Scott, are you suggesting that Gaius’ proposal for transforming the American health care system would lead directly to the violent deaths of tens of thousands of people?

Of course you’re not. Your cute little “gotcha” is both breathtakingly inane and grossly offensive.

Gawande’s post is exactly correct. It’s actually worse. I once had a patient who couldn’t pay me for his appendectomy—a laid-off salesman with three kids. I sent him a bill every month, and he paid me $5 or so. Now, my bill had to be for the same amount I charge Medicare patients—it’s illegal otherwise, triple damages if they ‘catch you’ with 1/3 going to anyone willing to blow the whistle on you. The dollar amount of the bill is most relevant not to actually assess the patient but to establish a ‘billing profile,’ so the percentage of your bill the third-parties actually pay, when they condescend to do so, is as high as you can get it. One can use the recommended bill-collecting leg breakers of the state medical society—yes, the society has recommended such services. I told him I don’t use bill collectors, and that he could sent me what he could. He did for a while, Then he didn’t.
The entire system should be nuked.

And once Iraq has been liberated (using the example of liberating Germany and Japan and turning them into democracies, thus proving it works), THEN we can have the ideological debate on whether it was right or not to do so.

You do support the war on those grounds, don’t you Gaius?

moreover, i do not see why principle and ideology should trump empirical data. we have the example of socialized medicine, and it clearly works vastly better. wadr to mr eudoxis, your claims about wait times are anecdotal—the oecd’s are statistical. it’s cheaper. and it covers everyone, as opposed to some or most—if you think wait times are sad, consider being uncovered as an infinite wait time.

the pragmatic thing to do would be to put aside ideology and admit that there is a better model in practice that we can copy—and then copy it. once that’s done and we’re experiencing the apparent benefits, we can have the ideological debate on whether it was right or not to do so.

Ted, wait times are obviously related to capacity but procedure based renumeration appears to play only a small part in expanding capacity.

http://www.pnhp.org/news/2004/october/17_million_veterans_.php
1.7 MILLION VETERANS LACKED HEALTH COVERAGE IN 2003

Harvard/Public Citizen Study Finds Sharp Increase Since 2000

…David U. Himmelstein, M.D., study author and Harvard Medical School Associate Professor, commented: “This administration professes great concern for veterans, but it’s all talk and no action. Since President Bush took office the number of uninsured vets has skyrocketed, and he’s cut VA eligibility, barring hundreds of thousands of veterans from care. Our president has put troops in harm’s way overseas and abandons them and their families once they get home….

http://www.citizen.org/publications/release.cfm?ID=7339&secID=1158&catID=126

…In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics. The number of uninsured veterans has increased by 235,159 since 2000. The proportion of non-elderly veterans who were uninsured rose from 9.9% in 2000 to 11.9% in 2003.

Many of the 1.69 million uninsured veterans in 2003 were effectively barred from VHA care because they had incomes above the eligibility threshold, or because of waiting lists at some VHA facilities, unaffordable co-payments for VHA specialty care, or the lack of VHA facilities in their communities. An additional 3.90 million members of veterans’ households were also uninsured and ineligible for VHA care.

The Medicare program (which covers Americans over age 65) covered virtually all Korean War and World War II veterans. However, 681,808 Vietnam-era veterans were uninsured (8.7% of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during “other eras” (including the Persian Gulf War), 12.1% (999,548) lacked health coverage.

More than one in three veterans under age 25 lacked health coverage, as did one in seven veterans age 25 to 44 and one in ten veterans age 45 to 65.

Many uninsured veterans had major health problems. Less than one-quarter indicated that they were in excellent health; 15.6% had a disabling chronic illness….

…While many Americans believe that all veterans can get care from the VHA, even combat veterans may not be able to obtain VHA care. The 1996 Veterans Health Care Reform Act expanded eligibility for VHA care to all veterans, but instructed the VHA to develop priority categories for enrollment. The VHA priority list includes eight priority categories, with veterans offered care based on their priority status and the resources available (Appendix)….

…In the 7 years after the passage of the Veterans Healthcare Reform Act, VHA enrollment grew 141%, from 2.9 million to 7.0 million. However, funding increased by only 60%. Because VHA funding did not keep pace with the demand for care, long waiting lists developed at many VHA facilities. By 2002, there were almost 300,000 veterans either placed on waiting lists for enrollment or forced to wait for 6 months or more in order to receive an appointment for necessary care (Memorandum from Department of Veterans Affairs to Chairs and Ranking Members of Senate and House Veterans’ Committees and VA-HUD Appropriations Sub-Committees, July 2002)….

Nope. The authors say (see their definitions of p. 62 of the referenced article) that the patients were inpatients, but the waiting times are counted from the time the patient is added to a list for the procedure until the hospital admit date.

Please note that the wait times shown are for inpatients. That is, the table shows mean wait times after being admitted to hospital. I knew wait times in some European countries were long (particularly the UK), but those numbers are astounding!

I should not be surprised at the Canadian numbers, (i.e. mean wait 4.5 months in hospital for kee replacement) even after we in the US take up the slack. Here at Mayo, we regularly process Canadian patients who have been on the wait list for critical surgeries. Case in point; we had a flight from Toronto with 36 lung cancer patients who needed primary tumor surgery. They came in on Friday and were on their charter back to Canada on Monday. The most recent X-ray was 6 months old!

Yes, we need to do something about people who don’t have adequate access to health care in the US. And, yes, we (as well as Europe) need to keep the costs from increasing at a dramatic pace. But please keep things in proper perspective.

1. getting rid of the special tax treatment for employer-provided health insurance, the original WWII mistake that helped lead to the disastrous coupling of health insurance and employment.

2. removing or reducing mandates on what insurers must cover and limits on their ability to price by individual risk. In general, whenever there is a regulation that tries to force the private provision of some cross-subsidy, it should be removed.

3. Remove regulatory barriers to entry into the insurance market and in particular to interstate expansion of competition. Ironically, here the feds might actually play a positive role, in a manner that would constitute a rare legitimate use of the interstate commerce power; they could either enforce a measure of uniformity on the morass of different state regulations, or else enact a “full faith and credit” law requiring that insurers licensed in one state be allowed to offer coverage to people in other states.

Disclaimer: I am not terribly expert on the devilish details of these things. For more professional views on how to do this, Arnold Kling’s series of health-related articles on TCS is a good place to start; Patricia Danzon also has a lot of good stuff, though it seems to be scattered about.

Told ya.

http://www.dav.org/voters/statement_ilem_040301.html

STATEMENT OF
JOY J. ILEM
ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
OF THE
DISABLED AMERICAN VETERANS
BEFORE THE
HOUSE VETERANS’ AFFAIRS COMMITTEE
SUBCOMMITTEE ON HEALTH
APRIL 3, 2001

…VHA will continue to face the same problems in the future if adequate resources are not provided. In fact, its problems will most likely be compounded in the future unless aggressive steps to correct deficiencies are taken now. It is truly disgraceful that the Nation’s largest health care system has been allowed to fall into a state of disrepair and overall decline. We may be serving our veterans, but are we serving our veterans well?…