

The issue is not privatization, it's capitalism. HMOs and drug companies and our culture of greed have created a health care environment where the rich get the best and everyone else settles.

I don't think we disagree much here. Healthcare is a market segment where the profit motive is fundamentally at odds with the nominal mission, which creates a permanent tension.

The government can't run health care any better than any other of its failed, mismanaged programs, espc. In this culture of greed.

Now you're falling into empty conservative rhetoric. Ronald Reagan's greatest, most successful lie was "Government is the problem." Government is no more automatically prone to failure than the private sector is automatically prone to success. The private sector fails all the time. Look at the statistics on the number of private sector mergers and acquisitions that meet their stated financial and business goals. It's abysmally low. Likewise, look at the statistics on how many major IT projects are cancelled or truncated. If the market were the magic conservatives like to think it is, companies would never go out of business.

Similarly, plenty of government programs work very well. Emergency services, for example. Virtually every community in the United States has a publicly-operated fire department, which generally enjoy sufficient funding and little political opposition. And fire departments tend to poll very well. How well would private sector fire departments function?

When you make a baseline assumption that everything government does will be a mismanaged failure, you'll find plenty of evidence for that due to observational bias.

For whatever it's worth, I don't presumptively assume that government healthcare is the answer. As it happens, Medicare is by far the most efficient healthcare funder in this country, measuring by overhead. That is to say, Medicare spends a larger percentage of every dollar on healthcare than any private sector insurance provider. It also polls very well in customer satisfaction. Hardly a failed, mismanaged program.

What government's proper role here is in regulation. That's how our system is established, right there in the Constitution, Article I, Section 8, Clause 3 — Congress is given the responsibility "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes".

The conservative panacea of industry self-regulation is a laughable myth. This has been demonstrated over and over again through our history, from the Gilded Age to Enron to the Wall Street derivatives nonsense of recent years. For-profit companies are by design and law intended to maximize both revenue and profit. Our current system evaluates this on a quarterly basis, with the "long view" being a year or two. There are explicit structural incentives for private health insurance providers to limit payouts, and reduce or eliminate coverage for expensive insureds. Like, say, me.

So whether government enters the coverage business directly (say, by expanding Medicare) or simply regulates the behavior of insurance providers, it must have a role.

Also, for more on my response to Ronald Reagan's anti-government rhetoric, see this post of mine.

If we want to change health care, we need to redefine it as about "Care" and "Health," not a family's egos. When the Schiavos can waste hundreds of thousands of dollars and resources keeping alive their dead daughter, money and resources better spent on someone with the hope of a quality of life, while other people die of diseases and injuries we long ago learned how to easily treat, the system is broken not from conservatism but from its heart. It's not about what it's supposed to be about, but the soft, bleeding heart Americans can't give up, can't let people go, can't allow our loved ones to die. Fine if those poor people do, but not our families.

The Schiavo case is a very odd example to cite in making a conservative argument, given the specifics of it. Her life was prolonged (at great expense, as you point out) against the wishes of her husband through the effort of significant conservative legal and political muscle, given that her parents had rallied the Right-to-Life movement. That was pretty much the opposite of bleeding heart liberalism, forcing government intervention into a private family matter and seeking to remove the decision from the hands of her husband, where it legally and morally rested. Conservative action prolonged Terri Schiavo's life, extended the expense for years, and made a political and media circus out of the tragedy of her death.

Speaking as someone who's been at death's door more than once in the past two and a half years (I came within about two minutes of death at the time of my original ER admission that led to the primary cancer diagnosis), I'd strongly prefer my loved ones not let go and allow me to die. I don't think it's a simple as people being willing to let go, and I don't think that's a "bleeding heart" issue.

It's a sick, corrupting philosophy which government control doesn't change. I've been around the health industry all my life. My dad's a doctor, mom's a nurse, dad trained paramedics and techs, uncle developed ultrasound tech and died of cancer for his effort -- it's a bigger problem than "limited government." It's an attitude.

Again, I don't think the American dysfunction around end-of-life issues is an inherently political issue, though it is certainly subject to politicization. Palin's mendacious "death panels" meme is a very good example of conservatives explicitly undermining efforts to make end-of-life care reasonable, for example. The dysfunction is much deeper in our national psyche than that.

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User: mevennen
Date: 2010-07-29 12:40 (UTC)
Subject: (no subject)
In my experience (for your friend's benefit, having been widowed 8 year ago and having had a partner go through cancer within the last 4, not to mention two relatives with brain tumours and parents in their 80s who are not in the best of health, my experience is pretty extensive), the UK system will generally do its damnedest to keep people alive and to cure them.
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User: nojay
Date: 2010-07-29 12:43 (UTC)
Subject: (no subject)
Just to correct a conservative Republican Big Lie, the UK's health system is not "single-provider" as there is a significant private healthcare system that runs alongside the National Health System (NHS). Many people have private health insurance in addition to their statutory right to NHS care. The largest insurer is BUPA which offers groups such as trade unions the ability to provide discounted private medical insurance to their members.

There is also a small but high-end private medical business, generically known as Harley Street after the locale in London where most of the practitioners have their offices, which provides top-class medicine for rich folks including wealthy foreigners such as Arab sheiks.
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User: arkessian
Date: 2010-07-29 13:51 (UTC)
Subject: (no subject)
NICE (said NHS committee) does have guidelines for the application of surgical procedures (again on a clinical cost-effectiveness and/or ethical basis).
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Kari Sperring
User: la_marquise_de_
Date: 2010-07-29 15:36 (UTC)
Subject: (no subject)
I have a friend in England who hs been denied surgery by their public healthcare several times for surgery the govt claims is non-essential but his doctor says is.

I hear these kind of anecdotes from Americans a lot. It does not reflect the vast majority of UK healthcare. Yes, we have waiting lists -- which are about to get much worse, since some of my compatriots elected the right wing, anti-public healthcare party into power. We have problems and postcode lotteries. But really crucial surgery being denied by the government? Not so much. The problem with stories like that and with another common US claim, that we Britons will all die from cancer because our healthcare is so inferior is that they are nearly all anecdotal, friends-of-friends' reports, or derived from the selective reporting of the right wing press. The NHS isn't perfect, certainly, but it's a lot better than it is sometimes represented as being.
I remain utterly baffled by the way that the words 'socialism' and 'socialist' and 'socialised' cause some Americans to immediately see the worst possible outcome and thus not stop to think through the implications of a proposal -- and, for the benefit of those who don't know me, yes, I do know your history. Universal healthcare provision is about reducing the impact of uneven levels of wealth for the population in such a way that everyone has access to high standards of care, not about dragging the rich down to some imagined gutter standard of medicine.
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Kari Sperring
User: la_marquise_de_
Date: 2010-07-29 15:38 (UTC)
Subject: PS
Am additionally highly entertained to note that the first 7 comments are all from mildly outraged Britons! The NHS? Is our preciousss.
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User: dionysus1999
Date: 2010-07-29 15:40 (UTC)
Subject: (no subject)
As someone who deals with insurance companies all the time (clerical staff for big college hospital system), I'd love to see the whole country insured by Medicare.

Strangely, it's not the private healthcare companies who are the biggest headaches, it's the Blue Cross PPO's, who are supposed to be non-profit. Terrible customer service.
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Kenneth Mark Hoover
User: kmarkhoover
Date: 2010-07-29 16:11 (UTC)
Subject: (no subject)
Excellent point. Single-payer is NOT single-provider. Of course, con$ervatives don't want you to know that...or, as I suspect, they're simply too ignorant themselves to know the difference.
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A large duck
User: burger_eater
Date: 2010-07-29 16:42 (UTC)
Subject: (no subject)
In the early '90's, the VHA was a disgrace. Clinton decided it needed to be fixed and he fixed it. Now its the best healthcare system in the U.S.--vets get great care (doctors are salaried, no fee for service), costs are low (doctors are salaried, no fee for service), and patient satisfaction is higher than in any other system (doctors are salaried, no fee for service).

The point is, a government program can be made better. It can be fixed. It just takes the will to do it.
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User: e_bourne
Date: 2010-07-29 17:08 (UTC)
Subject: (no subject)
We have public fire departments because we used to have private fire departments. When the house next door to you is allowed to burn because they didn't pay the fire department, the whole neighborhood can go up. Excellent for the fire department. Bad for the people living there.

I think this is a good analogy for healthcare. Your family can make my family sick if you don't have healthcare. If you don't have healthcare and so go to the ER because that's how you can get treatment, then the ER is always packed when I really and truly need it. I may die. My husband may die because you don't have healthcare.

Proper immunizations, checkups, health care for everyone is protection for everyone, keeps people productive, working, and the country as a whole in a better situation.

Just like having fire departments, police, and good roads. At least that's the way I see it.
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User: cathshaffer
Date: 2010-07-29 20:27 (UTC)
Subject: (no subject)
A common misconception about emergency room care is that you will die waiting for treatment in a crowded ER. Triage systems actually make this quite unlikely--anyone with a life-threatening condition goes straight to the front of the line, and you can't be denied treatment in an emergency room because of lack of insurance. A poorly run or underfunded emergency department might result in people dying before they are triaged, or being inappropriately triaged, but this is a breakdown at the administrative level. I actually see little support for your thesis that one group's lack of health insurance threatens the life or health of others. Immunizations for infectious disease are the only case where this could happen. However, through community public health programs, most people who want immunizations can access them. The uninsured most certainly are a moral and economic burden on the insured majority, however. I don't think they are a health threat.
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User: ulfhirtha
Date: 2010-07-30 00:33 (UTC)
Subject: (no subject)
"We have public fire departments because we used to have private fire departments" - yes! This point is one which needs making over & over in many areas as well as this one. As an example, We had a bunch of financial regulations because we tried it the laissez faire way & it nearly destroyed us. (in a series of crashes as well as 1929); the same can be said for food, health, fire & police and so on. It was unsatisfactory, to say the least.

Your larger point that the community's weal is best served by community-wide action is a fine one, and one that (as Jay notes) the Reagan mentality attacked. It is rather the point of *having* a community.
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Brian Dolton
User: tchernabyelo
Date: 2010-07-29 17:52 (UTC)
Subject: (no subject)
I'll echo the chorus of faint puzzlement about Bryan's friend in the UK, and I'd certainly like to know more details about what surgery this is and who is deeming it both necessary and non-necessary - someone mentions NICE above but even NICE is nto really "the government", it takes exactly the same role as any private insurance provider would do and decide what is and is not appropriate/affordable treatement. The difference, as several people alredy note, is that if you are going to die and the treatment will save your life, YOU WILL GET IT. Note, however, that if you are going to die and the treatment will merely move your date of death slightly, you may not, on cost grounds (this was the main source of rows over the NHS just before I moved over here, withlots of people claiming that the NHS was denying them treatment, while other people pointed out the treatment in question was not a cure, and had absolutely no record whatsoever of preventing death... nto something that any terminal cancer patient wants to hear, you obviously cling to every day you can wring out of the world, but ultimately if money is limited then someone, somewhere, has to make triage decisions... twas ever thus).

The "government can't run anything" crowd never fail to amuse me. I don't notice them capmaigning for privately run police, or military, If they did that I'd at least have respect for their positions, but to claim the government can't run healthcare (when Medicare and VHA show adequate examples that it can - find me a dissatisfied VHA recipient?) is just risible and I stop debating with such people at that point because it's clear they are not interested in considering evidence, they are only interested in repeating rhetoric.
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Tim W. Burke
User: timwb
Date: 2010-07-30 00:43 (UTC)
Subject: (no subject)
Didn't health care used to be run by non-profit corporations? What happened to that?
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User: farmgirl1146
Date: 2010-07-30 01:08 (UTC)
Subject: (no subject)
Private health care insurance often denies surgery and other treatments, and sometime refuses to pay after a treatment or surgery is done. Been there and had that done to me.
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kest: seal
User: kest
Date: 2010-07-30 03:39 (UTC)
Subject: (no subject)
Jay, I have a friend in America who has been denied surgery by their insurance company several times for surgery the insurance company claims is non-essential but her doctor says is. In fact more than one doctor because she got multiple opinions hoping to influence the insurance company's decision.

This chart is one of my favorites to prove the point that our current system isn't working. Personally, I highly suspect that the current costs have way more to do with the cost of administrative overhead due to the complexity of having so many interested parties than they do with rich American bleeding hearts not being willing to let their family members go.
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