How American Health Care Killed My Father
theatlantic.com
theatlantic.com
Instead, this is an article about business, efficiency, the impact of IT and modern business process on health care, and the impact our current system has on consumers and businesses.
I read The Economist, and think they occasionally do some pretty good politics articles, and having an on-line version, it would be easy to post them here.
As for political articles, the test is whether the article is an instance of the ordinary back and forth of debate on some political question, or whether it's about some deeper underlying phenomenon that only happens to be related to politics. E.g. "Politician A accuses Politician B of X" or "Why policy Y is good/bad" are probably both offtopic, whereas "How political campaigns use statistics" is probably ok.
It would also be a deterrent for those such as myself who flag articles for nauseatingly bad grammar. I don't have that much patience when reading pages with verbless sentences, "there is" vs "there are" mistakes, and that sort of thing. Most 20-somethings do, though. I flagged one just this week after running into a paragraph that started with the following sentence:
Anyway.
The way I had looked at the issue up until now was that this sort of flagging still had some use. Articles would rarely get killed for terrible grammar alone, but if they were also somewhat inappropriate for another reason, then the grammatical errors could push them over the edge.
"Why the US healthcare system is broken" (well written or not) can be judged "politics" by this guideline according to the "Why policy Y is good/bad" part.
That said,
suggestion 1: This would be a great addition to the HN guidelines. Appending the above to "Most stories about politics, or crime, or sports, unless they're evidence of some interesting new phenomenon." would add clarity.
suggestion 2: Can the "misflag rate" be made visible to flaggers as part of their profiles? This would help us improve our flagging.
For instance, if you're going to critique it, he says:
> Such a transition would require the slow reduction of Medicare taxes, premiums, and benefit levels for those not yet eligible, and a corresponding slow ramp-up in HSAs. And the national catastrophic plan would need to start with much broader coverage and higher premiums than the ultimate goal, in order to fund the care needed today by our aging population.
It's very difficult to take away benefits that people already have, which is eminently a matter of politics.
Also, note the "POLICY" at the top of the page. That's pretty indicative that it is politics.
I'm not saying it's not a good article, but it certainly isn't about hacking code or electronics, and only tangentially related to startups (in a way that lots of things are, if you want to make tenuous connections).
pg, however, thinks it is worth having this sort of article, so I am asking, honestly, how one distinguishes a good politics article. It strikes me as being a difficult thing to do, but perhaps he has some insight that I am not picking up. Perhaps it's simply a matter of taste.
The article obviously appeals to hackers (myself included), but I am not sure that it appeals more to hackers than to other intelligent people, so that test doesn't really work.
I, for one, like articles which intelligently discuss hacking economic and social issues. To me hacking is hacking. Almost all the software hacking I do is a part of a form of economic hacking, i.e. my business plan.
Reason being, is that a good discussion of the economics of some policy is about the most efficient to make it happen, but invariably the question comes up about whether it should happen or not. For instance, with health care, some people deeply believe that it should be available to all; others think the government shouldn't spend money on that sort of thing. With an article on the economics of cap and trade vs taxing carbon emissions, people will invariably pop out of the woodwork and deny that people can or are creating negative environmental externalities, or if they are, that anything should be done about it. And so on...
So... yes, they're separate, but the resulting discussions are indistinguishable in most cases.
As an example, if you look below at the comments, regarding school vouchers, someone corrects me that a "real" libertarian solution would simply be to abolish the idea of public schools paid for through tax dollars. There's such a fundamental disconnect in terms of someone who wants that, and someone, who, for instance wants a Nordic style state, that discussions aren't likely to go anywhere very good.
The author supports this point in rich and irrefutable detail. Read it and weep.
This article is indeed "not political" but ONLY in the sense that none of the efforts at a solution being debated even slightly address the crucial considerations that he makes. Shame on the solvers...
This was adopted a long time ago in the UK and became cemented in place with the MRSA outbreaks. Visitors can actually be removed from the hospital if they're seen not using the alcohol based sanitizer.
"Imagine my father’s hospital had to present the bill for his “care” not to a government bureaucracy, but to my grieving mother. Do you really believe that the hospital—forced to face the victim of its poor-quality service, forced to collect the bill from the real customer—wouldn’t have figured out how to make its doctors wash their hands?"
"But health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance."
"For that matter, try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. I called up several area hospitals, clinics, and doctors’ offices—all within about a one-mile radius—to find the best price. I was surprised to discover that prices quoted, for an identical service, varied widely, and that the lowest price was $1,200. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price."
"By contrast, consider LASIK surgery. I still lack the (small amount of) courage required to get LASIK. But I’ve been considering it since it was introduced commercially in the 1990s. The surgery is seldom covered by insurance, and exists in the competitive economy typical of most other industries. So people who get LASIK surgery—or for that matter most cosmetic surgeries, dental procedures, or other mostly uninsured treatments—act like consumers. If you do an Internet search today, you can find LASIK procedures quoted as low as $499 per eye—a decline of roughly 80 percent since the procedure was introduced. You’ll also find sites where doctors advertise their own higher-priced surgeries (which more typically cost about $2,000 per eye) and warn against the dangers of discount LASIK. Many ads specify the quality of equipment being used and the performance record of the doctor, in addition to price. In other words, there’s been an active, competitive market for LASIK surgery of the same sort we’re used to seeing for most goods and services."
We are all connected in this stupid country - if the family down the street can't afford preventative care, and the wife gets sick, and can't take care of the kids, and the husband misses work and gets fired from his job, and then they can't afford good nutritious food for their kids, so the kids go to school hungry and don't learn as well and don't test as well, the ripples can last for generations.
Here's the thing. People act as if healthcare is something that has to be earned, and deserved, and not only is this viewpoint inhumane (in the Greatest Nation in the World!), but it's economically indefensible.
If people don't get early medical care, their lifetime economic output can be greatly reduced. And their children are affected. If children aren't taken care of with nutrition and care, their mental abilities, abilities to stay in school, are affected -- and their lifetime economic output is reduced. And targeted poverty (as opposed to where everyone's poor) breeds crime. Which creates greater loss of human economic potential AND greater costs for the government.
The country benefits from more, healthier workers, who can think straight, and don't spend significant portions of their time figuring out how to scrape by. These people can then spend money. Middle- and lower-middle-class people spend far more of their income than higher income brackets, if only they have the money to spend.
Net effect: The benefits to the entire country outweigh the costs, in a system where costs aren't an arms race between health insurance providers, malpractice insurers, and other for-profit companies.
A stitch in time saves nine.
author: "umm..."
On the one hand, you'd further motivate those consumers who were already likely to avoid preventive care and ignore symptoms until they require costly (to me as contributor to the catastrophic plan) emergency and intensive care. And the author's position that folks would be able to withdraw funds that exceed a certain ceiling adds the perverse incentive to risk not spending this money, with the downside being absorbed by the catastrophic plan.
On the other hand, you'd do nothing to discourage consumers with irrational fears about their health from distorting prices upwards, or to discourage unscrupulous providers from fomenting those fears. The plan he describes takes fee-for-service and all its problems to a whole new level. I think of things like the celebrity anti-vaccine mess and the healthcare debate with its distorted media coverage and disingenuous advertising, and I have hard time accepting a consumer-driven market succeeding, even with all the government-collected and -analyzed data in the world.
Even worse, I fear that such a system would result in a tiered system, where the best and brightest providers provide excessive care to those with means while the rest of us continue to struggle with barely adequate, barely affordable care.
I don't think that any system that relies on healthcare consumers making the choice between limiting their usage of healthcare services and spending money is destined for success. Providers need to be rewarded for providing the best outcomes for the lowest cost with the fewest mistakes, not the most and most expensive services. Significant efforts must be made to improve the public health of Americans. The conversation should be about how to make those things happen. All this debate about who pays when is just a side show that is obstructing real reform.
It won't be perfect, of course, but a perfect system doesn't exist. I'm absolutely appalled that I'm paying (on average, as an American) over $1.5 million over my life for the present system, and can't imagine this would remain the case if pricing and outcome transparency were drastically increased. I think that quality and service would improve, while cost would decrease.
It certainly can, but from the point of view of statistics in human pathology, a complete non sequitur. For every person that neglects a checkup and misses early detection of a highly surreptitious, life-threatening disease, there will be ten for whom it either has no impact or results in low-grade, unremarkable chronic conditions that require occasional office visits and prescriptions.
Having to directly bear the cost of going to the doctor also provides a considerable incentive for leading a healthier life and staying away from bad habits with adverse medical consequences, in the same way that people are disincentivised to do avoidable things that hurt their financial standing in other areas.
. . . ;)
My theory is that the inconvenience of a major failure and the risk to life and limb are much more important to most folks than the tiny costs associated with regular and preventative maintainence. I know they're more important to me!
It's actually been rigorously shown to work the same way with medicine. There was a study on HSA / High Deductable plans already in use, and it found that use of preventative care actually increased compared to the baseline.
http://www.marginalrevolution.com/marginalrevolution/2009/08...
That being said, I lived under US government health care for a goodly chunk of my life (IHS), and until they fix that, they really have no biz working on anything else.
FWIW, Medicare, Medicaid, the VA, and medical care for soldiers are all pretty good on the US scale.
Ahoyhere's comment isn't the half of it. The incident happened at Walter Reed Army Hospital, which is the same place that US president's usually go for care. If stuff like that could happen there (it may have been a different branch in DC), what's the rest of the system going to be like?
I worked for a medical software company for seven years, converting Medicare specs for outpatient code editing into working programs. We would get regulatory updates once a quarter, make changes to the code and the data, test and ship. The fun part was that we would usually receive the reg changes 3 weeks before the hospitals had to have the updated application. Also, their reference application didn't match what was written in the specs. Worst of all, the spec changes were often unreadable and we would have to call DC to figure out what they meant. It will not surprise many of you to learn that they wouldn't know either and would "have to get back to us". I could go on and on...
Not to mention the older vets, especially from Vietnam. They are screwed at every turn and the previous administration cut their benefits even more.
Walter Reed is a huge military complex with Army and contractor buildings on the base. Most vets that go to Walter Reed end up under the military care. This is the old colonial style buildings that most people see. They are in pretty good shape and most vets don't have a complaint about Army care. The real fiasco is the private contractors. This is the part of Walter Reed people read about in the paper. They work under VA but since they are for-profit companies, you know the rest.
People like to use Walter Reed of why the gov't shouldn't get into healthcare at all. Walter Reed is an example of why private, healthcare companies have no business being in healthcare.
Your two party system is killing you in every area, and you don't even know it.
The argument itself though is very one dimensional. :)
Uhh, no. It just so happens that in this case some Republicans are the only people putting forward the idea of taxing medical benefits as ordinary income, to reduce the role of insurance in the system. I don't even vote, let alone think in terms of democrat vs republican.
Like food stamps.
But you're trying to have your cake and eat it too. You're basically saying "People deserve freedom! But not so much freedom that they can do things I don't like!"
Who draws the line, and where?
Basically, I would see school vouchers as being a way to compete between different schools teaching more or less the same things along more or less the same guidelines, and perhaps with no restrictions, on, say, hiring union labor.
I think the state has a duty to provide non-religious education to everyone, even if you're the lone Christian in a heavily Muslim area, say (or vice versa). If everyone could send their kid to a religious school, in some areas, the market would simply not provide for non-religious education.
That line of argument can be extended in all kinds of ridiculous directions. Should we ban Hummers off the roads? After all, they're driving on roads paved with your tax dollars, and you do not approve!
We should also ban rapists from drinking tap water. After all, my tax dollars pay for water treatment, and why should scum of the Earth like them get to drink it?
Do you see what I'm getting at? If you are going to insist that none of your money goes towards things you do not directly approve of, you're going to have to go for a 100% free-market economy - and by that I mean no police, no fire brigade, no public roads...
"Basically, I would see school vouchers as being a way to compete between different schools teaching more or less the same things along more or less the same guidelines"
... except if the schools teach things you disagree with. Like I said, it's "We should have freedom! But only for things I agree with"... which doesn't strike me as very free at all.
As an aside, one of the problems I see with the various interesting people of the internet is that, for a bunch of allegedly smart people, they harbor a lot of hatred and prejudice. You can't surf without running into hate-filled articles bashing the religious, unions, immigrants, poor people, etc ad nauseum.
For example, the law currently disallows polygamy - but if you look at all the cultures around the world you will find that monogamy is somewhat of a Judeo-Christian idea to begin with - at the very least there are many societies where it is perfectly acceptable.
So now the question must be asked: is our desire to have a monogamous society coming from our Christian roots, or is it something that transcends religion and becomes a shared ideology?
There are a great many issues where it's not easy to say "this comes from religion" vs. "this comes from our social order".
The world is certainly a complex place.
State-sponsored teaching that evolution is bunk, and that the koran/bible/FSM is literal truth, though, is probably crossing the boundary, and that's what we were discussing, not monogamy.
The problem though is that, from the government side anyways, the two arguments are not separable. As soon as you propose to limit/expand the freedoms of one special interest group, all of them swarm out of the woodwork.
The problem is also that you cannot say "this is crossing the boundary" without first defining what the boundary is. Sure, teaching creationism (for us) is well beyond this ephemeral concept of "the line", but fair governance requires us to actually define where "the line" is.
The availability and quality of schools is already a key consideration when choosing a neighborhood to live in. Forcing every last kid in Chinatown to go to a school at odds with their traditions is an affront to liberty. Offering the one Jewish family in Hicksville, Alabama the option of (a) moving to a bigger city, (b) commuting to a decent school, (c) homeschooling or (d) putting up with local school they hate the least, is more palatable to me.
In most cases, the solution would be, "don't live in Hicksville, Alabama if you can't stand the schools." But even if you have to, at least you have options (b) and (d). Public schools don't even give you that much.
Seems to me designing laws allowing some to discourage access to theological/scientific/ideological education that others may desire is the unjust approach.
The goal of the establishment clause, of freedom of assembly, speech, and press, is to protect individual ideological freedom from government interference, is it not?
What danger is there to religious or ideological liberty in allowing vouchers to be used at Catholic schools or Muslim schools or schools with Young Democrats cirriculum or schools with an atheist/skeptic focus? That the government would appear to be funding religious or ideological education? It is a danger to appearances only. The government is not paying more for the extra lessons, and the parents have freely chosen the school.
What danger is there to religious or ideological liberty in requiring--through legal or economic means--that children be educated in a school with only politically approved cirriculum? Two dangers: that the unconscious political or religious mores of a powerful majority will find their way into the approved cirriculum and that it fundamentally denies anyone with a minority view the ability to educate their children within their traditions.
It seems to me that the second case is far more destructive to our goal. The idea that we would like to economically prevent most Muslims from educating their children as Muslims ought to be repulsive to a society theoretically committed to religious freedom. Nor is there safety in sticking to a 'neutral' cirriculum; poli sci and civics have to be taught, American History has to be taught, and science has to deal with the evolution/intelligent design thing at some point. Defining neutrality on popularly divisive topics isn't easy -- and supposing the group that agrees with you will retain political control in the long run is foolishly optimistic.
There is the danger--nay, the certainty--that parents given the freedom to educate their children according to their whims will teach them destructive and false ideas. But this is simply an instance of the highest cost of maintaining a free society: tolerating certain evils because the associated liberty is worth it. It is not the job of the government to serve as a dogmatic gatekeeper, rather it is the job of free citizens to persuade one another in the public forums.
It is my opinion that allowing parents to educate their children any how or way they please, without bias for or against any institution except on the basis of its meeting a minimal functional standard, poses no danger to personal liberty and is in fact a great boon.
"Conservatives" don't hold a monopoly on using a market. In most cases, they're not even completely in the "free market" portion of the gradient.
Please stop with the partisan labels. They're really not all that helpful.
Well, for people with enough money, at least. For others it might not "work" because they would die.
Which is why the OP suggested a solution that was mostly market based, but with some thought given to those who would be excluded by the market.
OK, I am not being entirely serious here. but I think market solutions don't work that well when it comes to healthcare because patients can neither be fully informed consumers (without a medical degree) nor can they exercise a free choice about when they plan to fall ill. Consider: having your house burn down is also a bit unpredictable, so you buy insurance for that. And indeed, the costs of a home fire can run into the hundreds of thousands, not incomparable to the cost of health problems. And yet, fire insurance is way, way cheaper than health insurance. Why?
Hint: it's not due to competing fire departments. We used to have those, but we got rid of them for a reason.
My Dad was recently complaining that his prescription coverage was cut, so he was now paying about $100/mo for his prescriptions. I asked how much the pills would cost with no coverage, and he dug out the bills and determined they would cost about $600/mo. This sounds outrageous I suppose, until you realize that he pays about $1100/mo for insurance. Granted, that is for more than just drugs, but if insurance was really for unaffordable things, it wouldn't cost that much. My dad is still paying for his monthly prescriptions... just in a roundabout way.
Anecdotes aside, the article points this out too. Would you expect your fire insurance to cover the cost of batteries for a smoke detector? Of course not. But if it did, the batteries would most likely cost more, since instead of having to sell to millions of battery buyers in Wal-mart, battery makers would be selling to mere dozens of fire insurance companies, who would pass on the costs to those buying the insurance, and hence have no incentive to control battery costs. Even worse, the administrative costs of having people constantly file battery-replacement claims would dwarf the cost of the battery itself. So people would suddenly be paying $25 more a month to avoid buying $2 worth of batteries.
Sounds absurd I'm sure, but that is exactly how our comprehensive health insurance works today.
If people actually used health insurance for things that are equivalent to a house burning down, it would function more like other insurance, and get cheaper. I'm 26, and my most expensive health expense to date was my birth. The next closest thing was probably when I had my adenoids out when I was 7. After that, when I broke my big toe ($900). None of those are akin to having a house burn down or getting in a car wreck. The first two were predictable and all three could be payable with credit or HSAs. It makes no sense to pay thousands of dollars a month so you can go to the doctor for free when it would only cost $150 anyway.
My point, though, is that multiple competing private health care providers create administrative overhead without delivering the benefits of competition because sick people are a captive market, and thus normal market forces are unable to operate properly. If you look into the history of private fire companies you'll see problems which are echoed in today's health care system.
Furthermore, there are many free markets in which consumers cannot be fully informed which work just fine. I know very little about the design of video cards, the maintainence of automobiles, how to remodel a house, what makes a good lawyer, whether my glasses are good for my vision, or myriad other things I pay others for on a regular basis. Nonetheless, I am able to navigate these markets just fine and make tradeoffs according to my personal values. The combined effect of consumer reports, public opinion, and paid personal advocates seems to get me there okay.
I submit that in a free market, most would have no more difficulty shopping for a docter than they do for a mechanic.
And while patients cannot choose when or how to fall ill, they can choose what to treat, what to treat well, what to invest in preventing, and what to simply tough out. The dire necessity of my owning a car does not prevent competition between car dealerships.
We've posted the links repeatedly - preventative care improves quality of life but doesn't reduce cost.
And, pre-natal care is FREE in the US, yet many poor folks don't bother.
In other words, both assumptions for your argument are false.
That strikes me as a very questionable assertion. Health problems always get worse with time, becoming more complex and expensive to fix the longer you leave them. How could prevention possibly not reduce costs?
(1) Folks who live longer consume more medical resources, not less. (Dying is always expensive but living also has costs, so shorter lived people cost less.) (2) Preventative care doesn't always work. In fact, it usually doesn't. If it's cheap enough, that can be okay, but if it isn't.... (3) Saving someone from one or even a couple of causes of death is rarely enough. (That's why it often makes sense to ignore prostate cancer. Yes, it may get worse if left untreated, but old men die of lots of things.)
The numbers always matter. Health care is hellishly complicated.
You also seem to be thinking in terms of end-stage "keep them alive vs. let them die" issues. I was thinking more along the lines of toothaches, infected cuts, etc. Yes, it does get more complex - both medically and morally - as the patient gets older.
I'll agree with you on the "hellishly complicated" part though. The politics of elderly care are a moral minefield.
Lifetime is the only rational way to think about it on "govt scale".
Per-incident is really hard to sample correctly. Yes, if you can get someone to not be diabetic, you've saved money, but we're already trying a lot of preventative care so if you look at the incidents as opportunities, you're wrong.
Yes, we're already doing a lot of preventative care, and we're not seeing the results that its advocates claim. (Simple example - Every doctor already says "lose weight".) Most chronic diabetes folks are fairly resistent to preventative care, at least the inexpensive sort, and the expensive stuff isn't close to cost effective AND they backslide.
Here's a question - smoking has gone down by 50% over the past 20 years. Are we spending less on lung cancer?
> The politics of elderly care are a moral minefield.
Yup. 70% of US medical spending is on old people. If you're going to cut spending by 30%, a huge fraction of that has to come from old people.
Probably because it keeps people alive longer, so that they need more care. Smokers, allegedly, are much cheaper to care for in the long term than non-smokers, because they die early.
Pardon posting a political piece, but I was just reading this today and it explains the fallacy.
http://www.realclearpolitics.com/articles/2009/08/14/the_pre...
The free market!
I agree that there needs to be more direct competition for health care dollars.
The political pieces on HN are starting to overwhelm the technical articles. Isn't there enough of this on Reddit?
I think the key is that every story on the home page helps you to better understand how something works or why something happened. You know, the hacker part of "hackernews".
We should probably save the flags for stories that are being manipulated by spammers or small groups. Anything else will rotate off the home page in a few hours anyway.
Politics/economics are low hanging fruit that anyone can dig up a story on and comment on. Erlang vs Scala in terms of creating distributed systems... not so much. The first will always crowd out the second, given enough time.
It's a tough, but interesting, question. Limiting the topics allowed reduces the functional value of the group. But loosening it too much will reduce the quality of the group itself. I don't know the solution (yet).
I have a suspicion that these two things are mutually incompatible.
Personally I am not convinced what happened to Reddit and Slashdot etc would happen here anyway. It is quite possible that Reddit has accomodated all the people who wanted a current-style Reddit and they are all happy where they are. There is a finite number of people, after all, despite how it sometimes seems.
The people arguing against political topics here, based upon the experience at Reddit, do so referring to a single data point in a highly complex environment. I am far from convinced the argument is valid at all. Sure, discourage puns in comments and [PIC] links, couldn't agree more. But I am not sure forbidding whole topics as a rule is a good idea. Plenty of smart hackers are also interested in politics, and they might not be interested in participating in multiple discussion sites. If HN limits itself too much, they might get bored and leave.
Anyway, just my speculation on an interesting topic, not trying to mount a formal argument or anything.
1. It's about a non-technical political topic
2. I am British and care very little about the internal political arguments in the US concerning their health care system.
Although it refers to the US health care system, the narrative applies to health care delivery in general and is applicable to other countries.
You are right that it is non-technical, but it is of a higher quality and more intellectually satisfying than countless other submissions here. Presumably you also have flagged Signaling and Indian Higher Education though I'm not sure whether your nationality would make that more appealing to you.
One wrong doesn't justify another. But sure, flagged that too. I don't vote up or down based on "nationality". An inappropriate (for HN) article (subjective judgment to be sure) is surprisingly nationality independent.
If you had any idea about the complex mix of nationalities that are my daily life you'd realize that I couldn't give a damn about the country being discussed. I'm not interested in discussions of that country's internal politics. The article about Indian education was flagged for a different reason, it seemed irrelevant to HN how the Indian general education system worked. Really interesting topic for an article in The Economist, but I came here for code and related subjects.
Amen Brother!
Political articles should be (imho) shut down very fast. The "flag and wait for a moderator" tactic doesn't seem to be working as well as it used to.
How can we judge how well the system is working when we have no direct insight into it? Perhaps a moderator reviewed the post and found it to be of merit?
I said
"The "flag and wait for a moderator" tactic doesn't seem to be working as well as it used to."
there is a subtle difference between what I said and what you claimed I said.
My response doesn't make sense anymore now that you edited yours! :-) I am leaving it unedited however.
And by the way, the article is quite good, I just don't want it on HN.