Strengthening Constitutional Self-Government

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Health Care

Collective Payment and Rationing

Much of the dicussion of rationing health care has focused on end of life issues.  We currently spend a good chunk of health spending in the last few months of life.  Hence, the argument goes, we are being unreasonable, making heroic efforts to save and prolong life, when they, as a rule, have little prospect of doing much good, particularly in comparison with what the same money could do elsewhere.  Perhaps we might also look at beginning of life issues.  If we have bureaucrats deciding how to allocate money, might they decide that fertility treatments for women over 40 or so simply are not a good use of scarce resources?  Such treatments are not inexpensive, and as women age, the odds of having babies that cost more to raise than the average baby rises.  (I also fear that there would be subtle, and perhaps not so subtle, pressure  to abort children who are likely to have problems.)  Rationing such treatment would be a tragic cost of the centralization of health care.  If this bill passes, I hope that such choices are not taken away from us.

Categories > Health Care

Discussions - 22 Comments

Aren't there all sorts of "too expensive" medical treatments, tests and procedures that will limit health care for any given individual? If the group matters and the person does not matter, then all of those expensive, heroic things that doctors can do to save a life, at any point in the life span, will have to be curtailed for the good of all.

I know of an 18 year old girl who had a brain aneurism and has been kept alive for fourth months in the hope that she will recover. She has moved from one type of hospital to another and needs total care. The family writes about all of the wonderful people they have met who are in similar circumstances and about the medical miracles that keep this girl and others alive. All of this is ruinously expensive, but yes, she might recover. Should she die to spare the expense? Who makes that decision?

If we have bureaucrats deciding how to allocate money for medical care, might they decide that _________ for _______ simply are not a good use of scarce resources? Just fill in the blanks. Health care in America is expensive because it is wonderful. The only way to truly make it less expensive is to make it less wonderful.

Okay, I am willing to play the Liberals/Democrat's silly game. Let's discuss end of life issues. The first in line in all those in prison. Susan Aktins, one of Charley Mason's gang members, developed brain cancer a few years ago while serving a life sentence (at one time it was a death sentence, but it was over turned in 1972 when the Supreme Court of California ruled the death penalty unconsititional). Her medical care costs were over $1.2 million. The people of California also spent over $300,000 for the cost of guarding her room at the hospital. This nut job sliced up Sharon Tate and removed her unborn child from her womb. Then we have Grandpa Jones, age 76, who has developed a serious medical condition. He worked hard all his live, played by the rules, paid his taxes, raised his kids and there is a good chance that he served in the military. His medical care is going to cost a lot of money. So in discussing end of life issues - I pick Grandpa Jones to live. The nut job dies and we use the money we would have spent on the nut job on Grandpa Jones. Let's play the Democrat's silly game.

But the ACLU and the Courts probably wouldn't let us single out people in prison. They would, however, let us make a general rule, applicable to all citizens.
P.S. My security code words to get this post up on the blog, "government cropping."

Well, we the people could use a slaughter rule and overide the courts and the ACLU...

cowgirl, you mean Charles Manson.

Then maybe I am wrong. Federal prisoners have national healthcare, and you are right, they are being kept alive at taxpayer expense. Your tax-paying Grandpa Jones is presumably on Medicare and the expense to keep both of them alive is much of what Obama means when he talks about the expense of the current health care system.

Richard Adams, "Government cropping" -- How does Captcha know? I have "re-Dachau".

I think cowgirl's implication is that federal prisoners are being singled out in the other direction, being kept alive when a Medicare recipient might not be.

Fertility treatments for women over 40 are already rationed at the state level. In only 15 states are these treatments covered by insurance.

I bet that a majority of the population, or something close to it is in states were the treatments are covered. New York, California, and Texas all require it.

But the key question is whether, as the system builds, fee-for-service medicine is squeezed out, or made illegal. Will there still be doctors willing and able to let citizens choose such services if they want to?

Those state mandates for that sort of specialized coverage are one of the confusions and complications about the expense of private health insurance. Those states with extensive mandates have more expensive health insurance. Health insurance plans sold in those states must carry coverage for those treatments and procedures whether the purchaser needs them or not. This drives the average price up and often out of the grasp those who would purchase cheap insurance if allowed. Government in those states will not allow it.

In a more open private insurance system, a person could purchase insurance with or without coverage for such services. Allowing the purchase of insurance across state lines would help, too.

So do the hotbeds of progressivism and population such as Arkansas, Montana, and West "by God" Virginia.

Why would fee-for-service medicine go by the wayside? Insurance companies deny claims every day; they already ration their funds and I have no doubt that even with this reform they will continue to do so. People who have the means are then free to choose to pay for that service if they really want it. Fee-for-service will always be an option. Those with money will always be able to purchase the care that they want and need.

I am required by law to carry car insurance, but whether I file a claim against that insurance or choose to pay out-of-pocket is completely up to me. By paying out-of-pocket, I keep my premiums low and my insurance company happy. I don't see how this is any different.

Kate, this is just for you -

15 Executives Who Get Paid Millions to Deny (People Other Than Kate - for the time being) Health Care Coverage:

The way to end the problem of rationing by insurance companies is not to replace it with rationing by government. My odds of getting the care I'm seeking would be better with competing companies rather than with, in effect, one big company that has sovereign immunity from law suits. Far better would it be to peel back regulations, which would put people seeking care in the driver's seat. Would that be perfect? Hardly. But it would be an improvemet.

Yes, exactly. If national health care passes, those same people will be working for the government. There, after all, experts in their field. Private insurance with open options will be for the desperate rich, unless it becomes illegal because "unfair!" and undemocratic. Medical care is politicized in ways that are not useful and are or will be expensive in many different ways.

"They are" - sorry.

Golly, and an omission in the last line of -- "and those options are...."

Even after I sort through all of your edits, Kate, the post still makes no sense...

cowgirl, I would be very skeptical of the accounting which has it that Susan Atkins' cancer treatments cost $1.2 million. (A proximate relation of mine has in the last two years had the full monty of surgery, chemotherapy, radiation treatments, and hormonal therapies. The sticker price was just under $300,000).

I know of an 18 year old girl who had a brain aneurism and has been kept alive for fourth months in the hope that she will recover. She has moved from one type of hospital to another and needs total care.

Is she receiving medical treatment, rehabilitation, or nursing care? The problem posed by 'long-term care' is one distinct from that posed by the financing of medical treatments and ought be considered separately.

No one here appears to subscribe to Milton Friedman's suggested program: A public insurance program that covers expenses over a high deductible conjoined to out-of-pocket finance for mundane care.

Art Deco, the girl is still shuttling between types of care as she is awake, but not responsive and medical problems send her back to hospital, where she is this week.

In a sense, isn't Friedman's solution like what we have now? Young people without insurance (in Ohio, anyway) pay little out of pocket for catastrophes. They pay or mundane care themselves.

Richard Adams, yes, exactly.

If national health care passes, those same people shown in Craig's slideshow will be working for the government. They are, after all, experts in their field.

Private insurance with open options will be for the desperate rich, unless it becomes illegal because "unfair!" and undemocratic. Medical care is politicized in ways that are not useful and open options such as one might pay for now, if one chose to, are or will be expensive in many different ways.

AD, I Do! Though I am open to many different approaches on how we get there and there might still be some significant role for the government in either subsidizing or providing some very basic care (immunizations, check ups) for the very poor. I would also be in favor of a system that moved to renewable long term private health insurance that was high deductible, put most mundane csts on consumers (in exchange for higher wages and lower premiums) and portable.

Kate, I assume there are company insurance programs and household insurance that incorporate high deductibles, but that is quite atypical.

I am having a bad time writing today, which is oddly and sadly, why I am writing here instead of more productively.

There are very few states that allow insurance companies to offer high deductible insurance. State mandates are part of the problem. Again, open up the system and the free market (regulated lightly by government) would supply that stripped-down product.

However, what I really meant above was not that those young people are insured, but that they lack insurance and yet their catastrophic medical bills are covered by hospital charity funds or state programs. I know this is true in Ohio because it happens to young people of my acquaintance: students. Even my son benefited. He had an accident, poisoning himself with Jimson weed seeds to get high and misjudging the amount. (Any is too much) He had dropped out of college and was not on our insurance. A couple of months previously my husband had become disabled through a bicycling accident and we were struggling financially, so we could not pay for our son's hospital bills -- two days in intensive care, and another couple under observation -- though his recovery after was rapid. A hospital social worker came to us with forms to sign that made him a charity case who had a catastrophe. His hospitalization was entirely covered.

For weeks I wondered who to thank. If that funding had not been available, we would have paid off my son's bills, eventually. That in the same way we are still paying off my husband's medical bills, even though we have private health insurance.

My daughter-in-law whose health is chronically catastrophic has Medicare as secondary insurer to her husband's employer's health insurance. Despite both insurances, they are still paying off medical bills, some from up to eight or nine years back. As she put it today, every month everyone gets their $10, or whatever the arrangement is. They will be paying forever and do the best they can. They are grateful when private insurance and/or Medicare pick up the major portion of her medical bills, as it leaves their debt in the tens of thousands rather than the hundreds of thousands of dollars. Yet, they see it as their debt, the cost of keeping an ill person alive.

Health is a private matter and a personal responsibility. If someone will help you, that is a privilege and something to be grateful for. It is not a right.

Last I heard, about 15% of all medical expenses were financed through out-of-pocket payments, 36% through company insurance, 9% through household insurance, and the remainder through public expenditure. Your family seems to be going through quite a mangle and you have my sympathy. I think the difficulty is as suggested, that out-of-pocket costs arise from haphazard coverage gaps, rather than a general policy to socialize the costs of the unpredictable peaks in demand (e.g. from cancer diagnoses and car wrecks) and leave individual households to assume responsibility for mundane medical expenditures. I did some back-of-the-envelope calculations a while back from haphazardly collected information and it appears that ~43% of expenditure for medical care is for the rough stuff - hospitalizations, chemotherapy and radiation for cancer, kidney dialysis, and diabetes management. So, the share financed by cash-on-the-barrelhead should be considerably higher than 15%, but with insurance fairly comprehensive over and above the baseline. You do raise an implicit point about the vexed question of how to handle chronic illness. I think one possibility would be a fourfold classification of the population - the elderly, the disabled, the able-bodied but chronically ill, and the remainder, and have a schedule of deductibles appropriate to each.

Thank you for your sympathy. I was really offering my bona fides as a person exposed to the problems with the payment side of health care. I also have an 82 year old mother with memory and other age-related problems who is retired from the state of Oregon and on Medicare. She really could use a hip replacement, but her dr. tells her Medicare will not cover it. She is too old. She should get used to not walking. We make her walk anyway, telling her pain is part of life. She does it out of fear of becoming bed-ridden and forced into a nursing home. Modern medicine has kept her alive, but not comfortable nor fully-functioning. That may be true of young Brenna, my young friend who had the brain aneurysm, as well, to be kept alive, but not functioning.

Yes, how we handle chronic illness as an ethical as well as financial problem is what I was thinking about in my first comment.

Yes, the remarkable stuff in medicine is expensive. A cost-benefit of a national health system is that there is less incentive for competitive advances in medical technology. Medicare under-pays. When government intervention has killed off all but the most expensive private insurance, will anyone else be able to make up the difference? Of course not. Then our health care system will be too expensive and necessarily pared down.

I know the Cleveland Clinic is developing overseas facilities -- Dubai is one example. Perhaps a good use for a rebuilt Haiti would be to have it function as a medical haven for competitive, innovative, though expensive, medicine. Free-market medicine not all that far offshore of the US: if you haven't seen what the Clinic has done to horribly run-down areas of Cleveland you might not have a vision for what they could do in Haiti. Who do I propose this to?

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