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Evidence-Based Legislation? Lessons From Abroad

President Obama appears to be refreshingly pro-science in his outlook, publicly lauding objectivity and careful analysis. He has even been credited with saying that “we need evidence-based legislation” in regards to public policy. The New York Times reports:

Agencies will be expected to pick science advisers based on expertise, not political ideology, the memorandum said, and will offer whistle-blower protections to employees who expose the misuse or suppression of scientific information.

The idea, the president said in remarks before an audience of lawmakers, scientists, patients advocates and patients in the East Room, is to ensure that “we make scientific decisions based on facts, not ideology”: a line that drew more applause than any other.

But when it comes to healthcare reform, many policy decisions put us in uncharted territory, with intelligent arguments on both sides of many legislative options and no American historical frame of reference to help us determine the best course of action. In times like these, perhaps the best we can do (to promote “evidence-based legislation”) is to study similar policy decisions made by our Canadian and European counterparts.

In a quest to inform myself about healthcare reform and its consequences in other countries, I attended a conference entitled, “Lessons From Abroad for Health Reform in the U.S.” at the Kaiser Family Foundation on March 9th in Washington DC. The event was sponsored by the Galen Institute and the International Policy Network, both of whom are politically rightward-leaning non-profit organizations. So I listened with interest, understanding that there may be other perspectives not fully represented.

I wasn’t sure what to expect from the conference, and assumed that speakers would offer a blend of pluses and minuses culled from Canadian and European healthcare reform experiences. I have to say that the pluses were hard to come by – and that the minuses were so provocative that I have decided to repeat some here for you, and let you make what you will of them.

Switzerland: Mandatory Health Insurance Creates Payer Cartels

Dr. Alphonse Crespo, an orthopedic surgeon who practices in Lausanne, Switzerland, described what sounded like the utter decimation of a perfectly good healthcare system. He said that in the 1960s Swiss healthcare was decentralized and quality-oriented. The government provided subsidies for health insurance for the poor, and subsidized public hospitals who took care of the poor and/or uninsured at a 50% rate. Overall, according to Dr. Crespo, Swiss healthcare was efficient, effective, and had high patient satisfaction ratings.

In 1994, socialism came into vogue and reformers called for a redistributive model of healthcare, with centralization of infrastructure and electronic medical records systems that would be compatible with those in use by other European countries. Mandatory insurance was introduced, which shifted disproportionate power to third party payors. The payors focused primarily on cost containment measures and profitability, rather than expanding access to quality care. Regional hospitals were forced to merge with larger ones or else shut down. Wait times increased, lengths of stay decreased, and there was an increase in “critical incidents” (i.e. medical errors) by 40%.

In 2002 the health insurers decided that “more doctors result in higher costs” and successfully lobbied for a cap on the total number of physician licenses, so that in order to practice medicine, a physician would need to take over the practice of a retiring physician or one who died.

In 2008, the third party payers attempted to legislate their ability to decide which physicians could practice within the healthcare system, and which would be excluded from coverage. This did not sit well with patients, and they voted for “freedom of choice” in a referendum on the issue. Fortunately, they blocked the insurer move to ban certain physicians from insurance coverage. Unfortunately, the insurers succeeded in forcing a reduction in reimbursement for basic laboratory testing by 20%, thus forcing physicians to close their labs and send samples to a centralized location.  Apparently physicians are planning to strike in Lausanne and Bern next week over this issue.

Dr. Crespo argued that the unforeseen consequence of the move to compulsory insurance was the emergence of a powerful cartel of health insurers without any apparent cost savings, and a measurable decrease in care quality. In fact, Switzerland’s healthcare system rapidly plummeted from 4th place in the Euro Health Consumer Index, to 8th place over the course of a few short years.

He concludes:

“Once cartels have entrenched themselves, there is no easy way to dislodge them. Americans should think twice before opting for compulsory insurance, unless they believe that cartelized and rationed healthcare is really in the best interest of patients.”

Canada: A Political Healthcare Monopoly

Dr. Brian Crowley is the Founder and President of the Atlantic Institute for Market Studies in Halifax, Nova Scotia. He describes the Canadian healthcare system this way:

Canadian Medicare operates in an unregulated, tax-financed, pay-as-you-go model. Our provincial governments are our monopoly provider. They not only pay for necessary care, but they also govern, administer, and evaluate the services that they themselves provide. They define what we call “medically necessary services” and pay for 99% of all physician services. They also forbid the use of private insurance for medically necessary services. They set the budgets for nominally private healthcare institutions. They appoint the majority of their board members and have explicit power to override management decisions.

Under these circumstances, no hospital or hospital administrator can be expected to take any responsibility or initiative because decisions will always be second-guessed by those in political power.

Before the advent of competition in our telephone industry, dissatisfied customers faced the massive indifference of a bureaucracy that took their business for granted, despite some theoretically powerful regulatory agencies. Administrators of the Canadian healthcare system likewise suffer no direct consequences for poor customer service. They aren’t even answerable to a regulatory agency. Accountability is a vague political concept which cannot be enforced in any meaningful way. Like all monopolists, Canada’s healthcare authorities abuse their positions of power.

Dr. Crowley argued that the provincial governments have no desire to measure how many people are waiting for health services, how long they’ve been waiting, or how many people leave Canada to get treatment south of the border. (He claims that the US is Canada’s secret safety valve.) Apparently the province of Ontario contracted with New York State for cancer care for their patients when wait times became politically untenable.

A couple of years ago, the Supreme Court of Canada ruled that the healthcare system violates Canada’s charter of rights because it collects taxes, promises healthcare in return, forbids competing suppliers and then often doesn’t deliver the care. The justices summarized the situation this way: “A place in a queue is not healthcare.”

Canada-wide average wait times for surgery is 17.8 weeks, though in Saskatchewan, wait times for hip replacements are as long as a year and a half. That’s after a physician has ordered the surgery. Getting to see a physician in the first place is very difficult. Statistics Canada reports that 1/5 of Canadians do not have a family doctor.

Dr. Crowley suggested that the Canadian healthcare system has become an unresponsive monopoly though it wasn’t supposed to be that way. It was designed to usher in a “grand era of choice.” It was supposed to be a healthcare system in which people would be able to get all the healthcare they needed without having to “worry about the cost.” Dr. Crowley concluded that “some of the ideas bandied about in Washington will lead to the worst features of the Canadian system without that having been anybody’s intention.”

Conclusion

There is no healthcare utopia. As demand for services climb (with older and sicker patient populations) and expensive new drugs and technologies are developed, all industrialized nations are experiencing cost containment challenges. The need to ration care encourages shifts in power that can result in unintended consequences – including payer cartels and indifferent bureaucracies. As the United States congress prepares to legislate major health reform this summer, they will do well to gather all the evidence they can from countries who’ve previously enacted similar legislation.

In the end, though, it is likely that limited resources, a weak economy, and an aging population will pretty much guarantee dissatisfaction with our healthcare system in the decades to come. Will “evidence-based legislation” help us to avoid others’ mistakes? I hope so, but I’m also not holding my breath.

Posted in: Politics and Regulation

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72 thoughts on “Evidence-Based Legislation? Lessons From Abroad

  1. gimpyblog says:

    Doesn’t the US spend twice as much per capita on healthcare as Britain or France yet has similar outcomes (similar outcomes to Cuba too, iirc, confounders aside)?

    Which goes to show that whatever the problems with centralised health care it is vastly more efficient than the free market approach of the USA.

  2. David Gorski says:

    I wasn’t sure what to expect from the conference, and assumed that speakers would offer a blend of pluses and minuses culled from Canadian and European healthcare reform experiences. I have to say that the pluses were hard to come by

    And, given the sponsors of this conference, you’re surprised by this…why?

    After all, it sounds as though the purpose of the conference was probably not to present in an unbiased manner the pros and cons of various health care systems in Europe and Canada, but rather to point out all the problems with such systems as a strategy to stifle the move towards such a system here in the U.S. Your point about how difficult it will be to create an evidence-based healthcare system is, of course, well taken. The problem is that politics and economics are always major driving forces behind any such system–including our hodge-podge system. Science-based medicine often takes a back seat.

    As an extra aside, I was interested by this quote from you about Switzerland:

    Mandatory insurance was introduced, which shifted disproportionate power to third party payors. The payors focused primarily on cost containment measures and profitability, rather than expanding access to quality care. Regional hospitals were forced to merge with larger ones or else shut down.

    This actually sounds a lot like what we have in the U.S. now, except that here insurance is not mandatory and the government doesn’t control the supply of doctors. (Well, actually, it does to some extent through Medicare reimbursements to medical schools–no Medicare reimbursement for medical education, a lot less medical eduation–but its control is weak, and it does not dictate how many physicians go into each specialty.) Insurance companies have inordinate power and focus on cost containment and profitabiliity rathter than expanding availability of care. Meanwhile, hospital and health care networks are buying up independent hospitals left and right to create regional networks. Consequently, I’m not sure I see how making insurance mandatory and subsidizing it for those with low incomes here would actually make things much worse here. As I’ve alluded to before in other comments, we already have the worst of both possible worlds: government-controlled pricing of health care (through Medicare rates, which serve as the basis for what most third party payors will pay for services), but no universal coverage.

  3. jenniferkepler says:

    Just two brief comments- I am a BSN prepared RN originally from Michigan – When in Michigan I worked on a Cardiac Care Unit – -working in a border region, I can confirm that we had many Canadian patients who came to our Metro-Detroit area hopsital for their various surgeries and procedures not only for our hospitals (excellent) reputation but also due to long waiting times they (the Canadian patients) faced back home. (my mother, who is a cardiovascular NP with 25 years of experience can attest to this as well.) However, this being said, just because the Canadian system (and UK’s NHS) have massive problems and wait times does not mean that all National Health systems are disasters.

    In Belgium, where I currently reside, I have personally never experienced any undue waiting time for any procedure. In fact the UK has even sent some of their patients here for treatment due to their long wait time.
    My family physician has fixed hours daily (usually two hours in the morning and two hours in the evening) for office visits, he has fixed hours at the hospital and fixed hours for house calls (yes house calls). Additionally there is a rotating schedule for night, weekend and holiday coverage. Physicians may charge whichever fee they wish, however there is a recommended scale. I pay my doctor in cash (his current fee was recently raised to 24.50€- about $30 US- and I submit the receipt of the drop box of my mutual (insurance) within three days I am reimbursed according to scale- in this case about 19€- This is quick, efficient and works- there are annual limits to health care out of pocket costs based on your salary. Hospitalization is also covered, though most Belgians also have private insurance (mine coveres private room and any costs not covered by national insurance)This is not to say that the Belgian system is not without it’s flaws however.
    Over the counter medications are ridiculously expensive (I just paid 7€ – $10 for 10 ibuprofen), prescription medications seem to be only partially covered, but here, again, there is a ceiling to how much you can pay a year and it is reasonable (eg if you earn less than 15,000€ the limit is around 450€ or similar)- Anyway my point is that although every system has its flaws -one should dismiss all nationalized health care systems simply due to the example set by Canada or Switzerland

  4. Dr Benway says:

    Yesterday I spoke with a Canadian masters-level clinician. A couple of months ago she applied for a health job. No word yet. She explained that the government develops pools of applicants over weeks to months or more, then draws from those pools when deemed appropriate.

    It all sounds very slow and bureaucratic and not very adaptive to supply-and-demand shifts.

    The basic problem, I feel, is third party payment. People don’t excercise the same care when spending someone else’s money.

    The second problem is the delusion of the free lunch.

    The third problem is how farking much it all costs. No one will be sensible enough to save up for the proverbial rainy day, like a month in the ICU. Our economy simply isn’t set up for that. You’d have to be born rich.

    The fourth problem: most humans have some degree of executive function weaknesses. Even if born with a trust fund for catastrophic health problems, the money would get blown on stupid crap no one really needs long before age 35.

    So good luck, humans.

  5. Karl Withakay says:

    I’ve had numerous opportunities to discuss healthcare with my best friend’s father-in-law, who is a retired Air Force flight surgeon (Colonel) and current family physician. I can’t say I agree with his conservative, pure free market philosophy, but he does bring up numerous interesting points, of which I’ll throw out one or two here:

    He asks, “Do you have car insurance?”

    I reply, “Yes.”

    He asks, “What’s your deductible for an oil change?”

    I reply, “I don’t have one, I pay for those myself.”

    He asks, “Why?”

    I reply, “I don’t need a middleman to pay for my routine expenses that I know I’m going to have to pay.”

    He asks, “What do you use car insurance for?”

    I reply, “In case I get in an accident and it’s my fault, or the other driver is uninsured, or my car gets hailed on.”

    He says, “That’s how I envision health care; insurance is for unanticipated, non-routine health care expenses. Stuff that is routine is stuff we shouldn’t pay someone else to spend our money for us on.”

    (I believe he envisions a perfectly competitive market for physician services as being able to control the price of physician services since a individual payer has no power to negotiate prices, this is part of where I’m a little skeptical of his philosophy)

    In the current environment, he advocates choosing a high deductible health insurance plan with a lower premium and using a flexible spending account to pay for expenses prior to the deductable .

    He also recommends following the US Preventative Services Task Forces’ recommendations for what preventative services are and are not warranted as a step towards controlling costs.

    He points out Medicare and the VA and asks how well we’ve done so far with the government health care systems we already have.

    I’m not advocating his philosophy, but it’s interesting food for thought & discussion

  6. Dacks says:

    “Mandatory insurance was introduced, which shifted disproportionate power to third party payors. The payors focused primarily on cost containment measures and profitability, rather than expanding access to quality care.”

    If you change the first two words to “managed health care”, sounds pretty similar to the situation in the US.

    “Administrators of the Canadian healthcare system likewise suffer no direct consequences for poor customer service. They aren’t even answerable to a regulatory agency. Accountability is a vague political concept which cannot be enforced in any meaningful way.”

    Again, pretty similar. Don’t know much about the Canadian system, but it seems possible that there could be a regulatory agency overseeing the health care system. That might be more difficult here, given the plethora of insurance companies and the variations among state regulations.

  7. tarran says:

    One of the most frustrating things about listening to discussions of medical care in the U.S. is the way widely held, incorrect, economic myths are wrecking people’s attempts to reason their way through the problems.

    1) The U.S. does not have a free market in medical care. Far from it: the U.S. is closer to the Switzerland mandatory-insurance cartel than a free market. The number of providers are kept low, and regulation often prevents innovative methods of structuring the economic side of medical care from being tried (witness the Dr in New York whose attempts to keep patient costs down were nixed because he was acting too much like an insurance company for regulators tastes).

    2) Costs are not spiraling up due to improvements in technology and an aging population. Costs are spiraling up because they are subsidized by both third party payers and by the government. This phenomenon is not new to economics: I believe Bastiat was describing a similar phenomenon with food shipments in the 19th century. It is why college tuition costs in the U.S. are also dramatically increasing.

    3) Improvements in technology do not, as a rule, increase costs. I’ll give you an example. In the 1970”s Wang introduced the first Word Processing machines to the market. Previously, students wrote their papers on $50.00 typewriters. Did the cost of writing papers increase after Wang started selling their machines? Were college students driven to the picket line by their inability to write papers affordably anymore? No. People still used the old less expensive methods because the benefit of a Word Processing machine did not outweigh the additional cost. For some people it did, and they bought the machines. Others, on the other hand chose to keep using typewriters.

    Medical care is no different. Yes, a new technology might mean that an untreatable condition can now suddenly be treated with a $50,000 machine. But unless a more expensive treatment is considered worth the cost by the guys footing the bill, it will not be adopted. This is why improvements in technology appear to reduce costs not increase them.

    Many of the economic problems associated with health care in industrialized nations are the result of the divorce between those who seek treatment and those who pay for it. The incentives of service providers is to please those who pay them. Once the split occurs, patients become a cost to be contained and not a customer to be pleased. Subsidies to increase availability tend to merely increase prices. Regulations intended to correct for problems tend to reduce provider availability. These problems do not go away when the government comes in and announces it will cover all the costs.

    Medical care, like any other good or service is economically scarce, meaning that there is not an unlimited supply (compare this to oxygen in the air which is not economically scarce even though there is a finite supply). Since there is economic scarcity, there is going to be some level of unmet demand. The question is how do you structure things to maximize the incentives to innovate and contain costs, and nothing does that better than a free market. The only benefit the state has that private actors lack is the ability to force people to pay more money into a system than they otherwise would. Its involvement in the overwhelming majority of cases results in higher costs and less innovation.

  8. gimpyblog says:

    The question is how do you structure things to maximize the incentives to innovate and contain costs, and nothing does that better than a free market.

    That’s an interesting point and raises the question, is the function of a healthcare system to provide the best available care to the greatest number of people or to make money?

    What countries like Britain and France have is a political philosophy shared across the vast majority of the right and left of politics that access to healthcare is a basic human right so nobody should be deprived of a treatment because of their personal financial situation.

  9. tarran says:

    Crud:

    The url labeled as $50,000 machine was supposed to point to this youtube video. Woops.

  10. David Gorski says:
    The question is how do you structure things to maximize the incentives to innovate and contain costs, and nothing does that better than a free market.

    That’s an interesting point and raises the question, is the function of a healthcare system to provide the best available care to the greatest number of people or to make money?

    But is it really true that a free market does it better, especially given that no market is truly free? These days, I’m not as absolutely sure about the total superiority of unfettered capitalism as I once was.

  11. gimpyblog says:

    There are more questions as well about the benefits of continued medical research. The low hanging fruits were picked long ago so it can be argued that money should be invested in preventative rather than curative measures when it comes to the health of the population as a whole. Given that large swathes of the science community have a vested interest in maintaining medical research I suspect this is a debate unlikely to happen.

    Think how much money could be saved if you didn’t have to pay pharmaceutical companies for the latest drugs, only slightly more efficacious than its predecessor, but could rely on out of patent generics? It is possible that the rise of generics is a free market response to healthcare…

  12. tarran says:

    Gimpy,

    I have a question for you.

    When you say medical care is a right, doe that mean that Dr Gorski must treat you free of charge should you be unable to pay him? What if you present yourself at his office when he’s about to go home? Should he have to call his wife and say, sorry honey, a man has come and I must treat him regardless of my personal desires in the matter?

    The answer is clearly no. Dr Gorski isn’t your slave simply because he went to Medical School. It may be that he chooses to treat you for no pay, or cancel a night out with the wife to care for you, but he has a perfect right to decide that he does not want to treat you, but wants to go home, or treat someone else.

    No economy will provide all the medical care people need as a matter of right. The resources just aren’t there. At some point even the state has to say, “enough” and let some person go untreated. I don’t want to verge too far into political philosophy (it irritates most of the writers here), but the notion that you have some right that obligates others to care for you is far from some obvious conclusion.

    Compare this to the right to freedom of the press. It does not mean that anyone who owns a press has an obligation to publish your book for you. It merely means that nobody can prevent you from publishing something you want to publish on your printing press.

    Moreover, so what if Dr Gorski wants to make money? Should he be forced to treat you whether or not he makes money? This feudal notion that commerce is somehow wrong or grubby or beneath dignity is one of the most backward conceits to come down to the present – frankly, I consider it to be on a par with female genital mutilation regarding the amount of misery it leads to.

    Moreover, the notion that the failure of state sponsored rating agencies to accurately report the risk on state sponsored and state-promoted investment vehicles that were funded by money printed by state-chartered central banks somehow condemns unfettered capitalism is ridiculous. Especially when bankruptcy is the market response to poor investments or use of resources. As usual, the interventions in the government have propped up untenable businesses, ensuring that their eventual failure would be far more destructive than it otherwise would.

  13. Adrian says:

    I have a hard time sorting through the various political motivations in these studies. This is bad at the best of times and is very difficult today as the current federal government and several provincial governments are actively trying to undermine the national health care system. I think it’s due to a political ideology which rejects anything which smacks of a public safety net and idolizes anything American regardless of cost or benefit. This has been going on for decades and the BS level is high.

    That said, I think there’s some truth to some of these complaints but they’re overplayed and used to foster fear, uncertainty and doubt. It also doesn’t sound like much effort was devoted to presenting anything in context.

    Administrators of the Canadian healthcare system likewise suffer no direct consequences for poor customer service. They aren’t even answerable to a regulatory agency. Accountability is a vague political concept which cannot be enforced in any meaningful way. Like all monopolists, Canada’s healthcare authorities abuse their positions of power.

    True enough but there’s relatively little power given to these bureaucrats and I’ve heard no stories of abuse or neglect. The issues they are confronted with deal with making difficult trade-offs, how to provide care to everyone when there is a limited budget. There are issues of staffing, room availability, waiting lists and other problems. People who get classified as having low severity problems may have a poor experience as they wait a long time for surgery. People who live in areas with budget cutbacks may find there aren’t enough beds or surgeons and yes, many people are sent to the US but at the government’s expense. (There are some rich people who can afford to go to other countries for treatment, but I hardly see this as a major problem. No doubt these people would get superior, expensive treatment no matter where they live.)

    When you compare this to the unregulated and actively harmful actions of less-than-ethical HMOs there’s no comparison. With the private insurance system in the US, there’s a real and immediate financial incentive for insurance companies to stall, withhold care, missclassify or mistreat. Nothing comparable exists in Canada and neglecting to discuss this seems a gross misrepresentation.

    A couple of years ago, the Supreme Court of Canada ruled that the healthcare system violates Canada’s charter of rights because it collects taxes, promises healthcare in return, forbids competing suppliers and then often doesn’t deliver the care.

    I don’t know about this, do you have any references?

    I do know that the healthcare system does not forbid competing suppliers! This has been an issue for decades with ideologues from Alberta trying to undermine the federal health care system and through the courts things have settled. It does say that if a hospital takes provincial/federal money, it must be open to all Canadians and provide services for free. This is often spun as prohibiting competition but that’s simply not true. There’s nothing prohibiting for-profit hospitals from opening, but they must be purely independent. There are some, but they’re for cosmetic surgery, correcting sight and other non-essentials. The lack of private surgeries is simply because no business thinks it is economically viable to compete with the public system, not because they are outlawed.

    I think there are similar debates about this in education – do you allow private or religious schools to take state funding but, through the use of private fees, effectively exclude the poor or create a tiered system? Most countries I’m aware of have decided that the health of the rich and poor will be treated the same.

    Canada-wide average wait times for surgery is 17.8 weeks, though in Saskatchewan, wait times for hip replacements are as long as a year and a half. That’s after a physician has ordered the surgery.

    This is a very loaded set of stats.

    When studies have been done to break down the type of surgeries, Canada has a lower waiting time for essential surgeries than the US and longer for elective surgeries. Other studies comparing the wait time for specific surgeries (I believe one was on knee replacement) showed that though Canadians waited a little over 10% longer, we had the same level of satisfaction as US patients. We all want to reduce wait time but it’s a balancing act and even when we wait longer, it’s viewed as good enough by the patients.

    Getting to see a physician in the first place is very difficult. Statistics Canada reports that 1/5 of Canadians do not have a family doctor.

    Wow, another set of lying stats!

    Seeing a physician is trivial. There are walk-in clinics scattered throughout major cities and I’ve never had to wait longer than 45 minutes without an appointment. I’ve done this even when I’ve visited new cities in new provinces. Emergency rooms accept everyone and while it’s not first-come, first-served, anyone can visit a physician.

    As for not having a family doctor, this is a growing trend. It has little to do with poor health care system, it’s that the walk-in clinics are good enough for most people that we simply don’t bother getting a specific family doctor.

    The flip side is that 80% do have a family doctor. One they can see regularly, no matter what their income level of complaint, with no fear of bankruptcy. How many Americans have a family doctor or, if they had one, regularly avoided visiting them because of concerns over the financial costs?

    50% of bankruptcies in the US are due in part to medical costs. About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. There are a lot of figures presented about how long the wait is in Canada for surgery but ask yourself how many Americans don’t bother seeking medical help because of the cost or, if they’re poor or uninsured, the low quality care. Remember that the pool of people who are undergoing these operations could be much larger in other countries simply because they don’t have to decide between their health care and their house or food.

    Yes, Canada’s health care system isn’t perfect. No countries is. So pick the parts that you like and drop those you don’t. It’s not like Canada or Switzerland represent the only possibilities! These points are useful only to help people decide what form of single-payer health care system to implement, not for deciding whether to continue with the current American system.

  14. Adrian says:

    @tarran,

    When you say medical care is a right, doe that mean that Dr Gorski must treat you free of charge should you be unable to pay him? What if you present yourself at his office when he’s about to go home?

    I think you’re confusing the “right” to health care with the right to get a specific doctor to treat you at your convenience. In other western countries, citizens can get medical treatment, especially if you’re unable to pay (patients do not pay). There is latitude to select specific doctors and some specialities do require doctors go on call (e.g.: delivering babies) but these are negotiations. Offices close, doctors have shifts, but the system still works. I’m not sure why you act as if this is an insurmountable problem and equating universal healthcare to female genital mutilation is just preposterous.

  15. Canucklehead says:

    I’m not sure it is valid to compare the UK health system to those in Canada or the USA, one huge problem that these conferences and inquiries seem to miss the economies of scale. In the UK you have 60 million people living in an area half the size of British Columbia Canada. In BC we have almost 5 million people in an area twice as large, a density issue perhaps? How do we supply the same quality and quantity of health care when our resources are spread geographically so thin? Compare cities to cites of like size perhaps, but can you really compare rural Saskatchewan’s health system to what a patient in London UK might experience? In trauma we talk about a golden hour, in rural BC it might be an hour or more before an ambulance can even get to you.
    The BC government is trying to get a handle on wait times and has introduced a few initiatives to reduce the wait times for total knees and hips, some clients are seen and operated on within a three or four month period, which to my mind is appropriate. It gives them a chance to think the surgery option over carefully and to try some prehab to strengthen, mobilise and collect the appropriate post operative aides. It certainly isn’t perfect, but considering the geographic distances and the density of populations it seems to be working reasonable well (in my opinion anyhow).

  16. gimpyblog says:

    tarran

    I’ll respond to your first and last paragraphs.

    When you say medical care is a right, doe that mean that Dr Gorski must treat you free of charge should you be unable to pay him? What if you present yourself at his office when he’s about to go home? Should he have to call his wife and say, sorry honey, a man has come and I must treat him regardless of my personal desires in the matter?

    As Adrian says, I am not arguing that my physician is my slave, just that the costs of me seeing them are borne by the state (and ultimately the taxpayer) to ensure there are no inequalities in administration. I am arguing that a healthcare system should be a service offered by the state to its citizens to safeguard their health, just as an army is a service offered by the state to safeguard the security of its citizens.

    As usual, the interventions in the government have propped up untenable businesses, ensuring that their eventual failure would be far more destructive than it otherwise would.

    This comes back to my initial point to which you responded, I am not arguing that healthcare should sustain a profit, I am arguing that it is a basic right so should be provided equally to all. But regardless of this argument the percentage GDP spent on healthcare by the USA is much higher than that of other countries of comparable standard which strongly suggests that running healthcare as a business is remarkably inefficient.

  17. tarran says:

    My point. Adrian, is that at some point a right to health care requires someone to be forced to provide care.

    Under the scheme you describe, Dr Gorski is being paid, but the government forces people to pay Dr Gorski.

    Any “right” that forces people to do something on my behalf is not a right, but some privilege (although many modern philosophers like to call it a “positive right” to differentiate it from rights like the freedom of speech which do not compel others to any action which they call “negative rights”).

    There are some interesting articles on the subject
    Rothbard on Natural Rights
    Micha Ghertner on Equality and Rights
    Libertarianism and Postive Rights by Nicolas Maloberti

  18. daedalus2u says:

    terran, the problem with your approach to “rights” is that you then seem to be saying that there can be no “right” for property rights to be enforced on your behalf. There can be no “right” for police to maintain law and order in your neighborhood. No “right” for justice to be provided by a legal system. No “right” for contracts to be enforced and fraud against you punished or deterred.

  19. tarran says:

    One can always hire agents to work on one’s behalf. Human beings have non-coercively been socializing risk for thousands of years. It’s what insurance companies do.

    This is going to be my last post on the subject; I have to get back to work, and I’ve been warned in the past by Dr’s Gorski and Hall about threadjacking threads into discussions about politics. I am pretty sure they are not interested in a wide ranging philosophical argument as to whether or not people have a right to force others to take care of them or not. I think the Micha Ghertner article I linked to above has the shortest and best exposition on the issue that I’ve seen in a long time, and I hope people will read it and reconsider their positions in light of its analysis.

  20. daniel says:

    He points out Medicare and the VA and asks how well we’ve done so far with the government health care systems we already have.

    Medicare bites, but the VHA has gotten entirely rebuilt and is very nice these days.

    Most of America’s system is bad, but there are good spots, like the Mayo Clinic. It uses a lot of electronic medical records and analyzes everything it does using evidence-based medicine. Three cheers.

  21. daedalus2u says:

    Ah yes, the way warlords non-coercively hire agents to work on their behalf. You are correct, humans have been doing that for millennia and it works very well for some not so well for others.

    I think it is an approach that will work not so well for health care, particularly when infectious diseases are concerned. The cost to prevent disease is much less than the cost to treat it. Universal basic health care, vaccinations and preventative treatments would be an excellent first line of defense against a biological attack or pandemic and could be justified on biodefense grounds. In the event of a pandemic you need a massive surge capacity in health care. That surge capacity isn’t something you can turn on quickly. It is something you need to build and maintain by keeping the clinicians busy doing health care.

  22. Scott says:

    Interesting discussion. Here Ontario we measure and public report on a number of performance indicators, particularly wait times.

    Here are the wait times for a number of treatments:

    http://www.health.gov.on.ca/transformation/wait_times/providers/wt_pro_mn.html

    And if you’re interested in cancer, wait times are used to evaluate and drive performance in the system. Performance is measured and publicly available. For example, cancer chemotherapy wait times are reported here:

    http://www.cancercare.on.ca/english/home/ocs/wait-times/systemicwt/

    Let’s say you’re not interested in wait times, but in the overall quality of care – say outcomes in the treatment of different cancers:

    http://www.cancercare.on.ca/english/csqi2008/

    Different regions of the province (LHINs) are measured and publicly reported on. You can compare regional performance. Incentives are used to drive improvements and innovations in care that reduce wait times and improve treatment outcomes.

    I’m not certain what level of data is available to you in the US, if you are a provider or a patient trying to make decisions about your cancer treatment. In cancer treatment in Ontario we essentially capture all patients, all treatments, and all outcomes for all 12 million Ontario residents. The statement that there is no accountability within the system is incorrect.

  23. Adrian says:

    @ tarran,

    Any “right” that forces people to do something on my behalf is not a right, but some privilege (although many modern philosophers like to call it a “positive right” to differentiate it from rights like the freedom of speech which do not compel others to any action which they call “negative rights”).

    If that semantic clarification is your only issue, I’m not going to fight you. Of course I think this argument can be extended to argue that no one has any rights at all seeing as how no one is being forced to do anything but rather doctors are being paid to perform a job they worked hard to obtain.

    @Scott,

    In cancer treatment in Ontario we essentially capture all patients, all treatments, and all outcomes for all 12 million Ontario residents.

    I wonder what would happen to the mean and median waiting time for elective surgeries if American statistics captured all potential patients, including those who don’t seek medical care because of the costs or insurance problems and those who must fight with their insurers to gain coverage.

    Comparing straight numbers can be very deceptive when the US is silently excluding large portions of the population.

  24. David Gorski says:

    I’d also point out here that politics often trumps evidence in universal health care systems. For example, in the U.K. back in the late 1990s, there was a push to get every woman diagnosed with a suspicious lump or mammogram referred to a specialist within two weeks of her having seen her GP. At the Society of Surgical Oncology meeting last week, a radiologist from Germany discussed the problems getting patients MRIs before breast cancer surgery within the time frame after diagnosis mandated by the German government (two weeks, according to her).

    There is no evidence that such hard-and-fast rules lead to better outcomes, and, indeed, a fair amount of evidence that a wait of a month or two almost never results in an adverse outcome. That is not to say that such a wait would be acceptable, only that an arbitrary, government-mandated two week “fast-track” limit can have unintended consequences. Indeed, in the case of Germany, that leaves only about a week and a half after the pathology results come back to get the patient ready for surgery and get her in. If additional studies are needed, that can lead to rushing.

  25. Adrian says:

    Dr Gorski,

    I’d also point out here that politics often trumps evidence in universal health care systems.

    “Often”, really? How many anecdotes support that claim? Are you saying that the US is ruthlessly evidence-based without any political or financial trumps?

    There is no evidence that such hard-and-fast rules lead to better outcomes, and, indeed, a fair amount of evidence that a wait of a month or two almost never results in an adverse outcome.

    Interesting counter-point to the steady drumbeat calling for reduced waiting lists, especially since longer waits is one of the boogey men of universal health care.

    Clearly any system will have its glitches. Since the argument was that universal health care results in authorities who are unaccountable and who “abuse their positions of power”, it sounds like the worst accusations are that they’re trying too hard to improve service which is good enough. It’s a curious sort of abuse that most Americans would welcome.

    As an American doctor, do you have to deal with any comparable administrative hoops? Have you ever had to administer inferior treatment or even to suspend or withhold treatment based on insurance company guidelines (or patient finances)?

  26. Adrian says:

    “Often”, really? How many anecdotes support that claim? Are you saying that the US is ruthlessly evidence-based without any political or financial trumps?

    Oops, missed a smiley there. Sounded harsher than I meant.

    I thought it was funny to hear you imply that a virtue of US medicine is how science-based all decisions were. Surely we could find a blog somewhere devoted to exposing the problems with that claim… :)

  27. nixar says:

    That’s some fine evidence-based blogging you’ve got here, sir.
    You’ve brilliantly demonstrated that Dr Crespo doesn’t like the Swiss system, and that Dr. Crowley doesn’t like the Canadian system. Nothing else, however.

    “In 1994, socialism came into vogue” you write. Oh boy.

    The stupid,

    it

    burns.

    I’m French, and I love the French system. Numéro un. When I read about the US system, I just can’t believe it. I shit you not: I actually CAN’T believe it. It’s like I’m reading some dystopian post-apocalyptic SF novel. Just the mere concept of “pre-existing condition” is mind-boggling. Here, if you have a pre-existing condition, you get MORE health insurance coverage, because that’s how it should be. You don’t punish people for being very sick. I mean that’s what we do in civilized countries.

    It’s your right to be a right winger. Just don’t start labelling propaganda with the “evidence-based” since it’s about as “evidence-based” as the WSJ op-ed pages.

  28. weing says:

    Here is a link to an opinion piece that is relevant to this topic:
    http://online.wsj.com/article/SB123681586452302125.html

  29. nixar says:

    « He says, “That’s how I envision health care; insurance is for unanticipated, non-routine health care expenses. Stuff that is routine is stuff we shouldn’t pay someone else to spend our money for us on.” »

    That’s how right wing nut jobs envision it, but that’s idiotic. People aren’t cars. Analogies are only good for people too lazy to think. And this particular one says more about that guy than it says about health insurance. He’s in the army, so he knows about: 1. Killing people, and 2. getting orders from authority figures no matter how stupid.

  30. nixar says:

    That’s some fine evidence-based blogging you’ve got here, sir.
    You’ve brilliantly demonstrated that Dr Crespo doesn’t like the Swiss system, and that Dr. Crowley doesn’t like the Canadian system. Nothing else, however.

    “In 1994, socialism came into vogue” you write. Oh boy.

    I’m French, and I love the French system. Numéro un. When I read about the US system, I just can’t believe it. I shit you not: I actually CAN’T believe it. It’s like I’m reading some dystopian post-apocalyptic SF novel. Just the mere concept of “pre-existing condition” is mind-boggling. Here, if you have a pre-existing condition, you get MORE health insurance coverage, because that’s how it should be. You don’t punish people for being very sick. I mean that’s what we do in civilized countries.

    It’s your right to be a right winger. Just don’t start labelling propaganda with the “evidence-based” since it’s about as “evidence-based” as the WSJ op-ed pages.

  31. nixar says:

    « I’d also point out here that politics often trumps evidence in universal health care systems »

    And … the example you gave has nothing specific to universal health care. In fact, trying to correlate stupidity in health policy with the presence or lack of UHC is a completely pointless exercise, being that the only developed country w/o UHC is the United States.

    I could also point you back to stupid wasteful crap in the US, such as the over-use of MRI or even other types of imagery with dangerous radiation exposure.

  32. nixar says:

    I also want to point out that there is no waiting list whatsoever in France.
    Some specialists have a busy schedule and can sometimes only give you an appointment a few months in the future. But I can always go to my GP (or any for that matter) the same day. From what I learned with some surprise this is not the case for many insured Americans.

  33. nixar says:

    @tarran: « When you say medical care is a right, doe that mean that Dr Gorski must treat you free of charge should you be unable to pay him? »

    I’m 100% positively totally sure that’s EXACTLY what he meant. You’re so smart! You’ve must have read Ayn Rand!

    It’s just like when they say: “You have the right to an attorney.” It means you can pick any attorney, and he must do everything you say, free of charge. Or you have the right to bear arms, well, that’s when a bear is killed, the arms are cut off, and given to you. It’s YOUR RIGHT!

    Yeah, that’s exactly what he meant, and as a result your argument makes total sense.

  34. overshoot says:

    The question is how do you structure things to maximize the incentives to innovate and contain costs, and nothing does that better than a free market.

    A free market requires a number of factors which are not applicable to much of health care. Market information being one of them — how do I, as a heart attack patient, choose between Cardiac Surgeon A and Cardiac Surgeon B? One has a much better track record than the other, but for some reason they don’t have that information on their package labels. Consumer Reports has yet to have a “best surgeons under $10,000″ issue.

    Another is the ability to select between comparable alternatives. Again, as a heart attack patient, I’m not doing a whole lot of comparison shopping — and the fact that I happened to draw Cardiac Surgeon X, who has had more nosocomial infections in the last month than most group practices in the area manage over a decade, is not really going to change much.

    Then there’s my bargaining power with regard to prices: have you ever tried to discuss pricing with the anaesthesiologist you saw for the first time in pre-op? No? Somehow that doesn’t sound like a free market now, does it?

    When was the last time you got an estimate before heading into ER? I thought so; me too. I can say that paying more than $2000 to have someone tell me that I had a fractured tibia (no shit, Sherlock — I was there) and splint it (if I’d done that splint, I would have worn a paper bag over my head to make sure nobody ever connected me to it) is not what I would classify as reasonable fee for services. Then again, we didn’t have that discussion.

    There are plenty of other reasons why a doctrinaire free-market approach to health care is, at best, inappropriate — but three will do for now.

  35. weing says:

    You could always ask him if he gets the oil changed with the engine running. But whether we like it or not, we already have de facto universal health care in the US, except a lot of it is not reimbursed.
    Have you done a study that shows you can see your GP any day or is this just anecdotal? How would you go about finding out whether politics trumps evidence in a universal health care system?
    If you listen to testimonials, the HMOs here have plenty that show people are happy with their HMO. Most people are happy with them. Are they lying? Are they happy with the system because they don’t have to use it that much? If they get sick and have to use the system a lot, does their satisfaction with the system change?

  36. David Gorski says:

    “Often”, really? How many anecdotes support that claim? Are you saying that the US is ruthlessly evidence-based without any political or financial trumps?

    Straw man argument that you inferred without my actually having said anything of the sort.

    The barriers to evidence-based practice in the U.S. tend to be less politically driven and more economics-driven.

  37. David Gorski says:

    And … the example you gave has nothing specific to universal health care.

    Who said it did? What it is fairly specific to are government single payor plans, where it is easier to mandate such “guidelines.”

  38. David Gorski says:

    You don’t punish people for being very sick. I mean that’s what we do in civilized countries.

    What, you punish people for being sick in civilized countries?

    Sorry, couldn’t resist.:-)

  39. David Gorski says:

    I could also point you back to stupid wasteful crap in the US, such as the over-use of MRI or even other types of imagery with dangerous radiation exposure.

    Actually, there is considerable overuse of MRIs in–of all places–Germany. (MRIs also don’t result in dangerous radiation exposure.) Indeed, I heard a debate between a German radiologist and an American breast surgeon at the Society of Surgical Oncology meeting last week. Guess who was taking the side that preop MRI is necessary for all women with breast cancer? (Hint: It wasn’t the German.) Guess who used evidence from studies to back up her point and who used anecdotes? (Hint: The German used the anecdotes.)

  40. weing says:

    Interesting. I just got a letter from an HMO saying they will not authorize a breast MRI for my patient with an abnormal mammogram. Rationing is here. Now, I can go to battle with the HMO, will I go to battle with the government when it does the rationing?

  41. Jason Loxton says:

    From a Canadian:

    Canada has plenty of problems with its system:

    The waits times are real, the lack of family doctors is real (esp in rural and northern communities, although, as another commenter made clear, we have a great system of free walk in clinics, so everyone can still see a doctor at their convenience), and we face the same spiraling costs that the rest of the industrialized world faces….

    But, the pro/con comparison with the American model is fairly simple: where it counts (cost and outcome) the Canadian model is superior.

    We spend less than half what the US spends per capita, and have almost identical health outcomes, i.e., death rates per condition. Yes, you have to wait little longer up here, and no the hosptials aren’t as fancy schmancy as the private US ones, but we’re not dying becuase of it. You would think the Market folks would recognize–and support–good value when they saw it!

    Here’s (a report on) one recent study:

    http://www.cbc.ca/health/story/2007/04/18/health-canada-us.html

    That’s hard to argue with.

  42. Jason Loxton says:

    Here’s A SciAm article on the same study, if you’d like your science filter by American popularizers instead of our evil “socialist” public broadcaster:

    http://www.sciam.com/article.cfm?id=canada-has-as-good-or-better-healthcare-than-united-states

    Or the real article:

    http://www.openmedicine.ca/article/view/8/1

  43. Jason Loxton says:

    And one more:

    http://www.cmaj.ca/cgi/content/full/166/11/1399

    Death rates at American for profit vs. not for profit hospitals

  44. daniel says:

    Please let us not get distracted with public/private/HMO/pharma/socialized all that stuff.

    Can we agree that, no matter what kind of system we set up, that evidence-based medicine is very important?

  45. Since some of the comments here are directed at the comments I made at the Galen/IPN conference in DC on Monday, I thought that it might be helpful if I responded to a few points for clarification. The system seems to prefer shorter posts, so I’ll break it up.

    Re: the Supreme Court of Canada decisions, this was the Chaoulli case sumarised here: http://www.longwoods.com/product.php?productid=17188&page=4. A quotation from that summary: “… every judge hearing the case agreed that if patients are suffering from a life threatening or painful condition, with extended delays in obtaining services, without recourse, then their rights are being violated. This violation extends not only to death and physical harm resulting from long wait times, but to the resulting mental stress and anguish as well.” The judges ruled that the Quebec medical care system therefore violated the rights protected under the Quebec Charter of Rights. They did not rule on the impact of the Canadian Charter of Rights.

    In a different summary here http://www.canadianconstitutionfoundation.ca/files/pdf/fraserforum-02-01-2007.pdf , you can read:
    “Access to a waiting list is not access to health care,” opined Chief Justice Beverley McLachlin in Chaoulli v. Quebec (Attorney General),, arguably the most controversial – and surprising – Supreme Court of Canada decision in recent memory ([2005] 1 S.C.R. 791, at paragraph 123). A majority of the Court ruled that Quebec’s prohibition on private health insurance for medical services provided in Quebec’s government health system violated the “right to life, and to personal security, inviolability and freedom” set out in Quebec’s Charter of Human Rights and Freedoms. Looking at the experience of dozens of countries around the world which allow private health care while also maintaining a public system, the Court ruled that a prohibition on private health care is not necessary to protect the quality of the public system.

  46. Adrian opines that having a family doctor is trivial. I disagree. Family doctors are the gatekeepers of the health care system. You cannot have access to specialist services without having a general practitioner refer you. The doctor shortage is so severe now that doctors have begun resorting to lotteries to kick people off their patient rosters, (see Tom Blackwell, MD Uses Lottery to Cull Patient List, National Post Published: Wednesday, August 06, 2008); and we are about the face a wave of retirements in the system that will greatly exacerbate the shortage. It is true that you can go and queue in a clinic until you can see a doctor you have never seen before and who knows nothing about you if you live in an urban area where such clinics exist, or you can go to the emergency ward. Isn’t that what Canadians look down on Americans for forcing the uninsured to do?

    Adrian seems to think that waiting longer is viewed as “good enough” by Canadian patients, but again I don’t agree. It is easy to be so cavalier when you are not waiting yourself for medical services and are in pain or anxiety about your condition. If you want to see the latest data about waiting times, averaged across all ten provinces and 12 specialties. Go to http://www.fraserinstitute.org/researchandpublications/publications/6240.aspx .

    As for the comparability of wait time in the US and Canada, you might wish to check out the letter from a US physician in the WSJ a few years ago (Susan Weathers, MD, published April 30th, 2004). She wrote after reading an article about how patients were treated in the Canadian system vs the US system. Shge works in a county hospital and in reference to her uninsured patients she writes, “[The Canadian health care system] resembles the county hospital where I work. Our patients pay little or nothing. They wait three months for an elective MRI scan and a couple of months to get into a subspeciality clinic. Our cancer patients fare better than the Canadians, getting radiotherapy within one to three weeks. The difference is that our patients are said to have no insurance (a term used interchangeably with “no health care”), whereas Canadians have “universal coverage”.”

  47. Adrian also professes to find American HMOs to be scarier than the benign bureaucrats running Canadian medicare, but he misses the point, which is that in the US consumers have choices about who they get their care from and from whom they buy insurance. This is not true in Canada. You may not pay money out of your own pocket to buy health care services that are insured by government (unless the provider is completely outside the public system, and there is not enough of a market for that in most places; as soon as a doctor accepts one government health care patient, all his patients must be government patients), and if you are an insurer it is illegal to sell insurance for services that are publicly insured. Since most major expenditures would require insurance, that effectively outlaws private medicine except in a very narrow range of cases. But the demand for such services has now reached a point where a number of providers exist in a kind of grey market, tolerated by governments in some provinces, but always precarious, while other provinces outlaw it altogether. My point, then, is that no one in the public system gets paid based on whether you are satisfied with the system or with your personal outcome, and if you aren’t satisfied, the system doesn’t care (although you may be lucky enough to get an individual in the system who cares, but that is not the same thing).

    As for the claim that the bureaucrats running the system in Canada do not have an incentive to provide you with poor care, this is naïve. Because most hospitals are run on block budgets, and because the system is always underfunded relative to demand, the system always benefits from delays because it can push costly services into another budget year and no one in the system is rewarded for timely care. The costs of delayed treatment are borne by the patient and no one else. This is precisely part of the criticism that the Supreme Court made of the unresponsive monopoly provision of the Canadian system.

  48. Karl Withakay says:

    >>>
    That’s how right wing nut jobs envision it, but that’s idiotic. People aren’t cars. Analogies are only good for people too lazy to think. And this particular one says more about that guy than it says about health insurance. He’s in the army, so he knows about: 1. Killing people, and 2. getting orders from authority figures no matter how stupid.<<<

    nixaron, What an extraordinarily constructive criticism of my friend who is RETIRED from the AIR FORCE, not currently in the army, and has been in private practice as a family physician for a decade now, so he’s got plenty of experience in civilian heath care in the US, presumably more than you have had.

    As a side, I don’t know how it works in France, but in the US Air Force, MD’s don’t generally get to kill people unless the hospital gets overrun.

    Also, I don’t know what line of work you’re in, or how it all works over there in France, but show me a job where you’re not the owner or CEO that you don’t have to take orders from an authority figure , no matter how stupid. I’ve had to deal with that all my career.

  49. cheshireb says:

    You picked to examples, these are not the only countries in the world with socialized health care, was Australia or Japan mentioned?

  50. gimpyblog says:

    daniel

    Can we agree that, no matter what kind of system we set up, that evidence-based medicine is very important?

    I would say that goes without saying if I hadn’t experienced the quackery in the French system. The French love their quack remedies but most of their quacks are also fully qualified medical doctors so you don’t get many cases of people being sold quack cures at the expense of medical cures, they are just wrapped up in one neat package together.
    I suspect that from a point of view prioritising the publics understanding of healthcare quackery is bad, but from a public healthcare perspective as long as it does not supplant conventional medicine it is tolerable. The differences between the UK, where quackery is typically independent of ebm practitioners and France are quite striking at times although health outcomes are roughly similar (even though the French eat more fat, drink more regularly and smoke more to less detriment than the British).

  51. gimpyblog says:

    Karl Withakay

    Also, I don’t know what line of work you’re in, or how it all works over there in France, but show me a job where you’re not the owner or CEO that you don’t have to take orders from an authority figure , no matter how stupid. I’ve had to deal with that all my career.

    French GPs are self employed, obviously they have to follow government guidelines in terms of what to prescribe and so on and prices are fixed by the state*, but as a business they can run it more or less how they see fit.

    * There is also the curious phenomenom where French pharmacies are essentially operating a under a state controlled monopoly but prices are relatively low (although in the UK they are lower).

  52. nixar says:

    Dr. Gorsky; « Actually, there is considerable overuse of MRIs in–of all places–Germany. (MRIs also don’t result in dangerous radiation exposure.) »

    I know it does not, that’s why I said “other types.”

    « Indeed, I heard a debate between a German radiologist and an American breast surgeon at the Society of Surgical Oncology meeting last week. Guess who was taking the side that preop MRI is necessary for all women with breast cancer? (Hint: It wasn’t the German.) Guess who used evidence from studies to back up her point and who used anecdotes? (Hint: The German used the anecdotes.) »

    Guess who just used one (1) anecdote.

    Karl: « As a side, I don’t know how it works in France, but in the US Air Force, MD’s don’t generally get to kill people unless the hospital gets overrun. »

    - Doctor, have you ever killed anyone?
    - Never! without a prescription, that is.
    (Devos)

    « Also, I don’t know what line of work you’re in, or how it all works over there in France, but show me a job where you’re not the owner or CEO that you don’t have to take orders from an authority figure , no matter how stupid. I’ve had to deal with that all my career. »

    Show me a job that’s not in the army, and I’ll show you a job where you can quit if you don’t like it.

    I’m sorry if I’ve offended you by critcizing your friend, but the over-militarization of American society is worrying to an outside observer.

    I’m going on a tangent here, but seriously. Do you know what we see?
    - Lack of what we consider basic social services
    - Prominent religious nut jobs with major political influence
    - ENORMOUS prison population
    - A large share of the national budget is dedicated to military spending

    Okay, what country am I talking about? Pakistan or the US?

  53. Karl Withakay says:

    >>>Show me a job that’s not in the army, and I’ll show you a job where you can quit if you don’t like it.<<>>- Doctor, have you ever killed anyone?
    - Never! without a prescription, that is.<<<

    You just shifted your goalpost. You originally said, “He’s in the army, so he knows about: 1. Killing people…” You implied he knew about killing people because he was in the army (since you read so closely as to miss the fact he USED to be in the AIR FORCE), but then when I pointed out that Air Force doctors aren’t in the soldier business, you shifted you focus on killing to being about his being an MD.

    You ignored my corrections about his past and present states and missed my point entirely about your attack. You implied my friend was a “right wing nut job”, and I responded that it wasn’t a very constructive criticism. A constructive criticism I wouldn’t have taken offense from would have been something like, “Well, that’s a fairly typical attitude for a conservative right winger with a military background.” You could even have added you thought that attitude was idiotic, but you abandoned all pretense of constructive dialog when you threw out “right wing nut job”.

    I posted my original comment regarding my friend to stimulate dialog on his philosophy. “People aren’t cars.” is a good starting point, but constructive dialog would have been to then explain why health care is different than auto insurance, with support for your position.

  54. Scott says:

    For those of you interested in the original topic of the post, I recommend the OECD’s analysis entitled, Health Care Reform in the United States. It lays out the key facts of the US health care system in an evidence-based, dispassionate way:

    - many, but not all, Americans have access to great care
    - overall, however, the population ranks poorly in outcomes such as life expectancy, infant mortality, etc.
    - Americans spend much, much more money per capita than any other OECD country. (See figure 7). This spending is growing faster than most other OECD countries.

    So you’re not getting much value-for-money from the current system. The data suggests that for less money, the health systems of other OECD countries appear to be delivering better overall outcomes.

    The paper discusses a number of reforms, including comparative effectiveness.

    http://www.olis.oecd.org/olis/2009doc.nsf/linkto/eco-wkp(2009)6

  55. Scott says:

    …and if that link doesn’t work, try this one: http://twurl.nl/lbnsgh

  56. Fifi says:

    Anecdotes about anecdotes and no skepticism or evidence just repetition of anecdotes by profit-driven political ideologues and a conclusion based on these anecdotes? Really?

    http://www.sourcewatch.org/index.php?title=Atlantic_Institute_for_Market_Studies

    “Brian Lee Crowley is also a member of the low-profile but influential right-wing Civitas Society, founded by Calgary political scientist Tom Flanagan, campaign manager for and advisor to Prime Minister Stephen Harper.”

    “The Institute promotes free-market ideology, and is at the forefront of the battle against public health care in Canada. Among its sponsors or “patrons” it lists the pharmaceutical giants, Pfizer and Merck Frosst.”

    “Like its sister think tank in western Canada, the Fraser Institute in Calgary, Alberta, the Atlantic Institute of Marketing Studies issues annual “report cards” for public schools in Atlantic Canada, which lead to the impression that public schools provide poor education and receive a great deal of media coverage. [2] [3] [4] Many leading academics and universities in the region have sharply criticized the metholodology of the AIMS study of public schools, saying the results are without scientific merit.”

  57. Fifi says:

    *wanders back to own garden saddened by what she sees*

    Fret not, I realize that averting my eyes is the only cure for my frustration and need to speak up when I see fake pearls being plucked from the muck and considered valuable gems set in “evidence based” gold.

  58. weing says:

    “Many leading academics and universities in the region have sharply criticized the metholodology of the AIMS study of public schools, saying the results are without scientific merit.”

    Am I to understand that these academics are not driven by a anti-free market ideology?

  59. tarran says:

    Fifi,

    A person being funded by a company is no more likely to produce tainted science than someone funded, say, by the government.

    Yes, people are prone to bias. In science there are tools to compensate for such biases and, as much as practicable, to minimize them. Any experiment can be repeated by other scientists, and the results compared to the original research.

    I read comment threads spottily, so my impression could be wrong, but I have noticed you never get upset when a government-funded scientist makes claims to the effect that the government should expand its interventions in science or medicine. I can assure you, though, that is just as likely to happen as a Merc financed scientist is to publish a self-serving study.

    There are all sorts of factors at play here.
    1) Some people are shills.
    2) Other people rationally come to some conclusion and seek to put it into practice, – some of whom choose to work with people who would benefit from the practice.
    3) Some people don’t care who they work for, so long as they get funding and aren’t interfered with.

    How can you tell them apart? There is only one way; you rerun their experiments and try to reproduce their results. You analyze their research and try to identify flaws. Good science is good science, regardless of where the money that funded it came from. Bad science is bad science regardless of where the money came from.

    A long time ago, you accused me of wanting to keep slaves, simply because I am a “free market ideologue”. At the time, I didn’t tell you how personally offensive that is (my wife is the granddaughter of a black share-cropper who had scars from beatings he received in the Jim Crow south). I was shocked that an articulate interlocutor would buy into such a bizarre stereotype. I think you had better drop your prejudice that someone supporting or working for an organization that supports free markets is inherently unreliable.

  60. daedalus2u says:

    Insurance as an economic tool is used to aggregate rare adverse events that are too costly for an individual to bear and to distribute the cost among many where the average cost is bearable. The oil change analogy works for that. But car insurance doesn’t cover your engine blowing up because you didn’t put oil in it. If health insurance didn’t cover getting measles because you were not vaccinated, or didn’t cover other adverse events because of a lack of preventative care, then the analogy would be better.

    Much preventative care is required for children. Children don’t have incomes and so can’t afford to pay for their own preventative care. Similarly, children require education but can’t afford to pay for it themselves. Society has decided that having uneducated adults is undesirable, so society has decided to pay to educate children rather than have them become uneducated adults. Society pays to educate all children rather than compel parents to pay to educate their children themselves. There are reasons for this. Some parents can’t afford to pay to educate their children and leaving those children uneducated because of their parents’ economic means would result in uneducated adults.

    It is a tiny step for society to decide that it doesn’t want to have adults that did not receive basic preventative health care as children. Such care is considerably cheaper than the education that society already pays for. I think conceptually the idea of sick children becoming sick adults is less acceptable than uneducated children becoming uneducated adults.

    As I understand the philosophy of the “free market ideologues” I see it as a ploy to externalize costs and reduce taxes. I see it as fundamentally having a zero-sum mentality, where every financial interaction only redistributes wealth it does not create it. So long as wealth is distributed toward them it is ok, so long as it is distributed away from them it is not ok. Taxes to protect their own wealth (i.e. to support police, the military, the justice department) are ok (provided everyone is taxed, even those without wealth). But taxes that protect citizens and society (i.e. to support education, health care, environmental protection) are unacceptable.

    For the most part, preventative care is cheap compared to the cost of treating the things that it prevents. A society that spent more on preventative care might need to spend sufficiently less on acute care such that the total cost was less. If there is a single payer paying for both preventative and acute care, that single payer has an incentive to minimize the total cost by increasing preventative care expenditures. When preventative care and acute care are paid for by different parties there is no such incentive.

    If car insurance did pay for engines that blew up due to lack of oil and didn’t pay for oil changes, there would be no incentive for car owners to pay for oil changes either. Wait until the engine blows up, insurance replaces it, then wait until it blows up again.

    In one sense, that is the philosophy of the “free market ideologues”. Don’t pay to educate children so they grow up to be educated adults, but if an uneducated adult living in misery turns to crime, spend many times more to throw them in prison. The “cost” to the “free market ideologue” is the out of pocket taxes. The cost to society is the lost productivity of the cohort of uneducated adults as well as the cost of prison. The cost to society greatly exceeds the cost of educating those children, the cost to the “free market ideologue” doesn’t.

  61. Karl Withakay says:

    Thanks, daedalus2u. That’s the kind of discussion I was hoping for.

    The education parallel leads to some interesting thoughts about the US model for education.

    We provide publicly funded primary and secondary education here in the US, but we do so on a local and state basis, and as a result, the quality of education provided varies greatly from school district to school district across the country. Those who live in good school districts like the system because they have local control of the school districts and education funds. People in poorer school districts don’t fare so well.

    These days, we also have those who choose to opt out of public education demanding vouchers to help pay for their private education on the basis that it’s their money and they should be allowed to spend it on their choice of education for their children.

    I doubt anyone advocating publicly funded health care is advocating a similar system, but those two philosophies are going to surface in some form or another if we ever start to seriously work on some form of single payer system.

  62. tarran says:

    Mr Daedulus

    Your post is unfortunately flawed by several premises that are not accurate. The result, you are arguing against a strawman.

    I’ll run through them in quick order:
    1) Society decides nothing. Individuals make decisions. A couple of legistlators may write a law and convince a few hundred of their collegues to vote for it. Then a few thousand magistrates, administrators and beurocrats may decide to carry out that law.

    2) The state does not equal society (the philosophy that equates the two is called fascism BTW).

    3) Just because someone does not think the state should do something does not mean that they feel it should not be done at all; For example, I think that it is good that people have children. I do not advocate having the state assign men and women to breed. This position does not somehow mean that I am in favor of the extinction of the human race.

    4) The only difference between the state and a private charity – such as one providing free education to the poor – is that the state can compel people to pay for the charitable service by threats of violence, while a private charity must persuade people to donate to it. You assume that in the absence of the state providing public schools, charitable schools would not exist. Of course, this flies in the face of thousands of years of history where such schools did exist, and currently do exist, for example in squatter slums in Brazil wher the state refuses to provide services.

    A frustrating assumption that I find in debating people with your mindset is that you blithely assume that unless people are forced to do good at gunpoint, they will not choose to do so. Yet, welfare programs are politically popular. So are public schools and free libraries and public assistance for medical care. Does that not imply, somehow that there are vast numbers of people willing to donate voluntarily to such programs, that when faced with the refusal of the state to act, they would develop and sustain the institutions to provide those public goods? Look at what happened in the U.S. with Hurricane Katrina: While the Federal Government dithered, private actors where providing relief; walmart was trucking in water. Boat owners where motoring into the disaster zone to perform rescues. People were donating food, and offering their homes for emergency shelter. In that case the agents of the state not only chose not to help, but rather actively blocked relief efforts by private actors allowing people to drown or die of heatstroke or exposure.

    The vast majority of people are not evil. They are quite capable of planning ahead, and try to take care of themselves and those they love. The notion that these people will be doomed to miserable lives unless they are forced under threats of imprisonment or fines to do the right thing is, to me, quite bizarre. If the members of a society are so uncaring that they must be compelled to do good by each other, then there is no way the state is going to save them – its agents, after all, would be drawn from the same sick society.

  63. qetzal says:

    I know the stats about the US spending much more in %GDP for healthcare, while having worse healthcare outcomes than many other Western countries. We also hear frequently how ‘most’ people in the US have decent health insurance and access to good care, but a significant minority has neither.

    Is there any data that breaks down health care outcomes in the US based on whether one does or does not have insurance? IOW, are we screwing the poor and uninsured so the rest of us can have good health outcomes? Or are US health measures below par even for the group that has decent insurance and access?

    Anyone know?

  64. daedalus2u says:

    That is quite an argument you have put up to defend your position. Let me see if I have it right. The reason there is not enough funding of “good works” through charity is because taxes are too high. If taxes were lower, there would be so much funding of “good works” through charity that government support of “good works” would be completely unnecessary.

    Do I have that right? Do you have some evidence of that?

    The example you give of how effective charity is to fund education of children is the squatter slums of Brazil. So what we can expect from your suggestion is that our public schools will attain the effectiveness of the charity schools of the squatter slums of Brazil?

    Do I have that right?

    If we extrapolate your example to health care; there are charities that fund health care for people who cannot pay for it themselves. I recently heard that Medecins Sans Frontieres was expelled from Darfur where they had been providing charity care to refugees. Is that the kind of charity funded health care we could expect?

    Do I have that right?

    If you object to living in a place where taxes are taken and used for things such as education and health care, perhaps you should move to places where taxes are not taken for such things. It is my understanding that Zimbabwe doesn’t use taxes for education or health care. Perhaps you would care to move there or Somalia where (as I understand) they don’t have a government and so the tax rate is zero. By your “logic”, the place that has the freest markets and the lowest taxes should have the highest rates of charity.

    One problem of “free markets” is what is called the tragedy of the commons. All resources owned in common are exploited to exhaustion because who ever liquidates it first gets the entire liquidated value, even if the value over a long time may be many times the liquidated value.

    Many social goods suffer from this and are exploited. The trust that people have in each other is liquidated by con artists who exploit it and monetize it. The trust people have in health professionals is liquidated by CAM practitioners. Even the generosity that people have to give charity is exploited.

    The recent movie Slum Dog Millionaire gave an excellent example of this. Orphan children were “adopted” into groups where their charity receiving potential was exploited and optimized. A beggar who could sing with a beautiful voice earned more, so some children were given voice lessons. But a blind singer earned double; so the invisible hand of the free market increased the supply of blind singers to meet that demand. In other words, the exploiters of the begging children would blind those who could sing well so they would earn double.

    If the regulatory system (i.e. the government) allowed it, the free market would allow organs to be bought and sold. Orphan children wouldn’t be limited to begging, they could sell their organs too. A child singer could be blinded via donating corneas, rather than with a hot spoon. A safer, less painful and less wasteful course, and the blind singer would still earn double as well as get compensated for the corneas. Or rather the child’s handlers would get compensated. If organs could be bought and sold, there would be a pretty good economic incentive to adopt foster children, especially older children who’s organs are closer to adult size. That sounds like a win-win situation. Children get adopted, wealthy sick people needing organs can get them and entrepreneurial individuals are incentivized to adopt.

    Is that the type of free market health care system you want?

  65. Dr Benway says:

    In other words, the exploiters of the begging children would blind those who could sing well so they would earn double.

    Holy crap!

    Someone recommended that movie to me. Now I think I’ll skip it.

    I can handle off-stage cruelty –e.g., “What happened to Pete?” “Oh, it was terrible, blah blah blah” But scenes of cruelty-in-progress involving little kids or animals make me cry buckets.

  66. daedalus2u says:

    It actually is quite a good movie. There are some very dark and disturbing moments though. I don’t think they were “gratuitous”, that is I don’t think they were unrealistic or used only for theatrical shock value. It is much like Dicken’s Oliver Twist.

    I saw it with a friend who is pretty conservative, and afterward he said (jokingly) that this is what Obama had in store for us all. I disagreed and said this is the economic state the GOP tax cuts are trying to produce.

    It wasn’t poverty that caused the problems, it was disparity in wealth, where to obtain charity the poor would do anything.

  67. qetzal says:

    IMO, it was a very mediocre movie. The plot was fine but not much different from plenty of other movies. The acting was good, but not outstanding. The only noteworthy part was the setting/location, since it was mostly (or maybe all?) filmed on location in India.

    I wouldn’t recommend paying to see it at the theater unless you really want to see a movie and there’s nothing else you really want to see. Otherwise, rent it on DVD or wait for it to come out on HBO.

    OK, I’ll stop going off-topic now; just couldn’t resist commenting on the movie, cause it was so much less than I expected from the hype. IMHO, of course. :-)

  68. tarran says:

    Deadelus,

    I read your rebuttal to my lat post with a combination of bewilderment, amusement and even horror; it was so full of fallacies, and non-sequiturs, that I found myself wondering if someone was spoofing your identity, trying to discredit you by making bogus arguments that made you look irrational. Moreover, in a few instances you cited evidence that contradicts the case you are trying to make as supporting it.

    But, assuming that you are indeed you, I’ll take a few minuted to respond to them.

    1)Yes, high taxes can reduce private charitable contributions by reducing the discretionary income people have. To some degree that happens everywhere, including the U.S. However, given the tens of billions of charitable spending annually by U.S. citizens, the crowding out is nowhere complete. One area where state provisioned charity can have a negative effect is when people blithely assume the state is taking care of some charitable need when it is not. There were some studies that found this phenomenon in effect when comparing East Germany to West Germany shortly after reunification. I personally believe this phenomenon is not due to the fact that the state provides charitable services, but because powerful states encourage the population to be passive and discourages acts of private initiative.

    2)I don’t assume that ending state provisioning of charity will produce a utopia. I argue that it will merely improve the situation and definitely not lead to the bizarre dystopia you predict.

    3)In regards to schools in underserved slums, the schools in the slums of Brazil would be an improvement over some of the larger public school systems. For example in Washington DC, the public education system is not producing anything in the way of a educated populace. They are, however, spending $24,000 per pupil annual to do it. Even if there were no improvement under a private regimen – a notion that is laughably unrealistic – how much better off would the citizens of DC be if their education system merely consumed one tenth the amount of money that it currently sucks out of the economy in taxes?

    4)As to the Sudanese government expelling though threats of violence a charity providing medical care – this no more condemns the notion of private medical charities than the Holocaust condemns the religious freedom brought about with the repeal of the medieval laws that segregated Jews away from Christians.

    5)Ah yes, the Love It or Leave It argument. You know, it’s always funny to hear people resort to that; it was quite common to hear people say it to opponents of the Vietnam war by people who had run out of arguments as to why the war was good. I might as well suggest that you move to Cuba where they have wonderful state provisioned health care. Such arguments are meaningless. I am going to ignore Zimbabwe, since the government’s conscious attempts to wreck the economy through currency debasement are fairly well know and violent expropriations of property for the state and its allies are well known. But you are right to bring up Somalia. Guess what happened to Somali life expectancy after they kicked the government out? It improved. Guess what happened to immunization rates? They improved! Guess what happened to child mortality? It went down! In measure after measure of how well a society is doing, the condition of Somali’s improved when they through out the state and went back to being a kritocracy.The only areas where things got worse were in the condition of roads and in literacy rates, which makes sense when the capital structure of the economy is so poorly developed that the major wealth creating industry is cattle herding which requires a low degree of education to perform profitably. As the economy continued its post revolution trends, no doubt the capital structure would have been altered permitting people more leisure to devote to education while providing a better incentive to study with a decline in the demand for illiterate labor and an increase in the demand for literate labor.
    Yes, Somalia is a much worse place to live then the U.S. but when one looks at where they started, it becomes clear that “anarchy” is not the source of their problems. Incidentally, Somalia was not an anarchy but a kritocracy until the U.S. backed invasion by the Ethiopian army.

    6)As to your attempt to postulate a social tragedy of the commons in a free market economy, I found myself laughing at that one. I will, I am sorry to report, be sending that around to some of my economist friends for a good laugh. What you are describing is not a tragedy of commons. There is no finite pool of “trust” that is unowned and thus subject to exploitation. To the contrary, people’s willingness to trust or to risk in engaging in commerce with each other is the product of past experience and what they wish to happen in the future. You assume that one conman will result in his victims not trusting anybody. To the contrary, people differentiate between the reputations of the people they are thinking of doing business with (for example, people will differentiate between Dr Gupta and Dr Gorski), to the point where businesses spend significant amounts of their income in efforts to build or maintain their reputation. The institutions required to combat the problems you raise have been around since the middle ages

    7)As to slum dog millionaire condemning the free market, the production of maimed beggars is actually a phenomenon of unfree societies and not the other way around. Contrast the England of Charles Dickens’ youth with that of the U.S. at the time. In Oliver Twist Dickens describes his childhood, where the phenomenon you ascribe to free markets was lovingly detailed. Yet, this practice has been almost wholly absent from the U.S. of the time. Why? Because in England, with its mercantilist political order and rigid class structure, lower class people had their economic freedoms restricted to a degree that was absent in the United States – er, if you were of northwestern European descent anyway. It is important to note that Slumdog millionaire is accurate in as much as that stuff was going on in India to a frightening degree through the mid eighties while India was one of the most difficult places to start a new business, where any activity, even charitable activities, required navigation through a byzantine bureaucracy and dealings with a sclerotic court system that nevertheless vigorously enforced edicts to shut businesses down.

    Again, the desperation of people in the bottom of an unfree economic system hardly condemns free market ones.

    8)On the subject of buying and selling organs, your superstitious horror at the notion is just that, a base, barbaric superstition. If a person were to do a survey of all the countries in the world with respect to kidney disease, one would find one country at the top of the list for survival rates. Iran. What is unique about Iran? It is the only country in the world where people are allowed to sell kidneys. Not only do people get transplants promptly, but the existence of a market price encourages a sufficient voluntary pool of donors. The economist Walter Block regularly surveys his students to find out at what price (payable to their heirs or next of kin) they would sign organ donor cards. Usually he doubles or trebles the number of people willing to posthumously donate organs from this simple mechanism (most people seem to want about $1,000 for their organs, which is chump change). They view it like life insurance, or a hedge against funeral costs. You look upon this with horror. To me, it is the same horror with which some doctors greeted the notion of anesthetizing women during childbirth since it contravened God’s curse on Eve requiring women to suffer the pangs of childbirth.

    I could go on, but I am pretty much out of time. The short answer is, pretty much every time you asked if you were right: you were very wrong. Again, you seem to think it obvious that a sufficient number of people are so inherently evil that there must be a powerful organization threatening them with violent consequences unless they behave themselves. I doubt I can convince you in the comments thread of a blog that your fellow human beings are as evil as you seem to assume them to be. I will have to content myself by asking you to reconsider your preferred solution as to how to deal with evil. The 20th century is nothing if not a condemnation of the notion that the state is a cure for social ills. The ideology of the state’s masters is irrelevant; whether right wing or left wing, whether corporatist or socialist, the strong state is overwhelmingly associated with increased poverty and suffering. The reason is simple – the state attracts evil men who covet power over their fellow men.
    It is only through the decentralization of free markets and voluntary institutions that the influence of evil men can be limited. This blog stands in testimony to this fact. Without a Senator Harkin, how much money would the beneficiaries of NCCAM really have at their disposal to spread their quack cures?

  69. tarran says:

    Some errata on my last post:

    The links to the Somali paper should have been:
    http://www.peterleeson.com/Better_Off_Stateless.pdf

    Also, I meant to say that I doubted that I could convince Deadulus that people are not as evil as his arguments imply, rather than seeking to prove that they are as evil.

    Also, apologies for numerous spelling errors and offenses against good grammar.

  70. daedalus2u says:

    I don’t think that everyone is evil, just that some are. I think that most people are apathetic and to use the terminology of this blog are “shruggies”. They will do the right thing so long as it doesn’t take an effort or a fight. If it does, they will try to avoid the conflict and just keep doing what they have been doing. If it doesn’t affect them they will ignore it even if it is harming others.

    The child wasn’t poor because Byzantine regulations preventing the child from starting a business. The child was poor because the child was an orphan and the only adult willing to care for the child only did so to exploit the child’s value as a beggar. I don’t understand what basis you have for saying maimed beggars are not a product of a free market in begging. When a blind beggar earns double, any type of free market will increase the supply of blind beggars until the supply meets the demand. If blind beggars didn’t earn more, there would be no incentive to produce them. That is economics 101. If a good or service commands a higher price, the free market will produce more of it so long as the marginal cost of producing it is less than the marginal higher price. The out of pocket cost to blind a child is very small. If the child’s only economic value is as a beggar, the free market will dictate that the child will be blinded so as to maximize that child’s economic return. What is it about free markets that I don’t understand? Or is there something about free markets that you don’t want to understand or acknowledge?

    It was child labor laws that prohibited use of children as workers that removed the economic value of children as workers which freed those children up to devote time to education. It was not the free market that did so.

    As you say, a person’s trust is the product of their experiences. The more they are defrauded, the less trusting they will be. That is all I was saying, and that can be looked at as an example of a tragedy of the commons. If a person is protected from being defrauded, they will be more trusting.

    As far as Iran and being paid for kidney donations, the government pays $1200, the recipient pays some extra. Unemployment in Iran is 12% (2008), the average annual salary for Iranian nationals is $2,700 (2006). $1200 may be chump change in the first world, but to an Iranian it represents nearly a year’s wages at the Iranian minimum wage $1,440 (2005). In any case the sale of organs in Iran is not via a free market; it is highly regulated and subsidized by the Iranian government.

    Power corrupts, and absolute power corrupts absolutely. When the only power is the power of the market, the power of wealth will corrupt some of those that have it. Those who are willing to use evil means to acquire power will do so, and will then use that power to maintain and increase their power.

    When physical security is provided by the free market, either Security Company A protects everyone, in which case Security Company A is subject to the tragedy of the commons, or Security Company A only protects its contributing members in which case you now have competing security companies (aka gangs and eventually warlords). Once the largest security company gets large enough, it will be able to suppress the others. A security company willing to suppress the others will be able to out-compete them in the market place.

    In the absence of government regulation, that is what “free markets” evolve to. You end up with cartels and monopolies. Monopolies extract a disproportionate fraction of the value added in a production and distribution chain.

    That is exactly the problem mentioned in the post. Cartels of insurance companies reduced compensation for certain services, quality of care declined while costs did not. The insurance company cartels with their monopoly power extracted more value from the health insurance health care delivery system at the expense of the quality of care the patients were paying for and were receiving.

    A free market doesn’t have the ability to regulate itself. There has to be something outside the market, something that is not subject to market forces, and something that cannot be manipulated by the market to exert that regulation.

    The example you gave of Harkin is an example where that regulation is thwarted by market forces. Because CAM can pay to lobby Harkin, they can exert influence on the regulations affecting them. That is a problem caused by the market force of senators looking for campaign funding, not due to a lack of market forces.

  71. Dr Benway says:

    tarran, I’m sympathetic to some of your positions. I’ve had my own arguments with people who naively imagine we can fix social problems by passing laws. I’m also annoyed by unexamined faith in what government can accomplish.

    When you call the police to stop the bad people, but the bad people are the police, that’s when political naivete usually ends.

    Or, to use an analogy closer to home for this crowd: when the anti-Medicare fraud squad cherry-pick and misrepresent the facts to extort money from you, in order to advance some state attorney’s career, that’s when the naivete stops.

    A civil society evolves over generations among people sharing similar values regarding objectivity, autonomy, consent, and justice. The impetus toward civility can’t be centralized. It’s everywhere and no where.

    Authoritarian societies don’t sprout up crowds of Thomas Jeffersons overnight. Laws and other pieces of paper can only do so much. Note Iraq, fer ex.

    I give the libertarians points for largely self-consistent arguments. However, they often seem divorced from the messy reality real people face. They’re often short on practical details. Consequently, they come off as ideologues and ideologues, sadly, are teh cancer that is killing us. Busy people must tune them out.

    I don’t care who wipes the poop off a mentally retarded boy’s butt. It can be government, corporation, family, neighbor. Don’t care. Just need to know it’s getting done. If picking the best person for the job means it won’t get done, I’d rather pick someone else to do it, including de tax-happy gubment.

  72. Lame-R says:

    Leaving ideologies aside, how exactly should we perform an evidence-based analysis on this topic?

    As you all are aware, straight comparisons between indicators are unreliable; for example: infant mortality. Compared to Canada, the US comes up short. But is that due to lower quality of care, or lower access to care, or is it entirely unrelated to healthcare and derived from our higher teen pregnancy and premature birth rates, or does it vary based off socioeconomic factors, geography, etc.? Likewise with all the other common metrics–besides the ever-present issue of quality of data (biases, record-keeping practices, etc.) An in-depth analysis of each statistic reveals many confounding layers.

    How then do we perform a meaningful examination? Should we only include metrics that directly speak to the issue of healthcare legislation? If so, how do we control for unintended consequences–how do we isolate any legislation to the point where we can say they are/are not correlated with a certain outcome?

    Considering the variety of healthcare systems employed by other countries and their various strengths and weaknesses, I believe we cannot reasonably expect to come up with a ‘weight of the evidence’ conclusion as to what system is ‘best’. Rather, I think we must first identify our objective: are we looking to have the highest quality of care (and how do we define even that?), or the most access to care, or the cheapest care, etc.? We cannot have them all, so we must choose which ones are most important to us as a society. Then, and I believe only then, can we begin to analyze the experiences of other countries and draw useful conclusions.

    Until we define our goalposts, every single attempt to make an evidence-based examination of healthcare systems will devolve into an ideological slug-fest. We end up examining each other, instead of the data. Or I show up with a scale while another shows up with a micrometer; “It’s 3mg!” “No, it’s 3mm!”

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