I saw it at the premier here in Austin, so of course the audience was the self-selected most fervent singers in the choir, but I also felt something like what the reviewer describes. When the old British MP said the line about how after the Second World War, the feeling was that "if we could come together like that and spend all that money to kill people, we could do the same to provide everyone with health care", the entire audience cheered.

I loved that guy. American politicians aren't allowed to talk like that, and I so wish they would.

I hope this is true. I'm pretty much a true believer on health care, so it's hard for me to see through other peoples' eyes, though.

My mother, a socially conservative Gore voter whom Bush won over after 9/11 with all the terror talk, called me in a rage yesterday. The Scooter Libby pardon had pushed her over the edge—she's voting for a Democrat come 2008.

That is so awesome.

WBUR did a program about the movie, and one of the healthcare economists pooh poohed it. But then Uwe Reinhardt got on, and said, Look, he's not an economist, but he's doing something important that most economists don't do: he's asking ethical questions, and he's expressing moral outrage.

Yup. Michael Moore is awesome.

On the more sober side, I just had a chat with my gay friend in SF, who not only shrugged at the Libby thing--"all politicians do that, what else is new?"--but also flatly stated that no one would have any money if we went all socialist and had universal health care.

I did get him to admit that he didn't vote for Bush last time, though. But his boyfriend did.

That Michael Moore chap, I have certain reservations about him. He's manipulative and rather vulgar with his unrestrained use of documentary to make polemical points in the service of his liberal political views. Also, he certainly isn't svelte.

5 is awesome. As is the linked article. I hope my gay friend and his boyfriend are the losers in the next election.

YUPPY gay guys who vote Democratic only because they've discovered that the Republican party wants to get them but who are totally unconcerned about things like unions really piss me off.

Of course, there are certain issues I care about more than others, but the whole idea that the only thing that matters politically is what affects one personally really disturbs me.

I'm not sure about whether he tends to vote D or R, but his bf is a total Log Cabin weirdo. Charming, though.

9: One thing SiCKO stresses is that no, providing health care won't bankrupt us all. The scene with Moore talking with the older, very respectable, conservative Canadian man on the golf course about Canada's system, where the man says basically that you'll get rid of Canada's national health care when you pry it from his cold, dead fingers, is one great example.

but his bf is a total Log Cabin weirdo. Charming, though.

Not charming enough.

Charming enough for me to enjoy his company on the rare occasions I visit them, yes.

Tim is just mentally checking off all gay guys to see who will get to initiate him.

I think my friends are old-fashioned enough that they don't go in for that open relationship shit.

Haven't seen SiCKO, and I welcome the debate. Moore knows how to push buttons, which is good. But thinking that everything that is medically possible can and will be paid under UHC is disingenuous at best. Rationing of care will take place by law, as opposed to by price, which is what we are dealing with now. But pretending that there won't be rationing is silly. Try getting a heart valve after 75 years old under a UHC plan.

14: bring 'em to the meetup, let the commentariat convince 'em of the error of their ways. What could possibly go wrong?

18: I would, but alas, the Log Cabin's parents are visiting this weekend and my friend already has to make sure he can dine with me on Sunday, since, as he puts it, Log Cabin does rather tend to assume that my friend is available to follow his orders 24/7.

Log Cabin is a remarkable blend of conservative, charming, and queeny, you see.

16: Is not going into open relationships old fashioned for gay men, or newfangled?

I also think that 10 is an excellent point of view, although I arrived at it through being annoyed at those who assume that all gay Republicans are self-loathing pseudo-closeted traitors to their sexuality.

In defense of my friends with objectionable politics, I honestly think that the issue that they care about most is not gay marriage, but rather the incredible shittiness of the way the administration's conducted the war.

17: Break me a fucking give. In the world that the vast majority of Americans live in, care is rationed in accordance with insurance policy terms, which are set by some combination of statutes, regulations, and negotiation between insurance companies and employers.

22. Dave, if you want better insurance no one stops you from buying it. The whole point is that the employer is trying to minimize his payout, which is where the statutes and regulations come in. But shifting how the medical care is paid for will not change the fact that there are only 24 hours in a day and the popular docs need to sleep as much as the unpopular ones, so care gets rationed by price.

23: Do you have a point?

23: What color is the sky in your world? In the world that I live in, almost everyone who has health insurance gets it through their employer and employers offer a very limited choice of policies. The individual insurance market is limited, expensive, and pretty much unavailable to anyone but the young and healthy.

23: TLL, your ideological blinders are making you say stupid things--perhaps the strap is adjusted too tightly around your head? Under any conceivable universal coverage plan the U.S. would ever pass, nothing would stop *you* from buying better insurance. But in fact, yes, people *are* prevented from "buying it" under the present system, either because they can't afford it, because no one will offer it to them (pre-existing conditions, anyone?), or because their employer offers them one or only a limited set of plans.

yes, my point is that UHC is not the panacea that people want it to be, and Moore is feeding that delusion. UHC does not have to bankrupt the country, but we have to agree on what will or will not be included. People will still cry that they getting all they want or need. Every time I hear this discussed I hear alot of anecdotal evidence that basically boils down to I want someone else to pay for what I need for me or my family. I understand why people feel that way, but it is unrealistic to think that it will happen.

Charming enough for me to enjoy his company on the rare occasions I visit them, yes.

Ah, so you were just fucking with baa. Got it.

And BTW, I suppose I should apologize for being so aggressive about this right out of the gate, but TLL has been around here long enough that there's very little excuse for playing Econ 101 games with health care. We've had this conversation before.

yes, my point is that UHC is not the panacea that people want it to be, and Moore is feeding that delusion. UHC does not have to bankrupt the country, but we have to agree on what will or will not be included.

Like every other goddam civilized country in the world does. It's not rocket science, and it's been done successfully over and over, and the results are immensely preferable to what we've got now.

28: Nice try, but you notice that I actually took baa's explanation at face value. I wouldn't co-blog with Log Cabin, because I wouldn't want people to infer approval or tolerance of his politics.

Comments to the effect that no one can afford insurance support my statement that care is rationed by price. I don't see why this is contraversial. Maybe a vocabulary thing.

Yeah, Dave, how come you have to be so hostile?

I want someone else to pay for what I need for me or my family

Break. Me. A. Give. My fucking family is extremely well-insured, thank you, and I support universal health care because I know that a lot of people aren't, and that basic insurance for everyone is a public good.

What's the anti-universal argument, anyway? Me and my family are okay, thanks, so fuck all the rest of you?

TLL, the point you're making, in the context you're making it, is politically the same as a broader claim that UHC isn't something we should pursue. If you're only making the narrow point that it won't be perfect, I don't think anyone would disagree. The question is whether it would be far better than what we have now.

27: Again, break me a fucking give. Do some people have unrealistic expectations for universal health care? Sure. Some people have unrealistic expectations about where the sun is going to rise tomorrow.

And, more to the point, many, many people have unrealistic expectations that changing our current healthcare system would lead to a parade of horribles: economic collapse, limited access to care, 10 year waiting lists for a bottle of aspirin, etc. A great deal of money has been spent creating those unrealistic expectations. That's what Moore's movie is responding to.

32: "Care is rationed by price" has nothing on earth to say to the question of whether the necessary rationing can be done in a more efficient, humane, and civilized fashion than we do in America. Depending on the context, it's true, but I don't understand what makes you think it's useful or informative.

I support UHC, too, in principle. But I am as serious as a heart attack when I say that the discussions that I hear border on fantasy. One of the problems is a matter of scale. We are much bigger in both population and area than any other industrialized country. Moral hazard is a huge issue given the sums involved. All this is not to say it can't be done. As I said, I welcome the debate, but let's debate what is possible, not perfect.

Every time I hear this discussed I hear alot of anecdotal evidence that basically boils down to I want someone else to pay for what I need for me or my family.

Ah, I think I've diagnosed the problem. You've only been discussing it with idiots.

Nice try, but you notice that I actually took baa's explanation at face value. I wouldn't co-blog with Log Cabin, because I wouldn't want people to infer approval or tolerance of his politics.

Not sure that's going to cut it with the strasmelo/Kotsko crowd.

I don't even understand how you could argue about 'scale'.

That just boggles my mind.

All this is not to say it can't be done. As I said, I welcome the debate, but let's debate what is possible, not perfect.

I wouldn't sweat it. It's not going to happen any time soon.

I will go so far as to say that the law of unintended consequences will apply in a major way if the US adopts a UHC plan. A circuit court judge will rule that a treatment must be given, mainstreaming an experimental procedure for example.

And then the sky will fall.

Depending on the context, it's true, but I don't understand what makes you think it's useful or informative.

It's not intended to be informative. It's the first move in portraying yourself as all sober and analytical and shit. Then you start talking about how all those other people just want free ponies, but us grown-up dad party types are all about understanding that life doesn't really work that way.*

*Unless you're rich. Which, coincidentally....

LB, it will be the camel's nose. Mark my words.

40: Thanks for looking out for me. I'm sure Kotsko's going to savage me any second now.

But pretending that there won't be rationing is silly..

Pretending that there isn't rationing now is also silly (and you don't do it, I know). Moore's point is that rationing can be decreased. I believe him.

Moral hazard is a huge issue given the sums involved.

The line for free colonoscopies will be around the block! Women will get mammograms twice a week!

That's an argument I've never understood -- the idea that people are going to significantly overconsume health care in the absence of a financial incentive not to. There may be non-cost-effective treatments that they should be steered away from, or prohibitively expensive treatments that will have to be rationed somehow. But generally, people aren't going to go to the doctor whimsically -- they go when they're sick.

47: I'm a carer, B. That's how I roll.

Bigger country = more taxpayers. What a moron argument.

TLL's opinions are based on a mix of ignorance and ideology. I didn't see any actual facts at all. He seems to think we're dumb and uninformed.

The US pays more for health care than anywhere else without getting better care. There's an enormous insurance-company middleman sucking up a lot of the the money, and that's fine with Republicans because it's not a government middleman.

People, this is America we are talking about. We don't even funds our schools adequately, and you want to turn over 1/5 of the economy to the government? Wholy Moly, UHC will be so god damned underfunded it will make you cry. Look to the VA if you doubt me, and those are people who have fought for their country. Wankers like you, stand in line for your x-ray.

I, for one, intend to go get pelvic exams every Wednesday, right after my pedicure.

Recreational colostomies will become the rage, and we'll have to pay for them with our tax dollars because of a liberal judge's order.

The line for free colonoscopies will be around the block! Women will get mammograms twice a week!

Not the hazard I'm talking about. Look who gets paid farm subsidies, not the family farmer. It all goes to ADM. Now think who will get the money under UHC. Not the family doctor, that's for sure.

yes, we're unpatriotic for thinking that our uniquely fucked country can do the same things that all other countries do.

Republicans shoudl shut up about school funding, which they're against.

53: Wait, five minutes ago the problem was that we were going to bankrupt ourselves on unnecessary care. Can you at least stick with the same argument until we finish mocking it?

53: Okay, if your argument is that we'll systemically underfund health care because we're selfish fuckers and will cut off our noses so as to avoid sharing the pool with black people, then say so. But I kind of doubt it. The problem with school funding is race, and the problem with VA funding is that so few people actually know veterans (and that the Bush administration is evil). But people are pretty protective and okay with social security, for instance. And the difference between VA programs/public schools, and healthcare, is that everyone will use the latter.

Now, you *might* have there a good argument for making it illegal to own private insurance, as they've done in B.C.

Who gets the money now? Insurance companies and HMO owners.

and you want to turn over 1/5 of the economy to the government

That's why it won't happen all at once. At best we'll get incremental reform; at worst, we'll get another failure. (Also, my recollection is that the number is 1/6.)

Look to the VA if you doubt me

Indeed, TLL, tell us about the VA. By all accounts, they do a much better job than the rest of the health care system in this country. Check satisfaction rates, for one example. Check universality of covered patients, for another.

Now think who will get the money under UHC. Not the family doctor, that's for sure.

The family doctor isn't getting that money now, especially if they happen to live in RI. It's rather enlightening to talk to your local GP about reimbursement rates.

My doctor has a check pinned to the bulletin board in his exam room made out to him from some insurer in the amount of 23 cents.

56: The part that you're missing is that we've pretty much already gone through precisely the stuff that you're so scared of. Managed care was going to save us all a ton of money, and then it was evil managed care companies denying treatment, and then we got to a set of rules that delivered a level of care that most insured people could live with at a cost that most insured people could live with. We're not working in a vacuum here.

JE, I have served on the Board of both a hospital and an insurance company. I come by my ignorance honestly.

DaveL, we both underfund our schools and overutilize our parks. why would this be different?

Now, you *might* have there a good argument for making it illegal to own private insurance, as they've done in B.C.

For some reason, TLL is pretending that the only option is an NHS-style system in which there are no options other than the barebones state-run hospitals, unless you want to go to some other country. This is not the only option, of course, and there is absolutely no chance that every health care provider in the US will be nationalized under whatever UHC program eventually appears. That didn't happen in France or Germany. Don't be afraid, rich people; you'll still be able to avoid rationing and go to a private clinic. I don't know if you're fraudulently trying to scaremonger, or if you've just been successfully scaremongered yourself, but please stop spreading this fear, uncertainty and doubt.

Then why don't you bring information to the argument, instead of repeating things I first heard 20 or 30 years ago. Why don't you address the problem of uninsured Americans in some way? Why don't you address the comparisons with other countries in some way?

Your connection with an insurance company is not help at all. They'll be the big losers if we get a decent system, and that's one of the main reasons why we probably won't.

As I suggested above: usually the conservative American exceptionalism argument claims that the US is better than other countries. Your argument depends on the US being uniquely worse than the others.

DaveL, we both underfund our schools and overutilize our parks. why would this be different?

For starters, programs that serve everybody tend to be better-funded than programs that only serve some people, and federal programs tend to be better-run than state and local programs. But the main point is that "the government fucks everything up" is just a dumb argument. The government is already neck-deep in health care. We're not talking about taking the first bite from the forbidden fruit here.

Not a for profit insurance company, fwiw. Taft- Hartley employee benefit mutual. Besides, i am emotionally trying to counter act the emotions brought out by a movie. Facts don't enter into it. Please excuse my signing off, because I do think this is important to hash out. I'm sure there is a better way of doing health care than we are currently, and UHC makes sense from an administrative point of view, but the devil will be in the details, and you can buy a Congressman pretty cheap and make sure your detail is covered.

The linked article is really interesting, but I am skeptical of the attitude of "Wow, look at the impact in Texas, of all places."

The fact is, red states have a whole bunch of blue people in them - heck, I bet Utah goes 30% Democratic in national elections. That 30% is going to be particularly interested in checking out a Michael Moore movie when it comes to town. And will be particularly enthusiastic about it.

That said, I like Michael Moore a lot, and I like SiCKO better than anything of his that I've seen. (Though I haven't seen Farenheit 911 yet.) It really is great.

I'm sure there is a better way of doing health care than we are currently, and UHC makes sense from an administrative point of view, but the devil will be in the details, and you can buy a Congressman pretty cheap and make sure your detail is covered.

That's true, but if we treat people fairly, we treat people fairly. Who profits from it is another issue, and the doctors lobbying organization is insanely powerful.

I would like to see an enormous lump sum paid to Aetna, Blue Cross/Shield, and the rest, in exchange for them agreeing to no longer exist in any way, shape or form. That's how critical it is that everybody be in one risk pool.

50: Of course people will go to the doctor's more/get more procedures if it's free. You won't -- you aren't balanced on the margin of feeling that you would like to get more medical attention, but the monetary costs are too steep.

But of course there are a lot of people on the margin. If there weren't, then copays would be higher -- the system is currently designed to make sure that a substantial number of people are deterred from going to the doctor because of their copays.

This isn't an argument for or against UHC. It's a single element out of context. But get real: if you think that people in a UHC system wouldn't go to the doctor's more, you're making the kind of simplistic argument that gives TLL ammunition.

This isn't an argument for or against UHC. It's a single element out of context. But get real: if you think that people in a UHC system wouldn't go to the doctor's more, you're making the kind of simplistic argument that gives TLL ammunition.

What I think is that people would go to the doctor's more for preventive things that cost money but can easily be put off, and people would go to the doctor's more when problems are in their early stages and don't require catastrophic care.

End result: less catastrophic care.

TLL is right about one thing, which is that thanks to people like him treating taxes as the worst thing ever created by Satan, government programs in America are continually funded in a half-assed and ad hoc way. I read in the American Prospect (?) yesterday that in the US, 1% of people believe taxes are too low, while in the UK it's something like half the population. That's terrifying.

73: If I looked as though I were claiming that people wouldn't go to the doctor's more, I misspoke. The point of UHC is that more people would be able to go to the doctor when they need to. But they wouldn't have any particular motivation for going to the doctor when they aren't sick -- health care isn't a luxury consumable. Healthy people don't want to consume extra health care just for the hell of it.

The extra consumption of health care (barring the consideration of prohibitively expensive treatments, which I did mention earlier) is self-limiting. People don't want more health care than they believe they need.

The moral hazard argument kind of infuriates me. I have a good friend who works for the state department of health; a mutual friend was describing his allergies to cats and said that he might go get the allergy shots before his insurance ran out. She shook her head and tsked, "moral hazard."

How is this a bad thing? If he didn't have insurance, our friend wouldn't get the allergy shots, because he wouldn't be able to afford them, and would be miserable living with his girlfriend's cats. The problem, if we think honestly about it, isn't that my friend might use his insurance to get the shots; the problem is that without a job and insurance, he can't get them.

Health care isn't something we'd over-consume for the fun of it, like candy. We're not talking about cosmetic surgery, are we? Of course people would use health care more if they could afford it. I don't understand why that's supposed to be an argument against UHC.

Sigh. LB-pwned.

Perhaps a prohibition against recreational surgery can be written into the bill.

Free-marketers are can-do and optimistic about tech and about business, but they want government to fail, to the point of deliberately sabotaging it. I'd really love to see freemarketers (and neo-Confederates and neocons) become rejected pariahs the way we dirty filthy hippies have been. They completely deserve it.

Also, 73 seems to be operating on the misconception that universal care means nobody pays anything out of pocket for care. That's not necessarily the case. It's perfectly possible to include copays and/or deductibles in a universal system.

I'd really love to see freemarketers (and neo-Confederates and neocons) become rejected pariahs the way we dirty filthy hippies have been. They completely deserve it.

God bless Michael Moore. This is his explicit goal, and with more like him, this would be a better country.

What I understand to be the real flaw in the moral hazard argument, is that the sort of health care people are going to decide to use or forgo for economic reasons is really cheap. High deductibles, or being uninsured, will keep you from getting a $500 series of allergy shots. But the real expenditures, the ones that are bankrupting the system, are in the $100K livesaving treatment category, where economic incentives aren't the same sort of issue at all -- if you can pay, you do and live, and if you can't, you die, but you're not making a choice about how you want to spend your money.

The sort of cost-control you get from discouraging people from seeking 'optional' health-care is picayune.

I'm not sure that what's being described is a moral hazard, properly. As I understand it, the moral hazard associated with UHC is that we'll all start chain-smoking while bungee jumping. Because someone else pays.

I'm not sure overconsumption is a huge concern in UHC. As people note, care gets rationed one way or the other, and this seems especially true under UHC. As I recall, concerns about overconsumption were/are driven by concerns that the patient will demand care he or she doesn't need--brand name drugs over generics, etc.--and that doctors will over-treat, both because that pays for them and because of fear of a law suit. Neither seems something to worry about, especially, under UHC.

As people note, care gets rationed one way or the other, and this seems especially true under UHC.

No no no no no. Care gets rationed either way, but especially under the American system.

The extra consumption of health care (barring the consideration of prohibitively expensive treatments, which I did mention earlier) is self-limiting. People don't want more health care than they believe they need.

"We don't know what you have. We could give you an MRI, but it's probably nothing, and the odds that you have meningitis that will kill you are actually pretty damn low. MRIs are expensive, so we're just gonna hope it gets better."

"You have advanced lung cancer. You'll probably die. There's a bunch of chemo treatments that might help, but probably not, and they're pretty expensive, so we aren't going to give you them."

These are not things that Americans are used to hearing, and they will react negatively when someone says them.

But we spend more, so its likely we ration less.

84: Maybe I should have said "explicitly rationed"? That is, we will end up make political choices about what care to provide when rather than leaving the choice simply to the market.

OK, really, am I just unusually grumpy today or did someone put stupid juice in the water cooler?

87: They're largely political choices now.

89: They're pretty clearly not explicit, and, IIRC from last time around, having that conversation is one that politicians really, really want to avoid.

Perhaps a prohibition against recreational surgery can be written into the bill.

I tried to get my Munchausen's covered by my HMO, but they're fighting it.

85:

Also, doctors will get paid a lot less than they do now, but more in line with what they make in other countries.

Now these are not reasons we shouldn't have universal health care, and I say this as someone who a) had a probably non-cost-effective CT scan a couple weeks ago, b) went to college on the revenues from a couple of orphan drugs and a hep-C treatement, and c) is good friends with a few doctors.

But these are the vested interests that are at play.

ANything that deflates doctor's egos i'm in favor of

90: Not sure what you're driving at. What I'm saying is that what we have now is a system in which the ground rules on what insurers have to cover are driven in large part by political processes. Politicians don't write policies, but they do step in when insurance companies write policies that deny coverage for stuff that the political process decides they shouldn't. Going to universal care would put government regulatory/technical types into some or all of the space currently filled by insurance companies, but I doubt it would end up changing the politicians' role in setting policy terms all that much.

88 was not directed at 86 or 87, BTW.

65 -- Do you not see any difference between going to the hospital, and going to the park? Are they the same type of activity?

"You have advanced lung cancer. You'll probably die. There's a bunch of chemo treatments that might help, but probably not, and they're pretty expensive, so we aren't going to give you them."

Americans are used to hearing: "You've got congestive heart failure. There are drugs to treat it, and they work really quite well. In the greater scheme of things, they're not that expensive, but they're going to be hell to pay for on your income. If you can scrape together the money to fill the prescription consistently, you should do just fine. Otherwise, good luck."

I don't think the tradeoff is going to be that painful.

When I lived in France, it was 20euro to see almost any doctor (maybe 25 for a specialist?), 14 of which was reimbursed by the state, as long as you were covered by the state, but if you were rushed to the hospital for emergency surgery and a long inpatient stay, it was likely to be the same 20 euro, if you saw a bill at all. [David Sedaris has a funny essay about that.]

The very reasonableness of it didnt prevent a few chi-chi doctors from charging more, especially in Paris -- I once paid 75 euro to see an English speaking dermatologist because i didnt bother to ask in advance if she followed the pricing guidelines. And most people had a private insurance through their job that paid much of the part not-reimbursed by the state. On the other hand, if you didnt have even 20 euros, there were some uber-socialist medical centers that checked to make sure you were covered and then only charged you the 6. The dermatologists i saw there were just as good as the chi-chi one, but they didnt have really expensive furniture in the waiting room.

The point is just that rich or well employed people still have a perception of slightly better healthcare, and there's a copay to keep people from going to the doctor everyday, but everyone knows that _everyone_ can have adequate care -- and that's part of living in a civilized society. [maybe all of this is in Sicko, since i havent seen it yet.]

The idea isn't that people will get more mammograms, it's that they'll stop exercising and eating right and start just depending on Lipitor for all their cholesterol-reduction needs. And then pretty soon, hell, everyone's on it anyway so let's just go ahead and put it in the water supply.* Is that an unrealistic fear? Yes and no. I think we would trend in that direction. But we're trending that way anyway; no one exercises anymore and we're all getting addicted to our prescriptions. I'm not sure the acceleration would be measureable.

Is universal health care a good idea? I'm really not sure. Maybe I should see the movie.

*About three years ago I spoke with a high-level FDA official who indicated his strong preference for putting Lipitor in the water supply. This was before some of the more dangerous potential side-effects were known, but it still scared the hell out of me.

Depends on the doctors. And if the system's run decently, the ridiculous overheads of malpractice insurance (esp. for ob/gyns) should go away.

98: isn't that like a decentralized, von Mises market decision?

A decentralized, von Mises market decision to dramatically increase consumption of a heavily subsidized good? I'm not even sure what that means.

You know what's not going to be covered by any universal health care plan in this country anytime soon? Abortion, that's what. Probably no birth control, either. Certainly no birth control for those slutty teenagers.

. What I'm saying is that what we have now is a system in which the ground rules on what insurers have to cover are driven in large part by political processes.

Right, but the number of steps between the politician and the healthcare decisions matter. I would bet you could see analogues of some sort in education policy political fights. Also--and I don't know anything about this--but it would be interesting to know how other systems deal with end-of-life decisions and seemingly hopeless diseases. I'm thinking here of "pulling the plug" and diseases like AIDS in the eighties and early nineties.

None of this says we shouldn't have UHC; I'm pretty comfortable with a lot of the trades we'd have to make. I just think there are going to be trades.

But faith-based medical providers like televangelists will receive massive checks from the government. That's the political compromise you have to be willing to accept if you want to pass a reform like this in modern America. Is that something you're willing to swallow?

76: That's definitely a better argument, but there are still plenty of people who think that the level of healthcare that they want is a lot higher than what their doctor thinks they need.

I think that the real pro-UHC argument about this is a combination of what you just said (and point to other countries to show that moral hazard doesn't go spinning out of control -- people in [other country's name here] aren't in the doctor's office twice a week) and just saying that other savings will outweigh the costs of some frivolous doctoring (again, point to other countries for the low costs argument).

102: absolutely not. Otherwise where would the next generation of slutty teenagers come from? Oh, I see, you want this country overtaken by Muslim hordes.

102: Abortion might be a sticking point, but come on, people are used to having their health insurance pay for their birth control. That's not going to happen. And the televangelist thing is just silly -- I don't care how religious Americans are, no one's enough of a nitwit to argue that their faith-healer should be paid for by the government.

102: I'm currently in my prime time for not giving a shit whether those slutty teenagers have access to birth control, what with being too old to sleep with slutty teenagers myself, and yet with no children or prospects of children immediately on the horizon. So let the slutty teenagers eat cake!

OK, really, am I just unusually grumpy today or did someone put stupid juice in the water cooler?

Having read you here and in the "Just Because" thread, I'd say "both."

But I appreciate it, because I'm a bit grumpy today, too, and you've saved me from writing a lot of grumpy posts.

107: the ocean of nitwits is deep and wide, LB.

107: I think you overestimate the public. I don't see anyone actually paying for faith healers, but someone is going to try and get it paid for.

Damn it pwnd by ST.

I just think there are going to be trades.

Again, you need to rid yourself of the idea that rationing by price is somehow not rationing. Life is a series of tradeoffs, no matter how intelligently you manage life.

You know what's not going to be covered by any universal health care plan in this country anytime soon? Abortion, that's what. Probably no birth control, either. Certainly no birth control for those slutty teenagers.

Dude, popular vote shot down the abortion ban in South Dakota. I really don't think it's abortion and birth control are going to be a problem for UHC.

104: no, i spit at them.

Um, i totally read that as "pimp juice in the water cooler"

Again, you need to rid yourself of the idea that rationing by price is somehow not rationing.

Yes, but the people getting most screwed by the current allocation of resources are those who are famously ill-positioned to complain much about it. This time the allocation will be downwards. Totally justifiable, but it's not like people don't scream about redistributive taxes.

A couple of arguments here are running together.

One: do advocates of UHC sometimes suggest that UHC will not ration health care and we'll all get what we want? The answer to this is "yes." I haven't seen Sicko, but I understand one (very sad) story in the film is a guy with insurance who can't get reimbursement for a bone marrow transplantation. The idea that sad stories like this are uniquely a feature of private plans is a mistake. There will always be some treatment that is not covered. This fact, of course, is not an argument for or against government funded health care.

Two: do people consume more health care when they bear less of the cost. This is one of the few questions in social science where we actually have a prospectively designed randomized study, the RAND health insurance experiment. Briefly, the answer is "yes, people do consume more health care when insulated from costs." There is also very interesting evidence from Amy Finklestein's work that there is a supply side effect as well -- as reimbursement increases, more health care gets provided, more hospitals built, etc. Neither of these findings, I should add, are particularly counter-intuitive.

116 to 115.

118:

Two: do people consume more health care when they bear less of the cost.

See my 76.

118b: isn't it aknowleged that not everyone gets enough care now?

IS there any justification for waiting lines as a rationing measure? it seems like it would be better to have critiera like age/need for deciding who gets care.

118.3: which is weird, because per capita health expenditures are higher in the US than in any industrialized nation with UHC. Say, maybe the market incentives in healthcare create incentive to run the business inefficiently? It's, like, a market failure? By the same token, maybe nationalized healthcare would - because of fine small government enthusiasts such as yourself exerting pressure - actually have greater incentive to run itself efficiently than the current highly regulated de facto monopsonies created by employer-funded HMOs? Clearly not. Look at the VA!

It's hard to imagine that the US would overconsume health care more than it does now, if it moved to some sort of UHC. As it is, we're pretty much leading the pack in this (and in per capita costs). I'd expect the demographics to shift -- as it is now we have a ton of people who underconsume and a larger number who overconsume, but I can't imagine the situation getting much worse. Of course, baa is correct that this is largely encouraged by price insulation, which is rampant in the current system, it's just highly non uniform.

Anyone who imagines that UHC is all goodness and light and will solve all the healthcare woes imagineable is living in a fantasy world. But anyone who believes that actual, current, existing UHC variants aren't actually superior to the current US system is a fool. It remains an open question if there is a different path that is also superior to the current morass, but nobody is talking about it now and it seems silly to go looking for it when there are good answers out there already.

that actual, current, existing UHC variants aren't actually superior to the current US system is a fool

I think this way lies confusion. The question isn't whether UHC variants are better than the US system as a whole; the political question is whether UHC variants are better for the likely voter population than the US system is for that same population. Dunno; I'd guess yes, but I'd also guess that it's (a) a closer call than people think, and (b) a harder case to make convincingly to that population--however true--than people think.

So was Medicare. People are idiots. Once in place, it would become instantly untouchable.

118:

health care isn't a luxury consumable. Healthy people don't want to consume extra health care just for the hell of it.

But the Rand experiment, I think, shows this isn't true: people in the low deductible group consumed less care.

Also, just to reiterate, I think it is a mistake to see the cost-sensitivity only on the demand side. When you reimburse interventions, you (usually) create an incentive for providers. Someone in the system needs to care about costs. The question is whether that person should also be the patient.

. Once in place.

Aye, there's the rub. I asked at Ezra's place--and then didn't check for an answer--but is anyone aware of a program on this scale (reformation of, let's say, 1/6th the US economy) that has happened absent tragedy? I don't know how the Great Society gets counted. Some describe it as stillborn, relative to LBJ's hopes, and does JFK's death count as large-scale tragedy?

Someone in the system needs to care about costs. The question is whether that person should also be the patient.

This is exactly right. Are you fucking with me?

This is one of the few questions in social science where we actually have a prospectively designed randomized study, the RAND health insurance experiment. Briefly, the answer is "yes, people do consume more health care when insulated from costs."

Who cares? UHC isn't a mystery. We already know even generous programs like Sweden spend less per citizen than we do. Let's get on the wagon already.

127: Medicare has been a tragedy? Social Security has been a tragedy? Section 8 has been a tragedy? The GI Bill has been a tragedy? None of those is on the same scale, but really, look at the New Deal. Look at WWII, for that matter, if that's how you want to think about it. The US economy has been successfully reshaped (or repaired) by the government several times in our brief history. Healthcare is a domestic service industry. Sure, they have a lot of money, but it's not like it's going to cripple us in respect to China if some of that cash gets redistributed.

I suppose I don't understand what you're asking?

Apologies if someone has already said this, but it seems to me that arguing about the viability of UHC and trying to explain away this or that limitation is a sucker's game. Our position should be "How do you propose to make sure everyone is covered?" That's where we start. We already know that it's possible; only trolls and people with vested interests deny it. The argument should start with the moral imperative.

124: I don't think it's that close a call. I think it's overwhelmingly likely that it is better for this population, and I also think it's a tough sell. I'm fairly certain is a *tiny* segment of the US population that are better served by the current system that they would by by any conceivable system we'd end up, and most of them could wangle their way around any putative barriers or reduction of access they might see. I'm willing to believe Texas is worse than most states, but it pretty much seems like a clusterfuck here. About the best you can say about top-rate coverage here is `wow, imagine how much worse I would have been screwed without it'.

131: eh, I don't like arguments from the moral imperative. Not because I don't think it's there, but because explaining it to conservatives/libertarians evokes singing to rocks. There is a perfectly good case to be made that universal health coverage is (far and away) the most efficient way to manage medical costs in a developed economy, whatever moral hazards might be involved. Do people make the counter-argument in bad faith? Yes, sure, but it's hard to imagine Tim, baa, and TLL are doing that intentionally.

Sorry, inverted that: in RAND higher deductible --> less care.

Also, I notice that in these debates a lot of work is being done by the cross country comparisons. E.g., the data are produced that France spends less $ per capita on health care and has better outcomes (usually measured by life expectancy, or quality-adjusted life years). This is taken as evidence that we should switch to the French system, or one that is more like it.

I have a number of concerns about arguments of this kind: life expectancy is not terribly responsive to health care interventions, the US has different demographics than France, we eat differently from the French, we have more inequality than the French, we have more violence than the French, and so on and so on.

I am sure everyone here is familiar with these kinds of objections, and no doubt we will not come to resolution here. But it does raise a question in my mind: how important are these types of arguments to people's support for a more European system? Imagine, e.g., that we do a more complicated analysis, and discover that when we adjust for all these factors, life expectancy is significantly higher in the US than in France. Would this make people less desirous of a more European system?

: Medicare has been a tragedy? Social Security has been a tragedy? Section 8 has been a tragedy? The GI Bill has been a tragedy? None of those is on the same scale, but really, look at the New Deal

No, the tragedy was the Great Depression and the possibly JFK's death. That is, GWB had more power to get what he wanted because of 9/11.

Also, I notice that in these debates a lot of work is being done by the cross country comparisons. E.g., the data are produced that France spends less $ per capita on health care and has better outcomes (usually measured by life expectancy, or quality-adjusted life years). This is taken as evidence that we should switch to the French system, or one that is more like it.

Yes, people tend to look at how things actually work in practice. And it's not just specific countries, it's that every country on the planet spends less per citizen than we do.

Our position should be "How do you propose to make sure everyone is covered?"

So I quite like that. Here's one way:

1. Medicaid for the poor
2. Subsidize medicaid for the not-poor-enough on a sliding scale based on income
3. Require everyone above some income level to purchase health insurance - whether it is high deductible or low can be up to them

134: Seriouly, i don't think anyone disputes that higher deductibles -> less care. the question is, what happens if people got more care of that sort?

Imagine, e.g., that we do a more complicated analysis, and discover that when we adjust for all these factors, life expectancy is significantly higher in the US than in France. Would this make people less desirous of a more European system?

Are you imagining that people have done this analysis? Are we, as a ground rule, when talking about this? The numbers that have been produced so far - by experts, let's assume - pretty well universally support the idea that per capita health expenses in the US are higher than in France. Surely, all these experts could be wrong. But that should be our starting point for debate?

The pattern that manifests itself in health care in the US - the sickest patients are the poorest, least likely to be insured, least likely to seek regular medical care, most likely to use the emergency room - are simply obviated by nationalized health care. Similarly, the perverse economy of the American pharmaceutical industry, where marketing drives prescriptions drives research drives profit 20 goto 10, would become, instantly, vastly less pernicious in some variant of a single-payer system. Do you disagree with these two points? Or do you argue for some kind of next generation social science framework which may, hypothetically, disprove them?

137(3): and for those with prexisting conditions, who are denied care??

140: what kind of a dumbass gets sick, anyhow?

Re 136: gswift, you didn't answer the question I asked. Is the x-country comparison the main reason you support an EU system? If analyis showed that in fact, when adjusting for demographics etc. US got better outcomes than the EU mean, would that be decisive for you?

baa, you're quite right you have to be careful with these sorts of comparisons. On the other hand Canadians live substansively similarly to Americans, have better health care over all, and pay a hell of a lot less for it. And the infrastructure and supply problems are if anything *worse* in Canada. Not that there isn't anything wrong with the Canadian system, but it's problems are both smaller and more apparently fixable that in the US.

We don't even have to get into those sorts of comparisons, though. The US system is failing the people of the US in fairly obvious and addressable ways. The best general overhaul seems to be some sort of universiality --- single payer makes most sense here, but that's arguable. But if that change is too big, how about the fact that there are differential billing in exactly the wrong direction? That 10% or so of the population has no coverage, and seriously sub-par access to basic health care? That many Americans feel their basic freedom to choose a change in workplace is curtailed by insurance concerns? The list isn't short.

. Do you disagree with these two points?

I do. Or at least the assurance in stating them. I was fairly familiar with the arguments in the last go-round, and, IIRC, there was lots and lots of disagreement about what drives medical costs. I'd be astonished if that didn't remain true.

I think ogged's right--you do it because we should do it and we can afford it. Subsidiary arguments can be made to targeted populations.

Re 136: gswift, you didn't answer the question I asked. Is the x-country comparison the main reason you support an EU system? If analyis showed that in fact, when adjusting for demographics etc. US got better outcomes than the EU mean, would that be decisive for you?

Again, it's not country x, it's that even the best of the best of UHC countries get better results than we do, and for less money. Sweden, France, Japan, whoever. Your "what if" analysis is pointless. Studies have been done. We come out behind.

Even if people don't buy the moral argument, it's still a better option on purely pragmatic grounds. We're already spending more, and getting less.

baa's asking: what if we're spending more and getting less for reasons unrelated to the way we provide healthcare.

when adjusting for demographics etc.

Genuine question: what does this mean?

re: 139

In reverse order. I'm not sure I understand your point about the pharmaceutical industry. But I certainly don't view their profits as pernicious. I want there to be a huge financial incentive to develop drugs. And, as pharma spending is ~20% of US health care spending, I find it hard to believe that Pharma profits as a major element of the long-term unsustainability of current health care spending.

As to per-captia health care costs. I am really not aware that anyone has done the type of analysis that would definitively separate the contributions of the health care system to national average life expectancy. It's clear the US spends more, it's not so clear (at least, based on data I have seen) that the US doesn't "get more" (in certain ways) for that spend. I am all for finding ways to reduce unnecessary spending, but I would rather proceed incrementally and carefully, rather than make a major switch in the way health care is reimbursed.

144: but but but it's way cheaper. Look, I'm obviously not marshalling scientifically validated arguments. I don't even have citations. But I can't understand how the plain fact that this system works pretty well all over the world, combined with the fact that that just about every other large-scale social welfare program the US has implemented has turned out to be so popular it is practically political suicide to challenge it, should be subject to iffy, highly parsed quibbles over relative costs and relative savings. If we lived outside the US the idea that single-payer health coverage was better in pretty much every way would be laughably obvious. This is not a demographic thing. We're just sheltered, and wrong.

when adjusting for demographics etc.

I had in mind a hodge-podge of issues here:
% of the population which is >65
% of the population which is very poor (probably an independent predictor of poor health)
rate of death by violence/accident (effects life expectancy, but likely unrelated to HC)
Differences in diet (% obsese, e.g.)
Basic ethnic differences that because of culture (or maybe even population genetics) could influence health

what if we're spending more and getting less for reasons unrelated to the way we provide healthcare.

What if we're spending more on healthcare because of all the gorings by wild unicorns?

Canadians have similar lifestyles, Scots aren't short on violence, and so on. This is not a field devoid of study damnit.

146: I think that's pretty substansively been shown not to be the case. There is a lot of lobbying and misdirection, but not a lot of expert disagreement that I'm aware of.

I think there is one really important distinction that has to be made; there are two health care crisis in this country, and we shouldn't conflate them

All industrialized economies are in the horns of a health care dilemma, a combination of increased technical capabilities and (to a lessor degree) aging populations are driving us to the unavoidable conclusion that we can no longer really consider it even an ideal to provide, even on average, a standard of care that includes everything that is possible. This has become acutely true in some narrow categories for a long time now, but it is becoming more and more generally true. The cost of even keeping up with the technology we have clinically is becoming excessive, let alone developing everything we can.

We can't get out of this one. France (& Canada, and UK, and all the rest) are struggling with this too.

But there is another problem. Beyond this, and beyond `reasons unrelated' (they're all related, and of course if we lived healthier lifestyles here it would help), we do a bad job of delivering the health care we do have here. We do a bad job because we fail to provide reasonable access to far, far to many people for many reasons. We do a bad job because while much of the health care we do provide is technically very good (but this is not universally true), it is mostly very much overpriced. We prop up and inflated insurance industry which in turn props up inflated salaries (and legal fees, for that matter) because for the most part, the pain is distributed widely enough and invisibly enough (i.e. corporate plans) that people mostly don't realize how badly they are getting shafted. We do a bad job because we focus too much effort on what is profitable, and not what is needed --- that's a natural state for a corporation but a lousy way to design a health care system.

% of the population which is >65
% of the population which is very poor (probably an independent predictor of poor health)
rate of death by violence/accident (effects life expectancy, but likely unrelated to HC)
Differences in diet (% obsese, e.g.)

Gah. And we're to believe that we're so drastically different from other Westernized countries in this regard?

I want there to be a huge financial incentive to develop drugs. And, as pharma spending is ~20% of US health care spending, I find it hard to believe that Pharma profits as a major element of the long-term unsustainability of current health care spending.

The financial incentive won't be going anywhere regardless. With any luck the single-payer-oriented market will make drug development more focussed on genuine public health issues, instead of, say, keeping Bob Dole's boner medicine patented. I quote Kevin Drum:
"Now, the scaremongering alternative to this is that basic economics will fail because governments around the world are such ruthless bargainers that they'll literally drive pharmaceutical companies into the ground with their demands for ever lower prices. But seriously, how likely is this? The global aerospace industry is highly dependent on military sales, and their profits haven't been driven into the ground. Quite the contrary: Europeans are forever complaining that Boeing, for example, is essentially subsidized by the U.S. government because its high-profit defense business is more lucrative than its civilian business.

The fact is that selling to the government -- or, in this case, to a hundred separate governments -- is every bit as profitable as selling to private industry. (Does anyone seriously want to make the case that federal procurement is more ruthlessly efficient than, say, Wal-Mart?) Right now, the only reason European countries can get such low prices on drugs is because pharma companies know they can make up for it in the United States. If we stopped acting like chumps, they wouldn't be able to do it anymore.

Useful pharmaceutical development happening often (mostly?) in government funded university labs, of course, even in this country. I mean, I'm not trying to be complicated here. It's not complicated. System, attempted overseas, works way better than our system. QED. Anything else is fog and obfuscation.

I should add to that last bit --- the problem isn't that a profit motive for this sort of thing couldn't work in an econ-101 sort of imaginary world, it's healthcare isn't even close to that situation, and it's terribly unlikely that it will get to be anywhere close.

154.3 + "

. It's not complicated. System, attempted overseas, works way better than our system. QED. Anything else is fog and obfuscation.

Disagree. It's really, really complicated. (I think I remember a DeLong bit on this to exactly that effect; he's hardly a conservative or anything but a market oriented pretty liberal Democrat.) Throw the US out. Now you have a list of several countries with UHC with various outcomes. If it's as easy as picking the best one and simply adopting it, why haven't all other countries tended to the "best" system? Why is there anything but minimal variation?

I was wondering if our relatively high rate of poverty was one of the factors. Insofar as "accounting" for that means saying "if you ignore the fact that the poor are always screwed in America, we're doing much better than you'd think, "then that's unacceptable, no?

Off to bed...

But I certainly don't view their profits as pernicious. I want there to be a huge financial incentive to develop drugs.

You should familiarize yourself with how actual progress gets made in this field. The real work is done in university research labs on NIH funds. There's no shortage of scientists who would like nothing better than a steady supply of funding to crank this stuff out.

157: obviously complicated in the details. Not complicated in terms of likelihood of outcomes. Sure, we could fuck it up, people have. But we're replacing a fucked up system that is careening off in unexpected directions because it isn't, in fact, a particularly workable free market, public wealth and welfare-wise. I understand there's risks to UHC, and there are massive interests which will work diligently to fuck it up. But things here now are so much more broken than they are pretty much anywhere else. We could do almost anything, really short-sighted, foolish things, and it would still be an improvement over what we have now. That is what you can learn from looking at other countries. The details? Very complicated, yes. Best left to experts and politicians.

158: I'm going to guess, without evidence, that the causality might well flow the other way.

157: It is really, really complicated to try and prove a `best'. Even if that makes sense. And of course there are all sorts of confounding factors, and it's hard to even know what the correct sort of outcome questions are.

But wrt to the current system here, all of that doesn't matter. It's actually really simple. The best known health care systems are some sort of variant of UHC. The US system isn't in the running. It's also getting worse, not better. And it isn't working well here in the US. So *something* needs to change. Don't pick `the one' and copy it (because we don't know what that is). Make a home-grown variant. There aren't any guarantees, it would be silly to expect them. This stuff is hard, and there aren't any silver bullets. But the smart money says that moving to some sort of universal system will improve the US system dramatically. And it needs something to change.

"Imagine, e.g., that we do a more complicated analysis, and discover that when we adjust for all these factors, ", the factors being inequality. diet, violence, and etc. Given that the health outcome disparity between the U.S. and other industrialized countries (measured as either infant mortality or life expectancy) persists among many countries independent of the other factors, with the exception of inequality, one could attribute it to either an inevitable product of inequality of income or the inefficacy of our health care system. I suspect the two are not unrelated, but the data don't really support this. In any case, the data are clear on one point: socialized medicine has been cheaper and more effective than has private medicine. Why this should be so I do not know, but I cannot and will not ignore it.

You should familiarize yourself with how actual progress gets made in this field. The real work is done in university research labs on NIH funds. There's no shortage of scientists who would like nothing better than a steady supply of funding to crank this stuff out.

As someone with secondhand (immediate family) knowledge, I call bullshit. The University of Rochester developed the concept of a COX-2 inhibitor with NIH money. To take that research and turn it into something you can actually give a sick person, Big Pharma spent hundreds of millions of dollars. The result was what someone would no doubt call at least one me-too drug (Celebrex). And what do you know, it turns out that not making real people worse is a lot harder that figuring out the theoretical basis for making people better.

164: afaics (from a somewhat insider perspective) you're both partially right. Most basic research isn't done by pharma, but the R&D that pharma does do is expensive too. On the other hand, they spend a hell of a lot of money on other things (lobbying, marketing (both to consumers and physicians), etc) that gets subsumed into `development costs'. A third factor is that what we probably want is a profit motive to exist, not a profit to be guaranteed. Big pharma isn't hurting by any stretch of the imagination, and would do just fine with narrower margins. I'm not suggesting anyone should *enforce* this, but a less distorted health care pricing system would probably do it all by itself.

I'm obviously tired and should stop now: In 165 I didn't at all mean to suggest that big pharma is guaranteed a profit today. It's more like gambling with a table advantage.

It turns out that there's even a U.S. state that manages to provide something fairly close to universal coverage, albeit still based on employer plans for most people. One carrier, the local Blue, has a huge chunk of the market, Kaiser has most of the rest, what's in the policies is heavily regulated, etc. There are plenty of problems, but it works pretty well in comparison to what the rest of you are dealing with.

162: I don't disagree with that. But it's either (a) going to have to be incremental, or (b) going to have to wait for a very ugly recession. I vote for (a).

Beefo Meaty, with all respect, it's statements like 154 that make me concerned about how carefully advocates of government-as-sole-payor are thinking through implications here. To review:

1. In a previous comment, you decried pharma profits
2. Then in 154, you suggest that pharma profits are OK, and indeed will still be plentiful under single payer
3. But then, taking away with the other hand, you suggest that maybe pharma profits aren't important because useful drug development is happening in government funded labs, maybe mostly there.

To take the last point first, I am afraid this is simply incorrect. Government-funded academic reaseach does lots of wonderful, essential things. It does not typically -- indeed, hardly ever -- identify useful drug candidates, run pre-clinical experiments to winnow down a set of candidates into a lead program, and fund the clinical development and manufacturing scale up of that program. No doubt there are some occassions when academics do more, or even most of the heavy lifting (maybe paclitaxel is one of these cases). In general, however, this is simply an incorrect view of what drug development requires and where it goes on. Email me if you want more detail on this.

So, again, we are left with the importance of a financial incentive for producing new drugs (and new medical devices, and new diagnostics, etc). So now the question comes: who should determine the incentive? I say a system is better when:
--more people have a chance to make their own decision about cost/benefit
--the person making the decision is closer to the person effected
--there is more ability to adjust to a poor decision
--there is more 'feedback' between suppliers and customers
--issues unrelated to cost/benefit play less of a role
These sound to more like the characteristic of a market, and less like the characteristics of procurement under government monopsony. No doubt we will want it to remain a highly regulated market in many ways, of course. And in certain areas (diseases of populations withouth the ability to pay) we may need to supplement market mechanisms.

The University of Rochester developed the concept of a COX-2 inhibitor with NIH money. To take that research and turn it into something you can actually give a sick person, Big Pharma spent hundreds of millions of dollars. The result was what someone would no doubt call at least one me-too drug (Celebrex). And what do you know, it turns out that not making real people worse is a lot harder that figuring out the theoretical basis for making people better.

And how did Pfizer know the structure of Cox-2? Because Daniel Simmons identified it and sequenced the gene while at Harvard and BYU. Where do you think these enzyme cascades get elucidated? Not at Big Pharma. The reason Big Pharma has the money to put into screening a bazillion small molecules for specific targets along with clinical trials is that NIH funds research in these fields to the tune of 30 billion a year. Clinical trials could easily be publicly funded, and research universities with med schools would jump at the chance to get that funding.

Also, not to be contrarian, but TLL's arguments are not entirely bullshit. They're not the anti-UHC arguments he thinks they are, but rather a warning against the significant effects established interests will have on the enactment of UHC. If any kind of universal health care becomes likely, a lot of rich people will have a significant interest in the eventual form it will take. TLL's "scale" arguments are bullshit, but those about the rent-seeking possibilities are not.

169: I think I disagree with most of that list. Or think it's weirdly configured. Something's wrong there.

171: Yeah, but that's kind of a "duh" sort of thing. Nobody thoughtful is denying that transition is a huge issue and that a lot of existing players are going to need to be bought off in one way or another.

And how did Pfizer know the structure of Cox-2?

Vioxx was a catastrophe. Celebrex, somewhat less so. And the nature of the catastrophe had very little to do with understanding the structure of Cox-2 and running clinical trials. Rather, it had to do with trying to balance the anti-inflammatory and hypertensive effects by tweaking small molecules to the point where you have something you can give to people with arthritic pain and not kill any of them. Universities don't do this. In fact, a lot of academic chemists frown on it as uninteresting and menial work. They could learn, sure, but thinking that they do it now and drug companies just come in and free ride and scoop up all the profits is mistaken.

gswift -- I am having trouble thinking you are serious, or maybe I just am misunderstanding you. Of course academic research is essential, but it is in no way the whole story. The idea that pharma and biotech can just read off academic research to get drugs is preposterous. If they could, the majority of clinical candidates (that is, drugs good enough to actually make it into human) would not fail in development. p38 MAP kinase (crystal structure first identified by that well known university lab Vertex Pharmaceuticals, by the way) looked like a great target for inflammation. Those drugs have to date all been busts. IL-1 looked like a great target, and a drug even got approved there, but ultimate efficacy (and thus sales) were so well below hopes. Hey, selective COX-2 inhibition -- that sounded like a good idea! And these are just the failures we've heard of -- the ones were promising enough to make it far enough to make the ultimate failure sting all the more.

If your point is that all the work done by biotech and pharma could, in principle, be done by government funding, I have to agree. The government could also in principle take on all work done by the consumer electronics industry, or the automotive industry. I tend to think that's not the path to take if you want to maximize innovation. Do you disagree?

Universities don't do this. In fact, a lot of academic chemists frown on it as uninteresting and menial work. They could learn, sure, but thinking that they do it now and drug companies just come in and free ride and scoop up all the profits is mistaken.

Well yeah, universities and public hospitals don't currently do this side of it. But baa's " I want there to be a huge financial incentive to develop drugs." makes it sound like without drug companies, this work wouldn't get done. That's just crap.

Or think it's weirdly configured. Something's wrong there.

Yeah, there's probably some way I could have stated the point more obscurely and incomprehensibly, but not a lot of ways.

The main point is that we all agree (or should agree) that the profit motive spurs innovation. So the question is, who decides the 'right amount' of profit. In a market system, the 'right amount' emerges from the collective decisions of market players. It changes based on a multitude of circumstances too complicated for any one person to grasp. This isn't the "right" answer. It's just more likely to be useful than if the smartest expert in the world tried to decide the right answer.

And with political price setting, there is no guarantee that the decision will be made by the smartest expert in the world. We may get someone with an ax to grind, or someone who is responsive to specific interest groups, or someone who is lazy, or someone who wants to favor their pet project.

The government could also in principle take on all work done by the consumer electronics industry, or the automotive industry. I tend to think that's not the path to take if you want to maximize innovation. Do you disagree?

Yes, I do. Govt. funding for the clinical trial side plus a modest profit sharing/bonus program to researchers would drive innovation just fine.

without drug companies, this work wouldn't get done. That's just crap.

Now I'm not sure what the claim is. It's a matter of fact that for probably 90% of the new chemical entities approved for sale in the past 10 years, identifying the lead, pre-clinical development, clinical testing, and scale -up of commercial grade material were paid for and orchestrated by pharma/biotech companies. Government could of course take over this job. The question is why we would want them to.

Yes, I do. Govt. funding for the clinical trial side plus a modest profit sharing/bonus program to researchers would drive innovation just fine.

You would think this approach would be popular in Europe if it worked, as Europe is both technologically advanced and not philosophically opposed to government-owned companies. Yet this is not what occurs. Their drug companies are run pretty much like ours.

I don't think the government should take over running the pharmaceutical companies but there is nothing wrong with the US bargaining with drug companies to get cheaper drugs like canada does.

Pharmaceutical companies are in a little development slump recently. It isn't their fault; It is legitimately hard to come up with good new drugs. I would just be more worried about having a single payer US system reducing pharmaceutical R+D if the pharmaceutical companies were curing some cancer.

Govt. funding for the clinical trial side plus a modest profit sharing/bonus program to researchers would drive innovation just fine.

We're at an impasse here, I guess. If I may be so bold, do you have any direct exposure or experience with the process of drug discovery? I say this because I think your comments here reflect an incomplete view of what drug discovery/development entails. Usually this is a ten year process from thinking a target is a good idea, to finding some initial chemical probes against that target, to working up a lead series, to finding a clinical candidate, to designing and getting that candidate through clinical studies. Academics labs are not currently set up to do this work. If we want to have them do it, it will mean substantially revising the way they operate -- in effect creating little pharmaceutical R+D companies. As Jake points out, none of the great European pharma cos are run this way.

There's also the assumption that the decision process of a giant NIH for drugs will be as efficient as the millions of disaggregated decisions of the financial markets. This seems to me a scary assumption to make. There was no consensus in 1980 that proteins would be the next breakthrough area in pharmaceuticals. There was no consensus in 1990 that monoclonal antibodies were going to finally work after being a black hole for so many years. Yet some people took a gamble on it, now are rich, and that incentive created a horde of new entrants in the biotech industry. Sure, in principle, you could have a grant-making body that would take as many risks, and would place as many and as large bets, and would respond as quickly to new information as investors who are all looking to get rich.

If you like "that old British MP guy", you could always buy his ambient house album

A state run health care enterprise is bureaucratic, and I think the terrorists have shown over and over again, whether it's dealing with INS or whether it's dealing with airport security, they're very good at gaming the system with bureaucracies. They're very good at getting around bureaucracies. [...] And if one of your guys is a jihadist, if one of your doctors is spending all the time online reading Osama bin Laden fatwas, someone's going to notice that. But the National Health Service is more like the post office, you know there's a lot of anonymity, it's easy to hide in the bureaucracy.

clearing up some points ... (imagine a really irritating piano backing track playing over this bit)

For some reason, TLL is pretending that the only option is an NHS-style system in which there are no options other than the barebones state-run hospitals

That would not be an NHS style system. The UK has plenty of private medicine and plenty of rather chic and expensive hospitals.

and for this reason, nobody says:

"There's a bunch of chemo treatments that might help, but probably not, and they're pretty expensive, so we aren't going to give you them"

they say

"There's a bunch of chemo treatments that might help, but probably not, and they're pretty expensive, so we aren't going to give you them, so you will have to pay for them yourself if you want them, like they do in America".

healthcare is not rationed by policy in the UK. It is rationed by policy, then price. This fairly basic point of economics needs to be taken into account.

also, I double ubble promise you that the UK and Europe has a pharmaceutical industry and even invents the odd thing. It just isn't the case that the entire apparatus of American healthcare is needed for any drugs to be developed anywhere at all.

I double ubble promise you that the UK and Europe has a pharmaceutical industry and even invents the odd thing.

I hope no one disputes this. The point is that for Sanofi-Aventis, just as for Pfizer, the most profitable market is the United States. If the US market were to become less profitable, fewer funds would flow to drug development in the EU just as in the US. Right?

In the interests of moving that argument toward one that works - it certainly "isn't the case that the entire apparatus of American healthcare is needed for any drugs to be developed."

Shrinking the world market for drugs - as measured in revenue - will have some effect on R&D in that industry. How much? Hard to say. Right now, the American market is disproportionately lucrative for the drug companies, and shrinking that market, as measured in revenue, is exactly what nearly all UHC proposals aim to do by going to a monopsonist drug purchase system to ensure lower drug prices. That isn't a dispositive objection, but who wants to give the golden egg-laying goose indigestion if avoidable or mitigable?

It might be interesting to see if there's a way to leverage going to a UHC into faster and cheaper FDA approval processes.

If the US market were to become less profitable, fewer funds would flow to drug development in the EU just as in the US. Right?

Wouldn't bet anything important on this one. Marginal productivity arguments aren't very well suited to things like pharmaceuticals research, because you can't buy an infinitesimal unit of research, and drug approvals don't really work according to twice-differentiable Cobb-Douglas production functions either. The flow of funds to drug development is constrained by the supply of good ideas rather than anything else.

The flow of funds to drug development is constrained by the supply of good ideas rather than anything else.

There are certainly dollars chasing deals presently, at least in Phase II and higher. Substantially reduce the profitability of the US pharma market, however, and I suspect you'll see less private equity allocation to drugs.

drug approvals don't really work according to twice-differentiable Cobb-Douglas production functions either

Sorry, I am missing this. Is the argument that more capital doesn't lead to more entrants into the pipeline?

dsquared - Could you elaborate? I think I can see an argument that drug development funding wouldn't adjust in fine increments, but I do not see from the above why you would be confident that it wouldn't adjust significantly.

We should all be very, very scared by audience reactions like the one in this case. It proves that Americans can be easily stirred to action by a one-sided, manipulative presentation of an issue.

Even taking it as a given that there is a lot wrong with health care in America, any attempt to fix the system should be made carefully and with an intelligent weighing of the many difficult trade-offs involved -- not by an angry mob stirred up by tragic stories presented out of context. A more sober reaction to SiCKO is in the NYT, here.

It's a hits-based business which is currently earning big economic rents. It's actually quite difficult to scale a business like that up or down - you increase your risk if you become more concentrated in a few targets. It would be possible to price-regulate the industry out of business, but this is like saying that a 100% tax rate would mean revenue of zero - it doesn't give a licence to draw a whole Laffer curve and make very definite statements about where we are on it.

The USA is 50% of Pfizer's revenues and 50% of their long-lived assets (ie patents) in the last report and accounts. It isn't the whole story at all, btw - lots of Americans seem to have this belief that they pay for everything! in the entire world!

If I may be so bold, do you have any direct exposure or experience with the process of drug discovery?

I don't currently work in the industry. Majored in biochem at U. of Utah, with a number of my faculty involved in drug development. Wife is same major, and currently works in one of the largest research labs at HCI.

Academics labs are not currently set up to do this work. If we want to have them do it, it will mean substantially revising the way they operate -- in effect creating little pharmaceutical R+D companies.

Well so what? And I'm not saying we have to nationalize the entire industry. But to have a promising avenue not get tested because it won't be profitable is godamn ridiculous.

There's also the assumption that the decision process of a giant NIH for drugs will be as efficient as the millions of disaggregated decisions of the financial markets. This seems to me a scary assumption to make.

Ooooh, scary! Our current system of healthcare and drug discovery in this country doesn't get within a country mile of "efficient."

You do realize the NIH just doesn't randomly mail out money, right? Researchers write proposals, those proposals get evaluated, and money gets distributed. Researchers who get results tend to get more funding. Crazy, I know.

Here's the part that makes conservatives cry. Money goes to projects that look like they might yield useful results even if there's no prospect of profits.

Can I just say how funny it is to watch someone with basically no knowledge of economics (HC) trying to out-argue someone who actually knows a fair bit of economics (dsquared)? It's like watching a Rottweiler tearing apart a throw pillow.

There was no consensus in 1990 that monoclonal antibodies were going to finally work after being a black hole for so many years. Yet some people took a gamble on it, now are rich, and that incentive created a horde of new entrants in the biotech industry. Sure, in principle, you could have a grant-making body that would take as many risks, and would place as many and as large bets, and would respond as quickly to new information as investors who are all looking to get rich.

They took a gamble on the work of a research hospital., specifically, this guy.

DEVELOPMENT OF Rituxan can be traced back to 1979, when hematologist and oncologist Lee M. Nadler of Dana-Farber Cancer Institute, Boston, developed a mAb that bound to CD20, a cancer-associated receptor on B cells (antibody-producing immune cells).

You're on crack if you think only a business would have recognized the potential of this research. As dsquared mentioned, pharma is a hits based business, and this severely limits their avenues of exploration.

Lack of innovation if goverment funded? I bet a robust public funding of drug development would give you more innovation, as it could operate with an eye purely for results without worry of recuperating costs.

It's clear the US spends more, it's not so clear (at least, based on data I have seen) that the US doesn't "get more" (in certain ways) for that spend.

Lotsa nonsense in this thread. I'll note that drug companies spend more on marketing than research. And baa's assumption that drug prices won't change upward for Canada if the U.S. goes universal is simply a denial of the basic rules of supply and demand.

But with the quote above, we're getting into real flat-earth territory. Fact is, health outcomes are almost always better in countries with universal healthcare. There are obvious reasons for this. (Infant mortality is a big, easily measured one.) To suggest that this is just coincidence - well, they haven't proved evolution, either. So what?

One of the goals of universal health care is to get people to consume more health care. And of course, health in the US is worse because we have more poor people, since one of the salient features of our present system is that poor people don't get health care.

It still amazes me to see conservatives making the argument that the U.S. is too fucked up to do things other countries do. They concede that the US is significantly worse than most countries both in costs and results, but that kind of comparison is invalid because of -- something or another. Besides being unpatriotic and traitorous, this seems like desperate ad hoc argumentation, like in freshman philosophy seminars.

I don't think that we should look at public opinion for the reason why why don't have anything like UHC and perhaps never will. The insurance companies have a tremendous investment in the present system, and both the mass media and our political leaders have been bought.

Fact is, health outcomes are almost always better in countries with universal healthcare.

It does seem an article of faith with some people that universal health care must be bad, or that there's something special about the US system that makes it differently better. To this end they go through the most contorted arguments to try to make this so even in the face of overwhelming evidence to the contrary.

110: Hallelujah!

Beefo Meaty, with all respect, it's statements like 154 that make me concerned about how carefully advocates of government-as-sole-payor are thinking through implications here.

Baa, everything you say makes me concerned about how carefully opponents of government-as-sole-payor are thinking through implications here. You stipulate as a first principle, based on hand-waving "other factors", that the elephant in the room (higher cost, worse results) should just be ignored. And you demand that everyone else argue by the rules that you have asserted.

gswift -- I am having trouble thinking you are serious, or maybe I just am misunderstanding you.

Same to you, buddy. Your contribution her all just looks like ideological special pleading to me. A lot of what you say is relevant to details of implementation, but you are arguing against the whole concept.

I don't think that the American public should consent to be pharma's cash cow forever. If we think that Europe is free riding, we do the same as Europe and let pharma even things out.

Skepticism has been expressed about the contribution of medicine per se to health outcomes. The same skepticism can be expressed about pharma's contribution. A lot of the new drugs are marginally superior copycats, and drugs are only one factor in medical care and health. For example, trauma care has been revamped over the last decade or two, with good results, and new drugs has played (IIRC) a minor role.

We should all be very, very scared by audience reactions like the one in this case. It proves that Americans can be easily stirred to action by a one-sided, manipulative presentation of an issue.

Glad you finally got the word, GB. I feel your pain.

Things were going along so wonderfully, and then Michael Moore came along.

I don't care how religious Americans are, no one's enough of a nitwit to argue that their faith-healer should be paid for by the government.

When Massachusetts passed a law in 1989 mandating insurance coverage for all college students, it contained the following provision:

"A qualifying student health insurance program shall include services delivered in accordance with the healing practices of Christian Science."
Massachusetts G.L. c.15A, § 18, 3.04-2(b)

Now Christian Scientists are a surprisingly powerful constituency in Massachusetts, but surely no more so than Christian fundies in the U.S. as a whole.

BTW, there is no more passionate advocate of UHC than I. I'm just pointing out that the notion LB dismisses as unthinkable is not, in fact, that inplausible.

Quick points in a late thread:
1) Of course people will use more healthcare services if they're free. This isn't because people are greedy and selfish; it's because if you don't have health insurance, you can't afford to get the medical care unless it's really serious. You hope the cough goes away, or that the stomach pain isn't appendicitis.
The question is whether using more healthcare services translates into spending more healthcare dollars. 95% of medical costs now are incurred the last six months of life; if that holds true, then someone going to a doctor instead of waiting out a cold isn't going to overburden the system. What does overburden emergency rooms? People with no insurance or insurance that covers emergency visits but not doctor's appointments.

2) UHC doesn't outlaw private insurance.

3) Given 2), I'm not sure of the damage to the pharmaceutical industry. The government subsidizes the generic versions; people can either pay full price for the newer drugs or have their legal, private insurance do it. This is better than most people's options at this point because most drugs would be covered.

Very quickly...

Cala, do you have a citation for the "95% of health care costs occur in the last 6 months of life" bit?

if you can't find one, don't worry, that's because it's complete bullshit.

According to this:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1361028

60% or more health care expenditure over a life time (for those who live to 65) does take place over the age of 65. Health-care spending is heavily weighted towards the elderly and those nearing the end of their lives, but 95% isn't right.

3. Require everyone above some income level to purchase health insurance - whether it is high deductible or low can be up to them

Why? Why? Why? Why should I be forced to put money in the pockets of insurance company shareholders and pay the salaries of people who actively look for ways to give me less care, just because I make more than some arbitrary amount of money? If I'm going to be forced to participate in a system, I'd much rather it be a not-for-profit system, thank you.

"The last six months of life" includes the last six months of anyone who dies prematurely, not just old people. How much of this is directed to futile measures is unknown to me. If you spend (say) a million dollars trying to save five accident victims and save only one of them, that doesn't mean that $200,000 was well spent and $800,000 wasted, because you never know in advance for sure who can be saved.

It's actually quite difficult to scale a business like that up or down - you increase your risk if you become more concentrated in a few targets.

If you were talking just about big pharma, maybe. But we have lots of new entrants into the industry via small biotech. These are often single-program bets. They are easy to "scale down" = not fund. Also, I don't know PFE's net revenue breakdown, but I can assure you, the US is the most important market based on profitability for almost every drug. If you really doubt this, I will dig up some

gswift: if you think the story of the development of MAbs as an important therapeutic class is simply "it's all thanks to Lee Nadler," I don't really know what to tell you. Lee Nadler would not say that himself. Likewise, if you believe that a system of market prices retards innovation, and can easily be replaced by a system of expert judgments we are probably at a basic impass.

emerson: a number of topics have been treated in this thread. I didn't mean to "wave away" the cross country comparisons, but I do think there are reasons for believing they could be an inaccurate measure for judging total health care system efficiency. Even our government-run health care (Medicare) seems to be pretty expensive in terms of $/lives covered when compared to the EU states. So it is hard for me to believe that the key variable is "who pays" as opposed to what gets paid for, and what incentives exist. On pharma, I don't know what to tell you. Just based on the math, pharma profits can't be the problem with US health care. All pharma spend is ~20% of costs, profits are some small fraction of that. Eliminating 18% of 20% of spending, even if you could, just isn't making our spend go from 15% of GDP to Germany's 10%.

And baa's assumption that drug prices won't change upward for Canada if the U.S. goes universal

Where did I assume this? I do agree that it's fairly unlikely -- pharma wants to charge as much as they can now. If they could charge Canada more, they would. Why Canada would pay more in order to "make up" for lost Pharma profits I don't fully understand. But I do generally think we are moving towards more uniform world pricing.

The government subsidizes the generic versions; people can either pay full price for the newer drugs or have their legal, private insurance do it.

Cala makes a good point here that extending government coverage doesn't necessarily threaten innovation. It depends how you do it. Most of my points on pharma here are directed to a view which sees profits as opposed to innovation. The approach she suggests (governments pay for generics, individuals insure themselves or pay out of pocket for brandeds) would be a great start. I wish the Medicare prescription drug plan had been done this way. Indeed, I would much prefer a situation where people bore some element of the additional costs of branded products. There are some branded drugs out there that are really marginal improvements over the generics, and it would be great to decrease the economic incentive to use (and thus to supply) these drugs.

Why should I be forced to put money in the pockets of insurance company shareholders and pay the salaries of people who actively look for ways to give me less care, just because I make more than some arbitrary amount of money?

The question answers itself: Because it puts more money in the pockets of insurance companies.

In a capitalist system like ours, we need to assure healthy profits for insurance companies, because without it they wouldn't be able to research new ways to ensure that health care is used less.

As baa points out, the key problem with the American health care system is that people consume too much healthcare.

Sheesh. Don't you understand how markets work?

Why should I be forced to put money in the pockets of insurance company shareholders

The idea is: you should be forced to carry catastrophic insurance because if you are hit by a truck and can't pay, we aren't going to let you die. A similar (although not identical) logic is behind forcing people to have collision insurance as a condition of a driver's license. Whether that insurance is private or public I don't much care, provided that there is relevant competition among different offerings.

Baa, the elephant is still in the room. And you seem to be sticking to your traitorous American exceptionalism.

gswift: if you think the story of the development of MAbs as an important therapeutic class is simply "it's all thanks to Lee Nadler," I don't really know what to tell you. Lee Nadler would not say that himself.

That's not what I said at all. You're deliberately characterizing the advent of mAb's as the power of market innovation at work. Well, when the process to produce the damn things is invented at Oxford, and the mAb in question is identified at a research hospital, there's no reason at all to think the subsequent drug development and testing couldn't also be done with govt. funding.

Likewise, if you believe that a system of market prices retards innovation, and can easily be replaced by a system of expert judgments we are probably at a basic impass.

Jesus baa, you have no idea how this stuff works at all. You think some panel on high determines the course of all federal research? Take colon cancer. There's not a designated colon cancer lab that gets all the NIH money for research. There's a lot of labs in different universities, competing for grants, attacking various knowledge gaps, and attacking those gaps from a variety of angles. Funding is awarded without regard to potential profit. Yes, this includes drug testing on animal models. Moreover, their findings get published, and every other lab can then build on that work.

Portraying this as a system short on innovation and efficiency is completely divorced from reality.

The funny thing is, I'm fairly uncertain on the universal healthcare question, since I've never looked closely at it myself, but I tend to think it's probably a good idea based on the fact that so many people who opinions I respect seem to think it's a good idea (although how they all became such experts I'm really not sure), but to my mind baa's made many of the most compelling points in this thread. Which have largely gone unanswered. That so many UHC discussions seem to go that way is why I have my lingering doubts.

Why Canada would pay more in order to "make up" for lost Pharma profits I don't fully understand. But I do generally think we are moving towards more uniform world pricing.

I am mystified that you don't see the apparent contradiction between sentence 1 and 2 here. If pricing is already perfect and static, how can it become more uniform? And how will it become more uniform unless Canada (for instance) pays more? I'll ask you: Why would they do that?

And sentence 1 not only twists my words, it does so using quotation marks, for chrissakes. I mean, come on.

Companies aren't going to raise prices on Canada, relative to the U.S., to "make up" for anything. They are going to do it because the economics of the situation will change if the U.S. goes UHC because the U.S. (I'm guessing) will stop subsidizing the rest of the world as much as it currently does.

Granted, Canada may choose to do without drugs instead. But hey, that's the free market at work.

211: As I think should be obvious is you read my entire comment, I'm not against insurance, I'm against a for-profit insurance system, where profit is maximized as my access to health care is minimized.

Actually, I can easily believe that implementation of UHC could precipitate serious problems in the economy, but it's way past time to stop pretending the dilemma is all about ways to deliver the best care.

Although I do recognize that the incentive schemes in our "private" health care system are so egregiously fucked up that it's completely laughable when people use incentive-based arguments that as the main sword against UHC. The incentives won't be perfect but good god how could they be any worse?

Brock, as I said, Baa is using a list of things that UHC designers will have to think about as arguments against UHC. As I said, free-marketers are defeatists about government -- you can see that in several of his posts. Rather than asking "What's the best way to do this?" he's saying "There will be problems. Maybe we shouldn't try".

And I also said, free-marketers also sabotage government when they get a chance -- that's one of the Bush administration's main strategies. UHC is ideologically verboten to a lot of people, and they will throw any argument they can dig up at it.

Privatization of public functions is often worse than either private provision or government provision -- look at military contracting. Government-mandated private insurance would very likely end up as graft, along the lines of farm programs. Anti-government rhetoric often ends up validating looting the taxpayer.

Just to repeat, there's no reason why US patients should bear more than their share of drug development costs, if that's what's really happening. Level the playing field, and drug development will find its level. Baa can make a voluntary extra contribution to drug development if he so wishes, but I'd rather spend my money otherwise.

baa actually appears to be OK with some forms of UHC, inc. mandated insurance, no? (I don't, myself, like mandated insurance.)

John: I understand your point. I guess I'm just interested (and I assume baa is as well) in seeing that someone has actually thought through all these things that UHC designers will have to think about. And just saying "well it works in other countries; we don't have to think about them" doesn't really work. Maybe this step is premature, in which case, fine. But it's hard to get me to want to sign on to a massive overhaul of our government and our economy without having the details in place. I think UHC is potentially a very, very good idea. Is that all you want to hear?

I do agree with you that the people in government who are fighting against UHC because it would be so "problematic" are the same people who would be making all the problems.

And just saying "well it works in other countries; we don't have to think about them" doesn't really work.

More like, "it works for other countries, and while doubtless we're a unique snowflake of a country, I'm pretty damn sure it'll work for us too."

I guess I'm just interested ... in seeing that someone has actually thought through all these things that UHC designers will have to think about. And just saying "well it works in other countries; we don't have to think about them" doesn't really work.

Seriously, why the hell doesn't it work? People *have* though these things through. Anyone designing a UHC system has all the other extant systems to use as a starting point.

The anti-UHC people keep throwing up alleged problems which make UHC non-viable, when there is the example of all the other countries with UHC where it's extremely bloody viable. The anti-UHC people are the ones with burden of proof. Explain why a fully private system -- which as has already been pointed out, produces worst outcomes than just about every UHC system ever designed -- is better.

And then we get lots of mysterian reasoning about how the US is so different or the US subsidises everyone else. Well, bollocks.

But, gswift, you do at least understand why, given our unique position in the global healthcare market, and our nation's size, diversity and demographics, that's not self-evident, right? I'd just like confirmation that your "pretty damn sure" is based on something more than gut hunch. I mean, I'm pretty damn sure, too, but it *is* just a gut hunch, and I admit there are some interesting questions that need tackling.

Brock, it's not like this is a mysterious step into the unknown. We're last in line. I would be quite happy to flip a coin between the French, British, Swedish, and Canadian systems, but it shouldn't be too hard to work out a superior system based on the observed strengths and weaknesses of the already-existing systems and the specifics of American life.

The American people are a cash cow. The insurance companies, the drug companies, and possibly the HMOs will fight this tooth and nail. Our governmental system is designed for the benefit of grafters and self-interested obstructionists, and the media and Congress have been bought. That's what's really going on here.

The detail I worry about is, "How do we get this through Congress without it being loaded with poison pills and boodle?" That's an enormous detail, but it's not what Baa is talking about except that he relies on his contempt for the American political system (which his political friends, however, work very efficiently) to justify his assertions of impossibility. I would feel better about Baa's continued assertion that the US is uniquely fucked up if he weren't one of the people working to keep it that way.

baa (and other mandated-insurance advocates) a couple thoughts:
1) Speaking from personal experience, high deductible coverage sucks and having a system that would ensure people had that would make everyone feel better that we'd solved the problem, maybe, but mean bupkus in terms of actual health. My parents, 56 and 51, small businessman dad, have high deductible insurance. It means my mom's facing middle age with no access to health care for that weird palpitation she's been having because out of pocket will be in the thousands of dollars.

This leads me to 2):
Who insures the uninsurable? This is a bigger category than you think: again, my parents, no pre-existing conditions, excellent health histories cannot afford anything better than the high deductible nonsense that they have. They're not upper-middle class, but they're comfortable, home-owners, whole thing, not a 'demographic problem.'. Had my mom been treated for depression or dad had a heart attack, no one would touch them.

The state? Fair enough. But that's going to drive the insurance costs for the state through the roof. You need a big, healthy pool of applicants to make an insurance plan work. The market loves young people like me in perfect health. They don't like older folks. Why would we design a system so as to introduce competition for the most desired risk level?

Okay, I'm meant to be cleaning and organizing today, so I don't have time for more than a hit-and-run comment, with about 1/4 of the comments unread, but here's my thoughts:

1. Moral hazards
a. Malpractice insanity. A cardio-thoracic surgeon of my acquaintance is making the same amount (not adj for inflation) that he did in 1983, when you factor in malpractice insurance costs. Hazard: HUGE disincentive for talented med students to specialize in important life-saving work, pushed into plastic-surgery or something instead. Hurts everybody.
b. Lack of basic care. Almost everyone seems to agree this is a problem, yet when our evil governor here in MN forced huge spending cuts in the state insurance program, tens of thousands of poor folx were left with even less access to any sort of non-emergency health care than they had had before. I'm totally fine with a system that says "Okay, you want a liver transplant at 72? You're paying for 100% of it, 'cause this month we've got 20,000 babies who need their immunizations, 5,000 women who need pre-natal care, and 15,000 children who need glasses so they can keep up in school."
c. Distortion of electoral politics. As long as some kind of UHC is on the table -- and I think it will be until we get it -- the bad actors are going to be funneling huge amounts of scratch into the campaign finance system to prevent it from happening. Let's just get it over with and get some of that big money out of politics.
d. Over-use vs. under-use. I guess that there's a lot of commenters here who barely see a poor person, much less speak to one, in the course of an average week. Because where I live, one of the savage inequalities around healthcare is pretty obviously underutilization based on despair. If you know that you can go to the free clinic, but the care you receive will be harried, incomplete and demoralizing, why bother to go in at all unless you're in terrible pain? This is probably most severe in terms of dental care, gynecological care and regular adult check-ups, but it extends to all parts of health care in working-class areas, from what I've seen.

Also, I think Michael Moore needs to really look at some of his hypotheses and recognize that he must name the beast. This is all about capitalism, and the palliative effect of universal health care, while pleasant, shouldn't elide the fact that our civillization will be steeped in misery and oppression as long we maintain this wasteful, corrupt and ultimately self-destructive economic system.

gswwift -- we are talking past each other. I do not deny that the academic grant system produces great research. Nor do I deny that academic research is an absolutely crucial element in the development of new drugs. Nor do I think there's some single panel "on high" determining all grants.

What I do think is:
a) markets are good at assigning capital efficiently, and good at producing innovation. When resources get directed on the basis of profitability that's a good thing, according to me, because a profit opportunity means that you a providing something that people think is valuable. Also, high profitability draws new entrants.
b) the profit motive does not suffice. It tends to do a bad job at producing general research where value can't be captured, and it does a terrible job at producing products where there's a need, but no market (for example, endemic diseases of the 3rd world). In both those cases, I am pleased to have government funding, and would be happy to see more of it.
c) academic labs don't, by and large, do drug development. That's not what they are set up to do structurally, that's not what they are set up to do culturally. This is not to say that we couldn't decide to replicate a pharmaceutical company with government funding. We could. I suspect it would be a bad idea, for the same reasons that government run industries general tend to be bad ideas.

As for rituxan: I am sorry if I mischaracterized you. Arguing about one drug is probably not going to get us anywhere. But let me be clear that I'm not trying to either diminish the importance of academic research. No academic labs, no rituxan. No academic labs, no herceptin. The point I was trying to make is that once people figured out humanization had been cracked there was huge private investment in antibody products. The same thing is happening now with RNAi. This is a good thing -- we want the market to respond to new technology with investment.

political football -- I don't think there's a contradiction, although I may have expressed myself badly. The point that the price that Canada is willing to pay does not depend on how profitable pharma is, it depends on Canada's decision of how much the drugs are worth. You are correct that if Pfizer decides to charge more in Canada -- for whatever reason -- Canada will be free to choose to accept or reject that price. Which is fine. The uniform pricing refers to an increasing practice of not doing differential pricing by market because of the fear of reimportation. For the drugs I am aware of, this has led to them not being reimbursed in Canada.

Let me put it this way: I'd feel 1000x better about a UHC at a state-by-state level, with all 50 states designing and providing their own plans.

Any idea that replacing our current health care system with ANY OTHER first-world system (assuming that well-off people would still be able to pay themselves for things not recommended by the formulary) is laughable.

But baa is right about the importance of drug companies. Developing a drug is not the same thing as creating a molecule that has an effect on a certain type of cell or protein. There are tens of thousands of molecules that have anti-cancer or anti-enzyme effects in culture dishes for every one that turns out to be
A) Non-toxic
B) Able to actually reach its target area in the body before being broken down
C) As good or better than what already exists
D) not to mention what the best dosage is.

None of the work to figure out A, B or D, particularly the toxicity stuff, is done (in actual humans) without a financial incentive. My fellow scientists and I generate hypotheses about what substances and procedures could improve health-care practice, but we can't test the hypotheses in an academic environment. Hospitals can test things for efficacy without drug companies being involved, if we already know that the substances or procedures are safe and can actually get into the body, and the only question is what is better than the others. THAT (epidemiology basically) is something that hospitals and government agencies do much better than for-profit enterprises. But that's not drug development. The drug is already developed at that point.

Why is everyone banging the fuck on about pharmaceutical companies anyway? Drug expenditure is i) a relatively small % of overall health expenditure and ii) still done by private corporations even IN countries with entirely state-controlled health care.

It's a piece of misdirection.

People should quit talking about America's size. That's just no reason at all. More people = more taxpayers. Quit it, guys.

"Demographics and diversity": what's that a code for? Suppose I grant that the presence in the US of Mexicans, Negroes, Indians, and other colored peoples means that the cost will be somewhat higher and results somewhat worse. The US is still predominantly white, and demographics can't explain the really striking differences we see.

The fact that the US has more poor people than European countries is an argument in favor of UHC, not against. And maybe that factor will explain another slight difference in costs and results, but the differences are too dramatic for that to be the whole story.

And again, if the US is single-handedly funding drug development, we should quit. Funny how freemarketers tolerate and even advocate enabling free rider when big business profits from it.

Let me put it this way: I'd feel 1000x better about a UHC at a state-by-state level, with all 50 states designing and providing their own plans.

Oh, gawd no. Cripes, the Reds have already done their share of racing to the bottom, as I recall.

Why is everyone banging the fuck on about pharmaceutical companies anyway? Drug expenditure is i) a relatively small % of overall health expenditure and ii) still done by private corporations even IN countries with entirely state-controlled health care.

It's a piece of misdirection.

Frankly I didn't even think that this "pharmaceutical company" argument was somehow supposed to be part of the scare tactics against UHC. I thought it was another argument entirely. The issues are, as you say, entirely unrelated.

Except for the odd person who wants to nationalize the drug industry, which would work as well as nationalizing any other non-monopolistic industry.

What we should nationalize is clinical trials, comparing one drug against another.

224: See Canada. Bigger country, similar diversity and demographics. Smaller population. So it *should* be more expensive for Canada, but they manage better health care for less cost. In fact with a small tweak, I think the Canadian system could work here. For the most part physicians there are self-employed, but there are billing controls. Adjust that latter part and I believe it would fly very easily here. There'd still be a bit to do, for example malpractice is out to lunch here. But still, it's pretty close.

Let me put it this way: I'd feel 1000x better about a UHC at a state-by-state level, with all 50 states designing and providing their own plans.

You're getting weird, Brock. Helping out people in Texas, Mississippi and Alabama should be one of the goals. I find it amazing that you seem to prefer a hybrid monster federally-mandated state-by-state plan. States can institute their own plans already (Minnesota and Oregon already have). But then you risk free-riders and medical tourism.

People are so opposed to national single-payer that all kinds of garbled pseudo-federalist programs and public-private graft pumps look better to them. The new Medicare drug program was just boodle for the drug companies.

re: 234

Whenever universal health care gets raised everyone starts talking about drug revenues and R & D. It may be another argument entirely, but it's often presented as if it's intimately tied to UHC.

The anti-UHC people

Which are who, exactly? I think even baa has acknowledged UHC as acceptable, and maybe even good, in principle.

237: That is kind of weird. Regardless of the viability and desirability of change in the pharma industry, it's orthogonal the move to some form of UHC (or anything else).

re: 238

OK, those who have expressed 'concerns' it's viability.

re: 240

Gah, 'concerns about its vaibility'. Intrusive apostrophe, missing words. Coffee-deficiency, clearly.

236: Canada's UHS is mandated federally and managed provincially. It seems to work okay, though Alberta's HC seems to be better than Ontario's.

230: C) As good or better than what already exists

Which is often a narrow definition. IMX there are several drugs that work nicely on my blood pressure but the side-effects of some are crazy-making. I'd hate to see drug diversity go down.

Coffee-deficiency, clearly

This rolls really nicely off the tongue. Really: I've been sitting here for about 30 seconds saying "Coffee-deficiency, clearly" to myself (as I drink my coffee) and admiring the sequence of the syllables.

Cough ee dee fish ents ee clear lee.

It's a piece of misdirection.

Developing a drug is not the same thing as creating a molecule that has an effect on a certain type of cell or protein.

Yes! It's the left wing equivalent of the right wing habit of blaming our higher costs on trial lawyers. Except it's likely to be more counter-productive. The benefits of pharmaceutical innovation are enormous, and it is in all of our interests to make sure it continues. I would prefer, of course, that all countries pay their "fare share."

Again, I am really pleased to see various UHC-like reforms. I am pleased to see us adopt EU practices which have proven to increase efficiency and lower costs. What worries me is the desire to have radical change on the assumption that this will create a bonanza of savings.

Someone's been hitting the marihuana early.

On the contrary.

To the contrary.

(Which is idiomatic?)

You were up hitting the marijuana late? What are you trying to say. And I think it's "to the contrary."

251: I think so too. Late a couple of days ago, yes; but its effects are not persistent. So any weirdness on my part should be ascribed to uncorrected personality traits rather than momentary intoxication.

What worries me is the desire to have radical change on the assumption that this will create a bonanza of savings.

NOBODY wants to create UHC in order to save money. We want to create it because the current system is ludicrously unfair, nonsensical and stress-inducing. It seems like it will probably save money, but that wouldn't be necessary for it to be a good idea.

IMX there are several drugs that work nicely on my blood pressure but the side-effects of some are crazy-making. I'd hate to see drug diversity go down.

Good point. I would like to see just about every effective drug covered by the typical formulary, because every patient is a unique individual. I would also like to see absolutely no advertisements for drugs. Let the doctor make an informed decision, while the patient provides crucial information for that decision based on his own and others' anecdotal experience.

(Which is idiomatic?)

"Au contraire, Pierre" is the usual formula.

"Que pasa, kielbasa?"

Concerns about moral hazard and overconsumption of health care are a red herring. Yes, countries with UHC do occasionally take steps to rein in the consumption of certain services (Germany's decision to limit patient access to week-long "therapeutic" spa visits being a notable example). But you could eliminate all "frivolous" (by whatever definition you choose) consumption of health care and not make a dent in health spending.

Why? Because of our old friend the 80-20 rule: the empirical reality that the sickest 20% of the population account for roughly 80% of the health spending.

Put another way--imagine you're an insurer, and you have to choose between two strategies: (A) seek innovative ways to deliver quality health outcomes at low cost; or (B) avoid letting yourself be on the hook for paying for any of the sickest 20%. Even if you could succeed, using strategy (A), in reducing the cost of caring for the healthier 80% to ZERO, it would still be four times as remunerative to follow strategy (B).

Once you internalize this simple fact, it becomes clear that there is no way to guarantee affordable access to health care in a system where insurers can choose which risks to insure. And mind you, it doesn't matter whether the insurers are for-profit or not-for-profit, the same logic applies regardless.

By implication, anyone who tells you that high deductible "consumer-directed" plans will solve the crisis of escalating costs and declining availability either doesn't know what he's talking about, or does know but has an incentive to pretend otherwise.

NOBODY wants to create UHC in order to save money.

Au contraire, Pierre. I sure want to.

The fact that countries with UHC uniformly spend less on administration and overhead is part of UHC's political appeal. Take out the costs for marketing, disputing responsibility for payments, and insurer profit, and you save enough get the "free lunch" of covering our 46 million uninsured for no more than we spend in today.

Now the insurers will fight this tooth and nail, so the more pragmatic reformers don't propose to take ALL of their goodies away. But if you could magically eliminate the opposition of the insurance industry, you could in fact cover every American with no aggregate increase in spending.

Take out the costs for marketing, disputing responsibility for payments, and insurer profit, and you save enough get the "free lunch" of covering our 46 million uninsured for no more than we spend in today.

Cite?

but to my mind baa's made many of the most compelling points in this thread. Which have largely gone unanswered.

As Emerson points out, once you assume that there is no useful evidence that the U.S. healthcare system is worse than the many systems that have better outcomes, you can make all kinds of compelling points.

But I gotta say, I'm really stumped as to what point he has made that hasn't been answered. Can you point to something?

This McKinsey study is pretty interesting. I can just get the interactive exhibit to launch, so no comments on methodology etc. If anyone can get their hands on the full report, that would be great. Headline claim is that adjusting for disease mix, and purchasing power, the US still spends ~ $480B more, and ~$1,600 more per capita on HC than the EU. About $690 of that per capita is cost of inputs (physicians, nurses, drugs, etc.).

I don't care if the UHC saves money. We could spend the same amount as now, so long as more people could access doctors/NPs/dentists.

(B) avoid letting yourself be on the hook for paying for any of the sickest 20%

But those belong to at least two sub-groups. There's really sick but who will recover and do stuff vs. really sick and old and who are going to die real soon anyway no matter what the docs pull off this week.

Not insisting on making every effort, no matter how silly for the latter is going to require a cultural change in the US. And that will probably require a change in the narcotics laws. Near as I can tell with out actually trying it, dying isn't all that big a deal if the pain is gone.

We've been over this before. baa's concerns about "we eat differently from the French, we have more inequality than the French, we have more violence than the French" have been factored into various studies. They show that even accounting for these things, we still live shorter lives and spend more on healthcare than other countries.

They show that even accounting for these things, we still live shorter lives and spend more on healthcare than other countries.

The table to which you link also appears to suggest that the way we provide healthcare--that is, the mix of public vs. private funding--is a much smaller factor (1/8 of years lost) than I would have assumed, and that lifestyle factors are more important than I would have assumed.

Money wasted in terminal care is diminishing, if I'm not mistaken. "Heroic efforts" are being discontinued, and even the Catholic Church accepts that.

"Terminal", however, is not easily definible. There certainly isn't a matrix or algorithm that can tell you that. My father had two heart attacks and massive intervention when he was 62, and he lived 13 more years (though he never completely regained his strenght.)

My mother had a hip transplant when she was about 80, and it vastly improved her quality of life for her remaining 7 years. She was able to remain active until the very end.

OT, but I just found out they've release Spider-Man III! Exciting! I can't wait to go see it. I understand I'm a little late in coming across this news.

Everyone says it's crap, Brock.

259: Woolhandler et al, New England Journal of Medicine, Aug 2003.

Administrative costs in the U.S. (insurers and providers) total 31% of health spending, compared to 17% in Canada. The efficiency gap amounts to over $400 billion annually, more than enough to cover 46 million uninsured.

Correction to 269: should be "$300 billion", not "$400 billion". Was a typo.

Cruel person that I am, I would suggest that our proverbial UHC pay for everything except your last illness, ie last two weeks of hospitalization, etc. Means tested for reimbursement to the hospital or docs, ie take it out of the estate if there is one.

Oooh! Then there might be an incentive to kill patients! I smell movie plots.

'Course, in the real world they kill 'em anyway [double-effect, blah blah].

They would only kill the rich people, to get the payment. They would be incentivised (?) to keep the poor alive enough to check out, and die at home later. Medicare is already sort of like this.

They could stab the rich people with an icicle. It would melt, leaving no trace of a weapon. Da-da-DUM!

My mom died at home with a visiting hospice nurse and only palliative care for about a year. She did this because my dad, an M.D., had died in a hospital. Everyone was happier with my mom's treatment, especially my mom, and my dad bitterly regretted being in a hospital during his last days.

This was a single example of a case when better is cheaper, though I wouldn't want to mandate a rule.

The state of Minnesota paid for all of the hospice care, including oxygen and medications.

Heebie is not a reliable health care expert, in my opinion.

I want to freeze to death in a hedge-maze. Would the state pay for that?

Yeah, hospice treatment either at home or in a hospice plus large doses of opiates seem to be what a lot of people prefer.

re: 278

Kubrick, Inc. can arrange it.

277: Hey, I'm a doctor!

Would the state pay for that?

In most states it would cost an awful lot in air conditioning to maintain a refrigerated hedge maze year-round, so I wouldn't approve that if I was in charge.

Heeb, I fear that your fate is to be smashed by a 60-lb. Asian carp as you cruise along at 30 mph on your jet-ski. They leap up to 4 feet int the air when you frighten them, for example with your stupid jet-ski. No maze for you.

In most states it would cost an awful lot in air conditioning to maintain a refrigerated hedge maze year-round,

If they just put a unit AC in one spot, I could just drink the antifreeze when I got there. To save costs.

I will start up a government-subsidized Get Smothered by Nubile Chicks end-of-life care company.

Heeb, if you were a real doctor you could order people to take off their clothes and bend over. You could stick your fingers anywhere. All mathematicians get to do is add up long columns of figures with paper and pencil.

They leap up to 4 feet int the air when you frighten them, for example

I'll wear a bell around my neck to avoid sneaking up on them.

Then there might be an incentive to kill patients! I smell movie plots

This is in fact the plot of Robin Cook's medical thriller Mortal Fear.

I don't know if they ever made a movie out of it.

Heebie will be offered the CTO position but will decline, pursuing instead her Quixotic hedge fantasy.

Wasn't that a method of execution on Monty Python? IIRC Graham Chapman was chased by said nubiles, and while he was thus distracted fell over a cliff.

Heeb, if you were a real doctor you could order people to take off their clothes and bend over. You could stick your fingers anywhere.

This happens all too often. Diagnosis: real doctor!

287: They won't hear the bell, because carp aren't good at that stuff. So you'll need some sonar alert-y thing, which will make the baby dolphins cry.

Hey, 290 -- you know the rules.

Carp are freshwater fish. Dolphins will not be affected.

In related news, they've recently decided that the Baiji river dolphin is extinct. Read Douglas Adams' "Last Chance to See" for more on this beast.

No poofters?

One could start a fund for Heebie's hedge-care.

Hey, 290 -- you know the rules.

Hey, 290 -- that's Arethra Franklin.

No member of the Mineshaft is to maltreat the Abos in any way at all...if there's anyone watching.

SPARTA!

Aretha.

I've heard that nude full-body mathematics is coming up with results that cannot be attained using only the staid traditional methods.

True, discreet math is becoming outmoded.

Sometimes one and one makes one.

207: The problem is that if you don't require people to buy-in, the young healthy people (esp males) will opt out. That drives up price, so then the next tier opts out, and so on. At least, that's the theory.

. The efficiency gap amounts to over [$300] billion annually, more than enough to cover 46 million uninsured.

Mmm. I don't have access to the website, so I'm going from the abstract, but the numbers seem to be slightly off. The conclusion suggest we could save $750 per US person in administrative costs (" The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita."). Assuming 300 mil. pop., and 45 mil. uninsured, I get top administrative savings of about $225 mil. from the back of the envelope. That works out to about $5K per uninsured per year. Is that enough? Might be. I think the uninsured population includes a lot of people who don't need health care--the young, basically. Q&D google suggests that healthcare costs in the US per capita are around 5K ("The latest data from the Organization for Economic Cooperation and Development (OECD), which compare trends among 30 industrialized countries, show that the U.S. spent $5,267 per capita on health care in 2002--53 percent more than any other country."), which suggests it would be. But it's not self-apparent.

Once you assume that there is no useful evidence that the U.S. healthcare system is worse than the many systems that have better outcome

I hope I have not been making this assumption.

Slolernr, hey, I promised to read that paper, and I didn't. Thanks for the reminder. On a cursory glance, the study you linked there makes the claim that public systems in Europe are more efficient because they do more primary/preventive care, focus health care on the poor better, and do fewer high cost/lower return interventions. I find that plausible. And if we can increase efficient interventions via gov't paying for them (free well child for all, etc,) I'm all for it. That's not the same thing as claiming that less efficient interventions don't have benefits. Again, I am working not from my independent analysis of the literature, but from speaking with health care economists who say the "what are we getting for with that extra spend" question turns out to complicated, and that the answer isn't the "you're getting nothing, you fools!" one that looking at life expectancy would suggest. I'll also add that the general "free-lunch" thesis Lindert offers is fascinating. Do you know what the general discussion/response has been?

306: The reaction is going to be slow. Lindert's in a field where there are very few scholars, so there's not likely to be a huge number of studies agreeing or disagreeing right away. And it's only going to have an osmotic impact on more general historical and analytical work. I have not seen much policy-wonk impact in the U.S.

But yes, it's fascinating.

Here's some math:
304+305+306+307 = BUZZKILL!

305: SCMT, the $752 per capita is a little out of date. You get the $300 billion by taking the difference between 31% and 17% (14%) and multiplying by current U.S. health care spend (around 2.15 trillion). The average single health insurance premium in 2006 was $4,200 (source here).

Multiply that by 46 million uninsured and you get $193 million.

So I stand by my contention that you could theoretically insure all the uninsured with the administrative savings from a decently run national health care system.

And just to kill everyone's buzz, the full NEJN study on comparative administrative efficiency can be found here

390: $193million s/b $193 billion. AARRRGH!

But what's three orders of magnitude among friends, right?

Knecht Ruprecht, do you have the link to the accompanying Henry Aaron (Brookings, not Cooperstown) editorial?

Let's return to the topic at hand: Heebie's beautiful ass as seen by carp.

312: Sorry, don't have it. If I did, though, I'd gladly trade it for pictures of Heebie's ass as seen by a carp.

On a cursory glance, the study you linked there makes the claim that public systems in Europe are more efficient because they do more primary/preventive care, focus health care on the poor better, and do fewer high cost/lower return interventions.

Well, right. Sure there are tradeoffs, but that right there is how you make health care more efficient, markets be damned.

Somewhat OT, but 297.2 has me desperate to call somebody "Urethra Franklin"

Google it, Sifu, and you'll find that you're not alone.

Well played, Jesu.

Ezra Klein recommendeds this book:

http://www.amazon.com/Understanding-Health-Policy-Thomas-Bodenheimer/dp/0071423117

It gives a good overview of the us healthcare system and gives comparisons to other countries. It is very readable and statistics packed.

Canadians go to the doctor 20% more than Americans, yet pay 40% less per capita for doctor services. Free lunch, motherfuckers.

Baa is right that demographics affect health outcomes. African Americans are generally less healthy than white people who are generally less healthy than Hispanics. It is a kind of a mystery. That isn't any reason not to to go to a UHS.

I'm sitting on Heebie's ass right now!

Are your koi ogling it?

I keep koi in the toilet for that very purpose.

Relatedly, if you want to get over a woman quickly, there's nothing quite like imagining her on the toilet with the runs. Or so I've been told.

That only works if you had her on a pedestal.

A pedestal toilet would be a fantastic addition to the bathroom.

I certainly don't deny that imagining her with the runs on a pedestal above you probably works even better.

I've heard the sentiment in 322 before, and it does annoy the hell out of me. It's like, "I loved her, but didn't permit her to be fully human in my head. In order to disqualify her, I allowed her to be a regular human being."

See, now I'm getting all worked up.

Urethra Franklin doesn't care about heebie's butt.

Also, koi are carp, heebie. Never use that toilet again.

Hey, you put her on the pedestal. I put her on a toilet, which seems pretty human to me. Indeed, I would go so far as to say that it's at the toilet where we find our common humanity. Or something like that. Maybe "bare our common humanity." Hmm.

And, to wipe yourself after you use the pedestal toilet, we have...

Also,

I put her on a toilet, which seems pretty human to me. Indeed, I would go so far as to say that it's at the toilet where we find our common humanity.

Yes, I believe that's the point.

I think the trick works for women imagining guys, too, HG. It's just one of the desperate remedies that openness to relationships sometimes forces people to rely on.

Shamefully, drug companies aren't even working on a drug which would prevent people from falling in love. Falling in love is a primary cause of mental illness, suicide, murder, obesity, depression, bankruptcy, and tediousness, to say nothing about STDs.

The romance lobby's tentacles are everywhere.

When I want to get unhooked from a guy, I picture having a meaningful conversation with him. Zing!

Yes, I believe that's the point.

Blast! Hoisted by my own petard.

I think the argument heebie is making is wrong, though. It's not the toilet doing the work there--it's the runs. If you were trying to get a friend to stay away from a recent ex of hers, and you reminded her of all his unattractive moments or features, I'd bet all of them would qualify as human moments or features. I suppose there are people who see their loved ones with the runs and say to themselves, "I wish I could capture that moment in a bottle." I happen not to be one of them.

I also note that I think this would work equally well for women (or men) getting over men. Try it!

Or for anyone trying to de-emotionalize or de-romanticize their mental image of somebody else. Say, after a beloved aunt passes on. Try it, folks!

334 -- you misspelt "movements".

"I wish I could capture that moment in a bottle."

Happily, you could.

329. the wipers fomented the revolution in Zamunda
http://www.thisjustin.com/2007/06/26/a-peoples-history-of-zamunda

Or Gandhi. No longer will I be intimidated by that shitass motherfucker. He's ruined my life.

Heebie, you have resources other people don't. Most of us have to rely on the toilet trick.

How's it goin, Gandhi? Cramping a little? Getting a little rash maybe? Don't look for sympathy from me.

You too, Mother Theresa. Hitchens really had the goods on you, bitch.

Yeah....but....no.

Okay, let me be careful though, not to overstate it.

Before a date, it's fine to help yourself relax by reminding yourself that your stud hunky date muffin is human and craps like everyone else.

The problem is when the image is brung out to deal with the bitterness of rejection, that it starts to feel like he had her in the Mythological Feminine category instead of the Whole Person category. That's what bothers me.

The problem is when the image is brung out to deal with the bitterness of rejection, that it starts to feel like he had her in the Mythological Feminine category instead of the Whole Person category. That's what bothers me.

If you're going out with someone, you maintain a positive, romanticized mental picture of that person. After breaking up, it helps to replace that picture with something less appealing. That's all that's going on here.

And I said "brung" on purpose.

Indeed, who among us has ever gone on a date without first imagining the object little-a sitting on the toilet? Isn't that almost a human universal.

?

Honestly if it was somebody I cared about imagining them with the runs would just make me feel bad for them. Oh, poor lost love. Let me fetch you an IV of saline and some air freshener.

The problem is when the image is brung out to deal with the bitterness of rejection, that it starts to feel like he had her in the Mythological Feminine category instead of the Whole Person category.

Yeah, I don't get that at all. Someone's been rejected, and they want to remind themselves that it's hardly the end of the world, that the other person was human with all of humanities little unpleasantries, etc. Why is that bad? That seems like the best time to deploy it. Speed the healing process, minimize moping, reduce or obviate the bitterness of rejection. That seems like an unqualified good.

He had her, in the past, in whatever spot he had her in. I'm not sure how what he does today changes how he felt about her--that is, Mythological Feminine category--yesterday. He would have had her in that category yesterday whatever he did today, no?

345: We should totally date. I think I had bad chicken last night.

It's pretty perilous to be related by one of them Mythological Woman Category people. Belle Dame Sans Merci, etc. You deal with it as best you can.

Are you not a Belle Dame Sans Merci yourself, Heeb? Have you not left a trail of broken hearts and destroyed lives behind you?

"rejected by" not "related by".

If you're going to vomit, at least be naked doing it.

Are you not a Belle Dame Sans Merci yourself, Heeb? Have you not left a trail of broken hearts and destroyed lives behind you?

Of course I break hearts. Then I feed them to the carp in my moat. What, you want my poor fish to die?

You poop in a moat? Or are these distinct from the toilet koi?

They say that a carp who develops the taste for human flesh can never go back. They will turn on their masters, too.

Of course I poop in the moat: they're bottom-feeders!

The moat is where we carp on our common humanity.

I guess I'd just like someone to help try to explain to me why they think we'll end up with something more like, say, the UHC program in Canada, which seems worth emulating, and less like, say, the auto insurance market in Massachusetts, which is a complete fucking nightmare.

My worst breakup was on dual toilets, both with the runs.

356: wait, it's up to us to prove to you that health care is different than auto insurance? Seems like maybe the burden of proof should go the other way.

357: That's funny, and funnier if somehow--I can't imagine, but I can hope--true.

Carp do not eat feces. That's a myth, as this link explains:

Silver carp and bighead chiefly feed on natural food (plankton). By fertilization, a large quantity of plankton can be quickly produced so that the parent fish have a sufficient food supply. Therefore, fertilization, in accordance with water colour, is crucial to the success of rearing silver carp and bighead brooders. In the silver carp rearing pond, human feces is the principal manure (70 per cent); the remaining 30 per cent is animal manure. In the bighead rearing pond, there is 70 per cent cow manure and human excreta. Cow manure is suitable for the reproduction of zooplankton. A base manure should be applied before stocking; the general amount is 300-400 kg/mu. After stocking, additional manure should be applied at a rate dependent on condition of the pond and seasonal changes. Generally, additional manure is applied in small amounts with the frequency of application depending on the water colour. An average of 700-1000 kg of manure is applied each month.

http://www.fao.org/docrep/field/003/AC264E/AC264E02.htm

Not all feces; just HG's feces. It's the proverbial shit that don't stink.

They're bottom feeders, John. That means they eat other people's bottoms. What else do you need spelled out?

I think that imagining a carp eating someone's bottom is also a good way to fall out of love.

356: God, I thought I was done with this thread, but here goes: moral hazard is a serious problem for auto insurance, and a relatively trivial problem for health insurance. Massachusetts' auto insurance regulations force a lot of good drivers and bad drivers into the same risk pool, which benefits the bad drivers and hurts the good drivers. Hence, little incentive for a bad driver to become a good driver.

Now, who can tell me how that's different from health insurance? Right, you in the back, what's that you said? That it's not possible for a sick person through sheer force of will to become a healthy person? That's exactly right! So it doesn't matter so much if you put sick people and healthy people in the same risk pool.

Hence, little incentive for a bad driver to become a good driver.

Since fear of death and fear of the law are inconsequential factors for most people.

Further to 365: a friend of mine is an executive at a (major) auto insurance carrier that won't do business in Massachusetts because the regulations don't allow them to risk discriminate as finely as they prefer. He told me that the "dirty secret" (his words) of the auto insurance business is that people in lightly regulated states end up paying just as much as people in heavily regulated states once you take out-of-pocket costs into account. Why? If you live in, say, Colorado, and have a really good risk profile, you'll get super low auto insurance rates. But then you will almost never file a claim, even if the loss is well above your deductible, because then your insurance rates will go up. My friend says his company has studied the issue in some detail, and they found the phenomenon of "self-imposed out of pocket" costs almost entirely explains the difference in auto insurance rates between Colorado and Massachusetts.

The relevance of this to the health insurance debate is left as an exercise for the reader.

Following my link: the carp-farming community must occasionally be riven by shit wars, because running out of food for the plankton will totally ruin your carp harvest.

They leap up to 4 feet int the air when you frighten them, for example with your stupid jet-ski.

omg this really happened!I'm so thrilled!

That story was not nearly as cheery as I expected. Now I'm worried about carp! Heebie's fears are entirely reasonable! Our nation is infested!

It's nature's way of dealing with people who befoul the great outdoors with loud engines. I'm rooting for the carp. If only they could be trained to jump out of the snow.

Jesus, that's brilliant. Snow carp, menace of the winter trail!

Heeby's got it coming to her, for her attitude. Let's not get all relativist and tolerant about her hate speach.

You might get territorial contention between the snow carp and the polar bear.

374: It's looking like polar bears won't be a problem for much longer, and frankly, they were pretty ineffective at weeding out snowmobilers.

None of the work to figure out A, B or D, particularly the toxicity stuff, is done (in actual humans) without a financial incentive. My fellow scientists and I generate hypotheses about what substances and procedures could improve health-care practice, but we can't test the hypotheses in an academic environment.

Only because of funding. There's a plenty of people in the relevant fields who would like to do drug developement work.

I'm not saying we have to nationalize the industry. But pick 20 or so of the bigger research universities that already have established hospitals. U. of Utah, UCLA, U. of Washington, UNC, U. of Michigan, etc. Give them each a billion a year to do drug development, and you'll see plenty of stuff come down the pipeline.

"I've heard the sentiment in 322 before, and it does annoy the hell out of me. It's like, "I loved her, but didn't permit her to be fully human in my head. In order to disqualify her, I allowed her to be a regular human being."

See, now I'm getting all worked up. "

Whenever i meet a hot girl, i look for her flaws. Becuase if i can't find out, she will drive me fucking nuts and i feel totally powerless; she's got total say over my emotions.

What, you only let the flawless chicks rule over your emotions?

hm, i'm not sure i know how to describe the difference.

i just get an enourmouse sense of freedom and glee when i see the first flaw.

Whoa, calm down there dude. No woman is worth that kind of drama.

i love drama tho. what else exists other than the flow of feelings.

Free marketeer awareness of health care seems to stop about 1996, give or take. They know that the Veterans Administration used to suck and are still waiting for news of the Clinton-era reforms. They know that New Zealand instituted a bunch of privatizations, but not that they got rolled back or why or with what consequence. And they show no awareness at all that Taiwan instituted universal coverage in 1997, nor how that's gone in terms of costs, outcomes, and public reactions. When they manage to catch up by addressing all of these explicitly in any detail, then it'll be worth helping them move on to the early 2000s, and eventually to the modern day.

what else exists other than the flow of feelings.

Seriously, if the "flow of feelings" you love is finding a flaw in someone you find attractive, I suspect you've got a lot of unhappiness in your future.

what?

you can see more nuanced view of someone once they aren't just perfect. you can actually get to know them.

Only because of funding. There's a plenty of people in the relevant fields who would like to do drug developement work

And little indication that they'd be any good at it. In pretty much any field of study, academic research and industrial development have large and important differences that make it hard to cross over. These differences almost always relate to the comparatively mundane details of turning a good idea into something that is polished enough to work reliably and meet the needs of people who have money to spend on it.

You almost certainly wouldn't have the mechanical engineering department at a big school design a new diesel engine for a pickup truck, because they don't have experience thinking about orienting the oil filter so that you can change it without unhooking everything else, striking the balance between standardizing fasteners to simplify production and customizing to decrease weight and improve specific fuel consumption, or a million other things.

Computer science departments don't develop production-ready software. When I was at Cisco they worked with some (stanford?) guys who had a nifty algorithm to collapse ACLs to a patricia tree to program a TCAM; we beat enough constant-time improvements out of it to make it fast enough to run on the router and deal with the ghetto memory management algorithms that network devices have to deal with.

Law professors probably won't be great at playing games around the edges of the FRCP, and law reviews probably won't have articles about the best way to schedule your motion filings to screw the other side.

It's not the same work. It doesn't make sense to have the same people doing it.

It's not the same work. It doesn't make sense to have the same people doing it.

I'm sympathetic to your side of this argument, but...there are lots and lots and lots of jobs in a lot of different fields in which the experience-learning curve is relatively steep but very short. Say you follow gswift's plan, but not limit pharma. Give 20 bil. to the 20 top research institutions and let pharma run as they would like for five to seven years; then just see what happens. Maybe nothing would come of it. Maybe the institutions could ramp up fairly quickly. But what would it hurt?

And little indication that they'd be any good at it. In pretty much any field of study, academic research and industrial development have large and important differences that make it hard to cross over.

Who said it'd be the same people? You'd have pure research guys, and then there'd be the relevant departments to develop the research into an end product. There's plenty of people around not interested in managing a research lab. I know quite a few just in my and my wife's acquaintances. The VA manages health care just as well (perhaps better) than private insurance companies. There's just no reason to think we couldn't similarly have a publicly funded program to develop therapies.

If a university is going to have to hire the same people that would work at a drug company, and set up the same organizational structures, what's the difference going to be? What do you hope to accomplish?

The thinking seems to be: drugs are expensive. Pharmaceutical companies sure spend a lot on marketing, which patients end up paying for, and may also end up leading to people buying drugs that don't really help them. If it wasn't for those huge profits, drugs could be much cheaper.

So let's look at the value of a drug just about to get approval. The money to develop and approve the drug is already gone and is never coming back. Cost of goods is going to be lost in the noise unless you're doing something really weird like Fuzeon. The pharmaceutical companies will figure out how much marketing they have to do to get a certain amount of sales, and due to the low marginal cost of production this turns out to be a shitload. There's no reason the government couldn't do the calculation from its perspective and instead of buying a bunch of pills indirectly through Medicare, just buy the patent and make pills for the cost of production. This could make sense, depending on how the math worked out, and assuming that the relevant authorities had the courage to stick to the "it's not worth it, we aren't going to cover it" position.

It actually addresses what the notional problem is.

what's the difference going to be? What do you hope to accomplish?

We could get exploration into therapies that don't have good profit potential, i.e. molecules that can't be patented and therapies that don't meet the massive sales volume need to recuperate development costs.

Also, therapies developed via a publicly subsidized program wouldn't have to be patented. They could be manufactured by multiple companies just like the generics, and competition would keep the price low.

We could easily trim 20 or 30 billion a year from the military budget to fund such a program. We wouldn't notice a thing on our taxes, and we'd have an alternative pipeline for drugs with an eye for the public good instead of profit.

"I keep koi in the toilet for that very purpose."

Don't you mean "porpoise"?

Ok, now I think I'm groking the gswift proposal. My general belief is that spending $20B to set up full pharma R+D operations in an academic/government center would be money ill-spent, but among the many things the government spends money on with dubious likelihood of benefit, it would hardly be the worst. The Gates foundation move of simply offering large prizes for anyone who can come up with therapy for medically important diseases where there's no market sems like a better approach. Indeed, the government is already doing this for biodefense.