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September 27, 2009

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tm

If the demos is divided into those who choose without risking and those who risk without the ability to choose, would it be hysteric of one to ask how far, in, say, the healthcare debacle, this state of affairs is from a kind of mild-mannered, Minim-esque form of genocide?

Phil Cubeta

Death panels, Tm, the only way to control costs. Maybe we can get Bush to come out of retirement to head a commission making these live and death decisions, a la Schiavo.

tm

Yes, I see. Mr. Bush could tweet the names of those who need to fall on their swords, for the sake of Freedom on the March. I'm sure a few thousand Points of Light would oblige.

Phil Cubeta

Affordable, ubiquitous, on demand health care with no tax increases - Utopia? Doctors working a gunpoint. Living in little shacks. They must do it for the good of the country, not money, since health care must be affordable, unlimited, ubiquitous.

tm

When you put it like that, it seems better to remember Mr. Bush's Republican Solution: Those concerned for the public weal may volunteer to remain ill without seeking medical care. If they wish, they can put the dollarz saved to work purchasing usurious insurance for the slovenly underinsured. When the pain becomes unendurable, small tabs of cyanide (dosed out in Mission Impossible-branded sheaths) will be at hand. For Murka, no volunteer sacrifice is too great. Mr. Bush, show us the way.

Phil Cubeta

Given a finite sum for the entire population, say half uninsured today, or underinsured, how would you allocate it? What principles would guide that decision?
What mechanism to do the allocating?

tm

I may be missing what "it" is, in your question. If you refer to my suggestion that Republicans voluntarily forego medicine and embrace suicide, that's not allocatable - strictly volunteer basis.

If you are saying how would one allocate care, clearly we need to eliminate all differences. Everyone has equal access to healthcare, much as everyone has equal access to public transportation.

Once that little matter is cleared up, we look at the costs, the savings (having eliminated costly middlemen), and make some tough decisions about levels of care, and the sorts of medical care that simply can't be offered. Those who insist upon ultimate measures beyond what the public system provides will have the option of seeking out whatever Duchy or Fascist Regime Sara Palin ends up running, and paying privately for cryogenics etc.

Phil Cubeta

Total cost being held constant? So some have less than now? Given how taxes works, that means those who pay most for the system are very likely to see their own coverage decline. You can see why the rhetorical side of this swamps the actuarial. No one wants to lay it out plainly enough that each person can see the costs and benefits for him or her personally.

tm

It would be helpful to have some sense of how large a proportion of the population might be at risk of diminished benefits.

Basically we want everyone to have what Congress has, right? Now remove the profits of the middlemen - total elimination of "coverage" - what's left is simply health care. In Canada, it's not framed as entitlements (Canadians please correct me if I'm wrong), but rather as infrastructural limitation. I.e, the system can afford only two hospitals for some cities, so there is a triaging of care driven by that basic limitation.

Instead of 10 MRIs per person, as in Florida today, we may have 10 persons per MRI. It's the Roman method. Leave insurance to the wusses.

Phil Cubeta

Unlimited demand, limited funds, limited supply. Insurance just limits supply by concentrating on the good risks and leaving the bad, or expensive ones, out in the cold. Include those risks, and up goes cost. Given the nation's finances, and even states and municipalities going bust, we seem to be in for a long period of successive disillusionments. What no healthcare? How about limited fuel. High prices for food. How suffering is to be allocated. Goldman is doing well, though. So the system is working again.

tm

Cut back on big macs, television, video games, smoking, and cheese doodles and you've cut the obesity rate. Replace American Idol with Jack Lalanne reruns. Fewer doc visits might not be a bad thing for the hypochondriacs, and we suspect hospitals kill a great many people who went in healthy. Look at the Swiss! Less medicine, more medicine balls. The hills are alive!

tm

Re your point that "No one wants to lay it out plainly enough that each person can see the costs and benefits for him or her personally."

The absence of certain clarifying data goes a long way toward rendering this story unintelligible, intractable, and uninteresting.

We have more than enough media to ensure we never confront ourselves. Perhaps one of the philanthropic orgs you work with could produce a fair estimate of how many upstanding citizens would see some diminution of their Cadillac private plans under a fair, open system offering equal access?

With all the heroes, the investigative reporters, the agencies, the philanthropic concerned, how do we manage to hide so well from ourselves?

More than numbers, let's have their names. Have this out in the open, once and for all.

Phil Cubeta

The best I saw was a documentary by Moyers. His interviewee had studied and found that medicine like all else is a business now being run to maximize profits. Not just insurance companies, but hospital, pharma companies, vendors of medical machinery, all want to maximize sales.

tm

No surprise there: that is the corporate form.

wirearchy

In Canada, it's not framed as entitlements (Canadians please correct me if I'm wrong), but rather as infrastructural limitation. I.e, the system can afford only two hospitals for some cities, so there is a triaging of care driven by that basic limitation.

That's about right.

We also think of health care as part of the infrastructure that comes with living here. It's something we think taxes should be used to support.

Phil Cubeta

Maybe I am hanging out with too many conservatives. I keep thinking about Life Boat Ethics, by Garret Hardin,
http://www.garretthardinsociety.org/articles/art_lifeboat_ethics_case_against_helping_poor.html

and The Eleventh by Henri Barbuse, a short story.

Both force the issue of human suffering and ask, What do we owe to others when there is not enough to go around?

Basically, other than by price or rationing how do we allocate a scarce resource like expensive items of healthcare (MRI, heart transplants, dialysis, etc.)

Philanthropy, premiums for insurance, or taxes, it still comes down to allocating costs and benefits. How does society decide that Jack, age 89, on Medicaid, or a one payer health plan, has had all dialysis at 50,000 or 100,000 or one million a year that he is going to get? If he does the one million a year of treatment for the next 10 years, how many will have to pay how much to support that, and how is the cost apportioned?

I wish the public debate were like this. So we could see who would pay what and who would get what when healtchare is, as Obama, says, "affordable," "portable," and "without CAPs," or for that matter underwritin that would keep very sick people from getting one million of care a year for the next 30 years at public expense.

Maybe we all get a lifetime healtchare max benefit in return for our paying a percentage of income? We all pay the same surcharged percentge of income and all get the same total lifetime benefit?

Who knows what is fair, but for someone to get a billion of care and pay nothing for it, indigent for life, is that fair? When you know you are responsible through taxes to pay your fair share of what is "fair" for that chronically ill person? Say, your share of the bill for indigents is 3% of income for life, is that fair?

wirearchy

Who knows what is fair, but for someone to get a billion of care and pay nothing for it, indigent for life, is that fair?

Good question(s). I have gone through the whole of my adult life in Canada, and have only used the healthcare system a few times (less than I probably should have) but have a vague sense that along with a "feeling" that it is part of the infrastructure of our Canadian society (a feeling I suspect most Canadians share), I also have a vague "feeling" that I should not abuse it. I would expect a doctor to politely but firmly tell me I was a hypochondriac, or find a way to minimise or refuse services if I were perceived as becoming an over-regular user of the system.

I already trust them to escalate, and make wise choices about my care (subject to 2nd opinions if / when felt necessary) when faced with dollars-and-sense decisions. I also feel it incumbent upon myself to be as fully informed as possible when engaging with the health care system, and to be as intelligent and critical-thinking oriented as possible when I do decide to engage with the health care system.

I don't think everyone shares those or similar values, but I expect that a majority of Canadians do.

It's hard to articulate, but if you had grown up here or lived here for a while, I am guessing you'd "feel" it too, with respect to access to and reception of health care services.

Phil Cubeta

Interesting, so the care is self-regulated, people minimize their use of it. I wonder how the system deals with those who have long term, high cost needs, when those people opt for the maximum potentially useful treatment.

wirearchy

Interesting, so the care is self-regulated, people minimize their use of itHmm .. I can't presume to speak for everybody .. I believe that I hedged my words above appropriately.

I wonder how the system deals with those who have long term, high cost needs, when those people opt for the maximum potentially useful treatment

It might be useful to use a story involving me. so that 1) we know it's true, and 2) it demonstrates choices and responsibility as I experience them in the Canadian health care system.

For years I have had friends and partners urge me to obtain an evaluation and diagnosis as to whether I have sleep apnea, a relatively serious condition that affects daytime functioning and also poses an elevated risk of stroke and heart attack.

Well, I finally (after years of urging from those who know me) went about tracking it down.

1. A first ten-minute visit to my GP (at a Community Health Care clinic, open to all)

2. A referral to a Sleep Disorder clinic .. whilst there are five or 6 major hospitals in the Lower Mainland (greater Vancouver), there is only one Sleep Disorder clinic .. just like there is only one Sports Medicine clinic and one Memory and Aging clinic, etc. There is some centralization and concentration of expertise, equipment and resources, where it seems to make sense, and decentralizing and spreading around of expertise where it's appropriate.

Because sleep apnea is a specialty area and non-life-threatening, I had to wait (between 4 and 5 months) for an appointment with a sleep disorders specialist. No big deal, in this case, in my opinion. I fully expect that if I had had a stroke and showed up at an Emergency department of one of the hospitals, I would not have had to wait ;-)

3. I was given specialized diagnostic equipment (sensors-and-software-based) whereas 5 or 10 years ago I would probably have had to spend a (more expensive) night in a hospital bed, with cameras and recording equipment.

After wearing the equipment for one night, I turned it in and they downloaded the data.

4. Diagnosis: I have Severe Obstructive Sleep Apnea.

Now, I had a small sit-down and pow-wow with the sleep disorders specialist.

There were (or are) three options open to me (and here's where it gets interesting, I think):

a) a dental "appliance"
b) a CPAP machine (headgear and tubes that provide a steady flow of forced air into the patient's windpipe and breathing process)
3) an operation that changes the shape of your throat and breathing area a bit, basically by removing that dangly-bit-at-the-back-of-your-throat (uvula).

I told the doctor that I was not at all interested in wearing mechanisms and contraptions on my head whilst trying to sleep, so I wanted to know more about the dental appliance, but was most interested in having the operation (what I see as the easy way out).

Well, it turns out that I can't just have whatever I want from the menu.

First, both the dental appliance and the CPAP machine are only available by prescription from a specialist. Second, they are not part of basic health care, so one either pays for the appliance or the machine or uses their Extended Health Care plan (private insurance - if they have it available through their job or some other arrangement). Luckily, I have Extended Health via my common-law partner's job.

But I am still not free to demand whatever I want.

So far, I have argued with the specialist and have refused to try the CPAP machine (his recommendation and prescription) saying I don't even want to try sleeping with a contraption on my head .. to which he sort-of shrugs and says "well, you should try it anyway .. people report their sleep improves greatly"

So .. then I ask "well, what about the dental appliance?" to which he says "well, it's more expensive, not all Extended Health Care private insurance plans cover them and there's a decent chance you will find it uncomfortable. So, I still recommend that you try the CPAP machine".

BUT .. in my secret life I actually want the operation. easy-peasy .. go into the hospital, the surgeon cuts off a flap of skin (and removes your tonsils if they are still there or have grown back), you stay a couple of days in the hospital and Bob's yer uncle.

Well, it turns out that it's NOT that easy. He (the specialist), after all, has to recommend and prescribe that, and clearly, even though I ask several times quite pointedly about the operation and "why not" .. he says he will not recommend that. It's much more expensive and uses up the hospital's resources, and he will not recommend it (with one caveat) unless and until I try the other proven methods.

The caveat ? He would consider (though not guarantee) recommending and prescribing the operation if I were willing to pay for all of it .. but he's not even sure I could do that up here.

Of course I COULD do that elsewhere in the world .. pay for the uvulectomy .. but there's no fundamental guarantee that it will be effective (it's the least effective of the three methods above, and generally only used when the patient is morbidly obese, which I am not).

It might be my Canadian attitudes, but I think that the doctor mentioned above, and the health care system in my country, are being eminently sensible about all this. I am the one who is being less sensible.

One of the key points I want to make .. I cannot prove it, but as a generality I think that people in Canada are less selfish, on the whole, than USians and that the accompanying attitudes and psychology (of relatively less selfishness) appears in many aspects of daily life.

Please note that I realize that there are many extremely self-less USians of all sizes, shapes and ages .. and of course the USA would have the rest of the world believe that it acts (unselfishly) the way it does around the world for the benefit of everyone else's freedoms and democracy ;-) Heh ...

I think its a country built on selfishness.

tm

even though I ask several times quite pointedly about the operation and "why not" .. he says he will not recommend that. It's much more expensive and uses up the hospital's resources, and he will not recommend it (with one caveat) unless and until I try the other proven methods.

So the Canadian doctors husband (!) resources there in what seems a rational set of rules that balance collective means with individual ends? Unlike here in the US, where the more resources used, the more trips to Vegas they take?

Sort of like public transportation. It might be ideal to have the bus pick us up at home, and deposit us at the door of our place of work, but chances are if each Working Grandee insisted on his idiosyncratic route, few people would get anywhere. As stewards of the total medical resources, docs and other professionals in Canada maximize the available resources for their patients, but have the justification of the collective calculation when they deny certain options.

This effort at rationality is anathema here, where the very idea that some bum is going to enjoy years of therapeutic recovery treatments while Max Baucus risks losing the chrome on his hospital water bed is simply unUSian.

Phil Cubeta

"It might be my Canadian attitudes, but I think that the doctor mentioned above, and the health care system in my country, are being eminently sensible about all this. I am the one who is being less sensible." - I wish I knew many more humans who had this kind of moral imagination, able to stand outside themselves and take a glance at the larger whole. It is indeed interesting that the whole healthcare debate has been framed in terms of costs and benefits for each "me" considered separately, and the rights and entitlements of each "me" considered separately. To talk of the public interest is "socialism." As a result we all end up paying to much and getting too little. You might almost say that until we have better public education, better media in the public interest, and a more informed citizery (as opposed to consumers), we won't have a decent health care system, public or private. Who broke capitalism?

wirearchy

I've done rough approximations of the total insurance premiums I've paid to provincial governments during my adult life ... probably between $20,000 and $30,000. So far, I've probably used maybe $5,000 worth of services. But obviously, I am protected if I get into any serious health complications that require more resources.

The system we have pools all the premiums and adds from general taxation the remainder required to run and manage the health care system. That said, there have been enquiries and various government commissions, etc. looking at and worrying about the growth in health care costs since almost as long as I can remember.

I think it's a given that it is the third rail of Canadian politics .. mess with health care and you've got some explaining to do to the electorate

You might almost say that until we have better public education, better media in the public interest, and a more informed citizery (as opposed to consumers), we won't have a decent health care system, public or private

You think ?

I also think we are being reasonably effective with our public education system (though it could be much better) and we have a reasonably effective form of the 4th Estate, aka CBC. Much better than CNN, MSNBC or Fox.

Who broke capitalism?

The capitalists themselves, or their journalists (aka copywriters) and salespeople ?

It's quite amazing what the terms "capitalist" and "socialist" have come to mean relative to more stringent definitions of the terms.

Personally, I like the idea of what has come to be called 'social democracies" (even if not really democratic per se), and I wish Canada was more 'socialist' than it really is. We too have become quite consumer-oriented over the past 20 - 30 years. I don't see 'socialism' as diminishing the drive to compete where it really matters .. not in the ongoing accumulation of things material, but in the infrastructure and capabilities of a dynamic society that is relatively open to all (when compared with many or most other countries).

I'd like Canada to be a North American Denmark, Norway or Holland .. but drat ! it's too closely connected to that other country.

wirearchy

Proposed Republican health care plan for the USA:

1. Don't get sick.

2. If you do get sick, die early.

tm

PBC,

Your analysis is, I'd say, entirely accurate. I'm not sure if capitalism is broken. You put it:

the whole healthcare debate has been framed in terms of costs and benefits for each "me" considered separately, and the rights and entitlements of each "me" considered separately. To talk of the public interest is "socialism."

Instead of being broken, this might simply be Capitalism, the ding an sich. How we would begin to know, I can't say.

At some point in USian history, the nation's mind split into two different headsets: in one, there was the US, writ large, the entity symbolized by the flag. In the other, there was a giant class and category schism: corporate wealth, glamour, brands, mobility, brightness and joy on the one hand, and public poverty: rags, subways, snot, handouts, strikes, shitty bums on the other.

When we speak of "we," we can always be sure it is impossible to say which of these is in play, until other signifiers help sort it out. But they're all there, in play, all the time. If nothing else, the caricature of the healthcare "debate" is helpfully exposing some of these configurations.

Phil Cubeta

Ever read "Within The Context of No Context," by G.S Trow? The healthcare debate, flying saucer citings, Michael Jackson, a car bombing, ads for shampoo, a baseball player busted for dog fighting, a woman saved from drowning by her silone injections, all fly past in the context of no context, each mined for a lurid soudbite, "We will be right back after this." Trow was deploring the breakdown in the news industry but more generally among professionals who traditionally saw their role as being affected with the public interest. This may what people meant when they rebelled against Wasp Hegemoney, and the Patriarcy. What replaced that rather too civilized upper stratum with its standards and nobless oblige is far worse. Not a rabble but an elite that rises to wealth and power by mininstering to a rabble. (Murdoch, Fox, Limbaugh, among many others of all political ilks.) The quality of public goods and public life is increasingly unbearable. Again, even to mention them is to risk being called a socialist. "Public education, public television, publc option in healthcare" - all are doomed because they are public, not private, and private is good. This is the victory won by the neocon theorists and popularizers (at AEI, Enterprise, Hudson) that will far outlive their political rise and fall. Their way of thinking is now common sense for both parties when it comes to disparaging public options of any kind.

wirearchy

I walked home tonight from a volunteer meeting, about a 45 minute walk ... past a number of signs on buildings (re; renovation or expansion) and other elements of urban infrastructure (including a massive modernist statue) that made me feel a little warm when I realized that each one had some provincial or federal tax-based funding going into it. Each one could or is considered to be contributing to the public good or supporting and enhancing some capability or other that all can benefit from. I think our attitudes towards the role of government and the private sector are quite different north of the 49th. I wish some of my American friends could experience the tangible and visible difference(s) a different approach yields.

Phil Cubeta

Jane Jacobs comes to mind. http://bss.sfsu.edu/pamuk/urban/

Can we thrive as individuals, or have our children thrive, in a community that is corrupt, sick, selfish, driven by demogogues and exploited at every turn by those pandering and pimping products to every folly and vice? "Well, of course! answers the Idiot-MBA, "look at me!"

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