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[quote]I have called David Goldhill’s How American Health Care Killed My Father a must-read for anyone who wants to speak up in the health care debate. The New Yorker also has a must-read article on the issue called The Cost Conundrum. In that article we are introduced to the town of McAllen, Texas where Medicare spends much higher than average amounts per capita than the national average ($15000 vs $8000) in an area with much lower than average per capita income($12000 vs $21500) and cost of living. Atul Gawande, himself an associate professor of surgery at Harvard Medical School, introduces us to the town and begins an attempt to discover why the costs of health care are so high in McAllen.
Are the people there less healthy? No, they have higher rates of some health conditions than average and lower rates than average of other conditions. Overall health fails to explain the cost differential.
Was the quality of health care being provided higher than average? While they were not lacking for available medical technology or facilities the quality of care was, once again, nothing unusual.
McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
Gawande went to dinner with some McAllen doctors and showed them the data on health care costs in McAllen:
Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.
He then asked them why they thought the care was so costly there. One suggested the cost of malpractice insurance but then they admitted that since Texas had passed caps on malpractice lawsuits they had virtually no lawsuits to drive up the cost of care.
Finally a general surgeon among the dinner party declared that the issue in McAllen was overutilization.
Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.
Anecdotal evidence and agreement is fine, but Gawande went in search of more concrete evidence.
To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice . . . I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
Having identified the cause of the high costs the search was on for an explanation of why there was so much overutilization. The answer was in the culture of the medical practitioners in McAllen – they were very profit oriented rather than results oriented. I believe the one place that Gawande’s article falls short is that he stopped with exploring the cultures among the medical community and failed to examine whether the general community culture in McAllen helped to foster that inefficient mindset among the medical practitioners in the area. I’m willing to bet that such a short-sighted culture in the medical community might not need encouragement from the local culture, but could not survive if the local culture were one that actively discouraged a similar outlook in the community at large.
Talking to a surgeon from McAllen, Gawande concludes that whether we have a public option, single payer, or private health insurance will not matter if the culture in McAllen continues to become more common as it has been doing.
In contrast to McAllen, Gawande explores the cultures in the Mayo Clinic and the Medical community of Grand Junction, Colorado and finds that both of these low-cost, high-quality health care systems took very different approaches to each arrive at “accountable-care {organizations} . . . {where} leading doctors and the hospital system adopted measures to blunt harmful financial incentives {and} took collective responsibility for improving the sum total of patient care.” He also lists four other high-quality low-cost health care systems each of which has a culture of accountable care – the Geisinger Health System, the Marshfield Clinic, Intermountain Healthcare, and Kaiser Permanente.
Whatever approach Congress tries to take to reform our health care system they and the American people need to understand that we cannot successfully plant a Health Care tree. The only workable approach will be to plant Health Care seed and help it to grow into a health new health care system.
36 replies on “Medical Cultures”
The problem we seem to have is one of incentives. As long as health care providers are paid for each individual service they perform, they have every incentive to perform as many services as possible. The Mayo model and the others you mention are clearly moving in the right direction, but these care models pre-date our current health care cost problems, most were created in the first half of the 20th century. There might be little incentive for health care providers in communities today to voluntarily move to such a model and providing incentives through typical means like tax breaks might not be effective, certainly not in the short term. It also seems far-fetched to expect the government to set up it’s own Mayo-like systems and probably a bad idea anyway.
What government can do is change the reimbursement model without interfering with the provision of care in any way. Without such a change, it seems to me we are merely wasting our time and money. Of course, our political system is very efficient at creating waste.
This is definitely a problem of incentives, although it should be noted that the Grand Junction, Colorado system, which as I understand it has possibly the highest quality to cost ratio in the nation, is still paid per service – so while that setup lends itself to bad incentives, it can obviously be workable. The Grand Junction system was also implemented since the advent of Medicaid so it’s not that old.
As for the government setting up Mayo type systems – I think that’s beyond far-fetched. I am convinced that there is absolutely nothing the government can do that will, by itself, generate even a moderate probability of a system such as that being formed. This requires a drastic cultural change – one that I believe many individual doctors would welcome, but one where a single practitioner would probably sink if they were try to unilaterally withdraw from the current approach.
I think we might agree that the actual health care provided in the US is very good, if not the best in the world. What we have is a problem with cost. Simply providing access to everyone to great health care regardless of cost is not an option, and messing with the delivery of care is fixing something that isn’t broken. When we look at the statistics, it is clear that costs are rising out of all proportion to inflation and certainly providers aren’t blameless here, but they are responding to the market in predictable ways. I recall a conversation I had with a surgeon back in the mid-1980’s. I kidded him about how much he charged for a simple appendectomy and he told me that insurance would pay “reasonable and customary” fees but they didn’t tell him what that was, so he charged an amount far above it so he would get the maximum reimbursement. A response to market stimuli.
There are two huge challenges to addressing the issue of health care costs. The first addressing the costs headon: devising a payment mechanism that will reward providers for results; covering all Americans for preventive and routine care so we don’t end up paying for non-insured ER and ICU patients; insuring that providers are adequately but reasonably compensated; negotiating serious price reductions for drugs; and addressing the over and under supply of physicians and high-tech devices, etc. The second challenge is to find the political will across the party divide to devise and enact legislation. That is probably the more difficult of the two. One thing is clear to me: as long as the loudest and most powerful voices in our national debate are those of the health insurance and drug companies, we will make no progress at all. It is simply not in their interest to wring costs out of the system.
We do agree that the health care provided in the United States is very good. Having no experience with health care in other parts of the world I won’t try to make a statement about its relative standing in the world. I think the situation with your surgeon friend is a good demonstration of the non-political nature of the problem (meaning the solution does not require any legal intervention). If surgeons would make a price list the insurance companies could look at the list and the success rates of the surgeons and simply decide which surgeons they are willing to work with. A very reasonable argument can be made that surgeons can’t actually make a price list dues to the unpredictable nature of surgery. That’s fine, but it would not prevent the insurance companies from investigating and determining what they feel is a reasonable price for various surgeries and making their own price list of what they are willing to pay for surgeries and then surgeons can determine which insurance companies they are willing to deal with. Patients should then be free to choose a surgeon who is not covered by their insurance company with the understanding that they will pay the difference in price between what their insurance company pays other surgeons and what their chosen surgeon charges (in fact insurance companies should pay the difference if the patient chooses a surgeon with lower prices but then the patient is responsible to pay for any complications).
That is an example of how the free market can work without any change in laws – thus eliminating the second and harder problem.
David, the insurance companies have made up their own price lists – they just keep them secret because that better serves their interests. If they were to publish a maximum rate for any service, every provider would charge exactly that maximum rate. We would be exactly back where we are now. The problem with the market approach you suggest is obvious. Let’s say your family doctor says your child needs major surgery as soon as possible to alleviate a life-threatening condition. Are you going to shop around among local surgeons for the best price? No. You might want to find the very best surgeon available, but you’d have a hard time finding unbiased data on which to make such a decision, so you are probably going to use the surgeon and hospital your physician recommends.
There simply is no market place. You absolutely must have the surgery. The health of your child is far more important to you than cost, even if you had cost information. You are not capable of making an informed economic decision about whether or not to have the surgery, whether surgeon A is more capable than surgeon B, or whether hospital C is better than hospital D. The conditions for making an market-based decision simply do not exist. Now add in the problem that you are unemployed, have no health insurance and know that after your child recovers, you will be bankrupt and lose your home. That’s why we need to solve this problem.
First of all, I don’t think you give me enough credit for my ability to make an informed economic decision. Secondly, you misread or misunderstood what I wrote. My basic premise was not that I would make an informed economic decision, but that the insurance company and/or physician would. If insurance companies are willing to pay a specified dollar amount then why can they not advertise that price to doctors? Yes, the doctors will ask that full price but the insurance companies are required to set a price they are willing to pay. This is a cultural issue – the insurance companies set a price but hope to make more money by not telling anyone what that price is. Likewise, the doctors are unwilling to commit to provide their services for a set price that they are willing to publish, they would rather inflate their prices in case the insurance companies are willing to pay more. Consumers have abdicated their responsibility and allowed this double-blind culture to thrive and the result is that the costs of medical services rise as you said “out of all proportion to inflation.”
By the way, is it your problem if I am unemployed, have no health insurance and know that after my child recovers, I will be bankrupt and lose my home – is that my problem? It’s my problem and I am the only one with enough information to deal with my problem – which may include reaching out to others in my family or community for help.
David, first of all let me apologize if my tone got a little overheated. I hope we can continue this interesting exchange in a civil fashion. First, I don’t want a private insurance company to make decisions about my health care or my child’s care. They are far too involved in the process now and their interests are exclusively cost control, not the health of my family. What is my responsibility as a health care consumer? First of all, my responsibility is to obtain the best possible health care for my family. That responsibility overrides any consideration of cost. When I have the opportunity to choose between equally reputable providers for treatment I can plan, then certainly I might choose the less expensive, but that information is not available to me and often I simply do not have the luxury of making such a choice.
I cannot blame consumers for our current health care costs. We are simply reacting to the market created by insurers and providers. I don’t believe we have the time, or the information to make market-based decisions about health care. We have permitted this culture to thrive because as citizens we have neglected to require our government to intervene in a meaningful way. As individuals we simply have no power to address the structural inefficiencies of the system.
Lastly, if you are bankrupted by medical costs it is my problem because what happened to you could just as easily have happened to me. I know that in a similar situation, I would would have acted as you have acted and the financial impact on my family might be similar. Why should you or I be put in the position of exhausting our life’s savings in order to preserve our child’s life? Can we not work together as citizens to insure that all of us can receive the medical care we need without sacrificing our future? Why is that so wrong?
I do not believe that the responsibility is to obtain the best possible health care for your family can override any consideration of cost. Of course I am willing to pay for what needs to be done even if its hard, but there are times to say “we just can’t afford braces for our crooked teeth.” You’ll argue that braces are a lot different than injuries from a car accident or treatment for an unpredictable disease. I agree with you, but we have lumped those together in our health insurance plans – consumer mistake there. The fact is that we focus on the catastrophic care but we then treat virtually all the care as if it were catastrophic.
You treat the health care market as if consumers had no hand in creating this very market but that’s simply not true. I believe that a closer study of the uninsured, especially those who choose not to carry insurance, will prove that we have a lot more power to make informed economic choices about health care than we would like to believe.
Why should you or I be put in the position of exhausting our life’s savings in order to preserve our child’s life? Because sometimes that is what is necessary to preserve our child’s life and we think it’s worth it.
Can we not work together as citizens to insure that all of us can receive the medical care we need without sacrificing our future? I don’t believe that you and I are capable of making any reasonable choices to ensure that the poor people in Miami are able to receive the medical care they need. Can we work together? Yes, but I don’t think that we can do anything successfully on a national level – it’s just not granular enough.
Why is that so wrong? It’s not wrong, it’s simply not feasible.
Again I will quibble about consumer responsibility. In general we have no say in what is or is not in our health insurance plans. Most Americans who have coverage get it from their employers and while they may have some limited choices available, they certainly bear no responsibility for what is or is not covered. I can choose not to carry insurance but generally that choice is made by those who cannot afford their part of the premium and still keep a roof over their heads and food on the table, and those who are young and healthy and simply are betting they won’t need much in the way of health care. The key factor here is cost. I don’t know that they are making informed economic choices about health care, they are simply deciding to risk more imminent financial catastrophe in the case of illness or injury in lieu of paying regularly for some kind of minimal and confusing health insurance policy.
I will differ on the poor people in Miami as well. I think every sane human being wants to get good medical care when they are ill or injured. We might not be able to make decisions about healthy lifestyle choices or diet for the Miami poor, but we don’t need to do that. If they have access to regular checkups by a physician, that physician will make the proper recommendations. I don’t really want the government to make health care decisions for the poor in Miami, or for you and I. I’m only interested in creating a mechanism to pay for care. Even that might be better administered at the state level. Kucinich offered an amendment to permit states to setup single-payer systems, but that was ripped out no doubt due to insurance industry opposition. Private insurance has demonstrated that it is incapable of controlling costs and to the extent it does reduce provider and drug costs, it pockets the profits rather than passing the benefit on to the consumer.
Do we have to get coverage through our employers? Is that the best way? or is it simply the easiest and we choose to abdicate our responsibility? You’re happy to generalize about who chooses not to carry insurance, but you assume that is an irresponsible or uninformed choice. The only way to build a sustainable system is to build one where that is regarded as a legitimate (even if not optimal) choice.
I think that we can agree on principles such as the fact that every same human being wants to get good medical care when they are ill or injured, but that principles does not allow us to make an informed choice about what truly problems exist or need to be addressed in a health care system we have no connection with. The mechanism to pay for health care for the indigent is humanity – it is charity whether we try to force it through government or not, the problem is that when we force it through government it gets warped and exploited. When we leave it outside of government then it works in exact proportion to the goodness of society. Trying to force a government system to work is only a way to cover up the fact that our society is seriously ill – and government can’t fix that.
I’m not quite following you. I don’t think there’s anything illegitimate about not choosing to carry health insurance, unwise perhaps, but people make their own decisions based on what is available to them in the market. Is employer-based insurance the best way? No, I don’t think so. It’s what we have and the employer is absorbing some portion of the cost and, if they are large enough, are able to negotiate better pricing and better service. If I choose to purchase insurance as an individual, I don’t have clout with the insurer and my price will be higher and most likely my service poorer.
The problem with leaving health care to charity is that we aren’t really addressing any of the problems, and we are assuming that there are enough charitable people with enough disposable income to absorb the costs of everyone’s care. I realize our government is not currently an ideal solution to this problem (or any others), but that is in large part due to the fact that government, particularly at the federal level, responds to the desires of major corporations almost exclusively rather than to the public. If government is incapable of providing solutions to the problems we need it to address, then we need to fix it, not just live with the problems. In the case of health care, I am unwilling to allow the problem to fester because our government is broken. I’d rather fix the government.
Our entire health care reform push now is based on the assumption that not having insurance is not a legitimate option – that is why it morphed into health insurance reform.
I am not assuming that we have enough charitable people – I’m saying that if we don’t that’s an indication of a dysfunctional society which government can’t fix. I agree that if government is incapable of providing solutions to a problem that we still have to fix the problem and not simply live with it, but I am challenging your assumption that it is government that we need to fix. It is the problem that needs fixing and some problems cannot be addressed by government whether the government is broken or not.
We both agree that government is broken and needs to be fixed. Where we don’t apparently agree is whether a fixed government is capable of addressing this particular problem – I say it is not.
I don’t think we ever needed health care reform. The care is fine, we just need to reduce the cost and insurance plays a big part in the cost.
While fixing government is a tall order, it is simple compared to changing human nature. We can wish and hope for a more charitable society but there really is nothing we can do to make it so in the near term. Meanwhile, we have thousands of people dying because they could not afford proper health care and thousands of families destitute because one of their number is or was chronically ill. Some might be lucky enough to live in communities or church families where charity is available, but even that charity is variable depending on the overall economy. Unemployed people simply can’t donate as much regardless of their desire to do so.
My assertion is that a government incapable of providing for the general welfare of its people is a broken government. We certainly have a broken federal government, and the government in many of our states is broken as well. If we could do nothing more in the current health debate beyond shifting federal funds from wasteful militarism, for example, to the state governments, some of us might be able to resolve the health cost issue at the state level. At least those lucky enough to live in states with relatively honest and functional governments. I unfortunately, live in New York where our state government rivals Washington on the dysfunctionality index.
I count myself as one of those fortunate enough to live in a state with a fairly honest and functional state government. I can see how your outlook in New York would be more bleak than mine in Utah where our health care market is dominated by one of the model systems in the nation.
Here are two questions for you. Do you think it is possible for a socially unhealthy society to have a healthy government? Do you think it is possible for a healthy government to effectively govern a socially unhealthy society?
I believe that our society is fundamentally unhealthy socially – we are becoming more fragmented and dysfunctional over time – and fixing government will not be possible until we address that underlying issue.
A couple of tough question there, David. I think we’d have to first have a discussion on what we mean by a socially unhealthy society. I grew up in a small city in the 1950’s where communities were fairly close knit and when someone in your neighborhood was in trouble, you did what you could regardless of whether they were part of your church or a good friend. Was that socially healthy? Well it was if you were white, but that was Little Rock where everything was segregated from the water fountains to the schools.
If you mean the fragmentation and polarization that has happened since WWII, we need to think about why that happened. Why did Americans abandon dense urban settings where they knew their neighbors for spread-out suburbs? Why did Americans abandon streetcars and rail transportation where they would regularly come in contact with people from different walks of life and different backgrounds and travel almost exclusively by private automobile? Why did we rigidly segregate ourselves by economic class (homes from the $150’s on the left, homes from the $250’s on the right, etc.)? Why did we abandon high-rise downtown shopping for strip malls? Why did we choose to move from general interest publications and broad-perspective broadcast TV and radio to special interest mags and narrowly targeted radio and TV? (Ever read The Geography of Nowhere? )
This is a real conundrum and I don’t have the answers. Those of us who care about this country have to move past the polarization and keep talking to one another. That is the first step.
Your response demonstrates that we do basically understand what a socially healthy society looks like. Your description of Little Rock was clearly socially healthy until the context of segregation was applied. If Little Rock had been as you described among and between the whites and the blacks then I think it would have been a wonderful demonstration of a healthy society – I think you already knew that.
I think you also have a good grasp of the fragmentation that I was talking about as demonstrated by the examples you cited. I have not read The Geography of Nowhere and I won’t claim to have the answers on why our society has become increasingly polarized, but I remain convinced that this is the underlying issue that we need to focus on – without addressing it none of our other solutions will have more than a very temporary positive effect.
You are also right that continued dialog is the first step to closing the gaps.
“Why did we choose to move from general interest publications and broad-perspective broadcast TV and radio to special interest mags and narrowly targeted radio and TV?”
This effect started before Reagan, but it was Reagan that removed many of the government regulations related to this. For example the cartoon Transformers would have been illegal in 1979 because it was illegal to use cartoons for direct marketing. About the only regulations left are the are the banned no-no words, emergency broadcast system, and public announcement requirements.
Reagan also lifted some of the regulations related to media consolidation. And this surely didn’t help.
“Why did Americans abandon streetcars and rail transportation where they would regularly come in contact with people from different walks of life and different backgrounds and travel almost exclusively by private automobile?”
This is due to unchecked corporate corruption Great American streetcar scandal, Government Corruption Public Utility Holding Company Act of 1935 Out growth of suburbs with the formation of the middle class, cost/time efficiency ratio of privately owned cars vs waiting for buses. Their may be other reasons but I think that sums up the biggest ones.
“Why did we rigidly segregate ourselves by economic class (homes from the $150’s on the left, homes from the $250’s on the right, etc.)?”
Same reason that banks used to do Red Lining.
“Why did we abandon high-rise downtown shopping for strip malls?”
Driving distance. Population density growing enough to sustain more stores per measured unit of distance. Growth of suburbs have a lot to do with this.
In fact your questions relate a lot to the suburbanization that started in the 1940’s and ran through the 1980’s and somewhat into the 1990’s.
This has the interesting side effect spreading out the population(urban sprawl,strip malls), Concentrating the poor and sometimes minority groups(redlining again) into the city’s(they don’t have the money to move out). This effect deepens the social political divide between the small and big states.
Ronald, I can help but point out that a) your answers are quite correct; and b) they all represent examples of lack of regulation and citizen planning. We left all the big decisions about our built environment to the free market and therefore have an environment well suited to create profits but ill suited to social health.
It’s not often that I represent the minority view on my own website, but that appears to be the case here 😉
While Ron’s answers are technically correct as far as I can determine (I have no firsthand information on many of those things) it seems to me that he is answering the wrong “why?” He answered the why of “what is it that allowed people to {do niche publication} {move from public to private transportation} {segregate by economic class} or {substitute department stores for strip malls}?” I think the more important why that needs answering is “why do people gravitate towards each of those?”
Charles points out that each of these was a result of regulations being removed, but removing those regulations never included any requirement to make the changes that ensued. Why, when they are free to chose, do people choose niche publications? Why do they segregate themselves by economic class? Why do we prefer private transportation over public transit? Only in his answer to the high-rise shopping vs strip malls does Ron’s answer seem to address the underlying motivation for the change.
David, if we can convince people to ignore advertising, marketing, public relations and sales pitches of all kinds, then we will be well on our way to the socially healthy society. Unfortunately the billions spent every year on those efforts pay off. No one forces people to behave this way, but no one is putting any serious effort into convincing them not to.
We all tend to associate with people like us, and that was the case 50 years ago. There were expensive neighborhoods and run down ones even back then, but they were closer together and far more people used public transportation. I lived in a middle class white neighborhood as a boy but 2 blocks away was a small black neighborhood much further down the economic scale. I could walk 6-7 blocks in another direction and find upper middle class homes. Now those distances are further and since I have to travel in a car, I don’t see these different classes of people and the tendency is to think that if I don’t see them, they aren’t there – or at least there aren’t many of them. We prefer automobiles over public transit because the public transit systems in almost all American cities were systematically destroyed by General Motors (Ron has the link). In addition, many suburban developers didn’t want mass transit nearby because it meant that “those people” would have access to their newly crafted neighborhood.
I think we have to live with the realization that most people can be convinced to do something or not do something if a well-crafted and well-funded campaign is employed to that end. Should this be the case – no, but again we are up against human nature here. In the cases we’ve been talking about in the last few posts, no one realized at the time that we were setting ourselves up for social fragmentation or that fragmentation would be such a bad thing in the end. Perhaps one reason is that there never was an us, only individuals each making their own decisions in a vacuum.
It’s not that hard to see that everyone wanted a home of their own, and not just live in apartments forever.
youtube describes it best GM’s World of Tomorrow.
I love their 7 and 12 lane freeways moving at 100 miles per hour with different speed lanes. Count the number of times they refer to science and progress, truly this was created in a different age. Also note their isn’t one train or streetcar in that entire exhibit at the worldfair 1939. Now that is advertising.
So why is it that our natural tendencies make such bad choices, as voluntary segregation and a preference for personal transportation apparently are?
I agree that most people can be swayed by a well financed advertising campaign in any direction on any issue but i believe that this only works on a temporary basis. We do not need regulation today to recognize the downsides to urban sprawl.
I think Charles hits the nail on the head when he wrote “there never was an us, only individuals each making their own decisions in a vacuum.” Isn’t that the very definition of liberty, letting individuals make their own decisions? Of course there is no guarantee that they will make good decisions all the time, but wouldn’t you rather learn and grown as a society and take responsibility for your own choices rather than have your choices prescribed for you buy an abundance of regulations? I know that I would prefer liberty and all its downsides over central planning and all its upsides.
You can’t learn and grow as a society unless you are one. If you are a collection of random individuals each committed to making your own decisions independent of others, then society doesn’t really exist. There is a great deal of distance between radical individualism and a centrally planned society. One doesn’t have to be at either extreme and abandoning one doesn’t mean you immediately shift to the other.
As you say we don’t need regulation today to recognize the downsides to urban sprawl, but we are unable to overcome its ill effects. We can act individually by moving back into the city, but that social fragmentation will still exist and its ill effects will still poison our society.
I think I would amend the statement you made that I said hit the nail on the head – I would remove the last 3 words and I would change “an us” to “a collective.” It would read “here never was a collective, only individuals each making their own decisions.”
As you said, the is plenty of middle ground between radical individualism and a centrally planned society and I have never argued for a complete lack of regulation or oversight. The difference in opinions is probably that I believe in human creativity. If we have problems a people free to think and act independently will find solutions. On the other hand, people who are corrupt (corruption being the reason we abandoned public transit according to Ron’s answer) are creative enough to find a way around the regulations – bribe the auditor, cook the books, etc. As my mom used to say, “locks keep honest people honest.” Regulations are useful in catching honest mistakes and making more work for those who don’t want to follow the rules, but they are not very effective at actually preventing malicious actions.
If social fragmentation will still exist if we were to move back into the city that would indicate that suburban living is not the actual problem in question.
No I meant society, not collective. Again there’s a tendency to speak in extremes. We we say collective we think about soviet farms and situations where people are coerced. In a society, people voluntarily work together – not on everything, but when it becomes clear that working together will be more effective, they choose to work together.
Human creativity is important. We need the bright inventive minds that like Beethoven and Mozart, but without the combined efforts of a symphony of musicians much of their creativity would go unheard. We don’t all have to come up with separate ideas, we can work together – you contributing your ideas and I mine and others theirs and together we can find a solution we would be unable to devise separately. Regulations don’t prevent corruption but they can slow it down. That 35Mph sign doesn’t make everyone lower their speed, but most people do. Without the sign, and the occasional cop car hiding behind the tree, far more people would speed into town. But again, there can be too much regulation. If I set out on the highway coming into your town and set up signs reducing speed limits in 5mph increments every 1/4 mile and try to enforce each one, well you see the problem.
Social fragmentation is as we discussed a multi-faceted problem with multiple causes. If you eliminate one or even all of them in your life, the fragmentation will still exist in the society. You can feel pure of heart but you are just one person. We have a problem, for example, with dependence on foreign oil. You can trade your cars for a hybrid and an electric scooter and you will pay less of your income to the oil companies, but our national dependence on foreign oil won’t feel the impact of your wise decision. If we wait for enough Americans to decide individually to buy hybrids or drive less or put a solar array on their roof, we will never escape our dependence on foreign oil.
I’ll remove “collective” and replace it with “society” – I think that’s a fair trade.
Let’s run with your speed limit discussion. What is the purpose of having speed limits? Is it a matter of control, or is it a matter of safety and predictability on the roads? Obviously the second as evidenced by the fact that the police are often very relaxed about enforcing the speed limit and the fact that they can use their discretion to issue speeding citations for driving “too fast for conditions” even when a driver is not exceeding the posted speed limit. Having speed limits tells us something about the character of an unfamiliar road. We may not know that this is an area where children play or that there is a nasty curve ahead, but obeying an appropriate speed limit can help us deal with such hazards. (I say appropriate because cities can place a 25 MPH speed limit on a road that could clearly support 40 MPH safely.) Those who wish to ignore the speed limit will still do so and cause a danger to others – the regulation does nothing to impede them. Without a speed limit they could still be cited for excessive speed, it’s just that they would not know when that citation was going to come.
On your dependence on foreign oil example let me ask one question – is there something inherently undesirable about being dependent on foreign oil even if the foreign power were a democratic ally? I say there is no more danger in that than being financially dependent on massive domestic financial institutions. The danger is not in the dependence, but in the context of that dependence. Now, would my choice to drive hybrid or electric vehicles have a measurable benefit on the country? No. But, as the danger grows more and more individuals will choose to make the wise decision based on their own interest. Even if nobody were to make that choice voluntarily I guarantee that we would quickly find ways to be not dependent if the supply of oil dried up.
Social responsibility’s of the government when abdicated, Do not in fact end up in the hands of the individual. No individual has the money or resources to handle a social problem. So in fact when a social responsibility is given up the only other entity with the money and resources to offer a solution to that social problem is Business.
Business is amoral(neither good nor evil) and has no obligation to serve for the public good, business exists to generate returns for its shared holders nothing more and nothing less. I am not saying this is bad far from it this is what business should/needs to be, But I will say this needs to be part of the consideration of what the government should and shouldn’t do of what business should and shouldn’t do.
The welfare state(that is health care, life insurance, unemployment insurance, social security, retirement etc) when in the hands of business distorts the public good and the role of business.
Private health insurance stands to benefit from not paying out claims, refusing coverage for the sick, rescinding coverage, etc. Other private business’s benefit from employee lock-in with health benefits that keeps employee churn and wages down. I hear about people all the time who would like a better job but can’t quit because of the health benefits or because of a pre-existing condition.
Medicare runs with unmatched efficiency, Private industry can’t even come close to the low administrative costs of Medicare. Medicare has a mandate to provide health care not generate profits. Medicare’s approval is also much higher then private industry.
And while Medicare is looking at a $74 Trillion dollar deficit by 2070, almost half of this amount is from the unfunded drug mandate passed by republicans in 2003 to prevent further talk of drug re-importation and another 1/3rd of the this amount is from Medicare advantage plans fraud level. Of course Private insurance is much more bleak Medical inflation by this point will prevent over 150-200 Million Americans from access to any insurance coverage.
In fact by 2019 the administrative costs in private health care will be so great that if the federal government toke the money they spend on their own employee’s(FEHP’s) for private health plans and combined it with the Medicare trust fund they could do single payer without any new tax’s.
401K’s have no guaranteed benefit level and remove the employer from having to have a good plan due to risk of losses, 401K’s exist merely for the tax benefit provided to the employer. While pension plans are a disaster as well and are bankrupting business’s all over the nation(GM) all 20 of the largest pension plans are underfunded in the billions.
Social security on the other hand is actually working more or less as it should and is only projected to have a 14 trillion dollar deficit by 2070 where as pension plans around the country likely won’t exist anymore and 401K’s will have nearly or outright bankrupted at least 2 generations of seniors. lucky they still have social security. People just live longer then they used to, The japan approach to this is probably best simply raise the retirement age to 70 and social security will actually have a surplus by 2070.
The American experiment with Corporation control of the Welfare State has been an absolute disaster. It’s well past time to move on.
Ronald makes a very good point. The choice is not between “big government” handling social problems and individuals doing it, it is between government and big business, and business has only one interest – profit for its owner/shareholders. His examples are quite correct.
Back to the speed limit, there’s a little town a few miles south of me that has a 30mph limit in the village limits when traveling on the state highway. They don’t enforce it every day, but they do enforce it and everyone around here knows that speeding in Candor is not prudent. Business regulation works the same way. If I setup anti-trust laws and enforce them from time to time in particularly egregious cases, a prudent business owner will think twice about buying up his competition and the consumer will benefit. If I make it clear that I either not going to enforce the law or that buying a little political clout is all that is necessary to prevent enforcement, then I will end up with huge mega-businesses and no competition.
On foreign oil David, I would say that since we have to spend billions every year propping up oppressive regimes and station thousands of soldiers and fleets of ships in the Middle East in order to insure a supply of oil at a reasonable price, then that is a dependence we must end. If we want to price oil accurately, we need to withdraw our military completely from the Middle East and Central Asia and end our financial and military giveaways to non-democratic governments in that region and our tax breaks for the oil industry and then let the market do its thing.
If it were not for the power of the oil industry and those industries dependent on it, we would already be taking steps to reduce our fossil fuel use. As long as huge corporations can make huge short term profits on oil and coal, they will do everything they can to prevent this nation from considering conservation or alternative energy. These companies have spent billions convincing Americans that anthropogenic climate change is a hoax (and done right well at it) and billions more telling us how “green” they are while trashing entire ecosystems in the 3rd world. But in America, reality is nothing – perception is everything: part of that social unhealthiness we have been discussing.
Ronald would be making a good point if he were right but there are a couple of problems with what he said. First, he makes the assumption that these issues are the responsibility of government. I, and others like me are not convinced that these social responsibilities are government responsibilities. The second error in what he said was that the only options were government, individual, and corporate. He’s right that individuals cannot shoulder the responsibility on their own (except in very limited cases of course). The problem is that he does not take into account the place of mediating institutions. These groups, such as the Rotory club, have a capacity to address social needs that is similar in scope to a corporation but they have no profit motive. When government steps in to inefficiently address the social needs that these institutions have been addressing the mediating institutions begin to atrophy. Indeed they are in dire need of a revival because of all the government intervention.
The funny thing about health care is that a large number of health care institutions are not for profit enterprises and yet they are still exorbitantly expensive – you can’t blame that on the profit motive.
The American experiment with Corporation control of the Welfare State is a failure but it has more to do with “Welfare State” than it does with “Corporation control.” Government involvement in health care, higher education, an other such social responsibilities looks more like a cause than a cure.
On the speed limit – government regulators have made it clear that they almost never enforce their regulations strictly on anyone who has purchased a little political clout – only the little guys get regulated until one of the mega-businesses is guilty of an egregious infraction – then the government calls is a failure of regulation, an indication of too little regulation, and they impose new regulations on the little guys.
On foreign oil – you have just proved my point that it is not the dependence itself that is so dangerous, but the context surrounding our dependence (spending billions every year propping up oppressive regimes and stationing thousands of soldiers and fleets of ships in the Middle East in order to insure a supply of oil at a reasonable price). I absolutely agree that our dependence needs to end, but because of all the hidden costs of our oil individuals are less likely to make a rational choice for their own long-term good unless they have bought into the fear-mongering of the green movement. (I believe in being environmentally responsible, but the apocalyptic scenarios they promote are beyond reality and besides that, national security is a better reason to end our dependence than environmental responsibility.)
David, the Rotary Club is great for passing out turkeys twice a year and doing food and clothing drives, but it cannot address the underlying systemic problems that cause so many Americans to need that kind of support. We have one in eight Americans and one in four children (!) on Food Stamps. That’s a pretty tall order for Rotarians to handle, and besides there aren’t many Rotary Clubs in the areas where the poor live.
The welfare state is an attempt to solve the problem and in order to do that, it is necessary to wrest control away from the corporations. Were it not for public education, we would be a 3rd world nation and the increasing corporate involvement in the education process, particularly higher education is very destructive to the future of our nation. We have moved from a point when education was almost free in some states, to the point where most young people graduate (if they do) with huge loans to pay off. Instead of pursuing their dreams and their entrepreneurial ideas, they have to take the highest paying corporate job they can find simply to avoid bankruptcy. That is not in our national interest.
As for oil, if we had to pay the real cost of oil at the pump instead of hiding it in military appropriations bills and complex tax loopholes, we would be using a lot less because most Americans wouldn’t be able to afford it. If we stopped that now and the price went to $6-8 a gallon our economy would collapse. Instead, we have a corporate-sponsored campaign to pooh-pooh environmentalists since Americans are a lot more likely to believe that we need to save the environment than they are to believe that our leaders have repeatedly lied us into wars. I’m not an environmental fanatic, but most of the arguments I read against climate science appear to emanate from organizations funded by big oil. That makes me a great deal more suspicious of those claims than of scientists not on the Exxon payroll.
The Rotory club is only one example of a mediating institution and between a variety of such institutions they can do at least as well at addressing the underlying systemic problems as the government has been able to do and they do have presences among even the poorest areas. The poverty rate has not gone down since the advent of the welfare state in this nation. The cost of health care has risen at a faster pace since the government got involved in providing health care to the poor and elderly than it was rising before then. The number of people who are prepared for retirement by the time they are ready to retire has also fallen since the advent of social security. In fact the purpose of social security was not to help people who could not retire so much as it was to encourage people to retire in order to open up jobs for young people that were still being held by older workers.
I love the public education claim but the fact is that most kids could get at least as much education without public schools as they do with them if their families were not busy running on a treadmill to produce more revenue for an ever expanding government and their corporate leeches. As for higher education, the cost of a college degree has mirrored the cost of health care – after government got involved the costs began rising faster than before and, in fact, the costs of higher education have risen faster than inflation plus rising federal aid so that it is getting increasingly expensive to get a college degree even when student loans and grants are factored in – that started after the government stepped in to give aid because their stepping in created a way for businesses to profit from the government aid. Who benefits from that aid? It’s the banks loaning the money and the schools taking the grants, not the students supposedly receiving the benefit. Government is simply partially offsetting the costs of their involvement.
On oil – you don’t seem to recognize that you and I agree on this issue. We may disagree on the urgency and degree of veracity of the environmentalist claims, but we agree on the reality behind our dependence on foreign oil.
“The funny thing about health care is that a large number of health care institutions are not for profit enterprises and yet they are still exorbitantly expensive – you can’t blame that on the profit motive.”
Hospitals on average have 1 administrative personal per bed, Their are 4 administrative personal per Doctor in the average Doctor office. These are costs imposed by a grossly complex private health insurance system. So, Yes it is the profit motive in health care financing that is the problem.
Canada has less then 6,000 administrative personal for their 28 Million person country. We have well over 1,000,000 administrative personal involved with health care in this country we only have 7 times the population meaning that we are over staffed by at least 954,000 personal on administrative tasks because “its not the governments job”, Government bureaucrat between me and my Doctor HAH that sure sounds a hell of a lot better then what we have now.
“The American experiment with Corporation control of the Welfare State is a failure but it has more to do with “Welfare State” than it does with “Corporation control.” Government involvement in health care, higher education, an other such social responsibilities looks more like a cause than a cure.”
Its absurd to say that social security has caused the failure of the 401K or pension systems of this Nation. Its absurd to say that Medicare has force the private health insurance industry to have 25% claim denial rates, or decreasing Medical Loss ratio’s These things are drive by the profit motive.
“As for higher education, the cost of a college degree has mirrored the cost of health care – after government got involved the costs began rising faster than before and, in fact, the costs of higher education have risen faster than inflation plus rising federal aid so that it is getting increasingly expensive to get a college degree even when student loans and grants are factored in”
Higher education got more expensive because of the growth of technology. Similar to how technology has added to the costs of medical care. The more new things the schools have to teach the more new costs the schools have to shoulder. Them LHC’s, CERN’s, particle physics labs, computer labs, physics modeling computer clusters, material sciences labs, DNA sequencers, spectrometers, etc are spendy. Everything listed didn’t exist 100 years ago, much of it didn’t exist 50 years ago, and even a chuck of it didn’t exist 20 years ago.
“I love the public education claim but the fact is that most kids could get at least as much education without public schools as they do with them.”
Name me a single first world Nation that lacks a public education system, and has education scores higher then ours. Given how far down on the list we are that should give yea plenty of room. And from my family I can tell you without public education the best I would be at is maybe 6th grade level.
On the oil thing, I actually think for the moment the market is working on this one, the growth of Electric car company’s like Tesla Motorcars, and Fisker tell me that unless something big happens to upset the trend in battery technology(like how Exxon bought out the NMHI battery technology patents in 1999 to lock them out of the car market) then I think theirs a good chance we will have a vibrant Electric car market in the next 5-10 years. At the very least in 2011 when the NMHI patents expire we should see a lot of electric kite cars start making the scene.
Can you stand with a straight face and argue that government run health insurance is less complex than private insurance? Go ahead and argue that they have a lower overhead – they passed lots of their overhead back onto the private sector through taxes or regulations.
We have 11 times the population of Canada, not 7 and I don’t believe for one second that they only have 6000 administrative personnel in their national health care system? Whoever arrived at that number undoubtedly used a very restrictive definition of personnel because that adds up to only 7 administrative jobs for an entire hospital. While our population is 11 times the size of Canada’s population we have 40 times as many hospitals – are you suggesting that we eliminate 3/4 of our hospitals so that we can be staffed at the same level of hospital administrators per capita as Canada?
I was not claiming that social security has caused the failure of 401K or pension systems. In fact 401K would not exist without the government. I’m saying that the expectation that government would provide for our retirement needs has helped convince people that they need not save up their own retirement fund – it has contributed to a social propensity to not look after ourselves and prepare for the future. Neither did I claim that medicare as affected claim denial rates of private insurers. I simply said that the cost of health care began its steep rise shortly after medicare came into existence and has been rising faster than inflation ever since.
Why is it that technology suddenly made education and health care more expensive when it has directly lowered the costs of virtually everything else? (And if it is making health care more expensive how do we expect to invest more in medical technology while bending the cost curve down?) I don’t buy that argument. Technology is expensive, but it is not the cause of rising health care costs or education. The cause of rising health care costs and education has everything to do with our changing approach to health care and education and those are both directly affected by our changing expectations when suddenly the government will guarantee either one for us. P.S. Who’s paying for CERN, LHC, etc?
I’m not saying that we should do away with public education and I can’t name a country with better education scores than us which does not have a public education system, but try comparing the education scores of publicly educated kids to privately educated, or even home schooled kids – our public education is not making us more educated than our non public systems. Amazingly our public education system can’t seem to learn anything from the private education sector or event he public education systems of all those other countries who are outscoring us. If you study the education systems of some of those countries you would find that we are going in exactly the wrong direction in our public education.
I happen to have a bit of close second-hand experience here being married to a health care provider and knowing some others. Every doctor has to have either lots of administrative support or hire an outside vendor to assist with the considerable problem of filling out all the forms for all the different insurance companies and following up because they simply don’t pay on time and often “lose” your paperwork. Heath insurance companies employ health care professionals to figure out ways they can avoid paying claims, they instruct administrative staff in ways to obfuscate procedures and delay payment and their systems are notorious for being totally isolated from one another so that info you provided to one office simply does not exist in another. There is a reason for that – they aren’t just evil people – they are out to make money and every dime they pay in claims to a provider eats into their profit.
In the early 1990’s health insurers paid 95% of premium dollars in actual medical care. This year its 81%. That’s not because anyone is banking on a government takeover, it’s just greed. When we compare the administrative costs of private health insurance to Medicare, we find that private companies are almost 10 times as expensive. Since we de-regulated health care, every time a new technology comes out, hospitals and other providers are eager to buy it so they can get paid the nice fat fees for using it. Since no one is “rationing” the purchase of these expensive tools, more are purchased than needed in areas where there are patients able to pay (not enough elsewhere), and the more of these expensive machines sit in a hospital, the more physicians are pressured to prescribe their use. Again, rampant greed. There is no expectation that suddenly the government will pay for all this, quite the reverse. There’s an expectation that the billions the industry is spending in lobbying will prevent the government from controlling costs.
The current health care debate demonstrates nothing other than the complete inability of the federal political process to get anything done. After a year of wrangling, we are exactly where I figured we would end up. The Congress is dramatically increasing the financial burden on the lower end of the economic scale in order to funnel billions into the big health insurance and pharmaceutical companies, and there’s no attempt been made to address the key issues: escalating costs and lack of universal coverage. This is exactly how Obama planned it from the beginning and all the big industry players have been in on the joke all along. We have been treated to a year-long charade.
I work for a health care company and my mother and grandparents provided administrative support to a number of doctors. You are absolutely right about where we are and why we are there. None of the problems you mention are a result of government regulation, although we have other problems that are.
The Health care debate has landed almost exactly where it was at this time after the 1994 elections so far – the similarities are eerie. That being said, I think you give President Obama too much credit (or blame depending on your perspective). He did not plan for the debate to turn out like this. He bought into his own cult of personality and thought that he could actually get Congress and big government to operate in a way contrary to their very nature and pass a bill that would be good for the nation. (I say that in all sincerity despite the fact that what he thinks is good for the nation is so different in most cases from what I think is good for the nation.)
“I’m saying that the expectation that government would provide for our retirement needs has helped convince people that they need not save up their own retirement fund”
I don’t know anyone that isn’t saving for retirement in some form separate from Social security.
“We have 11 times the population of Canada, not 7 and I don’t believe for one second that they only have 6000 administrative personnel in their national health care system?”
That number references the number of administrators in the financing side of the system ran by the government. Remember that Canada uses Bulk payment and global budgets for their system, The cost savings from those to features which are exclusive to single payer is huge. The Administrative personal requirements to handle global budgets and bulk payment systems is minimal.
Doctors will submit the number of visits performed each month to the single payer system and receive a lump sum payment for those visits. They submit a list of patients seen along with the service rendered and the government sends surveys to those patients to confirm services rendered as a means of auditing the system. its easy to automate and cheap to run. Doctors are also given bonus’s for keeping certain health stats to above or below a certain threshold, for example their is a bonus if most of their patients have a low cholesterol level.
Global budgets work in that a hospitals basic costs are pre-calculated, and they are paid a single lump sum each year to cover all the basic costs(beds,attending nurses,ER,MRI,etc). Surgery’s are general still billed per service. Hospitals also get bonus for meeting certain stats, for example if they keep the staph infection rate low their is a bonus for that(this is why you are 6times less likely to get a staph infection in Canadian hospitals then in US hospitals). This bonus system sets the rewards where they should be.
Hospitals in Canada don’t have to worry about how many days they can keep you, how much your insurance will pay, pursing that payment, and all of the administrative backend to that.
It should be noted that Hospitals and Doctors are still private(their public hospitals as well) entity’s in Canada. Only the financing is ran by the government. And they do have privately ran Supplemental insurance their as well for those that want services beyond whats covered.
“Why is it that technology suddenly made education and health care more expensive when it has directly lowered the costs of virtually everything else?”
Sure they replaced some of their administrative personal with automation. But they have to train the next generation of people to use that automation, so its not as simple as buying 1 or 2 computers and calling it good, they have to buy 60 to 70 computers for use in class’s that teach the skill.
“If you study the education systems of some of those countries you would find that we are going in exactly the wrong direction in our public education.”
I agree but I would have to say this is because education is mostly funded by the states, when it comes to properly funding education the states are a total failure. Anything tied to state level taxation is a race to the bottom.
“P.S. Who’s paying for CERN, LHC, etc?”
CERN is funded by the United States government(lots from DoD), LHC is a consortium of country’s including Europe and the United states government. As for the rest of the list that would be public and private university’s generally with federal and state grants but on occasion with private funds donated as well.
The vast majority of money that payed for sequencing the human genome for example was public(federal grant), around 5-10% did come from private sources however.