Respectful Insolence

Before I try to leave this topic for a while (which, like so may topics in the past, has temporarily taken over the blog for the last few days), one of the comments I’ve kept hearing since I started blogging about the new USPSTF mammography guidelines is something along the lines of, “Well, if the government runs health care, naturally politics will impact any attempts at science-based guidelines. That may be true, but in fact excessive politicization has always been a problem in that area, particularly for breast cancer. There’s a good interview with to Dr. Barron Lerner, associate professor of medicine at Columbia University College of Physicians & Surgeons and author of The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America. The whole interview is worth reading, but here’s one point that I’ve discussed before:

In the early 1990s, there was some suggestion that if you did something called a bone marrow transplant, or stem cell transplant – which was a very aggressive treatment for metastatic breast cancer – that women live longer. The studies were very, very preliminary but word got out and women started coming to doctors, essentially demanding the procedure because they thought it might save their lives, or at least prolong their lives. The power of that lobby was so strong that insurance companies began to pay for the procedure, even though it was still experimental and its value hadn’t been proven. Again, you’d be very hard pressed to find examples like that in many other areas.

It turns out that when the randomized studies came through and we got good data — at the end of the 1990s — that treatment was, in fact, no better than standard chemotherapy and caused more harm along the way. So it was not indicated at all. But, again, this was an example of Congress, or the government, sort of sticking its foot where it shouldn’t — trying to do the right thing, trying to insure access for all women who have a serious disease. But if you don’t look at the data and you’re acting based on your heart, or your gut instinct, you often make the wrong decision.

I wrote about the issue of bone marrow transplantation for breast cancer before as a cautionary tale in the context of criticizing a bad article about the swine flu in which it was used as an example. I think Dr. Lerner underestimates the impact of quite a few prominent breast cancer oncologists who promoted the therapy, but his point is clear. Politics has trumped science before.

Now, as I’ve pointed out, the new USPSTF guidelines are more of a case of how much one values risks versus benefits and how far we want to go to save one life from breast cancer, because, when it comes down to it, even the critics of the guidelines really don’t question the studies and data used to derive to those guidelines. However, as much as my thoughts have evolved recently regarding whether the government should fund universal health care (remember, I used to be pretty conservative, politically speaking), one thing that does bother me about injecting more government into paying for health care is just what happened with the USPSTF guidelines. Instead of a sober, science- and policy-based discussion, we have seen moronic hyperbole and doctors who should know better calling the USPSTF brain dead sobriquets like “soft death panels.” The potential effect on science-based medical practice worries me.

On the other hand, it may come down to weighing the benefits and costs. In order to bring about universal health care coverage, it may be necessary to put up with periodic political rows like this whenever the science evolves treating common diseases.

Comments

  1. #1 Tim Slagle
    November 22, 2009

    There are problems with Government funded health care beyond the political, there is an even better economics argument against it.

    Since the amount of health care available is finite, there has to be a way to decide which patients get treated. In a free market, costs will have a balancing effect. As services become scarce, prices rise, and as prices rise people put off unnecessary treatment.

    There is also a really nice side benefit to rising prices, because when the price goes high enough above cost, greedy entrepreneurs will add more facilities in order to capitalize on the obscene profits potential.

    Under Government funded health care, everything is perceived to be free, so people flood the system. At that point, the government has no other choice but to impose rationing. Additional facilities are also slow to come on line, because rather than a greedy capitalist building a new clinic right away, the new facilities request needs to wind its way through the Congressional budget process.

    And it’s not a wild tin foil conspiracy I’m laying out here, it’s already going on around the world. In the UK cancer survivability is pathetic, because of the wait times imposed under government rationing.

  2. #2 Orac
    November 22, 2009

    That you would present these data shows that you do not know much about what you are talking about when it comes to cancer. Not surprising. Even a lot of physicians get confused. In any case, it’s widely agreed that much of the reason for this apparent difference is artificial and almost certainly due to overdiagnosis, where we diagnose a lot of very early cancers that would never threaten the life of the woman are diagnosed and treated, and stage migration, where more intensive screening tends to find preferentially less aggressive tumors. These factors give an apparent survival benefit that is not “real” but do serve as confounders in actually finding real differences. What they do is to produce a lot of women with diagnoses of cancer who in retrospect never really needed treatment but, because we can’t identify which tumors will and will not progress to threaten the life of a woman, we treat them all. For instance, if you look at Figure 1.2 here, you will see that the overall death rate from breast cancer is similar in Europe and the U.S. and that socialist paradise, Sweden, has very comparable, possibly better breast cancer survival than the U.S. Moreover, these statistics would seem to contradict what’s in that article.

    The figures cited in your article don’t even make sense; so I’d love to see the primary source for these figures. For instance, how can there be an overall survival rate of only 74% overall and 78% for stage I in the UK? Suffice it to say, it’s a lot more complicated than that pathetically simplistic hijacking of data would lead us to believe.

    Here are some of the real issues involved. Specifically, much of the apparent increase in survival is thought to be due to lead time bias and stage migration:

    1. The early detection of cancer: More complicated than you think
    2. Early detection of cancer, part 2: Breast cancer and the never-ending confusion over screening
    3. The paradox of screening mammography and breast cancer
    4. The spontaneous regression of breast cancer?
    5. Rethinking cancer screening?
    6. Really rethinking breast cancer screening (This is where I actually discuss the guidelines themselves)
    7. “Obama’s fixin’ death panels for your mama,” the misogyny gambit, and other idiotic responses to the updated USPSTF mammography recommendations
    8. “Obama’s fixin’ death panels for your mama”: The USPSTF recommendations for mammography used as a political weapon

    Similar considerations apply to prostate cancer, BTW.

    In any case, comparisons between nations are fraught with complications and difficulties. They are not as straightforward as you think. Also, in the U.K. and some other E.U. countries, there are actually standards in place that end up having women receive prompter care than they do in the U.S., with the vast majority being seen by a specialist within two weeks and being treated within 31 days. This is as good or better than anywhere I have ever worked in the U.S. You might also want to check out this series an acquaintance of mine wrote:

    Are Patients in Universal Healthcare Countries Less Satisfied?
    What’s health care like in Australia?
    What is healthcare like in the Netherlands?
    What is healthcare like in the Netherlands?
    What is healthcare like in Germany?
    What is health care like in France?
    What is the cause of excess costs in US healthcare?
    What is health care like in the UK, Canada and New Zealand?

    As for economic arguments, I used to be down with the whole free market thing about a decade ago. However, ten years of practice and real world experience in our dysfunctional health care system have led me to reconsider. In any case, here’s a challenge. I constantly hear conservatives extolling the benefits of the free market as the panacea that will cure our health care woes. Please show me an example of a nation–just one, although more would be better–that has successfully used the free market to bring affordable universal health care to its people. Seriously.

  3. #3 Ramel
    November 22, 2009

    and as prices rise people put off unnecessary treatment.

    Those price rises also mean that some people are simply unable to afford treatment that woulcd be considered neccessary, or are you ok with the concept of allowing people to die for the sake of increased profits?

    Oh, and if you want to be taken seriously never ever quote the Daily Fail, especialy on a scienctific or medical issue, you will be mocked relentlessly.

  4. #4 Tim Slagle
    November 22, 2009

    Funny.

    You’re so trusting of bureaucrats. Did you ever think that perhaps the Department of Health might fudge the statistics just a little, to make themselves appear more efficient?

    “the report provided “breathtaking” evidence of a confidence trick being played on the public, repeatedly told that waiting times for patients with suspected cancer are falling, while desperate cases were forced to the back of the queue.”

    http://www.telegraph.co.uk/health/healthnews/5460788/Patients-with-suspected-cancer-forced-to-wait-so-NHS-targets-can-be-hit.html

    I’m reminded of the popular old Soviet chestnut: “We pretend to work, and they pretend to pay us.”

  5. #5 Orac
    November 22, 2009

    One notes that Tim has not addressed any of the substantive discussion, for which I provided copious links. Most likely, he has not even read the links and thus still does not understand the medical and scientific issues involved. Instead, he prefers to rely on conspiracy mongering and talking points.

    Sad that. It was a depressingly bad argument.

    One also notes that Tim has not answered a rather direct and quite pertinent question; so I’ll ask again and keep asking every time he comments it until he directly answers it:

    I constantly hear conservatives extolling the benefits of the free market as the panacea that will cure our health care woes. Please show me an example of a nation–just one, although more would be better–that has successfully harnessed the free market to bring affordable universal health care to its people. Seriously.

    Please, Tim. I want to know. If you can produce a compelling and convincing example (or two or three), I might be persuaded.

  6. #6 Jefrir
    November 22, 2009

    Well I can see one obvious flaw in the idea of higher prices discouraging people from getting healthcare: medical treatment isn’t like most things people buy, where you can just do without it if it’s too expensive. In most cases, if you need an operation, you don’t get to decide not to bother. Therefore, it’s hard to see higher prices actually reducing the amount of treatment except in a very few cases. In fact, it may increase the amount of healthcare needed, as people ignore less serious things due to fear of the cost, and then need more care later when they become more seriously ill.
    I live in the UK, and we really don’t have horribly rationed healthcare. Any care is paid for provided that it is medically necessary (so eg. cosmetic surgery is not generally covered) and clinically effective. There are waiting lists for some things, especially elective surgery, due to historical shortages in staff, but these are coming down now. And, hey, if you don’t like it, you can still pay extra for private healthcare. It won’t get you any more in the way of necessary care, but it will get you that knee operation a bit sooner, and a more comfortable room while you’re having it. And, because the NHS trains the doctors, it’s cheaper than in the US.
    The NHS isn’t perfect, but it’s pretty damn good, and at least I know I will never go without treatment due to lack of funds.

  7. #7 Daniel J. Andrews
    November 22, 2009

    It seems our Canadian health care system works somewhat well. Not perfect, probably not the best in the world, but still preferable to no universal health care system. I don’t mind paying slightly higher taxes for it either. The whole “hurts the economy” argument is faulty, btw, and if you get your information about our health care system from talking heads and politicians, you are most likely hearing distortions and lies (as per usual among the antiscience crowd).

    I am curious though about the issue of gov’t interference. Orac, do you (or any other knowledgeable readers) know of any examples where our (Canuck) government interfered with SBM guidelines which wouldn’t have happened if we didn’t have a universal health care system? Anything like this would have escaped my notice for most of my life, and I’d like to be aware of it in preparation for future gov’t meddling.

  8. #8 andrew
    November 22, 2009

    I wrote on a previous Orac blog, that demand for health care will exceed resources and this results in rationing. The question is how is the rationing to be done, by cost or based on need. The resources being paid for by general taxation? A question for Tim, if a person has no money, due to being laid off from work, how will the “free market” accord them health care? Should the poor just die or does society have a duty of care to its members? Yes, there are problems with the NHS, few Britons would disagree, but the US system is far worse according to what is reported over here. I will ask again WHAT IS WRONG WITH SOCIALISM? Nearly all anti state care bloggers say it is bad but do not give reasons

    PS Define socialism please

  9. #9 military wife
    November 22, 2009

    I went for my first mammogram recently after being scolded by two doctors for having put it off well past my 40th birthday. I was by far the youngest woman at the gleaming palace (granite, beautiful hardwood, high end furniture, etc) of a “breast imaging and health” center. I was early for my appointment so I got to watch a steady stream of septuagenarians and octogenarians arriving, getting called back for their mammograms, and then leaving the center. Every one of them scheduled their exam “same time next year” and all were billed to Medicare, of course.

    I told my husband that if I make it to eighty, no way I’m getting my sad old boobs smooshed every year (or ever again), on the taxpayer’s dime or not. I also told him I think it’s a huge racket that our tax dollars are paying to build these centers all over the country.

    I guess I want to kill grandma or something. I’m thrilled this report came out…now I won’t feel bad if I wait another few years to get another mammogram.

  10. #10 mad the swine
    November 22, 2009

    “[I]n fact excessive politicization has always been a problem in that area, particularly for breast cancer.”

    No kidding! The fact remains, for example, (a fact your article doesn’t mention, hmmm) that the single highest-risk group for breast cancer is composed of women who have had abortions, and there is a direct correlation between the number of abortions and the risk of breast cancer later in life – but you’ll never see *that* warning coming out of feminist (read: anti-woman) liberal government offices.

    And, though I’m not Tim,

    “Please show me an example of a nation–just one, although more would be better–that has successfully used the free market to bring affordable universal health care to its people. Seriously.”

    Talk about begging the question! Free markets don’t provide universal anything – they provide the most high-quality services to those most willing and able to pay for them. I’d far rather live in a nation (the modern US) that has the best quality health care in the world, available to anyone who can afford it, than in some EU socialistopia that forces productive people to accept substandard health care in the name of providing some lowest common denominator to ‘everyone’. Universal health care is not good for society!

  11. #11 Orac
    November 22, 2009

    No kidding! The fact remains, for example, (a fact your article doesn’t mention, hmmm) that the single highest-risk group for breast cancer is composed of women who have had abortions, and there is a direct correlation between the number of abortions and the risk of breast cancer later in life – but you’ll never see *that* warning coming out of feminist (read: anti-woman) liberal government offices.

    The abortion-breast cancer link is a myth promoted by anti-abortion activists. I’ve actually written about the bad science behind it before at least a couple of times:

    Abortion and breast cancer: The Chicago Tribune feeds the myth
    It’s nice when your efforts are appreciated by those who need them the most…

    Nice try, though.

  12. #12 andrew
    November 22, 2009

    I assume that mad the swine is not poverty striken but has sufficient funds (or a job) to pay for insurance,Why is universal health care notgood for society? Oh I just reread his post,”forces productive people toaccept substandard health care” 1) prove your comment 2)does this mean that priests, politicians and lawyers who do not produce should not have health care?

  13. #13 epador
    November 22, 2009

    I always enjoy the thoroughness and logic of your scientific analysis (as in #2 above). Once you tread on politics that seems to go out the window, for some reason.

    Orac, when you really, really need it to get there the next day, do you use the USPS or FedEx? And why?

    How about some examples of Huge health care systems (not itty-bitty little ones 1/50th the size of our). Personally, I REALLY like what the Norwegians have done with medical care of physicians, But getting that to translate into our system would be a major war or two. How’s Russia, China and India doing on care for caregivers, much less the general public?

    You are sounding more [political rows] British as the years go on, (but knowing the origin of Dr. Who, that’s no surprise). Pip, pip, cheerio and all that rot!

  14. #14 red rabbit
    November 22, 2009

    I’m willing to bet mad the swine has health insurance, which is just another evil socialist way of rationing things. It excludes some people though which appears to make hom feel better because those people clearly don’t deserve surgery for their cancer because… well, they’re poor and therefore must be inferior.

    Or something.

    The Canadian system would likely be vastly improved were it a bit more centralised. Currently it varies incredibly from province to province, and the smaller provinces are having difficulty keeping standards up with fewer resources. We are able to send people from one region to another for more specialised treatment, however, which does mitigate some of that. Other than that, it works relatively smoothly.

  15. #15 Ramel
    November 22, 2009

    Can mad the swine explain how feminist liberals are anti women? Or explain why poorer people being left to suffer is a good thing for society? Did epador have a coherent point that I missed? Is there something wrong with sounding british? Will I even care about any of the answers?

  16. #16 Skeptico
    November 22, 2009

    mad the swine

    Free markets don’t provide universal anything – they provide the most high-quality services to those most willing and able to pay for them.

    I’ll take that as an admission by mad that free markets will not bring affordable universal health care to its people. Thanks for the confirmation.

    I’d far rather live in a nation (the modern US) that has the best quality health care in the world, available to anyone who can afford it,

    Tough luck if you can’t afford it then. For your sake, I hope you don’t lose your job or get a pre existing condition and have all your claims denied.

    than in some EU socialistopia that forces productive people to accept substandard health care in the name of providing some lowest common denominator to ‘everyone’. Universal health care is not good for society!

    Funny that in all those EU countries, they have better healthcare with greater patient satisfaction than in the US. Did you read those links Orac provided to denialism blog:

    Are Patients in Universal Healthcare Countries Less Satisfied?

    What’s health care like in Australia?

    What is healthcare like in the Netherlands?

    What is healthcare like in the Netherlands?

    What is healthcare like in Germany?

    What is health care like in France?

    What is the cause of excess costs in US healthcare?

    What is health care like in the UK, Canada and New Zealand?

    epador:

    Orac, when you really, really need it to get there the next day, do you use the USPS or FedEx? And why?

    I’m not Orac, but I’ll answer – in the specific case you mention I would use FedEx. But I would hate to have only Fed Ex – when I just want to send a regular letter that can take a couple of days I’d rather use USPS and pay just 44c instead of $15.

    How about some examples of Huge health care systems (not itty-bitty little ones 1/50th the size of our).

    See above – Europe is actually bigger than the US.

    Personally, I REALLY like what the Norwegians have done with medical care of physicians, But getting that to translate into our system would be a major war or two. How’s Russia, China and India doing on care for caregivers, much less the general public?

    Chinaand India – each of which is 4 times the size of the US. And with much lower GDP per head. And you are the one complaining about examples that don’t compare well to the US.

  17. #17 JScarry
    November 22, 2009

    One of the things that extreme free market advocates forget is that the efficiencies occur only if all parts of the market are allowed to move to a new equilibrium. The energy debacle in California is a case in point. The market for generation was de-regulated while the market for consumption was not. Companies like Enron took advantage of the situation and prices skyrocketed. And the state made some missteps as well.

    Health care is no different. There are so many places where it is tightly regulated and places where there are effectively oligopolies that there is no way it can ever act as a free market.

  18. #18 Tim Slagle
    November 22, 2009

    Sorry, I had previous commitments, so I could only give your response post a quick glance. Still not under the liberty to give it as much attention as it deserves, however:

    “Please show me an example of a nation–just one, although more would be better–that has successfully harnessed the free market to bring affordable universal health care to its people.”

    The lack of a working example should not to be construed as proof of unfeasibility. Before the 20th Century, a working airplane had not been built, before 1776 self-government was considered a ridiculous notion.

    We can find examples in history and in other sectors of medicine. The history of medicine between the founding of this nation and the middle of the the twentieth century was mostly free-market. And in that short span, we went from bleedings and barbers, to vaccines and open heart surgery.

    Meanwhile, since optometry has been paid out of pocket until recently, you can see the free market at work in that sector. Prices today are unbelievably cheap, and very few people who need glasses do not have them. Meanwhile contact lenses have gone from a luxury item only available for movie stars, to disposable lenses that almost anyone can afford.

  19. #19 Orac
    November 22, 2009

    In other words, Tim, you can’t give a convincingly applicable example and have to stretch and shoehorn an example whose applicability is dubious at best, in essence, admitting that there is no such example. Meanwhile there are many examples of various universal care plans with differing mixes of public and private insurance that do have a track record.

    Thank you. I thought it would be the case that you couldn’t give a compelling, evidence-based answer. Ideology is nice, but if you can’t even produce compelling arguments for why an unproven system would work better than what we have now or other methods with track records that we can evaluate I have a hard time being convinced that we should dismantle our current system in favor of a completely free market nirvana, as dysfunctional as our current system is.

    By the way, did you read up on lead time bias and stage migration yet?

  20. #20 Orac
    November 22, 2009
    Orac, when you really, really need it to get there the next day, do you use the USPS or FedEx? And why?

    I’m not Orac, but I’ll answer – in the specific case you mention I would use FedEx. But I would hate to have only Fed Ex – when I just want to send a regular letter that can take a couple of days I’d rather use USPS and pay just 44c instead of $15.

    Actually, I almost never have to send stuff personally. At work, I use whatever company my hospital or university has contracted with because otherwise I’d have to pay for it myself. Kind of like the way health care is now, actually.

  21. #21 Skeptico
    November 22, 2009

    Tim Slage

    The lack of a working example should not to be construed as proof of unfeasibility.

    Tim, that literally made me laugh out loud. Hilarious. Here’s your mistake: the ones claiming that the free market will provide satisfactory healthcare are the ones who need to support their case – the burden of proof is upon them, not upon anyone else to provide “proof of unfeasibility.” Still, thanks for confirming there is a “lack of a working example” as you put it. Or as I would put it – lack of evidence that the free market works well for healthcare. The question for you is, since we both agree there is a lack of evidence that this model works, why would you support it and oppose change to a different model, a model that has many successful working examples?

    Meanwhile, since optometry has been paid out of pocket until recently, you can see the free market at work in that sector. Prices today are unbelievably cheap, and very few people who need glasses do not have them. Meanwhile contact lenses have gone from a luxury item only available for movie stars, to disposable lenses that almost anyone can afford.

    Yeah, so relatively cheap health related items can perhaps be provided by the free market. Doesn’t really work if you need a $100K operation, does it?

  22. #22 Phoenix Woman
    November 22, 2009

    “How’s Russia, China doing” WRT health care?

    China has actually backslid — they used to have a “barefoot doctors” system that tried to care for everyone; now they have nothing. If you can’t afford a doctor — and most can’t — you don’t get treated. As T.R. Reid notes in his book The Healing of America, where he compares different healthcare systems worldwide, doctors in other countries, after lamenting the horrible situation of US healthcare, will follow up their laments with “at least you’re not China”.

    As for “evil government bureaucrats”: There are far less layers of bureaucracy in the Veterans Health Administration than there are in private-industry health care; there are also fewer mistakes, in large part due to the VA’s use of computerized systems (brought in thanks to the systemwide overhaul ordered by President Clinton back in the 1990s) to keep mistakes from happening. As a result, the VA now beats the pants off of even the Mayo in terms of care delivered.

  23. #23 Phoenix Woman
    November 22, 2009

    Oh, and as for The Horrible Terrible No Good Very Bad Waits for elective procedures in other nations:

    I was diagnosed with uterine fibroids back in 2002. The treatment of choice back then was uterine artery embolization — but my insurance wouldn’t cover it; it was either hysterectomy or nothing. The stated reason given was because UAE was considered “experimental” even though it had already been done in France for decades (it was originally used as a means to minimize bleeding during hysterectomy surgery; when doctors realized that the fibroids of women post-UAE had started shrinking on their own, the docs decided to start targeting the arteries that fed the fibroids). The probable real reason: Hospitals charged about $14k for it at the time, compared to $6k for a hysterectomy (which would have meant entering menopause two decades early as my ovaries would have been pulled out along with the uterus).

    So guess what? I didn’t get the surgery.

  24. #24 Kemist
    November 22, 2009

    Under Government funded health care, everything is perceived to be free, so people flood the system.

    Not quite. I live in Canada, and that’s not at all how we perceive it. We are highly aware that our tax money finances that system, and the excesses of administrators are often very badly publicized – they are wasting our money.

    If you get your own public healthcare system, one thing you must absolutely do is watch very, very carefully how the money is spent. It can be the best healthcare system in the world, or the very worst, just depending on how much you expect and demand from it – just like any democratic (elected) government service.

    At that point, the government has no other choice but to impose rationing.

    All systems impose a kind of rationing. The free market simply rations against the poor, whereas most public healthcare systems rations as to who is in most need of care.

    In our case, rationing takes the form of waiting. If you’re badly sick, you won’t mind waiting your turn to see the doctor. If it’s nothing serious, you’ll go back home. Emergency rooms and private clinics have a screening system which determine the emergency of your condition according to medical criteria.

    If you present yourself, say, with chest pain and a low oxygen saturation, you’ll be given a much higher priority level than a child with a sore throat, no matter how rich the kid’s parents are – and that, in my opinion, is how it should be.

  25. #25 Phoenix Woman
    November 22, 2009

    If you present yourself, say, with chest pain and a low oxygen saturation, you’ll be given a much higher priority level than a child with a sore throat, no matter how rich the kid’s parents are – and that, in my opinion, is how it should be.

    Oh, exactly. But in the US, the anti-gummint and thus anti-tax crowd’s motivations are driven in large part by things they don’t dare openly acknowledge — namely, that since they think that people whose skins are darker than theirs will benefit most of all from government aid, anything that hurts government programs is a good thing. That’s how Ronald Reagan won in 1980, as one of his top strategists explained:

    Listen to the late Lee Atwater in a 1981 interview explaining the evolution of the G.O.P.’s Southern strategy:

    ”You start out in 1954 by saying, ‘Nigger, nigger, nigger.’ By 1968 you can’t say ‘nigger’ — that hurts you. Backfires. So you say stuff like forced busing, states’ rights and all that stuff. You’re getting so abstract now [that] you’re talking about cutting taxes, and all these things you’re talking about are totally economic things and a byproduct of them is [that] blacks get hurt worse than whites.

    ”And subconsciously maybe that is part of it. I’m not saying that. But I’m saying that if it is getting that abstract, and that coded, that we are doing away with the racial problem one way or the other. You follow me — because obviously sitting around saying, ‘We want to cut this,’ is much more abstract than even the busing thing, and a hell of a lot more abstract than ‘Nigger, nigger.”’

    [...]

    The truth is that there was very little that was subconscious about the G.O.P.’s relentless appeal to racist whites. Tired of losing elections, it saw an opportunity to renew itself by opening its arms wide to white voters who could never forgive the Democratic Party for its support of civil rights and voting rights for blacks.

    The payoff has been huge. Just as the Democratic Party would have been crippled in the old days without the support of the segregationist South, today’s Republicans would have only a fraction of their current political power without the near-solid support of voters who are hostile to blacks.

    When Democrats revolted against racism, the G.O.P. rallied to its banner.

  26. #26 Dan Weber
    November 22, 2009

    It is very unfortunate that people get distracted by the “we should have government care” or “we should not have government care” argument. It has nearly nothing to do with improving health care.

    The government provides about $600 Billion worth of care every year. We could be trying to just make that $600 Billion more efficiently spent by the government. But the party that has traditionally been in favor of making government efficient has been all too willing to scream about “rationing.”

  27. #27 techskeptic
    November 22, 2009

    Free market zealots crack me up when they make claims about the supremacy of american healthcare technology (and then try do conflate that with healthcare system). I agree we do have good healthcare technology (so do the french and japanese) . however, the overwhelming majority of our technological medical advances come from…yup you guessed it… socialism! in the form of government grants for development. That goes for energy and military technology also.

    They continue to pretend that venture capital would perform the same job when VC monay represents a tiny fraction of the money spent on technology development and worse, VC money generally comes around after the technology has been developed but the product has not come to market yet. Yeah, grerat guys, way to be there for the hard part.

  28. #28 Ed Uthman, MD
    November 22, 2009

    Thanks for the great article, Orac. I am a practicing pathologist who makes significant money from the breast cancer screening process, so I can only lose financially if the new recommendations are put into place. However, I support the new recommendations. This has put me in hot water with some of my colleagues, but I have just been on too many wild goose chases of abnormal mammograms to support the status quo. Those resources can be expended much more effectively on other efforts in public health.

  29. #29 Will TS
    November 22, 2009

    Tim Slagle says:

    Meanwhile, since optometry has been paid out of pocket until recently, you can see the free market at work in that sector. Prices today are unbelievably cheap, and very few people who need glasses do not have them. Meanwhile contact lenses have gone from a luxury item only available for movie stars, to disposable lenses that almost anyone can afford.

    Oh, I get it. The free-market has improved optometry services and driven down the costs. Now everybody can afford high-quality, low-cost vision care. So why do charities solicit used eyeglass donations? Who could possibly need those when everybody already has good, cheap glasses? Must be those lazy welfare cheaters.

    Wouldn’t the same principles apply to all free-market services? Health care in the US is a free-market system today, if you’re under 65. Following Tim’s logic, health care should be inexpensive, high-quality and available to everybody. If the free-market is the best system for health care delivery, why isn’t the free-market delivering high quality-health care to everybody? If we can all have cheap glasses, why are people forced to choose between paying rent and buying medicine? If the free market controls health care costs so well, why isn’t it working now?

    I am not persuaded by the argument that the free-market is going to solve our problems (someday, in the unspecified future) when the free-market got us to this point. There is a conflict between the incentives of a free-market system and a health care system. Now we have to decide who we want to win, the market or the people.

  30. #30 techskeptic
    November 22, 2009

    Will TS,

    I know what the answer will be as I have had this conversation before. They will claim that we do not in fact have a truly free market for healthcare. For example you can’t by health insurance over state lines. There are a number of other minor gripes that constitute their thinking as to why we dont really have free market when it comes to healthcare.

    Regardless, we have the most free market healthcare and the most rotten in the modern world. Even macau beats us and a number of other countries I have no heard of before when it comes to longevity and cost.

    But to suggest that we should operate in a freer market than we have now, is like saying “Well, this sword poking me in stomach only hurts a little, it will probably feel better if I completely impale myself”

  31. #31 Pareidolius
    November 22, 2009

    Hey MTS, Tim and epador, when did we change our national motto from E pluribus unum to Ego sum pecuniosus, tu es mortuus?

  32. #32 andrew
    November 22, 2009

    There are few if any “free” markets in any area, all markets have controls to, there are quality and safety rules mandated by government in food production, pharmaceutical production etc. If the “free” marketers are correct there shouldn’t be hunger in the world as prices would fall to the levels people could afford. Jerry Pournelle ( http://www.jerrypournelle.com ) by no means a Democrat or socialist often observes that “ in a truly free market, Human flesh would be available in the market” ( this is hyperbole of course. The point Jerry is making is that all markets have controls usually based on moral or ethical values held by the society the market functions in. In Europe we have decided that a free market in Health is immoral as many of our co-citizens would suffer unnecessarily, can the free marketers on this thread show how their actions would reduce suffering given that not all people have the resources to pay for health care, many find it difficult to feed, clothe and house themselves.

  33. #33 Kemist
    November 22, 2009

    Meanwhile, since optometry has been paid out of pocket until recently, you can see the free market at work in that sector. Prices today are unbelievably cheap, and very few people who need glasses do not have them. Meanwhile contact lenses have gone from a luxury item only available for movie stars, to disposable lenses that almost anyone can afford.

    Er, as a student, I would like to protest that buying the glasses I need is nowhere near the “cheap” spectrum. So much that I had the same glasses for a long, long time and delayed changing my prescription until the headaches became unbareable – and I had to borrow from my parents at that point.

    I also pay out of pocket for the dentist, which is also quite costly. If fact costly enough for me (and many students) to avoid dentists for as much time as we can.

    I can’t imagine the consequences of having to similarly forego the doctor and endocrinologist consultations for my thyroid problem.

  34. #34 Keith Harwood
    November 22, 2009

    As I wrote to my MP regarding what appeared to be a reduction of service at a clinic I attend regularly, “The politicians and bureaucrats have to learn that health costs can not be controlled by pricing. It is not discretionary spending. People can not decide, `I can’t afford to have cancer this year so I will put it off until next’. If it were possible, I would have done so.” That’s true where the pricing is determined by those bureaucrats and doubly so where it is decided by for-profit companies. The difference is that in the first case the MP gets up on his hind legs in Parliament and something gets done, but it in the latter case, “You’re not a shareholder, so sod off.”

    In Tim’s world, relying on market forces to price health, I would be dead and my wife bankrupt years ago. And Tim, no doubt, would regard that as a good thing; if you can’t afford the treatment you need you deserve to die.

  35. #35 Bill
    November 22, 2009

    So, how do we here in the U.S. acclimate people to accept the realities of limited resources in public health care systems?

    60 minutes tonight pointed out the enormous amount Medicare spends on those who are in their last 2 months of life.

    Since Medicare can’t reject a treatment because of cost, they gave examples like $50,000 in cancer drugs (avastin) for an average 1.5 month life extension, or spending $40,000 for an implanted defibrillator for a 90+ year old with terminal cancer (again, CBS’s examples, not mine)

    None of the above is sustainable, but how do you tell people on Medicare or any other “sorry, we can’t cure you, so you’re being transferred to Hospice”

    Shoot, I’d love to see more palliative care available, even for those not yet sick enough to qualify for Hospice, given my 90-something grandmother’s recent experience.

    She had severe shortness of breath (she has CHF) outside of normal business hours.

    All she wanted was symptomatic relief, but the ER’s response was “well, if you’re not going to agree to undergo a cath, here’s a DNR, and don’t bother to come back”

    What the h*** is she supposed to do if she has pain or significant discomfort in the middle of the night again?

  36. #36 Shay
    November 22, 2009

    As services become scarce, prices rise, and as prices rise people put off unnecessary treatment.

    No, Tim, as anyone who works in public health can tell you, far too often they put off necessary treatment, as well.

  37. #37 Kemist
    November 22, 2009

    As services become scarce, prices rise, and as prices rise people put off unnecessary treatment.

    Just to clarify, which of these would you consider “unnecessary treatment” ?

    a) A 22 years-old student gets Hodgkin’s disease. He is not covered by his parent’s insurance, and they cannot afford to pay for his treatment, neither can he.

    b) A 22 years-old student gets breast implants for her birthday because her parents can afford to pay for the surgery.

    Is necessity the criteria that permits b) to get her intervention while a) is denied his ? I think this question is relevant because it’s obvious who would get treatment under free market conditions.

  38. #38 Sid Offit
    November 23, 2009

    @Andrew

    A question for Tim, if a person has no money, due to being laid off from work, how will the “free market” accord them health care?

    Perhaps he’s actually had the foresight to save in case he gets laid off.

    Should the poor just die or does society have a duty of care to its members?

    Society is made up of individuals who have no responsibility to pay to care for others. You however may donate as much of your hard earned money as you like in order to care for the uninsured

  39. #39 Sid Offit
    November 23, 2009

    @Skeptico

    Doesn’t really work if you need a $100K operation, does it?

    You fail to realize the interconnectivity involved in the debate. These operations wouldn’t cost 100k if people had a reason to worry about costs. But since the employer or medicare or medicade pays normal cost constraint mechanisms are absent.

  40. #40 Sid Offit
    November 23, 2009

    namely, that since they think that people whose skins are darker than theirs will benefit most of all from government aid, anything that hurts government programs is a good thing.

    Your right PW. The Great Society, public education and other big government programs has done marvelous job elevating the “dark skins” out of poverty

  41. #41 Sid Offit
    November 23, 2009

    @Techskeptic

    however, the overwhelming majority of our technological medical advances come from…yup you guessed it… socialism! in the form of government grants for development.

    Your right it only cost us a few billion dollars to get Tang from the space program

  42. #42 Sid Offit
    November 23, 2009

    There are a number of other minor gripes that constitute their thinking as to why we dont really have free market when it comes to healthcare.
    ————-

    Minor gripes?

    In 2010, CBO projects, about 100 million people will be covered by Medicare and Medicaid, the two main sources of public financing for health care.

  43. #43 Sid Offit
    November 23, 2009

    in a truly free market, Human flesh would be available in the market”

    Andrew, you’re makin me hungry

  44. #44 andrew
    November 23, 2009

    @ Sid Offet
    In 32 I asked how some one who can only just afford to feed,clothe and house themselves can afford health care, you say save before the lay off. My point is many poorly paid workers cannot afford health care whilst working, how do they save, what happens when the savings run out/

    “Society is made up of individuals who have no responsibility to pay to care for others. You however may donate as much of your hard earned money as you like in order to care for the uninsured”

    So do you pay your taxes for military protection or rely on “free enterprise”?
    The above quote can be construed as “society is composed of individuals with no responsibility to others”This is the beginning of Hobbesian theory and not true, individuals come together in society to provide things individuals cannot, such as Law, protection,and mutual support.(Actually it is debatable whether humans can exist outside of society given that they are social animals)The question is should society provide health care to its members? The western European answer is yes, as the side affects of poor health care out weigh the costs of a social system.

  45. #45 Ramel
    November 23, 2009

    So sid is not just an idiot he is an arsehole, and a racist one at that. Who knew…

  46. #46 Joseph C.
    November 23, 2009

    Regardless, we have the most free market healthcare and the most rotten in the modern world. Even macau beats us and a number of other countries I have no heard of before when it comes to longevity and cost.

    This is a bit misleading as the US does pretty well in things like cancer survival:

    http://www.webmd.com/cancer/news/20080716/cancer-survival-rates-vary-by-country

    US health care is obnoxiously expensive and not as good as it should be. But maybe, just maybe “most rotten in the modern world” is a bit much.

    Of course, it is possible that the improved cancer survival statistics in the US are mostly due to a windowing effect from aggressive screening, as Orac has described on here.

  47. #47 Kemist
    November 23, 2009

    You fail to realize the interconnectivity involved in the debate. These operations wouldn’t cost 100k if people had a reason to worry about costs. But since the employer or medicare or medicade pays normal cost constraint mechanisms are absent.

    And you seem to fail to understand that even if it cost 10K (a reduction of cost by a whopping 900% – that is a lower cost than what can be had for an operation in India, the closest approximation we have to “free market” health care, with the added bonus of having doctors who accept to work for third world wages), many people could still not afford to get treatment. If you get minimum wage, 10K is an awful lot of money that you will not be able to save even if you work for 20 years before you get sick.

    The thing is that paying out of pocket is only avisable and doable if you never get seriously sick while young, have a comfortable wage with no other responsability (ie young children) when you begin to have health problems.

    In fact, what is apparent is that what you have to say to young cancer victims is “sucks to be you, but I’d rather be able to afford a new car each year than making sure you get the treatment you need.”

    Your right it only cost us a few billion dollars to get Tang from the space program

    And that, of course, is the greatest achievement of your nation’s academic research programs. It’s nice to see the respect you have for people who work their asses off in your universities and public research institutes, often for lower wages and worse working conditions than what they could get if they worked for a big corporation. For grad students who decide to make a contribution to science while eating kraft dinner and working week-ends for a few years – contributions that are the meat of private enterprise innovation, in which they would never invest themselves (too much risk).

    Let’s see what is happening in those magnificent free market enterprises, namely pharmaceutical companies.

    The development costs of a new medication presently runs around 5 billion dollars and 7 to 10 years, which will get you a patent that lasts, in the US, 20 years.

    What that means is that no pharmaceutical company will ever invest in small market drugs, or drugs destined to poor populations. It can also mean it will lie, thereby costing many people their lives, to avoid losing their considerable investment (see Vioxx). It also means that many pharma companies, to increase profit, will invest in producing drugs which, because of a loophole in our laws, don’t need to be tested – supplements – rather than developping new useful drugs.

    Welcome to the free market.

    Meanwhile up here in Canuckistan with our evil socialism and public medical insurance, we have lower prices for medications. There are many americans who cross the border just to buy here. Lower costs in a public healthcare system. Who would’ve thunk.

  48. #48 Calli Arcale
    November 23, 2009

    Sid @ 39:

    You fail to realize the interconnectivity involved in the debate. These operations wouldn’t cost 100k if people had a reason to worry about costs. But since the employer or medicare or medicade pays normal cost constraint mechanisms are absent.

    That is a problem, but not as simple a one as you might think. The actual patient might be somewhat insulated from the cost, but the insurer is not, and as the insurer isn’t the one actually sick, the insurer will actually feel the bite of the price more than the patient will. Insurers have a strong motivation to keep the prices down. Deductibles are one way to discourage clients from choosing pricier options. The common practice of having a lower copay for generics versus brand-names is another. They will negotiate lower prices with the provider, and they may also expressly limit what they will reimburse. A growing number are offering percentage plans — where you pay a percentage of the costs of each procedure. This makes the price differential much more obvious to the patient, and they can seek lower prices.

    Where possible, that is. There is a fundamental problem in expecting the free market to equalize the system, and that’s the fact that in health care, you seldom have enough choice for it to make a difference. If you are in a horrible car crash and a helicopter is sent to pick you up, you are likely not going to be able to negotiate which trauma center you use, nor even whether you are transported via air or overland. (There is, of course, a huge price difference between the two. Yet people needing air evac are seldom in a position to express an opinion on the subject.) Even with non-emergency care, your options are sufficiently limited that I think it’s rather silly to call it “free market”. It’s not. It’s not exactly a monopoly either, but it’s along those lines.

    So the best means currently used to limit costs are those efforts led by insurers (negotiating fees, passing some fees on to the customer, and eliminating fraud). Private insurers do a better job of this than Medicare and Medicaid, currently, but we as citizens could demand more of the system. If we weren’t so resistant to the very idea of health care reform, that is.

  49. #49 SimonG
    November 23, 2009

    I’m not sure that the Free Market has any place in discussions of health care, simply because modern health care is inherently incapable of being a free market.

    One of the ideas of a Free Market is that if something becomes too expensive it encourages other producers to enter the market, introducing competition. But intellectual property rights make this extremely difficult: you can’t simply set up shop and produce somebody else’s patented medicines, or equipment.

    Intellectual property rights were introduced specifically to distort the Market; very few industries in the entire world don’t rely on IP and only those few can claim to be part of a Free Market.

    Unless, of course, one takes the view that the creation of IP in the first place is actually part of the operation of the Free Market. But in that case, the same arguments can be made for any social(ist) or government activity.

  50. #50 Scott
    November 23, 2009

    That is a problem, but not as simple a one as you might think. The actual patient might be somewhat insulated from the cost, but the insurer is not, and as the insurer isn’t the one actually sick, the insurer will actually feel the bite of the price more than the patient will. Insurers have a strong motivation to keep the prices down.

    The other part of the equation, of course, is the doctor. And the doctor’s incentives pretty well align with the patient’s. Most doctors I know went into medicine because they want to help people. That naturally leads to wanting to do tests/procedures/etc. that may help the patient, even if the cost/benefit ratio isn’t so great. (Just like the patient, the incentive to err on the side of caution is strong.) As a result, the people “on the spot”, as it were, both incline towards more treatment and less cost control, leaving it to the insurance company (more removed from the actual situation at hand) to be the one worried about cost control. Definitely not an ideal situation. Deductibles and co-pays help, but since the entire point of the system is to shield the patient from the full cost of their care, the scope for such methods is limited.

    That’s why I find proposals to move away from fee-for-service models – to health care providers being paid by patient, condition, and outcome – very interesting. Giving one of the decision-makers on the spot a strong incentive to keep costs down could work quite well.

    Or, it could work very badly. And there are innumerable practical problems to work out even if “work quite well” turns out to be correct. But definitely very interesting. And I’d be quite interested to hear the opinions of the various health care providers here.

  51. #51 Joseph C.
    November 23, 2009

    What that means is that no pharmaceutical company will ever invest in small market drugs, or drugs destined to poor populations.

    Not entirely true. Here is one example of a small market drug:

    http://www.xyrem.com/

    This is indicated for narcolepsy, which is fairly rare. The consequence of being a small market drug, however, is that it is fantastically expensive. Jazz Pharmaceuticals charges what some might describe as an unethically high amount (~$2,000/month) for such a simple molecule that has been in medical use for decades.

  52. #52 Kemist
    November 23, 2009

    Intellectual property rights were introduced specifically to distort the Market; very few industries in the entire world don’t rely on IP and only those few can claim to be part of a Free Market.

    Using proprietary (secret) procedures, as opposed to IP rights, presents a huge problem in medicine. First, it makes testing for safety and efficacy quite complicated, and therefore costly. It is possible, and we’ve done it in our lab, but it can become a major issue when it comes to testing on actual patients and medical use afterwards – because then, the company will have to release a lot of information to insure safe testing and correct treatment in case of adverse event.

    Another thing is that reverse engineering is very straightforward for a drug : you simply need an NMR spectrometer and a couple organic chemists. In a matter of weeks, or maybe months, the molecular structure of the drug can be known, and you can start producing your own, which much, much less investment than the company which actually created it.

    In this situation, removing IP laws would mean the end of innovation in the pharceutical industry – because they will have absolutely no way to insure a profit of comparable measure with the investment they made.

  53. #53 Serious sceptic
    November 23, 2009

    What kind of thinking sceptic asks for “universal and affordable” healthcare. Counsels of perfection, from the French Revolution down through the Gulag allow for no argument but coercion, and have no purchase on reality.

    Do we have “universal and affordable” anything, at high quality.

    Well, we do, pretty much. I’d say in this country food, clothing, and television approach being universal and affordable. But that is only because the market and progressive technological innovation has made them so.

    I have been shocked at how difficult it has been for the public and doctors to look at and evaluate the data on mammograms. They aren’t difficult to understand, especially if you format them as suggested in: Know Your Chances: Understanding Health Statistics by Woloshin, Schwartz, and H. Gilbert Welch.

    Mammograms are not free and are not harmless. To begin with they are unpleasant and time-consuming. And someone pays for the equipment and the labor and the expertise. Biopsies the same. Unneccessary treatment even more so, and in the mean time people who are futilely treated have adverse health consequences. IIRC, the best studies show mammograms have a neglible impact on overall mortality.

    But most people seem incapable of focusing on and grasping such unfortunate news (or good news, in a way.) Until penicillin, through thousands of years, healers have been revered even as they killed far more people than they cured. Universal health care would have reduced life expectancy. The same tradeoff takes place today, though the odds are not quite as unfavorable as they were. Every medical interaction is a potential source of harm to the patient. There are unpriced externalities to the practice of medicine. And their cost is born by the unsuspecting patient who thinks he is getting care that is essentially free, even though patients are bearing the costs indirectly.

    Most people will never understand this. If mammograms cost 50-150 dollars out of pocket, it would be much easier to communicate their ambiguous nature and reduce overuse. Money out of pocket is something that people understand and can use to make rational tradeoffs.

  54. #54 Heather
    November 23, 2009

    I am a woman in my 40s and was happy to see the new evidence-based guidelines. It is difficult to pass on preventive care when it is available, even if the risks of doing so are negligible. This is true not just for individuals, but for doctors recommending the care–even with negligible risks, if a doctor doesn’t recommend screening at the yearly interval to the one in X patient who has cancer that would have been detected–it is a big liability. As an individual, I am not very comfortable substituting my personal judgment for the judgment of the medical establishment when it comes to screening recommendations. Now, however, after reading the new guidelines and the data, I feel I am able to better make an informed personal decision. In my case, my doctor recommends that I get my yearly screening despite the new guidelines. I am going to wait until next year, however–a year ago when I switched to digital mammography, a previously undetected (benign) cyst was detected in one breast, which was thoroughly investigated and determined to be of no concern using every available machine the doctor-owned imaging center had purchased — repeat digital mammography on both breasts, ultrasound on both breasts, and MRI on both breasts. So I figure I am covered for at least another year, maybe 10 if I go by the guidelines. The imaging center, however, still has to pay for that new MRI machine, and it will be sitting idle a lot if there aren’t as many routine mammograms done (fewer routine mammograms = fewer false positives to investigate).

    My only concern is that breast cancer screening will not continue to be covered by insurance at the same frequency–laws on the books in the vast majority of states will prevent this from happening in the near future, but I do think it’s naiive to assume that with new/different recommendations, there won’t be any new/different legal or business decisions.

  55. #55 Scott
    November 23, 2009

    In a matter of weeks, or maybe months, the molecular structure of the drug can be known, and you can start producing your own, which much, much less investment than the company which actually created it.

    I (perhaps naively) thought that, even once the molecular structure is known, it would take a lot of work to devise a means of synthesizing it. Is that not true? Or is it just enough simpler to be accomplished “with much, much less investment”? If the latter, how long would coming up with a process typically take?

  56. #56 Tim Slagle
    November 23, 2009

    “I have a hard time being convinced that we should dismantle our current system in favor of a completely free market nirvana”

    I don’t recall anyone advocating such a thing. Those who prefer a “dismantling” our current system, are usually on the side of more government control.

    Most Americans recognize that there needs to be a government subsidy for those who honestly cannot afford to take care of themselves. Where the question arises, is whether that subsidy should be administered publicly or privately.

    There is a quaint idea on the Left, that the government needs to be totally in charge of its distribution. Their faith arises from a mistaken notion, that all the greed and corruption in the world, exists solely within the private sector.

  57. #57 Orac
    November 23, 2009

    There is an equally quaint idea on the Right that the Free Market will solve all ills when it comes to distribution of services and goods. Their faith results from a mistaken notion that all the greed and corruption in the world exists solely within the government and that markets don’t have excesses that need to be reined in. I know. I used to hold to this faith as zealously as you appear to do now. (Just ask my sisters if you don’t believe me.) Then I met the real world for a decade.

    I am interested, however, where a “private” subsidy would come from. We in essence have that now. It’s not as though the private sector is doing such a bangup job of providing these subsidies now. Certainly charitable organizations don’t have nearly the resources to take up the slack.

  58. #58 Joseph C.
    November 23, 2009

    I am interested, however, where a “private” subsidy would come from.

    If I read him correctly, he said that the subsidy should come from the government.

  59. #59 Tim Slagle
    November 23, 2009

    ” …a mistaken notion that all the greed and corruption in the world exists solely within the government”

    That is not true. Free Market advocates recognize that humans are quite imperfect, and assume the worst nature of man. When businesses are forced to compete in an open market, things like “excess” profits, and shady business deals will result in failure.

    On the other hand Governments create monopolies, and protect corruption. Bernie Madoff is sitting in prison, while Social Security is a legal Ponzi scheme that continues close to 3/4 of a Century after its inception.

    And I never said there should be a “‘private’ subsidy” (although churches and charities did a fairly good job of providing care to the needy through most of this nation’s history). I believe i said: “Most Americans recognize that there needs to be a government subsidy for those who honestly cannot afford to take care of themselves.”

  60. #60 Todd W.
    November 23, 2009

    @Tim Slagle

    When businesses are forced to compete in an open market, things like “excess” profits, and shady business deals will result in failure.

    Except that, in reality, they don’t result in failure when left unregulated.

  61. #61 Orac
    November 23, 2009

    @TimSlagle

    You said “most Americans” think that there should be a government subsidy, but do you? Moreover, why on earth should it be “administered privately”? Why not just directly administer it? Why create a middleman? Where’s the efficiency in that, particularly if it’s only going to be given to the minority (still many millions of people, but still a minority) of the population who don’t have insurance through their job or can’t afford it?

    Oh, and what Todd W. says. We don’t have a free market. The events of the last year have demonstrated that most conclusively. And in reality, the excesses of the free market need to be regulated just as the excesses of government need to be kept in check. Your faith in the free market to cause the failure of “shady” business deals is touching. In fact, it’s another example of part of what I said: The free market as panacea, only this time it supposedly keeps corrupt business practices in check. Sadly, it does not.

  62. #62 Sid Offit
    November 23, 2009

    the excesses of the free market need to be regulated

    the free market is a self regulating system

  63. #63 Kemist
    November 23, 2009

    I (perhaps naively) thought that, even once the molecular structure is known, it would take a lot of work to devise a means of synthesizing it. Is that not true? Or is it just enough simpler to be accomplished “with much, much less investment”? If the latter, how long would coming up with a process typically take?

    Perhaps you’re thinking of natural products – the total natural product syntheses, at least the kind that organic chemists test their mettle on, are typically complex multistep (>20 reaction steps) procedures which demand clever tricks – but are useless for drug production purposes.

    Small synthetic molecules used as drugs typically have a simple synthetic scheme, for reasons of costs – the more steps, the higher the production cost (the maximum economically sustainable number of reaction steps runs around 10 for most applications). Some synthetics are complex natural product derivatives obtained in a few simple steps – in that case, using available databanks, it’s quite easy to find a good match for a starting natural reagent and devise your own synthesis.

    Another thing is that structure identification often go hand-in-hand with synthesis – the latter is used to confirm your caracterisation findings. So if you have identified the structure, you already have a basic synthesis scheme.

    The bulk of drug development costs is finding the molecule that has good “drugable” potential, low toxicity, oral bioavailability, ect. among your typical hundreds of thousand candidates. Each of these has to be screened in vitro, in vivo, in pharmacokinetic assays, toxicity assays, and finally, in that costliest step of clinical testing.

    In the case of an accepted drug, all these things have been done. That reduces the investment needed to produce your own to a synthetic scheme and a formulation study – a trifle compared with the efforts needed to find the drug in the first place.

  64. #64 Patient
    November 23, 2009

    Orac Wrote:
    Please show me an example of a nation–just one, although more would be better–that has successfully used the free market to bring affordable universal health care to its people. Seriously.

    You certainly have thrown down the gauntlet, and I don’t believe anyone would be able to provide you with an example that would be satisfying. I don’t think a true free market economy exists anyplace in the world, so that would be the first problem. What I can offer is that Singapore and Switzerland have experimented with a more “free market” system than our own and have had some success at keeping costs down, but they also have some price controls in place, which means that they are far from a true free market approach.

    http://econlog.econlib.org/archives/2008/01/singapores_heal.html

    Healthcare Economist: Health Care Around the World: Switzerland http://bit.ly/gLL7V

    What they seem to be doing right is preserving a system that allows people that have more money to buy more in the way of health care. This may be distasteful to people from an ethical perspective, but it does preserve the incentive for doctors, medical device manufacturers and drug companies to continue to offer new and expensive technology and make a profit doing so. An alternative recommendation for our system is from one of the world’s leading health-care economists and the long-time head of the National Bureau of Economics Research:

    http://www.washingtonpost.com/wp-dyn/content/article/2009/10/07/AR2009100703048_pf.html

    You also wrote:

    There is an equally quaint idea on the Right that the Free Market will solve all ills when it comes to distribution of services and goods. Their faith results from a mistaken notion that all the greed and corruption in the world exists solely within the government and that markets don’t have excesses that need to be reined in.

    I am not a representative from the right, but I can tell you that you are mistaken about this notion of free market proponents thinking greed and corruption exist solely in government. That is not what the free market system is about. A free market, if done right, is, as Freidrick Hayek said, the system under which bad men can do the least harm. Generally speaking, I trust a true free market more than I trust the policing inclination and wisdom of politicians.

    I am a long time reader, Orac, and I think you are a intelligent and clever individual that provides a wonderful dose of Insolence every day for us all to enjoy. I am surprised and sorry that I must disagree with what you have written here because I do have tremendous respect for you. I guess that there are perceptions in medicine that differ from the perceptions in economics. Nevertheless, the Dean of Harvard Medical School and three past presidents of the AMA have noted their problems with the current health care reforms, so maybe you want to speak to that in future posts on this matter.

    http://online.wsj.com/article/SB10001424052748704431804574539581994054014.html

    http://online.wsj.com/article/SB10001424052748704471504574449513730221946.html

  65. #65 Todd W.
    November 23, 2009

    As a parallel to the Free Market/regulated market issue, let’s take a look at the food and drug industries. Prior to 1906, there was zero government regulation of the food and drug industries. The reigning thought was that the industry could regulate itself. Turns out, that didn’t work so good. See, you had companies cutting corners, putting their customers in danger either from contaminated or otherwise directly dangerous products, or from products that indirectly harmed customers (snake oil that did not do what they said they could, leading to worsening conditions or simply bilking the customers).

    As the corruption of the unregulated industry was revealed, laws were gradually put in place by government to protect consumers, to the point we’re at today, with a still under-funded, overworked FDA playing catch-up.

    Left to itself, some few companies would play nice, but many, many others would cut corners and be far, far worse than people currently view them to be now. It’s regulation that has helped to improve the situation overall.

  66. #66 Kemist
    November 23, 2009

    the free market is a self regulating system

    … provided infinite time and no qualms about lives lost during the “regulating”.

  67. #67 Sid Offit
    November 23, 2009

    @Todd

    after Sinclair’s landmark book, The Jungle, was published in 1906. It caused outrage in America and abroad and meat sales fell by half.
    ———————
    Sounds like the market punished the industry in a self regulating fashion

  68. #68 Chris
    November 23, 2009

    Maybe Sid Troll has some magic cures to sell, but he is being hampered by those pesky regulations.

  69. #69 Chris
    November 23, 2009

    Sid Troll gives a simplistic answer to a complicated situation. Obviously he is oblivious to the number people swindled, poisoned and those that died due to adulterated food and patent medicine. Cue the Ballad of Lydia Pinkham now.

  70. #70 Tim Slagle
    November 23, 2009

    ” You said “most Americans” think that there should be a government subsidy, but do you? “

    I personally would like to see Borg nanoprobes reprogrammed for their healing potential. But perhaps I’m just dreaming. We are in a situation right now where many people are dependent on the government to fund their health care, the majority of Americans agree with that, so it’s impossible to change it. Public Health is a legitimate function of the State. So why argue about hypotheticals?

    And the reason for private administration is to maintain efficiency. The 6% profit that insurance corporations earn, is miniscule in relation to the amount of waste and fraud they prevent. Without the profit incentive, waste and fraud grows unchecked. Government operations like the Post Office and Amtrak to continue to operate with efficiency that would result in bankruptcies in the private sector, and cost the taxpayers billions. on the other hand Fed Ex and Airlines quite often turn a profit — a taxable asset rather than a liability.

    Marxism was sold to the masses based on a mistaken notion that middlemen were making exorbitant profits that could be put to better use for the masses. What the misguided proponents did not understand, was that those middlemen were performing vital functions that was beyond the planners limited knowledge base. It was the inability of central planners to divine those functions that caused Marxism to fail.

    The excesses of government are seldom regulated. Sure, a Congressman or Governor might go to jail here and there, but overall the corruption continues on without them. It’s pretty hard to break laws, when you also get to write them.

  71. #71 SimonG
    November 24, 2009

    Kemist wrote #52:

    Using proprietary (secret) procedures, as opposed to IP rights, presents a huge problem in medicine.

    Sure. IP is important in lots of areas. I didn’t mean to suggest that it was a bad idea, (although I do think it could do with some revision), rather that the existence of IP means that any market which depends on it cannot be Free, so the Free Market purists should sod off or at least recognise that the Free Market is at best an unacheivable ideal.

  72. #72 Charles
    November 25, 2009

    Orac:

    I’d have been curious to meet you in your “free-market zealot” days. You seem to identify free-market advocacy (more properly labelled “Classical Liberalism” or “Libertarianism” than “Conservatism,” which embraces many impulses contrary to market freedom) with commitment to an extreme laissez-faire model with no demand-side assistance or redistribution at all. Were you down with the minarchist fringe? Murray Rothbard? David Friedman? :)

    Of the most influential economists in the modern Libertarian tradition– Hayek, Mises, Stigler, Buchanan, Milton Friedman, Vernon Smith, Israel Kirzner, or contemporaries like Tyler Cowen, Mario Rizzo, Gary Becker and the GMU “Austrians”– not one (not even Mises) is identified with such an extreme model. (Neither, of course, was Adam Smith.) This is particularly evident where Friedman, Becker, Cowen and many others write specifically on health-care issues; and Hayek explicitly thought his principles compatible with a fair-sized welfare state (cf. “The Constitution of Liberty”).

    Mainstream Libertarians have been– on balance and in various respects– proponents of generally FREER markets. This was no fringe movement. After a mid-20th-century peak of infatuation with command/collectivist economies, the world moved decidely in a libertarian direction for the remainder of the century: the fall of communism; the liberalization of the economies of southeast Asia, China and India; the revolution in development economics away from “import substitution” and toward freer markets and trade; and in Western Europe in the 1980s and 1990s the withdrawal (or in the stubborner countries, at least scaling-back) of nationalized industry and confiscatory tax rates. Half the guys I name-dropped above became Nobel laureates, as did several others of their persuasion.

    The libertarian critique of extensive state influence on the economy comprises three distinct but complementary thrusts. In ascending order of importance: (1) Though statist solutions pivot on positing government officials and bureaucrats as disinterested, objective and largely omniscient, they’re in fact just human beings subject (like all of us) to various myopias and incentive structures; the policies they create are not only fallible but also escape the quick corrective feedback a functioning market context affords. (2) Government devices for steering an economy– price controls, extensive taxing and redistribution, barriers to trade, extensive supply-side mandates– beyond a point erode the economic performance of a population insofar as they decouple reward from productivity (the familiar “incentive problem” of socialism– and certain civil service arrangements!). (3) As Hayek emphasized, the Economic Problem is how, in allocating scarce
    resources for maximum human utility, to make optimal use of knowledge that is never (and could never be) at any point given to one mind, or one planning agency or politburo, but which is distributed among the entire producing and consuming population, and which in considerable part is not even articulate-able but consists of tacit know-how, intuitions, preferences, etc. Only a decentralized system of largely voluntary production and exchange can discover optimal efficiency, which is an emergent order inseparable from this interaction.

    Mainstream Libertarians accord three related roles to government: (1) To provide a framwork for the market and society by enforcing laws, property rights and contracts. (2) Providing for those handful of sectors that are textbook “market failures”– i.e., where due to externalities, non-excludability from services, etc., a necessary good or service can’t be supplied on a for-profit basis (e.g., national defense; some types of basic research, infrastructure & environmental protection). (3) A measure of after-market redistribution sufficient establish a decent safety net for those unable to fill a role in the market (e.g., disabled) or otherwise unprovided-for victims of calamity.

    Of all the sectors not named in the last paragraph, health care is the toughest to apply free-market principles to. I would argue, though, that what makes health care distinctive goes a bit deeper than the insurance-related conundrums typically catalogued (moral hazard, adverse selection):

    In other basic necessities (food, clothing, shelter) markets have made a decent subsistence level so inexpensive that it can be guaranteed to all with a measure of redistribution light enough not to compromise economic incentives. But how does one apply a subsistence level to health care, which is after all the Final Frontier in man’s struggle with infirmity and mortality itself? As that frontier shifts outward, so do our expectations for access, as individuals, to the benefits of that shift. But unlike with (say) food, individuals differ vastly in the amount of medical intervention they’ll require over a lifetime. And the more challenging their medical needs, the more cutting edge and hence expensive their treatment is liable to be. These dilemmas will bear no relation to their individual abilities to pay these costs, and of course (cases of reckless risk or dissolute living aside) no relation to their individual “merits” in any decent human
    sense. So if, in the realm of medicine, we interpret “subsistence level” care (aspirationally, at least) as “what it takes to keep somebody alive to at least approaching the actuarial average, without serious disabilities or pain,” the whole economy will need to be significantly reshaped to accommodate it.

    The “death panels” are a GOP-preferred way of caricaturing an inescapable dilemma: No matter how rich we get we can’t, as individuals or collectively, afford everything we want. Some degree of scarcity obtains in that demand curves slope down while supply curves slope up. In health care, this chafes because, again, this is a Final Frontier: until we cure everything affordably and start budging the mortality rate down from 100%, by definition we’re going to be losing battles of life-and-death import (and serious quality-of-life battles) at every turn. In the meantime, as long as demand outstrips supply in medical curatives, some form of rationing will have to prevail. We chafe at the fact that, in America in particular, there is still a large residue of letting the market ration scarce/expensive care: if Bill Gates and I come down with the same rare cancer, he’ll still have more options than I will. But if government is going to underwrite access to
    medical care, then, inescapably, it will be bureaucratic fiat– however informed by “expertocracies”– that must do the rationing, granting or foreclosing upon treatment options for both individuals and society (the latter by driving r&d and other funding, for example).

    The challenge is to find a way to incorporate the cost-controlling, innovation-spurring mechanisms of markets wherever possible while defining some defensible “minimal” standard/level/package of medical care that every citizen can access– without making that also a ceiling binding on everyone else in society.

    I’d encourage you and your commenters to discuss the specifics of various reform proposals in light of these criteria, on the merits– and without worrying what political, economic or ideological context a given idea (or objection) represents.

    Thanks for your indulgence of this long-winded post.

  73. #73 Tim Slagle
    December 8, 2009

    O,

    I’m guessing that you dropped out of the conversation because i used the M-word. Sorry. In my limited knowledge of history, it was the only example that came to mind that typified the kind of philosophical error you were making, by suggesting that there would be more resources available for Health Care, if government was the sole arbiter of the allocation.

    Anyway, I ran across this editorial today that makes my point a little more eloquently:

    Alas, whether it be allocating health care or defining the kind of jobs the economy ought to create, the policies they favor suggest a strong belief that they know what’s best not just for themselves, but for everyone else too…. conservatives believe that even our smartest friend is no match for the collective wisdom of the marketplace.

    http://online.wsj.com/article/SB10001424052748703558004574582312065087466.html

    PS:Can I expect to see you at Santarchy this year?

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