Monday, November 23, 2009

Government - Run Health Care (GRHC)

[from Stu, images added by Ira]

This began as an email I sent to several friends, including Ira:
"An interesting article and also,as an aside, a good argument for govt-run health care..."

And I got the following response from Ira:

"I read the article through and saw no good argument for government run health care.

"Indeed, one of the mentions (bottom of page 7) had to do with reducing charges for use of a medical device that recently cost thousands of dollars less. Nope said the finance guy, as long as MEDICARE (i.e., the taxpayers) is paying the old higher prices, we should not cut our prices, even though we are non-profit!

"As I made clear in I favor Comparative Effectiveness Research (CER) and Quality Adjusted Life Years (QALY) which is what the star of the article is actually doing, but I do not think the US government can successfully pursue that path in the current climate. Look what happened to the breast cancer screening recomendations this week. They are based on CER and, when women and doctors screamed, the govenment back down almost immediately. I think private insurance companies are in a better position to push CER and QALY-based reforms that save real money.

"Where did you see good arguments for government-run health care in this article? "

My response to Ira is the same as my response to Dennis (not on this blog).
First, Dennis' comment follows:

"G-RHC is always attractive to those who believe in big-bigger government, something for nothing (or so it seems) and the philosophy of entitlements (regardless of costs or the negative realities of socialist experiments in other places). Good or bad the reality is our country is broke and cannot afford its current "entitlements" not to speak of its mounting debts and deficits or future entitlements. At some point reality crashes the illusions of the masses and the politicians who feed them. "

So, finally, here is my response to both of my staunchly conservative friends:

"OK, let the (respectful) discourse begin! While the proposition that, " G-RHC is always attractive to those who believe in big-bigger government, something for nothing (or so it seems) and the philosophy of entitlements (regardless of costs or the negative realities of socialist experiments in other places)." may be true, it is indubitably not true that all who believe in G-RHC want something for nothing regardless of the true costs (I know this because I am one of them).

However, the main point of the article was that you can't improve health care protocols without most of the participants adhering to the protocol. It is a statistical fact that you should minimize the variance of the behavior of the doctors if you want to change the protocol for the better. If every doctor tries different treatments then it's impossible to know which of them are really responsible for patient improvement or decline while, on the other hand, if you have a specified treatment plan that all follow and it isn't working then you know just what needs changing. You can't have many variables changing to determine which ones are producing the good results. This is simply what is known as the "scientific method".

Now the above is easier to do with the govt running the health care system than the way we have it now not only without centralized control but rewarding inefficiencies and expanding costs as the article explains. Some things work better if they are centralized and yes, even (shudder) collectivized; e.g. fireman, policeman, soldiers, national parks and interstates, and it appears to me (somewhat on the basis of other countries experience (like Holland)) that health care should be nationalized. No solution is perfect but the benefits, to me, outweigh the costs.

There will always be a tradeoff between the needs of the individual and society; the trick is to find the correct balance."

And finally, finally, here is Dennis' reply to me:

"Theory and abstractions are seductive - as are the plans of mice and men. The reality always proves more elusive and sometimes tragic. Americans may have to experience their own tragedy as they fall prey to the allure of socialist solutions - as the rest of the world discards them. An irony of our times.

I am more attracted to real experiences - and those I am aware of through friends, relatives, and others who have the experience of centralized medical systems is not encouraging (to me at least). Worst of all - is the destruction of the doctor-patient relationship and the need to finagle ways of getting attention (if not bribery then trips to other countries or high-cost private insurance when the state allows it). And - most important - how does a bankrupt system pay for it? The destruction of a system that works for most and that has been the most dynamic in terms of medical advances should not be undertaken lightly. There may be many regrets - as I think many are now realizing as they coalesce in opposition to some dangerious social experimentation. "

I now open the question to this blog.


Ira Glickstein said...

Thanks Stu for the new Topic.

I am copying some recent GRHC postings by Howard and me here from an earlier Topic to trigger discussion here.

Howard Pattee said...
Everyone should watch CBS Sixty Minutes on The Cost of Dying.

The basic problem is religious conservatives’ inability to accept death of the aged as often involving a human choice (i.e., triage or "death panels"). This makes it a political third rail, as we have seen in the current media.

Howard Pattee said...
I agree that governments are always subject to the same corruptions as private enterprises, no better nor worse. The fact is that the complex US health system is by far the most expensive in the world while its quality, especially for the young, is below average.

For example, Taiwan Health Care per person is <$900. US health care per person is $6700. US administrative costs are seven times higher than the average of OECD countries. I believe it is also a fact that all OECD countries have government administered health care.

Howard Pattee said...
I found the reference for my last comment.
U.S. Health Care Spending in comparison with Other OECD Countries. See pages 8, 11, 12.

Ira Glickstein said...
I watched 60 Minutes this past Sunday on The Cost of Dying. Thanks for providing a link so others can watch it on their PCs!

I was particularly angry with the old, dying man who had the nerve to expect a $400,000 heart and lung transplant (I am going from memory but I think that is what it was). It was courteously and gently explained to him that he had a choice of asking the staff not to resuscitate him if he had a heart failure and the SOB insisted he wanted to be revived and kept alive as long as medically possible. ...

The 60 Minutes story was excellent. The main doctor interviewed was very reasonable on how terminal patients and their families should be advised of their options for a peaceful end of life.

My only problem with the segment, and TV and press coverage in general, is that they do not make any attempt to explain Comparative Effectiveness Research (CER) and Quality Adjusted Life Years (QALY) to the general public.

I don't agree with you that it is only the "religious conservatives" who demand that everything medically possible be done for themselves (or their loved ones), without regard for cost. I think plenty of non-religious people and liberals feel that way as well.

Indeed, religious people, in general, should welcome death when the time comes, and accept God's will rather than demand heroic medical intervention. Conservatives should be concerned with fiscal responsibility and their duty to the next generation. When it came to her parents, my wife was the one who asked the doctors to set a "do not resussitate" order when the time came. My brother and I did the same when my father was at his end of life, even withdrawing oxygen and IV. (He happened to be in a Catholic hospital and they readily agreed with our decision.)

I think it was the leftist feminists, not the religious right, who derailed the new mammogram guidelines. They equated it to putting money ahead of a potentially small increase in deaths from breast cancer.

Ira Glickstein

Howard Pattee said...

Ira says, “I don't agree with you that it is only the "religious conservatives" who demand that everything medically possible be done for themselves (or their loved ones), without regard for cost.”

I did not say they were the “only” ones. I said they are the basic problem. I repeat my claim that this is a fundamental difference in values between conservatives and liberals. For the religious conservative mind, all the basic issues of life, sex, birth, and death, from abortion to end of life choices, sexual variations, stem cell research, and the evolution that produced it all, cannot be discussed in rational terms.

Conservatives regard these life, sex, birth, and death issues as the core of a “sacred” God-given value system. These values are explicitly supported by scriptures (but as Haidt’s studies show, they have a basis in primitive psychological instincts).

Ira goes on with his wishful thinking about how conservative “should” behave. He says, “Indeed, religious people, in general, should welcome death when the time comes, and accept God's will rather than demand heroic medical intervention.”

I agree. Indeed they should! As Prof Higgins would say, Why can’t conservatives be more like liberals?” The fact is that if any questions are raised about how to think about life and death, the response of the conservative is simple and inflexible: “We believe and teach the consistent tradition of the Church, based upon two thousand years of collective human experience and handed down from apostolic times as a clear, consistent and emphatic moral and theological conviction, accepted and affirmed by the People of God even to the present day.”

One can hear this dogma in any conservative church. But it is not limited to church. Just read the details of the "Terri Schiavo case" (e.g., Wikipedia) to see how the majority of political conservatives actually think and behave.

Ira, you can’t blame this type of thinking on your "leftist feminists."

Stu Denenberg said...

I'm embarrassed to admit that I did not read the prior discussion to Health Care and the ethical questions it raises before posting my GRHC post, so I will contritely try to catch up on the blog history before venturing any comments...

P.S to Ira: Is there a way to change the blog settings so that a Commenter has access to the more powerful Editor that a New Poster (with author priveleges) has?

Ira Glickstein said...

Thanks Stu and Howard.

1) BLOG COMMENT EDITOR: Sorry Stu, the Comment editor is limited. Once you've entered your text (along with HTML code) you can Preview your Comment and get error alerts if your HTML is faulty or if the total Comment exceeds 4096 characters. Once you Publish the Comment you cannot Edit it any more. However, the Author of the Comment can Delete it, and post a revised Comment.

2) HEALTH CARE PROTOCOLS: I agree with Stu that health care protocols are necessary to improve quality. The government has a role in funding the NIH and various universities and teaching hospitals to research best treatment practices and Comparative Effectiveness Research (CER).

3) COST CONTAINMENT: Stu does not mention how health care protocols can help contain costs. In the UK for instance, an agency named "NICE" decides general rules for coverage. No procedure/drug treatment will be paid for unless it is effective in extending "quality-adjusted life years" (QALY) and costs less than about $30,000 per QALY. Thus, someone expected to die in 3-9 months due to a heart condition is not eligible for a $100,000 hip replacement.

4) MAMMOGRAMS: Routine semi-annual mammograms starting at age 50 vs age 40 would save $X million and cost only Y lives. Divide the saved dollars by the QALY of Y 40-year old women who may die of breast cancer, and, if the number is over $30,000, set the guidelines to age 50 (as all European countries with nationalized systems have.)

5) CER/QALY STANDARDS: I would like NIH to set CER guidelines of life expectancy for given physical conditions and treatments. Insurance companies would use them as a guide to what they covered. Some would offer a policy that set QALY at $30,000, others at $50,000 and consumers would make a choice between higher or lower premiums and coverage levels. These CER/QALY standards would apply to Medicare and Medicade patients who could choose to buy additional coverage to raise the dollars per QALY levels.

SERVICES: Stu says some things work better when centralized and he cites firemen and policemen as his first two examples. Yes, there are economies of scale. You and I cannot each hire a private fireman and policeman. We can afford a community fire/police station that serves us when needed. But, although some standards for training and equipment are set at state and national levels, all fire and police departments are funded at the local level. And, most large businesses have their own security and fire safety staffs and only call upon the city departments for exceptional events.

7) ONCE UPON A TIME "NATURAL MONOPOLIES": We used to think the Post Office was a natural monopoly, but FedEx and UPS compete in parcel delivery and customers happily pay the higher prices for better service. Most personal messages now go by email. The telephone company was a natural monopoly, but I unhooked my phone landline a year ago and now have home phone via the internet plus cell phones. We use T-Mobile@home but there is Vonage and other competition in internet phone services. The government role is to set standards for sharing the radio spectrum and for enforcing contracts, and taxing us.

8) DO EVERTHING MEDICALLY POSSIBLE: Howard is right about the disgusting role of the religious right (and GOP politicos) in the Schiavo affair. I spoke out against them at the time. But this is not true of most religious people whose health care costs are far lower than most non-religious. According to the CBO per capita costs in the US vary from $5,200 to $13,900. Mormon Utah was the least expensive and Massachusetts (where Howard lives) the most expensive. Look at the linked map and you can "see" that the darkest counties (highest costs) correspond almost exactly to secular, Democratic areas and the lightest (lowest costs) to church-going, Republican strongholds.

Ira Glickstein