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Comment by eli_gottlieb | Hacker News Reader

So the good news is that Medicare is no longer blowing up in cost, and we now project being reasonably able to pay for it.

The bad news is, this reduction in cost seems to be happening at least partially because people are just getting less actual care.

The unremarked but persistent fact is that if we poured the savings from Medicare into preventative medicine - particularly into fixing problems of diet, exercise, and aging - we would not need anywhere near the same amount of health-care spending on the elderly.

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Define "less actual care". The two examples cited in the article certainly don't establish that.

Generic drugs are not "less care" than their name-brand counterparts, and a reduced hospital stay may be the result of improved treatments or the recognition of the danger of infection.

One of the things the US healthcare system has needed for decades is a rebalancing on the amount of healthcare Americans receive.

Canadians receive a lot less care than Americans do. They wait a lot longer for that care. Given the health problems Americans have derived mostly from obesity / diet, will that cause a lot of trauma to American patients vs what it does to Canadians? Maybe (I would say yes, but it's an extremely difficult data point to calculate)

I do believe that if Americans had a better diet and got more exercise, they'd need a lot less healthcare.

Americans are also the most over-tested, over-diagnosed, over-medicine'd people on earth. It's of course one of the factors for why there is so much cost in the system.

One of the first things that was always obvious that a government take-over of healthcare would focus on, is the amount of healthcare available, especially to older patients. Obama tried to dance around that issue when confronted with it when the ACA was being passed, but it was understood by anyone familiar with European style socialized medicine.

1) lower frequency of use; 2) squeeze pay for healthcare workers; 3) stop the rise of drug prices by refusing to pay the ever increasing rates or refusing to allow patients access 4) use cheaper alternatives when possible

As a counter point to that, my wife and I recently moved from the USA to the UK and we've spent more time at the doctor's in the past month than we had in the previous year in the USA.

Part of the difference is that, in the UK, the doctors have been treating my wife's problems as honest medical problems and not just beating the diet and exercise drumbeat regularly. My wife spent a good part of the last year essentially bed ridden. The US doctor performed test after test to find out what was wrong. She eventually prescribed some medication for my wife which made her violently ill, but the doctor promised her body would acclimate to the medicine and that, in a few months, she's be able to walk again.

Since coming to the UK, we've discovered that the battery of blood tests that were performed back in the USA was actually just the diabetes test being performed over and over again because the test kept coming back negative. The medicine prescribed was actually a drug for the treatment of diabetics, despite the doctor having twelve negative blood tests on my wife for diabetes.

Instead, the UK doctor considered the possibility that there was something wrong with my wife besides just being fat. After a week on her new medicine, she was starting to walk without a cane again. In the past two months, she's lost thirty pounds. It's amazing how much more exercise you can get when you're not bedridden. Next week, we're seeing a GI doctor because the UK doctor realized that A) my wife would lose more weight if she ate more salad, B) my wife would eat more salad if she didn't always violently vomit it back up six hours later, and C) regurgitating food eaten more than fours hours ago isn't normal. The doctors in the USA never could seem to figure out B and C, so they would just double down on A.

By the way, in case you think that it was just that one doctor, that's not even our worst experience with it. About a decade back, my wife went to the emergency room after getting stabbed. The nurse told her the the problem would go away with diet and exercise. A stab wound. Thankfully, she caused enough of a scene to get a second opinion and the STITCHES that normally accompany stab wounds.

You know, I've heard the term fat-shaming, but that is a pretty damn extreme example. A stab wound was blamed on being fat?

These kinds of things are very common for fat people. A lot of sites and forums that are frequented by fat people tell these kinds of stories. This is Thin Privilege[1] is a popular one on tumblr where people mostly submit their stories about being treated negatively for being fat and quite a lot of those stories revolve around medical and mental health care in ways that are quite horrifying.

[1] http://thisisthinprivilege.tumblr.com/

Don't promote this appalling nonsense, please. This is a site which actively promotes the idea that being overweight is healthy – which it is not.

I agree that it can be really easy to blame health problems on weight when there are more complex issues present, and the idea of blaming a stab wound on obesity is obviously ludicrous. That said, being overweight is almost always extremely unhealthy and a major cause of many illnesses. It's absolutely correct that there should be a lot of focus on that.

> being overweight is almost always extremely unhealthy and a major cause of many illnesses

This is not true whatsoever. Weight and health have only limited correlations, to say that being overweight means you are unhealthy is ludicrous. This is well studied and known.

This is just not true. Being overweight or obese significantly increases all cause mortality. Here's a study where they followed 527,265 people for 10 years:

http://www.nejm.org/doi/full/10.1056/NEJMoa055643#t=articleR...

"During a maximum follow-up of 10 years through 2005, 61,317 participants (42,173 men and 19,144 women) died. Initial analyses showed an increased risk of death for the highest and lowest categories of BMI among both men and women, in all racial or ethnic groups, and at all ages. When the analysis was restricted to healthy people who had never smoked, the risk of death was associated with both overweight and obesity among men and women. In analyses of BMI during midlife (age of 50 years) among those who had never smoked, the associations became stronger, with the risk of death increasing by 20 to 40 percent among overweight persons and by two to at least three times among obese persons; the risk of death among underweight persons was attenuated."

Did you even read the full results of this study? Only extreme BMI categories had strong correlations for increased risk of death and mostly for those who didn't have a chronic health condition at 50 already:

"Among all men and women, including smokers and those with preexisting disease, there was a U-shaped relation between current BMI and the risk of death, with the highest risk in the lowest and the highest categories of BMI. Overweight was not associated with an increased risk of death among men but was weakly associated with an increased risk of death among women."

Note that the highest and lowest categories were extreme values of weight for an individual and there were significantly fewer people in those categories compared to the others.

Moreover, the authors of this study even talk about being overweight vs. obesity in the discussion section:

"However, whether moderate elevations in BMI (i.e., overweight) truly increase the risk of death is controversial.2 Several studies reported no increase in the risk of death among overweight subjects even after those who died during the initial years of follow-up were excluded or subjects were stratified according to smoking status.25-29 Recently, Flegal et al. reported that overweight was not associated with an excess risk of death in the nationally representative samples of U.S. adults drawn from the National Health and Nutrition Examination Survey."

They go on to talk about possibilities regarding smokers with the data from this study.

Finally, it is worth nothing that this study follow those aged 50 and older and did so through the AARP's health survey and is specifically focused on the health of older people and that is only looking at correlations for individuals who are already at a higher risk of dying in the first place.

Yes, I did. I don't think you're interpreting the results correctly. The conclusion of the paper, in summary of all the evidence, is that "Even against the background of advances in the management of obesity-related chronic diseases in the past few decades, our findings suggest that adiposity, including overweight, is associated with an increased risk of death."

Please look at the figures, in particular figures 1 and 2 D/C. Among non-smokers, as the BMI increases from 25 there is an increased risk of death. You can see the trend clear as day.

Roughly speaking, the nurse saw that my wife was fat and therefore inferred that she must be diabetic. She saw the blood and assumed that my wife was suffering skin lesions from said diabetes.

My wife informed said nurse about the stabbing. The nurse, like anyone who has performed tech support, is aware that people lie about what happened. Furthermore, diabetes is fairly common while stab wounds are relatively rare. She decided that the probability of my wife suffering from a stab wound and not being diabetic was less than the probability of my wife being an embarrassed diabetic who made up a story about being stabbed. She therefore stuck with her original hypothesis and worked from there.

The last point seems to depend on a lot of assumptions. Simply making someone healthier for longer doesn't automatically save money: someone who dies of a heart attack before age 65 is actually the best financial case for Medicare, and improving their health moderately so that they still have heart disease, but it doesn't kill them until age 75, will cost more! Improving their health even more than that, so that they don't have heart disease, but die of cancer at age 85 after 9 months of chemotherapy and 3 months on life support, is more expensive still.

Well, admittedly, I was kind of assuming that we're "going in" having already ruled out saving healthcare money by causing people to die prematurely. But do you happen to know of a graph or table or something on the fiscal trade-offs between health, life-span, and spending on care, which would demonstrate that even if someone remains in very good health until they die, simply having them alive longer costs so much money that it would be preferable to spend less and have them die earlier?

Prevention and repair of the root causes of aging should postpone age-related disease, and thereby reduce expenditure. The overwhelming majority of expense occurs in the very late stages of death by aging, dealing with a failing body due to overwhelming levels of cellular and molecular damage and the various systems flailing in response to that damage.

If a person never gets to that point, if they can have a health profile that is effectively the same as a 30-40 year old in perpetuity, then the expense remains that way too.

Incremental advances towards that ideal will have incremental benefits in terms of cost of medicine over time.

None of which changes the fact that entitlement programs are a great evil, and put perverse incentives on the development and provision of services. Technologies enabling us to live for centuries in near perfect health will result in of course a vastly increased lifetime medical cost over the present horrible situation. Why should that be an issue? It should be a grand opportunity for providers of services, just as it should be for food companies, clothing companies, and so on. But instead we have these present debates in which people actually seriously argue that it's great for people to die young.

Unless, of course, better late life health allows people to work longer or contribute more to the economy in some way. In which case the impact on Medicare of healthy 65 y/o might not be so bad.

Your last paragraph just confuses me. The elderly are by far the most expensive group (in all countries) when it comes to healthcare. Saying that they "shouldn't be" is a little odd, because of the biology of why they're getting sick more often (or getting injured more easily).

You cannot "prevent" old age, no matter how much adverts tell us otherwise. All we can do is treat the symptoms of old age.

Unhealthy people often won't make it into Medicare as they'll be dead before they hit 65. Most people who enter Medicare, aside from being old, are in relatively good health (even compared to 50 year olds).

He's not saying they won't be the most expensive group, just that promoting a healthy lifestyle will possibly reduce the amount of later life care and support they would need.

For example, if we promote healthier eating habits, we might reduce the amount of late life treatment needed for obesity, heart disease, and diabetes.

I'm pretty sure the reality is exactly the opposite of that. Healthier lifestyles increase the amount of "later life care." See Japan as a perfect example, a very healthy aging population creating massive care market (and a big burden on the infrastructure).

People who live a healthier lifestyle live longer, and then get sick from old age (unavoidable). Which increases the amount and length of care. People who live an unhealthy lifestyle never make it to 65, thus never need "later life care" at all.

> For example, if we promote healthier eating habits, we might reduce the amount of late life treatment needed for obesity, heart disease, and diabetes.

Most people with those types of conditions (due to lifestyle, not age) never make it to Medicare. You still get the age related versions of those, and you get things like hip/knee replacements, broken bones, cocktails of daily drugs, cancers, strokes, and so on.

No amount of healthy lifestyle will make older people cheap to care for. All you'll do is increase the pool of older people by promoting healthier lifestyles.

If your goal is to increase the max average age of your population then healthier lifestyle promotion is going to accomplish that. If your goal is to reduce cost then doing "nothing" (and literally letting people die from their own neglect) is the thing to do.

People who argue the whole "fatties/smokers cost us money" thing haven't even given it a tiny amount of thought. Both groups die young, older people are the most expensive care period, therefore fatties and smokers never make it to the super-expensive part of their lives which is "good" (in financial terms, not moral terms).

Do those groups get sick at younger ages? Yes. But propping someone up with diabetes from 40-50 is nothing in cost compared to keeping someone healthy from age 65-75, because at 65-75 you'll still likely be treating diabetes but on top of that also tons of other ailments introduced by age.

>> But propping someone up with diabetes from 40-50 is nothing in cost compared to keeping someone healthy from age 65-75, because at 65-75 you'll still likely be treating diabetes but on top of that also tons of other ailments introduced by age.

I think this is part of the point. No one is saying age related conditions will go away or become cheaper to care for, but merely that you can reduce the costs by eliminating the additional health issues brought about by an unhealthy lifestyle.

You seem to also conflate a lot of lifestyle issues with age related issues. For example: you mention strokes, which can lead to expensive, long term care. Strokes do increase with age, but they are also tied to lifestyle choices, and can be reduced by a preventive care (http://en.wikipedia.org/wiki/Stroke#Prevention)

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