America’s Looming Primary-Care Crisis
newyorker.com
newyorker.com
The argument I've heard smarter, better informed people than me make is: If healthcare were nationalized, it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies.
When the government subsidizes farming corn on a massive scale, and all these corn-derived products make people obese and give them diabetes, it becomes counter to the government's own goals if its charter includes providing affordable healthcare to all.
If we don't stop subsidizing liquid sugar, it'll continue finding its way into everything possible.
What kills me is people proposing taxing products w/added sugar... talk about the American way; spend people's tax dollars on subsidies producing the sugar, then tax them again for consuming the thing you made cheap with their taxes! smh
If it affects them personally then they'd jump like a cat on a stove; but if it only affects the budget they aren't going to respond to any incentive.
If the US was being influenced by financial incentives it wouldn't be doing many of the things it does. Like tax cuts or spending more money.
Powerful donors should not exist.
Increasing corn production also does not play to a crucial constituency in the Presidential elections...
This obsession with “rich donors” ignores that voters will also get mad at politicians for the consequences of eliminating those subsidies.
The idea that nationalized healthcare (paid for by the middle class) will encourage politicians to tax the unhealthy food of the lower classes is fantasy - this has not manifest itself in other Western countries which do have nationalized healthcare systems.
Then again just ditching the subsidies would get the same thing done with less paperwork...
That's only one factor. Another is car dependence and lack of pedestrian-friendly built environments.
There is a lot of research on just how much harm it does us to sit all day, every day. We sit in a car to make a long commute to work. We sit our desks. We sit in the car again.
And hitting the gym occasionally doesn't fully compensate for living like that.
Urban planners used to configure cities to help promote physical health and we don't do enough of that anymore. It's nigh impossible to escape a sick outcome when trapped in a sick system that makes healthy choices largely out of reach for most people.
Every day US citizens waste hours life with transportation. I do believe in cars but I also believe we need to reshape how we live. If the US government allows our time to be wasted repeatedly by a variety of lobbies building infrastructure for a variety of interests it shows how little our leadership values the time of our citizens. I almost find it more egregious that government wants to waste the time of our citizens than wanting to eventually kill ourselves with emissions.
The US currently has an oversupply of labour and I suggest the US does something with it to reshape infrastructure to be less energy reliant.
The world should look into outfit and create houses with manditory natural cooling/heating, increase density in cities and towns to reduce habitat distruction and sprawl, reduce emissions of high GWP chemicals, and create a global political situation to reduce reliance on a failing economic system that incentivizes people to hide pandemics.
You can get that 60 minutes of exercise/physical activity if the transportation to various destinations is changed into a form of exercise for all or some part of it. In the case of a bicycle, it does require that destinations are less than 10 miles (16 kilometers) away, otherwise it would take too much time.
I'm not saying that it is impossible for the US to experience a food shortage or even that smart people in and out of government shouldn't worry about that eventuality. I am saying that current and past US programs to subsidize farmers probably do not do / have not done much to reduce that risk and that most of the group collectively deciding to continue the subsidies probably know or strongly suspect that.
In my experience, the elected representatives and other influencers arguing for the subsidies don't even use food security as an argument. (Again, like others in the thread, I am restricting myself to US food policy.) Instead, they argue that the family farm is a producer of particularly virtuous individuals, and it would be a shame if all the family farms were to be driven out of business by large corporations.
The US Midwest has the largest tract of arable land in the world and twice as large as the second largest. If the people of the world were redistributed among the countries so as to equalize the probability of famine among the countries, the US would probably end up with a population over a billion.
Funny enough, if you chopped off the fattest 5-6 states, the USA would compare more favorably.
Sources: https://en.wikipedia.org/wiki/List_of_countries_by_obesity_r...
https://ourworldindata.org/obesity
https://worldpopulationreview.com/country-rankings/obesity-r...
That is self evident in social behavior. Your theory is just an easily trotted out bogeyman.
The main difference is availability and price, especially the latter. A decent lunch near my office in my home country was 20-30 bucks (converted in USD), and I made X/year. Now I make 3-4+ times X, and you can get more food than I can eat at shit like Panda Express for 6-8 bucks. So vs my income, it's almost 10 times cheaper.
If it wasn't for health concerns, it no longer made sense for me to cook. So I just had delivery/takeout almost every day after I moved (switching country is stressful, so I was happy to get all the time back I could get). Then the health issues cropped up. Now I'm trying to dial it back, but its tough.
I know a _lot_ of people who had similar things happened to them after they moved here, and anecdotally again, one of them moved back and started losing weight super fast, without really trying.
The problem is, I think, often one of over-treatment. If hospitals are paid per procedure (as they are in the US) they are encouraged to do procedures that are actually bad for patients. Insurers can try to reign in over-treatment (to the horror of people who think that more healthcare is always a good thing), but regulators and customers (and activists) fear they do so targeting costs, not patient outcomes. It's all just a mess.
Here's a few issues:
* Over-testing is the most innocuous problem, but even tests aren't "free". At best, it's annoying and makes you not want to go back to see the doctor unless you know it's urgent (especially if it's costing you money or time). Tests might also the emphasis away from immediate treatments (both things that the doctor can do, and things the patient needs to do) as it becomes more of a "wait and see" game.
* Drugs. Obviously they cost money, and they can have side effects. Over-prescription is widely recognised as a major issue.
* Cesareans when they're a bad idea.
* Heart surgery when it's a bad idea.
* Aggressive treatment (especially of cancer) that statistically decreases the quality-adjusted life years a patient has, but hey you have to do something right?
I could go on, but there's really a ton of things where a hospital should do nothing, but has a lot of pressure (from patients and profit motives) to act. While insurers can try to control this, I think it goes without saying that they're also not entirely the good guys, and giving them too much power to reject treatments is also a bit worrying. Confrontational systems might work in the legal system, but it's too slow and expensive to work in healthcare.
Let's look at the special interests the US has (it's not just corn syrup!):
* Caps on doctor training spots. Obviously this is not unique to the US, but a free market solution is hardly going to work when you cap supply.
* Existing players (insurers, hospitals) want high overhead (regulations, admin) to create a moat.
* Drug companies in the US want high drug prices. Australia will subsidise drugs, but only if the drugs are priced right (which creates an incentive for companies to offer deep discounts in Australia). In the US, this kind of bargaining doesn't happen to the same degree. People online keep telling me that the spending on drugs is good though, because it's driving research (it's fine with me if Americans want to spend all their money subsidising the rest of the world).
People have to realize that the wealth America gained post WW2 was poured into making life comfortable and easy (institutionally and economically).
This had the unintended consequence of making Americans (on average) some of the unhealthiest humans in the world.
About a year or so ago I subscribed to "direct/concierge primary care practice". I pay $80/month and in exchange getting an access to a primary doctor who takes care of keeping an eye on me, my blood pressure, all my prescriptions (some of which used to require monthly visits to specialists). I am also getting access to really cheap prices on labs, typically 30 min visits same or next day if I wanted (unlimited visits per months), EKG when I wanted to put my mind at peace right there in the office ($25 one time fee), etc. Doctor is available over the phone, text or email. Does not dismiss me when I mention "I've read on internet..." something and actually explains things. Basically, I think it will take care of the most of my health care needs, as well as puts my mind at ease thanks to easy access to the doctor.
The doctor also refers me to specialists who's cash-prices were often below my co-pays.
For major accidents I still have a traditional health insurance with high out-of-pocket limit bought at the marketplace (self-employed).
This practice existed for quite some time and thanks to the subscription-based fees (not episodic described in the article), I expect it to be a long-term sustainable business. It is also owned by the doctor as far as I am aware. They explicitly do not deal with private or public insurances. (Although by recent law changes I can charge monthly fee to HSA account).
There are a few practices like that in the area. Can't say if others are similar in experience, but fees - are. So it looks like it is possible to build sustainable business around primary care. But it takes a different approach.
https://www.nextavenue.org/direct-primary-care-time-with-doc....
Disclosure: I am the founder of Akute Health which makes software for DPC practices. https://www.akutehealth.com
Disclosure: I am the founder of a DPC software company. I absolutely love this model for so many reasons. I’d love to answer questions people have.
The idea is that higher utilization of primary care results in lower hospitalizations and specialist visits, which are very expensive for all parties. This has actually been proven in studies comparing total health spend by large employers before and after adding DPC for their employees. So spend a bit more in primary care, get high touch service, and lower cost in the long run.
Medicaid, btw, is our social safety net health insurance program. Most Americans have insurance though their employer which is usually a high deductible plan. Meaning, you have to spend thousands of dollars before insurance will start helping to cover the cost of healthcare for you.
The thing is - the most expenses I had throughout the years I lived in the USA were on primary doctor and labs. Only in one year out of 10 I had an accident where without a regular insurance I would be screwed.
So high-deductible plan + direct care is the most optimal setup for me right now.
Simple solution: balance reimbursements towards primary care. But I assume there is a powerful lobby with deep pockets that will fight such a change.
Radiology and anesthesiology are also two "cash cows" of procedures. All of internal medicine wants radiology for tests and needs anesthesiologists if surgical remedies are required.
Primary care pays less because it requires less additional training than the specialties. Although some specialties aren't higher - Children's Oncology for instance.
"Supply, demand, and what the market may bear do."
I agree about "what the market may bear". Normal supply and demand market ideas really don't apply to a lot of medical areas.
Of all the specialties, it's one of the easiest to "offshore". Just send the data to Elbonia and have someone there examine it.
There was a company hyped on Wall Street doing this a number of years ago, but my Google skills are lacking and I can't seem to find it any more. IIRC they were sending the data to civilized countries such as New Zealand (great for time shifting if for nothing else). So maybe they just weren't competitive with Elbonia.
Here's a similar comment someone made on HN a few days ago: https://news.ycombinator.com/item?id=23882138
Here's the first Google hit on "remote radiology": https://argusrad.com/8-remote-radiology-benefits/
8 Benefits of Remote Radiology
REDUCES COST
NO SHORTAGE OF RADIOLIGISTS
Welcome to the global race to the bottom!
Why learn relativity and quantum mechanics when some one can undercut you ?
there just aren’t that many people willing and capable.
You can see the effects of this in the clinics popping up inside a lot of grocery stores in the US. They have nurses on staff who can do standard procedures like flu shots, strep tests, common cold treatment etc. And to me, it seems, the outcomes are effectively the same. You get your tests, if it comes back as something known, they prescribe you meds. If not, they advise you to go to the hospital or a specialist.
This is more deadly than it appears on the surface.
For example, this article on life expectancy is a good read. One should pay close attention to the case of South Korea and how they are focusing on the health of the younger generation, which has the best payoff (By the way, I am both a citizen of the US and Croatia. The biggest difference: Croatia is going the right way, the US is not): https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
Archived version of link: http://archive.is/3EpBi
No one’s gonna die, that’s when it’s all going to come to a head. We cannot afford Medicare for all when everybody is fucking sick.
Your framing is boring, we need to figure out how to make the care as widely available as possible regardless of the payment model.
Funding certain kinds of care with heavy taxes on things like smoking makes a lot sense.
Other things like unhealthy eating (or sitting, HN participants, lookin' at you) are so much harder to draw easy lines dividing contributing activity from everyday liberties that it makes less sense. You can work at the margins with something like soda taxes or maybe even incentives around bloodwork but the tradeoffs are less clear along with the dividing lines.
Sounds like a problem.
We can and should have lots more doctors (and other primary care providers), but we've long restricted that because people have wacky ideas about things like economics and intelligence.
Boy howdy.
There are three major parts of the economy which are extensively regulated to achieve political goals: health care and higher education (on the national level with some state involvement) and housing (city-level zoning, with occasional other mandates particularly in places like California).
Notice then the three areas where prices have become radically more expensive over the past several decades, fomenting a crisis that threatens our prosperity as a nation: housing prices, higher education prices, health care prices...
Canada has more regulated health care than the US, and yet the health care has better outcomes and is delivered at a lower price. It isn't perfect, but having seen both systems, the Canadian one is overall better.
One of the reasons, although not the only one, for higher education prices is less subsidies for education at the state level.
I agree that city zoning, and the lack of quick public transit, explains much of the increased price of housing. But some of this increase in cost is due to increased population, and the amount of land in and close to cities being fixed. Higher density would help, but higher density housing to also more expensive to create than lower density housing. A lack of regulation also leads to outcomes like houses in Houston being build on flood plains.
There is a role for government and regulation, and a role for free enterprise, but to understand the balance one need to look a other countries it see if they have a better balance and what works well.
This isn’t a US only issue.
[1] https://www.ctvnews.ca/health/despite-more-doctors-many-cana...
Here's the article I read a few years back that made me think this is the case:
I know it's mises.org, so hold the pichforks until the end. Even if they're way off base, there's got to be some value to be gleaned:
Evidence to the limitations. https://skeptics.stackexchange.com/questions/4561/does-the-a...