Screw Cuba, How About Them Albanians? (And Other Musings)

One More Time…

Let me try to explain this again. American medical care is expensive for everyone because the costs are shifted from one set of consumers to another. Most of us are not sick and except for the odd hospitalization for something unexpected don’t really require that much doctoring. There is, however, a small but significant subset of the population who use a terrifically disproportionate amount of health care. I write about this group extensively on my blog and they include the living dead vegetating in pre-death staging areas nursing homes, the multiply comorbid, and people who make bad lifestyle choices resulting in a state of perpetual symbiosis with the local hospital. Upon this group of people is brought to bear the full might of our technologically sophisticated but extremely expensive medical arsenal.

I treated a 79-year-old man the other day who has, I kid you not, eight stents in his coronary arteries, a history of three pulmonary emoblisms (emboli?), a greenfield fiter in his unamputated leg, diabetes, peripheral vascular disease, renal failure, a colostomy, a PEG tube, senile dementia, emphysema, and a string of minor strokes before the Big One that knocked out what looked like the entire left hemisphere of his brain. I have no doubt that the cost of his health care just in the last few years would be enough to pay for the health insurance of an entire Cuban province and probably runs into the millions of dollars, not one cent of which he or his family have paid or even expect to pay because you are picking up the tab with your outrageous health insurance premiums and twenty-dollar aspirins. Maintaining an ICU bed, for example, costs a typical hospital several thousand dollars a day and this gentlemen has spent months in the ICU while his family urges us to keep his heart beating regardless of the cost.
In Europe, this patient would have died fifteen years ago, probably after his first heart attack. Maybe he would have gotten the first heart catheterization, maybe he wouldn’t, but as his comorbidities snowballed the Freeloader Kingdoms would have cut their losses and, while advanced treatments are theoretically available, the reality of rationed care would have finished him off. A Greek doctor of my acquaintance related to me that even what we consider routine critical care would be considered extremely heroic and almost unheard of over there.
The argument goes that if this poor son of a bitch only had access to good primary care he wouldn’t have found himself in these dire straits requiring this level of care. Putting aside the obvious fact that many such patients in the United States have had excellent access to primary care (many of my ICU patients are retired from GM), and the dubious belief that primary care will keep people from cramming the metaphorical pie into their notional gob-holes, let’s asume that cheap primary care would have made this guy well and allowed him to live comfortably and productively into his golden years requiring nothing but a couple of inexpensive pills and a few doctor’s visits to manage relatively benign complications of his well-controlled medical problems. If this is the case and if all that is required to make the United States a Cuban-style health care paradise is cheap primary care, why should the government have to pay for it at all? In other words, if it’s cheap, why can’t people buy it themselves? A doctor’s visit here or there and a few pills probably costs less than most people spend on cable television. I know for a fact that one of my frequent patients can afford a thirty dollar a day marijuana habit (but won’t scrape together a couple of bucks for antibiotics at the local Wal Mart which practically gives away a long list of generic drugs) so a couple hundred a year for his doctor visits is a trivial amount.

Primary care is cheap. It’s so cheap that it makes no sense giving it away for free, particularly when to give it away is going to require the massive bureacracy typical of all government solutions, a bureacracy that will inevitably stifle everything that is good about American medicine and turn us into just another society with excellent access to health care unless you really get sick at which point it is hasta la vista, baby. For the sake of your fear of cutting into your blunt money, you are willing to turn over close to twenty percent of the economy to people whose only talent is that they have no talent for anything but government.
Still, nothing is really going to change. All we’ll be doing is throwing bad money before good because while a small percentage of patients who are destined for the comorbidity jackpot may have a come to Jesus moment where they decide to modify their behavior, most will continue as if nothing happened and arrive on schedule, after hitting all the expensive milestones, to thier fabulous yet terminal month in the ICU.

It’s not as if the public will actually accept rationing of care for their demented granny. Any politician who suggests that to control costs we need to put her down like a dog (so to speak) is destined to go down in flames. What is will happen is that we will continue to spend fantastic amounts of money on health care and when the numbers get too alarming, measures will be taken to control costs that, by removing the incentive for productivity, will make the problem worse.

Or Look At it Like This…

Consider the American military in comparison to the typical European military. The American military is an expensive, technologically sophisticated organization that is twenty or thirty years ahead of anything the Europeans can field. We almost can’t share the same battlefield because of the speed and sophistication of American weapons, command and control, intelligence, and logistics. The American military can do things and go places. The Europeans have difficulty doing anything including finding reasons to maintain the militaries that they have.

But the Europeans do spend less and they do get whatever it is they want from their armed forces. And yet the capability to transport a couple of Marine Regimental Combat Teams or an Army Armored Brigade anywhere in the world on short notice doesn’t come cheap, nor are carrier battle groups operated on a shoestring. You get what you pay for. A primary care military with conscripted soldiers who don’t expect to do much is fairly inexpensive and looks pretty good until you have to make it do something. A working war machine isn’t pretty and to make it do something requires the dedication of motivated troops and frightening amounts of money.

Life Expectency

With the exception of Japan, the average life expectency of every country in the developed world hovers around 80 years. The average life expectency in the United States is 78 years. In the European Union it is about 79 years. The difference is nothing to get excited about and seems to be unrelated to per capita expenditure on health care. Those cheese eating surrender monkeys (the French I mean) may be healthier than Americans but they only live, on average, a couple of years longer than we do. It may be true that they only spend half on a per capita basis what we spend on health care but perhaps past a certain point there is no relationship between life expectancy and health care expeditures. Sure, you’re screwed if you’re from Namibia (average life expectancy of 40 years) but you’d be hard pressed to make the case that we get all all that much of a bang for our bucks or that European health care is better based on a a few months difference in life expectency.
I mean, the Albanians spend next to nothing on health care (36 bucks per head per year) and they still live almost as long as the typical citizen of the European Union. How on Earth is this possible? Albania is a shit hole. The only Third World country in Europe. Do French politicians propose that the EU go to the Albanian system to save money?

Perhaps because life expectency in part depends on cultural factors which have nothing to do with the medical care, it is a poor indicator for its quality. I have travelled extensively in Europe and I have never seen anything remotely close to the five and six hundred pound behemoths that hardly raise an eyebrow in our hospital. But this is more a result of the thirty buffet-style restaurants within two miles of the place than some hard-to-define shortcoming of our health care system. I know for a fact that many of these monsters will enjoy terrific access to health care untill the day their bad heath finally catches up to them and they become a statistic dragging down our average life expectency. If you look at it this way, and factor in things like gang violence which decreases the life expectency of black men to 67 years, the premature babies who we try to save at gestational ages which would make the Europeans laugh contemptuously, and half a dozen other cultural factors which have nothing to do with health insurance it is a wonder that we live, on average, as long as we do. Apparently, for every Tupac harvested early to the Lord we have a ninety-year-old vegetable sucking life through plastic tubes bringing up our average.

Addendum: I propose the following thought experiment. I live in an average Midwest city with a population of around 200,000. Let us charter a bunch of airplanes and exchange the non-medical population of the city with the population of a similar-sized French city, say Toulon. Let us then follow the two cities for the next couple of years and see how they fare in regard to health care costs. I predict the following: We will get a much deserved vacation, working at our hospital will be a cake walk, and those poor French bastards will reap the adipose whirlwind as their health care costs skyrocket and they feverishly brush up on their atrophied critical care skills. Either that or when we switch back we are going to be minus a lot of our citizens.
Next: The annual “Welcome to Intern Year” article. I promise.

83 thoughts on “Screw Cuba, How About Them Albanians? (And Other Musings)

  1. Out of curiosity, does anyone have actual studies on whether increased access to primary care improves outcomes in the US? It’s quoted as gospel all the time, but I saw that (fairly dated) RAND study that said it doesn’t do much. Honestly, most of the uninsured people I see with late stage exacerbations of chronic disease didn’t get to that point because they were uninsured. They were both uninsured AND got to that point because of the underlying confounder of being the kind of people who drive their car for 100,000 miles without changing the oil.

  2. You seriously should write a book. Incredible read. The entire situation always appears hopeless. The only thing you can do is go about your business put as much as you can into your house and retirement and wait for the politicians to make that much worse. Then go do something else.

  3. It has always bothered me, the life expectancy statistic. Too bad we don’t have a metric for quality of life expectancy. I’m not going to say that the quality of the 78 years in the US is better than the 79 years in France, but shouldn’t that question be addressed by anyone that is going to throw those numbers around as if it is the end-all of the conversation? If a terminally ill cancer patient is maintained with pain control for five years and dies at 78 in the US, I’d take that lot over the untreated cancer patient living six horribly painful years in Europe. Price tag and all.

  4. Topher, you have to take into account that he was indicating that life expectancy can be largely due to culture and social choices, not medical treatment…yes, someone may be kept alive who has cancer for 5 years in the US, but in Europe, that someone may not have cancer in the first place because that someone won’t have the mindset to try to compete with his/her car for who weighs the most, smoke two packs a day, or any of the other ridiculously stupid & risky things that Americans do.

  5. I’m one of those people that probably uses a disproportionate amount of health care dollars. I have type 1 diabetes and wear an insulin pump. I have reflux disease and have been on expensive PPIs since high school, along with Reglan, Domperidone, Zofran, Carafate, and a small pharmacy consisting of pretty much every GI drug known to man. I have asthma for which I take Advair 500/50 and Singulair- both expensive, both lacking generics. I’m in counseling. I used to see a chiropractor before I realized it was doing didly squat. I’ve been hospitalized 3x in the last 12 months for vomiting and dehydration which resulted in lack of diabetes control (though I am typically very well controlled). I shuddered to think of what I have cost my insurance company. I’ve actually felt guilty about it on occasion. But in the end, I’m not being excessive- I’m using the resources I need- which is what health insurance is for. And as far as I can tell, BCBS isn’t hurting for it.

    I’m not old (I’m 21), I’m not approaching death, I’m not partaking in risky behavior (no drinking and driving, wear my seatbelt, no smoking, rare fried foods, I don’t own a motorcycle). I ski, I snowboard sometimes, I swim. I drive. I’m sure people have died from these things, but they have yet to contribute to any of my huge health care costs. In fact, they have probably deducted from them.

    I was unlucky. Should I not be living my (very full life) because of that?

    (Whoa.  I am on record as generally being in favor of high tech, expensive medical care and of taking care of the poor.  I’m just pointing out that it ain’t cheap.  And I guarantee that with a little bit of responsibility on your part, your health care costs are reasonable and something that we are all happy to help with.  But suppose you were a 60-year-old vasculopath who refused to quit smoking and continuously thrombosed his grafts?  How about that?  Should the public subsidize irresponsibility?-PB) 

  6. Oh- and as for good primary care. One can be seeking primary care and still have poor primary care. There was the primary care doctor that missed my diabetes, or the primary care doctor that missed my dad’s CHF. There are primary care physicians that fail to instruct 300 pound patients on healthy weight loss, or primary care doctors that put their IDDM patients on set doses of 70/30, never adjust it, and let them run a1cs at 12% for years without so much as a referral to an endocrinologist. There are primary care doctors that fail to do many things.

  7. Very entertaining read, as always. Americans are not willing to judge whose life is or isn’t “worth” the technologically sophisticated interventions. The result is that both the nearly brain dead nanny with 0 quality of life and the very nice 21 year old above (Christine) whose immune system really screwed up her otherwise normal and full life get equal access to whatever they need. It’s a slippery slope – judging the value of a specific human life, and rationing care. While it may be clear that heroic measures in the stroked out, end-stage patient with no cognitive abilities may not be a worthwhile use of resources, the idea of making a list of conditions or situations that wouldn’t merit resources is not ethically palatable to Americans. We can think of exceptions to the rule, and we’re terrified that our family member (or we) will not get the heroic measures we desire. We’re gamblers by nature – if there’s a 1% chance that doing something medically courageous may return us to a decent quality of life (or perhaps just adds a good year), but costs $500K, we’ll try it.

    So, I guess we have to either: 1) accept that we are providing heroic measures to all, which will result in a colossal waste in resources but will sit well with us ethically or 2) begin the process of rationing care, limiting heroic measures in certain circumstances, and praying that we don’t somehow block a Christine from accessing care with our rules.

  8. Healthcare is costing more and more but health professionals are being paid less. Who’s making the big bucks on this, because that’s where we should start if we want to reduce costs.

  9. Panda,

    Your writing is beautiful. Your point of view is fascinating. I tend to agree with a large portion of what you write. The inappropriate heroic measures we subject our sick, disabled, elderly, and premature to is lamentable. The insulation of health care consumers from real costs, the GD lawyer-driven CYA testing, etc etc all has been expounded on by you with eloquence, and you’re dead on.

    But, I disagree with your views on the accessibility of primary care. Your experience under the EMTALA noose has colored your perception, as you see the patients who show up there willing to take their free primary care from you. There is a large portion of the population (often the working poor) who goes without. A $2500 ER bill for a 23-hour rule out CP and stress test takes a long time to pay off on $8 an hour.

    (No one pays, or even expects to pay, their ED bill. The hospital may as well save the postage and not even send the bill. They never try to collect, either, because it is usually more trouble than it is worth. I had a nice, twenty-one year-old uninsured girl come in the other day for a mild sunburn. I mean mild. If she expected to pay the four-hundred dollar bill do you think she would have come in? Not hardly. It is understood by everyone that Emergency Care is free and the bill is just a little bit of interesting fluff to add a little spice to the visit. I bet if we charged a ten-dollar fee for level 1 complaints we would clear the waiting room.-PB)

    I take care of a lot of these folks, because they can afford our $10 copay (I work in a health center, so my salary is subsidized in a number of ways by the government.) A lot of them are proud, hardworking people who either started life without the leg-up that I had or have made a few bad decisions. Stocking the shelves at Wal-mart is about all they can do.Primary care CAN be cheap. HCTZ, metformin, and aspirin can make a huge difference. But start talking Advair, Nexium, and Actos and we’re talking numbers that a lot of people can’t afford. Fortunately, if they live near a health center, lots of that can get covered.

    But when a 43 year old uninsured diabetic has atypical chest pain, I can’t get them to go the ER. When a 55 year old has 3/3 positive screening hemoccults, he can’t afford his colonoscopy. When a postmenopausal woman has pelvic pressure for 3 months, she can’t afford a pelvic ultrasound.

    Primary care is cheaper than the horrifically abused end of life care that society can’t seem to see for what it is. But it ain’t always cheap. I do not claim that better primary care will save any healthcare money in the future – frankly, I doubt it will. But it doesn’t mean that it’s not a good idea to make accessible to people who need it. The abuse of the medicaid population is horribly frustrating. But from your vantage point in the ER, you are missing the non-medicaid non-abusers who are dying young of untreated treatable conditions.

  10. I am on record as being in favor of providing medical care to the helpless and the poor. But as primary care for most people is fairly cheap, and since most people are not poor and willingly pay for things that are nothing but luxuries (booze, smokes, drugs, cable, personal watercraft, cell phones, designer handbags, those funny rims that spin on their own) there is no reason why they can’t pay for their own doctor’s visits and a few generic pills here or there.

    Society should be structured to encourage personal responsibility and punish the converse. As almost every social pathology you can name is the result of a lack of personal responsibility and as these problems cost money, you can’t on one hand complain about the cost of supporting the illegitimate children of a twenty-million baby-daddies but at the same time support social programs that encourage this practice.

  11. Nice post. I think everyone just needs a little accountability. Perhaps the ER should start charging a copay? If the complaint is legitimate, then no copay. If it’s something nonurgent and the patient is just trying to get away with free healthcare, then there should be a copay (which should be higher than the neighborhood primary care clinic). When I used to do primary care, I had patients w different insurances, including medi-aid. The ones that have no copay seem to come by all the time compared to the pts w even a $10 copay. Regarding rationing of care, we are doing this routinely in organ transplants, and that’s just the way it is. Personally, I have no problems keeping someone alive no matter how “messed up” they are as long as they still have some cognitive function.

  12. You know, I agree that primary care access isn’t really the issue. My pregnant patients all get free prenatal care. I think that because it’s free, they don’t really value it. The end result is that they may or may not come to their appointments. Even the high risk hypertensive diabetics with nephrotic range proteinuria will often not be compliant with doctors’ visits or with our recommendations, and for poor pregnant women, all of their care is free.

    Sometimes I wonder that if we charged them like… $15 per visit if that would cause them value their care more and be more compliant. My adventures among the urban “under”served have taught me that many of them take their free medical care for granted and don’t really value it very much. And, to be honest, there are other barriers to compliance with diets, etc when you’re poor and live in an inner city that lacks grocery stores, etc. However, I feel like most of my patients could at least try (and at least bathe!).

    At the same time, I think you underestimate the vulnerability that we all have to medical catastrophe. I had an initial flare of ulcerative colitis a few months ago, and if it weren’t for my insurance, the work-up alone cost thousands and thousands of dollars. I always look at my bills, even though my insurance covers stuff, and I had an ED visit that was $1000 in and of itself. The meds I’m taking for it right now cost $700/month (ok, well, I pay $15. Yay for health insurance). The thing is, I’m basically healthy otherwise. Never spent a day in the hospital. It never really occurred to me that I could actually really get sick. So, right now, if I had a catastrophe only health insurance policy, I’d be screwed, because there’s no way I could afford $700/month for meds. At the same time, I was unable to work with the profuse bloody diarrhea (and resulting anemia), arthritis, abdominal pain, fevers and mind-numbing fatigue that I had from the UC.

  13. Actually, some EDs are very persistent about billing. I went to an ED once and the bill for for my short visit was $180, which I thought my insurance would pick up, so I didn’t pay it. A couple of months later, the hospital threatened to send it to a collection agency…. I figure if they gave two $hits about that little bill then they must try to collect on people that are regulars.

  14. I assure you that the thought of paying even the smallest amount for their care never crosses the minds of our frequent utilizers of emergency services.

  15. I share the idea that people simply need to take responsibility for themselves. Obesity is a condition that no one with a clinically, normally functioning brain should suffer from. It’s just common sense.Yet morbid obesity is often portrayed as a “disease” as if the problem was not with that individual.
    “dahm, I’m so fat I get in my own way”. The idea to stop eating never seems to cross their mind.

    As far as financing the care for such people, now thats laughable. How did u put it once PB
    “no pay, no play”? So long as they take responsibility and take measures (get a job, pay your taxes, or get some health insurance) to provide for their health care people should be able to obtain it.

    If you can afford to take the time to siphon cash from tax payers, you should dam well be able to pay some taxes.

  16. According to Tim Harford in The Undercover Economist (which everyone here should read!), the solution is not “market-based or single payer, market-based or … (bang head against wall),” but (as always) somewhere in the difficult middle: everyone pays for his own health care via a health care savings account, with access to catastrophe insurance (which is cheap). The government contributes to (if not covers) the savings accounts of the poor and the chronically ill. As soon as people pay their own way, they start to ration their own care (rather than the government or insurance company doing it). Actually there’s a bit more to it than this (it’s a good book), but that’s the nutshell.

    In line with this thread (and Panda’s themes in general):

    – Culturally, politically, why does such a system described above work so well in Singapore, but can’t get off the ground in the US?
    – As patients choose their own doctors, how will doctors’ behavior and profession change?
    – How does one rightly determine a catastrophe? How about “chronically ill”? What administrative and legal costs are associated with these determinations?
    – How do we handle childbirth costs in such a system? (This is an interesting thought experiment, by the way.)
    – Assuming that the most burdensome health care costs are end-of-life (or other) technology-intensive or lifestyle things that are so fashionable to rail against these days, does Harford’s system—which all but eliminates unnecessary ER visits and other patient perversions—make enough of a difference?
    – Will stories of people martyring themselves (or searching the Internet for answers) to avoid medical costs be sensationalised by the media, resulting in a pendulum swing back to where we are today?

  17. Wonderful writing except that the studies have been done for risk-adjusted life expectancy. The results are that the Europeans still live longer and spend less.

    (Well, how about them Albanians?  They live longer than Americans and spend nothing (practically) on health care.  Like I said, life expectancy is a poor indicator how well medical care is delivered.  It is a better indicator of lifestyle.  The other question is, why don’t people in countries with great health care live to be ninety, on average?  Could it be that after you secure a reasonable water supply, provide vaccinations, a decent diet, and a reasonable expectation of not being massacred in a pogrom or genocide we just have a natural expiration date which, despite the money we spend, is hard to get past?  I’m not saying that some as yet undiscovered medical advance will not extend the lifespan of the Western World (to the dismay of the nanny-state that relies on people working then dying quickly) but we are at a point of diminishing marginal return where, like we do in the United States, we dump vast amounts of money into a patient and only extend their life by a year or so.-PB)

  18. Panda- Thank you for your comment on my comment. I have no doubt that your intentions on the original posts meaning had very little to do with my specific situation, and far more to do with a much broader more generalized problem. Trust me, I’m aware of the problem. I’m still just a student, but I’ve been exposed to health care enough to know what you mean. We’ve had people on my floor in their 90s with end stage pancreatic cancer with mets who were full codes. I don’t get that at all.

    Val Jones, you perfectly summed up my concerns- that somehow limiting access to health care would be a slippery slope. My biggest fear is not being able to get the care I need simply because I am a drain on the system at times. It’s weird to be afraid of the system you work in sometimes.

  19. Re: “A Greek doctor of my acquaintance related to me…”
    Greece just happens to be among the poorest countries of Europe. A fair comparison would be: what’s the standard of care in countries with comparable (per capita) economic power? If you talked to a French/British/German doctor, you’d find that the quality of healthcare in these countries is on average no worse than in the US.

    Re: “In Europe, this patient would have died fifteen years ago”
    Once again: There is no “Europe” as far as healthcare goes, just thirty-something European countries with thirty-something different healthcare systems. Your example may be true for countries like Greece, Albania, and so on. But your example is also patently false for countries like France, Germany, and the UK, where the patient would have received similar care and not have died fifteen years ago.

    So when you’re relating the arguments of your “European” acquaintances, you should always take them with a grain of salt, and ask yourself where exactly your acquaintance is coming from. Whenever you write “in Europe…” it devaluates your argument, because someone could accuse you of comparing apples and oranges, or worse, of deliberately distorting the facts.

    (I repeat, in the United States we make heroic efforts on behalf of patients for whom our continental cousins would do nothing except offer hospice or paliative care.  In Greece, for example, as well as much of Europe, something as routine as hemodyalysis, something that even our 90-year-old demented, stroked out, nursing home fixtures get, is hard to come by over a certain age and past a few comorbidities.  In fact, many of the defenders of the Freeloader Kingdoms point to this with pride as an example of a system that prioritizes spending rationally, something that we do not do here in the United States.  This alone contributes to our high per capita costs.  Add in the crushing burden of operating in a predatory legal environment, something that you folks do not have to worry about, and you can see why we spend more.-PB)

  20. BUT the studies have been done. The reason we spend more is because everyone in healthcare makes more money especially the Docs, hospitals, and drug companies. Pandabear, you have a way with words, but that does not equal facts.

  21. Whoa. If you cut the salaries of doctors in half, the cost of health care would only decrease five percent as payments to doctors accounts for only about ten percent of health care spending. Unfortunately, cutting salaries in half would probably result in cutting physician productivity in half as well. You cannot isolate the medical industry from the rest of the economy. Using myself as an example, I could easily have made (and did make, actually) half of a typical doctor’s salary in a non-medical career without eight years of grueling training (medical school and residency), the debt, and (frankly) the abuse I have had to endure for the privilege of listening to some drug addict complain that she’s been waiting fifteen minutes for her pain meds. If medicine didn’t pay well, given the other economic opportunities in our country for the smart and aggressive, you’d have very low-quality doctors, in general, or at least doctors who wouldn’t exactly kill themselves to see a lot of patients. The typical French doctor works, what? 35 hours per week or some such low number dictated by his robed masters in Brussels. An American doctor who works 60 hours per week considers himself to be in a lifestyle specialty.

    I think the Europeans, living as they do in a society that protects them from the necessity to be aggressive in life, don’t understand the imperetives of American life. Fifty thousand bucks a year might be great in France where the salaries are lower and people are generally content with smaller houses, smaller cars, and smaller families but in the United States, and I say this with pride, life is something of a jungle and you have to be a little predatory to make it.

    As for hospitals making money, it is true that terrific amounts of money are processed through hospitals but hospitals are, in fact, expensive to run. Maintaining an ICU bed, for example, costs four thousand dollars a day and my hospital has close to 100 of them.

    I am perfectly serious when I say that most of the money spent in the hospital goes to the nurses, collectively that is, as well as the rest of the ancillary staff. Good luck trying to get the nurses or anybody else but physicians to take a pay cut (which is what we do every time medicaid or insurance decreases reimbursement).

    Now, I happen to think that as a society we are ridiculously over-doctored to the point that we waste tremendous amounts of money on needless hospitalizations which are often futile as well. But that’s a political issue as everybody wants to save money untill it’s their grandma who is turned away because sticking another pacemaker into her isn’t cost-effective.

    I could save millions for my hospital just by sending a large portion of the uninsured patients who we admit home for outpatient follow-up. Hell, they don’t need to be hospitalized for their work-up but we do it anyways because not only is that the paradigm of American medicine but to not do it opens you up to the full fury of the legal profession who predate on our society.

    So you see, blaming hospitals and doctors is identifying the symptom, not the cause. As for drug prices, well, I always have done my best to prescribe generic medications and use the simplest, cheapest regimen for the patients especially if they are uninsured. That is an easy problem to solve and does not necessarily require the government to set prices. On the other hand some new drugs are clearly better than the ones they replace otherwise we would still be using the same drugs that we had in the sixties. We also don’t want to stifle research and development of drugs which our country and our money subsidize for the whole world.

  22. You make some great points, but I see the problem in much simpler terms.

    First the reason health care costs are increasing so rapidly, is because the population is aging, and the demand is outstripping the supply.

    It’s the simple law of supply and demand, and there is nothing we can do about it, until at least we can increase the supply.

    Secondly the reason health insurance premiums are increasing so dramatically, is due to cost shifting, which you mentioned in the beginning of the article.

    Health care providers are forced to provide care to anyone, regardless of their ability to pay, and when they can’t or don’t pay, the cost is shifted to those who can pay for their own health care directly or purchase insurance to help cover expenses.

    This trend will also continue until eventually no one will be able to afford health insurance, forcing health care providers out of business (as already evidenced by the closing of many ER’s). Eventually no one will receive care at any price in the US.

    There are some things government does best. One is the military, and two others which come to mind are our police and fire departments.

    And the same goes for health care.

    In order to maintain a solid health care infrastructure, we all have to contribute to it, just as we do with our military, police and fire departments.

    Yes taxes will increase, but what’s the big deal? We’re already paying for the health care of those who can’t pay, through hidden taxes, such as increased health insurance premiums and health care costs.

    At least with everyone contributing to the system, the burden will be spread more equitably throughout society.

    Health care providers will no longer have to figure out how they are going to cover the costs of providing free health care.

    And our emergency rooms will no longer be overburdened treating non emergency cases, and health care providers will then be able to focus their attention on providing the best possible care.

    Until we start treating our health care infrastructure like we do the military, police and fire departments, our health care system is doomed, and no amount of “skin in the game”, HSA’s, HDHP’s etc. will do anything to solve the problem.

    The rest of the world has recognized it, why doesn’t the US?

    One thing to remember, unlike our police and fire departments, which we may never avail ourselves of, everyone will avail themselves of our health care system, sometime in their lives, therefore everyone should have to contribute to support it.

  23. Marc,
    “everyone will avail themselves of our health care system, sometime in their lives, therefore everyone should have to contribute to support it.”

    Sorry, but why? It’s my money, and my choice. If I can take care of myself, and pay my way, why should I be forced to pay the tab for the individuals who don’t? At its root, this is about justice. I have the right to keep the money I make. You insist that you have the right to the money I make to pay for others. I disagree.

    Health, unlike national defense, policing, and fire fighting, is an individual responsibility. It is in fact my duty to take care of myself. If you are prepared to state that it is my duty to take care of my neighbor, then you also give me the right to insist on conditions for my neighbor’s care: i.e., weight loss, cessation of smoking, daily exercise, etc. He who pays the fiddler calls the tune. And, as seen in the UK, the unhealthy will be put through a hellish dance.

  24. The Police have always belonged to the state, because they are force. Whoever has the guns is the de facto state. Fire is a bit more convoluted, but it can be argued that fire protects everyone, as an out of control fire in a city impacts everyone’s property. There is no legitimate argument for federal fire protection of local cities. Health, outside of basic sanitation and infectious disease control, impacts mostly the individual and is mostly related to controllable factors.

  25. “everyone pays for his own health care via a health care savings account, with access to catastrophe insurance (which is cheap). ”

    My university alumni association and the professional society I belong to both offer catastrophic insurance. BUT…you can only purchase these policies if you already have regular medical insurance. Yeah, catastrophic insurance is cheap because these insurers cherry-pick their insurees (well-educated employed professionals who already have insurance), and because they know that it’s the insurees’ regular insurance that will be footing the majority of a person’s medical bills. What a deal….

    I think before someone says ‘catastrophic insurance is cheap’, they should look into how these policies are currently offered to the public. They’re cheap for a reason.

    To Tom – go ahead. Opt out of current health insurance plans. Pay your own way. Don’t pay for someone else’s medical care.

    But just try and get catastrophic insurance for that inevitable rainy medical day. Good luck.

  26. Miami_med, “Health, outside of basic sanitation and infectious disease control, impacts mostly the individual and is mostly related to controllable factors”

    And just what are those controllable factors for say lung cancer, for those who don’t smoke and never did? And what are the controllable factors for lymphoma or leukemia? Especially in children.

    If it was that simple, we wouldn’t need a health care system.

    And is it still an individual problem when your neighbor, or someone you come in contact with on the street, who has some infectious disease, decides to pass it along to you, because he couldn’t afford to get basic health care?

    And Tom, you can complain all you want about not being responsible for some other guys health, but unless we (the population of the US) start recognizing health care as societal issue, rather than the responsibility of the individual, things will not change, and they will only get worse.

    In the end we won’t have a health care system at all. It will simply collapse under its own weight. And you won’t be able to pay your own way when the time comes. And it will come.

    And those like Warren Buffet and Bill Gates, they’ll just end up going to Europe for their care.

  27. “Most of us are not sick and except for the odd hospitalization for something unexpected don’t really require that much doctoring.”

    Thanks for pointing this out. Hardly anyone else mentions this pertinent fact.

    Why does the healthcare profession generally tippy-toe around the fact that most health problems are the result of lifestyle choices, which people have the right to make but don’t have the right to dip into other people’s pockets to pay the costs?

    I’ve been poor and without medical insurance. It was financially critical that I kept my family healthy and we were. There was never a month when I didn’t put a few dollars into a savings account “for emergencies” (still do) of which life is full (still is).

    People have completely lost awareness of the old saying that there are no free lunches. There is nothing free, much less healthcare. What gov’t pays for it also controls access to. Money for it comes out of our pockets, but only pennies go to providing us the service. The largest part goes to bureaucrats who decide who should get what, when they’ll get it, even if they should get it. You have to be deaf, dumb and blind not to be aware of what’s happening in countries that do have ‘universal (socialist) healthcare”.

    IMHO, those who want to be deadbeats living off the earnings of others should just quit their jobs, dump their families and go live on the streets. Then, at least, you won’t get away with phony compassion and phony condescending superiority. You’ll be easily identifiable as the deadbeat and thief you are, shunned by society.

  28. How many people get lung cancer who DON’T smoke?

    How many Leukemics and Lymphoma victims are there?

    You think the epidemics of Strep or meningitis the occur sporadically in schools are because people didn’t have access to “basic health care????

    You think the average Joe who shows up to the ER with a deep neck abscess due to bad teeth couldn’t HONESTLY have afforded dental care (ANOTHER huge issue which no one seems to bent out of shape about) in lieu of the subwoofer in the trunk of his car??

    Next thing we’ll hear is that Warren Buffet or Bill Gates will go to Cuba for their medical care.

  29. “The largest part goes to bureaucrats who decide who should get what, when they’ll get it, even if they should get it.”

    Yeah Peggy, I’d much rather have my health care decisions in the hands of some health insurance flunky, whose compensation, and that of the CEO, is tied to insuring you don’t get the care you need.

    After all we all know those health insurance profits go into building more hospitals and training more health care professionals, improving the system for everyone.


    (Whoa.  My hospital is in the middle of a multi-million dollar expansion that will double its current size and this is strictly because there is some profit to be made in the health care industry.  By comparison, the little Charity hospital in a neighboring Parish from my own (we have Parishes, not Counties, in Louisiana) has not expanded in twenty years and is chronically short of funds, doctors, nurses, and support staff because there is no profit to be made in government-run health care and every improvement has to filter through the legendary corruption and of our state government, a government which uses public money to buy votes and not necessarily for the public good. 

    By your reasoning, there would be no hospitals in the United States because, as you know, most of them are privately operated and not organs of the state. 

    Your faith in the benificence of gubbmint’ is puzzling.  -PB) 

  30. Marc,
    re your statement, “you can complain all you want about not being responsible for some other guys health, but unless we (the population of the US) start recognizing health care as societal issue, rather than the responsibility of the individual, things will not change, and they will only get worse. ”
    First, face it, I’m not responsible for my neighbor’s smoking and diet choice. One would think that obvious. Second, choice is an individual issue, not a societal one.

    I contend that precisely the opposite of your statement is the case. If a person takes responsibility for the health care they consume, they tend to be more efficient in using it. Come now, surely you know how the “To each according to his need, from each according to his ability” theory played out. The Soviet Union has fallen. Let go, already. The model you embrace doesn’t work.

    With the government model there is no recourse, the bureaucrat speaks with the force of law. With an insurance company, there is recourse, namely its competitors and the law. Again, surely, you know this.

  31. “And just what are those controllable factors for say lung cancer, for those who don’t smoke and never did? And what are the controllable factors for lymphoma or leukemia? Especially in children.

    If it was that simple, we wouldn’t need a health care system.

    And is it still an individual problem when your neighbor, or someone you come in contact with on the street, who has some infectious disease, decides to pass it along to you, because he couldn’t afford to get basic health care? ”

    I’m pretty sure that I’ve been on record in the past arguing that the one legitimate role of government in healthcare is infectious disease control. It is not the role of the government to tax everyone in order to pay for someone’s bad luck. Charity is good, but universal healthcare isn’t charity. Your argument is based on the premise that everyone should be required to pay for everyone else’s bad luck. We don’t all agree with that. Life isn’t always fair. The role of government isn’t to create a super fair utopia, it is to handle defense and arguably situations necessary for the whole of society to function. 99% of healthcare doesn’t meet either of these definitions. I don’t really believe that we do need a public healthcare system.

  32. WHOA PB!

    I guess you didn’t read my post thoroughly.

    I didn’t question the profits of HEALTH CARE providers.

    If you read the post again, I said HEALTH INSURANCE providers.

    In case you didn’t know, there is a difference.

    So I’ll ask again, exactly what do HEALTH INSURANCE providers do with their profits

    (Give it to their shareholders. Is that a mystery or do you not understand capitalism?-PB)

  33. Once again: There is no “Europe” as far as healthcare goes, just thirty-something European countries with thirty-something different healthcare systems. Your example may be true for countries like Greece, Albania, and so on. But your example is also patently false for countries like France, Germany, and the UK, where the patient would have received similar care and not have died fifteen years ago.

    So when you’re relating the arguments of your “European” acquaintances, you should always take them with a grain of salt, and ask yourself where exactly your acquaintance is coming from. Whenever you write “in Europe…” it devaluates your argument, because someone could accuse you of comparing apples and oranges, or worse, of deliberately distorting the facts.

    Coming from Europe, I have to tell you that Panda is dead on target. If you are old enough (or sometimes not), you run the risk of dying on the waiting list in places like the UK. As far as getting major operative/critical care procedures done, none of the Europeans (including the French and Germans( are anything close to as interventionalist as Americans.

  34. There are some things government does best. One is the military, and two others which come to mind are our police and fire departments.

    Slighty off topic, but have you looked at crime statistics? Not such a good outcome, especially the murder rate. No, government ain’t that hot in that department, either.

  35. Yes PB, I do understand capitalism. Companies exist to benefit society. They produce products and supply services that individuals can’t provide efficiently on their own.

    (No. No. No.  Companies exist to benefit their owners.  They produce and supply goods and services that individuals can’t provide efficiently on their own so their owners don’t have to eke a meager living out of hunting and gathering.  The benefit to society is incidental (but very real) and only a result of the desire of fellows like me to keep my wife in the style of which she deserves.  Economic systems that inhibit the drive towards benefiting ourselves result in stagnant, freeloader societies where the benefits of enterprise are stifled, leading to generalized poverty for all.  That’s why increasing marginal tax rates past a certain point stifles economic growth.  Nobody is going to work harder if the extra money he makes is taxed at a rate of ninety percent.  It just ain’t worth it unless one is a zealot. -PB)

    The main purpose of business is not to make a profit, it is to supply products and services which individuals cannot provide efficiently on their own (I know, I repeated myself, but it is important to emphasize.)

    But on the same note, profits are necessary to ensure the business can continue to exist, and to improve the products and services produced.

    For example, oil companies reinvest their profits in discovering more oil deposits, and to build more efficient refining capacity etc.

    Automobile manufacturers, build better, safer and more fuel efficient cars.

    Computer companies, i.e. Apple, produce new and better products to make our lives easier and more productive.

    And on and on and on.

    Certainly these companies return some of that profit to investors who risked their capital in starting and supporting the companies, and which they are entitled to.

    Health insurers don’t benefit society in the same way. They don’t reinvest their profits to improve health care or even the delivery of health care. They exist only for their own benefit, and in fact act in total contradiction to the best interests of their customers and society, in order to increase their profits. And as far as I’m concerned, we don’t need those kind of businesses.

    If that’s the kind of society you want to live in, well, you’re living in it now.

    Just don’t get sick. That’s when you’ll really discover just how good your health insurance really is.

  36. 15% of lung cancers occur in never-smokers. Have some heart here.

    The firefighter analogy is interesting. We seem to be paying for other people’s bad luck there, and noone is clutching their wallet and screeching and hissing about socialism over that.

    And if capitalism were working properly, generic drug prices would never have have reached their ludicrous heights before Walmart
    finally saved the day just recently, at least where i live….

    By the way, Singulair from India is quite affordable. 30$ versus 120$/month in the US.
    It’s only, like, 13 years post introduction, with life and EMS-saving preventive potential. If I keep hearing about R+D costs and how we’re the only ones doing it I’m going to start asking why the french are the only people who are seriously developing anorexiant drugs. What a fucking breakthrough that would be.

    I still think we should look at Canada a little more closely. Every time I go to Vancouver, I wonder…how come they have such fabulous public pools? Why do ours look like salt licks in comparison?

    The other day I was in a beautiful park. I went to the bathroom. There wre no doors on the two stalls and the main door had no latch or lock. I preserved my dignity and made it home, walking with a certain stiff-legged measured gait and determined facial expression.

    By the time we’re done, Irak will have a better infrastructure.

  37. Mick,

    Perhaps we are thinking of different things, but I consider the insurance I have as “catastrophic illnes” insurance and it is my main insurance.

    My health insurance company does not phrase it as such; instead it is a “high-deductible traditional indemnity” plan. I pay ALL my healthcare costs up to an out of pocket total of $2500 per person or $5000 for my family. Beyond that, I contribute 0% and the insurance company picks up the rest.

    While I do not have an HSA, I oculd have one with this policy. This is an individual plan, purchased directly from the insurance company, because I am a student and my husband is self-employed.

    I can’t remember when the last time I used $2500 on healthcare in a year (perhaps when I had my appendix out when I was in college and stayed in the hospital for 3 nights) so this is a great plan for me. All things considered (like the amount of debt I am accruing for my training) $2500/$5000 is the upper limit of my personal risk. This plan costs approximately $100 a month and covers two young healthy adults who exercise, eat relatively well, and do not smoke.

    These types of plans are not out of reach at all.

  38. On a different note, I am off to Africa for a month and won’t be able to read up on Panda much while I’m there. Keep fighting the good fight Panda!

  39. That’s great Random MSII. Let’s see your young and healthy, and seldom need any health care. The insurance companies love people like you. It’s basically free money for them.

    And it’s cheap for you, because your young and healthy.

    But what about the 50 or 60 year old, diagnosed with a terminal illness, who just lost his job, and had insurance purchased for him through his place of employment?

    What do you think insurance will cost that person?

    But why should you care about those persons? It’s not your problem is it? Besides they probably led an “unhealthy lifestyle”, and their illness is a result of that.

    That won’t happen to you. You won’t get old, and I’m sure your parents provided you with a set of genes that will counteract any potential illnesses.

    And let’s not forget, you also live a healthy life style, so you can’t possibly succumb to a similar fate.

    Ahhh! But there in lies the rub. It doesn’t matter how healthy a life style you lead, you can still get sick, very sick. Trust me, I know.

    But still it’s not your problem is it?

    And it never will be, that is, until you’re diagnosed with some unexpected terminal illness. And then no one will give a damn about you.

    But I know, that could never happen to you!

    Have fun in Africa!

  40. I never said it could never happen to me and my comment was directed towards pointing out that the higher deductible healthcare plans were available. No matter who you are and what your health status, a high deductible “catastrophic plan” is lower cost than a 100/80 PPO plan. I pay less out of pocket for the plan I currently have (premium-wise)than I did when I was working and had that 100/80 PPO plan with all the bells and whistles. I admit that when I am older I will pay more for healthcare; I never attempted to state any differently. My comment extended solely to the fact that insurance for “catastrophic illness” is available in forms other than that of which you were speaking.

  41. I wasn’t really speaking of any particular type of insurance. Even with all the bells and whistles, at your age insurance is relative cheap when compared to those that are older.

    I was actually trying to point out the inequities in our system, which result in many people not being able to afford, or even obtain health insurance because of preexisting conditions, which in many cases, are through no fault of the person.

    I also was hoping to get across to the vast majority of young and/or healthy individuals, just what is in store for you when you do get really sick.

    It is at that point that you discover just how flawed are entire health care system is, and how many hoops you have to jump through to get the care you need.

    But until then it isn’t your problem, and there in lies the problem.

  42. “Apparently, for every Tupac harvested early to the Lord we have a ninety-year-old vegetable sucking life through plastic tubes bringing up our average.”

    Come on PB, your generalizations of black men and old folks are crappy.

  43. On the contrary, I think all his generalizations and that sentence in particular to be original, hilarious, and statistically accurate. And besides, there was no reference to race in that comment.

  44. glyph –

    “If you look at it this way, and factor in things like gang violence which decreases the life expectency of black men to 67 years,”

    Those are the “Tupacs” PB was referring to. But then again PB only cares about certain people who don’t take up his time or resources.

    (I must take exception to this.  I believe I am on the record as generally being supportive of the heroic measures we take on behalf of the premature, incredibly old, and those with astounding catalogues of comorbidities.  I merely point out that this kind of thing ain’t cheap and to think that making health care free is going to make it cheaper is ridiculous.

    I also welcome criticism but the smarmy, puritanical impulse that you display which is nothing more than your desire to stamp out any kind of thoght with which you are uncomfortable is disturbing.  Let’s say, for the sake of the argument, I had made a disparaging remark about blacks.  So what?  Is it your sworn mission in life to cruise the ether primly pointing it out here and everywhere else where opinions are not sanitized for your protection?  Good Lord.  If that’s all you have to contribute you can find millions of sites on the web with much more traffic than mine. -PB)

  45. Wait a minute. Tupac was a black man who was a victim of gang violence and I have several 90-year-old almost brain-dead patients living through tubes on my current service (ICU).

    These are not generaliztions at all but discrete facts and have as much an influence on average life expectancy as any other fact.

  46. I happen to have liked Tupac and have the usual polite interest in gangsta rap that I have for Reggae, country, opera, and every other genre or music except metal. I just don’t like metal. Sorry.

    I actually don’t really listen to music that much so my interest in all of it is merely polite. I certainly don’t need to be connected to an iPod 24/7.


    Best band in history?  Of course, the Talking Heads.

  47. “Wait a minute. Tupac was a black man who was a victim of gang violence and I have several 90-year-old almost brain-dead patients living through tubes on my current service (ICU).

    These are not generaliztions at all but discrete facts and have as much an influence on average life expectancy as any other fact.”

    PB – yes I understand your statement of discrete facts. Perhaps your vernacular is just a part of your charm. Your wit is the most enticing part of your blog.

    Another question for you however, which is unrelated to the original topic: Do you care about your Tupacs and veggies, or is your interest in these patients merely polite?

  48. I am more dispassionate than compassionate but I try to be conscientious and professional. Of course I care, but if you ask me whether I worry about my patients when I go home at the end of a shift or sign out to the person on call (I am in the ICU this month) the answer is usually not although I have occasionally come in at night when not on call to make sure something important was followed up.

    I imagine that you would get the same answer from most doctors.


    Compassion talks a good game but as the hospital is empty at night despite the suffering of our patients, I can only surmise that most other doctors, mid-levels, and day-shift nurses only have a fair-weather compassion that will not withstand the tug of a stomach towards a home-cooked meal or the setting of the afternoon sun over the children’s soccer game.

  49. On another topic, if I didn’t throw a little literature into my articles but instead described everything with the realism and economy you demand my whole blog would be:

    Panda Bear, MD

    I don’t like residency because the pay and hours are terrible.

    We need to stop spending money on futile care.

    Bad habits contribute to bad health and encouraging, through government policy, irresponsibilty will have and has had deleterious long-term consequences.

    Sarcasm here.

    And here.

    The End. Forever.

  50. Hmm, heres a quiz for you. Pick one race that is most likely to become a gangster rapper, make millions of money, and then get shot in the street by somebody you pissed off?
    (skinny white guys named Marshall is not the right answer)


    We have already established that Tupac is a metaphor for the perils of being a young black man living in the urban environment.   And I will swear on a stack of Bibles that young black men have a higher liklihood of dying in a drive-by shooting and from sundry other unnatural causes.  If this is not the case you need to go to the NAACP website and tell them to put a sock in it.

    What is your point?-PB)

  51. I’m ageeing with you. I was trying to point out to tsiridium that what you said was not being unjust or unfair or racist, it was simply true.

  52. I’m agreeing with you. I was trying to point out to your critic above that what you said was not unfair, unjust, or racist, it was simply true. I hate it when people complain about metaphors/generalizations/stereotypes that while overwhelmingly true are considered “politically incorrect”.

  53. I also welcome criticism but the smarmy, puritanical impulse that you display which is nothing more than your desire to stamp out any kind of thoght with which you are uncomfortable is disturbing.

    PB – I am not trying to be smarmy or stamp out free thought. I like your blog, albeit highly conservative, and agree with many things you have posted. Sometimes your writing gives the impression you care very little for people (which you have stated is dispassion).

    Thanks for the post, it is interesting as always.

  54. “I hate it when people complain about metaphors/generalizations/stereotypes that while overwhelmingly true are considered “politically incorrect”.

    Hate is a strong word. You are going to give yourself a headache.

  55. Random MSII –

    What is commonly sold today as ‘catastrophic insurance’ is not the same as ‘high deductible insurance’. The former is a supplemental plan, the latter a primary health plan.

    When I was in my 20’s, I had the same thoughts as you – didn’t worry about any serious or chronic illness befalling me, didn’t think much could go wrong beyond having appendicitis, the flu, pneumonia, etc. None of my friends ever had a serious illness, either.

    Now that I’m in my late 40’s, it’s a different picture. I’ve got two chronic problems that have responded well to treatment, but I’ll have to take medication or have minor procedures for them for the rest of my life. My drug copays alone per year are now $1500, and I’m fortunate to have drug coverage. Then there are office visits, tests, non-covered items, etc.

    I know 4 women in my circle who’ve had cancer, had a co-worker who’s had cancer, another who died of leukemia, a former boyfriend who died of a heart attack – and all under the age of 55. No wonder health insurers prefer healthy 20-somethings’s. They’re a bargain.

    I agree with Marc – a person doesn’t realize how convoluted our health care system is, until they or a family member gets sick. Until you yourself have experienced it firsthand, it’s difficult to imagine. Dealing with insurers isn’t a problem at all – until you hit a wall where they won’t cover this, and they forgot to tell you they won’t cover that, or they will only cover it for some conditions, but not the one you have, etc.

    I can’t imagine what this is like for someone with a life-threatening illness.

  56. Mick,
    “No wonder health insurers prefer healthy 20-somethings’s. They’re a bargain.”

    If you strike just one word, 20-something’s, you’re spot on. To retiterate, health is, largely, the result of personal choices. And why is it just that the healthy pay for others?

    Bad luck and genetics is why a rational person buys insurance. That is reasonable, in that lightning may strike anyone, just as anyone can roll snake-eyes in the DNA game. Paying for a gastric bypass operation for some-one I’ve never met is an entirely different proposition. Choice got them there, and it is, in fact, fair that they pay the cost of their choices. Have they tried to stop eating? What about a liver transplant for the alcoholic who won’t stop drinking, or long term care for the continuing smoker with emphysema? What should they pay? Come, now, answer me, what should people who make these choices pay? And why must I pay for them? Why must my health care costs be tied to theirs? Is that just?

    Never mind, I know what you’ll say, I lack compassion, right? But you’re demanding that I show compassion without giving me a choice, by taking my money, without my consent. Why would anyone resent that?

  57. I wrote this before – if you don’t want to pay for anyone else’s healthcare, then opt out. Don’t buy insurance. Pay your own way, all the way. Do what you can to stay healthy. Assume you’ll be healthy forevermore (I know I thought that for myself. Ha Ha.)

    I’m curious – what kind of insurance do you have now? Employer-sponsered? Some employers let their employees opt out of their plans. Have you?

    I’m also curious – what age range are you in?

  58. Mick,
    I do not fit your twenty-something-without- insurance stereotype. Anything more than that would be personal information, and is not open for discussion in a public forum.

    Regarding the justice of the healthy paying for those unhealthy by their own choices: unimportant? If you do support a single-payer system, it should be addressed at some point.

  59. Jesus, Tom, what business are you in? How old are you, for goodness sake? There are a lot of people named Tom, you know.

    Morbidly obese people would not subject themselves to gastric bypass if they had another “choice”.

    Morbidly compulsive eaters are ill, they have a psycho-neuro-bio-hormonal derangement, period, and can no more lose weight than a diabetic can cure himself.

    It is funny how you only mention alcoholics and fat people as the resource drains. What about preemies and gorked patients and complicated elderly patients? They are MUCH more expensive and they too, can not help themselves.

    The liver transplant situation is ridiculous, really those patients are just research animals.

    I’m just thinking a single payor system is not so bad, because I like Canada, and listening to all the gnashing over “my money” makes me vaguely dyspeptic.

  60. Gaye,
    Upholding the right to private property is one of the key roles of government. To erode that right for the sake of individual, rather than societal good, seems a bad move. I’m sorry that my insistence on the right to private property causes you unease, but the insistence of others that they have a right to my property causes me unease.

    The examples chosen were to exemplify those who are in fact ill due to their own choices. Regarding the morbidly obese, the best advice for weight loss remains the same: “Eat less, exercise more.” You seem to believe that those suffering from morbid obesity have no choice in the matter. They do, and they choose every day. So do smokers and drug addicts. Those suffering from the consequences of their own choices live in a hell of their own construction, built carefully over a lifetime, and they will not thank you for dragging them out of it.

    You’re right, there are a lot of people named Tom. I’m not one of them. I do not disclose personal information in a public forum, sorry. Could you address the justice of the healthy paying for those unhealthy by their own choices?

  61. Very simply. Healthcare technology exists and cures or helps all sorts of unfortunate people
    who have absolutely NO role in their health crises. We all agree that if the fire is sweeping over the plain, we put it out, even if it benefits only a few people and kills some in the process. Similarily, we all agree that if a vibrant person we love suddenly gets their kidneys zapped, they ought to get a chance at life if the technology we have affords that.

    You ask us to start parsing based on people’s role/responsibilty in their problem. First of all, doctors would never get adequate training if they did not have a chance to work on the self-destructive amongst us. If you are a hospital worker of any stripe you know that. The whole profession relies on “the problem” and we might as well revert to selling snake oil if we cannot obtain adequate training. Justice is much more complicated than you paint it. If we hadn’t had all those alcoholic pancreatitis people to treat, we would not have the kind of expertise we have today to treat, say, gallstone pancreatitis.

    Now I would agree with you that futile care is not only a waste of my money, but that, much, much more importantly, it is a veiled, unacknowledged inhumane practice in many cases.

    I would also agree that in addition to futile care, there exists corruption in decision-making around surgery. EG, why can a fat person lose a good 30-50 pounds with the help of a simple inflated balloon device inserted via endoscope in France, but that patient has no such option in the US, where GB is considered the gold standard for definitive treatment of obesity? (BTW, said french approach involves 15 minutes, sedation, and an IV line. Not a single cut. Hmmm.) Of course, when you are talking about The Mound People, GB is the only effective therapy. But for the Plumper people, well, go get diabetes.
    Eat right, exercise, blah blah…

  62. try practicing medicine in Canada.

    we have free healthcare here with all the same problems (physical and cultural)you speak about. Our system is not as glorious as everyone thinks it is. there are long wait lists for important procedures (orthiopedic surguries like hip replacements are very long) and getting an MRI is out of the question unless you are dying (still with a long wait list). I dont know what the problems are, I cant imagine contemplating them, but I still believe in the system regardless of the problems it has. free universal health care. I cant imagine living without it.

    (Uh, so you’re saying that it’s great unless you are dying or need an important intervention to improve your quality of life?  Good Lord. This is just what I am saying.  Free health care is great until you need it.  And I shudder to think that I have to point out to anyone who purports to be part of the productive sector of society that there is no such thing as “free health care” as it does not spring, fully formed, out of somebody’s ass.  You pay for it directly out of taxes which, if you add them up and considering that expensive interventions are severely rationed, probably costs you much more than the value you get.  If you are not in the productice sector you pay indirectly by living in a society with a terrific drag on economic growth, high taxes, which generally limits material prosperity for everyone.

    Free indeed.-PB) 

  63. Giving your age range is tantamount to releasing private info on the Internet? We’re not asking you to give out your Social Security number. We’re simply trying to get a read on what perspective you are coming from in regards to health insurance, which is age-rated when bought individually.

    BTW, as I said before, I’m a 48 year old woman with two chronic conditions. I purchase my own insurance, an HMO plan that has limited drug coverage but is otherwise a decent plan.

    There, now anyone will be able to figure out who I am, where I live, and what the status of my health is. Next thing you know, someone will steal my identity. (Just being sarcastic)

  64. While reading this portion “There is, however, a small but significant subset of the population who use a terrifically disproportionate amount of health care. I write about this group extensively on my blog and they include the living dead vegetating in pre-death staging areas nursing homes, the multiply comorbid, and people who make bad lifestyle choices resulting in a state of perpetual symbiosis with the local hospital. Upon this group of people is brought to bear the full might of our technologically sophisticated but extremely expensive medical arsenal.” … I wondered if you’ve read this book “The spirit catches you and you fall down” by Anne Fadiman…

    I just received it from the medschool I’ll be matriculating in this fall, and I’m only about halfway through but I thought lot about your blog while reading it. I wonder what you’d think of it if you’ve read it, but if you haven’t, I think u may find it interesting asuming you find the time to read for pleasure…

    Anyway, like pple have pointed out, you’re blog is both entertaining and very informative. Also very well written. Take care.

  65. ” Healthcare technology exists and cures or helps all sorts of unfortunate people…”

    So does safe car technology, good housing technology, and even healthy food technology, but we don’t give these things away to everyone, because it would simultaneously lower the quality and value of the products and become an unaffordable boondoggle. Thank Lenin for any insight is to what happens when you take this thought to its logical conclusion.

  66. Your comments on the state of our health care are dead on. I agree that socialized primary care wins for no one, absolutely no one. However, I am troubled by your statements to the elderly. Is it a fact? Absolutely. However, there is no solution to that problem, and I do not consider it ethical to stop the feeding tubes if the family wants it left on. I know that is not what you mean’t, but I thought I should clear this up. Also, I feel on a whole that your remarks to the elderly are completely degrading. I’ve learned more about how to live from my patients at the nursing home I work at (I’m a CNA), then I have working anywhere else. I think there is a major problem with this country on how we respect our elderly.

  67. I am completely old-school in my respect for the elderly and am in complete support of providing them with medical care to improve the quality and length of their lives.

    However, I am also completely serious when I describe the absolute waste, the inhumanity, and the futility of much of the care we provide and I am not exxagerating in the slightest, as many of my readers may be able to attest from their personal experience, in my description of ancient, demented, stroked-out, immobile, bed-sore collecting nursing home patients who have no quality of life whatsoever but upon whom is lavished a stunning amount of medical resources.

    There is a time to live and a time to die. There is also a line, sometimes hard to define but usually obvious to anyone with a little common-sense, beyond which it makes no sense to keep spending money. Considering that every day we keep a patient from being “terminally weaned” (from the vent) costs somebody, somewhere several thousand dollars it is not hard to see that if we are eager to give scarce money away there are hundreds of better uses for the money than supporting the indecision of grieving or guilt-ridden families blithely ordering us to spare no expense.

    I guarantee if we made families pay one-tenth of the bill every day in cash up front even families that could afford it would look for the plug themselves. And it is a rare family that ever says, “We will take our mother home, bathe her, spoon food into her mouth, wipe her ass, and keep her company until nature takes it course.”

  68. And we are not talking about “feeding tubes.” Feeding tubes are not medical problems per se, although they can lead to many medical problems. The issue is whether your demented grandmother who cannot even raise herself from the bed and is oblivious to the world needs a PEG and a trach to begin with.

    Suppose your eighty-seven-year-old senile granny has a massive stroke which leaves her completely paralyzed and unable to even swallow or clear her airway. The standard of care in the United States is to send her to the OR for a tracheostomy tube for breathing and a PEG tube for eating after she has spent a couple of weeks on the vent in the ICU.

    After this she is sent to an LTACH (Long Term Acute Care Hospital) where she is warehoused for several years, the monotony of her existence broken only by frequent presentations to the ED for shortness of breath, altered mental status, or fever for which she is admitted, often to the ICU, has her life saved, and is sent back until such a time as she finally codes, we break all of her ribs, shove tubes down her throat, stick lines in her large veins, and jolt her with enough electricty to cook a small turkey or a couple of chickens.

    And occasionally we bring her back from the dead, crushed ribs and all, and keep her tortured, rotting body alive for another couple of days whiile the family, who forgot all about her while she rotted in an out of the way nursing home, exhort us to take heroic actions to prolong her suffering while they come to terms with their guilt.

    If I’m lying, I’m dying.

  69. “Morbidly obese people would not subject themselves to gastric bypass if they had another “choice”.”

    Gaye, when I was younger, I was morbidly obese. One summer I cut my caloric intake to about 1/3 of what it had been, started running and biking daily, and lost over a third of my body weight in a few months. Since obesity is almost universal on both sides of my family, I still need to exercise regularly and carefully watch what I eat every day.

    On the bright side, I used to worry about what I’d do if I came down with diabetes, but apparently that’s just as curable. Heck, maybe I could knock that out in less than two months.

  70. You have never been morbidly obese by my reckoning. While science has yet to prove it, I am convinced that the truly morbidly obese have no ‘mind mechanism’ to overcome their inexorable biological exigencies. Is this a word?

    I am happy for you that your mind won out.

  71. Yikes…what a can of worms you’ve opened here! As someone who’s seen the consequences of the excessive use of healthcare resources by both the extremely young and the extremely old, I could say plenty. I can completely understand how it’s possible that certain types of people very well contribute heavily to their own health problems, but blaming the users isn’t going to be very helpful in fixing a seriously broken system.

    I think part of the reason we work so hard and use up so many resources on the very young is that we are looking at their potential in the future as balancing out the costs in the immediate now. The case could be made that we spend ridiculous amounts on the micropreemies, but then you slide down that slippery slope of who decides what the cutoff age and/or weight is at which treatment is not initiated. There should be some common sense here, but that often gets lost in emotion and argument. Sometimes it’s hard to tell who will emerge relatively unscathed to live a full and productive life, and therein lies the problem.
    I was, a few decades ago, one of those tiny babies who was the subject of much debate among doctors…and am grateful there was one rogue among them who decided to provide the necessary surgery and thus preserve my life. So perhaps I’m a bit prejudiced in that regard.

    As for the old folks, I saw also what futile care does to seniors and their families. There comes a point where the deterioration in the quality of life should be the primary consideration; being 88 years old, demented, incontinent, with clogged arteries and chronic malnutrition is no way to live. The slow slide from “vibrant senior citizen” to “moribund, pathetic shell of a person” is terrifically painful to watch. No amount of medical treatment is going to really help when all of your body systems are slowly shutting down, and prolonging this process in the name of keeping someone alive is cruel, IMHO. Obviously for all our technology, we don’t have the answers. I don’t think any one system really does. But we can’t let it degenerate into “whoever can pay gets the care”, either.

  72. Gaye, I went from 5’4″ and 175 lbs to 120 lbs. I think you’re engaging in what’s known as the “No True Scotsman” fallacy. As in, “No true Scotsman hates haggis.” “Well, I know a man born and raised in Edinburgh named Scotty McScotterson who wears a kilt everyday who doesn’t like haggis.” “Then he’s no true Scotsman!”

    You’re perhaps being too kind to me, but I think that by the rest of the world’s reckoning, at 5’4 and 175 lbs I was the living definition of morbidly obese. You seem to be using the term in a way different from the rest of English speakers.

    And thanks, I’m happy too. Being thin beats the hell out of being the way I was.

  73. My experience having an 85 year old father in a nursing home has been that doctors are very reluctant to bring up the subject of DNR’s. In my own situation, the only persons who have either brought up the subject or wanted to discuss it were two social workers at the nursing home. We’ve had some in depth discussions, and my brother and I have signed the DNR order, and we’ve made certain that the order will follow him if he’s sent to the hospital. We’ve also had an eldercare lawyer discuss this all with us, to make certain that my father’s legal affairs are in order.

    The nursing home has also held seminars for families about DNR’s.

    The only health professional who has come out and said the words ‘your father’s health is slowly declining’ has been the nurse in his unit at the home. From what I can tell, doctors or their residents or their nurse practitioners make decisions about my father’s physical health on each day that they see him, and that’s it. No attempts to discuss the overall situation with us, and the inevitable end that will someday come.

    All of the sick and demented patients who end up in the ICU’s have been under the care of doctors for years before they ever end up in the in the hospital in that state. What is the responsibility of any of those prior doctors to at least make the attempt to discuss DNR’s with the patient’s family? Leaving this discussion until the patient is in terrible straits, with the family upset and in turmoil, is a recipe for disaster. Then again, since Medicare doesn’t allow billing for ‘discussion of DNR’, I assume doctors have no incentive to bring up the subject, because, you know, these discussions take time. If only Medicare had a billing code for these discussions, maybe the situation would change (yeah, I said this, and I mean it.)

    I firmly believe that doctors should not blame families solely for these situations. Some of the responsibility lies with doctors. Some of the responsibility lies with hospitals, who endlessly advertise their services and give the impression that no one, absolutely no one, ever leaves their hospitals dead.

  74. Chris,

    it is true that I scratch and tunnel at the edges of language.

    What I mean to say is that the term morbidly obese (to me) means the person is parked permanently in the state, due to unsurmountable biological factors. The other people who are obese may eventually manifest that they are in fact, willing/able to respond, and this “will” also has biological determinants. So i consider them to be really in a state of morbid obesity cocooning, distinct from morbid obesity. What a maze.

    Just my take. I’m patiently waiting for an effective drug to be developed so that this whole problem/discussion would GO AWAY.

    and i spent the day painting and absolutely do not grasp the Scot analogy, although i am certain you make a good point. I do know that the scottish have an extraordinarily high opinion of themselves and I have never met one who wasn’t on the ball. Also in their favor is the fact that they are staunchly anti-english.

  75. And yes, everyone in medicine would be fascinated by Fadiman’s book, “the spirit catches you and you fall down.”

    Gawande’s “complications; a surgeon’s notes on an imperfect science” is also brilliant.

    Verghese’s account of the emergence of HIV in small-town tennessee, “another country” was good too. I do not recommend his recent work “the tennis partner”, about his relationship with a polyaddicted tennis partner medical student, then resident, under his attending-ship. Slow and depressing, and amazingly ignores the brutality of residency training. And burns up oodles of good will by spending a shitload of time talking about , the physics, mechanics, and vagaries of fucking tennis.

  76. so, somebody likes jeremy clarkson from top gear?

    ‘cheese eating surrender monkeys’


  77. This has been a very good thread. PB, I very much enjoy your writing, and your views. I would add that Cuba is in no way a medical paradise, Sicko notwithstanding. is a good site to visit, and follow the links on health care, etc.

  78. As a nurse who has split her 23 year (so far!) career primarily between ER/ICU/Psych, I enjoy your writing.

    As to what needs to be changed in healthcare, well, our views are pretty much diametrically opposed.

    But, as with you, I have very little use for “The Man.” And, indeed, The Man truly does hold the reins. Thus, it is somewhat ironic that the great hope I now have that this next presidential election WILL FINALLY bring about some form of single payer healthcare system in this country, comes via The Man – because, The Man is disgruntled with the 73% rise in healthcare costs over the last few years and is screaming that something’s gotta give – he is no longer willing to pay his share of employee benefits – which, for instance, as The Man says, who is embodied in Ford Motor Co – etc, cost more than it costs him to build his cars!!!!

    Even the man is tired of a CEO of the largest healthcare insurer in the US having a salary of $122.7 million. Ah, at long, long last, there is SOMETHING on which The Man and I clearly agree.

    For anyone’s perusal who wishes to gain more factual information on what a single payer system (NOT socialized medicine – with which there are MAJOR differences)would look like:

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