Tuesday, December 01, 2009


Yes, US healthcare costs too much. Yes, too many people in the US have no health care coverage. Yes, there is administrative overhead by the shovel load. Yes, insurance companies can be arbitrary and foolish.

But there might be worse things. I noticed this snippet from The Economist of a couple weeks back, in an article about "guaranteeing" the delivery of public services:
So, for example, existing targets for NHS patients—to have hospital treatment within 18 weeks of referral by their family doctor, and to see a cancer specialist within two—will become legal entitlements.
Four and a half months? This is the goal to which we are striving?

Then, adding nutty to pointless, the Democrats have cooked up a new way to pay for the additional wait: tax cosmetic surgery at 5%. Not only is there a whiff of sexism here, since women are the primary consumers, but there is no rational way to tax buxomizing without also grabbing a slice of the orthodontia pie. Straightening teeth is nearly a right of passage, for which parents already pay dearly. Every time the hope arises that politicians could not possibly be more stupid, politicians promptly dash it.

But, hey, wait, never mind. There is no need to worry about taxing anything! health care premiums will not go up, because, according to Timothy Noah at Slate,
... fully 59 percent [of those purchasing health care through exchanges] won't be paying sticker price. That's because their incomes will be sufficiently low to qualify them for a government subsidy toward the purchase of their health insurance. For this subsidized majority, premiums will be 56 percent to 59 percent lower than they would be if health reform were not passed.
Where the term "government subsidy" absolutely must mean Totally Magical Fairy Dust Money.

There are real issues with health care provision, ranging from moral hazard through tax code distortions to whether the concept of "insurance" is even appropriate.

I don't have to be in favor of the status quo to conclude Obamagrrr stands about as much chance of success as a bunch of monkeys trying to fly by mounting a football.


Blogger Harry Eagar said...

18 weeks is a LOT faster that my wife and I are accustomed to, and we have the most gold-plated health insurance you can get in the United States.

December 01, 2009 5:18 PM  
Blogger erp said...

Harry, what kind of gold-plate insurance do you have?

We have the most pedestrian of health insurance -- Medicare and BC/BS supplementary and we've never had to wait more than a day or two for any kind of medical procedure. Certainly a week's wait would be unusual -- perhaps a doctor is on vacation or the like.

When my husband had a heart attack, the ambulance was there immediately, he was admitted, stabilized and scheduled for surgery a day or two later. He certainly would have died if he wasn't even seen for 18 weeks.

December 01, 2009 6:58 PM  
Blogger Hey Skipper said...

My experience, and everyone else I know, is like erp's: see a GP, get the referral, see the specialist in a matter of days.

It is interesting that erp brings up Medicare, though.

My wife is a nurse for a GP. She tells me that the practice is no longer accepting new Medicare patients, and is thinking of sending all the others somewhere else.

Why? Reimbursements are derisory.

Obamagrrr somehow thinks that reducing them is going to fix health care cost.

Well, yes I suppose it will. Kind of like it does in Cuba.

December 01, 2009 7:06 PM  
Blogger Susan's Husband said...

I am in the erp and Skipper camp with never having to wait more than a few days with a very generic health plan. When my father had his health problems that eventually did him in, waiting for treatment was never and issue and he certainly did not have any "gold plated" health plan (and that was in Texas).

December 01, 2009 8:31 PM  
Blogger Mark Frank said...

I cannot understand why critics of the US health plan keep on comparing it to the NHS. It is completely different. Neither of the US health plans include public ownership of the delivery of medical services.

Having said that, I should point out a couple of things about the NHS. It is best considered as a basic minimum health service available to everyone which you can top up with private insurance if you wish (many people do). As a basic minimum it is not bad and extraordinary value for money (less than half the cost of US health care). The 18 weeks is a target for all sorts of conditions from a coronary to an ingrowing toenail. Actual times will depend on many factors, but typically if you have something which requires a high priority you will be treated much sooner. I have some experience of relatives with cancer and they have always been treated in a very timely manner. On the other hand relatives and friends requiring a new hip have had to wait months.

December 02, 2009 2:26 AM  
Blogger Harry Eagar said...

I have an excellent, covers everything company plan, and my wife has an excellent, covers everything government plan, and we are cross-covered.

My wife needs shoulder surgery. It is not urgent, but when she decides to go ahead with it, she needs to schedule at least 3 months in advance.

Last year I came to the age when the doctors want you to have a colonoscopy. Again, not urgent, but there was a 2-month wait for an opening.

Of course, I live in a small, rural county.

Yesterday, I was interviewing a physician who is also a member of the state Legislature. Where he works, last year 4 out of 12 physicians left (primarily low reimbursements) and many people had no access to a physician at all.

Several of my doctors have told me they are just about to stop taking new Medicare patients, and one told me he would retire if income was his only motivation.

To the extent that overall medical cost increases have been slowed, it's been by screwing down Medicare reimbursements, now to the point where it no longer makes economic sense to invest in obtaining a medical education.

I'd have thought you guys would have been more sensitive to that issue than you seem to have been.

December 02, 2009 10:13 AM  
Blogger erp said...

I didn't support Medicare when it was enacted and don't support it now. However, it was only when we became 65 that I learned the full extent of the Medicare monopoly. After age 65, one can no longer purchase private insurance. It's Medicare or an HMO which just adds another bureaucratic level for distributing and rationing Medicare dollars.

Doctors, have been short-changed by Medicare because CW has it that doctors are greedy bad guys. You remember Obama telling us that doctors remove their patients' tonsils and cut off their feet just to make a buck and there was no outcry in the media calling him a lunatic.

IMO our doctors are the best because as they've traditionally made a very a good living, many of the smartest students opted for medicine. Since that's no longer the case, we'll have mediocre people beholden to Washington enter medicine.

The Mayo Clinic has a large facility in Jacksonville, about 75 miles north of here. They accept Medicare patients, but add 15% to Medicare approved amounts. We went there a couple of times, but they'd anticipated Obamacare because being seen at the Mayo involves being herded from large waiting areas to smaller and smaller ones until finally one gets into the core module where the physicians hang out. It's rather dehumanizing.

Funny story -- one of my doctors sent me to a good friend of his at Mayo and I was given the VIP treatment -- whisked through and treated like a cogent human being. Alas, that didn't hold true for my next/last visit.

I haven't heard of any doctors around here who don't accept Medicare and I doubt there will be many as there's loads of competition and us geezers may not remember what day of the week it is, but we still remember how to do arithmetic.

Harry we are sensitive -- to this problem and many others -- that's why we vote Republican.

December 02, 2009 11:16 AM  
Blogger Susan's Husband said...

Excellent summary sentence, erp!

This is the end game of any government paying for health care scheme, which is why we oppose more of it.

December 02, 2009 12:21 PM  
Blogger Hey Skipper said...


I must admit my comparison with the NHS wasn't precisely on point; however, it wasn't entirely off, either.

At least a few Democrats, including Obama, desire to turn turn US health care into a single-payer system. Like the NHS was up until the early 90s (my memory could be off here), and Canada still is (again, IIRC). They should, but won't, be careful what the ask for.

As a basic minimum it is not bad and extraordinary value for money (less than half the cost of US health care).

I wish I knew why the NHS is cheaper. I have a couple guesses: rationing by supply instead of cost, and some degree of free riding (the US pays more for pharmaceuticals because the rest of the world pays less).


Yes, perhaps that small, rural county could have something to do with it.

I'd have thought you guys would have been more sensitive to [where it no longer makes economic sense to invest in obtaining a medical education] than you seem to have been.

Gee, I could have sworn I took a passing whack at that already. Clamping down on Medicare reimbursements amounts to aggravated lying in the first degree. Among the truly offensive things about Obamagrrr is the frequency with which this comes up, without the tiniest acknowledgment that those costs get paid all right, just off-budget (i.e., by those not on Medicare); worse, there is no recognition how the Medicare budget has exploded beyond its original estimates. Just like Obamagrrr will.


Health care provision presents some very thorny, and probably irreconcilable, issues. No one pushing Obamagrrr gives me the tiniest inclination that they have a clue what those might be.

As for tag lines, what rep said.

December 02, 2009 1:54 PM  
Blogger Harry Eagar said...

I'm not defending Obama's plan. I accept that single-payer is what you get when you impose a public option, so if you're going there, may as well buy a through ticket.

However, there is this point: Costs are going up fast. Real fast. And if it hadn't been for putting the screws to Medicare schedules, it would have been even a lot faster than fast.

Something not quite sustainable there.

Sometimes I wonder, though, whether people listen to themselves. One answer to high doctor prices has been (from the libertarian/free market side) throwing open the medical schools and producing more doctors.

But see: 'Since that's no longer the case, we'll have mediocre people beholden to Washington enter medicine.'

Query: how many physicians are not trained in the US on the government dime?

If you're going to get gummint out of health care, what is your plan to get it out of the medical schools?

Of course, we could always import physicians from Africa. Let the Africans pay for our medical training. That would fix erp's worry about low-quality students, too.

Africa trains only the best. (My mom's GP is from Africa. She thinks he is wonderful.)

December 02, 2009 3:42 PM  
Blogger erp said...


1. Can't you understand that we don't want the government training doctors or anyone else. The government should get out of medical schools and every other kind of school including kindergarten and nursery schools. How other countries around the globe handle their education isn't any of our business.

2. Good people who can't afford the tuition can get loans and scholarships they way they used to; unqualified people shouldn't be in graduate school anyway.

3. If scientific research hadn't been corrupted by the chasing of federal grants, the whole silly global warming nonsense would never have happened.

4. We conservatives have no problem with Americans who were born in the wrong country coming home from Africa or Outer Mongolia or any and all points between.

5. Medicare costs have gone up because of bureaucracy, not payments to physicians. SEIU members don't come cheap either. Let us geezers buy private insurance instead being forced to buy Medicare and costs will come down sharply and fast.

December 02, 2009 5:18 PM  
Blogger Harry Eagar said...

Well, one way to be market-efficient is to let some of the poorest people in the world pay to train our doctors and nurses.

It may not be moral or socially desirable or efficient, but, hey, it's cheap and that's all that matters.

And if you think that a private system in which students borrow works, why don't you ask a young doctor what does happen. I did, just yesterday.

He'd have done better financially to have skipped college and started clerking at Home Depot.

This particular doctor is now 39 and has fewer assets than the Home Depot clerk would have had at 29.

December 02, 2009 9:05 PM  
Blogger erp said...

Harry, are you being deliberately obtuse?

Doctors aren't making the money they used now because there's no free market for their services.

That's the point of my last two comments.

That's what's wrong and why we'll no longer have the "best and brightest" going into medicine. They'll all be working at Obama's version of Home Depot.

December 03, 2009 6:19 AM  
Blogger Harry Eagar said...

And why is there no free market for their services?

Insurance reimbursement.

And who is responsible for that? (Hint: not the national government)

December 03, 2009 10:42 AM  
Blogger Susan's Husband said...

Hint: the federal government by making employment provided health insurance tax deductible, and via Medicare.

P.S. It's hard to take seriously someone who thinks "free market" means "it's cheap and that's all that matters".

December 03, 2009 12:35 PM  
Blogger erp said...

Harry, pace.

Your last comment can't be topped.

December 03, 2009 12:56 PM  
Blogger Harry Eagar said...

Ah, well, if I am wrong, how do you explain Vera Wang knockoffs?

December 04, 2009 11:19 AM  
Blogger Susan's Husband said...

Your continuing confusion with instances vs. generalities vs. universals.

December 04, 2009 12:09 PM  
Blogger Hey Skipper said...

One answer to high doctor prices has been (from the libertarian/free market side) throwing open the medical schools and producing more doctors.

Yes, that is one small part of the puzzle.

I am baffled as to why the AMA has a veto -- or even a vote -- as to accrediting med schools. That would be just like, and just as stupid, as giving ALPA the sole right to accredit flight schools.

The government's role should be solely in enforcing standards through initial and recurring licensing exams and operational evaluations.

Government is most definitely not out of aviation, but the government most assuredly is not riding herd over Embry Riddle. And we are not importing pilots from Africa, either.

And if you think that a private system in which students borrow works, why don't you ask a young doctor what does happen. I did, just yesterday.

Just like most pilots in the US do now. They borrow heavily to get the required training, then spend around a half dozen years making a derisory income (plus getting OJT and experience) before making real money. Check with those guys at 39, and a lot of them would have been better off at Home Despot.

Check again at 49, though, and you are likely to get a different answer. And this is in a profession with a heck of a lot more downside financial risk than medicine.

There are two primary elements to health care delivery: cost and accessibility.

Coming to terms with costs requires allowing supply to meet demand, eliminating barriers to competition in all their multifarious forms, and removing the blood loss through tortious parasites, and a good dozen other things.

Even then, cost will certainly be too high for the poor to afford. But that entails an entirely different set of problems.

December 05, 2009 4:46 PM  
Blogger erp said...

The poor can afford to go to prestigious schools if we return to the concept of scholarships for scholars, not for affirmative action. There are funding possibilities out there. It's not an easy path, but in the end, those who make it through are the better for it.

December 05, 2009 5:55 PM  
Blogger Hey Skipper said...


The poor can afford to go to prestigious schools if we return to the concept of scholarships for scholars, not for affirmative action.

Sorry, insufficiently clear wording on my part.

What I meant to say was that no matter what we do in terms of applying market discipline to health care, it will still be too expensive for the poor to afford.

There is a decent Left argument to be made here, but it is an entirely different problem from ungooning what we have now.

December 05, 2009 7:39 PM  
Blogger erp said...

Skipper, I think we've already had this conversation somewhere.

If we really want to have good, cheap and convenient health care for low income people, we'd have free clinics in neighborhoods where they're needed funded by local taxes and charities and partnered with local hospitals.

Communities could also offer scholarships to medical school in return for a stint at the free clinic for a few years.

The costs would be a fraction of what it costs now for Medicaid and use of ER's.

There are many many ways to solve this and all our other "problems." What we need, to use a phrase I've always liked, is "people of good will."

Those are in mighty short supply.

December 06, 2009 6:06 AM  
Blogger Harry Eagar said...

'we'd have free clinics in neighborhoods where they're needed funded by local taxes and charities and partnered with local hospitals.'

We do have those where I live.

They work reasonably well, if you're not sick, and if your problem isn't with your teeth.

As far as I can tell, the AMA does not have a veto or a vote on accrediting medical schools:

"The AAMC represents all 131 accredited U.S. and 17 accredited Canadian medical schools; approximately 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 125,000 faculty members, 75,000 medical students, and 106,000 resident physicians."

December 06, 2009 8:40 AM  
Blogger erp said...

Harry, it would be no great trick to make the clinics work to serve the sick and the dentally impaired as well. Be a lot cheaper than Obama's $1,000,000,000,000 and counting plan which probably wouldn't serve the most needy either.

BTW - Will the plan now being debated cover dentists and eye glasses?

December 06, 2009 9:47 AM  
Blogger Hey Skipper said...

Regarding the AMA supply of physicians:

Profession and monopoly, a book published in 1975 is critical of the AMA for limiting the supply of physicians and inflating the cost of medical care in the United States. The book claims that physician supply is kept low by the AMA to ensure high pay for practicing physicians. It states that in the United States the number, curriculum, and size of medical schools are restricted by state licensing boards controlled by representatives of state medical societies associated with the AMA. The book is also critical of the ethical rules adopted by the AMA which restrict advertisement and other types of competition between professionals. It points out that advertising and bargaining can result in expulsion from the AMA and legal revocation of licenses. The book also states that before 1912 the AMA included uniform fees for specific medical procedures in its official code of ethics. The AMA's influence on hospital regulation was also criticized in the book.[24]

More here.

December 06, 2009 1:42 PM  
Blogger erp said...

Clearly, the AMA is politically motivated, but I'm not sure that transferring oversight to the feds or even a state agency is an improvement.

December 06, 2009 1:51 PM  
Blogger Harry Eagar said...

Yes, the AMA wants to have a lot to say about the supply of doctors, but so far as I can tell, it does not extend to accrediting medical schools.

There are 3 ways to go about that: regular med schools, osteopathic colleges and Caribbean schools (not to mention importing doctors from Thailand or wherever).

Like a lot of would-be monopolists, the AMA has lost some of its grip over the years, especially since Manion's decision in the chiropractic case -- and that was about 30 years ago.

I am so old, I can remember when the AMA was foursquare agin socialized med'cine.

December 07, 2009 4:46 PM  

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