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Comment by danso | Hacker News Reader

This reminds me of the health care cost paradox that Atul Gawande wrote about in 2011. In Camden, NJ, one percent of the patients accounted for as much as a third of the city's medical costs. A doctor proposed in a small study that giving these lost causes better care actually reduced costs overall. But good luck convincing politicians to devote more money to cocaine addicts and extremely obese patients.

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...

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It's not just medical care. Housing follows the same trend[1].

These kinds of studies make me wonder if, politically, we care about cost savings at all.

1. http://www.upenn.edu/pennnews/news/housing-homeless-mentally...

I think we care about cost savings politically, but we don't care about evidence. If someone holds the political belief that cutting public services for the poor saves public money, it's unlikely that any number of studies will change their mind.

Politicians seem to have decent motives, but the system is almost inherently allergic to facts.

I've been watching these issues for a long time and here's the conclusion I've come to:

Americans care far more about people getting "what they deserve," than caring about costs in the long run. Many of the Americans who have the least will still argue against people like them getting "free" things like healthcare -- "I DON'T HAVE HEALTHCARE, LOOK AT ME, I'M FINE". Because they believe those other people don't deserve it. On some level, they believe they don't deserve it either. (In America, land of opportunity, you get what you deserve! So if you don't have it already, you don't deserve it, post ergo propter hoc.)

This also explains why allegedly fiscally conservative Republicans don't support a guaranteed minimum income, because "those people" haven't "earned" it -- no matter that the uncountable costs to society, and the totally countable costs to the government/taxation system, is much greater when people go poor and raise their children in poverty and in slums.

Americans, by and large, are so afraid that one person will get something they don't "deserve" that they'd rather punish them, and everyone else, many times over. The opposite of "Better 10 guilty men go free, than one innocent suffer."

IMO this also explains our ridiculously punitive sentences, instead of simple rehabilitation which is proven to reduce recidivism. "Why would you give them THERAPY? and GYMS? and let them have PUPPIES? THEY'RE SUPPOSED TO BE IN JAIL!" And why so much (much more than you'd think) of the general spirit seems to be against young women who are raped. And on and on. People obviously must be getting what they deserve, or nothing makes sense about their beliefs about themselves, their country, what they've achieved (or not) in their lives, etc.

(I say "Americans" because I've lived for years in another country and traveled all over, and this is far from a universal feeling.)

Puritannical background at work? Perhaps. Certainly not Quaker.

Don't give up hope. Cities are making progress in HRF and preventive care.

What does HRF stand for?

Why more money? It seems that even more money could be saved by excluding drug adicts and those who are so fat that their fatness interfere with their treatment.

Did you read the article? These people still are treated in emergency care...doctors and emergency medical staff will not ignore someone who needs ER care. Inevitably, most of these patients can't pay, which means the public pays.

But putting extra money into the care of these patients prevents costly ER episodes...a little more money upfront apparently saves money in the long run. But of course, we mostly obsess about what we have to pay upfront

This reminds me of two quotes:

> Those who don't make time for exercise today will have to make time for illness tomorrow.

and

> An apple a day keeps the doctor away.

It's all the same concept - preventative care now keeps you healthy for tomorrow and out of the ER.

From the article ER wasn't the expensive part, it was the months in ICU.

No reason you couldn't identify him there -- granted it would only cut down, not eliminate the costs but it would give a decent motivation to become more healthy.

No, it would not.

People who inject heroin know that injecting heroin is harmful. People who are bariatric patients know that being 500 lbs is considerably risky for their health.

Telling these people that they will have yet another bad thing happen if they continue their existing behaviour has little effect to change their behaviour. There's already a long list of bad things. That's why people who've had their leg chopped off continue to inject heroin in the other leg.

Hmm, maybe just send them directly to an addiction treatment program would work?

Yep, the other factor the article mentions is the patients "died, reducing their costs permanently". We could just round up the obese and drug addicts and save a whole bunch of money by killing them.

You could have the healthiest country in the world by a huge margin if you just summarily executed anyone who got a serious illness!

Getting a drug addict to medical treatment (and addiction harm reduction measures such as clean needles and prescribed heroin) means that they are avoiding crime to get the money to pay for drugs; they're avoiding spreading various diseases such as HIV, hepatitis, etc (which can all be expensive to treat) and they're at less risk of losing limbs or needing very serious surgery.

It also helps to keep them out of prison.

Even if you hate people who are addicted to drugs and you think they deserve a miserable horrible life you should be persuaded by the fact that modest spending early on prevents large spending -funded by your taxes- later on.

How much more money is saved if they stop?

Look I don't care if they do drugs, but I will argue against wasting more money on them, unless that money is spent on the real problem: getting them out of their drug addiction.

Most of us don't want to live in a society where making bad choices in life (or having bad luck) excludes you from live-saving care.

And since HN tends to lean anti-social: for the objectivists: most of us would don't want to get denied care because we look like a junkie during an emergency.

I think you meant anti-socialist. While HN might or might not lean anti-social, I'm not sure it would have a clear effect on political arguments.

I wouldn't want to exclude them, I just don't want to spend (even more) money supporting their bad habits. It is a two-way street: they want more money? They have to take that in the form of drug treatment.

The libertarian in me don't want to waste money on them at all but I am not blind to the fact that their life wouldn't have been as miserable as it is if we didn't have a stupid war on drugs.

How do you propose, in the middle of a medical emergency, to identify the people who have been excluded with enough speed to deny them expensive care but not harm the chances of saving someone who has not been excluded?

I agree with the general point, but real medical emergencies aren't Grey's Anatomy or ER with people screaming for this or that medication and running down the halls.

You have 4.5 hours to treat someone for a stroke and 6 hours for an MI. Not that you don't have to go quickly, but you also don't have to rush unnecessarily.

There clearly are some medical emergencies that need responses that fast, otherwise I wouldn't see so many ambulances flying by with lights and sirens. Now, maybe there aren't enough of those in the problem category to make a difference in costs. However, even 4-6 hours seems like a pretty short amount of time given that you're going to be trying to identify someone as on a blacklist when they most likely will be trying not to be identified, and measures like requiring ID before treatment will exclude a lot of people not on the blacklist.

You have 4.5 hours to treat someone for a stroke if they teleport to the hospital the second they notice the first symptom. In real life, you often have an hour or four where the patients wait for their weird symptoms to go away again because they don't want to overreact and bother some busy doctor who should be taking care of Serious Emergencies, and then another half hour to get them to the ER, and then you're lucky if they're still in the treatment window at all by the time a doctor sees them.

There's not a lot of running down halls in screaming in real ERs, but there's also no time to, for example, send someone to go home and get the ID the patient forgot in their panic and hurry, to prove they're not blacklisted "no medical treatment" somewhere.

joshgel, I don't know where you live, but in my country, hospitals are publicly rated on their performance in treating MIs with angioplasty within 90 minutes of patient arrival, insured or not.

From the article one of the guys spend months in ICU -- that shit costs a fortune daily.

So it seems reasonable to simply tell him that the next time he comes in he has to be active in a program to improve his general health otherwise he gets booted once he has been positively identified unless he can pay himself.

Anyway it seems that one of the consequences of what the doctor did was that he lost weight and improved his diet -- I would want to see much more focus on that and none at all on the touchy-feeley stuff.

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