1) Healthcare will never be reformed. It will eat us. Accept it.
2) Death Panels won't turn out to be as cold heartedly technocratic as you like. Expect instead that they approve lots of expensive stuff for powerful interests.
3) If I could reform one simple thing, I would state that if government medical expenditure in the last year of life is less then $X, then the deceased can pass on ($X - expenditure) to their designated beneficiaries. This would prompt people to have some skin in the game on end of life care, which is where the money is.
4) I think congress should pre-commit to capping government health expenditure at some % of GDP higher than now such that it won't come up in the next election cycle. I doubt they will stick to this (look at the debt ceiling or doc fix), but it does provide a point of action where "do nothing" succeeds rather then having to "do something". "Do nothing" is always easier for politicians.
There is family infighting over money all the time. Money is important, and it should be fought over when we are talking about large life changing sums.
We got the hospital bill from my Dad's end of life care. It was north of $400,000. And that is with a person who did accept hospice care at home in the end. I really appreciated the last moments of my Dad's life, but he was very miserable during most of them. If you told him to end it a couple weeks earlier he could pay for his granddaughters college or give them downpayment on a house he definitely would have done it. But we don't allow people to do that, we only allow them to pay hospitals absurd sums of government money to keep them alive in pain.
And of course we never had to deal with Long Term Care. It was always our intention to care for our parents ourselves in our home. But you don't get paid for that. Your only option is "free" Medicaid (after you've lost all your assets and have little income). I would much rather just pay people who care for their elderly parents rather then sticking them in nursing homes.
Like every other decision there are tradeoffs and we should trust people to make those trade offs. Not give them only one option that also happens to be bankrupting us.
I think I would accept your argument more easily if you started off with paying people to take care of their own parents, which is really a great idea. To bring in money when people are already dealing with a death in the family seems rather cold hearted.
Same thing with special needs kids. In Massachusetts, where I live, it used to be a family member could not be paid to take care of a child. I'm not sure exactly how it works, as I'm still researching it, but it seems some bureaucrat finally realized that you could pay family less to do the same care, and it would cost the government less.
"To bring in money when people are already dealing with a death in the family seems rather cold hearted."
Get over it. If your inability to deal with discomfort costs a family life changing money that is selfish and weak. Anyone who really cares about their family isn't narcissistic enough to give all that up so they can circle the drain in some miserable death rattle.
The money that was spent on my Dad's end of life care, which he barely benefited from (perhaps didn't benefit from), could easily have made his life dramatically better spent on anything else. Those second jobs, the waking up at 3am, the material sacrifices. All would be unnecessary by simply managing end of life expenditure better.
If you put a price on it that can actually be acted upon people will figure out right away that the way we do things not particularly noble. It's just the easy way out paid for by someone else (though ultimately by all of us).
I'm sorry about your Dad. I have also lost people I love, and we deal with it in different ways. I cannot see a politician using this argument with much success on the public. I think the angle of doing things out of respect for their life, rather than cheapening their life (which is how this reads to me emotionally, but maybe it's just me), is more likely to help society function better.
I don’t predict political success but not because the system is morally correct or avoids “cheapening human life”. In politics people don’t have skin in the game so it’s all signaling.
One way to enable transparency on what does and doesn’t get covered, within Arnold’s approach, is to have policies identify the maximum dollars per QALY it will pay (or some other similar metric). All such metrics are flawed, and the result of bureaucratic processes. But it seems better to have that bureaucracy assign a number before the claim then check the policy to find the cutoff than to make a decision directly about coverage then justify it after the fact.
Separately, policies like the add-on policy might say that they will not require step therapy. Step therapy is the process of having to try X before Y will be covered, which you have to try before Z will be covered. It is particularly noxious for cancer, where step therapy means doctors are unwilling to prescribe combinations of therapies, and combinations seem to be particularly effective for some cancers because cancer tends to evolve around any single therapy.
Re: "The key to better health in this country is to come up with a way to reduce the incidence of obesity and substance abuse."
What does "the biomedical progress of science golden age" (Cowen) hope to offer on the behavioral health front? Gene-editing for self-control and delayed gratification?
There is the "Ozempic class" of drugs, which are now widely anecdoted to reduce cravings and improve self control generally. If that pans out, and Arnold is right, the impact of these drugs on population health between now and 2100 should be enormous.
Americans do not make use of low cost-benefit procedures without a prescription. We do not have a system that incentivizes prescribers to take account of the costs of what the prescribe relative to benefits. It is NOT a quirk of the American psyche.
I will agree with you that Mr Kling is mistaken calling this is a quirk of American psyche.
Everybody wants something for nothing. As a consequence of both widespread government funded health care in the form of Medicaid and Medicare, and the knock-on effect of the WWII decision to not tax employer-paid health insurance premiums as income, we have a situation where large numbers of people have access to funds that can only be unlocked by seeking some form of medical care. And certain people act surprised when that's exactly what they do.
Mr Kling is completely correct that the resolution to the problem is not to implement either individual or collective 'death panels' but to get to a place where individuals are making their own cost/benefit decisions in consultation with medical providers.
Medical students are actually taught NOT to consider what a test or therapy will cost. They are taught to do whatever is reasonably possible to cure or manage what's troubling their patient. Not surprisingly, most doctors have only a vague idea what something will cost. And what is "reasonably possible" keeps ratcheting upward.
Arnold wrote: "All sorts of studies show that people with “better” coverage do not on average enjoy better health outcomes. The key to better health in this country is to come up with a way to reduce the incidence of obesity and substance abuse." Yes, that is the way to improve statistical averages. But each of us is concerned with his own health and that of loved ones rather than statistical averages. Those who avoid obesity and substance abuse still have choices to make about diagnostic and therapeutic procedures, and intensive and intelligent use of them usually does lead to better health and longevity. With information easily available on the internet, any well educated person is capable of learning what is known in general about his condition and carrying out intelligent discussions with medical providers about which choices promise the best outcome.
“With information easily available on the internet, any well educated person is capable of learning what is known in general about his condition and carrying out intelligent discussions with medical providers about which choices promise the best outcome.”
I am a practicing physician. Respectfully, you vastly overestimate the ability or willingness of people to do this. It is a rare patient or family member who doesn’t want “everything done for mama”. Why not, when they won’t be paying the bill?
I agree that unfortunately most people don't do what I suggested. All I said was that many were now capable of easily doing so with a little effort. With respect to end of life, having a living will is a way to save next of kin from making poor decisions based on emotions of the moment, that they may later regret.
Agree obviously with all the conclusions, but I don't think this has ever been a good way to frame the problem:
>The most important policy problem is that people want unlimited access to medical services without having to pay for them. When the political system tries to accomplish this, the result is excessive spending on medical care.
I've never found this a compelling argument.
1. In the countries where governments attempt to create universal access without pay, the result isn't excessive spending, it's poor spending (because of regulations) and shortages across the board. This is more true the more restrictive the policy is. Price controls create shortages. Canada and the UK have terrible health care systems that people flee. As far as I can tell every government run health care system comes actually massively underspends on care itself and creates enormous inefficiencies.
2. The underlying idea that there's a kind of market failure because people will expend money on treatments that don't matter to you or me is entirely irrelevant. De Gustibus non est disputandum. I wouldn't buy a BMW or caviar. And I don't want to pay for someone else's BMW or caviar. But I don't begrudge them their right to spend their money how they want.
That's the real point here. Government health care systems want to pretend everyone gets a BMW and caviar, and they want to be sure that no one gets a BMW or caviar without their approval.
Moving to a two-tier system is an improvement simply because it's a step forward for freedom. If people want something, they can pay for it.
Richard Hanania says that there is a $100 bill on the sidewalk for medical innovation: Reform or repeal of medical-privacy laws (HIPAA etc) that impede the disclosure, aggregation, and analysis of medical data.
See his Substack essay, "Privacy versus Progress in Medicine," at the link below:
'All sorts of studies show that people with “better” coverage do not on average enjoy better health outcomes."
Really? All the studies I know of say poor people have far worse health outcomes than rich people. And worse health insurance.
I suppose if you control for income you could compare but I'd think that would be confounded by super healthy being more likely to skip insurance and chronically ill being unable to go without it or at least doing everything possible to get the best coverage possible.
Thank you for identifying the bias of sick people choosing better coverage. My contention with health care system is that it is a sick care system and doctors do not have time to address approaches for greater health but can write a prescription for pharmaceuticals in the 5 minutes the insurance covers. My organization is involved with a local startup called fresh Rx prescribing vegetables. (Plant based diet reverses obesity, diabetes and hard disease)
The goal of reducing obesity and self-destructive behavior is . . . laudable.
After pondering . . . recall the seven deadly sins of the religious, Christian, past.
One seems apropos (from Wikipedia)
“Emotionally, and cognitively, the evil of acedia finds expression in a lack of any feeling for the world, for the people in it, or for the self. Acedia takes form as an alienation of the sentient self first from the world and then from itself. The most profound versions of this condition are found in a withdrawal from all forms of participation in or care for others or oneself, but a lesser yet more noisome element was also noted by theologians. Gregory the Great asserted that, "from tristitia, there arise malice, rancour, cowardice, [and] despair". Chaucer also dealt with this attribute of acedia, counting the characteristics of the sin to include despair, somnolence, idleness, tardiness, negligence, laziness, and wrawnesse, the last variously translated as "anger" or better as "peevishness". For Chaucer, human's sin consists of languishing and holding back, refusing to undertake works of goodness because, he/she tells him/herself, the circumstances surrounding the establishment of good are too grievous and too difficult to suffer. Acedia in Chaucer's view is thus the enemy of every source and motive for work.’’
Who analyzes human thought, personal choices, individual responsibility, in this depth anymore?
Isn’t that what’s you’re wishing?
“Sloth subverts the livelihood of the body, taking no care for its day-to-day provisions, and slows down the mind, halting its attention to matters of great importance. Sloth hinders the man in his righteous undertakings and thus becomes a terrible source of human's undoing.’’
more simply, health insurance is not health care.
1) Healthcare will never be reformed. It will eat us. Accept it.
2) Death Panels won't turn out to be as cold heartedly technocratic as you like. Expect instead that they approve lots of expensive stuff for powerful interests.
3) If I could reform one simple thing, I would state that if government medical expenditure in the last year of life is less then $X, then the deceased can pass on ($X - expenditure) to their designated beneficiaries. This would prompt people to have some skin in the game on end of life care, which is where the money is.
4) I think congress should pre-commit to capping government health expenditure at some % of GDP higher than now such that it won't come up in the next election cycle. I doubt they will stick to this (look at the debt ceiling or doc fix), but it does provide a point of action where "do nothing" succeeds rather then having to "do something". "Do nothing" is always easier for politicians.
Last year of life is way more than other years but still maybe 10% of total.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0174
On the scientific side, See how Ezekiel Emanuel's thoughts have progressed since 1994: https://www.nejm.org/doi/full/10.1056/nejm199402243300806
I actually think the 1994 article more accurately reflects the reality.
On the emotional side, imagine the familial infighting that would result.
There is family infighting over money all the time. Money is important, and it should be fought over when we are talking about large life changing sums.
We got the hospital bill from my Dad's end of life care. It was north of $400,000. And that is with a person who did accept hospice care at home in the end. I really appreciated the last moments of my Dad's life, but he was very miserable during most of them. If you told him to end it a couple weeks earlier he could pay for his granddaughters college or give them downpayment on a house he definitely would have done it. But we don't allow people to do that, we only allow them to pay hospitals absurd sums of government money to keep them alive in pain.
And of course we never had to deal with Long Term Care. It was always our intention to care for our parents ourselves in our home. But you don't get paid for that. Your only option is "free" Medicaid (after you've lost all your assets and have little income). I would much rather just pay people who care for their elderly parents rather then sticking them in nursing homes.
Like every other decision there are tradeoffs and we should trust people to make those trade offs. Not give them only one option that also happens to be bankrupting us.
I think I would accept your argument more easily if you started off with paying people to take care of their own parents, which is really a great idea. To bring in money when people are already dealing with a death in the family seems rather cold hearted.
Same thing with special needs kids. In Massachusetts, where I live, it used to be a family member could not be paid to take care of a child. I'm not sure exactly how it works, as I'm still researching it, but it seems some bureaucrat finally realized that you could pay family less to do the same care, and it would cost the government less.
"To bring in money when people are already dealing with a death in the family seems rather cold hearted."
Get over it. If your inability to deal with discomfort costs a family life changing money that is selfish and weak. Anyone who really cares about their family isn't narcissistic enough to give all that up so they can circle the drain in some miserable death rattle.
The money that was spent on my Dad's end of life care, which he barely benefited from (perhaps didn't benefit from), could easily have made his life dramatically better spent on anything else. Those second jobs, the waking up at 3am, the material sacrifices. All would be unnecessary by simply managing end of life expenditure better.
If you put a price on it that can actually be acted upon people will figure out right away that the way we do things not particularly noble. It's just the easy way out paid for by someone else (though ultimately by all of us).
Addendum: money is fungible only within a system. The money spent on the elderly would not be transferred to the family.
I’m trying to change that.
I'm sorry about your Dad. I have also lost people I love, and we deal with it in different ways. I cannot see a politician using this argument with much success on the public. I think the angle of doing things out of respect for their life, rather than cheapening their life (which is how this reads to me emotionally, but maybe it's just me), is more likely to help society function better.
I don’t predict political success but not because the system is morally correct or avoids “cheapening human life”. In politics people don’t have skin in the game so it’s all signaling.
One way to enable transparency on what does and doesn’t get covered, within Arnold’s approach, is to have policies identify the maximum dollars per QALY it will pay (or some other similar metric). All such metrics are flawed, and the result of bureaucratic processes. But it seems better to have that bureaucracy assign a number before the claim then check the policy to find the cutoff than to make a decision directly about coverage then justify it after the fact.
Separately, policies like the add-on policy might say that they will not require step therapy. Step therapy is the process of having to try X before Y will be covered, which you have to try before Z will be covered. It is particularly noxious for cancer, where step therapy means doctors are unwilling to prescribe combinations of therapies, and combinations seem to be particularly effective for some cancers because cancer tends to evolve around any single therapy.
Re: "The key to better health in this country is to come up with a way to reduce the incidence of obesity and substance abuse."
What does "the biomedical progress of science golden age" (Cowen) hope to offer on the behavioral health front? Gene-editing for self-control and delayed gratification?
There is the "Ozempic class" of drugs, which are now widely anecdoted to reduce cravings and improve self control generally. If that pans out, and Arnold is right, the impact of these drugs on population health between now and 2100 should be enormous.
Americans do not make use of low cost-benefit procedures without a prescription. We do not have a system that incentivizes prescribers to take account of the costs of what the prescribe relative to benefits. It is NOT a quirk of the American psyche.
I will agree with you that Mr Kling is mistaken calling this is a quirk of American psyche.
Everybody wants something for nothing. As a consequence of both widespread government funded health care in the form of Medicaid and Medicare, and the knock-on effect of the WWII decision to not tax employer-paid health insurance premiums as income, we have a situation where large numbers of people have access to funds that can only be unlocked by seeking some form of medical care. And certain people act surprised when that's exactly what they do.
Mr Kling is completely correct that the resolution to the problem is not to implement either individual or collective 'death panels' but to get to a place where individuals are making their own cost/benefit decisions in consultation with medical providers.
Medical students are actually taught NOT to consider what a test or therapy will cost. They are taught to do whatever is reasonably possible to cure or manage what's troubling their patient. Not surprisingly, most doctors have only a vague idea what something will cost. And what is "reasonably possible" keeps ratcheting upward.
Arnold wrote: "All sorts of studies show that people with “better” coverage do not on average enjoy better health outcomes. The key to better health in this country is to come up with a way to reduce the incidence of obesity and substance abuse." Yes, that is the way to improve statistical averages. But each of us is concerned with his own health and that of loved ones rather than statistical averages. Those who avoid obesity and substance abuse still have choices to make about diagnostic and therapeutic procedures, and intensive and intelligent use of them usually does lead to better health and longevity. With information easily available on the internet, any well educated person is capable of learning what is known in general about his condition and carrying out intelligent discussions with medical providers about which choices promise the best outcome.
“With information easily available on the internet, any well educated person is capable of learning what is known in general about his condition and carrying out intelligent discussions with medical providers about which choices promise the best outcome.”
I am a practicing physician. Respectfully, you vastly overestimate the ability or willingness of people to do this. It is a rare patient or family member who doesn’t want “everything done for mama”. Why not, when they won’t be paying the bill?
I agree that unfortunately most people don't do what I suggested. All I said was that many were now capable of easily doing so with a little effort. With respect to end of life, having a living will is a way to save next of kin from making poor decisions based on emotions of the moment, that they may later regret.
“having a living will is a way to save next of kin from making poor decisions based on emotions of the moment“
I also wish that were true. At least half the time those are overridden by squabbling relatives who can’t agree on how aggressive to be.
I can’t begin to tell you how truly broken the “system” is.
Agree obviously with all the conclusions, but I don't think this has ever been a good way to frame the problem:
>The most important policy problem is that people want unlimited access to medical services without having to pay for them. When the political system tries to accomplish this, the result is excessive spending on medical care.
I've never found this a compelling argument.
1. In the countries where governments attempt to create universal access without pay, the result isn't excessive spending, it's poor spending (because of regulations) and shortages across the board. This is more true the more restrictive the policy is. Price controls create shortages. Canada and the UK have terrible health care systems that people flee. As far as I can tell every government run health care system comes actually massively underspends on care itself and creates enormous inefficiencies.
2. The underlying idea that there's a kind of market failure because people will expend money on treatments that don't matter to you or me is entirely irrelevant. De Gustibus non est disputandum. I wouldn't buy a BMW or caviar. And I don't want to pay for someone else's BMW or caviar. But I don't begrudge them their right to spend their money how they want.
That's the real point here. Government health care systems want to pretend everyone gets a BMW and caviar, and they want to be sure that no one gets a BMW or caviar without their approval.
Moving to a two-tier system is an improvement simply because it's a step forward for freedom. If people want something, they can pay for it.
Richard Hanania says that there is a $100 bill on the sidewalk for medical innovation: Reform or repeal of medical-privacy laws (HIPAA etc) that impede the disclosure, aggregation, and analysis of medical data.
See his Substack essay, "Privacy versus Progress in Medicine," at the link below:
https://www.richardhanania.com/p/privacy-versus-progress-in-medicine
'All sorts of studies show that people with “better” coverage do not on average enjoy better health outcomes."
Really? All the studies I know of say poor people have far worse health outcomes than rich people. And worse health insurance.
I suppose if you control for income you could compare but I'd think that would be confounded by super healthy being more likely to skip insurance and chronically ill being unable to go without it or at least doing everything possible to get the best coverage possible.
Thank you for identifying the bias of sick people choosing better coverage. My contention with health care system is that it is a sick care system and doctors do not have time to address approaches for greater health but can write a prescription for pharmaceuticals in the 5 minutes the insurance covers. My organization is involved with a local startup called fresh Rx prescribing vegetables. (Plant based diet reverses obesity, diabetes and hard disease)
Arnold
The goal of reducing obesity and self-destructive behavior is . . . laudable.
After pondering . . . recall the seven deadly sins of the religious, Christian, past.
One seems apropos (from Wikipedia)
“Emotionally, and cognitively, the evil of acedia finds expression in a lack of any feeling for the world, for the people in it, or for the self. Acedia takes form as an alienation of the sentient self first from the world and then from itself. The most profound versions of this condition are found in a withdrawal from all forms of participation in or care for others or oneself, but a lesser yet more noisome element was also noted by theologians. Gregory the Great asserted that, "from tristitia, there arise malice, rancour, cowardice, [and] despair". Chaucer also dealt with this attribute of acedia, counting the characteristics of the sin to include despair, somnolence, idleness, tardiness, negligence, laziness, and wrawnesse, the last variously translated as "anger" or better as "peevishness". For Chaucer, human's sin consists of languishing and holding back, refusing to undertake works of goodness because, he/she tells him/herself, the circumstances surrounding the establishment of good are too grievous and too difficult to suffer. Acedia in Chaucer's view is thus the enemy of every source and motive for work.’’
Who analyzes human thought, personal choices, individual responsibility, in this depth anymore?
Isn’t that what’s you’re wishing?
“Sloth subverts the livelihood of the body, taking no care for its day-to-day provisions, and slows down the mind, halting its attention to matters of great importance. Sloth hinders the man in his righteous undertakings and thus becomes a terrible source of human's undoing.’’
This from centuries of observation and insight.
Clearly rejected in current thought.
Thanks
Clay
"Most medical procedures have some benefits."
And later: All sorts of studies show that people with “better” coverage do not on average enjoy better health outcomes.
Isn't the latter what we care about? I'd also say that Vinay Prasad has done lots of great writing about net negative effects of medicine.