Respectful Insolence

Burning stupid and hypocrisy

No comment other than I’m not surprised at the hypocrisy:

Visit msnbc.com for Breaking News, World News, and News about the Economy

No comment here either. As they say in law, res ipsa loquitur.

I’ve been intentionally vague regarding my position on the Obama health care reform initiative because, well, mainly I haven’t entirely made up my mind about it. However, what I have made up my mind about is that I’m tired of seeing such obvious lies about it.

Comments

  1. #1 Trevor Anderson
    August 14, 2009

    It is natural to hope that things are true which please us, and to hope that things are false which scare us. We may even hope things to be true that make us angry, for there can be something deeply satisfying about righteous indignation. The danger arises when these emotional influences outweigh our natural doubt and curiosity, and we believe or disbelieve things without due diligence.

    The “Obamacare death panel” allegations are a classic (and disgusting) example of this mental shortcoming. Rush and Newt and Palin are so eager to be pissed off at the left that they jump all over this without even the slightest amount of reflection, evidenced by their prior statements supporting what is actually being proposed.

    To be fair, this isn’t just a failing of right-wing nutjobs. I myself fully believed the Bush “French don’t have a word for entrepreneur” story (http://snopes.com/quotes/bush.asp) until I was told better.

    This problem falls more heavily on the religious right (although that opens a chicken-and-egg question), which I find a little ironic. After all, the religious mindset typically puts humans on a pedestal above all animals, and what else justifies that pedestal more than our superior reason? And yet I would say it is not our rational mind but our emotional mind – which we share with the rest of the animals – which is the foundation of religious belief.

  2. #2 Emerson Cardoso
    August 14, 2009

    A single question, my zealot of the “truth”. So to which vaccine company you work for?????

    http://www.anovaordemmundial.com/

  3. #3 Pierce R. Butler
    August 14, 2009

    Trevor Anderson @ # 1 – The Snopes rebuttal to the story about Bush’s mal mot comes from Tony Blair’s “director of communications and strategy” – in other words, the poodle’s Karl Rove, whom there is no more reason to believe than any other accomplice to major war crimes.

    Which brings us back, approximately, to Limbaugh & Co, I’m afraid…

  4. #4 Chris
    August 14, 2009

    Obviously this new troll has not bothered to read the information provided at the top left of this page. Since when did vaccine companies need surgeons? Nor has he read much of this blog when he pulls the lame “Pharma Shill Gambit”.

  5. #5 Monado
    August 14, 2009

    Wow. Just wow. Facts, anyone?

    My doctor moved to the U.S. because she was tired of waiting for the standard amounts that Ontario doles out to doctors for their services. After several years of dealing with a dozen different insurance companies looking for ways to deny elegibility to their insured customers, she came back.

  6. #6 Donna B.
    August 14, 2009

    Wow…

    Gingrich says the current healthcare reform bill is a framework on which all sorts of things we don’t yet know about can be hung from, possibly at the government’s whim and that we shouldn’t trust the government.

    And Maddow thinks he’s talking about killing Grandma or something?

    Sarah Palin were talking about Dr. Emanuel’s theory/proposal “complete lives system” coupled with Obama’s earlier statement about panels deciding what coverage/care could or would be offered under the new system and wondering if the mandate to pay doctors for giving living will advice was a part of that progress.

    I have no idea what Rush was talking about, but the legalzoom ad he read said zilch about “living” wills, unless you assume all wills are living since we can’t write them after we’re dead.

    (I have not paid any attention directly to Rush since he called Chelsea Clinton a dog and don’t intend to start now. I think he’s a despicable person.)

    Sometimes I think people can search the area between the lines so hard they hallucinate about lines that aren’t actually there.

  7. #7 CulturalIconography
    August 14, 2009

    Donna B: I don’t listen to Rush either. Tried it a couple of times, just to be fair. Actually made it through most of his TV show once (back when he had one) and part of his radio show and concluded he has nothing to say I could possibly be interested in. It’s just noise.

    He’s like Coulter, Hannity, Savage, et al; either he really believes the filth he spews, in which case he’s an deranged evil pig, or he’s just doing it to get money from ignorant, bitter and angry people, in which case he’s a hypocritical evil pig.

    I have to laugh when cons say, “He really popular and has a huge audience!” So? Lots of people can be terribly, horribly wrong, too.

    Guess I must be one o’ them socialist/fascists from Kenya, or Mars, or whatever the home planet of the Cylons is …

  8. #8 pinkyrn
    August 15, 2009

    Yes, the stupid, it burns. Why not let the folks who want to die, die? Stop intubating 95 year olds when they have a laundry list of diseases that will never be cured? Seems the folks who have the most opinion have never worked in a hospital.

  9. #9 Robert W. Donnell
    August 15, 2009

    Orac,
    I must respectfully disagree. Rush has never expressed opposition to the *pure* notion of living wills. His opposition is to government involvement in the decision making process, particularly any pressure or coercion, either in perception or in fact. If you listen to his ads for Legal Zoom the main pitch is that it is a do-it-yourself option, with patient and family fully in control. Big distinction, don’t you think?

    Mr. Gingrich needed to be more careful with his words but there was no inconsistency if you listened closely. This MSNBC piece was an unfair juxtaposition of remarks taken out of context. Gundersen is a Lutheran based system (and as such would be expected to be very pro life), which is different from a government based communal system. Current government policy leadership in health care is biased toward rationing selectively against the elderly(just read Zeek Emanuel’s Lancet article!). Again, big distinction.

    Sarah Palin has been over the top, but the same distinctions apply. I don’t think the pure notion of living wills is what’s on the table at all. But I think the policy implications of the government option are very important.

    No gotcha moments here. This MSNBE piece was a cheap hatchet job. Where’s that Oracian nuance and attention to detail I’ve grown to love?

    I was hoping for some down time this weekend. Now I may have to write another post. Dangit.

  10. #10 Orac
    August 15, 2009

    You might have a point with Rush, less so with Newt Gingrich, but you’re off the ranch with Sarah Palin, I’m afraid. She made a frikkin’ proclamation as Governor of the State of Alaska encouraging people to prepare living wills, fer cryin’ out loud! How is that not using the power of the government to encourage living wills? True, it’s not legislation, but come on.

    No, Dr. D, the smear campaign about “death panels” is one of the most despicable lies I’ve ever seen in my life watching politics. It’s so transparently false and so cynically calculated that it embarrasses me that I used to consider myself a Republican. (Well, an independent who voted Republican most of the time.) It’s stuff like this that drove me from the Republican Party.

  11. #11 Robert W. Donnell
    August 15, 2009

    Like you, I’m disappointed at the hyperbole. It’s no different from the dems a few years ago scaring seniors that the republicans wanted to make them choose between medicine and food. It’s politics as usual. Where the MSNBC piece missed the boat was the claim that the republicans are talking out of both sides of their mouths.

    I have to disagree with you about the difference between legislation and a proclamation to raise public awareness. I believe the distinction, especially given the direction current policy makers are bent, is huge.

  12. #12 Orac
    August 15, 2009

    Oh, come on. The Republicans are talking out of both sides of their mouths. They had no problem with encouraging living wills in Medicare legislation because they were in power then and it was their bill. The whole “health care reform = slippery slope to Hitler’s T-4 euthanasia program” is such an incredible load of bollocks that it deserves nothing but contempt and ridicule. Yet the press actually takes this loony conspiracy mongering of the tinfoil hat brigade seriously and treats it with far more respect than it deserves.

  13. #13 The Hypocrisy! It Burns!!!!
    August 15, 2009

    I like the title of your article here, David.

    “Burning Stupid and Hypocrisy”

    That should be the new name of your blog!

  14. #14 Robert W. Donnell
    August 15, 2009

    I went to the PDF of the Republican bill you referenced. As best I can tell it’s quite a different animal from the provision in HR 3200, which seems to take things to a new level in several ways, one of which is that it makes the EOL counseling a performance measure. (See this post):
    http://doctorrw.blogspot.com/2009/08/end-of-life-counseling-issue-needs.html

    HR 3200 also gives a great deal of discretionary power to a health benefits advisory board which, I’ll say again, in this particular administration, is bent toward rationing against elderly.

    Again, no one on the right that I know of is opposing the pure notion of living wills or health care planning. But when you consider the implications of the current bill and the policy agenda behind it, slippery slope and unintended consequence arguments become relevant.

    But I wish the Republicans hadn’t hyped the issue so. All they really needed to do was grab the link to Zeek Emanuel’s recent Lancet article and circulate it around. Great primary source material and, as you said, res ipsa loquitur.

  15. #15 Orac
    August 15, 2009

    Regarding Ezekiel Emmanuel, you might want to read this:

    http://www.time.com/time/nation/article/0,8599,1915835,00.html

    There’s been a whole lot of cherry picking going on regarding Dr. Emmanuel’s publication record, and he has been consistently against euthanasia, it would appear. As for the Lancet article, a quickie perusal doesn’t reveal anything disturbing that would make me think Emmanuel wants to kill grandma if we just give him the power. It looks like a nuanced bioethics paper on how to set priorities when health care resources are extremely limited. I’ll read it in more detail later; maybe I’ll even blog it next week, although it’s a long article.

    Bottom line: This whole bit about the “death panels” is a cynical ploy that fills me

  16. #16 David
    August 15, 2009

    Hi all,

    I thought these words nicely captured the problem with HR3200 and may explain why some of us are feeling uneasy about the bill:

    “It is complexity for complexity’s sake. When one parses out all the legalese, cross-references, and unnessessarily tortuous syntax, one is often (if not in each and every case) left with nothing concrete. To a great extent, the meanings of large sections of HR 3200 are not merely difficult to ascertain, but are fundamentally indeterminate. It has no definite meaning. It is designed for ambiguity.

    This is legislation designed to create a legal framework under which huge cadres of unelected, politically-appointed policy mavens and bureaucrats will determine – by publishing hundreds of thousands of pages of regulations, rules, and guidelines – what our new healthcare system will look like. And until those regulations and guidelines are actually created – and this “creation” will be a never-ending process rather than an act – anybody claiming to know the precise nature of our new healthcare system under HR 3200 is engaging in one of the following: lying, projecting one’s own wishful thinking, or extrapolating on the perceived behaviors and beliefs of those who (one surmises) will finally get to make up all the rules.

    So nobody voting for HR 3200 will possibly be able to say with any degree of certainty what they are voting for, or what, precisely, a healthcare system will look like that comes from this bill.

    This is what makes the debate so difficult. On one side, we have politicians telling us all will be well. We will finally insure 47 million Americans currently without insurance; we will reduce the cost of healthcare without affecting quality; we will not raise taxes to do so; those happy with the insurance they have now can keep it. And the actual language of HR 3200 (at least arguably) may not explicitly contradict any of these claims.

    On the other side, we have politicians arguing the opposite on all these points. And HR 3200 seems quite consistent with their predicted outcomes as well.

    The fact that the language of HR 3200 is completely consistent with either of these interpretations reduces the debate to a aeries of “Uh-huhs” vs. “Huh- uhs.” The ultimate meaning of HR 3200, by design, is completely open, and finally, will only be determined by armies of commissions, regulators and bureaucrats once it becomes law.”

    Link to article: http://covertrationingblog.com/uncategorized/james-madison-sarah-palin-and-hr-3200

    After getting a headache reading a lot about healthcare reform, I found that this idea succinctly summarizes the problem with the bill. Do others feel the same way, or are there holes in this argument I am looking for?

  17. #17 David
    August 15, 2009

    Sorry about the poor grammar in the last sentence. I meant to ask if others felt the same way about HR3200 as the author above, or if there are holes in his argument.

  18. #18 Robert W. Donnell
    August 15, 2009

    David,
    Your’e right on the money, as is the Dr. Rich post to which you link.

    Orac,
    Yes, it must be said that Zeek Emanuel is opposed to euthanasia. No, he doesn’t want to kill gramma. But the Lancet paper and other of his writings make it clear he’s for age based discrimination. When the resources fall short he wants to deny gramma basic care because she’s old. We’re not gonna kill gramma but it’s her duty to die. That’s the philosophical bent of the folks Obama has surrounded himself with. That, combined with the inscrutable language of HR 3200, is cause for concern.

  19. #19 John G Leggett
    August 15, 2009

    Is it hyperbole from the first five hundred pages, with several quoits from the legislation, along with the url for GPO. You may look up the rest at your leisure.
    http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt.pdf
    As a senior I am worried about page 29, 30, 42, 59, 65, 95,124, 195, 272, 425, 427, 430.

    The basic problem is the built-in conflict of interest. The government had a roll with insuring that there is both fairness and accountability in healthcare. When the government is the implementing body its automatically a conflict of interest. It needs to control cost as do all private healthcare companies. They all do this by trying to limit services. Now you can change providers and go to the government for redress of grievances. If the government is the only provider and you must subsidize the government plan so that it will soon eliminate all competition. Who will you go to when you have a problem with the plan?

    There are a few studies of the length of time it take to get care all of them say that the times are shorter in the US than in any government run healthcare system. There is lots of information about how in an attempt to control costs all governments health care plans ration care. Leaving the patient without redress.

    Page 29: Admission: your health care will be rationed!

    3 (2) ANNUAL LIMITATION.—
    4 (A) ANNUAL LIMITATION.—The cost-shar-
    5 ing incurred under the essential benefits pack-
    6 age with respect to an individual (or family) for
    7 a year does not exceed the applicable level spec-
    8 ified in subparagraph (B).

    Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process)

    11 SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.
    12 (a) ESTABLISHMENT.—
    13 (1) IN GENERAL.—There is established a pri-
    14 vate-public advisory committee which shall be a
    15 panel of medical and other experts to be known as
    16 the Health Benefits Advisory Committee to rec-
    17 ommend covered benefits and essential, enhanced,
    18 and premium plans.

    . Page 42: The “Health Choices Commissioner” will decide health benefits for you. You will have no choice. None.

    3 SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.
    4 (a) DUTIES.—The Commissioner is responsible for
    5 carrying out the following functions under this division:
    6 (1) QUALIFIED PLAN STANDARDS.—The estab
    7 lishment of qualified health benefits plan standards
    8 under this title, including the enforcement of such
    9 standards in coordination with State insurance regu
    10 lators and the Secretaries of Labor and the Treas
    11 ury.

    . Page 50: All non-US citizens, illegal or not, will be provided with free healthcare services.
    . Page 58: Every person will be issued a National ID Healthcard.
    . Page 59: The federal government will have direct, real-time access to all individual bank accounts for electronic funds transfer.
    . Page 65: Taxpayers will subsidize a ll union retiree and community organizer health plans (read: SEIU, UAW and ACORN)
    . Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange.
    . Page 84: All private healthcare plans must participate in the Healthcare Exchange (i..e., total government control of private plans)
    . Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens
    . Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan.
    . Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter.
    . Page 124: No company can sue the government for price-fixing. No “judicial review” is permitted against the government monopoly. Put simply, private insurers will be crushed.
    . Page 127: The AMA sold doctors out: the government will set wages.
    . Page 145: An employer MUST auto-enroll employees into the government-run public plan. No alternatives.
    . Page 126: Employers MUST pay healthcare bills for part-time employees AND their families.
    . Page 149: Any employer with a payroll of $400K or more, who does not offer the public option, pays an 8% tax on payroll
    . Page 150: Any employer with a payroll of $250K-400K or more, who does not offer the public option, pays a 2 to 6% tax on payroll
    . Page 167: Any individual who doesn t’ have acceptable healthcare (according to the government) will be taxed 2.5% of income.
    . Page 170: Any NON-RESIDENT alien is exempt from individual taxes (Americans will pay for them).
    . Page 195: Officers and employees of Government Healthcare Bureaucracy will have access to ALL American financial and personal records.
    . Page 203: “The tax imposed under this section shall not be treated as tax.” Yes, it really says that.
    . Page 239: Bill will reduce physician services for Medicaid.. Seniors and the poor most affected.”
    . Page 241: Doctors: no matter what specialty you have, you’ll all be paid the same (thanks, AMA!)
    . Page 253: Government sets value of doctors’ time, their professional judgment, etc.
    . Page 265: Government mandates and controls productivity for private healthcare industries.
    . Page 268: Government regulates rental and purchase of power-driven wheelchairs.
    . Page 272: Cancer patients: welcome to the wonderful world of rationing!
    . Page 280: Hospitals will be penalized for what the government deems preventable re-admissions.
    . Page 298: Doctors: if you treat a patient during an initial admission that results in a readmission, you will be penalized by the government.
    . Page 317: Doctors: you are now prohibited for owning and investing in healthcare companies!
    . Page 318: Prohibition on hospital expansion.. Hospitals cannot expand without government approval.
    . Pa ge 321: Hospital expansion hinges on “community” input: in other words, yet another payoff for ACORN.
    . Page 335: Government mandates establishment of outcome-based measures: i.e., rationing.
    . Page 341: Government has authority to disqualify Medicare Advantage Plans, HMOs, etc.
    . Page 354: Government will restrict enrollment of SPECIAL NEEDS individuals.
    . Page 379: More bureaucracy: Telehealth Advisory Committee (healthcare by phone).
    . Page 425: More bureaucracy: Advance Care Planning Consult: Senior Citizens, assisted suicide, euthanasia?
    . Page 425: Government will instruct and consult regarding living wills, durable powers of attorney, etc. Mandatory. Appears to lock in estate taxes ahead of time.
    . Page 425: Government provides approved list of end-of-life resources, guiding you in death.
    . Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.
    . Page 429: Advance Care Planning Consult will be used to dictate treatment as patient’s health deteriorates. This can include an ORDER for end-of-life plans. An ORDER from the GOVERNMENT.
    . Page 430: Government will decide what level of treatments you may have at end-of-life.

    4 ‘‘(B) The level of treatment indicated under subpara
    5 graph (A)(ii) may range from an indication for full treat
    6 ment to an indication to limit some or all or specified
    7 interventions. Such indicated levels of treatment may in
    8 clude indications respecting, among other items—
    9 ‘‘(i) the intensity of medical intervention if the
    10 patient is pulse less, apneic, or has serious cardiac
    11 or pulmonary problems;
    12 ‘‘(ii) the individual’s desire regarding transfer
    13 to a hospital or remaining at the current care set
    14 ting;
    15 ‘‘(iii) the use of antibiotics; and
    16 ‘‘(iv) the use of artificially administered nutri
    17 tion and hydration.’’.

    . Page 469: Community-based Home Medical Services: more payoffs for ACORN.
    . Page 472: Payments to Community-based organizations: more payoffs for ACORN.
    . Page 489: Government will cover marriage and family therapy. Government20intervenes in your marriage.
    . Page 494: Government will cover mental health services: defining, creating and rationing those services.

  20. #20 Luna_the_cat
    August 15, 2009

    Jeezus, Leggett, talk about reading in a lot of things that aren’t there.

    I have neither the time nor the inclination to go through all these point by point, but let’s just take one right now:
    “Page 29: Admission that your health care will be rationed!”

    No, you twit. Page 29 sets limitations on how much you would have to pay. It sets limits on how much personal contribution you have to make towards healthcare costs!

    Page 30 refers to the how they’ll set up the panels to decide what benefits different plans will cover. You’ll have a choice of plans. It is absolutely no different than what you get from any insurance company, and there is certainly no reference to a lack of appeals process.

    The whole bit on pp.427+ about end-of-life care very specifically refers back to use of the plan set by the individual in question during consultation.

    And so on.
    As far as I can tell, ALL of this is just a reading comprehension fail on your part.

  21. #21 Dr. P
    August 15, 2009

    Two quick responses to Mr. Leggett;You seem to be under the impression that under a private insurance plan you’re not already subject to commissions that ration your care and deny benefits and nothing could be further from the truth. It would however be easier to switch options within the exchange;on the part of *gasp* illegal aliens, section 24 specifically exempts thier participation.The linguistics infrastructure is for spanish speaking LEGAL immigrants and citizens who speak Spanish;I don’t know how you read illegal into this, since I take care of many families who are legal and Spanish speaking.Otherwise I have to say I appreciate the reasonable discussion on this board whether I agree with the poster or not. It’s hard to discuss facts elsewhere without the partisan hyperbole.

  22. #22 Sullivan
    August 15, 2009

    Rush Limbaugh is telling us that the government will let people “loop out”?

    This from a gentleman who got himself addicted to prescription pain killers?

    http://www.cnn.com/2003/SHOWBIZ/10/10/rush.limbaugh/

  23. #23 Joseph Hertzlinger
    August 16, 2009

    This is clear evidence that we can’t trust liberal Republicans. (A bill expanding prescription drug benefits is not a conservative policy.)

    OTOH, ensuring that a given Republican is a conservative is an unsolved problem.

  24. #24 RevRon
    August 16, 2009

    Those who are railing so loudly against the very concept of rationing healthcare services have apparently never been involved in a triage situation, where the patient load far overshadows the available care-giver resources. I’d take it one step further, and suggest they might benefit from a stint in a major city’s trauma center. Those who require immediate treatment – and have the best chance for survival – get treated first. Those with a slim chance of survival or a meaningful quality of life fall somewhat lower on the list. While it’s easy to sit back and pass judgment on the decision-makers, the truth is that when actually faced with such difficult choices, we have to shift from an emotional to a more pragmatic approach. And believe me, anyone who has been in the position of choosing who gets saved has to deal with their own conflict, and doesn’t need (or deserve) to be condemned.

    Rationing is an unfortunate but unavoidable reality until such time as the ratio of healthcare providers to patients improves. When the ER no longer serves as primary care facility for a significant portion of the population, genuine emergencies will be dealt with much more efficiently, healthcare costs will be more likely to decrease, and that rationing everybody is so concerned about will diminish, as well.

    If all concerned were more focused upon actually improving the situation than in earning cheap political brownie points… never mind. Might as well say that if grasshoppers carried .45s, mockingbirds wouldn’t mess with them.

  25. #25 Orac
    August 16, 2009

    Indeed. We ration care right now. We have always rationed care. We always will ration care. It cannot be otherwise because need outstrips resources. The question then becomes: What is the fairest way to ration care? If you think of the question that way, it becomes a lot less black and white, because value judgments are inherently involved in such decisions.

    As for “age-based discrimination,” as Dr. RW charges Ezekiel Emanuel with being in favor of, again, depending on what you mean by “age-based discrimination,” we practice age-based discrimination now.. We have always practiced age-based discrimination. We probably always will practice age-based discrimination. For example, if you’re over 80 and have cancer, you’re less likely to get radical treatments of many kinds because your inherent life expectancy is lower and the equation looking at the risk of such treatments compared to the potential years of life saved. True, we may disagree vigorously at what point, at what age, the equation shifts to having such treatments not be worth doing, realizing that advances in medicine have made more aggressive treatments on older people more possible, and that equation is very much affected by comorbidities, but let’s not fool ourselves. Age is frequently a major factor in the overall equation. It’s true at the other end of the spectrum, too. We will often go much farther trying to save a child, even to the point of subjecting them to much more radical interventions, than we ever would with the elderly.

    Most octogenarians would probably agree with this.

  26. #26 Robert W. Donnell
    August 16, 2009

    Your points are well taken, Orac. Yes we do ration. The difference from other health systems is we don’t ration explicitly. Many are saying we should get over our dread of the R word and start being explicit in our rationing. Would that make it more fair or just inch us down some slippery slope? I don’t know.

    And yes, we have age based discrimination. There’s a difference between the type of discrimination we have now, though, and Zeek Emanuel’s discrimination. His is largely utilitarian value based (can we justify health care for an elderly demented patient who’s just a mouth to feed and water but has no value to society) whereas ours is primarily medically based (could gramma tolerate chemo, etc.), and the only values we now respect in such decisions are the values of the patient (would gramma want to live like that?).

    So there’s a difference.

    Obama’s policy wonks miscalculated. They failed to realize that there’s a uniquely American value that holds the worth of the individual above the good of the commons. Like it or not that’s entrenched in our culture and it’s what’s driving all the town halls, You Tubes and fishy emails.

  27. #27 Donna B.
    August 16, 2009

    Orac, the difference between octogenarians choosing less intervention for themselves because of their age and an insurance co., the government, or some other arbitrary way of making the decision for them is HUGE.

    Guidelines, best practices, whatever the nomenclature are arbitrary, some less, some more.

    My father, at age 86 was offered whatever treatment for his stage I nsclc that he wanted. It’s a great compliment to our medical system that so many options were available to him.

    His initial inclination was to not even have a biopsy to confirm what imaging showed. He may end up being correct that the # of his remaining years wouldn’t be changed. It was actually curiosity that got to him. He had to know.

    Once he knew, he chose the least invasive course of treatment — radiation without adjunctive chemotherapy because he did not want to decrease his activity level (which still includes earning money and physical labor.)

    Yet, I can very easily see an arbitrary rule being made that anyone over 80, or 85, or choose an age might be eligible for only one type of treatment or none at all.

    I understand that rationing takes place now and one of things that I understand the reform is to do is to remove some of the rather arbitrary methods insurers use now (pre-existing conditions, for example).

    What I don’t want to accomplish is merely exchanging one set of arbitrary rules for another.

  28. #28 Clay
    August 16, 2009

    Robert W. Donnell,

    Please read RevRon’s excellent post at #24, and take note that the title of Dr. Emanuel’s article in the Lancet is “Principles for allocation of scarce medical interventions”(emphasis mine). Also, do you really have a complaint about Dr. Emanuel’s conclusions, or are you just upset at the fact that there are situations where care has to be rationed? If the latter, then I wholeheartedly agree. This world leaves much to be desired.

  29. #29 Robert W Donnell
    August 17, 2009

    Clay,
    I suppose it depends on how we define scarce. By most people’s reckoning our resources are scarce right now. Of course rationing has to be done in sone triage situations but even there it is done by medical criteria (salvageability)rather than some age-based criterion of value to society. That’s what I object to about Emanuel’s statements. And I don’t think he was talking about acute triage situations, BTW.

  30. #30 Orac
    August 17, 2009

    Dr. RW,

    With all due respect, have you actually read the whole paper? Seriously. If you did you would know what Dr. Emanuel was talking about. Here’s the abstract:

    llocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems.

    Here’s the first paragraph:

    In health care, as elsewhere, scarcity is the mother of allocation.1 Although the extent is debated,[2] and [3] the scarcity of many specific interventions—including beds in intensive care units,4 organs, and vaccines during pandemic influenza5—is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary.6

    Another excerpt:

    Some people wrongly suggest that allocation can be based purely on scientific or clinical facts, often using the term “medical need”.[13] and [14] There are no value-free medical criteria for allocation.[15] and [16] Although biomedical facts determine a person’s post-transplant prognosis or the dose of vaccine that would confer immunity, responding to these facts requires ethical, value-based judgments.

    It’s a bioethics paper, and it’s primarily about triage for truly scarce medical resources, like organs for transplant, vaccines in some countries, etc. All of these are examples in which various criteria that have used age as one of the major factors, among other things. It is not per se a paper about nationalized health care or rationing under such a system.

    Personally, I find the rants of “no rationing” to be naive at best and disingenuous at worst, because rationing is taking place, and right now it is pretty much arbitrary, based more on cost, the flip of the coin (do you have decent insurance?), and other factors, including what part of the country you happen to live in. The difference is that Emanuel’s proposed system, whether you object to it or not, is not arbitrary. It is based on bioethical principles with broad agreement, and he goes into painstaking detail to discuss them. You might object to how those principles are integrated into his proposed system, but, honestly, it’s far less arbitrary than the system we have now, and, unlike the current arbitrary hodge-podge, it has at least some bioethical basis behind it.

  31. #31 pv
    August 17, 2009

    Being British, but living in another Country, I have been royally entertained by what passes for debate about the provision of Universal healthcare in the US. Imo a better debate would be one about the lack of a decent education system in the US because, judging by the oceans of moronic anti-British NHS fiction masquerading as fact, there is little evidence of reasoned or informed argument or respect for truth and facts.

    What strikes me most is that in the US it seems that it’s better for an Insurance company, pharmaceutical company or lawyer to grab a large slice of the health care budget for its own profit than have it invested in actual productive health care. The other thing that strikes me is the general meanness and contempt so many Americans have for their fellow humans when they are ill – seemingly.

    I should point out to all State healthcare detractors that all healthcare systems are rationed by availability of resources. You can never have enough resources.
    In the US the rationing is done by excluding those who don’t have enough money; which is currently millions of people. Those with the most money get the best care, and those with no money get pretty much the worst, if any at all.

    In other Countries, like those in Europe for example, we pay for our healthcare through our taxes and, although it’s never perfect (just as 45 million Americans who don’t have private health insurance isn’t perfect) it works for most people (unlike in the US where the richest always win and the poorest always lose). We devise other more or less ethical ways to ration resources rather than just treat the poor (of any age) as undeserving scum (none of this “no credit card no treatment” medieval nonsense). And private health insurance does exist for those who want or can afford it, in order to provide additional healthcare in excess of what might be provided by the State. The State I should add provides for much that Insurance companies won’t touch – which is not too dissimilar to the State picking up the losses of the Banks, eh. Isn’t the Capitalist religion fantastic? Banks and Insurers pick up all the profits and the credit for them while passing the losses and the crap onto Joe Public to pick up the tab.

    Then of course there’s the unspoken matter of how Insurance always manages to drive up the costs of medical care (look at car repair costs if you want another example)… It leads to massive profits for the Insurer, massive and not necessarily merited profits for the medical professionals, an irresistible incentive for unnecessary medical treatments and interventions, medical hucksterism, inflated drug prices and so on – and massive insurance premiums.

    We weak and woolly Brits along with most Europeans like our State healthcare systems, not because they are Socialist or Communist, but because they are for the most part a civilised way of dealing with healthcare and the human suffering caused by ill health. We consider it to be a right – like Universal human rights. We criticize our healthcare systems because they aren’t perfect and because we constantly want to improve them. Of course we don’t want to pay any more for them than we already do so sometimes our criticisms are unjustified. But they are ours and we pay for them. Americans who like to criticize foreign State run healthcare systems neither pay for them nor generally seem to have a clue about them. It’s all about that nasty “Socialism”, those nasty terrorists and Reds under the bed nonsense. Hence, as I intimated at that start, the desperate need for a decent education system in the US.

    What I’d like to know is what is so civilised about a healthcare system that excludes millions because they don’t have insurance, or that rations healthcare according to the wealth of an individual. And what’s so civilised about about a healthcare system where the main priorities are Insurance company profits, drug company profits, medical professionals’ profits, lawyers’ profits? I suppose as long as it’s not “Socialism” who cares! Americans annually spend twice the percentage of GDP that the Brits spend on healthcare, and it’s still a nation of sick and ailing fatties, addicted to therapy and quackery.

    If I fall ill and require hospital treatment on one of my trips to the UK I know very well that I won’t be asked to show my credit card or my insurance details – even though I haven’t lived there for ten years. It’s not perfect but it’s certainly civilised and far preferable to the cynical, parasite infested system seemingly regarded as so wonderful by so many in the US.

  32. #32 pv
    August 17, 2009

    Incidentally can I just say here that Rush Limbaugh, apart from having a very silly name that sounds like it should be a sexually transmitted disease, is, as we British are apt to say, an ignorant wanker.

  33. #33 J Todd DeShong
    August 17, 2009

    Rachel Maddow totally rocks!! I’m so glad she is gaining viewers and fans.
    JTD

  34. #34 J Todd DeShong
    August 17, 2009

    Also, Limbaugh was not only addicted to Oxycontin, but like the chicken~sh*t he is, had his MAID go out and score for him!
    JTD

  35. #35 Robert W. Donnell
    August 17, 2009

    Orac,
    I did read the whole paper but it was a quick read. The paper does not lend itself to a quick read. I am in the process of going over it in more detail and will try to parse out the nuances. That will require a longer reply than is appropriate here, so I will respond in a post on my own blog soon.

    Although there are some vague areas and multiple possible interpretations of the policy implications of the paper, nothing I have seen in going over it again, so far, mitigates my original concern.

    Some of our disagreement may have to do with philosophical bent, and cannot be appealed to evidence.

    I did erroneously attribute to this paper something he wrote in an earlier paper which I will deal with in the blog post.

  36. #36 Uncle Dave
    August 18, 2009

    The national health care debate, oops did I say debate? sorry I meant national health care scare could best be summed up by watching the film Dr. Strangelove or How I Learned to Stop Worrying and Love the Bomb.

    Brig. General Jack Ripper – Its all about Precicious bodily fluids and flourodated water. “They look a lot like our soldiers general?” “Those commies are clever bastards!”

  37. #37 Orac
    August 18, 2009

    Dr. D,

    You might be interested in this take (and the National Review article it discusses) on how rationing works now, namely rationing by price:

    http://scienceblogs.com/authority/2009/08/national_review_on_health_care.php

  38. #38 John G. Leggett
    August 20, 2009

    Oric,

    I am sure, if I show up in a hospital with a heart attack the same time there has been a terrorist attack or another Hurricane Katrina. During triage I am not going to come first. My first cousin’s mother-in-law died in Baton Rouge from an untreated infection just after Katrina. I do not want the decision to be made, to let me go because we have spent the money for the year, or I am not going to live long anyway so that is a good place to save. Especially so that on the next bed down we can save the 17-year-old gang banger who has been shot over a drug deal that has gone bad.

    Here is what Wikipedia has to say about the British system. http://en.wikipedia.org/wiki/Criticism_of_the_National_Health_Service

    I am a 67-year-old male who has had bypass surgery. I am concerned about any system that leads to some type of NICE. I say this from the somewhat selfish point of view that after paying for Medicare for some forty plus years, I am now told that I mush accept less care so that we can give more care to those who have not for whatever reason paid their share.
    http://en.wikipedia.org/wiki/NICE

    It does seem to me a bit much, asking those of us who have paid in, not to want what they have paid for. It would be easy to fix the high cost of medical care in the US by just dropping medicaid. Wham there goes 320 billion that the uncaring taxpayers are now paying for all the poor who do not pay taxes. I am tired, that after years of working like a dog. I am being told that I am greedy and selfish for wanting the 45 to 50 percent who pay no federal income tax to pay something. If I hear that they pay SSA etcetera and that is a large part of their income. I am going to scream. (7.5% $20,000 =$1,500
    7.5% $100,000 =$7,500) It is the same rate for everyone. Where is my tax break here?

    Now there are things that the government ought to do to improve care and reduce cost. The law that prevents Medicare from negotiating with drug companies is an abomination. I would go one step further and tell the drug companies that they can charge all the markets will bear. As long as they charge the same to any first world country. I am tired of paying the total cost of drug research so that Canada and Europe can get the new drugs cheaper.

    We could also lower the cost of Medicaid by insisting that any Medicaid/ welfare recipient was on birth control before they received their check/payment. I say this because I cannot figure a way out for a 17-year-old girl without any education and three kids. I also limited my fertility to the number of children I could afford to raise.

    I want the US Government to first fix all the problems, they have with their current program’s VA, Indian, Medicaid and Medicare before I am willing to intrust them to increase the scope of these programs. I doubt it even then, because that would still leave the worst problem of National Healthcare System. If the government both runs and oversees the health care system, there is the inherent conflict of interest between the two functions. I want the government to be and impartial judge of any problems I have with private healthcare. I do not want there to be nowhere to go if and when I have a problem. See above NICE for everyone who thinks it cannot happen here.

  39. #39 Robin Levett
    August 22, 2009

    @John G Leggett:

    I am tired of paying the total cost of drug research so that Canada and Europe can get the new drugs cheaper.

    If you did so, I would understand the feeling – but you don’t. When I last checked the figures (in the last couple of years), the entire difference between the prices negotiated between the UK NHS and drug companies, and the USA drug prices, was accounted for by marketing spend – in particular direct to patient marketing. The R&D contribution per tablet sold was the same.

    I’m sick and tired of this claim being repeated; it’s time the USA consumers realised that some of the biggest drug companies are in fact European owned or based. Therapeutic drugs are not the USA’s gift to the world.

  40. #40 John Leggett
    August 22, 2009

    Robin Levett,

    Two minuets research on the internet says different. I have not done extensive research but if I am wrong I would like to see the research. Please send me some sources.

    http://www.americablog.com/2009/07/advair-costs-13-price-in-europe.html

    http://www.highbeam.com/doc/1P2-7826688.html

    http://www.manhattan-institute.org/html/miarticle.htm?id=3240

    thanks John

  41. #41 Robin Levett
    August 22, 2009

    @John G. Leggett:

    Again, you pointed to Wikipedia; how about a choice quote from the page you linked to:

    “NHS access is therefore controlled by medical priority rather than price mechanism,”

    How scandalous…

  42. #42 John Leggett
    August 22, 2009

    Robin Levett,

    Two minuets research on the internet says different. I have not done extensive research but if I am wrong I would like to see the research. Please send me some sources.

    A quoit from the Chicago Sun Times URL below.

    “Late last month, when European health ministers were being advised of the importance of drug pricing freedom, the House approved a bill on drug reimportation by a whopping margin, 243-186. Reimportation would allow Americans to purchase pharmaceuticals from nations like Canada where governments fix drug prices. In other words, it’s a back door for introducing price controls. ”It’s about money, the money that the pharmaceutical companies are making on the backs of the American people,” Rep. Dan Burton (R-Ind.) explains.

    Actually, it’s about research and development. And here’s the connection between Europe’s decision and Congress’ folly. Pharmaceutical innovation is pinned on profitability. While 20 years ago pharmaceuticals were largely developed in Europe, European price controls made drug development an American enterprise. Fifteen of the 20 top-selling drugs worldwide this year were birthed in the United States. And even European firms such as GlaxoSmithKline have moved essential work across the Atlantic, to American shores. No wonder the EU is reconsidering their regiment of price controls.”

    http://www.manhattan-institute.org/html/miarticle.htm?id=3240

    http://www.americablog.com/2009/07/advair-costs-13-price-in-europe.html

    http://www.highbeam.com/doc/1P2-7826688.html

    http://www.manhattan-institute.org/html/miarticle.htm?id=3240

    http://www.house.gov/cummings/pdf/intl.pdf

    Robin, “NHS access is therefore controlled by medical priority rather than price mechanism,” IF it were only true url below quoit.

    What NICE has become in practice is a rationing board. As health costs have exploded in Britain as in most developed countries, NICE has become the heavy that reduces spending by limiting the treatments that 61 million citizens are allowed to receive through the NHS. For example:

    In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer. This followed on a 2008 ruling against drugs — including Sutent, which costs about $50,000 — that would help terminally ill kidney-cancer patients. After last year’s ruling, Peter Littlejohns, NICE’s clinical and public health director, noted that “there is a limited pot of money,” that the drugs were of “marginal benefit at quite often an extreme cost,” and the money might be better spent elsewhere.

    In 2007, the board restricted access to two drugs for macular degeneration, a cause of blindness. The drug Macugen was blocked outright. The other, Lucentis, was limited to a particular category of individuals with the disease, restricting it to about one in five sufferers. Even then, the drug was only approved for use in one eye, meaning those lucky enough to get it would still go blind in the other. As Andrew Dillon, the chief executive of NICE, explained at the time: “When treatments are very expensive, we have to use them where they give the most benefit to patients.”

    http://online.wsj.com/article/SB124692973435303415.html

    See also in Canada.

    http://www.vancouversun.com/story_print.html?id=1878506&sponsor

    As I said before, I am a sixty seven year old cardiac patient. Because I am a 67 year’s old, I am somewhat cynical about government promises. You may be willing to trust some faceless bureaucrat with your life, without any recourse. I would prefer not to do so. Maybe it is because I spent twenty four years of my life as one and understand what goes on when you are forced to match expenditures with your budget. We are going to save 50 billion a year from Medicare without any cuts. If you believe that I some water front property for sale about 100 miles south of Mobile. I started paying in to Medicare when it was passed

    A brief history of Medicare. http://seniorjournal.com/NEWS/2000%20Files/Aug%2000/FTR-08-04-00MedCarHistry.htm

    July 30, 1965 Medicare and its companion program Medicaid, (which
    insures indigent recipients), are signed into law by
    President Lyndon Johnson as part of his “Great Society.”

    Ex-president Truman is the first to enroll in Medicare.

    Medicare Part B premium is $3 per month.

    1972 Disabled persons under age 65 and those with end-stage
    renal disease become eligible for coverage. This is strange for a program for seniors maybe it should have been part of Medicaid.

    Services expand to include some chiropractic services,
    speech therapy and physical therapy.

    Payments to HMOs are authorized.

    Supplemental Security Income (SSI) program is established
    for the elderly and disabled poor. SSI recipients are
    automatically eligible for Medicaid. I wonder why there are problems with the trust fund.

    1982 Hospice benefits are added on a temporary basis.

    1983 Change from “reasonable cost” to prospective payment
    system based on diagnosis-related groups for hospital
    inpatient services begins.

    Most federal civilian employees become covered.

    1984 Remaining federal employees, including President, members
    of Congress and federal judiciary become covered.

    1986 Hospice benefits become permanent.

    1988 Major overhaul of Medicare benefits is enacted aimed at
    providing coverage for catastrophic illness and
    prescription drugs.

    Coverage is added for routine mammography.

    1989 Catastrophic coverage and prescription drug coverage are
    repealed. The cost were so high that seniors revolted.

    Coverage is added for pap smears.

    1992 Physician services payments are based on fee schedule.

    1997 Medicare+Choice is enacted under the Balanced Budget Act.
    Some provisions prove to be so financially restrictive
    when regulations are unveiled that Congress is forced to
    revisit the issue in 1999. I wonder how many people died?

    1999 Congress “refines” Medicare+Choice and relaxes some
    Medicare funding restrictions under the Balanced Budget
    Refinement Act of 1999.

    2000 Medicare+Choice Final Rule takes effect.

    Prospective payment systems for outpatient services and
    home health agencies take effect.

    Medicare Part B premium is $45.40 per month.

    Thanks John

  43. #43 Robin Levett
    August 22, 2009

    @ John G Legett:

    Two minuets research on the internet says different.

    Well, there’s your problem – two dances is, what, ten minutes max…

    Here’s a webpage forming part of a subsite explaining the UK PPRS:

    http://www.abpi.org.uk/publications/publication_details/pprs/section5.asp

    Note:

    Each company’s R&D allowance comprises up to 20 per cent of total home NHS turnover (when assessing profits) or 17 per cent (when considering a price increase)

    So the agreed (because the deal is negotiated) price of drugs sold into the NHS includes an allowance of 20% for R&D in the initial price. The price also allows, by the way, 21-29% profit.

    An aside although of course there’s an element of blowing their own trumpet:

    For many years Britain has been home to a pharmaceutical industry that is second to none in Europe and surpassed only by the United States in its success in developing world-leading new medicines.

    This achievement has helped to ensure that the industry plays a major part in enhancing both the health and wealth of the UK. The National Health Service has been a major beneficiary of the many advances made by the pharmaceutical industry.

    Yet this country’s domestic spending on pharmaceuticals is low compared to the value of the medicines produced here, and when compared with consumption in most other major countries in Europe and further afield. It is also low in comparison with the amount spent on research in this country (Figures 1 and 2).

    (from http://www.abpi.org.uk/publications/publication_details/pprs/section2.asp)

    What’s the proportion of the US price ploughed back into R&D?

    Well, this report, relying upon a study by two researchers, gives 2004 figures:

    The researchers’ estimate is based on the systematic collection of data directly from the industry and doctors during 2004, which shows the U.S. pharmaceutical industry spent 24.4% of the sales dollar on promotion, versus 13.4% for research and development, as a percentage of US domestic sales of US$235.4 billion.

    So that’s 13.4% of sales income that goes back into R&D; only 2/3rds the UK proportion. 24.4% of the US price, however, goes into marketing spend – as opposed to the 6% allowed for in the UK price. Remember that because DtP advertising isn’t permitted here, and because the NHS is the largest purchaser and isn’t that impressed by glossy television ads, that 6% is probably not overspent.

    But what about the difference in drug prices?

    …After adjusting for such factors as well as the role of generic equivalents, volume discounts, and frequency of use, they found that the average US consumer would have paid 3% more in Canada, 27% more in Germany, 30% less in France, 9% less in Italy, 8% less in Japan, 44% more in Switzerland, 9% more in Sweden, and 24% less in the UK.

    (From http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1936287)

    After discounting for the price difference, the 20% of the UK price going to R&D is equivalent to 15.2% of US prices – still slightly more than the US R&D proportion. Marketing in the UK is 6% – or 4.56% discounted – as opposed to 24.4% – a difference equivalent to 20% of the US price. OK, marketing doesn’t quite make up the entire difference on these figures – but it’s pretty close to doing so. If I remember rightly, when I checked this up some of the figures were different, but then that was probably a difference in the year for which the figures were published.

    It’s true that the NIH study refers to 1998 price figures whereas the PPRS has been running since 1999, and the NYU figures are from 2004.

    Table 16 on this page:

    http://www.abpi.org.uk/statistics/section.asp?sect=4

    shows however that average drug costs per person in the UK actually jumped from 1998 to 1999, and continued to increase by a total of 75% to 2004. I can’t see that the relationship between US and UK prices would have changed that much over the period.

    It is true that there is apparently a difference in overall sales volumes between the two markets, even taking account of the different populations; the NHS (which is the largest, although not the only, customer) spent around $16-20 billion on prescription drugs in 2004. The overall drug market in the UK in 2004 was worth £12.32 billion, or $20-25 billion. Adjusting for population, we spent only three-fifths what the USA spent; but so what? We still contributed (in dollar per head terms – 3/5 of our 20% is 12%) almost the same to R&D on drugs. We just didn’t spend so much on being sold the damn things.

  44. #44 Robin Levett
    August 22, 2009

    @John G Leggett:

    I’ve just submitted a longish post with a number of links which is being held in moderation. The bottom line is that you shouldn’t believe all you read on right-wing sites. Reality has a well-known liberal bias.

  45. #45 Robin Levett
    August 23, 2009

    @John G Leggett:

    In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer. This followed on a 2008 ruling against drugs — including Sutent, which costs about $50,000 — that would help terminally ill kidney-cancer patients.

    Problem is this just is no longer true. In February this year, NICE approved Sutent for kidney cancer.

    http://scienceblog.cancerresearchuk.org/2009/02/04/nice-recommends-sutent-sunitinib-for-advanced-kidney-cancer/

    As for your specific paragraph, Pfizer pulled one of its studies on the use of Sutent on advanced breast cancer in June 2009. Why? Because:

    The independent Data Monitoring Committee (DMC) found that treatment with sunitinib in combination with paclitaxel would be unable to meet the primary endpoint of superior progression-free survival (PFS) compared to the combination of bevacizumab and paclitaxel.

    http://www.fiercebiotech.com/press-releases/pfizer-discontinues-sun-1094-trial-sunitinib-plus-paclitaxel-advanced-breast-cancer

    Sutent isn’t come kind of wonder drug that is clearly better than the competition; it’s failing in head to heads against the standard of care.

  46. #46 Robin Levett
    August 23, 2009

    @John G Leggett:

    Shorter version: Sutent is approved for kidney cancer; Pfizer hasn’t yet demonstrated efficacy (over current treatments) for Sutent in other cancers.

    I know, by the way, that there is a trial in Wales on use of Sutent in advanced breast cancer.

  47. #47 Robin Levett
    August 23, 2009

    @John G Leggett:

    Another short comment; the USA spends more government money per head of population on healthcare than the UK government does – and yet still leaves 15% uncovered.

  48. #48 John Leggett
    August 25, 2009

    Robin, I never said that there are not problems with health care in the US. I even gave what I still think are two ways that cost could be reduced. I have a third that at first glance looks crazy. Triple the pay of primary care physicians. I pay my internist $1500 up front each year. For this he limits his practice to 600 hundred patients instead of the more standard two thousand patients. The statics I have read say. “What does all of this mean for patients? Patients in MDVIP affiliated practices are admitted to the hospital at dramatically lower rates than non-MDVIP patients.”
    http://mdvip.com/NewCorpWebSite/ValueInPrevention/HealthcareStatistics.aspx

    This makes sense to me, during the spring of 2007 I had bronchitis twice and pneumonia once. I saw my doctor the same day. I came down with symptoms. If as frequently happened before I joined. I was told that the first appointment was in a week. How much more likely would it have been for me to have made it into a hospital?
    I by the way already have a healthcare power of attorney and a living will. I do not need or want to waist my time on government forced counseling.

    I said in one of my previous posts that one other way that healthcare costs could be greatly reduced. Is to, mandate that every welfare recipient is on birth control with either a patch or month long shot administered before they receive their check. I would be willing to pay them a thousand dollar bonus. If they become permanently sterilized. I had a vasectomy thirty years ago. So I am only saying do what I do. It is none of my business how many children anyone who does not get my money to support themselfs has. It does become my business when I am asked to support them.

    I guess this is another right wing blog.
    http://www.nytimes.com/2009/08/21/health/policy/21seniors.html?_r=3&hpw

    Another right wing blog.
    http://www.reuters.com/article/newsOne/idUSTRE57K4XE20090821

    How much health care are we going to get if the country is bankrupt. Germany 1920′s, Greece 1940,s, Argentina 1970′s. You do know what the correct name for income transfer is. It is called armed robbery. Taking property from someone to give it to another. That is what Robin Hood was a highwayman after all.

  49. #49 Robin Levett
    August 25, 2009

    @John Leggett #48:

    I didn’t say you did; I objected to your claims that there are death panels in the NHS, relying upon Wikipedia which, contrary to your claim, specifically pointed out that NHS care was rationed by clinical necessity rather than by income of the recipient.

    I guess this is another right wing blog.

    Another right wing blog.

    Neither Reuters nor the NYT are a right wing blog – but th fact that your health system is in deep trouble is hardly news; and what relevance their criticisms of Obama’s plans have to your claims that the US contribute more to drug R&D through higher prices I have no idea.

    How much health care are we going to get if the country is bankrupt. Germany 1920′s, Greece 1940,s, Argentina 1970′s.

    UK 1948. Do you have any idea what the UK’s economic position was after WWII? We’d just gone through 6 years of war, had the centres bombed out of half our cities and massive damage to our capital; we’d been gouged to the hilt by US arms manufacturers, and had a national debt well over twice our GDP – we only finished paying off the WWII debt recently.

    The figures show however that the NHS costs less per head than your system; in fact, our entire spending on healthcare, government and private – per head – is less than your government spends on healthcare. The question is how can you afford your current healthcare system if you go bankrupt. You already have 45 million with no coverage at all (outside the emergency room).

    I do not need or want to waist my time on government forced counseling.

    You don’t even know what’s in the bill, do you? Free clue; the provisions for end of life counselling in the bill mandate its availability, not its uptake.

    You do know what the correct name for income transfer is. It is called armed robbery. Taking property from someone to give it to another. That is what Robin Hood was a highwayman after all.

    I take it that you’re not a Christian then; or if you are, you’re one of those that believe that the sacred texts stop at Leviticus and only restart with Revelation.

    Even if you’re not; how is it I can read your words, since surely someone with your views shouldn’t freeload on the taxpayer’s dime – or take advantage of the technological benefits available in an advanced society – by using the Internet? I presume you stay at home – you wouldn’t freeload on the taxpayer dime by using publicly funded roads, would you? (etc etc etc).

  50. #50 John Leggett
    August 26, 2009

    @Robin Levett #49:

    First I think we ought to take this off the blog. I am enjoying this discussion so here is my email johnron@verizon.net I will be on the road to Friday so donot expect and anser before that.

    Neither Reuters nor the NYT are a right wing blog – but th fact that your health system is in deep trouble is hardly news; and what relevance their criticisms of Obama’s plans have to your claims that the US contribute more to drug R&D through higher prices I have no idea.

    Robin my brother wrote me this maybe you can anser his questions.

    I continue to be perplexed by all of this. Just What Part of America’s Health Care services (the best in the world) is broken? We all complain about having to pay so much money for our health needs. There are catastrophic consequences that can result if we can’t afford proper care – but what are we trying to address. I am not sure that the problem has been sufficiently defined. What is so unlikable about the private health care initiatives that are out there?
    Are there not enough physicians? The answer could be Open up new schools to enable more aspirants to become physicians.
    Are there not enough nurses? Ditto.
    Is it the number of people who are under-insured (anywhere from 5 to 40 million people depending upon the study)?
    Should there be required insurance for everyone here? Why? Is this an entitlement? How will it help? What problem does it cure? Who should provide the insurance? Why? How?
    Are those not insured being denied medical services? If so, when? How? Why? What circumstances? (This can be addressed I would think in a number of ways)
    Is it that there aren’t sufficient venues for treatment?
    Is it that drugs are too expensive? The government already has a prescription subsidy program of some sort – does it need to be more robust?
    Is it that there aren’t enough physicians in rural areas?
    Is it that there is too much need in urban areas, such that the urban systems are over-stretched beyond capacity?
    If we are going to throw lots of money at this problem, how do we direct it to be most efficiently spent (not by Democrats)?
    I have been paying into Medicare for about thirty (30) years and am yet to draw the first penny from its resources. How can Medicare be a model for how best to efficiently run an insurance program when it has been pre-funded for a number of years and still operates on negative margins?
    Everywhere you look these days there are “Doc in a Boxes.” Does the Government need to set up their own “Doc in a Boxes” to treat those who are being turned away (?) by existing medical services (if any are?)
    Should emergency rooms be the first treatment area for all uninsured? [They are quite expensive]
    My head just hurts from all of this stuff, but I’m not ready to be put out to pasture or planted in the pasture just yet.

    UK 1948. Do you have any idea what the UK’s economic position was after WWII? We’d just gone through 6 years of war, had the centres bombed out of half our cities and massive damage to our capital; we’d been gouged to the hilt by US arms manufacturers, and had a national debt well over twice our GDP – we only finished paying off the WWII debt recently.

    I did not mention UK, if you have paid of your WWII debt you are in much better shape than the US we have not paid of our WWI debt much less our WWII debt.

    The figures show however that the NHS costs less per head than your system; in fact, our entire spending on healthcare, government and private – per head – is less than your government spends on healthcare. The question is how can you afford your current healthcare system if you go bankrupt. You already have 45 million with no coverage at all (outside the emergency room).

    You are making my point why would we want to increase spending power to anyone who is doing such a poor job of spending currently. We also get better healthcare. I am really uncaring when it come to people who are illegal entering the country some 10 to 20 million depending on who reports. I do not much want to pay for the 9 million who make over $75,000 a year.

    http://www.cnsnews.com/Public/Content/article.aspx?RsrcID=51443

    I do not need or want to waist my time on government forced counseling.

    You don’t even know what’s in the bill, do you? Free clue; the provisions for end of life counselling in the bill mandate its availability, not its uptake.

    Start reading at page 439. While the language is obscure. It is not the only thing we have to go on. Read

    http://www.washingtontimes.com/news/2009/aug/26/the-government-death-book/

    I take it that you’re not a Christian then; or if you are, you’re one of those that believe that the sacred texts stop at Leviticus and only restart with Revelation.

    Where does it say in the bible that there are any benefits to anyone who surrenders their property when some one points a gun at them? I ascribe to the Jewish view on charity. Charity given anonymously if the best.

    This is the liberal canard that conservatives do not care. The facts show different conservatives on average give about twice as much as liberals. If even half of the liberals gave as much blood as I have over the last fifty years. It would eliminate all the blood shortages in the US.

    Even if you’re not; how is it I can read your words, since surely someone with your views shouldn’t freeload on the taxpayer’s dime – or take advantage of the technological benefits available in an advanced society – by using the Internet? I presume you stay at home – you wouldn’t freeload on the taxpayer dime by using publicly funded roads, would you? (etc etc etc).

    I object to your statement about freeloading. I have paid more than my share of taxes for the common good. It is being asked over and over again to pay someone else’s that I object to. I do not know how it is in the UK but in the US around half the people pay no federal income tax. We taxpayers are spending around 320 billion dollars a year, for the federal medicaid program for the poor and illegals who pay nothing.

    Posted by: Robin Levett

  51. #51 Patient
    September 3, 2009

    Orac,
    An oncologist weighs in on the rationing problems here with some very interesting points:

    http://www.firstthings.com/onthesquare/2009/08/confessions-of-a-health-care-rationer

    Brief quotes:
    “People accept the certainty of a bearable cost to avoid the risk of an unbearable one. But to the extent that these collective programs sever the connection between paying for health care and receiving it, they generate increased demand for health care. The individual feels that he has already paid for health care. When he is sick, or thinks that he is sick, he feels fully entitled to care with no consideration of cost. After all, he has already paid for it, hasn’t he? Given the limited amount of health care that may be bought with the aggregate funds of the group, this untrammeled demand for it must always result in rationing. This is true whether the collective effort is a private insurance plan or a government program. Rationing is inevitable in all collective health care financing schemes.”

    and

    “An alternative to explicit government mandated healthcare rationing is rationing by private industry. There is one great advantage that private healthcare rationing has compared with government rationing: competition. In the private marketplace, there will be a number of insurers, each with its own criteria and implementation of rationing. A company which is unreasonable or high-handed in its coverage decisions will find that its unhappy customers soon become its former customers. It’s true that millions of Americans have their healthcare plan chosen for them by their employers. But employees, both as individuals and via unions, certainly have an impact on the choice of company health plans. Also, it must be kept in mind that the management of the company is almost always covered by the same healthcare plans offered to the rank-and-file employees.”

  52. #52 Ramel
    September 3, 2009

    I’m always slightly stumped when faced with a claim like “There is one great advantage that private healthcare rationing has compared with government rationing: competition”. Are people really that dumb?

    Competition between companies basically amounts to who can make the greatest profit, this is normally achieved by working very hard to take the largest possible sum of money from the customer while giving them the smallest possible return. How the hell do people fail to understand this? This is why peoples health care decisions are dictated by insurance company employees whose christmas bonus depends on them denying as many claims as they can possibly get away with.

    Markets are useful to society for driving things such as technological innovation, but we should never lose sight of the fact that they are selfish by their very nature.

  53. #53 Ramel
    September 3, 2009

    Oh and,

    Also, it must be kept in mind that the management of the company is almost always covered by the same healthcare plans offered to the rank-and-file employees

    It should also be kept in mind that the managment of the company is almost always much better paid than the rank-and-file employees and can carry much higher out of pocket expenses.

  54. #54 Autodidactyl
    September 4, 2009

    This is a curious post by Ramel. Most people who think that markets and profits don’t work in health argue that market mechanisms can’t operate because of certain “market failure” conditions– say, adverse selection or moral hazard in insurance, or asymmetrical information between providers and patients. But it sounds like you’re questioning the efficacy of markets, competition and profits.

    “Competition between companies basically amounts to who can make the
    greatest profit,…”

    So far so good.

    “this is normally achieved by working very hard to take the largest possible sum of money from the customer while giving them the smallest possible return.”

    Um, no. As you note, companies compete with each other, not with the consumer. In a functioning market, they compete for profit by competing for market share– to the advantage of the consumer– by offering (a) a better product/service, or (b) a more cost-efficient deal on roughly the same product/service. Excessive profits are competed away; firms strive to increase output to cost (input), driving innovation and capital investment.

    It is where there is NO competition that firms lack the incentive to innovate, or to keep prices reasonably related to costs– since where else can consumers turn? This happens with monopolies and with price-fixing cartels. A reestablishment to market freedom– the entry of competitors looking to explode these fiefdoms by offering consumers a better alternative– restores the impetus to efficiency.

    “Markets are useful to society for driving things such as technological innovation….”

    How do you think this works? The profit motive! In an economy based on voluntary exchange, the only way to get money is to offer someone something they value in return. Having to compete with other providers impels you do your best to offer good value. In a functioning market dollars are “certificates of performance.” They’re also purchasing power– so your power in the market as both supplier and consumer will be enabled by performance.

    You are not the first person in history to question a system based on something as “selfish” as the profit motive. A little thing called the 20th century provided a number of global experiments with alternatives. It turns out that that the market and its pricing function comprise an irreplaceable discovery process for determining how resources can be allocated efficiently AND when you disconnect rewards from achievement (e.g., by banning profits or controlling prices) you pretty quickly erode the economic performance of a population. Also consider the “expertocracies” that try to replace markets in allocating resources turn out to be poor substitutes for the emergent order that results from the interaction of millions of free buyers and sellers. Plus, consider that the bureaucrats that policy textbooks depict as disinterested, objective and omniscient agents ALSO turn out to be human beings with fallible perspectives, facing their own political incentive structures, and make the WRONG decisions for their OWN self motives.

    “It should also be kept in mind that the management of the company is
    almost always much better paid than the rank-and-file employees.”

    It’s also worth pointing out that under competitive conditions, any firm that devotes too little of its budget on capital investment, r&d or recruiting and maintaining a skilled workforce will lose out to firms who take care of such expenditures with an eye to improving their own productivity and increasing their market share. Blowing your budget on upper management salaries or even excessive shareholder dividends is no strategy for the firm’s success. (It can, of course, profit a few here-and-gone administrators; but the bankruptcies, acquisitions and liquidations that befall the firms will, ultimately, provide the incentive for industries to restructure misaligned executive incentives.)

    “…but we should never lose sight of the fact that [profits] are selfish by their very nature.”

    The premium that economists place on results rather than intentions tends to irritate moral philosophers. Perhaps moral philosophers should renounce any good or service that is made available to them from any motive apart from altruism or principle.

    Again, we can discuss elsewhere the reasons why markets may or may not function in the context of health care, or sectors of it. But it’s nonsensical to imply that they can’t because health care is too important to be left to the profit motive. Food, clothing and shelter are overwhelmingly provided by the market (while experiments with government management of food provision around the world are an unhappy tale indeed– cf. Mao’s Great Leap Forward, Lenin’s War Communism, etc.). We don’t lament providers profiting from our hunger, nakedness and need for shelter. If they can profit from our illness while providing what we want– the best treatment possible– I for one will begrudge them nothing.

  55. #55 Ramel
    September 4, 2009

    It is always nice to get an intelligent response, I’m a little tired but I’ll do my best to return the favour.
    I am not arguing in favour of total communism and the complete abolition of the market, if my post gave that impression then I probably should have worded it better. My position here is specifically on the argument about whether the market will ever provide healthcare equal to or better than a government run single payer system or “public option” insurance.

    “this is normally achieved by working very hard to take the largest possible sum of money from the customer while giving them the smallest possible return.”
    Um, no. As you note, companies compete with each other, not with the consumer. In a functioning market, they compete for profit by competing for market share– to the advantage of the consumer– by offering (a) a better product/service, or (b) a more cost-efficient deal on roughly the same product/service. Excessive profits are competed away; firms strive to increase output to cost (input), driving innovation and capital investment.
    It is where there is NO competition that firms lack the incentive to innovate, or to keep prices reasonably related to costs– since where else can consumers turn? This happens with monopolies and with price-fixing cartels. A reestablishment to market freedom– the entry of competitors looking to explode these fiefdoms by offering consumers a better alternative– restores the impetus to efficiency.

    First off I stand by that statement as being for all intents a viable alternative definition of marketing. This is why companies spend a fortune on logos and package design, it increases sales and therefore profits without actually changing the product.
    Monopolies are one common result of the market, weaker companies are out competed and go bankrupt or are bought out leaving a small number of larger companies that no new comer can realistically compete with, these remaining companies then sit and stare evilly at each other bringing us to the next problem. Price fixing cartels, either organised or as a result of a “Mexican standoff”, are another all too common result of the markets. For example Pepsi and Coke, they both sell a similar product at the same price one could hypothetically reduce their price to increase their market share, so why don’t they? Well if one did the other would have to follow suit to stay in the game, and this would reduce the profits of both companies. This pretty much the same thing we see in insurance providers, if one was to start offering better a better deal to the public the others would have to do the same and all their shareholders will make less money. The only way around this is to regulate insurance provision so heavily that you have public insurance in all but name.

    “Markets are useful to society for driving things such as technological innovation….”
    How do you think this works? The profit motive! In an economy based on voluntary exchange, the only way to get money is to offer someone something they value in return. Having to compete with other providers impels you do your best to offer good value. In a functioning market dollars are “certificates of performance.” They’re also purchasing power– so your power in the market as both supplier and consumer will be enabled by performance.

    I don’t disagree that technological innovation is driven by the profit motive, but the problem is that new products command higher prices due to their strong position with regard to the competition. This is not a big deal if we’re talking about the latest iPod or TV, but in medical care it means only those with excellent insurance or their own oil well can afford the treatment.
    Innovation to reduce costs and improve efficiency is a good point for markets that I will partly concede, however incentives to achieve this can be introduced to a government system. The useful aspects of market forces can be harnessed within a government system such as bidding for contracts, for example by choosing a generic over an identical branded drug to reduce costs.

    You are not the first person in history to question a system based on something as “selfish” as the profit motive. A little thing called the 20th century provided a number of global experiments with alternatives. It turns out that that the market and its pricing function comprise an irreplaceable discovery process for determining how resources can be allocated efficiently AND when you disconnect rewards from achievement (e.g., by banning profits or controlling prices) you pretty quickly erode the economic performance of a population. Also consider the “expertocracies” that try to replace markets in allocating resources turn out to be poor substitutes for the emergent order that results from the interaction of millions of free buyers and sellers. Plus, consider that the bureaucrats that policy textbooks depict as disinterested, objective and omniscient agents ALSO turn out to be human beings with fallible perspectives, facing their own political incentive structures, and make the WRONG decisions for their OWN self motives.

    I think that using angry, violent, authoritarian dictators who appointed people to positions in control of resources based nepotism, loyalty or ideological purity is a little like using the crusades to argue that attempting to bring others around to your world view is inherently wrong. For a more relevant example contrast the health care provision of just about anywhere in the developed world with American health care.

    “It should also be kept in mind that the management of the company is
    almost always much better paid than the rank-and-file employees.”
    It’s also worth pointing out that under competitive conditions, any firm that devotes too little of its budget on capital investment, r&d or recruiting and maintaining a skilled workforce will lose out to firms who take care of such expenditures with an eye to improving their own productivity and increasing their market share. Blowing your budget on upper management salaries or even excessive shareholder dividends is no strategy for the firm’s success. (It can, of course, profit a few here-and-gone administrators; but the bankruptcies, acquisitions and liquidations that befall the firms will, ultimately, provide the incentive for industries to restructure misaligned executive incentives.)

    Ok, going off an a slight tangent here, my point was that insurance that may be acceptable for a well paid executive (the people who get to decide the company’s insurance policy) may place unreasonable costs on a secretary or a van driver.

    “…but we should never lose sight of the fact that [profits] are selfish by their very nature.”
    The premium that economists place on results rather than intentions tends to irritate moral philosophers. Perhaps moral philosophers should renounce any good or service that is made available to them from any motive apart from altruism or principle.

    I did not say that such selfishness is an intrinsically bad thing, hell buying a CD instead of sending any money beyond what you need to survive to help staving kids in Africa is a selfish act. My argument is that companies work for the good of their shareholders, but some things such as healthcare, the military, the fire brigade or the police should be run for the good of every one and not the good of some guy’s wallet.

  56. #56 Autodidactyl
    September 6, 2009

    Thanks for the response.

    I refer to what goes on between two or more suppliers in a market as “competing.” What goes on between supplier and consumer I’d call “bargaining” or driving a bargain. I assume that, as a consumer, you strive to get the best value for your money– in your terms, to get the most product/service as possible while surrendering as little money as possible. The supplier is doing the inverse. But, in a market context with no coercive regulation, each of you can walk away from the deal if you deem the terms unsatisfactory. Relatively few things that I find myself wanting or needing don’t have at least remotely acceptable substitutes that I can procure elsewhere; and in a competitive market there are other suppliers of roughly the same or similar good or service looking for my business.

    Again, in a functioning market, competition erodes excessive profits and discovers a true price. As a consumer I may start out wanting an HDTV for, oh, $35. I will quickly discover that no one can cover their costs and earn a motivating profit by offering one at that price. A firm that makes them might prefer to charge me $12,000 for one. They will quickly discover that in doing so they have ceded the market to suppliers willing to price at or near what turns out to be the equilibrium price.

    As to monopolies: There is a good deal of literature on the subject, much of which suggests that even markets with only a few major suppliers tend to remain competitive; cartels are tough to maintain—–the temptation to break ranks and reap increased market share (lower unit price more than compensated by increased volume of units sold, good for shareholders) tends happily to be too strong. But I think a bigger point is the role that government often plays in making a field less competitive. In the 1950s and 1960s big businesses in the U.S. tended to be very happy with the heavily regulated business environment in the wake of the “Treaty of Detroit.” It turned out that regulations stipulating elaborate labor benefits, production schedules, etc. (including airline, trucking etc. regulation) worked to protect large established businesses from competitive entries that couldn’t afford these transaction costs. Big firms were more secure, shareholders got modest but largely guaranteed returns, workers felt all but invulnerable—and consumers paid the freight.

    As to ads and marketing: When products are essentially similar, ads can make a big difference by successfully depicting a given product as hipper, sexier, and more stylish. But ads also convey substantive information about product differences, and particularly in major purchases consumers care about such things more than some social critics would have us think. Anyway, marketing is seduction, not coercion, and seduction is typically a mixture of substance and style. Where substance leaves off, marketers discover that style—a certain image, say—is part of what people want. That’s an aspect of taking freedom seriously.

    As to innovation: Many important new goods enter the market at a high price. During the time these spend as “luxury goods” the wealthy are in effect paying the cost of further development to achieve more cost-efficient manufacture, allowing the good to be priced down to the mass market. In capitalism the payoff is a mass market, which is why, say, Mr. Ford wound up so much wealthier than Messrs. Rolls and Royce. I think it was Joseph Schumpeter who said that while royal women had had silk stockings for centuries, the achievement of capitalism was to make them affordable to factory girls.

    This post isn’t about health care financing as such. Let me hasten to say that I don’t relish any more than you do the thought of somebody suffering acutely or even dying because they can’t afford treatment that exists and that many others can easily afford. Like you, I want the most/best health care to be accessible to the most people. From my acquaintance with the subject thus far I am less sanguine about achieving that goal through centralized government management, and suspect that a well-designed marketplace—supplemented with demand-side vouchers for low income people—will wind up better performing the needed combination of tasks: Controlling costs, driving innovation, broadening access. But again, this is for another, less general post.

    Finally, as to collectivist societies I never said anything about violence, oppression, human rights violations, etc. I realize all socialist/collectivist/social-democrat systems are not totalitarian Communism—although giving sufficient power to centralized government to “manage” the economy rather than leaving it largely to free exchange can bite a society in the ass down the road. My remarks were about the relative efficiency of free vs. controlled economies in general. Again, I am happy to address what seem to me the trade-offs between the approaches to health care taken by the US and by various other developed countries (which as you know differ considerably among themselves, though almost all have more government control than the US) in a dedicated post or posts. But I’ll end here by saying that one thing I’ve come to appreciate about competitive market settings is that, where they function, they tend to make the performance of their participants efficient by tracking reward to achievement far more acutely than occurs in bureaucratic settings, where signals to change policy (and authorization to do so) tends to be glacially slow, and where individual performance is camouflaged by bureaucratic mass and often difficult to access by incentive structures beyond doing the minimum and keeping your head down.

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