"God help you. You're on dialysis."
theatlantic.com
theatlantic.com
The majority of renal failure in the US is the result of diabetes or hypertension. The huge increase in the number of dialysis patients is overwhelmingly attributable to these two causes. In the vast majority of these cases, renal failure can be prevented with relatively inexpensive intervention to better manage the primary condition.
In most other developed countries, it is politically straightforward to spend $20,000 a year on coaxing and cajoling a patient into managing their diabetes better in order to prevent them from becoming a $70,000 a year dialysis patient. Needless to say that the benefits to this approach are greater than just a cost saving.
The United States has a quite peculiar set of popular attitudes to healthcare. It is clear that a large number of US citizens believe that healthcare ought not be a universal right, but most also find it unpalatable to simply allow people to die of preventable diseases. Consequently, cheap early intervention to preserve health is often shunned in favour of expensive, late intervention to prevent death. To my mind the most egregious example of this is drug abuse and alcoholism - huge amounts are spent on ER care for disastrously ill addicts, but little is spent on basic social work and rehabilitation.
I can't honestly say that I understand the mindset that completely opposes government involvement in healthcare, but it seems obvious to me that the current situation is the worst of all worlds - the worst outcomes and the highest costs. I don't know how healthcare became such an ideological battleground, but it's not doing anyone any good - not patients and certainly not the taxpayer. I really don't want to be negative, but I have no idea how this stalemate can be broken.
We also have one of the highest taxes on nicotine sales in the country, for similar reasons.
I say that government can experiment in social engineering, but only as long as they're completely transparent about what they're doing.
From wikipedia:
Under the theory of positive and negative rights, a negative right is a right not to be subjected to an action of another person or group—a government, for example—usually in the form of abuse or coercion. A positive right is a right to be subjected to an action of another person or group. In theory, a negative right forbids others from acting against the right holder, while a positive right obligates others to act with respect to the right holder.
What's your feeling on that positive right? I've encountered people who argue against democracy, and I've encountered people who will re-word the right as stated above and then call it a negative right. I disagree with the former, and the latter only succeed in demonstrating that the difference between positive and negative rights is one of phrasing, and not of the right itself. Do you have a different take on the matter?
So the question isn't over whether there's a positive right to health care--- almost everyone agrees there is to some extent. The disagreement is over which kinds of care are included in the right.
Morally we are obligated to save the emergency patients life but also morally we shouldn't have let their condition slip to the point it is in.
I've never been able to give that a more benign reading than "as long as it doesn't cost anyone enough to seriously affect the problem". I'd rather be required to pay to keep society at least minimally humane, than voluntarily pay for gates and guards to protect me from the poor, desperate, and angry.
That's the dilemma of a certain category of moralists in the United States: people shouldn't have anything they can't pay for, so they deserve to suffer and die, but it's immoral not to help them and unseemly to leave them helpless and suffering. Torn between the desire to enforce justice on others (let the bums die!), fulfill their own moral obligations (do unto others!), and maintain appearances (we're ranked with Mexico, for God's sake?), they muddle through in contradictions.
In reply to dantheman's sibling comment, there may be some people who reason that way, but the popular argument is based on no clear conception of anything. It's just contradictory impulses that aren't logically reconciled at all. That's how it can be so popular to decry "socialism" while simultaneously defining socialism so broadly that almost all Americans support some instances of it.
I think certain interests in US have put a considerable effort into their propaganda to make it so. It stems from the "Red Scare" and what used to be the fear-du-jour for us before it was replaced by "terrorism". But the previous fear hasn't been completely replaced. It was planted there and periodically, when appropriate, politicians and other interests are able to tap into it to further their purposes.
Think of these fears as backdoors into into a system. The typical access to a system is through a rational, objective argument. The faster and more effective is to bypass that use the "fear" backdoor.
These fears take a while to cultivate. Once they are there, they are ready to be used and abused.
It's a bait-and-switch. Socialism defined in one way (collective ownership and management of the means of production) is anathema to almost all Americans and probably (I'm guessing) to most Europeans. Americans believe it's an inherently inefficient system leading to relative poverty compared to private ownership and competition, not to mention much less freedom. That kind of socialism is unpopular and indeed scary.
Collective ownership and management of some fraction of economic output -- i.e., taxation and public spending -- is universally practiced throughout the world and nearly universally accepted (though in many cases the collective nature of management is just theoretical, with the majority of citizens having no say.)
The genius of right-wing American scare pundits is to erase the difference between these things in the American mind, making "common sense" exceptions for some kinds of spending. Spending on the wrong things is "socialism." It's a flexible and pragmatic smear. Right-wing pundits and politicians have a lot of reasons for disagreeing with different kinds of government spending (some very sensible): it's inefficient, it takes from the deserving to give to the undeserving, it hurts poor people by making them lazy, it gives too much power to unelected officials, and so on. Whatever the reason for attacking spending, any bad spending is "socialism" and, being logically indistinguishable from full-scale authoritarian Socialism, might lead to it. (The focus on logical equivalences and consequences, and the fear that runaway logic can blow up a society the way a runaway reaction can blow up a nuclear plant, is reminiscent of arguments between parents and children. It makes more sense to be afraid of runaway sentiment, but they're not going to say anything bad about unfounded, immoderate emotion because unfounded, immoderate emotion is their business.)
Thus, they can take any minor disagreement about the scope of government involvement between citizens in a stable, relatively politically homogeneous country (especially considering our remarkable diversity in other ways) into a clash of ideas between sensible conservative people (who closely resemble the average American) and card-carrying, bomb-throwing, society-subverting leftists, or their stooges who are too naive to realize the importance of the logical equivalence between taxation and collective ownership.
The policy is that the government shouldn't be involved in private affairs and that while public encroachment in these spaces may make things cheaper in the short-term, everyone, except perhaps a very small portion, will be worse off as the intervention matures.
I don't necessarily agree that government should stay totally out of the matter at this point either, and I of course concede that it is a little off-kelter to have the same group screaming bloody murder when they think that they may go to a government-sponsored doctor but happy to submit to electronic strip-searches and groping at the airport, but I didn't want such a gross mischaracterization to slip by without challenge. There are many generous people in the United States and many who'll help you if you need it. The opposition is not hostility to the poor, merely a different conception of the proper place of government.
I agree with your basic points. But as someone who both is American and has a serious life threatening medical condition, I think there must be some deeper reason for this American quirk.
I know that a lot of "standard wisdom" concerning nutrition and the like not only doesn't work for me but is actively harmful to me. I have managed to get off 8 or 9 prescription drugs and now manage my health issues via diet and lifestyle (and herbs and supplements when necessary). But I have gotten there by following a pig-headed, asinine, "don't tread on me" sort of path. It has been really important to actively reject outside intervention in favor of home-grown solutions for my issue. I suspect something similar may be true for most Americans. America was founded by social outcasts who left their countries of origins to go elsewhere under really harsh, deadly conditions -- conditions which were, nonetheless, more tolerable than the social expectations they were fleeing.
Most people cannot fathom my choice to live without furniture and without a car. I sleep on the floor and most of the time I own only two or three outfits. I get lots of comments from people who are often just trying to make conversation but nonetheless are basically butting in to things that they know nothing about and which are none of their business. For example, I do not own a jacket. Jackets are too hard to keep adequately clean and most are not designed to be washed regularly (ie every single I wear it). I find that undershirts work better for me than jackets. I have also been known to walk to work in flip flops in 40 degree weather. People inevitably feel compelled to tell me to get a jacket or comment that my feet must be cold or something. It is usually under circumstances where I do not have the time (even if I had the inclination) to explain to them that whatever annoyance I suffer from the cold is laughable compared to the suffering it has allowed me to walk away from. It is also usually from people at work, this in spite of a company policy that no one other than my immediate boss is to offer "constructive feedback" on my appearance, and then only if I am in violation of dress code. It annoys me to no end yet I realize that if I made a big stink about it, I would most likely be the one deemed to be 'a problem' (and it would unnecessarily call attention to my medical condition, which I do not wish to do). Most of these people are well-meaning and genuinely concerned for my welfare and/or just trying to make conversation. So I try to handle things diplomatically and lightly and good-naturedly, without referencing the serious medical situation that drives my unconventional literally "remarkable" (ie worthy of remarking upon by these people) choices.
So I think it is possible that most Americans have some deep-seated reason(s) for balking at the idea of someone interceding in their diet and lifestyle choices at an earlier stage in the process. I know outside interference is one of the things that I feel most threatened by. Since I don't have a doctor's note for doing what I do, I can't really justify or defend it on some kind of "legal" grounds or some such. I'm just some lone nut-case who occasionally makes fantastical claims that most folks find unbelievable -- an issue I work very hard to keep out of my place of employment.
It is unfortunate that the results are so expensive. But I am not entirely convinced that the cajoling and convincing that works in other cultures would necessarily be such a good thing for a society of outcasts who could not conform and chose to face so much hardship in order to start over elsewhere. For me, conforming -- even in seemingly small matters like wearing a jacket -- leads to enormous suffering and would eventually kill me. So I just am unable to "go along to get along", in spite of internal wiring that makes me want very much to do that. But I just can't. Maybe a lot of Americans also just can't, yet are willing to accept intervention at a later stage of more serious crisis because at that point there is nothing to lose and a great deal to gain.
Americans are irrational. We are superstitious and confuse things like the availability of early treatment with being forced to use it. We are also selfish and unwilling to live with the results of our poor decision making process.
PS: It's not hard to demonstrate that universal heath care would cost less and be more useful than are current system. However, most people already decided to do something else so people are not going to change their mind over something as silly as a rational argument.
Anyway, I really have no idea what your point is. So probably no point in going on.
EDIT: In regards to the PS you added after I replied, since diet and lifestyle changes have been my primary means of getting well and I have not seen a doctor in several years, I don't much care what the US does about the "healthcare system".
On the surface that may seem like a perfectly rational standpoint. The reason why it's part of a superstitious belief is how that idea links up with other ideas. You are not arguing based on social data, but rather the abstract idea of what America is and for better or worse that's an superstitious argument.
Anyway, Western Medicine as understood by the specialists in their respective areas is vary different from that practices by doctors in the field. It's all well and good to prescribe proper nutrition and exercise, but there is no reason not to do it. If your goal is peak physical condition then there is a lot of research in that area, but doctors work around the lifestyles of their customers and most practical research is designed for that setting.
PS: The heath care system protects you in ways that you are probably unaware. Sanitation, food safety, vaccination area all obvious, but healthy populations reduce the spread of disease. The influenza outbreak of 1918, a global plague that killed between 20 and 40 million people, resulted in large part from a local breakdown in heath care on the front lines. http://virus.stanford.edu/uda/
Edit: The evidence of the breakdown starts with: However, a first wave of influenza appeared early in the spring of 1918 in Kansas and in military camps throughout the US http://virus.stanford.edu/uda/ and it's well worth the read.
In addition to resolving my own health issues, I have also raised two "twice exceptional" kids (gifted and learning disabled). The more gifted of the two was never identified by the public school system as gifted. He was always in special ed. My sons and I have walked away from a conventional lifestyle much as early immigrants walked away from the lifestyle of their native lands to come here. Europeans generally don't understand quite a few things about American culture, including the gun culture here. But Europe killed off most of its deadly animals a long time ago. We still have bears and wolves and poisonous snakes. We also have a lower population density, which means that if you get into trouble, you are more likely to have to deal with it yourself. There may be no one to call upon, much less police to intercede.
Additionally, studies show that Americans generally view more space around them as "theirs". One study found that some criminals in jail claimed such a large space around them as "theirs" that you basically couldn't be in the same room without them feeling you were in their space. This likely was a factor in their generally aggressive/violent reactions to things that wouldn't provoke others. The fact that Americans tend to claim so much more body space than Europeans or Middle Easterners may be part of why we are viewed as "the ugly Americans" -- it likely causes us to start conversations with people whom we think are "in our space" but who view us as butting in inappropriately. This view of or need for more space may well be due to physiological wiring, not just culture. It may well be part of why Americans prefer to spread out and create suburban sprawl rather than live in denser urban settings.
That is just a few examples. I don't think my assessment that Americans on the whole are likely wired differently from other people is simply superstitious. There is substantial evidence that we are misfits and loners and overly aggressive by the standards of more "civilized" cultures. We are mavericks and discoverers and explorers. This may be part of why we were the first to make it to the moon. Those traits are not simply pathological, with no good in them. But they do cause enormous problems in some settings. And there is substantial evidence that traits like that are rooted in physiology -- that "mental" differences are rooted in physiological differences (such as brain wiring).
FWIW: My medical diagnosis is "atypical cystic fibrosis". The typical prognosis for CF is that you get gradually sicker and sicker until infection has eaten away your lungs and you qualify for a lung transplant or die. I am not using diet and lifestyle to seek some kind of peak performance from a place of basic wellness. I have used them to stop being bedridden, close the hole in my left lung, get off 8 or 9 prescription drugs, get well enough to work a full time paid job for the first time in my life, and get well enough to live without a car and get around mostly on foot.
Peace.
There is a difference though. You are probably in the top 1 percentile when it comes to intelligence and being able to rationally research and figure out what it better for you.
But what about the other 99% ? They choose to lead a lifestyle that might in chronic and expensive (yet initially completely preventable) diseases. Then they rely on emergency room treatment and in the end they end up costing everyone more time, money and energy.
U.S. already spends more on healthcare than West European countries that provide a public option and yet delivers worse care for the average of citizen. I don't know that what we have is because we don't provide a public option or because we _do_ provide any govt. sponsored health care. I strongly suspect it is the former, not the later.
Note, that if we didn't have a "free" emergency room treatment option + Medicare and Medicaid, the argument for a completely govt. "hands-off" approach would be stronger. Let everyone who could not achieve a certain financial prosperity just die off. They are unfit anyway. Eventually only the healthy and/or wealthy will remain. I think that would be very disturbing but I think there are segments of the population who would strongly support this.
However, now it turns out that the same people that are severely against govt. doctors telling them what to eat will run the the same govt. run hospital when they have a heart attack. And eventually everyone ends up worse off. The doctor's time is wasted, the patient is in critical condition and dying, everyone's money is wasted.
Perhaps in the end it comes down to education. I think the younger generation is brainwashed into believing certain things about independence, self-reliance, freedom, and so on. But they are not educated to the level where they can function in such a self-reliant manner. I am not. I do not have the tools or the ability, for instance, to test every single piece of meat or produce that I buy in the store. Maybe I am being slowly poisoned. The same thing with medicine. I don't know enough to choose the best medication for me. If I had a serious condition, I doubt I would have the knowledge to pick between prescription mediation A or B.
The point is that our cultural attitudes might actually be harming us as a nation. They are predicated on certain conditions that are just not true anymore. What used to be an advantage has become a disadvantage. And I think we either make the conditions true again (educate the hell out of everyone) or we should try to slowly change our attitudes.
B) Having very successfully raised and homeschooled two special needs kids and largely resolved my supposedly unresolvable health issues, I have found that wondering why people do the seemingly "stupid" things they do is more valuable and productive than just condemning them for their stupidity and insisting they do...whatever my personal bias suggests is "the right thing" when I don't even know what is really causing the problem.
C) Our cultural attitudes may well be harming us as a nation and as individuals. That doesn't necessarily mean that what works for other nations will be our salvation.
If you want my opinion on some possible viable solutions: What I am finding is that a lot of people, regardless of intelligence level, are using the internet to do their own research and find solutions that work better than what doctors are generally telling them. I also toy with the idea of creating a simulation (aka "game") to teach other people who may not be as capable as I am of figuring it out from scratch how to achieve similar results anyway. There are substantial obstacles to me getting that done. I don't know if I can overcome them in addition to my daily battle to overcome my genetic disorder. I suppose time will tell.
That is interesting. I know the military is trying this. They have a limited amount of time to teach a larger and larger amount of things to new recruits. They are experimenting with VR environments.
But I can see how that could be applied to other things. Perhaps a sim environment that lets someone see how molecules interact.
I am not really thinking in terms of how molecules interact. I am thinking in terms of how to convey the means to avoid exposure to germs/toxins/etc and also how to convey the subtle cumulative impacts of dietary choices. I think many people prefer pills to dietary changes because the difference a pill makes is readily recognizable whereas dietary impacts are far subtler and easily overlooked, thus not really taken seriously by many people. I've made substantial changes in my body chemistry, in part by micromanaging my diet. This has (apparently -- by observation) made changes in things most people think can't be changed. They need a more explicit mental model and I need a more information dense means to convey my ideas and experiences. The written word on my website is just not adequate to the job.
One example of this that is frustrating and heartbreaking at the same time is a piece by Gladwell called "Million Dollar Murray"
1) They make something free
2) The market for private delivery of the same thing dries up. Those few that still want to pay must pay much more than they would have before the government started giving it away for free because the market has shrunk so much
3) The same thing happens to alternatives to the thing they made free
4) Decisions are now made by those delivering the process instead of the person choosing between the alternatives. Costs and benefits are no longer weighed together or by the person that cares about the outcome the most.
5) The corporations and unions move in and start influencing the decision makers, carving out expensive niches for themselves
6) Things that truly matter but aren't profitable for the politically connected fall by the wayside
7) People getting something free put up with it because ditching the free thing for same thing done right is now a super expensive alternative
8) Delivering the free thing grows more expensive, much faster than the rate of inflation
9) Eventually the tax payers fight back and the costs of delivering the thing are slashed, along with quality. The corporations and unions have to spend and/or threaten more to hang on to their protected positions.
10) Those getting the service for free now have to spend all their time at rallies and fine tuning the stories about how badly they're being treated.
Happens with health care. Happens with roads. Education. City services. Anything they give away for free or heavily subsidized.
And i grew up in a city with one of the best public library systems in the country. You'll still notice that it was populated with plenty of Barnes & Nobels and Borders book stores.
Oh, and i'll note that the Ambassador Bridge, the Blue Water Bridge and basically any bridge in and out of Ontario to the US are privately owned toll bridges, which charge you to travel over them.
[edited to remove pointless but cathartic ad hominem]
You also don't know which is cheaper, public education or private. You know that in a government-subsidized environment, public was cheaper to you than private, but what a freaking surprise, when you pay for public school whether you attend or not, then must pay for the private school on top of that. Of course X + Y > X... but school's only free if you never pay local taxes.
But regardless of your answers, its clear to me that many places have governments that are better at pursuing the their national interest, at least in some areas.
Well, one reason is many other countries have proportional representation. At least when its rationally implemented. In PR countries, people can actually choose to be represented by someone that agrees with their values. And if that person or party sells out, that party will lose support or the party members will pick a different candidate next time that will do what they want.
In the US, elections are winner-take-all. So representatives don't have to align their behavior with the beliefs of their supporters; they just have to convince the most people that they are better than the other options. It becomes a con job.
Candidates must tell different things, lie even, to get the most votes or they get no power at all. An expensive process that candidates in a multi-party system don't really have to do because the people pick their party by their values and the membership of the party know their own people. They don't have to struggle to get ALL the power or none; they get their share.
So what you get in the legislature in PR countries are groups that more closely represent the different groups in society. Some want more government, some want less. But in the US system, you just get people who want more power for themselves and have no incentives to stick to any set of values and many dollars given to them to go along with all of the piranhas that abuse our system.
And it probably will not change until the system hits a wall where all of the tricks and cheats have been exhausted and we are finally forced to live within our means.
For instance, in my country, Australia, our government provides interest-at-inflation loans to all students for undergraduate degrees. The loans are repaid via income tax, and repayments only begin once your income exceeds a certain threshold. Almost nobody defaults, since the payments are just subtracted from your paycheque before it even gets to you, just like your income tax. At the same time the repayments are calculated to never be too onerous, and you're only ever paying the principle. I don't know what stops universities from inflating their fees --- presumably the government has guidelines for costs of courses eligible for these loans. A typical 3 year arts degree might cost about $30k. The good universities are about on par with the good US state schools in rankings. We don't have any universities equivalent in quality to the top tier US schools. I believe this is a sane and sustainable system. Our single payer health care system isn't perfect, but it's a lot better than the USA's system.
It's possible that it does come down to the subtleties of our electoral systems. It seems a little unintuitive to me, since folks here do mostly make their choice between the two major parties and pull for whichever they like. On the other hand we do have single transferable vote for our senate, which always elects some independents who represent their constituents. We also have compulsory voting, so you can't pull any shenanigans to disenfranchise people or discourage them from voting.
I don't particularly care how much government you have in Austria, but that's really none of my business. If people are unhappy with it, they can change it.
The things our government does badly do much more damage to us and to the world and we have little ability to change it.
That's why you ought to care how much government we have in Australia, and how much government they have in Germany, Denmark, Sweden, etc. The countries of the world form a natural experiment that provides some evidence about the effects of certain policies. This evidence points against the "big government always bad" hypothesis.
So, mortality rates on dialysis do suck. It's not necessarily a reflection of bad care, though that certainly happens. Once you require dialysis, that means your kidneys are trashed. They don't work well enough to function, so you need kidney replacement therapy. This generally doesn't happen in isolation. If your kidneys are that damaged, you generally have serious underlying health problems (diabetes, high blood pressure) that have also affected your brain and heart... so it's only a (short) matter of time before you have a devastating event.
There are diseases which only affect the kidneys in isolation, and those people tend to live a long time on dialysis.
The comparisons to foreign countries is always important but I feel like the article dismisses some of the country-specific factors
"Yet Italy spends about one-third less than we do per patient. These results reflect lower overall health-care costs and a __patient population with lower rates of diabetes and heart disease__, but also important divergences in policy and practice."
Less diabetes and heart disease would be a huge factor in the difference in spending and mortality rates. Those are massive implications, and also indicate that their dialysis patients might be due to different (less systemic) diseases.
In the end, it's probably only one factor. I think it's likely that underlying U.S. cultural differences are another. I believe expectations and beliefs about death and elderly may be different abroad, though I don't have any citations for that. In the U.S., it's seems hard to deny people dialysis. I'd be curious what the average age of people on dialysis in the U.S. vs abroad are. I expect the U.S. average age would be much higher.
I think american families tend to want dialysis and are more reluctant to accept that it's simply the end of the line. To be fair, it's a hard decision to not accept what seems to be a life extending treatment. And it's incredibly hard as a physician to refuse dialysis to anyone, especially if the family wants it.
I also expect these same attitudes pervade u.s. trained physicians who may skirt these subjects of death more apprehensively because they also share those attitudes. The cover your ass mentality also tends to mean people err on the side of doing more, when doing less may be more appropriate.
I wouldn't think they would even need to be placed to high, just used to identify when a patient is coming to the end of the line and the benefit of the dialysis would be minimal.
You're right of course that this is just part of the bigger problems with the US health care system as it currently exists.
I have some knowledge in this area because I'm currently working on the software for a dialysis machine, and in this context have talked quite a bit with people working in the industry who know and can compare the situations in different countries.
Previous thread on it.
In summary, my side business (macrumors.com) became successful enough that it made significantly more than my income as a doctor. Combine that with the lifestyle of being a doctor being bad, and wanting to spend more time with my young kids. It was still a hard decision at the time due to the sunk costs of becoming a doctor but on paper it was an easy decision.
I run a small team (five of us) of developer/journalists. We're in a new-ish field of journalism called "news applications." Essentially it means we make software instead of using words or pictures to tell journalistic stories. There are crews like ours (some bigger, some smaller) at the New York Times, LA Times, Chicago Tribune, the Guardian in the U.K., and elsewhere.
Our work includes the Recovery Tracker http://projects.propublica.org/recovery and the recent "Docs for Dollars" project http://projects.propublica.org/docdollars that analyzes payments from pharmaceutical companies to doctors.
You can see pretty much all of our work at http://www.propublica.org/tools
The kidney is not a simple organ and once you start implanting foreign material into people you run into some major issues. Clotting and infection for example. In comarison, artificial heart (a mechanical pump) seems a simpler task and I don't remember hearing much on widespread applications of that lately.
Did anyone actually watch that movie?