Don’t Just Do Something, Stand There: Part Three

(In which we mostly belabor the obvious.-PB)

Mostly Over-doctored

How much health insurance do most people need for most of their lives? The answer is none. Most people are fairly healthy and have mostly healthy children who could probably manage to go years between visits to the doctor. When they do go, it is mostly for a minor self-limiting complaint or a long-term health problem that is under good control. Insurance, and forgive me for belaboring the obvious, is supposed to ameliorate the effects of unforseen and and rare events which a visit to the doctor for a cough or an ear infection is most certainly not. We insure our houses against fire, for example, not because fires are common but because the cost of rebuilding a house, the repository of most people’s wealth, is more than most of us can afford to pay. There is no such thing as “lawn mowing insurance” or “garage floor painting” insurance because these tasks are routine and an expected part of home ownership. Putting on a new roof stings a little, I admit, but most normal maintenance of a home won’t bankrupt anybody.

The trouble with health insurance is that it’s not really insurance at all, at least not how most people view their other kinds of insurance. Rather than serving to protect us from the catastrophic financial effects of a major illness, health insurance has become an expensive middleman between the consumers and producers of medical services. If your car needs an oil change, you change it. If you need new tires you buy them. If you need to go to the doctor for your annual physical however, you engage a complicated bureacracy which exists to shift costs from one set of consumers to another. This is why the health insurance for a typical family may cost them or their employer in the neighborhood of twelve to fifteen thousand dollars per year even though their actual expenditures for medical care in any given year are not even close to that amount.

Routine health care is not even completely covered under even the most expensive health plans. There is always a copay and a lot of essential services that the typical family really needs, such as dental and vision, are either not covered or involve an even bigger copay. It has to be this way because health insurance is a ponzi scheme with hordes of investors at the bottom of the pyramid paying the dividends of those at the top who are, in this case, the extremely sick and the uninsured.

It wasn’t always like this. Our current model of health insurance is the result of two historical trends, the first of which was the explosion of medical knowledge and technology in the 1960s. Before this time medical care was relatively cheap because there wasn’t really that much that could be done. Hospitals were more like hotels than the patient processing plants they are today and the amount of doctoring received by a patient was limited by the amount of doctoring that could actually be done. This also limited the number and sophistication of the support staff and equipment required for a typical hospital or clinic. Health insurance before that time was rare and most people payed out of pocket for their doctor visits. It was just expected. Society had not been medicalized and people grew old and died without fanfare because there was nothing else to do.

This is not the case today where our ICUs and nursing homes are filled with the warm dead, people who in many cases are only kept alive at the end of a long and expensive journey through the medical system by increasingly expensive and futile medical heroism.

So there is no question that the real cost of medical care has increased, on the high end anyways.

The other trend was the incredibly high top marginal income tax rates which began to rise in the 1920s, peaked at 94 percent in the forties and, before President Reagan (PBUHN) took an axe to them in the mid-eighties, had stabilized in the high seventy percent range. The result was that increasing the pay of white collar and skilled labor in the post-war boom wasn’t much of an incentive as a raise was often eaten up by increased taxes in the higher income brackets. This was the age when companies started offering fringe benefits to their employees in lieu of increased salaries. One of these was comprehensive health insurance which has now become an expected part of the compensation package for any good job even though the original rationale for offering it has disappeared. Most people would probably be better served if they got the raise and payed for their own medical care as the marginal rates are not nearly as high as they were forty years ago.

The income tax is progressive of course, and the middle-class hardly pay any compared to the upper middle-class and the wealthy. In this case, there would seem to be even more of an incentive for middle-class employees to prefer the money over the insurance. Money is money. Insurance is wasted money unless you need it.

The unfortunate consequence of almost universal health insurance (because 85 percent of Americans are covered under some insurance plan or another) is that the true cost of health care is masked from the consumer. Everybody complains about the cost of medical care but it is a generalized, non-specific complaint. The high cost of medical care is an abstraction to most people most of the time. They have the occasional hospital stay, pay a small fraction of the total bill, let insurance handle the rest, shrug their shoulders and move on. The poor and the government-insured care even less because they are never expected to pay much, if anything, for most of their medical care. If the insured had to pay the complete bill the cries of outrage would send fear and panic through the entire health care industry.

The Big Lie, the scare tactic used by the usual suspects in their craven lust for political power is that people need comprehensive health insurance. They most certainly do not. Most people most of the time need so little medical care that most of the money spent either by them, their employer, or the government is wasted as far as it benefits them. Consequently, In a country where almost everyone can borrow money for automobiles, personal watercraft, and all manners of luxury items, there is no reason why most of us should not be expected to pay for most of our medical care most of the time (even if we have to borrow a little). No reason, that is, except that we have been conditioned to expect it for free. Not to mention that to merely suggest that maybe, perhaps, just possibly, a visit to the doctor is no different from a financial point of view than a visit to the hair salon would be political suicide for anyone with the guts to say it.

It’s easier to give other people’s money away, and more gratifying too because it earns one the reputation for being compassionate even if the long term consequences are harmful to the public.

There is the difference between what people want and what they need. While everybody wants somebody else to pick up the tab, the tab is going to bankrupt the nation. What most people need is an inexpensive high-deductible insurance policy to protect themselves against financial disaster if they should require some big-ticket medical care. Almost nobody, for example, can afford a kidney transplant or even the medical consequences of a serious car accident. Not to mention that people do grow old and eventually, many but not most, will require the expenditure of fairly large sums of money to preserve their quality of life.

The key thing to keep in mind is that the various plans proposed to insure the entire nation will do nothing to lower the cost of medical care because they are just another scheme to shift the costs from one set of consumers to the other. The only difference will be that instead of half, every single health care dollar will take a trip through the federal sausage mill. The money is going to come out of somebody’s pocket and it’s not going to be the government which has no pockets, just hands to grab from one to give to another

It’s just rearranging deck chairs on the Titanic. Twenty years from now when medical spending has doubled as a percentage of GDP the same people will be crying the same tears over the same problem because the entropy of government winds down to expecting less and less of the people while trying to give them more and more. This is why the concept of Health Savings Accounts (not to mention privatizing Social Security) invokes such howls of rage from our ruling elites. Not only do they hold the people in contempt thinking them incapable of planning for their own future but the money tied up in these accounts and owned by citizens is just another chunk of money that cannot be stuffed into the voracious maw of the political influence machine.

As for the poor, well, we live in a society that is both opportunistic and compassionate. It would be demoralizing to our nation to have the disparities of medical access so wide that the poor and ignorant suffer or die from conditions that those who can think and plan ahead easily eacape. We will, unfortunately, always need to give medical care as charity. But the key here is that primary care is no bargain. The connection between good health and acccess to primary care is tenuous. The factors which contribute to poverty and ignorance also contribute to poor health and we have been fighting those since the Johnson Administration with little or no success. Bad health in the poor is mostly a the result of social problems which have shown a surprising resistance to huge doses of federal dollars. Dumping even more money onto the poor is mostly the same as trying to treat a disease with an antibiotic to which it is resistant. Staph Aureus laughs at your ineffectual pennicilin. The poor will laugh and ignore your ineffectual primary care.

What the poor need is the same as everybody else. Major medical insurance for which, if it absolutley must, the goverenment can pay. We certainly pay enough to support the poor now. May as well spend it where it will be effective, that is, on management of the acute health problems that people who don’t think and plan ahead are going to get no matter what we do. To hell with it.

There are many conflicting forces in medical care, each one trying to stiff the other with the bill. The insurance companies want to pay as little in claims as possible which is understandable given the nature of their business. The medical industry, from physicians to the lady mopping the hospital floors, would like to get paid fairly for their services. The government wrings its hands at the cost but at the same time would like as many people dependent on government as possible. The people want all the medical care they can eat but they want somebody else to pay for it.

Nobody else can pay for it unless we become a nation with a government whose sole function is to provide health and other benefits to a universal dependency class in some decaying freeloader heaven.

46 thoughts on “Don’t Just Do Something, Stand There: Part Three

  1. Long rant; hard to know where to start. You seem unfamiliar with the idea of risk pooling — you imply repeatedly that the healthy who pay more than their health care costs are somehow wasting money or that it is money ill-spent. But if the healthy did not pay more than their actual costs, there would be no pool to fund the care of the seriously ill. You acknowledge that the major driver on health care costs is the end-of-life care, ICU care — the 5% who consume 95% of the resources — and yet you subscribe to the canard that HSA will somehow change consumer spending patterns in a way that will effect cost savings. HSAs do nothing to curb the real costs — the high-expense, high-resource procedures — while reducing the overall amount of funds available for risk pooling. Ditto for Medicare’s recent interest in price transparency — it will do nothing to actually control costs, since the high-volume consumers generally are not in a position to price-shop. You make the absolutely baseless (and mind-blowing) assertion that “The connection between good health and acccess to primary care is tenuous.” Um, if you’re going to claim something like that, I’ll be wanting more than your word for it. Sources, please? And more than one paper from the American Enterprise Institute, please.
    And again, your contempt for the poor, or as you so charmingly put it, the “people who don’t think and plan ahead,” shines through clearly. I don’t know what your religion may be, but Jesus had a few somewhat nicer things to say about the poor that have guided much of my life.
    And one last note — you make a snide comment about how the “ruling elites” have “howled in rage” about HSAs. I should note that the ruling party for the past sixteen years – the GOP – has in fact advocated HSAs. It’s the folks who pay the bills (you know, the free market) which has been completely indifferent to them. if they were all that great, you would think people would be clamoring to get into them. Yet they are not.

  2. Show us the literature that establishes that expanded health coverage=better health.

    There is no causal relationship between health insurance and better health even the most hardcore health reformists like Ezra Klein have to cede that point

    The biggest way to reduce costs right now is to put an age limit on the ICU. No admittance over 75. There is a finite amount of dollars and why should end of life care take away healthcare choices from the young.

  3. The ruling elites do not want the public to control their own money and want as many as possible beholden to government. This is an immutable fact of life and transcends wonkery. Ronald Reagan did not and to his credit, George Bush does not and it is not his fault that his idea to privatize social security was never implemented, in part because the Usual Suspects are always able to drum up the usual fear that the usual people have of being responsible for their own lives.

    The issue is not whether most people want comprehensive health insurance but whether they need it. And they don’t need it, mostly. The idea is to make people both responsible and aware of what there health care costs and who pays. What you are saying is that people should be forced to buy health insurance that they don’t need which is a collectivist argument. If five percent suck up 95 percent of health care dollars, then it seems that the problem is the five percent, not the other 95 percent and you are in a sense, agreeing with me that they don’t need comprehensive health insurance except that they have to subsidize the small minority of people who do. Talk about the tail wagging the dog. For the sake of a small percentage of the public who could probably gain better and cheaper care if some of the other problems I have addressed in other articles were corrected you would hijack the entire medical care industry.

    Are you saying that the money that the government currently spends subsidizing worthless efforts towards primary care for all could not, with some intelligence, be used to provide major medical care to the very sick and old? My point is that the government (and the public) have no business trying to pay for everybody’s inexpensive primary care (which is collectively extremely expensive). People who value it and their health will pay for it and people who don’t, won’t. Just like today but there will be no government money frosting the sorry cake.

    As for the poor and the dependency class, the inability to think and plan ahead is probably their defining characteristic, especially in a society which has incredible potential for upward mobility for those who can.

    On politics, the Lord is silent as He transcends earthly things. I have read nothing in the Bible either for or against Single Payer, neither does the Lord either advocate nor condmen the formation of a dependency class although there are enough parables about faithful masters and good servants to lead one to believe that He did not frown on a fair day’s work for a fair day’s pay.

    Forming a permanent freeloader class is no mercy and no benefit to people in the long run. I don’t see a lot of joy in our dependency class and there is no practical amoount of freebies you can give them to change this.

    Do your own research. My conclusions are easy to substantiate with a few clicks. Most studies touting the benefits of primary care are fairly shoddy and prove what the advocates of universal health care want them to prove.

    This is a “big picture blog” so I leave it to the wonks to fill in the details. A combination of health savings accounts, real transparency in medical services pricing (including medications) which will only come about when people actually feel the money leaving their hands instead of our current system is the only way to pay for medical care that will not bankrupt us in 20 years. Either that or make us just another stagnant Freeloader Heaven.

    I also have to point out again that your response is emotional.  I never said, or I don’t think I did, that primary care is not important and people don’t benefit from it.  What I said was that access to primary care is not the panacea, the silver bullet, not by a long shot, that people hope it will be because having access to it is not the same as the horse drinking (once he has been lead to water, you understand).  But we all agree that on an individual basis, primary care is relatively cheap and thus, there is no reason why most people in our mostly middle-class and mostly prosperous country cannot afford a visit or two to the doctor and some generic pills.  Anecdotally I have patients who pay 200 bucks every month for “corn rows,” a traditional braided African hairstyle that falls in and out of popularity (or that’s what my sister-in-law from Camaroon calls it and she makes a killing as hairstylist doing almost nothing but…which is how I know how much it costs) but who cannot even afford tylenol for their children.  And I have plenty of old, sick as stink GM retirees who have had fantastic access to primary care for their whole lives but are still coughing up chunks of their lungs and dying by pieces.

    Sometimes you have to step back.  I dare say that we have the sickest people in the city if not central Michigan in our hospital.  But not everybody is that sick. I am intimately familar with the health problems of my wife’s legions of relatives in Louisiana (because their health is all they ever talk about…they never shut up) and ain’t one of them despite their advanced age, even a tenth as sick as even one of our garden variety patients. 

  4. Dr Wannabe, I swear I am almost done opining about Health Care and will soon return to medical school and residency topics. Keep reading and as always I don’t have so many readers that I can ignore their complaints.

  5. Ha! You ignore that, lacking an ever-growing client class, and possessing no marketable skills, the elite would be forced into labor or some other demeaning way of making a living. Or maybe that’s exactly the Randian dystopia you want?

  6. Love your post, as always. I had a question, though.

    As part of years 1&2 med school, I spent a bit of time working in a free primary care clinic where those who couldn’t afford to pay / pay for insurance could come for treatment. I’d say at least 75% of the patients who would come would come not because they couldn’t afford a trip to their doctor (because they could have) – they came because the costs of their medications per month were too great.

    So, my question is, what role do you think the extraordinary cost of many medications plays in all of this insurance hell? Or did you already cover this in a post I missed?

  7. I’m a big fan of yours, and I usually agree with your positions, but I’m not buying this one.

    Health care has a low probability of an extremely large loss, which makes it perfect for insurance. It is no more a “Ponzi scheme” than any other insurance. (By your logic, fire insurance is also a Ponzi scheme because only the bastard whose house burns down benefits.)

    And of course most people would save money if they didn’t buy comprehensive health insurance! Every buyer of insurance is playing a negative expected payoff game, and (theoretically) knows this. Because most people are risk averse, they still buy the insurance. The old analogy is: You and 9 other people are shipping $100 worth of goods each across a river. You know that one of the boats is going to sink. So, you bargain with the other people and decide that each of you will put $10 into a pool before they cross, and the owner of the boat who sinks gets the pool. In this example, the expected payoffs are the same, but add in some overhead costs and you have simple insurance. The basic idea is I’m risk averse: I’d rather have $1000 with 100% probability than $10,100 with probability 10%.

    Now, are there things wrong with health insurance? Certainly. Deductibles maybe should be higher, since routine checkups don’t fit the “low probability of extremely high loss” criterion. Plus, people should always be a little worse off than they started whenever they make an insurance claim, since if they’re the same or better, people will take advantage of the system and make everyone else worse off. Plus, vision and dental insurance make no sense to me.

    It actually may be beneficial to have a widespread government program because it removes adverse selection (i.e. only sick people sign up for insurance), and could possibly lower costs for the individual. However, government paternalism is generally abhorrent to me, and I somehow think the government would manage to make it more expensive even though in theory it should be less expensive.

  8. Panda, I love your blog and always enjoy what you have to say. However, as a resident in a large county hospital, we see two groups of people your post seems to neglect. First consider the seriously ill whose problems could have been alleviated by good primary care. Think the chronic hypertensive that if treated, may not have stroked out and racked up hundreds of thousands in an ICU stay. Or the septic patient who couldn’t afford to go see her PCP when her diabetic foot first started looking bad.

    The second group of patients is the “can’t afford to go see a PCP so I had to come in with this hangnail” bunch. If we give up on primary care for the underserved, we are resigning ourselves to seeing their minor health care needs in the ER.

    It seems to me that if we decide to push “catastrophe only” health insurance, it actually becomes even more important to continue improving primary care to those who can’t afford it, so as not to overwhelm a system that (at least during the transition) may be even more precarious.

    PS-I know you take alot of flack for your stance about residency work hours, but I couldn’t agree more. We should work long and hard hours, but not at the expense of our health. Thirty hours is still ridiculous!

  9. Most medications for most people do not cost that much, mostly. If you prescribe mostly generics and older, perhaps slightly less effective versions of the same medication, most people can probabaly afford them. In my little sample of patients, most of the poor can afford many other things that are mostly luxuries even if they cannot afford the few simple medications which would, most of the time, be perfectly effective for most of their conditions.

    HCTZ, statins, beta-blockers, ACEI, and Aspirin are what most people need most of the time.

    Besides, most Americans are not too poor to afford most of their medications most of the time. I could say “Fuck the poor” and most of the people who needed most of their medications would be able to afford them most of the time, that is if most of them put the same priority on their health that they do on other important things in their lives. The question is whether,in our mostly prosperous society where almost everybody has the means to pay for primary care is whether we’re going to let the little freeloader tail wag the big productive dog.

    Better to just give outright charity to most of the people who need it than to dress it up and give it the imprimateur of some kind of right when it most certainly is not. You are never going to shrink the dependency class if you insist on keeping them dependent.

    If I mostly only use $3000 worth of medical care evey year for which I am sure to pay $15,000 per year, most people would look at this and say, “wow, I’m getting screwed” and the fact that their extra $12,000 is going for some nebulous public good would be a matter of profound unimportance.

    To pay $600 bucks a year to inure my house against loss is prudent and justifiable. To pay $300,000 a year for the same insurance on the same house so I can insure the houses across the street at well is idiotic.

  10. Anna, there is no correlation between access (access, not use) and good health. Believe it of not. I was going to do my research on it and thought this hypothesis was new and original only to find that not only has it been studied but it has pretty much been proven.

    I agree completely that primary care which is actually accessed pays huge dividends in later years. Oh boy do I agree and I sometimes can’t believe that many of my patients who have had the best primary care access in the world (old school GM employees, I mean) have never-the-less arrived in our ICU with no lungs, no legs, and a third of the cardiac capacity of similar patients who give a crap about their health and are no different than the guy in the next room who had no insurance for his whole pre-medicare life.

    I think my critics are confused at what I said. There is no cost savings in giving people access because statistically, the outcomes will be the same between people with and without access to primary care. That’s why when it comes to health care, it makes more sense to not throw good money before bad.

    This idea is heretical to the Pharisees of the Conventional Wisdom but right or wrong, there is some good evidence to support it. The emotional, knee-jerk response to what should be a simple question of statistics and economics is typical of zealots everywhere.

    Also, except that some people just seem to have bad protoplasm, most people would be fairly healthy if it wasn’t for bad lifestyle choices. People who ignore this cannot possible really work with real patients. For every Hypertrophic Cardiomyopathy we see a hundred Ischemic Cardiomyopathies from cocaine. For every Type 1 diabetic we see 100 obese type 2 diabetics who could control all of their symptoms by losing weight. See my point? Individual responsibility which can only be encouraged by allowing individual responsibiity, something that we avoid at all costs, is the only way to solve most of the problem for most of the people.

  11. Hello Dr. Panda Bear, I just want to say your blog has been very education and entertaining for me; not just because of your opinions, but those of your verbose commentators! I’m not even going to jump into this argument, but thanks for having such a great blog to help me procrastinate 🙂

  12. We keep hearing political nonsense that preventive maintenance is better than medicine. That somehow, the costs of healthcare will drastically decrease if people start dieting and exercise. As part of my 2040 campaign for president, I will suggest that instead of giving away free medical insurance, every citizen will have free gym memberships and fresh, organic vegetables. No one will be allowed to visit a doctor unless he can demonstrate that he has exercised a minimum of 6 times within the previous two weeks and has not had added salt or sugar to any of his meals.

  13. Panda, I really do love your blog. If I were in charge, I would propose relatively cheap catastrophe only insurance and have everything else come out of pocket. In order to make this work though, I think the amount a physician charges would probably have to go down. It really shouldn’t cost $125 to spend 10 minutes with a doctor to diagnose an ear infection. Nor should my husband’s trip to the ER a few years ago (which ended up being due to severe dehydration, all that was done for him was to give him IV fluids) have cost something like $2000. It seems that those who are uninsured (and responsible enough to actually pay their bill) are charged for the fact that a lot of people don’t pay, or they are charged a higher rate because that is the only way the physician can get a certain payment from the insurance company.

    The tough thing is that those who truly need insurance, i.e. a child born with cystic fibrosis or my sister in law with Multiple Sclerosis, have a very tough time getting it as it is. What would we do for them in this new scenerio? Natural selection would let them die. I guess thats all right if the person involved is not someone you know, but the moment it is my child that has some illness that is treatable, you can bet that I’m gonna want everything done for him. Who would pay for that? How do we value a life? And is the person who is sick due to factors out of their control worth more than the individual who made mistakes (started smoking, gained a lot of weight)?

  14. If people had to pay their own doctor bills, the price would go down. Period. Same with the price of medications. People turn their noses up at generics (believe it or not) because there’s no incentive not to. Start paying for your own routine medications and the generic Simvastatin starts to look mighty good.

    As to what a doctor visit should cost, it should cost what the doctor thinks it should cost. If he’s right, people will pay, if not he’ll have to lower his price until they do. How is this different from any other profession?

    Most people do not have cyttic fibrosis but I am perfectly willing to pay taxes to support the giving of charity to those who really need medical care and can’t afford it. We are not just economic machines. But paying to support a kid born with CF is different than admitting the same drug addicts ten times a year or keeping a tube-fed zombie alive in the ICU.

    Rule number one in the Pandaverse: If you currently smoke, drink or do drugs and will not quit there is no way I’m giving you money for your meds until you dip into your cigarette and beer money.

    (As if crack addicts give a shit about primary care anyways.)

  15. But the point is this: Most people should buy major medical policies (unless they want to throw themselves on the mercy of charity hospitals) and pay for their own primary care out of pocket. Why this bit of common sense causes so much wailing and gnashing of teeth is beyond me.

  16. Great post. In response to one of your last points, I think that there would be plenty of private charity for the CF kids without having to pay taxes or get the government involved at all. If you ever want to write a guest post for my blog (As you’ve officially turned yourself into quite an internet economist), I’d love to have it.


  17. What about chronic mental illness? Schizophrenia, bipolar disorder, even some forms of major depression…

    Seems to be a subject that a lot of doctors ignore completely when they discuss the current medical crisis.

  18. Lisa,

    Your husband didn’t pay $2,000 just to get IV fluids. He had a triage nurse give him a quick run through. He had a physician run through a thoughtful (yet quick) history and physical to come up with a differential diagnosis and to rule out other potentially lethal causes of illness. Your husband probably got a test called a chem-7 with a blood draw by a trained phlebotomist and reading by the lab. He had access to the hospital’s equipment, including the monitors, lab, and bed. His visit also caused an inordinate amount of paper work—all so he could just get an IV for dehydration.

    That $2,000 went toward paying for a lot of equipment as well as paying the salaries of a bunch of highly trained folks. It also went to paying for the homeless guy out in the waiting room who faked chest pain in order to get a sandwich. Finally, I doubt you actually had to pay the full $2,000. My guess is you had a deductible, while insurance took the rest.

    As soon as healthcare becomes a personal, pay-for-it-yourself system without all of the lawyers swarming overhead, the cost of medical care will go way, way down.

  19. You’re singing my tune, although you’re Pavaroti to my Alvin the Chipmunk.

    Health “Insurance” is indeed a misnomer. Primary care should be considered “maintenance” and paid for out-of-pocket.

    Rock on. (By the way, I just blogrolled you.)

  20. “Twenty years from now when medical spending has doubled as a percentage of GDP…”

    This strikes me as a very optimistic estimate.

    Reagan and Bush still want to control the public’s money, they just have a different system for establishing that control. Favoring one politician over another is like picking between fatal cancers.

    The trouble with bureaucracy is that it will never, under any circumstances, let itself be shrunk. Pols are only too happy to propose creating a new bureaucratic agency to study reducing the bureaucracy, and so forth. In establishing the immense, extensive medical bureaucracy that we currently labor under we’ve set in motion a process that only outright rebellion can reverse.

    Of course people fall in the same pattern as bureaucracy, once you grant them a ‘right’ like cheap health care it cannot be taken away without overwhelming social upheaval. You’re telling the truth, but, alas, it’s a fart in the hurricane.

  21. Not to mention that to merely suggest that maybe, perhaps, just possibly, a visit to the doctor is no different from a financial point of view than a visit to the hair salon would be political suicide for anyone with the guts to say it.

    I think you make a lot of good points. But this isn’t one of them. I’m sure you’re just saying this as an embellishment, but it’s highly unlikely that neglecting hair style is going to have any measurable effect on one’s productivity as a worker (while poor health, even something “as minor” as the flu, does reduce productivity). I mean, damn, it would have to be a seriously catastrophic hair day.

    There is no cost savings in giving people access because statistically, the outcomes will be the same between people with and without access to primary care. That’s why when it comes to health care, it makes more sense to not throw good money before bad.

    I agree with you that some people make bad choices (i.e. choosing the expensive hair style over primary care), but you (and pretty much everyone else) are only considering health care in an isolated context. Many of these people who you point out make bad choices (for example, spending money on cigarettes but expecting to get free health care) are also lacking in education which time and time again has been proven to have significant effects on improving health status. People should know that smoking is bad for you. But not everyone really knows why, and not everyone knows that smoking not only kills you, but also premature mortality and increased morbidity. I mean, seriously, how many people who don’t work in health care know what “morbidity” means? The CDC/U.S. Department of Health and Human Service’s “Chartbook on Trends in the Health of Americans” shows extensive data indicating that increased years of education reduce the incidence of smoking. In 2004, 29.1% of people who didn’t graduate from high school or get a GED smoked, 25.8% of those who did graduate, 21.4% with some college education, and only 10% of those who graduated from college smoked.

    So yeah, it makes sense that throwing money at people won’t necessarily help: that is, improving access won’t necessarily mean improving proper usage, as you have stated. But at the same time, even though it is easy to cast blame, it makes little sense to criticize people for their decisions when they don’t necessarily have the means (i.e. education) or the luxury of time and attention (i.e. financial freedom -> time) to attend to their actual health needs. As you pointed out, most people (rich, middle class, and poor) are pretty healthy through most of their lives – at least, they seem healthy. This doesn’t account for diseases that show no signs until you’re dead or at a stage such that you can’t prevent it: hypertension (high blood pressure, leading to heart failure) is the most prominent example. Most people, while they might have a vague idea of what causes a disease, don’t know how diseases happen. People think to themselves, “Well, I’m going to have to die somehow anyways,” but they don’t realize how much earlier they might die or the length of pain and suffering they might have before they die. How could they know? While there are other reasons to be skeptical about providing primary care for all, it’s not a valid argument to write off this idea on the simple notion there is no way that people will ever make the right decision.

  22. Edit: But not everyone really knows why, and not everyone knows that smoking not only kills you, but also increases premature mortality and enhances morbidity (i.e. reduces quality of life because you can’t breathe, you go blind, you had a stroke and lost half your mental faculties and mobility, you have gangrenous fingers, etc.).

    Edit: By “incidence of smoking,” I meant “prevalance of smoking.”

    Ugh – I’m falling asleep at the keyboard.

  23. The only way to make people responsible and self-sufficient is to require responsibility and self-sufficiency. If this means that some people are going to smoke and drink themselves to death then fuck ’em. You can’t mobilize a small squad of social workers, physicians, and cops to follow everybody home and make ’em eat their vegetables which is what it would take.

    Not only would this be ruinously expensive, a waste of time, and degrading to the people who you are trying to help but it shouldn’t even be a priority for a country of free people.

    But it would be just another day in Freeloader Heaven.

  24. Love your blog, as a medicine resident, I have to say I agree with most of what you write.

    If I could comment on the current discussion, the contention that most people who are poor lack the ability to make good choices is right on. THat is certainly not the only factor contributing to their condition but is nonetheless from my observation, a common characteristic.

    The statistics given by Apollo actually support this theory: In 2004, 29.1% of people who didn’t graduate from high school or get a GED smoked, 25.8% of those who did graduate, 21.4% with some college education, and only 10% of those who graduated from college smoked.

    Apollo states that (paraphrasing) these people smoke due to their lack of education. In reality there is only correlation, not causation in that statistical set. to use a completely played out example, ice cream sales increase in the summer months, so does the crime rate. Do increased ice cream sales really lead to more crime?

    the statistics actually point to a trend that people who drop out of school (a poor choice) tend to make other poor choices (i.e. smoking)

    AS a final point, I just asked my 9 year old son this evening what happens to people who smoke. his reply: “they get lung cancer and die, or their lungs don’t work right”. he’s not a third grade dropout (that I know of, Q2 call ya know)

    Keep up the good work,

  25. The only way to make people responsible and self-sufficient is to require responsibility and self-sufficiency. If this means that some people are going to smoke and drink themselves to death then fuck ‘em. You can’t mobilize a small squad of social workers, physicians, and cops to follow everybody home and make ‘em eat their vegetables which is what it would take.

    Mmm, hyperbole. To each problem, you refer someone to the person who can help. Just as you might consult a neurologist for someone you suspect has epilepsy, you could connect a patient who needs nutritional interventions with a nutritionist, someone dealing with an abusive partner to the cops, someone needing help finding employment or housing to the social worker. Doctors don’t necessarily need to do the counseling and intervening. We would charge a lot more anyways.

    Requiring responsibility and self-sufficiency sounds nice. But at the same time, we don’t always blame people for not taking all the responsibilties they could or should take.

    Not only would this be ruinously expensive, a waste of time, and degrading to the people who you are trying to help but it shouldn’t even be a priority for a country of free people.What I’m talking about is education: basic health education. It isn’t nearly as degrading to suggest that people can be better educated than what you’re suggesting: that poor people lack sense and intelligence, and that’s why they make bad decisions. People generally aren’t dumb; but that doesn’t mean they’re informed an d have ALL the knowledge they need to make good decisions.

    There’s only so much information you as the doctor can provide in your office, in the clinic, or on your service – given the limited time, and also since your time costs so much. But others (with the intelligence and knowledge of physicians to inform them) can incorporate this, with relative ease and low overhead, into general education. Until something like that happens, however, there’s no basis for blaming people for making bad decisions if they don’t have the knowledge to make informed decisions.

  26. Oi – my bad about the weird formatting of that last comment.

    Apollo states that (paraphrasing) these people smoke due to their lack of education. In reality there is only correlation, not causation in that statistical set. to use a completely played out example, ice cream sales increase in the summer months, so does the crime rate. Do increased ice cream sales really lead to more crime?

    the statistics actually point to a trend that people who drop out of school (a poor choice) tend to make other poor choices (i.e. smoking)

    I love this commonly cited example of ice cream and crime: it demonstrates how easy it is to come up with inane examples to counter otherwise reasonable hypotheses. Sure, there’s no randomized controlled trial proving that having less education turns people into smokers. That’s the exact same argument that the Tobacco industry used for decades when doctors and scientists said that smoking kills you: they said, “Where’s the RCT? You haven’t proved it with your own gold standard.”

    On the other hand, I do think that your second point (your interpretation of the CDC’s data) is more reasonable. However, it makes the assumption that people drop out of school by choice, or that they don’t continue on to college or a later degree by choice – which is often false, if you consider that advanced education is expensive with respect to time and money. Sometimes people need to work to support their families, but we as a society don’t believe that kids should do this, which is why we have child labor laws. These laws don’t remove the impetus to start working “early”, though.

    It’s a simple idea I’m suggesting: that most people don’t have the full picture, but we (health care professionals) can help amend that. With a little more perspective and a little more useful knowledge (i.e. how to eat well when you only have McDonald’s in your neighborhood), people might actually be able to have the chance to make good decisions and enact those interventions in their own lives.

  27. Until something like that happens, however, there’s no basis for blaming people for making bad decisions if they don’t have the knowledge to make informed decisions.

    This is typical of the more education mindset of the left (seeing everyone as a child in need of education).

    Guess what?

    The folks we are talking about have been told ad nauseam that their choices and behavior is harmful to their own health.

    They have been told by their teachers, classmates, neighbors and anyone else who gives a damn about them, never mind their physicians (when they actually see them).

    Their cigarette packs, their booze is labeled to warn of dangers. Public service advertisements flood the airways and if they’d pick up a newspaper, they’d find daily pontifications about healthy living choices.

    They choose to ignore this advice and keep smoking and drinking, etc.

    They made their choices with all the information easily available to them. Now, stop treating them like children, because it only perpetuates the problem.

  28. I used to think that access to primary care was the magic bullet to cure most of our health care woes.

    Then I worked at the VA.

  29. Panda Bear: You have the courage to say what I have been saying all along. We in America value our haircuts more than our healthcare, until we are in dire straights.

    My dad paid for healthcare for 9 kids on a middle class wage in the 50’s and 60’s by paying the doctor for routine care and having insurance for catastophic events.

    If he can do it, so can we.

  30. Apollo, I appreciate your insights on health care and I have become something of a closet fan of your blog. I also appreciate your take on the lost productivity of sick citizens as a justification to keep ’em healthy.

    I have to point out however, putting on my rapacious social Darwinism demeanor, that most of the people sucking up most of money for medical care are not exactly productive members of society. From a grim, completely economic point of view it would be better to not offer any medical care (like they do in the Great Freeloader Nations Across the Water) because these people are no longer productive.

    Not to mention that the dependency class, a good portion of the patients that I see and almost all you probably see living as you do in our lovely and misunderstood state of Louisiana, are not and will never be productive citizens in any capacity. I know that the language is fluid and doublespeak has become the rule but “productive” means that a citizen contributes his labor or his skills to an enterprise that adds value to the nation. Even the taco-jockey is productive, you understand, because his lonely vigil at the drive-thru late at night contributes to everyone’s material standard of living.

    The dependent poor are a drain. We need to take care of them as a civic and Christian duty but let’s not get silly.

  31. I appreciate it, Panda Bear, and I find your perspective quite meaningful, at the very least that you have several more years of experience and thousands of hours more in the field than I do. I worry, though, that the general messages that get across to those who make bad decisions are the wrong information: simply, that what they do is bad, and that we are judging them for it. I think, and I’m pretty sure that you agree (despite the many passionate outbursts that appear on your comment threads), that there are much more respectful ways of criticizing another person’s ideas and much more respectful ways of lending them a helping hand without condescension. I certainly don’t believe that there’s a magic bullet out there in education, but it makes me wonder if relatively small changes (coupled with other small changes) in the ways we do things can make a difference.

  32. I forgot to mention: I agree with you, though, that a lot of these people aren’t productive, and that giving them health care alone won’t make them productive. But it might put them in a position such that other people (educators, employers, etc.) can get them to be productive (if those other people are at all competent, which is a big if in a lot of places).

  33. Naw. You know better than that. Nothing is going to make them productive except the twin threats of starvation and deprivation, two things from which most of the dependocracy are protected.

    And the people we are talking about, the young poor, who are just learning the freeloading trade don’t need health insurance. They’re mostly young and able-bodied. It’s the older, more experienced licensed professional freeloaders who need health insurance.

  34. With regards to Lisa’s post above – Physicians will also bill higher than cost. A large physician group near me negotiates reimbursements as a fraction of billing price with the insurance companies. Docs inflate their billing knowing that they’ll collect an agreed-upon fraction of the bill. The inflated “price” is never actually paid, and the real cost of the service is never known. Smoke and mirrors.

  35. I agree with Apollo that education is essential for individuals to make proper healthcare choices. Where should this education start? The home is the obvious first choice (for me) is the home. However, if you have parents who have made or continue to make poor choices, then what chance is there that you will learn the proper lessons about healthy living? The second choice would then be school. Now I realize that this choice is cancelled if the student drops out, but nevertheless, perhaps the education is already weak. I would think it may well be considering the fact the PE classes are consistently being cut from elementary curriculum. In my early education, proper health education came primarily from sects of my PE class. Also it instills the want to be outside, active, and competitive; all aspects for a healthy body. So what does it say of our ruling bodies of education that health education has been drastically decreased? Fixing healthcare in America involves more than the healthcare industry. We must attack it from all angles, while at the same time respecting the culture of our society (ie not making a universal, single-payer system).

  36. I have the solution. We should all just refuse to care for people until things change. We are the ones who will be giving the care, right?

    I’m with Dr.Wannabe. It’s great to see such a lengthy and thought provoking discussion about this topic, but let’s save the rest for the novel, Panda (I would buy it). Let’s get back to the fun stuff!

  37. I am working on an article on Alternate Medical Careers which will be appearing shortly.

    I apologize for digressing. Unfortunatley I don’t always have a good article in me and lately I’ve been drawing a blank about what to write about medical school and residency.

    Your suggestions are appreciated.

  38. And I did just publish one about medical students and interns. I’m also going to finish categorizing all the old articles so they are easy to find.

    As always, I appreciate your reading my blog.

  39. I wish this perspective received a lot more attention, but you’re the only one I’ve ever seen addressing it with any kind of depth. Even if it is not the best solution, it at least deserves a lot more attention.

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