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May 3rd, 2009, 10:21
Since public health care is apparently going to be at the top of President Obama's agenda for the next 100 days, and the potential swine flu pandemic sort of puts it there anyway, I thought it might deserve its own thread.

For starters, here's Nicholas Kristof today on NY Times: IMO he gives a pretty good overview of the situation in the US, with regards to public health and the pandemic. He includes a nod to Dubya, who increased American preparedness for flu pandemics significantly, but argues that the main reason for the underperfomance of the US health care system is overinvestment in expensive and often unnecessary diagnostic systems such as CAT scans, and underinvestment in preventative and public health measures.

Being a columnist, he has his politics, of course, but in this case he steers nicely clear of proposing any canned solutions.

[ http://www.nytimes.com/2009/05/03/op…ml?ref=opinion ]

So, folks — what's the health care system like where you're from, what works, what doesn't, and what improvements can you think of? Is there something you think that you could successfully adopt from some other model, or something you think works so well in your system that other countries might want to copy it?
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May 3rd, 2009, 16:20
Are we going to dip into morality, cuz one problem we have over here is spending tremendous amounts of money delaying the medically inevitable. That's really a cultural issue more than a political one, but it contributes measurably to high costs.

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May 3rd, 2009, 16:24
Why not? It's kinda hard to keep ethics out of the discussion anyway, since unless someone comes up with a system that's able to give absolutely everybody any kind of treatment regardless of cost or conditions, some trade-offs will always be necessary.
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May 3rd, 2009, 18:04
Interesting article. As someone who's lived through multiple American political regimes, and watched the state of everything involved in providing commonplace service to individuals deteriorate since the hate for government action in anything became fashionable and the worship of a totally unregulated free market replaced it, I concur with the article in that our health care system is overwhelmed right now just like education and everything else, with stuff it doesn't have the resources to handle.

The balance between what an efficient free market and an efficient central government can cooperate on to provide in the way of services is totally out of whack. I blame Reagan for beginning this slide—a great example of a charismatic president who, like Obama now, was immensely popular independent of his actual politics and able to push a personal agenda (huge Cold War era deficit defense spending, tax cuts that reduced government revenue and spartan reduction in government services outside the military.) Some of this was good for the country and some wasn't, and likely Obama's iniatives will turn out much the same.

Before Reagan, (perhaps as a legacy of FDR) in any given major situation affecting the whole country, government was generally viewed as the proper responsible party, and expected to do something to address it, or at least take up the slack. It may have gotten fat, corrupt and complacent, but the gradual shift from Clinton on of replacing it with fat,corrupt complacent private sector actors with little concern for or investment in the public welfare has proved to be, speaking charitably, not the answer either.

As one of the 47 million Americans without health care, all I can say is I hope something positive happens to change the current set-up before I get too old and sick to care, because right now I can't afford to die.

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May 3rd, 2009, 18:12
I think an underlying problem is general government inefficiency in the US. You are already paying about $3000 a head in federal money for healthcare; many countries manage universal public healthcare for about this much, and the best systems in the world don't cost much more. IOW, if you were as good as the French, you'd only pay $1000 per head more than now in taxes — but $3000 less per head on average in health insurance (either direct or via your employer).

But how to get there is the problem. You're getting lousy value for money on defense, education, and health care. Reagan tried to "starve the beast." That, obviously, didn't work. Any other ideas on how to improve the value you're getting?

The numbers say that if you managed to improve efficiency in primary education to the level of Scandinavia and health care to the level of France, and improve efficiency in military spending in the same proportion, you could have world-class education, health care, *and* military power — and end up paying *less* taxes. How's that for a political goal?
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May 3rd, 2009, 18:27
It's a great goal and I'd like very much to see it happen in my lifetime, but the combination of voter apathy and the entrenched power of interest groups is going to be tough to overcome.

I believe that until the average citizen here is as concerned, vocal and involved in demanding accountability from the government as s/he is in, say, the NFL playoffs or Brangelina's or Octomom's latest emotional crisis, the usual suspects will continue to have their way with our money and lives.

To restore your faith that I haven't joined dte totally on the dark side, I do think things are trending that way at the moment. The AIG bonus outcry, and even the 'tea parties' are a sign that people are beginning to realize they have more control than they think in what happens in Washington.

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May 3rd, 2009, 18:34
Nice article, but I think his jab on those who didn't want pandemic spending in the stimulus article was uncalled for. It should be in a health related bill or the Omnibus bill. I'd be against including it on reasons of principle, even if it was for a program I liked (such as if they wanted to include increased foreign aid spending in the upcoming Health care bill).

I look at things like healthcare/welfare/etc as …a necessary evil. I don't think anyone else is entitled to these things if they are not paying for them, but I think it's a good idea for society to provide for its less fortunate members. In my home town in California (the population now is around 90k but is closer to 150k if you include the unincorporated areas and the small mainly Mexican town about a mile away) we used to have two decent-sized well run/staffed/equipped hospitals. Now we have one hospital and that one is facing severe budget issues.

There are a lot of reasons why, but a large part of it has to do with emergency room costs. If you don't have health insurance, you end up waiting until you are really sick and going to the emergency room, which is extremely expensive. Now, add in to this that there is an extremely large illegal immigrant population in my hometown due to it being an agriculture-heavy area, and these costs rise exponentially.

I think if we can implement a health care system that is relatively inexpensive (compared to the current costs accrued from emergency room visits), that won't impact the quality of care for those already with health insurance, and will give people quick access to care they need, then we should do so. I dont believe we should drown government in the bath tub, but I don't think it should be necessarily involved with every solution to every problem. I look at it the same way I look at the "hard power vs. soft power" debate in foreign policy.

Neither answer is completley correct, it's about "smart power". "Big government" is not the answer, and neither is "small government". It's about "smart government". Government needs to have well-defined, narrowly tailored interests and goals. It should be large enough to effectively achieve these goals but small enough so it doesn't become bloated and inefficient like it tends to in the States. Efficiency is where it's at.

And on the moral/ethical note, I think health care has really become 'death care' in the United States. All I'm saying is, if I have some disease/condition/old age that's going to give me a slow and uncomfortable death, please pump me full of morphine or smother me in my sleep with a pillow.
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May 3rd, 2009, 18:46
And on the moral/ethical note, I think health care has really become 'death care' in the United States. All I'm saying is, if I have some disease/condition/old age that's going to give me a slow and uncomfortable death, please pump me full of morphine or smother me in my sleep with a pillow.
I totally agree—I'm seriously considering going to the expense of a living will or whatever it's called, no matter which way the debate on who's paying for my care goes—as long as someone is picking up the tab, there will always be a general reluctance to pull the plug on an 'investment' in my continued life as a human turnip.

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May 3rd, 2009, 21:46
Um… "expense?" In my neck of the woods, you pick up a form at the health care station, fill it, and leave it at the front desk. Do you need a *lawyer* for that sort of thing there?

By the way, here's some more NY Times grist for the mill — "How To Stop Worrying And Love A 52% Tax Rate," or something like that — an American test-driving the Dutch variant of Eurosocialism:

“Over the course of four years, four human beings end up going to a lot of different doctors,” he said. “The amazing thing is that virtually every experience has been more pleasant than in the U.S. There you have the bureaucracy, the endless forms, the fear of malpractice suits. Here you just go in and see your doctor. It shows that it doesn’t have to be complicated. I wish every single U.S. congressman could come to Amsterdam and live here for a while and see what happens medically.”
[ http://www.nytimes.com/2009/05/03/ma…l?pagewanted=1 ]
Last edited by Prime Junta; May 3rd, 2009 at 21:51. Reason: Found more pertinent quote.
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May 3rd, 2009, 22:14
Originally Posted by Prime Junta View Post
Um… "expense?" In my neck of the woods, you pick up a form at the health care station, fill it, and leave it at the front desk. Do you need a *lawyer* for that sort of thing there?
Apparently you can buy a pre-formatted legal doc online for about ten bucks or perhaps free somewhere, but if I'm going to do it I figure we'd do a complete will for the two of us, which mostly does require a lawyer—at about $100 per hour.

By the way, here's some more NY Times grist for the mill — "How To Stop Worrying And Love A 52% Tax Rate," or something like that — an American test-driving the Dutch variant of Eurosocialism:



[ http://www.nytimes.com/2009/05/03/ma…l?pagewanted=1 ]
Keep talking it up—Europe's looking better all the time.

I won't share with you the complete sob story of how we lost our insurance, but without it it's an ugly world out there especially bureaucratically speaking. It's possible by filling out forms and joining discount clubs to get things like discount generic prescriptions from some pharmacies, like Wal-Mart, or we'd be going without. I slipped a routine physical,mammogram and blood work in just before our coverage ran out, and if I'd had to pay for it, it would have cost over $1000. Going to the regular doctor's is a nightmare—everything is cash on the barrelhead or charge it on your VISA. Fine until you get seriously ill and then who knows what happens, but you can plan on long-term debt(including bankruptcy and losing the house in a really serious illness, which god forbid). Fortunately my husband (the smoker) can access the VA system, and I'm fairly healthy for an old woman, but it makes you think about everything—what will I do if I slip on the ice, have a wreck, get pandemic swine flu and have to go to the hospital, etc.

Insurance through our employers was always great, and I never worried about it, but without it, believe me, the world is a much scarier place.

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May 3rd, 2009, 22:24
Originally Posted by Prime Junta View Post
Um… "expense?" In my neck of the woods, you pick up a form at the health care station, fill it, and leave it at the front desk. Do you need a *lawyer* for that sort of thing there?

By the way, here's some more NY Times grist for the mill — "How To Stop Worrying And Love A 52% Tax Rate," or something like that — an American test-driving the Dutch variant of Eurosocialism:



[ http://www.nytimes.com/2009/05/03/ma…l?pagewanted=1 ]
You need a lawyer for a good living will. They're not all valid in certain states and there's ways they can be ignored or not paid attention too, etc etc etc. States can ignore DNRs/etc filed in other states. It's not like it happens all the time but it happens enough that people have to be aware of it.

One of the problems w/ Federalism, I guess.
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May 4th, 2009, 01:31
Australia's health system may not be anywhere close to perfect, but from all I hear it's a 1000 times better than what you have in the US and a lot cheaper too!!

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May 4th, 2009, 03:36
I think we definitely need a general shift in how we pay for and provide healthcare, but I don't have the hate for the current system that a lot of people do. Obviously, I have health insurance, so that helps.

While it has been at times frustrating to do with the insurance aspect, I think the overall experience really varies greatly depending on what facility you use (and that in and of itself is part of the problem). We of course only really hear about the horror stories, as is the nature of the media. I'll present the other side of it.

I've been going to Sloan-Kettering Hospital here in NYC for about 6 months for treatment of a minor issue. My experience has been so fantastic that I have switched as many of my wife's and my doctors (not that we have tons, but a few) to doctors at this hospital. Why? They've done some pretty basic things that have totally streamlined the process. First, before I ever saw a doctor there, they took me to a registration room where I filled out all the standard forms. At the end, they gave me an ID card that they said I could use at any doctor in their system. Now when I go into see a new doctor in their system, I don't fill out any of the general forms, I just present the card and they get it online (I still have to fill out the form related to why I am there specifically of course). All my medical records are kept in the general hospital's server and any doctor there can access them. When it comes to billing, they take no money at the doctor's office. It's all centralized. They deal with the insurance and when it is all done, they send me a bill (none of this bill me the full amount, then rebill after insurance, etc.). And it's electronic. I get it via email. Heck, I can even get it via text message!

It's slick and efficient and I love it. It reminds me a lot of how my father describes the VA (my Dad thinks the VA is the best thing since sliced bread).

One more thing I love about our system is that I can go to any doctor I want, whenever I want (assuming they have an appointment available). I don't need a referral (I have a PPO), even if it is 'out of network,' the insurance still has to cover up to their standard negotiated rate. I don't want anyone, especially the government, telling me what doctors I can see.

It's not perfect by any means, but it's not near as bad as it would seem just from reading the head lines.

I disagree with this statement though from the original post "US health care system is overinvestment in expensive and often unnecessary diagnostic systems such as CAT scans, and underinvestment in preventative and public health measures."

While I certainly agree that we can gain a lot of efficiency simply by a better application and promotion of preventative care, I don't think we have over invested at all in diagnostic systems. I LIKE the fact that if I need some test done, I'm not waiting weeks or even months to get it done. When I had an MRI done on my knee after a skiing accident, it was done 3 days later. It's not like we have equipment sitting around gathering dust in general.

One of the main frictions we have in this country is an inherent distrust of the government doing anything right, much less efficient. People like me that have good healthcare, hell I would put the care I am able to receive against any anywhere else in the world, are going to fight like hell against any proposal unless we are 100% sure that our standard of care isn't going to go down, or cost more. So far, none of the 'universal' proposals I've seen have been able to do that.

That's certainly a selfish way to approach, I won't deny, but I'm much more concerned about my and my family's well being that the rest of the country.

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May 4th, 2009, 04:26
We did that legal dance about a decade ago, magerette. The lawyer did it as a "package deal", so we paid $300 (IIRC) and got living wills, ummm, dying wills, and all the various powers of attorney all in one fell swoop. Nice and neat, all legal, and didn't get soaked on the "per hour" game.

I remain very disappointed that I couldn't jam thru my wish to have my corpse thrown in a ditch somewhere. None of this boo-hooing at a viewing and expensive boxes with pretty lining and screwing up traffic on the way to a cemetary…

Back to topic, seems to me you take care of the easy stuff first.
1) Let people die. Mrs dte works in a nursing home and it's ridiculous what's going on in there. You've got people taking a dozen different pills every 4 hours. If someone's really got that many things wrong with them, pull the meds and let them go. A fair bit of the time, it's a circular chase, though—take one pill for a legit problem, but it causes a side effect, take a pill for the side effect, but it causes a different side effect, and so forth. Stupid. I realize I'm a cold-hearted bastard, but we're bucking nature and the people spend their lives stuck in bed waiting for exactly what we're spending millions to delay.
2) Deal with the emergency room problem that Rith mentioned. First off (cold-hearted bastard again), cut off the free medical care on demand for illegals. Make legal immigration just a little more appealling and illegal status just a little less appealling. Second, set up some clinics. These should be funded with the government money going to emergency rooms right now when they get misused. Perhaps the hospitals kick in, since they're getting out from under a significant hit to their bottom line. Pattern it after the "immediate care" centers that are popping up everywhere. $20 (traditional co-pay for insured folks) to make folks take it a little seriously, and you get seen by a doctor (or maybe a nurse practitioner to save cost) and get a round of antibiotics or an x-ray or whatever. They don't touch serious problems. This is for coughs and colds and the occasional broken bone. I'd prefer for it to be privately run, but if you big government weenies really want it as the first step in your march to HillaryCare, I'll live with that.

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May 4th, 2009, 05:58
I don't get this free healthcare to illegals bit. Here, if you're a resident (legal) you get subsidised or free healthcare, but unless you're a visitor from a country with whom we have a reciprocal agreement (like England), everyone else pays FULL cost, or has their personal insurance pay it. No gov't issued health card, no service unless it's cash upfront and visitors, or illegals can't get those cards!!

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May 4th, 2009, 06:21
Originally Posted by dteowner View Post
2) Deal with the emergency room problem that Rith mentioned. First off (cold-hearted bastard again), cut off the free medical care on demand for illegals.
There's a reason this won't ever fly: it goes contrary to the fundamental medical ethics that get drilled into med students from day one (and usually predate med school for most of 'em anyway).

Simply put, you'll find it difficult to find a physician who will agree to refuse care to someone whose life is in danger, regardless of the conditions.

You are referring to ER care — which is only free if you're indigent. If you're not, they will bill you, and go after your car/house/whatever, if you don't pony up. Right?
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May 4th, 2009, 06:25
Originally Posted by blatantninja View Post
One of the main frictions we have in this country is an inherent distrust of the government doing anything right, much less efficient. People like me that have good healthcare, hell I would put the care I am able to receive against any anywhere else in the world, are going to fight like hell against any proposal unless we are 100% sure that our standard of care isn't going to go down, or cost more. So far, none of the 'universal' proposals I've seen have been able to do that.
What about a parallel public/private system? The gov't provides public health care one way or the other, either by being the provider itself, or through an insurance system like in the Netherlands, as described in the other NYT article, or by compensating health care costs against a standard baseline, and if you want something extra on top of the "baseline" level, you pay for it out of your pocket (direct or via supplementary insurance). How would that lower the standard of care available to you?
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May 4th, 2009, 08:43
Originally Posted by Corwin View Post
I don't get this free healthcare to illegals bit. Here, if you're a resident (legal) you get subsidised or free healthcare, but unless you're a visitor from a country with whom we have a reciprocal agreement (like England), everyone else pays FULL cost, or has their personal insurance pay it. No gov't issued health card, no service unless it's cash upfront and visitors, or illegals can't get those cards!!
There's a whole lot of Afghans in burns wards all over the country who'll never pay for the care they'e recieving. We still treat illegals, we just don't have many and most of them get locked up in conventration… *cough* detention centers.
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May 4th, 2009, 11:09
This is a bit of a tangent, but I thought it'd be interesting to hear what especially "frog-march-em-to-the-border" dte thinks of this particular bleeding-heart illegal immigration story:

[ http://www.nytimes.com/2009/05/04/ny…immigrant.html ]

Salient points:
* Chinese illegal immigrant, who is mentally ill, and unable to either defend herself in immigration court or obtain travel documents needed for her deportation.
* Been in jail for about a year.
* Suffered abuse in China before coming to the US.
* Likely to die fairly soon if no-one intervenes.
* Her sister (presumably in the country legally) has offered to swap places with her to save her life.

So, dte — what would you do? Put her on a rowboat in LA and point her west? Something else, what?
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May 4th, 2009, 12:41
Originally Posted by Prime Junta View Post
There's a reason this won't ever fly: it goes contrary to the fundamental medical ethics that get drilled into med students from day one (and usually predate med school for most of 'em anyway).

Simply put, you'll find it difficult to find a physician who will agree to refuse care to someone whose life is in danger, regardless of the conditions.

You are referring to ER care — which is only free if you're indigent. If you're not, they will bill you, and go after your car/house/whatever, if you don't pony up. Right?

It's really easy to ditch out on an ER bill or get it comped if you're low income.Illegals don't have any ID and just give fake names/addresses/social security numbers anyways.
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