It's good to fear single-payer policies like that. But there is no reason that a single-payer policy has to have any of those characteristics. Nor is there any reason beyond faith to think that the current system either:

• provides people the care they most benefit from, or
• efficiently incentivizes innovation.

I'll grant you the third point, though. The current system definitely does not force anyone into any sort of medical surveillance. As the post shows, the methods used to pay for American healthcare actively discourages this.

It's good to fear single-payer policies like that. But there is no reason that a single-payer policy has to have any of those characteristics.

Do you mean it need not have the characteristic that the single payer is deciding policies of what will be paid for? I'd like to better understand what you have in mind. Obviously a lot of decisions would have to be delegated to care recipients and to providers -- anything else would be a managerial impossibility. But, at the end of the day, you have a single payer employing all of the check writers in the system and setting, at least, the range of acceptable providers and procedures, budget rules, etc. You wind up with a homogeneity in these policies where, currently, we have a slightly more contentious, chaotic system. Are you sure increasing rather than decreasing homogeneity is the right way to go?

In the current private system, one of the ways that insurers compete is on the type of flexibility they afford subscribers to choose providers and courses. In a lot of cases, and not just the super rich, consumers make choices out of their own, post-taxes pocket (e.g., consider the large numbers of patients who pay out-of-pocket to get consultations about medical marijuanna).

I don't claim that the current system obviously or provably provides people the care they most benefit from. On the contrary, I think "provides people the care they most benefit from" is very, very hard -- possibly impossible -- to quantify. When you look at individuals, it is easy to say "Ok, that person is getting poor care because they lack access," or "This other person is getting poor care because expensive procedures of dubious effectiveness were substituted for less expensive care that is at least equally effective." But when you try to generalize that to the whole system, it's a very hard scientific question to even formulate let alone answer.

As for innovation: well, I happen to think that the market for innovation is horribly distorted. Patent law, in particular, is creating incentives that seem not appropriate for good medical policy. Nevertheless, it does seem that the US is the leading medical innovator and there is quite a bit cooking in the investment pipeline. I wouldn't be cavalier about disregarding these things and, for that matter, how US-driven medical innovation keeps costs down in socialized systems abroad.

-t

In a lot of cases, and not just the super rich, consumers make choices out of their own, post-taxes pocket (e.g., consider the large numbers of patients who pay out-of-pocket to get consultations about medical marijuanna).

"Consumers"? We aren't consumers. We're sick people and potentially sick people.

Unlike with your "consumer/choice" concept (which makes it sound like getting medical services is just like buying a car or a sweater) in most medical procedures there is a "best choice" and after that there are alternatives. Often these alternatives are turned to when the first choice is ruled out for one reason or another. There's "choice", for sure, but it's medical, not economic. And it largely belongs in the hands of trained medical practitioners.

When I am sick or injured - I do not want a choice. The very thought is absurd - I do not have a medical degree; I do not want "choice". I'm not buying a tie. I want an expert to fix my problem. I want my doctor, who I trust, to take charge and choose the treatment that his best trained professional judgement dictates my case requires. I do not want a "choice". And even in that very tiny and narrow range of cases where two possible treatments exist I'd ask him for his advice; it's what he's actually trained in. I do not want "advertising" to play the role it does in American pharmaceuticals. It means making your product more attractive than a competitor's. Here's a bizarre thought - you know what should make one company's drug more attractive than a competitor's? Its performance and its lack of side effects.

If I wanted "choice" I'd go to med school. "Choice" is for "consumers". "The best choice" is for patients.

What cracks me up is American pharmaceutical commercials where they say "Ask your pharmacist about Glaxoproxamineophenylastic!" Yeah, that's what we need, millions of uninformed people advising their doctors on a course of treatment they saw on TV.

How about this - "I'm not a doctor, if your drug's so great go convince him yourselves"?

Unlike with your "consumer/choice" concept (which makes it sound like getting medical services is just like buying a car or a sweater) in most medical procedures there is a "best choice" and after that there are alternatives.

That's a very deep ontological claim -- that there is some "best choice" which is independent of who the patient is and what they value. I'm not sure I buy it. I think there is a lot of evidence against it! A glaring set of examples can be found in end-of-life decisions: the decision of what heroic measures to invoke when is very much up to the patient and, even if all medical care is free regardless of what the patient chooses, economic factors (such as the non-medical burden on family) are sometimes important considerations. Less traumatically: choices about pain management vs. joint replacement -- what's your formula for "best choice?" How about medical pot vs. alternatives for migraine sufferers? What about choices involving off-label uses of drugs? If there is some objectively "best choice" -- why is it hard to get N physicians into a room, in any but trivial cases, without getting N contradictory recommendations? Consider a patient with a serious but non-urgent condition, who has the means, and who would prefer to pay for lots and lots of consultations in order to better understand their options: do you think patients of less means might benefit from that kind of spending?

I do not want "choice". I'm not buying a tie. I want an expert to fix my problem. I want my doctor, who I trust, to take charge and choose the treatment that his best trained professional judgement dictates my case requires.

Well, you can do what you like but, personally, I think that you have a naive and vulnerable understanding of where medical science is at these days in terms of the quality of its theories and the uniformity of its results. If you read the (often anguished) accounts of patients with tricky accute conditions, one of the common themes is that "experts" can't be identified all that easily and that most providers are not expert. "Shop around" is common advice. Not making decisions based on trust is common advice.

What cracks me up is American pharmaceutical commercials where they say "Ask your pharmacist about Glaxoproxamineophenylastic!" Yeah, that's what we need, millions of uninformed people advising their doctors on a course of treatment they saw on TV.

We're not too far from agreement there. The drug companies are given a huge economic incentive by the particular way that patent law is applied and because of the particular way that FDA approval works. As a result, they are a strange industry in which people make investments that can't possibly pay off in less than a decade and by the time a drug comes to market, there are something around $1B in sunk costs behind it. This gives consumers a very distorted range of choices, based on a scientifically suspect approval process. It's obscene and it definitely needs reform. "Single payer" will mess with that system, knocking some of the profit incentive out of patent medicines -- but it won't do squat for the IP landscape and regulatory problems that are the the real crisis.

-t

prefer to avoid doctors and will live with chronic conditions, rather than fix the problem-like a shoulder, as you get older. There are lots of different ways to approach a problem, not one. Which is why medicine is an art, as well as a science.

If you're in an age group sport, maybe you fix it. But maybe you go to a guy who shows you a treatment that is consistent with a different training regime.

If you're not, and you have to do your own tree trimming, maybe you fix it. But maybe you go to to a guy who shows you how to work around the problem and prescribes still a different regime.

I believe, but cannot prove, so I will not assert as anything other than a conjecture, that this is one reason why we spend a lot on health care here.

In this case we are consumers, not simply patients in need of triage.

I don't see quite how a single payer system allows for all these various aspects of medicine, under a single rubric.

http://mauberly.blogspot.com/

Your conjecture is shared, at least here.

People get confused, is my guess, because on the one hand we spend boatloads per capita on medical care but, on the other hand, we have way, way too many people who are structurally excluded from access (and that demographic reaches all the way up into middle class types who lose employment or property when their luck goes just a *little* bit bad).

Separating concerns there is something to consider: yes, as progressives, one good reason to participate in the political process is work on problems like access but, no, it doesn't follow from that that the dollars currently being spent are spent poorly. Things like OECD measures of population health don't speak very directly to the quality of a medical system. The open source studies I've been able to find on things like individual patient outcomes point to some problems (e.g., the "too high a value on specialists/expensive procedures" problem, or the "lack of coordination" problem). But nothing that really makes a compelling case that we're doing less than well with what we've got.

Another conjecture, by the way, is that USian medicine basically subsidizes the socialist systems in states that best the US in things like OECD measures. Under this conjecture: thwrack the US system and, inevitably, you'll be harming those other systems.

Hard problems to think clearly about. I don't know where some folks get their apparent confidence in their conclusions.

-t

Hard problems to think clearly about

Only when rigidly-held preconceived ideological blinkers constrain your set of possible answers.

I don't know where some folks get their apparent confidence in their conclusions.

My entire life's experience living in such a system - first as a child, then an adult, then as a middle-aged man and father. The experience of my family, my spouse, my friends, my colleagues.

What have you got in the way of "theory" to give five seconds of serious challenge to that?

Another conjecture, by the way, is that USian medicine basically subsidizes the socialist systems in states that best the US in things like OECD measures. Under this conjecture: thwrack the US system and, inevitably, you'll be harming those other systems..

Yes, I've heard that argument many times. O Noble America, to offer up some 40 to 60 million of its own uninsured citizens as sacrifices in the name of holding the torch of medical progress aloft for the rest of the planet.

Thanks. I'll tell you what, let's just go without that sacrifice (the one nobody's actually asking you to make) for fifty years or so and if it stifles planetary medical development significantly we'll phone you immediately and ask you to put it back the way it was.

You don't need rapid pharmaceutical development today to alleviate human misery on a vast species significant level anywhere near as much as you need food in peoples' mouths, fresh water and some old-but-still servicable anti-malarials. Not another "Stiffy Pill" or headache remedy to cure pain caused by the crushing anomie of suburbia or a new antidepressant that has no side effects beside the occasional homicidal rampage.

but, and it's a big one, you need no theory here. You need to see what is going on in Canada and here without theory. Compare them; then make a judgment which you prefer, and why, without theory. If you prefer yours, great. If you prefer ours, great. If you don't like either, great. Give a reason(non theoretical) for another choice. This is a practical problem.

Nobody cleans up a toilet with theory. Why should this be any different?

http://mauberly.blogspot.com/

that with some exceptions choice is unnecessary, and you reach for that example?

Be my guest.

A glaring set of examples can be found in end-of-life decisions: the decision of what heroic measures to invoke when is very much up to the patient and, even if all medical care is free regardless of what the patient chooses, economic factors (such as the non-medical burden on family) are sometimes important considerations.

Dude - it's America in which governors like George Bush sign legislation to terminate life support of patients when they can no longer pay - against their will and/or the will of their families

And the Terry Schiavo case demonstrated the mirror image, government forcing the continuation of someone's life - against their will and/or the will of their families.

Yes, well done for spotting an exception. In this case, there is clearly a choice. Unlike in America, in Canada they actually let us make that choice.

The second may merely be an example of the insanity of pandering to hardcore religious zealots. But the first is flat-out execution by poverty.

Consider a patient with a serious but non-urgent condition, who has the means, and who would prefer to pay for lots and lots of consultations in order to better understand their options: do you think patients of less means might benefit from that kind of spending?

Now it comes out. The true face emerges - "If I'm rich and unwell, why shouldn't I be able to purchase the service?"

Because then rich people with hangnails get to displace poor people with sucking chest wounds. And the Hippocratic Oath and ancient custom forbid all doctors to make treatment decisions based on those criteria.

Resurces are limited. Why should you be permitted to purchase your way ahead of someone who's really sick just because you have money?

I'm not playing your silly "why shouldn't they?" game. Why should they?

If you were on a sinking cruise liner, would I find you standing at the taffrail selling lifeboat tickets?

One final thing -

I think that you have a naive and vulnerable understanding of where medical science is at these days in terms of the quality of its theories and the uniformity of its results.

I'm Canadian, and I trust my doctor to be both reasonably skilled and uncorruptible. You are American - you do not. I rest my case.

I'm Canadian, and I trust my doctor to be both reasonably skilled and uncorruptible. You are American - you do not. I rest my case.

That's a funny joke.

-t

That's why you keep saying "choice". It's because your medical system's become so fiscalized you can no longer tell when you're being prescribed a drug or a treatment because it's in your medical interest or someone else's fiscal interest.

You're obsessed with "choice" because you know your system's rotting in the guts; your "choice" is the choice of a "consumer" to switch used-car dealers.

My personal concerns with choice... since you've made them a topic:

No, I don't think our system is rotting to the core. I think we have problems with access, education, and with the drug industry's incentives.

On access, I wonder if the answer might not be a combination of insurance industry regulation (ruling out acceptance and rate discrimination on certain criteria) combined with, perhaps, an earned-income health benefit (i.e., a tax refund, potentially in excess of taxes paid, ear-marked for personal medical savings accounts). That could be effectively redistributive without too badly hurting employers, etc. I don't have any a priori problem with taxing the rich for this purpose.

On education, well, I think you and Ian are minor versions of a major problem: that people think of medicine as magic. For example, given the appalling infant mortality rates, disproportionally aportioned to our poorest communities, people overlook the near impossibility of affordably buying a healthy diet in those communities and leap immediately to the practice of physicians as the proximate cause. What the hell? That's putting the cart before the horse. First things first: let's get to a state where this stressed part of the population has the economic option to take good care of itself day-to-day! (I've spent some time in "the ghetto," as a guest of people who live there. Good grocery stores, well promoted, would have a vastly higher level of participation than, say, the right to a free wellness checkup once a year.)

On drug industry incentives: well, you know, I think the combination of the current patent regime and FDA approval system creates pretty insane investment horizons. That leads to a perpetual $1B/pop release of new products that are unimportant substitutes for other products and/or that medicalize problems that don't obviously deserve medicalization. Don't worry, though: the Canadian single-payer will be sure to get you a good deal on these drugs.

And, most personally: So, as it turns out, I have various issues with arthritis, a back problem, and some other orthopedic issues. Best science offers a menu of drugs, surgery, physical therapy, and lifestyle adaptations. Nobody, anywhere in the world (not even in Canada) has a definitive recommendation -- it's all trade-offs. Some courses are well known and others are experimental. The spread of the range of costs for a chosen course is huge. I'm rather far from well-off, although it's a roller-coaster ride. It's a very difficult set of choices. The course I'm currently thinking about working towards is a mix of pot (the most gentle drug for pain mgt.) and physical therapy to put off more intrusive / extreme interventions as long as possible (since their side effects / recovery times / outcomes are, globally, so sketchy). Yet, that course is one that my own federal gov't hasn't gotten around to approving in the medicare system or the VA system. And it's a course that I can conceivably arrange to afford out of either post-tax or, ideally, pretax-medical-savings-acct funds. The course I want doesn't have democratic approval but I happen to think it's the best course for me.

I haven't bought a tie recently but my major purchases in the past 9 years included a bunch of other kinds of clothing along with a lot of other basics like household appliances (e.g., an apartment-friendly washer and dryer) and cooking equipment (e.g., nice knives, pots and pans, etc). I made fairly personal choices to favor lasting value over fashion and flash -- and it's paid off well. Why should health care be all that different?

-t

and best wishes for progress or respite. I have a friend on pain management for a back injury, and he'll be on it for the rest of his life.

Nobody, anywhere in the world (not even in Canada) has a definitive recommendation -- it's all trade-offs. Some courses are well known and others are experimental. The spread of the range of costs for a chosen course is huge.

My friend fell off a bike (no helmet - I know, don't say it) and injured his back twenty years ago. He was offered a choice of surgery with (IIRC) a 60% chance of fixing the prob and a 20% chance of scarring that would make it worse - or a range of other options (can't recall now). He rolled the dice. He lost - hence his pain control.

He was an independent contractor; being laid up meant zero income, but unlike his peers that I know south of the US border who have no health insurance he had BC Med. Again - our system offered him choice without any fiscal incentive one way or the other - even "not getting treated" offered no fiscal advantage. After that equation was eliminated, it was all about his pure choice - and thus the consequences of that choice were all his responsibility as well.

I have friends up here whose vets have told them that they will face a far higher bill for their pet than they can afford and seen the anguish they go through when they realize they have to make hard choices - find the money or let their pet die. One couple I know racked up an incredible eighteen thousand dollars in medical bills for their cat.

But I cannot imagine how a person endures that process vis. a human loved one. The mother of my Oregonian onetime fiancee was diagnosed with cancer (and was either uninsured or underinsured or they simply didn't pay - I can't recall) and given about three years to live. The daughter tried everything. She sold the family home and spent every penny raised from what would have been the daughter's home and inheritance, bankrupted the family and then the mother died - pretty much on schedule - three years later.

Her choice was limited to "spend every penny you have vainly trying to save or prolong your mother's life" or "don't". That's not a "choice".

I can just see dealing with "what's your dog's life worth to you?". I have no idea how someone copes with "what's your mother's life worth to you?" Or "what's a five percent chance of saving her life worth?" Or "what's a five percent increase of her chances worth?" That sort of calculus is beyond immorality, beyond moral degeneracy, beyond obscenity.

good looking numbers are now pharma reps; buying lunch for the docs and the nurses is the acid test.

http://mauberly.blogspot.com/

in a free market. Innovation is simply able to occur without agency oversight. This makes nothing equal.

But it does allow medicine to develop with fewer non medical interventions.

Here in America there are a host of competing agencies, as well as insurance companies, that have made medicine a mess.

But until you can answer the question how much medicine you get for the dollar here vs how much you get somewhere else, e.g., Canada, you're just talking politics. You're not talking about medical care.

http://mauberly.blogspot.com/

http://www.geographyiq.com/ranking/ranking_Infant_Mortality_Rate_aall.htm

http://www.oecdobserver.org/news/printpage.php/aid/1988/OECD_in_Figures_2006-2007.html

http://mauberly.blogspot.com/

You tell them about round wheels, and you talk and talk - "and it costs less, don't you see, because you smash tires and axles less frequently and the glass in your windscreen isn't always shattering and from the end-user perspective it's just wayyy easier on your ass, dude"...

And then you hear them arguing the merits of cars with triangular wheels because there are 25% less bumps per mile...

Ian, you're pulling stuff like this:

If you're rich the US system may work slightly better for you (and I do mean rich, as in having multi-millions). If you aren't, the Canadian system will probably do better for you.

out of your butt. "Which system works better" is a very hard question to even define, objectively.

The most objective things you have going are that (a) US population health has some problems; (b) per capita medical spending in the US is unusually high. You are foolish to assume that the structure of the medical system or the amounts spent are the prime determinants of population health.

One could as easily say that, evidently, the main reason we have population health proplems compared to Canada is that we don't spend as much per capita on hockey. (Did you catch the Sabres / Rangers game today? Go Buffalo!)

-t

"Which system works better" is a very hard question to even define, objectively.

Perhaps. Of course that's "define". To "judge" which works better - from a user perspective, it's a complete no-brainer. Using your tools of definition you come up wiuth results that are puzzling and ambiguous; I submit that the analytical tools you are using are selected specifically because they produce ambiguous results in a situation which is utterly non-ambiguous but must not be seen to be so. "Teach the controversy" sorta thing.

What do you think of regulatory rules that distribute the currently uninsured among insurers, forbidding rate discrimination or refusal on the narrowest grounds we can come up with that fix those problems? Combined with redistribution in the form of an earned-income tax credit for (dependent included) medical savings accounts?

Of course, we should also liberalize "dependent" to include things like same-sex couples but, let's not stop there --- as far as the feds are concerned, any group that forms contracts in certain ways should count as a "family".

The "controversy" matters because I'm pretty sure "you guys" are promoting solutions (like "single payer") that are entirely faith based once we analyze beyond the buzz-words. Solutions like I'm describing above are, comparitively, far more gentle interventions.

-t

OHIP picked up my tab in 72. I got no beef with you guys.

But you show me that dollar for dollar we get less medical care. Show me that we don't get more.

In my town, you get whatever you need, even if you're from south of the border. We pick up any emergency care from all over West Texas. They'll fly 'em in with copters. The docs work for free on you. The hospital doesn't charge. It's like Tucson here, where they're going broke.

We eat it all. I'm just a poor bean counter in the middle of it all.

http://mauberly.blogspot.com/

You pay 50% more, and have metrics that are the same or worse than countries who pay much less. It really is a no-brainer and I really have no idea what you're asking for if you won't accept such metrics, which I've provided in both posts and comments. And Canada isn't even the best - you do significantly better on one metric than Canada. Germany or France beat the pants off you.

I really have no idea why it is that you seem to think that you're paying 50% more, leaving 43 million people uninsured, have worse infant mortality, comparable life expectancy, less beds, less doctors, less specialists and shorter stays but are somehow getting more for your money.

Since, unlike dasht I think you're a good faith actor I'm left, at the end, to scratch my head. I simply can't imagine what it would take to convince you when there is so much evidence that already appears to answer your question.

I've even posted, in the past, some of the theoretical reasons why:

http://agonist.org/ian_welsh/20070111/an_insurance_primer

Based on very simple actuarial principles, it would be shocking if a non-managed insurnace system didn't cost more. This isn't a case where theory and practice diverge (though such exist) this is a case where what one would expect from a private insurnace system is exactly what you get.

"You pay 50% more, and have metrics that are the same or worse than countries who pay much less."

I have seen the metrics. I don't dispute them. They are metrics for a particular kind of system that does a rather basic kind of medicine that does not cater to the consumer society that we Americans are.

(I might point also out that we are overrun by illegals who domino at the door, which accounts for some of the infant mortality.)

It should be no mystery that, in a culture in which 70+% of GDP is consumer based, medicine would be somewhat different from cultures in which consumers contribute much less.

Your metrics do not prove that we get less care here for the money. We just don't get the care that you count as care, in the way that you count it.

But you still count the money we spend on other "non essential" medicine. Then you say we are spending twice as much.

But it is not necessarly for the same thing. My example of the treatment of a shoulder shows how there is not one way to go with it. A patient, if he needs coddling, gets it here, depending on what he wants to do. This can run up the bill. But he still gets the care for the bill.

But you have a protocol under which he does not get the options and which costs less. So in your view, you take care of the shoulder for less. But you don't do the same thing. Because it is not essential to put him back in his age group tennis for old folks.

These kinds of case abound and have something to with the recent raising of the copays.

"less beds, less doctors, less specialists"

Also true. I do not have stats to show the mileage we get out of these. The docs here work much harder so we get a lot of mileage out of them. And they do the charity for zip.

This is in contradistinction to family practice docs up your way who shut their offices down before the year is up because they have been paid all that they are allowed.

If we simply did triage on patients, i.e., ran the ones out who did not need the essential care, it would cost a whole lot less.

Now, I have no complaint about your system. We need a system that covers the uninsured; it may be that yours is a model for a basic program.

But from what I can see, you have not shown that we, in principle, because of our system, overpay for the care that we do get.

I do agree that insurance companies have made a mess of much of what we do here.

http://mauberly.blogspot.com/

not morals

Dr. Robert Kimball, Past President, Medical Society of Nova Scotia, now practising in North Carolina: I left Canada because I was unhappy with the direction health care was going and I felt powerless to change it. That was when government in Nova Scotia started closing hospitals and cutting back on operating room time. In both Canada and the US you've got this balance between individual rights and what's good for the community. In Canada the balance is more on the side of the common good. In the US the balance is more toward what's best for an individual. So in the US they ration health care by price, while in Canada we ration it by queue. Down here doctors [have] probably got several nurses and at least one medical office assistant and several people doing insurance work, so more of the dollar goes to administrative costs than back home. Canada spends health care dollars more efficiently. But in Canada doctors like me cannot order CT scans or MRIs. Down here I'm in a little town here where we've got an MRI sitting in our backyard and the CT scanner is next door.

http://www.cmaj.ca/cgi/content/full/168/6/751

http://mauberly.blogspot.com/

You indirectly touch on something when you talk about your town: medical service accounting and medical service reality seem to have a pretty tenuous connection in the US. For example, one of the ways people compare medicare to private insurance is to ask: "What percentage of what is billed do they each pay?" 30% is pretty high. The one's that get really screwed in this craziness are un-/under-insured property owners whose theoretical liabilities turn into reality.

There's a heck of a lot of muddling-through going on and highly localized decision making (sorting out, for example, the people in need of unpaid treatment from the no small number of bona fide junkies and psych cases). It's almost ideally Marxist, in some aspects.

-t