Let me start with some clarification on the choice thing…. The context for that statement was choosing an insurance policy….There are lots of choice opportunities prior to that trip to the emergency room.
Fair enough, I presume you’re talking about shopping around for a private policy, but no one is suggesting that choice in coverage be removed. One of the great difficulties in the discussion is to consistently make it clear which aspect of healthcare one is talking about – delivery of services, and/or financing them. Unfortunately even those with insurance are oftentimes getting screwed. Making a selection in a dysfunctional universe doesn’t speak to the crux of the problem, how to make sure that everyone has guaranteed access to a minimum of healthcare. The fact of the matter is that something like close to half of healthcare expenditures in the US are already publicly financed, that’s quite a choice right there, why is that. It’s reported that significant chunks of Medicaid recipients are satisfied with their healthcare while significant portions of the privately insured are dissatisfied with theirs. Why is that. The research suggests that one’s level of expectation has a lot to do with it. The evidence that being able to choose private h/care insurance is somehow valuable, is lacking. That doesn’t mean doing away with choice altogether.
I do relate well to the peace of mind issue. I remember how wonderful it felt, despite the dreadful circumstances… You accept whatever you're given and it's not necessarily the optimum. In a hospice scenario, there's no real downside to that. The patient, after all, is going to die regardless.
Ending one’s days in a hospice is fitting, but it need not necessarily be a passive experience, unless one is truly debilitated and without faculty. Accepting sub-optimal outcomes is a regular part of life, we get used to it, it’s important for our peace of mind. In hospice the emphasis shifts to the quality of the experience as opposed to it’s length, so I don’t see how there are no downsides to hospices not optimizing their product. I think that how you feel when you go out is an important experience for an individual. We recognize such as dignity, which is the whole reason for going there in the first place.
But for those of us who hope to live for a long time, there's a trade-off. We can go passive and trust the system to do a pretty good job for us, which it probably will… Or we can be assertive about our own care and put in the effort to optimize our prospects. The former gives us peace of mind. The latter may give us better results.
I suggest that the choice is not so binary and that your linkage is suspect.
I could see myself going for the peace of mind. I'm very hassle averse so I could decide to minimize my hassles and take the more passive route. Or not. Different tolerances, different choices. While I may choose the low-choice option, I don't think we should give up the choice to make that choice…..
We might have a difference of opinion as to how hassles operate or how peace of mind arises, perhaps even disagreement about what these ultimately are, however, I suspect not, despite the dreadful circumstances is a key thought, you should hold onto it. I do know what you mean though, yours is the popular view of how such events appear to us in the reality of our daily lives. But ultimately the extent to which things are hassles, depends on one’s state of mind, or do you disagree. The conventional iteration is exogenous, the ultimate one endogenous. Peace of mind is great, we all want it, the default setting is that it is easily shattered by trivial and non trivial events, more of it is better, it is possible to make it a permanent feature, this takes a lot of work, the means are available to all of us. In my experience those with the most steadfast or strongest sense of it, the least fickle or fleeting experience of it are advanced buddhist contemplatives. They have made a tremendous effort to achieve it, so while being passive might minimize a hassle, I remain unconvinced that it leads to peace of mind. Ultimately the strong version of it does not arise passively and it does not depend on outside circumstances.
I get a couple of thousand dollars of blood work done several times a year and I have a new test in mind for this year. I'm not the only one…I don't think we should give up the choice to make that choice.
I see, you and others 'volunteer' for health care. I think that’s a good thing, I laud your approach, wish that more were inclined to take an active interest in their health. But am I to assume that you volunteer every year for thousands of dollars of unnecessary blood tests. If so then why are you doing them. You seem to have a strong disposition towards rationality, so that glove doesn’t fit. I do not ask just to pry into your affairs, I hope that everything is ok, but I find it surprising that you are so proud of being economically irrational. True, we can drive ourselves nuts in pursuit of information, peace of mind is a balancing act, but if you are guilty of such inefficient behaviour your claim to be interested in reducing health care costs rings hollow! Perhaps you wouldn’t bother if you knew the tests were really not needed. Contrary to what you said above, I suggest that your active participation in managing your own health and not your passivity, is what brings you peace of mind.
Regarding you key premise about voluntary and involuntary, having had several days to reflect on it, I'm still not buying it.
If you don’t agree, fine, I can live with that. I think you are wrong. What if I said that consuming health care was both involuntary and extremely unpredictable, that these interrelated factors made hc different. Would you buy that? The point is that the majority of hc expenses occur where there is very little choice, your life is at stake, and actions, expensive one’s, are a matter of necessity. In other cases of insurance, replacement costs are pretty easy to quantify. Medical outcomes are not nearly so clearly defined. In hc costs the old 80/20 rule applies, people going to doctors on account of the sniffles is not what is driving up medical costs. Medical costs aren't going up because people volunteering for hc. Medical costs are largely technologically driven, more Medicine becomes available (new expensive treatments for onerous cases) and unlike other commodities which drop in price when more is available, in hc, in the aggregate costs go up. We consume heath care services when the integrity of our being is compromised ie we fear that something is or may be wrong, ultimately we fear dying, and we never know when that is going to happen. No-one volunteers for this.
It's true that catching problems early can save money…from a strict cost perspective, it's not at all clear what the net is.
Isn’t saving money a net result, you’re confusing me.
Some tests … testing everyone … no test. Some tests… The long and short of that is that you can't generalize. I'd like to see more study in this arena.
I am not against studies examining specific aspects of early detection however many epidemiological factors lie outside the strict domain of health care, whether public or private, so narrow studies while no doubt helpful, are not a panacea in and of themselves. Therefore, I think you can generalize plenty. The long and short of it is that you don’t need millions of studies to accept that early detection and it’s corollary, prevention, reduces costs. Parsimony. The fact that medical testing is imperfect doesn’t invalidate the general efficacy of early detection. Urban cancer rates from smoking are going down in the face of institutionalized prevention. If we were suddenly convinced to stop filling our bodies with junk, healthcare costs would plummet. In natal care it is clearly proven that early detection has a very significant impact on outcomes, and lowers costs dramatically over the long run.
Maybe your mind is boggled because you're tangling two different kinds of efficiency...On one hand we have what I will call streamline efficiency. I think that's what you mean when you talk about economic efficiency.
Yes it is. What I mean when I talk about economic efficiency is getting the most bang for your buck. True that words have popular and technical meanings, but what you call streamline efficiency imo is commonly known as economic efficiency. As in That's the kind of efficiency you get out of single payer. The processing runs like a clock and costs come down....Then there's efficiency in the capitalist sense, called economic efficiency. It's a rowdy process…. This is the exact opposite of what you get from centralized, streamlined systems. It seems a contradiction from the common-parlance term, efficiency. It might appear that way to you because you are confusing economic efficiency with creative destruction or growth, or as you say innovation.
If we choose streamline efficiency, we lose the innovation of the market. Our systems may be streamlined and cost-effectiveIf we choose market efficiency, we lose streamlining.
I get your point, but in the jumble of the real world beyond the domain of neoclassical economics, again, such outcomes are not so binary, rather there is a reciprocal interdependence, hence the import of the involuntary and unpredictable nature of health care consumption. My mind might be boggled but you are confused. Now you’re confusing market efficiency with the messy business of growth. Market efficiency arises as a result of buyers being fully matched with sellers, it’s not something anyone chooses, apart from their individual actions in setting price. The strong belief is that more efficient markets optimize our well-being. But for some reason in the US wrt private health insurance it has been decided that this is not the case. I’d like to know why. The holiness of this object, (private insurance) is then bandied about and pedestalized (I don’t think that’s a word)…we cannot mess with the free market... as if private health insurance were a good example of it. To be truthful, perfect markets don’t actually exist, they arose as a figment of someones imagination. Efficient markets, so the theory goes, are predicated upon perfect information, upon unconstrained freedom of choice and moral virtue, all of which are glaringly absent in private health insurance. The sanctity of the situation is overwhelming, it boggles my mind.
Despite all that, what you’re saying is basically right, I think, at least in some respects. <g> The situation is one countervailing conditions - the static aspects of economic efficiency and the dynamism of growth. There are long term trade-offs between these competing economic welfares and balancing them out is a challenge for any firm, get it wrong, you’re gone. Except if you’re a US health insurance company. Exactly how private health insurance companies accord with free market ideals while harboring massive economic inefficiencies is beyond me but there you have it. Throw in a healthy dose of demand for welfares of a social nature and you have a boondoggle of a problem. Govt provision of health insurance is not perfect either, there are opportunities for increased politicization through lobbying – could things get even worse than they are. It’s a big problem, a political one. The govt already finances the expenditures to a significant degree and this public-private split does not seem to have deterred innovation by drug companies. Losing the “innovations” foisted on us by the private health insurance industry on the other hand, would serve us well, imo.
Why do you suppose it's called single-payer if it's intended to have multiple payers?
Beats me, habit I guess.
That's your ranking of values. Mine, too. Not everyone's.
In Medicine “do no harm” is a very strong ethical principle, much more powerful than a value judgement.
The key element for me is that all voters will pull benefits from the system but a minority will pay for it. When the majority is dissatisfied with the core system while others have supplemental insurance, they will either vote for costly increased benefits or deprive the "rich" of their privilege.
But this would be nothing new, it’s already the status quo, an ongoing issue. We are always juggling competing imperatives, which is precisely why we need good governance, these are not easy issues. The fact of the matter is that we have found that best case scenarios emerge where the economically strong make “sacrifices” for the good of the whole, in regards to economically weak. This is the foundation of an ethical society. Such is demonstrated in ample ways, both domestically and internationally. What exactly is it that makes healthcare unique. <g>
Surely you learned about the goose and the golden egg at your mother's knee.
Well my mom was (is) a mildly voracious reader, if that’s possible, but my dad did better in the story telling dept. To this day he reads and tell stories to children, one of his better qualities. He is part of a group of Seniors who devote time and effort to this in schools where needed. It may look like he’s doing it for the kids, and sure he is, but the benefit he derives himself is enormous, definitely fosters his sense of personal wellbeing. As he as become less vigorous, this is something that he can do which brings tremendous joy and meaning to his life.
The economics of this scenario have a strong pull toward cooked goose.
I think your fears are not unfounded, but overblown...economically the situation would clearly be more efficient. I’m sure that there are sets of numbers out there attesting to this. I don’t feel like looking for them. Your fears prevail. The problems we face at present are not because of a strong pull towards cooked goose, but because of the strong attachment to one. The current system is cooked and once something has been cooked it is very difficult to uncook it. |
