I awoke with a start this morning with an image of my late father, a physician, and suddenly I realized I had not put up the health care thread I had promised to many of the regulars on this blog. It’s not that I am not interested – I am very interested – it is just that the rush of political/media events that usually dominate this site has been particularly great.
We are supposed to be in the midst of a health care crisis, and I imagine we are, but it seems to me that we have been in one as long as I can remember. Still, the numbers of the uninsured continue to rise and those of us with insurance see our co-payments mounting into the stratosphere and our choices of care restricted. There must be a better way, but is there? I would like to think there is because I am one of those who believe that health care is or should be a basic human right – like universal education. Yet, I also know that if you are seriously sick today, for the most part you want to be in the good old USA where the quality of medicine is the best, not waiting on line for service in one of the societies with national health plans. (I have been in the position!) I further realize that most medical innovation comes from America or the dreaded, over-priced pharmaceutical companies, a product of the market. I want more of that innovation, better drugs, increased longevity. Who wouldn’t? It’s a conundrum.
Anyway, I am deliberately being brief to throw the discussion out to the commenters on this blog, many of whom – for personal, profession and scientific reasons – know far more about the subject than I do. Have at it.
UPDATE: This was not instigated by Kaus‘ importuning the blogosphere to get beyond Rathergate to other issues, which I read after writing this.
MORE: Patrick Lasswell ruminates on health here.
I have an idea for looking at this issue: is healthcare in principle any different than any other “commodity,” and, if not, why should it be treated, in principle, different than any other commodity? Example: I believe the costs of healthcare have risen just about the same as the costs of automobiles over the past 30+ years, but nobody clamors for government to take over the auto industry, and nobody would seriously argue that automobiles aren’t central to the American existence.
Anybody who has had a loved one sick lately knows that modern medicine can almost do miracles. My suggestion would be that we appreciate this positive fact rather than accentuate the downside.
I never know what to believe about the number of uninsured because the figure has such political currency. And is health care a right? If so, does that mean food, clothing and housing are rights, too? Because you cannot be healthy without them.
So it gets sticky.
Underlying the medical expense issue is fundamental economics. As we become more economically productive, the cost of labor necessarily rises. Businesses that prosper today have all figured out ways to reduce the number of employees needed to deliver their product or service.
Medicine, however, is about as labor intensive as it gets. Using highly skilled, highly paid labor. Two years ago I had two carpal tunnel surgeries — routine, 20 minute procedures. Just for fun I kept track of how many people I interacted with from my surgeon to the clerk admitting me to the hospital. Quite a few, and they all deserved to get paid well.
Technology, which in other industries lowers costs, actually adds to medical bills. Think CAT scanners etc.
So, a long-winded way of saying “I dunno the solution.” But I do know this: believing the government will be more efficient is moronic. Just stand in line at the post office or watch the LA public school district in action.
First: If health care is a fundamental right, it is different than other fundamental rights such as free speech, freedom of religion, protection against illegal search and seizure, and the right to bear arms. The other rights do not require that someone else pay for your right out of their pocket. If health care is a right, then payment by others must become a government enforced taking.
Second: Universal health care for all health costs is silly. It would be like universal gasoline insurance, where an insurer payed for your cost at the pump. Insurance, by its nature, collects “a little” from a lot of people to pay out “a lot” to a few people who were unfortunate. If everyone is collecting all the time, its not insurance.
People are not demanding free health care insurance. They are demanding free health care, health care that someone else will fund, be it the government, the insurance company, or the drug companies. But there is no free health care, and never will be. Someone must pay for it.
The entire system is broke, both structurally and economically. Insurance companies, doctors, drug companies, patients, governments, unions, businesses are all contributing to the problem as they struggle to protect themselves against the staggering costs.
It’s going to take some clear thinking and some political muscle to fix it.
Worth noting that our per-capita health care costs are lower than many/most of the nationalized systems. It could be lower still, but most of that will come from streamlining and market efficiencies, not from more regulations than create additional drag.
Part of our problem is that we’ve been coerced into giving below-market pricing to the rest of the world, either in the form of direct charity, or through extortion and threats of cloning. As a result, the US market is pretty much the only place left where drug companies can make a profit, so we are the market where all of the profit is being made. Want lower prices here and still have good products? Then raise prices elsewhere so that the market can do its magic. Price-fixing here (or doing something with the same result, like opening Canada’s pharmacies to US sales) may make it easier for some buyers in the short term, but will make the problem worse for everybody in the long run.
We also need significant levels of tort reform. Loser pays attorney fees, limits on damages, etc.
We should also look at reinstating Glass-Stegal, which was a depression era law that prohibited insurance firms from owning banks, and which was revoked by Rubin under Clinton when insurance companies complained about missing out on the stock market bubble (Rubin ended up taking a job as co-chairman of CitiGroup, the biggest beneficiary of the law change). I’m not saying that this SHOULD be reinstated, but only that it should be evaluated.
Anyway, we need to do what we can to streamline the market and make it more transparent and easier. That’s what gives us the high quality at relatively low costs today.
Roger:
Although this may seem counter-intuitive, comprehensive near universal health insurance is the primary cause of rapidly escalating medical costs. When someone states that we now have say 40 million people without health insurance his is also stating that by implication 230 million
Americans are covered. Basically, few people incur high direct medical costs anymore. This has created an insurance based care system that is overused and underpriced, while at the same time penalizing people who either lose or chose not to carry insurance. The solution to the problem is not socialist health care or more insurance, it is less insurance for day-to-day care.
Health insurance, like all insurance, should cover catastrophic events not day to day events. Nobody would think of buying “insurance” for normal car care so why would you buy insurance for that 15-minute visit to the doctor when you have a strep throat?
The current insurance system is really a boon to the affluent/rich, who are well provided with high quality insurance or are self-insured. Before we constructed a system of near universal insurance, doctors engaged at is called ìprice discriminationî, i.e., charging different people a different price for the same service. This is how the medical profession redistributed income from rich to poor. The affluent would be charged say 25 dollars for an office visit while a working class family would only pay 5 dollars. I have experienced this in my own life. When I was in grad school I still went to my childhood dentist in Chicago. He was probably one of the top 5 in the City. The first thing he always asked was how I was doing. He never charged me more then $10 for an appointment or filling regardless of how much time he spent. There was no charge for a cleaning. I went to him once after getting a real job. All of sudden I was paying 50 bucks for an appointment and variable charges for the other services. That is how the medical system worked in this country until the mid-1970s. If we return to a system where insurance is provided for catastrophic events the system will slowly revert back to the way it worked before we created a ìcheapî medical care system for 90% of the people.
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Roger: thank you for starting this particular “issue oriented” thread (not that your threads are not issue oriented). I agree with the posters that have characterized health care as an economic commodity, because that characterization is essential in developing responses. One of the important considerations is relooking at the notion of who is responsible for providing health care coverage. That task has fallen to employers in our particular system. But I think that model is outdated and reflects an era wherein jobs were lifetime vocations and employers were viewed as more pateralistic. It also reflects an era where unions had considerably more clout than they do today. The nature of our economy has changed but the older employer-provided insurance has not. (It should also be noted that lack of health insurance does not equate to lack of health care.) It seems to me the very first step in the process of developing solutions to health care provision is to gain consensus on such fundamental questions as the nature of health care as a commodity (or is it a right). Once that question is resolved (faint hope there), then we can move forward into identifying solutions. In an era of sound bites and generally superficial reporting, I have serious doubts that we will get beyond the first step–but this thread is a good first start.
It’s about cost. No one wants to pay the cost. I don’t blame them.
One obvious approach then is to reduce the cost. Don’t cover all medical costs, just major medical. Implement tort reform. Remove legislative and administrative burdens from business relative to health care. Reduce illegal immigration. Don’t pay for rich people who are old simply because they are old. Increase use of hospice to reduce the incredibly expensive efforts to briefly prolong lives filled with pain, suffering, and incapacity. Implement tort reform. (Oh, I already said that.) Implement tort reform.
It may all sound heartless, but I don’t care. I do care, however, if precious health care resources are wasted and squandered to the detriment of us all.
Jim Bass ó Have medical professional salaries risen significantly? Or between HMO’s and the Edwards-inspired rise of LLC’s, are we inserting new and expensive layers of bureaucratic/corporate cost between health care and customer?
Also, another reason for the rise of medical costs, ironically, is the increase in federal and state money available for it. In a shocking display of market forces, when you make more money available (Medicaid increases, SSI increases, state medical increases) for the the same size pool of customers (sick people) to buy a limited amount of stuff (medical services for sick people), the price of the stuff goes up. Add in the fact that government agencies almost always dispense this money carelessly and erratically, and you have a ripe field for runaway price growth. Indeed, the government becomes a de facto competitor with the public for these services, and drives the overall price increases with its careless spending.
That said, any caring society has a moral obligation to care for its wounded. But I’ll have a couple of horror stories about that when I get home from work later…
I think that problems in health care and problems in the labor market are linked. The labor market is unnecessarily gummed up with legal constraints about provision of health care insurance.
One of the earliest issues to address is whether the state has the right to compel healthy people to buy health insurance, or to compel firms to require all their employees, including the healthy ones, to buy insurance.
Compulsory coverage solves what the economists call the “adverse selection” problem (only non-healthy people will buy it), but reduces mobility in the labor market. People who have coverage will not want to change employers, and healthier people have a disincentive to seek employment with firms that have coverage.
Employers are burdened with the administrative costs of health insurance programs and are less likely to hire new people–they will try to get more work out of the ones they already have.
If we are going to have compulsory health insurance, why link it up with employers? Most of us, except those who walk to work or take the subway, are “compelled” to buy car insurance, but we are free to select the providers we want without involvement of our employers.
My proposal: government disinvolvement with the labor market in regard to health care. If tax incentives are offered to employers who provide insurance, they, the incentives, should be neutral in regard to the size of the firm.
Damn–I have an all day epidemiology training today so I am going to have to play catch up on this thread!
One thought re costs of health care: The 10 ten causes of death for adults are fairly closely associated with human behavior. if we as a nation stop smoking (which we are), eat properly, exercise, lose weight and get an annual physical we could reduce the death rate for the top ten causes by 50%. If we dont do that we incur tremendous costs for end of life treatment for those unwilling to make behavioral changes that no democracy could mandate.
And demographically speaking as our population ages, we are confronting the morbidity that comes directly from the aging process.
I think it is important to at least identify and agree on on such fundamental issues as these as prelude to discussions of policy proposals.
First, I like Jerry’s idea!
Second, our health care system is expensive but itÔøΩs also still the best. One problem with it (aside from Jerry’s point) is the myriad of abuses it suffers.
I could be wrong but I think the trickle-down theory applies here. It’s painfully obvious that meritless lawsuits against doctors abound which cause the malpractice insurance rates to go up which causes the doctors to charge higher fees which causes health plans to raise their rates to the everyday Joe on the street.
Changing to a federal plan (or socialistic medicine) will not solve our problems. It can and will produce substandard health care.
We’re voting in Florida this November on an amendment to change the way compensations are disbursed between the trial lawyer and the patient. In essence it says the patient will get 70% of all compensations up to $250K and 90% of any higher compensations. There are pros and cons to this, but I think it’s a good first step toward eliminating the meritless cases. Doctors like this because the lawyers take is cut from a routine 40% to 30% and they’ll be less likely to take the frivolous cases. Many lawyers have said plainly that they’ll be forced to charge their fees by the hour, which I take to mean that patients will have to come up with money up-front. Money many of them don’t have. I also take this to mean that (some) lawyers will do this in retaliation. I don’t want to paint all lawyers with a broad brush. For the most part they are principled men and women. But let’s be grown ups and see things for what they are. Doctors are leaving Florida in droves and need relief. And we need doctors.
Most of these cases go to arbitration and never see the inside of a courtroom. Our “jury of peers” are as much a part of our litigious society as anyone else, a society where someone else is always responsible. (Case in point; last year my husband severed two fingers in a high-powered fan. Luckily, they were reattached. But many people asked him, matter-of-factly, “Whom are you suing?” He only laughed and said, “I should sue myself for stupidity.”) When ridiculous (and they don’t have to be totally gross) sums are awarded for the pettiest issues or when the defendant truly did no wrong, we tend to lose faith in that system so arbitration has been the only recourse. The shame is that we have to go this far largely because insurance companies can’t trust a jury of peers to decide fairly. I’ve sat through a few of these myself and too many times seen two parties leave unhappy rather than actual justice being served. Somebody is sure to get money and somebody is sure to pay. Where’s the justice in that? How does this help our rising costs? All it does is slow it down a little. A bandaid on a compound fracture. The small token phrase that in paying up, the payor is “not admitting any guilt” is hardly comforting.
Long comment. I apologize. I get so worked up.
If I could dump all the articles I’ve saved over the past year into this thread, I would.
Even Scotland’s HC is going bankrupt.
Canada’s pouring 41 BILLION loonies in over a 10-year period. Good thing they don’t need a military.
—
And I’m throwing this into the mix, this is from CA and Ahnold not signing the illegal driver’s license law, from a posting today at Dailypundit:
http://www.mexidata.info/id272.html
ìHowever it is now September and he has not responded whatsoever, although we will insist on approval of the bill, basically so that illegal migrants can have access to education and health services in the U.S.,î Firebaugh added.
Assemblywoman Cindy MontaÒez, from the San Fernando Valley, said that it is vital for Mexico to ask Schwarzenegger to approve this legislation ìso that he would know that not only people of California, but an entire country is asking that he sign the bill.î
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… but an entire country is asking that he sign the bill.î
100 million more people, added to the already 20 million here.
Well, that should turn us into Mexico quickly.
Care to guess how much I care that Mexico is asking he sign the bill?
We hear statements that 15% or so of Americans are uninsured. I believe this is false; in fact, 100% of Americans are uninsured. Because of accounting practices and tax laws, so-called insurance via employers are really nothing more than pre-payment schemes allowing those with such arrangements to pay for health care with pre-tax dollars. Such arrangements are obsolete because of the radically changed nature of employment. They are also massively distorting of health care economics.
Many experts suggest mandating coverage by all employers. This being a mainline expert opinion, I would strongly suggest looking at the effects of a law to prohibit any employer from providing coverage. Or, at least, cause such coverage costs to be taxable. This plus a voucher for every citizen to acquire what we used to call “Major Medical” insurance with a large yearly deductible might loosen the governmental dead hand enough to let the system find its own way.
As to drug re-importation from price-controlled parts of the world, this is a singularly bad idea. If the drug companies believe that their ability to recover R&D costs from patent monopoly in the US market is threatened by re-importation, they will simply stop exports. These exports are merely gravy on the meat; drug companies are not about to throw out the meat to save the gravy. Canada and similar price-controlling areas will be major losers unless they give up price-controls and pay US prices, thus destroying the incentive for re-importation.
The 40 million number of uninsured bandied about is misleading. I think I read the number is actually under 10 million. Of the other 30 million lumped in there are people who by choice do not carry insurance. Either because they have the means to pay, or more preponderantly are young and healthy and rarely see a doctor. These people would rather have the income than pay the premiums.
Another group that makes up 30 of those are children who are covered under some form of government insurance, their parents simply haven’t filled out the paperwork which they can do at the doctor’s office if they need to go.
So, no, I don’t think we have a ‘crisis’ though I do believe some type of reform is necessary that would hopefully reduce the costs, confusion, and bureaucratic madness and fineprint a bit.
Some of this is via Marginal Revolution in Dec of last year:
http://www.cis.org/articles/2000/coverage/coverage.html
http://www.cato.org/dailys/05-20-04.html
http://techcentralstation.com/082404B.html
Who are the uninsured?
As the Democratic candidates call for various versions of national health insurance, we will hear a familiar fact many times, namely how many Americans lack medical insurance. According to one estimate, it is over fifteen percent of the population, which amounts to about 43.6 million people.
But who are these people? In reality many of them are immigrants. Here are two simple facts:
Immigrants who arrived between 1994 and 1998 and their children accounted for an astonishing 59 percent or 2.7 million of the growth in the size of the uninsured population since 1993.
The total uninsured population is one-third larger (32.7 million versus 44.3 million) when the 11.6 million persons in immigrant households without insurance are counted.
Hispanics have by far the lowest rates of being insured, here are some visuals. 41 percent of adult Hispanics are uninsured, of course many of these are recent immigrants, Hispanics as a whole account for over 12 percent of national population.
I am all for a liberal immigration policy, but I do not feel we are obliged to offer health insurance to all comers. In fact I suspect that national health insurance would, in the long run, lead to fiscal pressures to limit immigration, thus damaging the health of potential immigrants.
Nor do immigrants rush to buy their own health insurance, in many cases I suspect they would rather send the money back home, where health care crises are likely more severe:
Lack of insurance remains a severe problem even after immigrants have been in the country for many years. In 1998, 37 percent of immigrants who entered in the 1980s still had not acquired health insurance, and 27.2 percent of 1970s immigrants were uninsured.
Many other Americans lack health insurance because they are out of work. True, a good health care system should be robust to macroeconomic disturbances, but with employment and productivity rising, these people do not represent much of a current case for reform.
It also turns out that many of the uninsured are uninsured for only part of the year. According to the CBO, those uninsured for the entire year amount to somewhere between 21 and 31 million, knocking a full 12 million off the original total.
Some of the uninsured are more accurately a counting error:
According to the National Center for Policy Analysis (NCPA), [a] verification question lowered the estimate of the number of uninsured living in households with annual incomes of $75,000 or more by 16 percent. The verification question lowered by 4 percent the number of uninsured living in households with incomes under $25,000.
Many of the uninsured are in fact college students, who either rely on their parents, or are covered under their parents’ policies, read here. One estimate suggests that one out of seven college students lacks insurance, but it is hard to believe that most of these people have no other resources supporting them.
Finally, the uninsured often have good access to medical care. Consider this:
15 million of the uninsured have incomes of $50,000 or more. The fastest-growing population of uninsured has incomes exceeding $75,000. About 14 million are eligible for Medicaid or the State Childreníís Health Insurance Plan but are not enrolled.
The “entire year uninsured” receive about half as much care, in dollar-valued terms, as the fully insured. As a last resort, you can always show up at an emergency room and simply demand care. In the year 2001, uninsured Americans received at least $35 billion in health care treatments.
The bottom line: When you put all the pieces together, the crisis of the uninsured is not nearly as bad as it sounds.
Posted by Tyler Cowen on December 4, 2003 at 07:55 AM in Current Affairs, Economics, Medicine |
(Excellent points above on the basic economics here – I was aware of the huge inflows of cash being funneled into health care over the years, but it never really registered that the finite “resource” the cash is chasing boils down to skilled, specialized labor.)
I wouldn’t worry about the high cost of pharmaceuticals – we are seeing the creeping nationalization of the drug industry, currently by the growing political demand for drug re-importation.
No, I’m not happy about it, both as a consumer and an investor. On the bright side, however, countries with socialized health care *cough* Europe *cough* will no long be able to freeload off the U.S. On this issue, at least.
The settlement between the states and the tobacco companies have established the precedent that a legal industry can be forced to bear the costs that society has to pay as a result of that industry’s products.
Perhaps the single most important factor in the cost of medical care is litigation. Everything, from new cancer drugs to electrical outlets used in hospitals, must be designed, manufactured and marketed with an eye towards being sued. The threat of litigation drives the cost of everything associated with medicine up.
Because the trial lawyers, as an industry, have made society pay those increased costs, based on the tobacco precedent that industry should help bear those costs.
There should be a 50% tax on attorney’s fees for tort cases. That tax should help fund health insurance for the uninsured.
JuanBgood:
I think your point about what a “right” is hits the mark. If I don’t have a “right” to your spare tire for my automobile, why should I have a “right” to some of your money because I have the whooping cough?
A fundamental right is something you are born with, to protected by the government, not something granted by others, subsidized by others, or created by the government. If this is true, then healthcare–however defined–is not a “fundamental right.”
As for the comments about the trial lawyers, etc., I might mention one, somewhat off-thread point: on balance, companies, hospitals, and doctors have better access to the very best legal talent than plaintiffs do. If they are settling frivolous cases and thus driving up the cost of healthcare (I’m skeptical of this…) it is their own fault.
There are many factors at work but you can’t remove basic economics from the issue. Richard McEnroe is absolutely correct that if the government increases spending and if the supply of providers remains the same the price will rise.
One serious problem is that the supply of providers is kept artificially low through the mechanism of limiting enrollment at medical schools. This is performed by the AMA by limiting accreditation. This is well-documented by Milton Friedman in his book Capitalism and Freedom. This is a guild protecting its turf, something straight out of the Middle Ages.
Shortly after reading about the process in Friedman’s book I was able to watch the process in person. Kansas, particularly western Kansas, has a chronic shortage of doctors. Many towns don’t have even one. The only medical school in the state, the medical school of the University of Kansas, is located at the extreme northeastern tip of the state on the Missouri line. The state, and in particular the biggest city Wichita, wanted another medical school in Wichita. Wichita State University started a quasi-medical school. They were trying to slide their way into having a real medical school eventually without bringing down the wrath of the AMA (or of the rival University of Kansas). Initially they were only doing some of the preliminary education for students who would later enter KUMed. After a few years of legal mushiness the AMA stepped in hard and force WSU to make its intentions clear. They made it quite clear that they were not going to accredit another medical school at WSU and so the school there was transformed into a mere adjunct of KUMed. Victory for the AMA and the University of Kansas. Defeat for the people of Kansas.
The supply of doctors remains artificially constrained nationwide.
At least part of the problem, it seems to me, is the two-class labor system in healtcare. Doctors are considered godlike figures, are encouraged to be egotistical, and…as the previous poster points out…there is reason to believe that their supply is artificially constrained by guild-like (or cartel-like) practices. Then there are nurses, with vastly lower status (within the healthcare establishment) and incomes. There’s not much in-between.
I can’t think of any other industries that operate this way. In most fields, there is a whole hierarchy of skill levels and associated incomes/costs. If you’re in manufacturing and you want some tooling made, you call the $60K toolmaker. If it ran like healthcare, your choice would be between the $35K production machinist (who lacks toolmaking skills) and the $250K VP of Manufacturing Engineering.
Ok, I’ll put my 2 cents in on this.
From what I understand from talking to my wife who is an executive with a large healthcare corporation, these are the major causes of spiraling healthcare costs in the U.S. of late:
A> Excessive Government Regulation at ALL levels ñ Federal, State and Local. Regulation = operating overhead, and those costs are passed down to the consumer. This affects all facets of the healthcare industry; for the healthcare industry is one of the most, if not the most, heavily regulated industries in America. Ok, so the pharmaceutical industry is largely unaffected by state and local regulations, but they are hugely affected by the FDA, and the lion’s share of the spiraling costs of new prescription medications is due to complying with onerous FDA requirements. Hospitals are hobbled by bureaucrats at all levels ñ from copious record keeping requirements (which aren’t all bad, but it ain’t free, folks) to the ridiculous CON (certificate of need) requirements that are required for doing any new hospital construction or expansion, especially for private sector facilities operating in the general vicinity of government owned/operated facilities. It can take YEARS for a private hospital to get government approval to add new beds, OR’s or ER’s. Not only is that expensive ñ these are lawyer intensive operations, and that ain’t cheap ñ but it needlessly dries up the supply of such facilities and as such drives up the cost of use of these facilities. And don’t get me started on the overhead associated with Medicare/Medicaid compliance.
B> Tort: Frivolous and Predatory Lawsuits. If this one thing could be brought under control, the entire industry could turn around in short order. The current atmosphere of lawsuit abuse is extremely destructive to the industry, to the point where doctors ñ good doctors, that is — are leaving practice due to spiraling costs of malpractice insurance. It is becoming very difficult in some areas to find healthcare providers at all (in particular, OB/GYN’s) since so many have either fled tort prone areas or have left practice altogether. In some states, doctors are even organizing ìstrikesî in protest of this. And the doctors aren’t the only ones affected by this. In ALL cases, malpractice insurance costs have spiraled to crippling levels, and these costs have to be passed on to the consumer as well.
C> Increasing cost of equipment. While new lifesaving technologies are wonderful to have, they aren’t cheap. While it is true that the cost of any particular technology is always decreasing, they tend to be replaced by newer, more effective, and more expensive technologies as they are developed. Ok, people, if you want the best healthcare available you are going to have to pay for it. If you want healthcare based on yesteryear’s technologies, it’ll be cheaper, but at what cost in lives? I see no way around this problem, we’ll just have to live with it. I, for one, would rather pay more for better care, as long as the care was actually better.
D> Increased demand due to the general availability of managed care, health insurance and government healthcare programs. Ah, yes, supply and demand rears it’s ugly head. Demand for healthcare is rising faster than the supply, and that increases cost. Universal healthcare only makes it worse, and by throwing more government funding (read: your tax dollars) at the problem just increases the demand and the money supply without increasing the healthcare capacity, which will of course lead to more spiraling costs. Ergo, the universal healthcare ideas being tossed around by the left aren’t the answer.
E> Gentrification. There isn’t a fixed amount of ìneedî that can be determined on a per capita basis for a population over time. It depends on the demographic mix of the population. If a population consists mostly of young adults, there will be a lower per capita health care ìneedî than if the population consists mostly of senior citizens. Senior citizens have more ìneedî for healthcare than young adults do. And as such, they create more demand on healthcare resources than young adults do. We are facing a changing demographic right now. The U.S. Population has always been weighted heavily in one age group, commonly referred to as the ìBaby Boomersî. I am one of them. As these Boomers reach retirement age, which is now happening, they individually require more health care than the did as young adults. This leads to a general increase in demand for healthcare resources, and that leads to increasing healthcare costs.
While I am certain that there are many other factors that apply, these are, IMHO, the most significant.
So, with all of these rising costs, one would expect that the healthcare corporations would be making record profits. This is not the case. For example, the stock of the company that my wife works for is at near all-time lows. Why? In short, the worst offenders are Government Overhead and Torts. Now, who are responsible for the Government Overhead? Well, they are a result of the ìNanny Stateî who refuse to allow the healthcare industry to operated with little in the way of fetters, largely imposed by and championed by the Left. Torts? Well, that comes from the Tort Lawyers, of course, and they stack overwhelmingly to the Left. Once certain Vice Presidential candidate who I shall not name here, but leave as an exercise to the reader, epitomizes them.
So, who is largely to blame for spiraling healthcare costs? Leftist Tort Lawyers and Leftist bureaucrats. In other words, it is the fault of the Left in general. The same Left who are screaming loudest about those same spiraling healthcare costs. I assert that they CAN’T be the solution to the problem, because they are the CAUSE of the problem!
And my suggestion for the solution to these problems? Well, widely available healthcare is something to be desired, so reigning in the demand is not an option. Better technologies are to be desired, so limiting that is also not an option. There is nothing that can be done pertaining to Gentrification other than recognize it and increase capacity to deal with it. That leaves Tort Reform and Reducing Government Overhead. And the Left absolutely refuses to allow either of those 2 things to happen. Therefore, the only really viable way to do it is to remove those same Leftists from the positions where they can further obstruct. And the polls are right around the corner. Go Vote!!!!
What you said Roger is certainly true. As a small business with just my husband and I (and our 4 year old son), our coverage costs us over $900.00 per month; and our benefits shrink.
I have also just witnessed first hand, the decline of quality of care as well.
My mother was transported by ambulance on Tuesday (she’s 83) to the hospital with what seemed like a pinched nerve; she could not put weight on her right thigh nor leg at all. She had not fallen.
The doctor attending took x-rays and said he saw nothing. He gave her some Valium (which can be also used as a muscle relaxer I learned), and some Morphine, and said she’d be on her merry way by that afternoon. After a while, my mother was happy to report that she felt *wonderful* except for the knot in her hip which still prevented her from getting up.
Fortunately, the attending doctor happened by and asked her if we had a family orthopedist; we do, so he called him (he’s been practicing for 24 years). Our orthopedist then came over and looked at the x-ray and said he saw something that bothered him (possibly a hair-line fracture), and ordered at CAT-scan. Well, that apparently turned up some sort of bump near a disk in her back (perhaps a hernia?) that may be impinging on a nerve. MRI has since been ordered.
What if we had had to rely on the attending doctor?
I understand that the interest in becoming a doctor is declining. We seem to be in a vicious cycle of law suits and then wonderful people who would be fabulous doctors choose a different profession because they don’t want to deal with the suits or the insurance costs.
My OB who was my doctor for 20 years (and had the best reputation around) retired because she was forced out of business due to the insurance costs.
Something has to be done, but I sure don’t know what that would be.
PS: Small businesses really feel the brunt of insurance costs and taxes. Our business only grosses about $130k per year. About 45% goes to taxes; federal and state. And our business and health/life costs us upward of $25,000 per year. That doesn’t leave a lot to live on – and we can’t afford to hire anyone (even though we need the help).
Reimportation of drugs will have only one effect: there will be fewer new dugs on the market. People rarely realize that it does take on the average 16 years to successfully bring a new drug to market. It is also difficult for people to realize how many promising drugs are dropped after years of investment before one marketable drug is made available to patients. I believe that the costs are on the average something like 800 million per single drug in. If pharma companies are spending that much, they have to bring back the money to somehow to just cover the cost. And, lest we forget, companies are in the business of making profit for their shareholders. If we remove the incentive for making this nasty thing profit, why should the bother to put any money into R&D?
Reimporation also will not work as a free market to lower our prices because pharma sells the drugs to countries with national health programs under a compulsion: a country sets up the price for the drug at or just above const, and if the company refuses to sell there the country threatens to break the patent (there are lots of variants here, but artificial pricing factor is always there). So companies sell on a foreign market, but do not introduce new versions of drugs, limiting them to the high priced American market. Thus we end up with a pilgrimage of Canadian patients to the US border towns to get the new drugs.
There is also an argument that we donít need new drugs, the old ones are fine, and the new version are only a plot of those greedy pharma companies to rob poor patients of their money.
People who make this argument surely never experienced any medical condition in which side effects of a medication can almost make a patient question whether the original complaint was worth the treatment, only to be switched by their doctor to another (sometimes it takes few tries), usually new medication, and experience feeling of almost magical relief. Or had to remember to take medication 4 times a day, while now only one pill suffices.
I will also add that drugs are critically important in helping to reduce necessities of more radical and costly intervention. How many people these days have surgeries for stomach ulcer? Well, these were mostly eliminated by these miraculous little pills that right now one can get over the counter: Tagamet and Zantac. And now there is Acidex available by prescription, new, expensive like hell, and twice as effective.
Here is a transcript of TCS sponsored a debate on the issue of prescription drug reimportation with Milton Friedman explaining why he is against it.
http://www.techcentralstation.com/020204D.html
OT
“This was not instigated by Kaus’ importuning the blogosphere to get beyond Rathergate to other issues …”
I’m not sure that’s what Kaus is suggesting since he references this Pinkerton article, which might be coupled with this second Pinkerton article wherein a variety of significant questions, worthy of a serious investigation, are noted.
Rathergate need not be obsessed over or marginalized, it needs a reasoned and proportional response. A knee-jerk twitching from obsession over a story to suddenly treating it like “yesterday’s news” is precisely one of the problems with old media. Hopefully one of the mediating qualities new media will bring to the fore is to avoid both extremes and help to render proportional and due responses and coverage instead. Also, I believe it’s a both/and rather than an either/or quality that Kaus himself appears to be suggesting.
Too, the WoT will remain a media/military/political campaign for as long as it lasts, which may be one or two decades or more. Hence thoughtful vettings or critiques of media are particularly important – “thoughtful” implying a commensurate, evenly weighted quality and avoiding the binary switching noted above between red hot obsession followed by dismissing it as merely “yesterday’s news.”
Regarding shortages of providers: there is such a critical shortage of nurses that there are companies set up here in California dedicated to bringing qualified nurses from Philippines. Each and every nurse working for my dermatologist if from there. And why not? They are qualified, come speaking English, and cost much less that the natives. I donít know whether we can call this outsourcing, insourcing, or what.
Lapsed Randian:
I believe the costs of healthcare have risen just about the same as the costs of automobiles over the past 30+ years…
Do you have a source for this? I’d love to see it. Quite the contrary I believe that healthcare costs have risen dramatically in real terms since 1965.
I don’t much care for the assertion of health care as a right but rather as a benefit which, as a wealthy nation, we wish to extend to our citizens.
Ursus:
Worth noting that our per-capita health care costs are lower than many/most of the nationalized systems.
Do you have source for this? On the contrary our per capita expenses for health care are a multiple of the closest competitor see here and here.
Oyster:
Second, our health care system is expensive but itÔøΩs also still the best.
By what metric? I won’t argue that it’s possible to get fantastic health care in the United States but the only metric in which we lead the world in health care is physician salaries.
richard mcenroe:
Have medical professional salaries risen significantly?
Not only have they risen in absolute terms significantly faster than the non-health care rate of inflation they have risen faster than the salaries of any other profession.
I’ve posted my thoughts on this subject here.
No one has mentioned another significant problem with our health care system: it’s immoral. I’ve written on this subject here.
I would much prefer a market-based system. But in the current system we have both monopoly and monopsony and I honestly don’t see any way to get to a market-based system from where we are right now.
Very good coments, by and large.
Let me start by outlining my background, which will highlight my prejudices.
I was educated in hard sciences (physical chemistry and molecular biology) before going to medical school at the University of California. I completed residency (also at a UC) and was a Robert Wood Johnson Clinical Scholar. I have worked in academic medicine, community medicine, general practice on the Navajo Indian reservation, and a very large HMO. I am the assistant chief of a large department, and will soon be chief of same. My wife has a similar background, but is a much more capable administrator than I am, and she is high in the ranks of high-level people in our organization.
I am at present a psychiatrist; most of my work is consulting on, and treating, cases sent me by internists, pediatricians, surgeons, ob-gyn’s and other specialists and generalists. I am considered an expert in psychopharmacology.
This background explains my prejudices, and the weaknesses in my arguments, such as they are.
In my view, the basic problems we face can be summed up in Jamie Irons’ Three Iron Laws of the Medical Care Marketplace:
(1) Everybody wants everything.
(2) Nobody wants to pay anything (or, what is the same thing, wants somebody else to pay for everything.)
(3) Nobody under thirty thinks they will ever need anything.
These “laws” are deliberately stated in a crude way, to make their point.
The problem of adverse selection, pointed out above, is THE BIGGEST PROBLEM in coming up with a solution to our medical care system ills.
Also, as has been pointed out above, we must always keep in mind that most of us use about 90% of our health care dollars in the last few months of our life.
Jamie Irons
Excellent post, Dr. Irons!
Since this is no longer off-topic, I’m bringing this back from “Off Topic”, where it fell with a dull thud anyway….
———————————————–
Jamie Irons–Sorry to take up Roger’s bandwidth on a personal item, but when the dust settles on this memogate thing, perhaps we could ask our host to do a thread on health care in the US. (I peeked at your website). One of my doctoral field areas was health care administration, and I currently work in public health. This group would have some wonderful ideas I am sure. What say you?
I’d also be interested in this. Some time ago, I posted this as a comment at Jeff Jarvis’ place (Jeff doesn’t permalink comments, but it’s in there):
The problem with this whole argument [about health care in the US, and the potential for some kind of national health care] is that there are already so many perverse incentives and so much actuarial idiocy in the US system that it’s hard to sort out anything in the data. Still, there are some obvious things:
(1) corporations can buy insurance with pre-tax dollars, individuals must use post-tax dollars. This means individual insurance is at minimum about 16 percent more expensive than company-paid insurance.
(A single-payer system would eliminate this problem, since it would all be paid for with some kind of tax; given the other examples of government efficiency, I wonder if the advantage wouldn’t be lost through inefficiencies.)
(2) there’s no easy way to form a pool of risk; this means small companies have to pay relatively more per person.
(A single-payer system enlarges the risk pool, but so would allowing insurance companies to treat their entire policy base as a single risk pool. The single-payer risk pool is bigger than any individual company’s policy base, but the marginal advantage becomes vanishingly small. This is why relatively big companies like Sun and IBM “self-insure”: it’s cheaper to simply pay the costs than to buy insurance. The mathematics of this aren’t instantly obvious, but it can be proven.)
(3) HIPAA etc regulations make it nearly prohibitive for small companies to get health insurace if they can afford it.
(I can’t decide if I think single-payer would change this; cynically, it seems more likely the companies would simply have the whole burden of HIPAA imposed on them no matter what, even the small ones that had avoided it before.)
(2 and 3, by the way, are the base of “employee leasing” companies like Administaff, which outsources the whole HR thing … but adds profit margin to the deal. It’s a sign of the perverse incentives involved that the economies of scale mean that the complications of setting up Administaff’s HR operation in a whole separate company, including effective double taxation of the costs, plus a good bit of margin, is still far less expensive than doing small-business insurance and HR.)
(4) The lack of any predictable bounds on malpractice awards means that the mathematical risk per doctor is very very high, and as a result, malpractice insurance is extremely expensive.
(This is easily proven mathematically, which is probably why the discussion almost always is suborned with discussions of “incompetent doctors and greedy insurance companies trying to cheat sick babies”. The only way a single-payer system could help with this is if it included limits on malpractice awards; since you could simply limit malpractice awards without the other baggage, you can’t call this an advantage of single-payer.)
(5) the malpractice poroblem means that lots of defensive procedures and tests are performed, which raises costs.
(Many studies about this, but it’s easily confirmed simply by asking any random doctor. Single payer would have at best no effect on this without malpractice reform.)
(6) the tax problems and risk-pool regulations mentioned above mean that insured people are nearly wholly insulated from medical costs. There is no economic incentive to hold the costs down.
(Single payer would eliminate what little connectin people have now.)
(7) medicare and required-coverage regulations make treating many insurance patients uneconomic — which means insurance companies and doctors have to transfer costs to people who are paying privately, or to better insurance.
(Either single-payer wouldn’t change this, or single-payer would have to reduce coverage over the current regulations. No obvious advantage to single-payer there.)
(8) the legal requirements that everyone be treated in emergency rooms, regardless of ability to pay, mean that the costs of emergency treatment are transferred to private patients and the insured.
(Single-payer just means the transfers happen in Washington, instead of in the provider’s accounting department. The only way single-payer could improve this situation is if the costs of single-payer could be reduced below the costs of making an on-paper transaction in an accounting office.)
Jamie Irons & fatherson,
Adverse selection applies to single adults, almost always under the age of forty. Families and older individuals have risk incentives to obtain coverage.
I also suggest you check out Ramesh Ponnru’s cover article in the current National Review paper edition on the Bush plan for near-universal portable (non-employment) private health insurance. He dances around the concept of portable pensions.
Speaking of “Off Topic”, I would like to start the discussion of DNA coding and morphology we started down-blog a little ways. BY the time I could come back to it myself, I was too far behind….
Would some of you folks like to volunteer to become co-”editors” of the “Off Topic” site, so several of us can throw a possible topic onto the pile?
No one has mentioned another significant problem with our health care system: it’s immoral. I’ve written on this subject here.
Dave, you seem to be implying that for a Zambian doctor to decide to leave Zambia and come to the US, where he/she can make more money and have a more pleasant (and safer) life, is somehow immoral.
This is a use of the word “immoral” with which I’m not familiar. Could you expand upon it, perhaps?
Dave Schuler:
Re: your request for a link on the cost of automobiles:
I learned this information from an unimpeachable source, and I resent your well-financed, right-wing tactics in challenging the integrity of my earlier comment. My source’s name is Lucy Ramirez….
Seriously, check out the Sacremento Bee Online, August 29, 2004. David Weintraub’s article, “Is There A Health Care Crisis? The Numbers Tell a Different Story,” covers this issue, and also refers to a lot of recent research on this issue. Sorry, I still haven’t figured out how to do the “link” thing.
Ok, one thing I didn’t address was the pharmaceutical reimporation idea what is floating around in certain circles. Katherine covers the subject pretty well, but there is still a few points to bring up on this subject. Let’s look at a subject that she alludes to, and that is that it isn’t cheap to develop a new drug. In fact, it is REALLY expensive. Profit considerations aside (yes, they are private companies who are in business to make profit for their stockholders, but that is actually a pretty minor cost in the long run, and the actual production costs of drugs is trivial, hence Canada), one has to ask: �Why is this development process so long and expensive?� Well, there are 2 main reasons, maybe 3. The first reason is that R&D is just plain expensive. It would be expensive no matter what ever else is happening, and that cost must be recouped. The second has been covered as well, and that is that there are many of these R&D projects that fail for one reason or another, and those costs must be recouped as well. Nothing can be done for these 2 costs other than cease these R&D operations, and that is just not a viable option, as has been previously explained. And those 2 still don’t explain the long delay involved between the conception of the product and the final release of the product to the marketplace. So, why the delay? Why are new medications on the market in places like Europe YEARS before they are in the US? And why the extra costs? One little acronym will do: the FDA. The FDA is KILLING the industry with their overzealous testing and retesting requirements and their bureaucratic overhead. Why won’t the FDA allow for the submission of previously gathered test results from overseas? I mean, if the methodologies used were valid, why repeat the test in the US? Testing and Retesting is expensive and time consuming, you know! I’m not saying that testing is a bad thing, mind you. It isn’t. But it can be taken way too far, and that is what is currently happening. It is noteworthy that in the comparatively recent past there has been some reform along this line � certain new medications are now given a �Fast Track� approval process, but what about the others? And why is it Ok for one medication to get a �Fast Track� through the system but not others? It seems to me that all should be given that treatment, or none of them, from a safety standpoint. The �Fast Track� is either safe, or it isn’t. If it is safe, it should be the general policy, and that would reduce costs. I, for one, would be in favor of getting the government out of the business of dictating drug safety tests entirely and allow private laboratories to do it (think: Underwriter’s Laboratories for drugs). I would allow the drug companies and attending physicians to make the final safety determinations. That would provide a triply faceted platform of checks and balances which would both greatly reduce total costs as well as still provide for patient safety. Keep in mind the fact that NOTHING that the government does is cost effective. Never has been, and never will be!
Remember this, for it is true: The government can’t be the solution to the problem, since the government is the cause of the problem.
One pundit (I can’t remember if it was Walter WIlliams or Thomas Sowell) a while ago pointed out something that is quite applicable here. The FDA is a bureacracy. Fact. And as such is populated by bureacrats. Fact. Bureacrats are constantly worrying about CYA. Fact. They are more concerned with the survival of their bureau and their own jobs than ANY THING ELSE IN THE WORLD. Fact. Now, for any drug coming on the market, there are 2 populations of people who may die pertaining to it. Those who die from unforseen complications because it may have been released too early and was not safe, and those who die from their illness because it was delayed and was not available to cure their illness. Where is the headlines? In the former, of course. Where are the majority of deaths going to occur? In the latter, of course. So, what is the job protecting bureaucrat going to do? Well, avoid the headlines, of course. There is no cost to the bureacrat pertaining to being overly cautious, the bureau stays in business, and the bureaucrat keeps his job. The patients die, and the costs spiral. Your tax dollars at work.
I’m also going to throw something else in here which will add to overall costs.
Testing all babies for genetic diseases. I’ve read a couple of articles, one in People, if our children had only been tested for this……
And who’s going to pay for this?
http://www.chron.com/cs/CDA/printstory.mpl/health/2805595
“Texas’ largest medical liability insurance provider said Monday it will cut its rates by 5 percent starting in January.
The drop by the Texas Medical Liability Trust, or TMLT, comes on top of a 12 percent decrease the company implemented last January, after a new law and state constitutional amendment allowed a cap on jury awards and limited insurance companies’ liability.”
Can you ask for a better example of cause and effect?
(link thanks to “GruntDoc” http://www.gruntdoc.com/)
Jim, your link 404′s … which is a shame, ’cause I’d love to read it. As I noted above, there are awfully good actuarial reasons why unbounded malpractice awards should have the effect of raising insurance costs radically.
This should work:
Link…
I think this one is the one you wanted, though.
The first one failed because the href string ended with “)/”. The second one is to the “permalink” for the article itself.
Maybe I should post a tutorial on linking on “Off Topic” as well?
Looking at Katherine’s response on re-importation, I realized how ill-written my earlier post was.
Just to be clear: I do not recommend drug re-importation, as it will indeed cripple innovation. However, I think politicians will allow increasing re-importation (leading to de facto price setting), and that we will see a corresponding drop-off in R&D. Thus, we won’t have to worry about new high-priced drugs because there will be fewer new drugs at any price.
So in short, please don’t beat me with my old microeconomics textbooks. I did pay attention in those classes, I swear.
“As for the comments about the trial lawyers, etc., I might mention one, somewhat off-thread point: on balance, companies, hospitals, and doctors have better access to the very best legal talent than plaintiffs do. If they are settling frivolous cases and thus driving up the cost of healthcare (I’m skeptical of this…) it is their own fault.”
I’m not sure about the “very best legal talent” issue, and reference an article in the May 24, 2004 Crain’s Chicago Business. It’s subscription only online, but, in short, it stated that defense attorneys are paid “nothing close to what (attorneys) might command in another specialty.” The article goes on to say “major (Chicago) law firms have shed med mal practices, considering them unprofitable, and several defense attorneys have jumped to the plantiffs’ side.” The insurers are blamed for being penny-wise and pound-foolish, cheaping it out on lawyers in an attempt to to clamp down on litigation costs.
Disclosure: I work for a med mal insurer, but on the investment management side. Thus, I cannot attest to the veracity of this article from personal experience. Crain’s in general has been very hostile to the med mal liability insurance lobby, so filter the article through that bias as well.
Charlie (Colorado):
Dave, you seem to be implying that for a Zambian doctor to decide to leave Zambia and come to the US, where he/she can make more money and have a more pleasant (and safer) life, is somehow immoral.
This is a use of the word “immoral” with which I’m not familiar. Could you expand upon it, perhaps?
Sure. What I’m saying is that the U. S. effectively offshoring its training costs for medical doctors (and nurses) is immoral. Training costs are heavily subsidized by the home countries. There’s no conceivable way that Zambia and a host of other poor countries can outbid the United States. And these doctors are desperately needed there.
Letting a kid die for want of a doctor to treat him in his home country so we don’t have to wait for treatment for a hangnail here is immoral.
One might say that that’s Zambia look-out. That would be a pragmatic judgment and, as a pragmatic judgment, it may be correct. But it’s not a moral judgment.
There’s a worldwide market in health care services and the U. S. health care system is raising the cost of health care worldwide.
I want to repeat: I would prefer a market-based system. But Milton Friedmann catalogues the obstacles to establishing such a system pretty well in one of the articles I cited above. It’s just not politically possible to get there after all of the poor choices we’ve made over the years.
BTW, Lapsed Randian, for the reference. I’ll check it out. What you’re reporting is completely inconsistent with every source I’ve ever seen and, in particular, the Friedmann article I’ve mentioned before.
Charlie:
I believe that a single payer system [government] will solve the liability problem. National Health establishments can and will restrict your right to sue them. I don’t see a big medical malpractice industry in Canada or the UK. However, I don’t think it worth trying single payer just to get rid of the ambulance chasers. The best way to bring malpractice awards under control is outlaw contingency fees for individuals and limit fees in class action suits to something like 5% of the award.
Percy D:
I used to be an equity partner in a 300+ lawyer firm, not unlike the kind you refer to, and it is true that the mega firms tend to look down their noses at the med mal lawyers. Relative to the plaintiff’s side, however, hospitial and companies still have access–on balance–to better legal talent.
Getting alittle further off thread, it is a dirty little secret in the legal community that most lawyers will do anything to avoid trial, and thus, even frivolous plaintiffs end up with settlements rather than the serious thumping they deserve. This is especially prevalent in the med mal area, but it is still always (theoretically) the client’s (i.e., the doctor’s, the hospital’s, etc.) choice to settle such cases.
Maybe Roger can open a “most lawyers suck” thread some other day.
BTW I don’t think much of drug re-importation either but I believe that the “stifling of innovation” argument is a red herring. I’ve written about that previously here. For the claim that any reduction in profits for drug companies will result in substantially decreased research to be true, it would seem to me you’d have to be able to demonstrate that drug companies use their profits to fund research and that doesn’t seem to be borne out by the facts.
Drug companies are in the marketing and rent-seeking business not the innovation business.
On the contrary I think that you’d get more innovation if the barriers to entry were lowered and the patent laws reformed to require real innovation to secure a patent and the term of the patent made variable based on the ROI rather than a fixed term as it is now.
Jerry:
I agree with your rationale pertaining to the single payer taxpayer funded system. While it would ultimately solve the tort problem, it brings about the next problem of the “Golden Rule”, where the one with the gold (the government, not the taxpayers in this case) gets to make the rules. And we know just how well the government operates. As for me, I don’t want a Canadian or British style healthcare system. No Way! The negatives far outweigh the positives, it is throwing the baby out with the bathwater. A good first step is what you suggest, as well as what Jim in Texas has brought up about what is happening in Texas. Tort reform is 1 of the 2 things that have to happen for us to get out of the mess that our healthcare industry is currently in.
Charlie:
I disagree with your point about our recruiting overseas doctors being immoral. No, it is not at all immoral. We have a need to fill, and are willing to pay to fill it. Our health care system, flawed as it is, is still vastly superior to what is found in the rest of the world. What we need to look at is why it is that the overseas personell find it desirable to come to the US to work. Could it be that the mostly socialized systems in the rest of the world repells that talent? The answer is for those other countries to reform their own health care systems and encourage their own, native talent to stay. It is their problem, not ours. We should be HAPPY that highly valued (to us, that is) talent chose to come here to work. It is shameful to those countries that their own talent choose to move on to “Greener Pastures”. It is their own fault for choosing to implement backwards healthcare systems, and I have ABSOLUTELY NO SYMPATHY FOR THEM. If they want to keep their own talent and attract others, then they need to compete, and that means ditching their socialist policies and allowing the free market to take hold. Fat Chance of that happening…
Two problems – one mentioned, one not:
1) Perverse selection (my term – somewhere in economics there is another meaning). Insurance companies will not insure those who need it the most. If you have had insurance all your life (paid by your employer and maybe partly by yourself) and at 50 decide to quit and start your own business, you had better better be healthy if you want any form of insurance at any price. All those payments don’t count. It’s not like life insurance. In the industry, this is called medical underwriting and it means not insuring known risk. It is the flip side of adverse selection. An example: Blue Cross in Arizona won’t sell you insurance if you have EVER taken an antidepressant (which, I should point out, are sometimes prescribed for non-psychiatric purposes including antihistamine effect, but even so, this is a bizarre underwriting rule). The effect of this situation is to cause people of my age to cling to employers. There is some relief (COBRA, state risk pools) but overall it is a scary situation. Absolute portability would solve this problem, but may have economic repercussions.
I’m a conservative, but this is a case where I think government intervention is needed if we desire all people the ability to purchase health insurance. We might have to make insurance mandator for young people in order to pay for the sick who now gain coverage.
The economic effects of the current private medical underwritten system include excessive unemployment of older employees (often the best experts), the necessity to put your entire savings on the line for the first major medical emergency, the failure to form new, dynamic companies because of the inability to insure the older employees (I’ve been there), the fact that a traditional life of saving may lead to old age pauperhood – which is not a good economic incentive.
2) Discriminatory pricing – as an individual, you will find that a hospital will charge you vastly more than what they charge insurance companies – sometimes five times as much. The reason is that you have no power to negotiate prices down, and they have to make up for managed care discounts and no-pay patients.
The main problem in the US is a medical payments problem, not a medical care problem. We have outstanding care. But we have a payments system that is irrational, full of gaps, has silly incentives, and in general is a mess.
A few other issues:
Get rid of first dollar payments and go to medical savings accounts (catastrophic coverage). We are used to having medical care cost virtually nothing – maybe a 10 or 25 copay for anything. That leads to inappropriate incentives.
Automate the payments system (and the rest too). As a software person in the medical payments industry, I can confidently say that the medical world is the least automated and least standardized of any major industry. HIPAA can help, but the electronic message standards are far from optimal, don’t use XML, and can be misinterpreted easily. In other words, it’s a standard that’s not a standard.
Unlock the MD supply – stop the AMA’s prevention of new doctors. No more doctors graduate today than 30 years ago. However, a whole lot more osteopaths are graduating, as the AMA has no control over them.
Accept the fact that the young are going to pay for the old. They need to recognize that, with any luck, they are going to be old also. It is human nature to have worse health with age. This fact is why engineers over 50 mostly cannot get hired – companies know that they will raise the insurance pool costs.
Oops! Did I say Charlie? Yep, I sure did. Sorry, Charlie. I should have referred to David S.
Jerry, start paying attention to Canada, read some Canadian bloggers and their papers, don’t go for single payer.
I have a separate file on Canada’s HC.
Start w/the Frasier Institute.
Could someone comment on the feasability of Jerry’s earlier post regarding price discrimination and charging for health care based on income? I’m not normally in favor of such, but it seems like a decent idea, especially if this is how the system used to work. Any takers with a knowledgeable opinion? I’m worried that such would set a bad precedent such as tiered pricing for college? Any ideas?
Sure. What I’m saying is that the U. S. effectively offshoring its training costs for medical doctors (and nurses) is immoral. Training costs are heavily subsidized by the home countries. There’s no conceivable way that Zambia and a host of other poor countries can outbid the United States. And these doctors are desperately needed there.
And you are thus saying that the US should prevent Zambian doctors from coming here, even if they want to and we want doctors.
As I say, this is a use of the word “immoral” with which I’m unfamiliar.
Sadly, however, that’s a rhetorical trope: I’m actually all too familiar with the impulse to make someone a slave to another’s sense of “morality”.
ìyou’d have to be able to demonstrate that drug companies use their profits to fund research and that doesn’t seem to be borne out by the facts.
Drug companies are in the marketing and rent-seeking business not the innovation business.î ??????????????
David Shuler, please explain what all those PhDs MSís and BAs do in research laboratories of Merck, Pfizer, Hoffmann La-Roche, Bristol Myers etc.? I know it is cool to play with new fangled technological gadgets and do experiments for pure fun and God knows some are done for the pleasure of it. But companies eventually need to see tangible results to justify the expenditure. And where exactly is the money coming for all those research labs if not from the money that companies make? PhD scientists in drug discovery may not command highest salaries, but they donít come cheap. Neither do the supplies and equipment needed to run a smallest modern lab. (Actually, the supplies and equipment are the real killer regarding the cost.)
I agree with one point: big pharma companies often find it easier to team up or buy up small biotech firms with promising products than to develop the stuff themselves. In that case they use their own house scientist to evaluate whether the purchase is worth the money. On the other hand, small biotech may have huge talent, but usually lack resources for unbelievably expensive clinical trials necessary for FDA approval, so well explained by gb_in_ga. If you take away the ability of big pharma to make money they will not be able to run the clinical trials for drugs developed by the little guys who have no profit, only very impatient investors.
So in the end this works out to the benefit of both sides. Of course, if the FDA lowered the barrier of entry for small biotechs, by easing on the approval process, they may have a chance to compete with the pharma giants. Alas, at this point regulation rigs the game for the benefit of large established firms.
Tom Holsinger (10:57 AM)
I’m not a health care policy wonk, but as I understand the term “adverse selection,” it refers to a population’s effect on an insuring entity.
For example, if a large HMO, like my own, offers insurance at a reasonable rate to all comers (as we try to do), we will necesssarily have to charge (on average) a higher premium, in order to take care of the sicker members.
Other insurers may offer a lower premium, but only to those who are quite young and entirely healthy (this is called “cherry picking”).
All other things being equal, over time people with established conditions will gravitate to “my” system, hence “adverse selection.” (Adverse to “my” system, that is, as in time it will not have enough young, healthy members to keep it afloat).
While everyone’s arguments are good ones, I keep coming back to my (half jesting) “Three Iron Laws of the Medical Marketplace.”
Somehow a way has to be found for the young healthy population to support the older and/or sicker population — without killing off the economy, or motivating the younger, healthier people to kill off the older and/or sicker ones!
NOT AN EASY PROBLEM!
And while I respect the motivation behind the “single payer” idea, it really just begs the question. (Who pays the single payer, and how much, and where do the payments go?)
Jamie Irons
Jerry: I believe that a single payer system [government] will solve the liability problem. National Health establishments can and will restrict your right to sue them. I don’t see a big medical malpractice industry in Canada or the UK. However, I don’t think it worth trying single payer just to get rid of the ambulance chasers. The best way to bring malpractice awards under control is outlaw contingency fees for individuals and limit fees in class action suits to something like 5% of the award.
Me: The only way a single-payer system could help with this is if it included limits on malpractice awards; since you could simply limit malpractice awards without the other baggage, you can’t call this an advantage of single-payer.
In other words, yeah: exactly.
Jamie Irons and Charlie,
Your points are well taken. Let me add a few.
My background: Developmental Immunobiologist, Neurologist, Fellowship Trained, NIH Stroke and Epilepsy Research, University and Community Practice, Pain Management Expert.
The problem is one of medical payments as well as risk reduction/prevention.
If patients actually paid for their care, i.e. fee-for-service, if they owned and took care of their heath, the way they do their home or cars, the population’s general well-being would improve. People must be incentivized to be healthy. The incentives today do not materially exist.
Similarly, if the community directly shared the cost of liability insurance, the overall costs of providing care would diminish. Couple fee-for-service in the outpatient realm with catastrophic insurance (and yes, it is a form of pre-payment).
In my field, there is a shortage of practioners in much of the country, not because of inhibitory or other limitations of entrance into the neurosciences, but because of the unfavorable cost-benefit relationship in purusuing training in neurology and its subsequent practice.
Universal Coverage will limit the quality, availability, and raise the cost of care. Medicine is an exceedingly difficuly art to master, it is even more difficult (if not impossible) business to manage.
Entitlements only grow in cost. There is no example of which I am aware to the contrary.
The problem is a systems problem, which requires systems solutions. It may not be fixable, but first and foremost, people must own and care for their health and not rely on the government to do it for them.
Getting alittle further off thread, it is a dirty little secret in the legal community that most lawyers will do anything to avoid trial, and thus, even frivolous plaintiffs end up with settlements rather than the serious thumping they deserve. This is especially prevalent in the med mal area, but it is still always (theoretically) the client’s (i.e., the doctor’s, the hospital’s, etc.) choice to settle such cases.
No, that’s not a dirty little secret, it’s a natural consequence of rational choice in an environment where the downside risk is effectively unlimited.
Settling for $100,000 a hundred times is still cheaper than the occasional $200 million award.
Thanks for the link, Roger. I’ve been thinking about this for a while. I think that this is the biggest domestic problem the United States faces. My problem with nationalized health care is that you don’t kill a monster by expanding its stomach.
All
With regard to BigPharma and R & D, Pfizer alone spends somewhere in the $7 Billion dollars a year in research.
And who is BigPharma?
It’s anyone who has a pension fund, retirement fund, or individual equity stock owner.
NB: I own not a single cent, ZERO, pharmaceutical or related stock.
My background: Developmental Immunobiologist, Neurologist, Fellowship Trained, NIH Stroke and Epilepsy Research, University and Community Practice, Pain Management Expert.
Cool.
You know, folks, we’ve got quite a freakin’ seminar here.
M2T: immunobiologist and neurologist. Jamie: MD (I’m not sure if he’s ever revealed his actual specialty, but I’ll say it’s one that applies to a lot of the trolls, anyway.) WB: PhD mathematician. Catherine: Widely published expert on autism, as well as lots of other stuff I’m sure. Jerry: senior naval officer. RogerA: Another MD? Something good, I recall. John Moore: another mathematician, no? As well as ex-career military, I think.
And lots of others I remember being impresed by.
Charlie:
I guess my post was not clearly written…What I menat is that single payer governement systems automatically end malpractice suits. Governments are not about to allow themselves to be sued. Its something that liberals, particularly liberal trial lawyers, don’t get. If the government doesn’t want to be sued, it simply issues a regulations saying so.
Next time I will write more clearly.
Some comments on previous posters:
Jamie Irons “Three Iron Laws” hits the nail on the head as far as the incentives for heath care run.
Healthcare is different from most other commodities because the is practically no upper limit on demand (save the hours in the day of the demander.) Given that there is unlimited demand, there has to be a mechanism for limiting supply. Currently that limit is the monitary cost.
Two problems have arisen lately: third-party pooling of costs through insurance coverage, and political moves to assert a positive right to medical care.
JuanBGood:
There is a good discussion of “negative rights” verses “positive rights” at:
http://volokh.com/archives/archive_2004_06_07.shtml#1086708760
In the early 1990s the State of Oregon tried to craft a method of overt rationing of health care to uninsured people by creating a list of procedures. At the top of the list were no-brainers such as vaccinations; at the bottom of the list were experimental procedures such as (at the time) liver lransplants. But no matter where they drew the line, some poor, sick kid was going to be shut out of some procedure. This created an intolerable political pressure an the attempt at overt rationing was abandon.
Jerry, you think that a single-payer health system will not let itself be sued. I think that is naive. Ralph Nader destroyed “Pay as you Drive” no-fault car insurance in California that would have reduced overall yearly insurance costs by $15 billion because no-fault by it’s very nature has to remove the ability to sue.
And in my neck of the woods (Pacific Northwest) lawsuits are filed daily by environmental groups every time someone in the forest service _thinks_ about changing any one of a myriad of contradictory natural resource regulations.
Health care needs to close the feedback loop on costs and performance. Americans do need to realize that goods have become fantastically cheap, but professional services have become very expensive.
Certify more doctors? That reminds me of the joke about what they call the person in medical school that graduates at the bottom of his class:
Doctor.
Some things shouldn’t go to the lowest bidder.
Jerry. Don’t apologise. We’re agreeing.
Beryl, I think Jerry may have somwhat the better of it on the “let themselves be sued” argument. At least, it’s certainly the case in Canada that you have no effective recourse against pretty egregious real malpractice.
gb_in_ga,
The reason we are pulling in physicians from abroad and depleting foreign populations of their locally-trained physicians, at great cost to foreign taxpayers, is that we pay our physicians a lot more. The last time I saw the facts on this was an article in The Economist about 20 years ago, but at that time the average physician in the US was paid 7 times the average salary in the US, whereas in Britain, Germany, and Japan the figure was 2x. I very much doubt that our physicians are any better (or worse) on average than the ones in those three countries.
We pay a lot more, in turn, because we have an artificial shortage of physicians induced by the AMA, see above. A free market will always try to meet an artificial demand one way or another.
That artificial demand could not be sustained in a completely free market. So in effect physicians are using the apparatus of government to enforce their monopoly. It is in effect a kind of socialism in which the physicians, rather than the public at large, benefits. Exactly the situation that Adam Smith condemned.
Dave Schuler,
I tend to agree with you on the morality issue, at least up to a point.
Drug companies are in the marketing and rent-seeking business not the innovation business.
How about if we change that statement to: “It is your opinion that drug companies are in the marketing and rent-seeking business not the innovation business.”?
My opinion is that certain drug companies are certainly in the innovation business. Where do you think that SSRIs came from? What about acid-blockers? My life is immensely better because of the invention of acid-blockers.
I happen to have intimate knowledge of Eli Lilly’s immense efforts (and costs) to create new drugs.
Can we at least agree that not all drug companies are alike?
In general,
We should consider the political realities. I would never make a decent politician, so take the following with a grain of salt.
1) It is my assessment that there is a large faction within the US which wants to turn us into a socialist nation. They are, literally, socialists. In many cases this is simply because they want to personally hold the reigns of power, or else sincerely believe that they would do a better job than messy democracy could ever accomplish. Certain senators from New York come to mind. This group will start proclaiming that health care is a “right” (whatever that means) in order to further their agenda. People like to have lots of “rights” so that will be a powerful tool.
2) There is a populist element present which hates big companies and rich people (physicians). They don’t really care what’s best in the long run, they just want to punish the rich.
Group 1) sees socialized medicine as an opportunity to begin the complete socialization of the economy. The system is seriously flawed and they will offer to fix it. Group 2) can be used by group 1) as a tool to begin the process of socialized medicine.
3) As Jamie Irons says, people want free health care and I have but little doubt that most Europeans are convinced that they really have free health care.
4) Most physicians live in an environment where they are treated like Gods all day long. They in fact do have power of life and death over their patients, which is a Godlike power. The consequence of this is that most physicians believe themselves after a while to be Godlike beings. After a while they are certain that they deserve a salary which is 7 times the average and a lot more too and that they and they only should be setting all healthcare policies.
This accounts for the problematic phenomenon mentioned above by photoncourier that there is too sharp a distinction betwee the jobs of “nurse” (slave who does all the dirty work and heavy lifting) and “doctor” (self-proclaimed Godlike figure who comes in with a John Kerry fake but accurate smile, asks a couple of questions, writes something on the clipboard, and collects the gigantic fee for five minutes worth of work).
5) None of the above groups have any real incentive to be honest about what is going on; rather, they will all push their own agendas with whatever lies and half-truths are available. Thus, while there will be lots of honest in-depth studies which will appear in the academic and high-end political journals, and there will be some honest discussions as in this thread, for the most part none of these articles or discussions will amount to a hill of beans in terms of the policies that actually get adopted.
Socialized medicine is a stick with which to beat the lawyers and the physicians. In general, it will probably not be the best system one can build but it will be the only system we can create which will cut through the Gordian knot of today’s health-care catastrophe. I think it is just as certainly in our future as is gay marriage.
Charlie, best characterize me as engineer (hardware and software) with extra math background. Military was naval air reserve ( P-3 Orion radio operator) – not career – just 2 fascinating years of active duty and some drilling. There are others on here with more military experience than I. I did observe that interesting incidents (and hence stories) occur at about ten times the rate in the military of that of a normal civilian life (and I chase tornados, which adds a few, especially this year).
Anywho….
My daughter has been doing basic research at one of the nation’s top research institutes into the genetics of a common psychiatric disorder. The primary competition for publishing was a pharmaceutical company. The pharmas have two major costs: R&D and advertising. Both are valid – the advertising means having reps introduce the medications to doctors, who tend to be conservative in their choices.
I have to be a bit vague because of the extreme competitiveness of this sort of research.
In any case, while the Pharmas, like any business, will use any trick in the book to increase their profits, they do in fact do a lot of research, and the rest of the world is free-riding on what we pay for medication.
The main tricks involve various ways to extend patents, or to create a new drug in an existing family by a minor tweak to the molecule. The hard work is novel drug discovery and the extremely time consuming and expensive process of qualifying those drugs. The Martha Stuart fiasco has its roots in the FDA denying (for no good reason) certification of a drug that they have since approved.
As I understand it, all you have to do to get extended health care in the US is to be sent to prison.
There, you can get almost any type of procedure done, for free.
Gender-change, heart transplant, etc…
lindenen,
This doesn’t directly answer your question but Andrew Odlyzko of the University of Minnesota has written some excellent articles about price discrimination from the economic point of view. One of them is here.
WichitaBoy
Being a physician, but being at the same time hardly god-like, your comment reminds me of a remark (IIRC) of Dorothy Parker’s friend Alexander Wolcott, who quipped, when a friend made him godfather of one of his (the friend’s) children:
Always a godfather, never a god!
Jamie Irons
Military was naval air reserve ( P-3 Orion radio operator) – not career – just 2 fascinating years of active duty and some drilling.
P-3′s … and you said Moffatt… when were you there? I was doing P-3 software when I lived off the end of the Moffatt runway.
WichitaBoy
We pay a lot more, in turn, because we have an artificial shortage of physicians induced by the AMA, see above…
I think the AMA would be surprised to learn it has this power.
Jamie Irons
“They in fact do have power of life and death over their patients, which is a Godlike power. The consequence of this is that most physicians believe themselves after a while to be Godlike beings”..but there are lots of professions in which people deal in life and death. The average air traffic controller is probably responsible for more lives in an average month than the average physician in his entire career. And what about structural engineers, nuclear and chemical plant operators, etc etc? None of these professions have a reputation for being particularly arrogant.
And arrogance *is* a problem among physicians. Not all of them are, but enough to make dealing with the profession often an experience more unpleasant than it need be. Surely there are safety implications, also: arrogance leads to failure to listen and to understand and acknowledge one’s own mistakes.
WichitaBoy:
Ok, I will claim ignorance about the physician situation in Japan ñ it just hasn’t interested me at all. It does seem that the AMA is part of the physician pay problem, as you point out. Since the AMA is an organization by and for the physicians, they function as a cartel, with all of the negative baggage associated with such. Ok, so the answer to that is to reign in the AMA as well, or count on the free market forces that act to counter such cartels. Primarily, I’m talking about ìexternalî cartel busters, who in this case would be those very same overseas physicians that you speak against. While that cartel may act to limit the introduction of ìNewî domestic physicians and as such keep the supply artificially low, the influx of ìExternalî physicians acts to counter that effect. While some of what the AMA does is good (stressing high standards is a good thing in the medical arena), the cartel effect is bad. But it is still not that large of a proportion of the entire cost of medical care. The AMA physician cartel is not the ONLY cause of the relative physician shortage in the US. As I understand, that cartel basically acts to limit the supply of physicians to what they perceive to be the actual demand, just enough to do the job, and at the same time keep physician standards high. That would be fine and good, if more expensive than what might be otherwise. I can live with higher costs in that arena if the physician supply remains adequate and the quality is top notch. What they have not factored in is the increased retirement rate and premature practice closeures do to increasing malpractice premiums due to torts. This throws off their calculations, creating even more demand than the system allows. Hence, the need for physicians from outside of the AMA cartel. Ok, so there is the question of just how qualified these physicians are. They seem to be doing well, by and large, from what I’ve seen. And I am not particuarly concerned about the welfare of foreign taxpayers. The answer for them is to create the conditions which would encourage those physicians to stay home, and is therefore their own domestic problem. If the overseas countries want to keep their physicians, then they need to see to it that they are paid more. If they won’t pay them more, they shouldn’t be surprised to seem them emmigrate. Again, it isn’t my (or should I say our, as in the US’s) problem. It is a free market in that respect, you know. Apparently we value them more than their home countries do. One side effect of having those higher physician salaries you speak of is that they tend to NOT leave. So at least our talents aren’t draining, and the physician shortage is not as bad as it could be.
Oh, and I’m not at all concerned that a physician in the US is making some percentage more or less than those in GB or Germany. They have different systems. You could just as well have referred to the old Soviet system. Just because the physician pay is less doesn’t mean that it comes in at less of a cost. That cost typically comes at the expense of quality of care. Let’s not let that lapse.
Perry,
My wife was a paralegal for a Worker’s Compensation applicants’ attorney, and then for an insurance defense attorney (not medical malpractice). She told me years ago that the whole insurance industry was so nickle & diming insurance defense counsel to death, including the medical malpractice ones, that they could not afford to train new associates in elementary litigation. The ones in my area have had to start doing plaintiffs’ work just to train new associates.
I’m a California trial court research attorney – law & motion is 95% of my practice. There has been a dramatic decline in the quality of work done by insurance defense counsel of all sorts over the past ten years. Lots and lots of cases which would have been terminated on summary judgment, or by limitations defenses at the pleading stage, are going to trial because insurance defense counsel lack elementary paperwork litigation skills.
oops, I meant to address that post to Lapsed Randian.
Jamie,
There is a difference between mandatory coverage and single-payer. I agree the latter is dead on arrival, due to an acute case of brain-death.
Someone correctly noted that the problem is coverage and payment – specifically that the existing mechanisms for risk assessment, aka underwriting, and cost oversight are broken.
With regard to BigPharma and R & D, Pfizer alone spends somewhere in the $7 Billion dollars a year in research.
I can see I confused several people when I wrote that BigPharma was not in the innovation business. Please read the post I linked to when I made that statement. That Pfizer spends $7B per year does not mean that Pfizer considers that to be its core business. I’ve checked the annual reports of the five largest pharmaceutical companies over extended periods. Increased profits don’t appear to motivate them to spend more money on research. R&D has been going up in BigPharma at the rate of inflation but no higher although their profits have gone up at several times the rate of inflation.
When a farmer makes a profit he’ll buy more land, plant more crops. A bowling center proprietor builds another alley. A storekeeper expands his operations. A lawyer may hire another lawyer. They expand their core business.
When BigPharma makes a profit (as they have) they spend more money on marketing and rent-seeking. That’s their core business.
When BigPharma makes a profit (as they have) they spend more money on marketing and rent-seeking. That’s their core business.
That suggests that rent-seeking etc has the highest rate of return. Do you expect reducing their profit margin would change that?
Guys, the AMA has nothing to do with limiting the supply of physicians.
Reality* limits the supply of physicians, as it limits everything else.
It is tremendoulsy expensive to educate a (good) doctor.
(The best bargain in my life was my UC medical education, in my last three years of medical school, after I’d established my residency.)
I’m sure you could Google the cost, but neither the AMA nor any other “guild” organization — still less the legislature! — could Google that cost away.
I hate these automotive analogies, but here goes: if Lamborghini (sp?) owners were to get together to form an ALA (American Lamborghini Association) in an effort to keep Lamborghini’s in short supply, so that only they, the elite, could own them — exactly what effect would this have on the abundance or scarcity of Lamboghini (sic — Italian plural employed
Jamie Irons
*A very wise psychoanalyst, Don Schwartz, once told me: Reality sucks. But it’s the only game in town.
Great discussion (and surprisingly civil!).
As a physician, I have to take some issue with some of points raised. First of all, while I respect Milton Friedman, and believe in the power the free market, the law of supply and demand only works in a truly free market. American medicine is far more regulated when Soviet state industry ever was. The idea that physicians fees and resulting healthcare costs will magically drop if somehow the AMA loosens up the supply of physicians (which I am not all convinced is done for purely economic reasons, although no fan of the AMA in general) is a fantasy. The vast majority of physicians fees are fixed either by federal regulation or contractual agreement with insurance companies. At the same time, physicians are businesses like any other, with rapidly escalating overhead costs which are beginning to bump against their virtually fixed incomes. The reasons for this have been well described on this discussion, and include spiraling malpractice premiums, unfunded federal mandates such as federal compliance and HIPAA, increasing health insurance costs for employee benefits, as well as a relatively scarce pool of highly qualified employees such as nursing and billing specialists. Opening the floodgates of physician supply will not drop prices, since prices are not determined by the usual supply and demand principles, but rather by federal law and an increasingly monolithic health insurance industry. In my state, Washington, there were over 80 insurance carriers providing health insurance in the late 1980s. There now are three or four. Single insurers now cover huge swaths of the patient market, and therefore did not give physicians the flexibility to negotiate contracts. Increasing the supply physicians would likely result in an increase in healthcare costs, as increasingly desperate physicians increase volume in an attempt to compensate for worsening financial viability. Another myth, is that increasing the supply of physicians will magically alleviate the problem of physician deficiency in underserved markets. No offense to folks who live in small towns, but I somehow doubt that physicians will flock to tiny rural villages simply because the AMA lets more docs be trained.
One last point, which I discuss on my blog The Doctor is In, addresses the uninsured population. I cannot get a home mortgage without homeowners insurance, nor can I drive a car in Washington state without car insurance. The reason is simple: my misfortune or misjudgment forces other people to pay for my problems. It is for this reason that I believe mandatory catastrophic healthcare insurance covering major medical expenses should be introduced. This can be funded for low income individuals by reducing or eliminating the business deduction for employer based health insurance.
Dr Bob
Dave S.
By and large, the profits of the big pharmaceuticals are not an issue to the consumer. Other than, of course, the concern that comes because of negative press from the media and leftist pols who use the pharmaceutical companies, like the rest of the healthcare industry, as whipping boys. Unit cost of medications are an issue, however. Personally, I could care less how much profit Pfizer makes. If they are nice and profittable, I might want to buy their stock, and I am assured that they will be around for a while longer making more medications, which is a good thing. I do care about what my per unit cost of medications are (within reason, let’s not kill the goose that is laying golden eggs), and I do care about whether or not a medication is even available at any cost, or is killed off for reasons other than medical. And that is still largely determined by R&D costs and government interferrence & overhead. After all, the production costs, marketing costs, distribution costs, etc. are still comparatively little compared to the cost of R&D and government interference. And there isn’t anything that can be done to limit the R&D costs short of squelching new product development, and that is not to be contemplated.
Oh, and have you considered that marketing costs are just another form of overhead? I assure you that is the truth. Marketing overhead is not taken from the profit, but is part of the cost of doing business. If you don’t market a product it doesn’t sell. If it doesn’t sell, you can’t make any money, even to cover your other forms of overhead. And that applies to any product, in any industry, not just pharmaceuticals.
Pfizer R&D expenses, from the income statement:
2003 $7.1B
2002 $5.2B
2001 $4.8B
It’s also interesting to note that “cost of goods sold” (manufacturing costs + costs of ingredients) equalled $9.8B for 2003..ie, more than R&D costs. So, while its true that manufacturing costs as a % of revenue are smaller than in most other industries, they are not trivial.
Meant to mention in the above post: I’m a Pfizer shareholder.
Dr Bob makes a good point about the monolithic nature of the current fee structures due to federal regualtions (I did mention Medicare/Medicaid before, didn’t I? I never did mention HIPPA, but that is a big bear, too.) and large scale managed care contracts. My wife has informed me of some real disasters that have happened when some of those large scale managed care providers have gone belly up and ceased payments. Disasterous! It is one reason why her company’s stock took a big hit, as they had to eat a bunch of receivables from this one managed care company that went bankrupt.
Oh, and I’m not at all concerned about the high cost of physicians’ salaries. I WANT my doctors (both of them, my IM and my Cardiologist, as I am in a Cardiovascular high risk group) to be well paid and well qualified! Please, they earn it! They have paid their dues! Part of what we are paying for is their skill and expertise, and I want as much of that as I can possibly get! After all, my life is depending on it — literally.
Charlie,
Yes – Moffett in the big blimp hanger.
And stealing computer time at Stanford.
The P-3′s I flew on didn’t have computers – A and B models.
Photon:
Where does new product startup costs figure in? Where does governmental regulation compliance costs figure in? These aren’t R&D. Well, one could make the case that a goodly portion of regulation compliance cost is shifted to R&D, but I’m not really sure just how that accounts for it. Do those costs get figured into “Costs of Goods Sold”? Those are largely costs incurred before actual production begins, and yet are apportioned throughout the “Life Span” of the product, until patents run out and the medication may or may not be placed over the counter. Isn’t it funny how the price of a medication holds high for a period of time and then falls when the next better one is introduced? Hmm, sorta like microprocessors — it is obvious that the actual production costs are quite low, since they won’t sell a product, even an obsolecent one, for less than it costs to make. Even overseas or in places like Canada. Like microprocessors, R&D costs, marketing costs and other such startup costs push the wholesale/retail prices high until they are recouped. And then the next version comes out and we are at it all over again.
Charlie(C): I am a doctor who puts in appendices rather than remove them
. Health care admin was one of my doctoral field areas thus my interest; also retired army last serving with the JCS as a strategic planner.
All: thanks for a wonderful thread; truly a colloquia in issues of American health care.
With respect to Dr. Bob’s point, I used to feel the supply of docs was artifically constrained, but Dr. Bob has hit the nail on the head: The government, specifically Medicare, is the largest purchaser of health care and the Usual and Customary Rates are what drive all insurance rates. I recently underwent a bout of prostate cancer including both a prostatecomy followed by radiation. The treating clinic and docs were reimbursed at 48% of their charges. Someone is paying for the difference; specifically, all of us because these costs are passed along.
The acceleration of technology is also taking more of a physician’s time: When CAT scanners take more slices, a radiologist has to read more slices: Thus–more precise diagnosis but more physician time. And the hardware is not only expensive but increasingly has a shorter life span.
Some commenters have pointed out the importance of taking responsibility for our own health just as we take care of our cars. Neonatal care, care during the first years of life, immunizations, and annual physicals will go a long way to improving overall health along with the behavioral changes to reduce the top ten causes of death. If single payer options are considered, perhaps they should focus on the very basics of annual examinations.
As someone said above, this is genuinely a system problem and will require a system solution. Sadly, I doubt that our political system can take care of it.
I agree with Dr. Bob about mandatory catastrophic coverage. The costs are paid now anyway – by an uncompensated ER visit, the life savings of a middle class person unable or unwilling to buy that insurance, or the government. Furthermore, the obscene price differential for the uninsured is clearly a signal that our payments system is totally out of whack.
Just imagine you lose your health insurance (more properly termed pre-paid health care) and then are seriously injured or are diagnosed with cancer. Got any assets? If so, the medical system will have them pretty soon, charging outrageous fees (except for some MDs). Then you will have no assets – life savings wiped out. So there you are, maybe still sick, and a pauper. The same situation as if you lived off the state all your life.
I predict that this will be a more and more common outcome as the population ages and more boomers lose insured jobs and are unable to find others.
As to physician pay – they worked hard to get the ability and knowledge to practice, they deserve a good income, although deserve and “free market” are contradictory concepts.
I do have a question for the doctors on here. Why do all doctors seem to be busy all the time? If there were a non-shortage, one would expect that doctors not work obscene hours and it wouldn’t take many weeks to see a specialist.
One more comment…
Pay by what you are worth or own?
That’s a terrible idea. Why should your cost be related to your economic status? We already do this with income taxes and it leads to all sorts of distortions.
I can see providing care to those who cannot afford it, but a graduated (“progressive”) health payments system is seriously nuts.
RogerA:
I agree with what you are saying, at least up until your last point. I do not believe that it is true that our political system is unable to take care it the problem. I think that it is more accurate to say that our political is unwilling to take care of it. They could do it if they had the gonads to do it. It would take upsetting of some apple carts, but it can be done.
John Moore: I will defer to the MDs on your question, but I think we might find that the number of specialities is inversely correlated to malpractice costs.
I think there is a trend in which Nurse Practitioners and PAs are moving into primary care providers–and I think that is a good thing; it makes more efficient use of MD time. As medicine has become increasingly complex it takes increasingly longer to train MDs–Just look at the field of radiology where 30 years ago there were X-rays–period. Now there are any number of imagining systems to be learned.
RogerA:
I do agree with you on the Nurse Practitioners and PA’s. They are a good thing, and do help make better use of the MD’s time. They are like extra sets of eyes and hands for the MD’s. Kudos for them! Unfortunately, there are still many people out there who are scared of them. And then there are those who insist that if they are going to show up and pay the office visit fee, they want to see an MD, not a Nurse or a PA. I think it is something that will have to grow on the consumers. I think that most of your population base are still going to want to stay with their old ways they grew up with and trust until they are dragged — kicking and screaming — into the new ways of doing things.
gb_in_ga: One of the system problems is (IMHO) that we romanticize the Marcus Welby image: and unfortunately, I think that image is predominately in the age cohort that is most likely to be aging! I think the PA/ARNPs are particularly good in prevention and healthy behavior education–In fact, I prefer to have an ARNP as my PCP because they seem to take more time with histories and intake.
John Moore
See my Iron Law Number 1 of the Medical Care Marketplace.
Jamie Irons
John Moore
Further reflection on your last question:
Over 15 years of serving in the same department, it has consistently been true, that though our “service population” (number of patients we’re responsible for) has grown moderately, our number of providers has grown such that it should more than compensate for the higher number of potential (and actual) patients. Yet, in spite of shortening our appointments and doing more appointments per day, and restricting the range of our services (although I am a highly trained and very good therapist, I no longer do therapy, nor do any of my colleagues) we are busier than ever!
This is Jamie Irons’ Iron Law Number 1.
Jamie Irons
Jamie Irons:
I just looked over your 3 Iron Laws, and have a couple of exceptions on the 3rd law. First: Women of child bearing age, especially when actually child bearing, come to the quick realization that they DO need care, even if they are less than 30 years of age. This is the OB/GYN thing. The other is related to the first, and that is that young adults may think they do not need care themselves, but they are very concerned about their children, even if they are less than 30 years of age. This is the Pediatric thing.
Other than that, people in their teens, twenties and 30′s think they are indestructible. And then along comes the 40′s, and with that comes reality…
Wichita Boy
“Most physicians live in an environment where they are treated like Gods all day long.”
Huh?
With all due respect, please, tell me where this happens, any one place, let alone the many places where it happens to “most physicians”.
I am sorry if I get, well, snarky about this, but there is no greater nor more upsetting canard than this one.
If physicians are given deferential treatment, say, in their offices, or in a hospital, it is afterall, their workplace.
In my 20 years of being part of the medical community, whether at a big city teaching hospital, a state psychiatric facility, a rural health clinic, an Indian health service, a community hospital, I have never once, not once, seen or heard anything to lead me to believe that doctors have a G-d-like existence.
Again, with all due respect, see twenty sick, frightened, and desperate people in your office, handle several catastrophic emergencies in a hospital, go back to your office to see another 20 or so patients, go back to the hospital for several more hours, and then take call that night and spend the entire night in the ICU or ED and go back to your office the next morning for an office full of patients (and phone messages from your sick and frightened patients)..
It is not an easy job, even when it is an easy job.
It is not a desirable job, even when it is a desirable job.
For many, medicine was once a calling, now it just damn hard work.
Pity.
gb_in_ga
You’re entirely correct, of course, and the Iron Laws, being iron, are brittle in just the way you describe.
As I said when I first introduced them, I don’t mean them to be taken too seriously, and certainly not literally; I think they are merely a useful heuristic device to call attention to certain relatively intractable features of what we’re up against.
Jamie Irons
RogerA
No, when your physicians are paid only 48% of their charges, and you are a Medicare recipient, your doctors do not get the other 52%.
The physician fee schedule is artificially inflated because of this.
Most physician practices collect somewhere around 55% of their charges (some more, some less).
Of this, overhead is usually about 50% (practice are very expensive to run and it is also expensive to collect money from insurance carriers as well as patients).
After taxes and the like, your doctor only ever sees about 10-15 cents on the dollar, if they’re lucky.
And as far as doctors being rich, yes some physicians today still pull in seven figures (plastic or cosmetic surgery, some urologists, ENT, and anesthesiologists), maybe 1-2% do. The average for medical specialties is variable, GI $300,000 or so, Non-interventional cardiology is also somewhere in $300,000 range. Internal Medicine averages around $175,000, Neurology $150,000, Family Practice $140,000, and so on. These are rough numbers, and they do vary be region.
These are big numbers yes. But so are the costs in training (included in this are the many years of deferred income), high personal and economic risks, including but not limited to, burn-out, divorce, suicide, depression, substance abuse and dependency, and litigation.
And no, I am not suggest anyone pity their doctor. But be aware that the complexity of care is ever increasing, as are the administrative, legal, and regulatory constraints of practice and practice management.
It may be easy to blame the people who provide care, manufacture health technology, pharmaceuticals, third-party payers, etc. for the high price of health care.
But the truth is that health care costs are first and foremost dependent on people maintaining their own health, and for the fact that we will all get sick, and most of the health care costs we will ever use will be spent preventing us from dying.
The solution must come from restructuring the entire system.
AHH Healthcare. Too Many Experts. Head Hurts. BEER!!! Hmmmmm….
As to blaming physicians for the state of our medical care system (and they (we) do deserve some of the blame), Kafka has a wonderful story, “Der Landartzt” (“The Country Doctor”).
At one point in the story, when the patient is lying in bed with (IIRC) an open wound in his side, the villagers outside the window chant (again IIRC):
Und heilt er nicht, so totet ihn,
‘S nur ein Artzt, nur ein Artzt.
And if he doesn’t heal [the patient], then kill him;
It’s only a doctor, only a doctor.
(Forgive my recollected German, it’s been many a long year.)
Jamie Irons
Jamie Irons:
Yes, I understood. And yet these exceptions are large enough, and significant enough, that 2 large medical specialties are largely devoted to those very groups. And to a significant extent ER and trauma focuses on this group as well. Of course, nobody goes out of their way planning to use them.
But your point is well taken about the young not really wanting to participate in the system. They think it doesn’t apply to them, but it does. Either when catastrophic illness strikes them down in their prime (like my first, late, wife) or when they finally get to their 40′s and reality raises it’s ugly head.
gb_in_ga
As to the young (I was once one of them, and I fathered four more!):
They discount the possibility (understandably) of illness or serious injury.
Unfortunately, the rest of society cannot discount that possibility.
We all have to pay (as indeed we should) when things go wrong.
Reality again.
This aspect of reality is (in populations) highly predictable.
It is an astonishing fact that in the county in northern California where I work, for example, there are (almost exactly) 13 suicides per year, year after year. Doesn’t matter how good the economy is, or who is president, or how well the Giants or 49ers are doing, or how many innovations Silicon Valley is producing.
Same with the incidence and prevalence of STDs, tuberculosis, AIDS and leukemia.
So how do we persuade the immortal young to pay into a system to take care of these problems, when they have the (reasonable) expectation that lightning will not strike them?
Jamie Irons
Jamie Irons:
And now you ask one of those $24 dollar questions. It is one of those questions that we have had since the dawn of time. How to convince the young that they are not indestructible until it is too late? And how to convince the young that they are actually part of society and should therefore wisely contribute? Or for that matter, how to convince the young to be serious at all?
There are times when the young surprise us, and rise to the occasion. But those tend to be the exceptions rather than the rule. And are not to be expected. I know, I know, I sound like a total cynic on this, but it sure seems that way at times. While I am not at all in favor of compulsary insurance or any other form of coercion, it may be necessary to start a nice, large PR campaign (publicly funded? Again, I don’t like using tax dollars but I don’t see any alternative at this point) that would go to educating the young adults that there is always the possibility of catastrophic illness or injury, and that participating in group insurance or managed medical plans is in their own best interests. At least, if you put it that way — that it is in their best interests — they may voluntarily start increasing their participation. Similar PR campaigns have been directed toward that demographic pertaining to drugs and tobacco usage, and they appear to have some success.
I have come to the (very anti-conservative) conclusion that catastrophic health care coverage should be mandatory, just as auto insurance is. Without that, the most healthy cohort will not be fully represented in the risk pool.
Combined with that is a requirement of no medical underwriting for that insurance (i.e. guaranteed insurability).
The first solves the problem of adverse selection.
The second solves what I called perverse selection.
The Bush HSA’s are a step in the right direction, and folks in the payment industry think it will be a big deal. But without the two requirements above, already sick people will be outside the system, which is a very, very unpleasant and financially dangerouos place to be.
Required coverage results in the young supporting the older. That is necessary in any system and happens today (although in some countries the rationing of life saving procedures is extreme, so the old are allowed to die when in the US they can have many more years of healthy life).
If you look at a large company, there will be lots of healthy young people. To start with, people with certain illnesses are unlikely to be employed. An insurance company will take that company and give it a good price.
Now look at a middle sized company with one high-risk person. The insurance company will offer two rates – with and without that high-risk person. This is called lasering. How many people are losing their jobs (and after 18 months, their group coverage) because of this? It’s invisible. My employer chose to self-insure a breast cancer patient to avoid driving up the cost for eveyone else. This is insurance?
Now go start a little company – toss in a few friends. Oops… fred once was treated for depression. You can buy insurance but not for fred. This happened to me once – I was buying health insurance for a startup.
Get layed off at 55. Try to buy insurance. If you have pre-existing conditions (pretty common at that age), you will either not be able to buy it, or you can buy insurance that will cover everything but what you have (so if you have high blood pressure, it won’t cover heart attacks and strokes). And this doesn’t even consider the price.
The health payment system is illogical and immoral (and furthermore, a worry for me personally). The market will not deliver in any scenario I have considered. Health care is not like ordinary commodities in that certain care is going to be purchased, regardless of cost. HSA’s can reduce the tendency to overutilize care (put another way – copay’s are a great idea for insurance companies because they significantly increase the money flowing through the system).
Metoothen: Sorry–I didnt mean to imply that Docs were somehow beating the system–I was trying to point out that the Government is the biggest buyer of health care and as such their pricing schedule controls the market–Docs, hospitals, and everyone else has to try to recoup their costs.
The cost of such things as health care privacy add layers of bureaucracy just to maintain government mandates; the accelerating pace of technology forces providers to upgrade their capital investments to keep pace with good health care practice, probably long before they have recovered their sunk costs.
Please understand me: Docs and hospitals are not the villans in these piece. Add to some of the above issues the notion that consumers of health care services fail to distinguish between needs and wants and the failure to make the crucial distinction inflates health care costs.
I think there are some potential bright spots. One would be the internet. During my bout with prostate ca I found webMD to be an invaluable resource; it provided really good information to assess options with my urologist. I dont know how many consumers use webMD or similar sites, but clearly the internet provides basic information that permits consumers to lower the transaction costs when confronted with a health care decision.
Again, sorry if I implied that physicians were somehow gouging the system–they are not. The problem is a market problem introduced when their is a singler buyer who can control the market–and that would be the US government.
I lived in Canada as a teenager from 1979 – 1981. I developed a cyst in my left wrist. I had to wait 3 months for this simple outpatient surgery. During that time the cyst continued to grow and was very painful.
Compare that to health care in the USA and there is no contest. The falacy is that anyone in America is denied health care. My mother is unemployed and uninsured. Two weeks ago, she had surgery to remove a tumor growing behind her eye. Just this afternoon, my sister called to tell me she was being taken from a follow-up visit to the Emergency Room because she had a blod clot in her leg, and they wanted to make sure to get it removed before it dislodged and caused a heart attack.
Now, despite her uninsured status, she had been able to get medical care. Has it been more inconvenient to wait at the county hospital than in a cozy private practice? Yes. Has she had to turn down some offers of employment because she had to take care of her medical problems first? Yes.
But the point is she was NOT denied service despite not having insurance and also not having the personal resources to pay for her care. And all of that has occurred and is occurring in the fascist state of Texas – go figure.
gb_in_ga: You raise some excellent points about health care education. I am not willing to write off the young; I think healthy lifestyles messages do work. For example, the incidence of smoking based on the recent BRFSS survey suggests people are quitting smoking at significant levels. But attitudes do die hard. We are trying to fluoridate the water in county jurisdictions and it is meeting with tremendous opposition. Frustrating often, but I think good public health messages are valuable tools to improve overall health–the anti-smoking messages appear to be working and I think public health messages may be an overlooked and underutilized component of good health.
To put things in perspective, however, in my rural county in eastern Washington state, the public contribution to public health district comes to $1.01 per citizen per year! We dont have a hell of a lot of capacity.
I have a bit here How the drug companies use government to steal from you. This is the context of the drug war. It is also probably true in other areas of medicine.
I quote Benjamin Rush a signer of the Declaration of Independence.
Drug companies are suppressing medical research to increase their profits.
Yes they do good. And they do it because it is profitable. They are very far from honesty about their methods. Very far.
I have a bit here How the drug companies use government to steal from you. This is the context of the drug war. It is also probably true in other areas of medicine.
I quote Benjamin Rush a signer of the Declaration of Independence.
Drug companies are suppressing medical research to increase their profits.
Yes they do good. And they do it because it is profitable. They are very far from honesty about their methods. Very far.
John M:
Yes, you have a good point on it being extremely difficult to get insurance if you have a pre-existing condition — even one that is adequately treated and is no longer a long term risk. That is the situation I am now faced with — I am in my late 40′s and one of those programmers found stranded without meaningful employment and with a pre-existing medical condition. Never mind that the condition is completely controlled with the existing treatment regimine. It is still an impossibility to obtain non-group insurance. Thankfully, I am covered under my wife’s group plan, so it is not an immediate problem. But it is a concern. And it certainly does not help in trying to find a new position, even though I am quite willing to completely forego coverage due to my wife’s group policy.
However, I am still not in favor of compulsary, coercive health insurance, ala mandatory automobile liability insurance. It just rubs me wrong, government really shouldn’t be forcing people to do that sort of thing. It is a slippery slope thing. Maybe there needs to be some sort of publicly available group health insurance where the carrier HAS to accept anyone who desires it, but I don’t see how the cost of that sort of policy wouldn’t be excessive. Short of cost controls, and that is a road best not travelled, we know that price controls cause more problems than they solve.
The HSA’s are a good idea, but you still have the problem of coercing the young into participating. And, how do you gracefully implement them for those already in need of care? The assumption is that the savings have already been set aside, but for those of us already at the age of need haven’t had time to accrue those savings. So, it is a good long term solution that doesn’t solve the immediate problems.
And we really don’t need to create ourselves a “Medical Social Security” type of system, where the young are taxed (like, with “mandatory government health insurance” for instance — waddles like a duck, quacks like a duck, it’s a duck) to support the elderly — it would just become another Social Security style boondoggle that that ultimately collapses under it’s own weight when the demographics become top-heavy, like they are starting to do now. Nope, bad idea.
I work for a Home health care agency and it seems to me that adminstrative costs are requiring too much of the health care dollar. For instance a nurse in our company may make $23 an hour, but the company bills $84 an hour. And that is in an area in which costs are thought to be less.
Let me see if I can get the link to work this time:
Drug companies steal from you
If you have not yet been diagnosed and prescribed/treated, or if there are improvements on the horizon for your illness, then you want to be in the US medical system. Once you have been correctly diagnosed and prescribed, you would then want to move to a country with socialized medicine.
Political ads about people who need certain medicines and can’t afford them are all drawn from the population of persons already diagnosed and treated. Their needs are legitimate, but they are only part of the picture.
BTW, there is a growing contradiction on both sides of our current liberal/conservative dynamic: pro & anti stem cell research, pro & anti pharmaceutical companies, lots of folks seem to hold contradictory views.
Terrye,
A markup of 2.5 to 3X is not unreasonable. Don’t forget. Your office needs to be paid for. The building heated and cooled. Phones need provision. The admin needs to get paid. The parking lot for your car needs to be resurfaced from time to time etc. Some one needs to track to see if you are following regultions and must submit the paperwork to you know who.
In the industry I work in (custom electronics) the markup is 4X.
Until you have done a business of your own you have no idea.
Roger A,
Every 10% rise in the cost of cigarettes increases overweight by 2%.
There is no free lunch.
M Simon and Terrye: both of you have excellent points: media discussion of health care issues invariably fail to cover the overhead costs of health care–in economic terms the fixed costs–and all too often it is the government that adds to those fixed costs by mandating procedures–the privacy act madness is one such mandate, but there are many many more as any provider could tell you.
Scott H:
Fascist State of Texas? That’s not the Texas I know and love. I’m an ex-pat Texan “stranded” here in Ga. While Ga isn’t all that bad, I’d still go back “Home” at the drop of a hat, if I had the chance. Oh, well, the wife’s job has us here and so here we are.
But seriously, folks — Texas is nowhere near as backwards as most people who have never been there perceive, as you likewise allude to in your post. For the most part, there are a whole bunch of incorrect, misleading stereotypes about Texas and Texans.
M. Simon, I’m no more in favor of Prohibition for drugs than I would be if we still had Prohibition on alcohol, but I’ve got to say, your argument kind of escapes me (read: it’s nuts.)
I know a fair lot of doctors, and being an descendent of the autochthonous Americans I’ve got more than a little acquaintance with people with substance trouble.
I’ve heard the “self-medication” theory of addiction before, and I’m very unconvinced — although I’d love to hear Jamie’s take on it. I will say, however, that I don’t know of many MDs who don’t approve of medicinal marijuana, and I’m not aware of any particular interest in the War on Drugs among pharmaceutical companies — just among the puritan element who are “afraid someone, somewhere, is having a good time.”
Given that your argument appears to depend primarily on the notion it’s the Medical Establishment and the pharma companies behind marijuana Prohibition, it’s not off to a great start.
Fascist State of Texas? That’s not the Texas I know and love. I’m an ex-pat Texan “stranded” here in Ga.
Uh, GB, I think that was sarcasm.
M Simon: precisely–there is no free lunch–I am fundamentally a biostatitician–I can tell the public what the aggregate costs are of doing X or doing Y. It is one thing to know that the incident rate of having prostate cancer is 17 per 100,000 in Grant County, WA. It is another thing to realize that you are one of the 17! (been there done that)
To create reasonable policy, however, policy makers must focus on the large impersonal numbers. Unfortunately, the open source stories of the media focus on the individual; and, while those stories are tragic, they are, nonetheless, not a good basis for the creation of public policy.
I don’t mean that to be unfeeling or harsh. Public policy makers must focus on the aggregate statistics and set aside the personal stories, no matter how tragic or heart-rending.
John Moore,
The only way to beat the problems you speak of is a willingness to die when we are costing more than we are worth.
We owe it to our children.
You were planning on living forever?
Charlie (c)–re your OT idea, please contact me off blog.
You were planning on living forever?
Well, yes, actually.
RogerA
Thank you for your kind remarks.
And no, I did not think your previous comments were inflammatory or derogatory.
If my post suggested otherwise, please forgive me.
I was only trying to explain how the system seems to work from the physician side.
gb_in_ga,
I understand well your situation. In our practice we are all self-insured. Our practice is too small to economically justify a group plan. We pay low monthly premiums and have high deductibles (ranging from $5,000-10,000) per year. Coverage is available but at a cost.
And yes, mandatory catastrophic is unsettling for many, as a State intrusion in the liberty of the individual. Fair enough. But as a policy issue it is in line with precendents set in other areas.
Scott Harris
You points are well taken. Look at what is happening in Los Angeles County. The county hospital system is collapsing with the closing of hospitals due to the unreimbursed costs of care of providing care for the uninsured (many of whom are illegal aliens).
Teaching hospitals are under similar pressures. Much of the care provided is not reimbursed. Some of the cost of providing care was relieved by the savings by employing house staff (residents). But now, residents can no longer work more than 80 hours a week (yes, that is a reduction!).
M. Simon
Charlie:
I’m well aware of that. And I was being sarcastic as well. But, you see, there are SO many uninformed out there, and SO many who take any sort of opportunity to take potshots at us, that I instinctively come to my homeland’s defense when anything of that sort comes around. And, if you’ll note, I give him the credit for not buying into the stereotypes. His post is actually a stereotype debunker, and I heartily approve of the message he brings. I’m not at all miffed by what he had to say, in other words. I was just being pre-emptive.
Charlie(Colorado),
Since you haven’t read my article(which has actual refrences disputing your points) let me give you the short form:
Marijuana could replace a significant proportion of the anti-anxiety drugs on the market. That is a $40 bn a year market. It also turns out that pot might help in tumor reduction and alzheimers.
Now guess who some of the biggest contributors to the “Drug Free America” campaign are?
When the costs of the drug war finnaly are tallied you will beappalled. It is not just the folks in jail. Or the thefts to support inflated black market prices.
BTW the largest association of Drug Councillors in America agrees with my evaluation of drug use.
Let me start you off with a question that will solve all our drug problems if answered: What is addiction? (my thesis is people take pain medication for pain).
In any case check in on my site over the next few weeks as I plan to re-run all my drug war articles.
MeTooThen:
So, what you are saying is that since we have already started down the slippery slope of government coercion, that makes it ok to continue down that slope? Nope. That dog don’t hunt.
Just because we did something unwise in the past doesn’t make it Ok to use that as an excuse to do likewise now. It was unwise then, and is unwise now.
On the topic of the supply of doctors vs the amount of time doctors spend working, I think there’s a perfectly plausible market-driven reason for the issue that doesn’t have to do with an under-supply of doctors, which is that the out-of-pocket cost of medical care isn’t very strongly connected with the real costs. If the insured had to pay a $100 fee for a doctor visit, instead of a $10 co-pay, I suspect that internists could go back to playing golf on Wednesday afternoon.
Similarly, if the internist got to keep the $100, instead of getting $48 because of the insuror’s policies, they might be more willing to spend more than ten minutes with you.
As I noted above, in effect, the insured get their insurance paid for with pre-tax dollars; as was noted elsewhere, the insurors use their near-monopsony to compel lower prices, which then drives up the cost to others with no monopsonaical powers. What’s more, the fact that medical providers are compelled to provide care to the uninsured adds even more to medical costs, which are then passed along to the uninsured.
RogerA, maybe you have the numbers at your fingertip, but I’d be very interested in trying to figure out what the actual costs would be in, say, a system in which there were a statutory upper bound on malpractice awards, where everyone was expected to pay for the regular doctor visits — but on a pre-tax basis, just as the corporations do — and in which there was an “insuror of last resort” to provide catastrophic-illness coverage to evreyone who doesn’t have it otherwise.
My suspicion is that the real result of this would be to reduce costs dramatically.
M. Simon: I am basically a libertarian at heart. I believe that were we to decriminalize drugs and get into the drug provision business, we would probably be better off from an overall economic standpoint; viz, we would reduce common crime, prostitution, and a host of other societal problems–I suspect that no matter how draconian our punishments there is some small percentage of people who will be engage in risky behavior. IMHO better to control that behavior than expend the resources to arrest and prosecute it.
Having said that, I remain unconvinced that marijuana use is any more safe than tobacco use–it is probably a carcinogen, and the dose rate. if smoked from street supplied grass, cannot be conrolled. Were it to be provided to the using “community,” the best I could see would be some USP variant of the active ingredient THC. No toking on a doobie in other words. I dont believe for a second that MJ is benign–at best it has the same risks of tobacco, and at worst, it is a psychotropic and that cant be real good.
John Moore: The P-3′s I flew on didn’t have computers – A and B models.
Okay, they were flying D’s when I lived there. 78-83.
Charlie (C)–Sorry, I dont have those figures available, but you raise a very significant question. And a question whose answer does appear to be along the lines you suggest. I will have to scramble and do some research. Will get back to you ASAP.
No, M. Simon, I did read your article; that’s how I knew that you were arguing for a self-medication model for addiction, and for the notion that the drug companies were behind the War on Drugs.
As far as the self-medication model goes, it’s either unpredictive or vacuously predictive: either it makes the claim that only people in some kind of overt pain become substance-dependent, or it asserts that the addicted must have had some kind of unresolved pain by the very fact of having been addicted.
On the other topic, merely noting that pharma companies contribute money to the War on Terror doesn’t imply causation. There are several good reasons they might choose to involve themselves in the WoT in order to insulate themselves against, for example, the accusation that they weren’t paying for the War on Drugs.
John M.,
I hate to tell you this but alcohol is an “adictive” drug. Tobacco is an “addictive” drug. Why do they get a pass?
In any case your studies of brain chemistry are behind the times.
Research is refuting all your points. i.e. every thing you know about “drugs” is wrong.
People in chronic pain chronically take drugs (or alcohol, or overeat, or over sex – any thing to get the receptors filled). Why is that so hard to understand?
It is not a moral issue. Just because society and medicine do not recognize how our bodies actually work is no reason to stick with failed dogma.
The keys are genetics and an understanding of PTSD.
The genetic component? Pain memories decay faster for some than others. Which is why after trauma many people drink to excess or otherwise self medicate for a few weeks until the pain wears off. The problem is that because of their genetic constitution, for some the pain never wears off. Or wears off very, very slowly. (5% of all heroin addicts quit every year without treatment. With treatment 5% a year quit. Obviously treatment means in this context making the patient comfortable. Not cure. i.e. treatment as it is now presented is a scam.)
Give up your DEA talking points and do some research. Or if you can’t wait answer me: what is addiction and why can’t it be cured? Why is treatment no better than doing nothing? Is PTSD a moral failing?
Before you start your rant again look up Dr. Lonnie Shavelson and tell me what his work means in your context.
It is the end of phlogiston science re: addiction.
People chronically take pain medication for chronic pain. The fact that medicine does not recognize drugs as a treatment for PTSD is proof of nothing except ignorance. Ignorance is a lot easier to dispell if it is not tied to belief. When it is tied to belief you often have to wait for the true believers to die off before change can take place.
It is why death is so important for humans. It is part of the learning process in every way.
Can anyone tell me what high-deductible catastrophic-care insurance actually costs?
Actually JM the model is predictive. I could if I had the research money predict who will become a long term addict.
1. Find those with the genetic susceptability
2. Check out their level of trauma
That will give you with a high degree of confidence who will become addicted. I can tell you who. At best the addiction theory can tell us how many (what percentage).
Now what can your theory predict? Can it predict who will become an addict?
My model is falsifiable. Is yours?
For this study (given that there is a war on) I would evaluate combat veterans. Which is how we learned about PTSD in the first place. Funny thing is our Army is doing just such a study with results due in another year or three. The Israeli military is already doing research into the connction between drug use and combat. There is a connection. In fact it is a cliche. The hard drinking combat veteran.
The military wants drugs that will allow kills without remorse. That would give us more than the 4% of the population who actually fire their weapons into the enemy in combat.
Not at this time, but my husband will be looking into it. I read, but didn’t save, the article that big corps are looking into the HSAs, possible target date of 2006.
gb_in_ga
I am not so sure it is a slippery slope.
There are different ways of measuring the cost or value of governmental intrusion into our lives.
I don’t see it as a slippery slope. You perhaps do. Fair enough, again.
One way or another, ultimately we all pay for our nation’s health care, whether through our own health insurance premiums or through the taxes we pay.
How best to distribute the costs of providing health care to our nation, or what the structure of those payments will be is open to debate.
I do not take the position that eliminating all State intrusion is either necessary or beneficial. I take the classical-liberal that view that government as necessary but inherently dangerous (I swiped this from Shannon Love, OT, but here).
Again, this is debatable, but I prefer mandatory catastrophic insurance to the alternatives.
Scott Harris ó The National Health in the UK just killed a very talented and nice old lady I knew. Actually, they had two shots at her and took both. The first time she went in, she was told she had a hole in her cornea and was told she would have to wait six months for an operation. This, to a nationally renowned costume designer for movies and stage whose eyesight was her livelihood. The second time she went back for a physical she was told, “Oh, yes, you have lung cancer. Come back in three months and we’ll see how you’re getting on.” She’s dead now. But their paperworkmis filled out just so.
Government medicine here in the states just took a crack at a friend of mine, whose health has been getting progressive worse for years (serious thyroid problems). But there is, apparently, ONE doctor in Waukegan who is authorized to certify people as disabled for the state, and he is notorious for not doing so “to keep costs down.” My friend finally came up with an excuse to get to Cook County in Chicago; they took one look at her and bundled her into ICU for a week to treat her congestive heart failure that horse leech had been overlooking. If that quack had done his job, she could have been treated for far less than it cost to hospitalize her. But hey, all his paperwork is in order.
If we’re going to have state-supplied medicine, and I believe we have a moral obligation to our neighbors to provide at least a survival-level of urgent treatment, we must nevertheless find some way to administer it that keeps it out of the hands of the kinds of people who run DMV offices.
The falsifiable comment should have been directed at Charlie (Colorado).
What I’m saying Charlie is that I can predict in advance at a high confidence level which combat vets will become long term addicts or otherwise have severe long term problems with the combat experience.
Can you?
It ought to be easy (given the $$$ and about 4 or 5 years) to prove or disprove my theory.
Fortunately the research is underway (other studies suggested this line might be profitable). Be prepared to change your mind. Be prepared (all you drug warriors) to ask forgiveness from those you have unjustifiably persecuted (those in pain). Well given that the Kerry performance is no human abberation an apoogy would be a bit much to ask for. I will settle for the usual. Silence.
MeTooThen:
My impression of the viewpoint of the “Classical Liberal” has always been that the best government is that which governs least. It is the model where governments push the maximum freedom (read: Liberty, as in Liberal) and personal responsibility on the individual citizens. It is that which minimizes coercion to the least amount necessary to provide for defense against external threats, to provide for internal defense against criminals, and to provide a viable framework for the orderly conduct of business with minimum interferrence. And that’s just about it. It is that model which is promoted by the Libertarians of the big “L” variety. I’m not quite to that point, but almost. And then 9-11 came along, and I left that camp due to their moonbattery. But I digress. What you suggest — government mandatated catastrophic health insurance — does not fall into any of the categories that the “Classical Liberal” would agree are justified jurisdictions of the government, at any level of government. That would fall under the heading of personal responsibility of the citizenry as individuals, and is the viewpoint that I take. Sorry, it just isn’t the government’s business to see to healthcare. It is a personal responsibility. Just because the government has intruded on that turf in the past doesn’t make it right, and certainly isn’t reason for further intrusions.
The drug war is not driven by science or reason.
It is only money holding it together.
Police salaries and overtime. Rent seeking by drug companies. Prison guards needing work. Towns where prisons are the sole industry. etc.
There is zero proof that our current line on drugs helps. We have a lot of evidence on how it hurts.
Charlie (8:21 PM)
Charlie, this is profoundly true!
(It could be thought of as a corollary of Jamie Irons’ Second Iron Law of the Medical Care Marketplace)
If we are made to pay for what we (say we) want, we will (seem to) want less.
As a resident learning psychoanalysis from Bob Stoller (see his classic “Sexual Excitement”) I thought it cruel to believe that patients would only benefit from their therapy if they were made to pay for it (even if on a “sliding scale” for the indigent).
How naive I was!
Jamie Irons
M. Simon
I mean no disrespect.
There is some truth in the view that the War on Drugs “creates” rather than solves the problem it is trying to address.
But if you know a lot of drug abusers up close and personal, as I do, you learn that there is an irreducible moral element to the problem of drug addiction, and trying to explain that away by appeals to drug addicts somehow being helpless in the face of their pain is ultimately a disservice to the people that you are purporting to help.
When I was a second year medical student I had an memorable encounter with a heroin addict. “Doc,” he asked me, doing me the favor of pretending I was a real doctor already, “Do you know how to tell when an addict is lying?”
“No,” I replied, honestly and innocently enough.
“His lips are moving.”
While my little vignette hardly captures the immense complexity of the addiction problem, I think that addict’s bedrock honesty goes a lot further toward illuminating the problem than many of our efforts to legislate or theorize away the moral dimensions of addiction.
Jamie Irons
Here is my ideal study.
1. Find a large group of heroin addicts.
2. Find out the DNA differences between this population and an “average” population.
3. Once the DNA connection is known pre-screen combat soldiers (double blind)
4. Develop an intensity of combat questionare
5. Do field studies (the questionare) after each combat incident
6. Follow up the vets for at least 5 years.
Now any of you who believe the current model:
Design a similar study to verify your model. Show me.
Now answer this question. Why are female heroin users overwhelmingly (the Shavelson study) victims of child sexual abuse? Is that predictible given the “addiction” model. (i.e. drugs are addictive – don’t do them).
The abuse connection is why only about 50% of those with the required genetic make up are addicts. Studies show that “addiction” is only 50% heritable. The other 50% is accounted for by trauma.
DNA is why some people don’t “get over it”.
J. Irons,
Why do addicts have to lie in America?
Why did Jews have to lie in Germany?
The lying is not a function of the drugs. It is a function of the persecution. The above refrenced url goes into a study on the paralles of Jews in Germany and drug users in America.
Why do addicts lie? Because pain relief is more valuable to them than truth. Severe aversion to pain is not unknown. It is the basis of torture.
Now I do believe intervention may be able to cut montths off the cycle by introducing drug reductions as the pain receeds. However, trying to get an “addict” to quit before the pain dies down is hopeless.
BTW did you know that according to the latest DEA reports that it is impossible to tell those in “real pain” from the “addicts” just by their drug seeking behavioirs? People in “real pain” will lie and Dr. shop to get relief. Just like addicts.
The DEA pdf on pain relief. or this faster loading review.
Stressed soldiers to be treated with cannabis
M. Simon
Why did Jews have to lie in Germany?
I have to say that as a Jew I find the implied comparison here unbelievably offensive.
What in G_d’s name does the situation of Jews in Nazi Germany have to do with the problem of addiction?
Jamie Irons
M Simon
If I am giving DEA talking points, it is pure coincidence. I am, however, tired of people pushing marijuana as some sort of magic elixer.
I am well familiar with the mechanisms of anxiety. The idea that drug prohibition is caused by drug companies is tin foil hat thinking.
Look at the polls. There is overwhelming support for the drug war. As I said, i disagree with that war. However, I also disagree with pro-marijuana arguments. Marijuana is just one of a number of psychoactive plants which happened to become very popular. I guarantee that it is not an anxiolytic for some people. Furthermore, when good, well understood, high purity anxiolytics are available at low price from generics makers (not big pharma), one would be silly to smoke a joint for anxiety relief.
Marijuana is a good intoxicant. For some diseases it may have medicinal value. I have never heard anyone propose it for anxiety.
You ask about alcohol and cigarettes. Both do great damage and are legal. This fact is utterly unrelated to the legality of cannabis. It is a rhetorical point, a discrepancy in the laws – so what?
If you want to do some good, get the DEA to stop harrassing doctors who prescribe large quantities of pain medication to patients who need it. Too many Americans suffer too much pain because of DEA’s policies.
As to your theory of addiction, it’s old stuff, and it doesn’t stand up as a complete model. Some people are addiction prone to certain drugs due to differences in numbers of brain receptors or differences in neurotransmitter levels. Having been addicted to nicotine (which is addictive to a high percentage of people), I know where that addiction came from, how it worked, and how I ended it.
PTSD, by the way, is a fad disorder in the psychological world. Although it is a real disorder, it is also easy to fake.
What I’m saying Charlie is that I can predict in advance at a high confidence level which combat vets will become long term addicts or otherwise have severe long term problems with the combat experience.
Can you?
No, but then …
It ought to be easy (given the $$$ and about 4 or 5 years) to prove or disprove my theory.
… apparently neither can you. You’re asserting your theory as fact and then in the very next graf you’re saying “and I could prove it.”
Here’s a little hint, M. We’re talking about “science”. In “science”, we don’t assert as true an untested hypothesis.
But then…
I could if I had the research money predict who will become a long term addict.
1. Find those with the genetic susceptability
2. Check out their level of trauma
That will give you with a high degree of confidence who will become addicted. I can tell you who. At best the addiction theory can tell us how many (what percentage).
… you apparently don’t believe that self-medication is the only reason for addiction either.
Now this actually makes sense — the notion that there is both a genetic susceptibility AND some precipitating event or history. It also fits with the fact that a lot of people have lengthy opiate therapy for severe pain and don’t develop an “addiction” in the normal sense.
Now what can your theory predict? Can it predict who will become an addict?
My model is falsifiable. Is yours?
I must have missed the place where I proposed a model.
Fortunately the research is underway (other studies suggested this line might be profitable). Be prepared to change your mind. Be prepared (all you drug warriors) to ask forgiveness from those you have unjustifiably persecuted (those in pain). Well given that the Kerry performance is no human abberation an apoogy would be a bit much to ask for. I will settle for the usual. Silence.
I swear, it must be “Silly Assholes Free Internet Day” at the day care center or something.
I admit I’m not as insulted as I was by the loonie who implied racialist motives, but still, I defy you to find anything I said favorable about the wWar on Drugs. While you’re looking, I suggest you read the part of this thread in which I talked about Prohibition. If it wasn’t clear, I apologize, and will now clarify what I meant: I am absolutely opposed to prohibition, and feel that adults should be permitted to buy whatever drugs they want.
But then, considering that you almost immediately resorted to the ad hominem circumstantial, and considering your obvious confusion between an unproven theory and a fact, I suspect that you’re actually not tall enough to ride this ride.
M. Simon:
If you are trying to show the PTSD leads to drug addiction, you have to show not that some combat veterans become addicts but that there is a statistically significant difference between combat veterans and the rest of the population. My guess is that you will find that opposite occurs at least in today’s all volunteer force.
It also seems that you still buy into the big lie about Vietnam Vets. Former SECNAV James Webb has repeatedly shown that Vietnam vets have a lower rate of psychological problems then WWII vets did. The reason: Vietnam vets spent less time in combat and for the most part had less intense combat experience.
Jerry, I think he’s trying to argue instead that addiction as an outcome is likely given both a genetic predisposition and some history of physical or emotional trauma that leads to self-medication.
Not that he’s doing a very good job of it, but I think that’s what he’s trying for.
The problem with that is that it’s pretty much vacuous — not that it isn’t predictive, but that it isn’t any more predictive than the null hypothesis, nor than a pure genetic predisposition model.
The difficulty is that it’s almost impossible to find someone who hasn’t got a history of significant physical or emotional trauma by 20-25 years old, and — since people with a genetic predisposition to addiction tend to have chaotic and abusive childhoods — the supply of people who dno’t have both predictors is awfully large.
This is not to say that his theory is necessarily implausible, but it would take a big-population study with some awfully subtle controls to distinguish among the various potential mechanisms.
I agree with you, though, that he seems to be falling for the “druggie vets” myth, and that Webb’s data is actually a counterargument to his model.
M Simon:
I find that I must agree with Charlie on this one. Your arguments ring hollow.
But I am still opposed to the war on drugs, and I do this on 3 bases.
First, I am ideologically opposed to the war on drugs as it is an affront on personal freedom and responsibility, as the use of intoxicating drugs has no bearing on internal security, external security, nor has it any bearing on the orderly conduct of business as a whole. I feel that people should be able to engage in activity that is harmful to themselves as they choose, as long as that activity harms nobody else (except, perhaps, their immediate family). Ergo, if you want to be dumb and do something that harms yourself, knock yourself out. Just as long as nobody else is harmed and I don’t have to pay for it. Oh, and just because your activity may be harmful to the business you work for is not reason for government coercion, either ñ the business can take care of it’s own, they can fire you if they wish. Again, it’s not my problem, unless you decide to run me off the road or something. Then I’ll see you prosecuted for harming me. The whether or not drugs (or alcohol, for that matter) were in use is immaterial.
Second, on a practical basis, I am opposed to the war on drugs as there is too little return on investment ñ this war is a rathole to pour our hard-earned tax dollars down with nothing to show for in the end. We spend our taxes to halt illegal drug use, and yet we still have illegal drug use, and have had for quite some time. Stupid waste of money.
Third, on a practical basis, I am opposed to the war on drugs because the illicit status of the drugs combined with the desirability of these drugs has created a sizable and powerful criminal class dedicated to production and distribution of those drugs. A similar criminal class was in place a century ago dedicated to the production and distribution of alcohol. Like alcohol, the substance is not the inherent evil, but the gangsters who are producing, smuggling, and distributing the product turn out to be among the most ruthless and violent thugs of their day. Like with alcohol, the obvious means to put these thugs out of business is to legalize the product that form the basis of their business. In other words, if the drugs are legalized, they won’t have to be smuggled, and if there is no smuggling to be done those thugs will have to find something else to do, like maybe something constructive for a change.
You will note that I do NOT advocate the legalization of currently illicit drugs for medicinal purposes. This is no oversight. While it may be true that certain illicit drugs may have valid medical uses ñ for that matter many most certainly do ñ in many if not all cases there are better, currently legal alternatives available. That is, with the exception of certain classes of drugs like barbiturates which are quite valid drugs with clearly beneficial medical uses that also happen to be used illicitly. In such cases, they are already legal for therapeutic use. I specifically exclude Marijuana and other forms of cannabis from that exception, in that while it may be true that there are actual therapeutic uses, in no case are they the best or only medication available. And yes, I include chemotherapy side effects.
Above, JuanBGood wrote: “If health care is a fundamental right, it is different than other fundamental rights such as free speech, freedom of religion, protection against illegal search and seizure, and the right to bear arms. The other rights do not require that someone else pay for your right out of their pocket.”
Now in fact we routinely expect other people pay for us to exercise similar rights:
Payment is almost as direct for education, grades k through 12.
Most people who routinely exercise their “bill-of-rights” rights (like the ones quoted above), require organizations to exist that
constantly fight to keep those rights operative. Paid for by others, of course.
Most people who exercise their freedom of religion do it by going to a house of worship that is mostly paid for by others.
Religious building fund costs probably rise almost as fast as health costs, definitely ahead of inflation.
People who exercise their right to bear arms expect others to pay the cost of that right. We pay for some of the carnage those guns produce, and we pay for the extra police who try to keep the playing field equal, AND we pay for all the heavy artillery those police need to protect themselves against rightfully-born arms that fall into the wrong hands.
- The Precision Blogger
http://precision-blogging.blogspot.com
For someone who self-identifies as “the Precision Blogger”, you have made some remarkably imprecise statements.
Now in fact we routinely expect other people pay for us to exercise similar rights:
In fact, I don’t think any one of your examples stands up.
Payment is almost as direct for education, grades k through 12.
This is paid for by taxation, but then this is one of those “positive rights”.
Most people who routinely exercise their “bill-of-rights” rights (like the ones quoted above), require organizations to exist that
constantly fight to keep those rights operative. Paid for by others, of course.
In general, this is only true of very special marginal cases. Very few people need the ACLU to protect their right to speak, publish, and assemble freely; when that help is necessary, it’s paid for not by a tax, but by voluntary contributions, in money or in kind.
Most people who exercise their freedom of religion do it by going to a house of worship that is mostly paid for by others.
No, the right to free exercise of religion doesn’t require a building at all. If people voluntarily join together to build a church, they do so in general by forming a non-profit corporation that holds the property; the money comes from people’s voluntary contributions. While there may be a co-operative aspect to this, it’s not paid for by compulsion of others, which is what a “positive right” would imply.
The US is, in this, quite different from other places. In Germany, for example, if you are a member of one of the “established” churches, you are taxed to pay for that church. (The result is dramatically lowered church membership, by the way.)
In any case, there are plenty of churches that meet in members’ living rooms, and there are plenty of people whose exercise of their own religious beliefs don’t require a building at all.
Religious building fund costs probably rise almost as fast as health costs, definitely ahead of inflation.
Since your point was wrong anyway, this may not matter, but can you offer any kind of support for this notion?
People who exercise their right to bear arms expect others to pay the cost of that right. We pay for some of the carnage those guns produce, and we pay for the extra police who try to keep the playing field equal, AND we pay for all the heavy artillery those police need to protect themselves against rightfully-born arms that fall into the wrong hands.
The amount of completely nuts in this statement is daunting, but I’ll fisk it anyway. The whole argument depends on the notion that the negative right not to be restricted in the ability to own weapons in fact requires positive expenditures, where in fact the ownership of guns does none of those things. The evidence that gun ownership causes “additional carnage” is very poorly supported; the opposite appears to be true, that is, wide-spread ownership of guns in the US appears to correlate with lower, not higher, murder rates, and crime rates in general.
Thus, in fact, gun ownership is a negative cost in terms of policing; the gun owner, by voluntarily owning a gun, reduces the costs for their neighbors even if the neighbors don’t own guns.
Precision Blogger:
I’m afraid that I do not actually agree with your last post. While it is true that in may aspects of life our society expects for somebody else to foot the bill — wrongly so, but that is what is expected. But some of the examples you cite are not valid.
I agree with your example of eduction. It is not a “Bill of Rights” right. Yes, I’ve read the Bill of Rights, and I don’t see anything about education there. In fact, there is no inherent right to an education at all, contrary to what our “intellectual superiors” tell us. And I most certainly DO object to having to pay taxes to support public schools (which shouldn’t exist, anyway) since I do not have and never will have children of my own. I feel that it is the parent’s individual reponsibility to see to the education of their children instead of the collective community. I mean, why should I have to pay to school somebody else’s kids? They had them, they should school them. It’s only fair.
Now, for going to the house of worship that is paid for by others. Uh, no, that isn’t the case at all. At least, not at the church that I go to. (BTW, I’m non-institutional Church of Christ, others are almost certainly different, though…) While visitors are certainly welcome, the rank and file membership pay for the building and upkeep themselves. No outside money. None. Nobody else is paying for it except for the people who attend there. Outside monies are neither solicited nor accepted. As it should be. And no, we do NOT accept funds from GW’s faith based initiative. For that matter, we don’t engage in those activities to which the initiative is targeted. And just how much the building costs relative to the inflation rate or to medical care is immaterial to the argument. Now, as for those other religious organizations that do fit your bill, well, let’s just say that they are wrong on that point. Really, Really wrong on that point. But I still don’t know, right off hand, where any denomination is receiving monies from outside of the denomination for building purposes. Hmm, I’ll take that back — a while back the City of New Orleans was solicited for funding to do repairs on St. Louis Cathedral in the French Quarter, which I heartily disagreed with — if the Catholics want a nicely rebuild church, they need to raise their own money from within their own ranks.
Now, as for the guns. First assumption is that you refer to the NRA. Hmm, that is an organization by and for gun owners, voluntarily paid for by gun owners, and nobody else. While it is true that they do much in the way of advocacy and protecting 2nd Amendment rights, they are funded by their membership. I see no problem there. As for the carnage you speak of, well what you are getting at is really twofold. First, we have the problem of violent crime as such. Get it through your head: “Guns Don’t Kill, People Kill”. It is a crime control problem, and people are the perpetrators. If guns were disallowed, people would find other means to commit violent crime. Violent crime did not begin when guns were invented. Get over it. Remember when that guy crashed his truck into the Luby’s cafeteria in Gainsville, Tx some years ago? Yep, he came out shooting, killed a whole bunch of people who just sitting there eating lunch. Defenseless people. Now, what would have happened if just a half dozen or so of that crowd were packing themselves? Ok, he’d have gotten a couple of shots off, and then turned into swiss cheese. And you talk about cost? How many post offices are shot up because nobody else was packing when the perp started shooting? The real answer is MORE weapons in the hands of the citizenry, not less. Secondly, the carnage you speak of may be referring to catastrophic medical costs due to gunshot wounds. What you imply is that it is the government’s responsibility, hence ultimately the taxpayer’s responsibility, to pay for medical care of that variety. I do not agree with this. I assert that it is the individual’s responsibility to see to medical care — even catastrophic injury. In the case of the victim of violent crime, this should instead be paid for by restitution coercively received from the perp, after all, the perp did it, therefore the perp should be unconditionally responsible for ALL damages, including medical. While this is not currently the case, that does not make the current situation right. Police artillery? Why? What good does it do when they show up 1/2 an hour late and the shooting is already done, the bodies are already cooling on the floor? Ok, so they have to do busts on some ruthless thugs at times and need extra firepower — sounds like a good job for the local militia, like for instance the National Guard, or maybe the Texas Rangers. What, don’t live in Texas? Too bad. I wish I was back there. But by and large a well armed citizenry who know how to use their arms removes the need for the “heavy artillery” of the police. Any thug waving heavy power gets cut down by a half dozen or so citizens. Case closed. Cops not needed, they couldn’t get there fast enough anyway. (Think: Coffeyville, Kansas) The other reason for the police having to carry heavy weaponry is to quell, suppress and oppress the citizenry itself. This implies a government run amok, and is a major argument for the very existence of the 2nd Amendment in the first place — the ultimate check against unchecked government power — popular revolt. Thankfully, the founding fathers saw fit to include it in the Bill of Rights.
But you are correct in what you say in 1 respect. It is true that somebody did have to pay the cost of the Bill of Rights, never mind that our own government has trampled all over it. Those people are the soldiers who have fought, bled and died over the centuries to protect and preserve it. And the taxpayers who footed the bill to equip them. Let us not forget them.
Let’s adress the perceived need for mandatory insurance.
First, the claim is made that young people forego insurance because they’re not thinking straight. Now since we’re not talking about actual children here, I’m not prepared to grant that assumption. Instead, observe that there is all the reason in the world for the young to decline to buy “group health insurance” that charges them the same rate that older people are charged: because it’s a blatant rip-off!
In every other insurance market, insurance companies are permitted to charge according to risk factors without much interference. Older people pay more for life insurance than younger people. Smokers pay more for life insurance than non-smokers. No one bats an eye. But as soon as health insurance companies start breaking people up into risk categories, and charging people according to their individual risk profiles, people have a fit.
Let the insurance companies freely set rates based on individual risk factors. They’ll offer plans dirt-cheap to younger folks, and buying those plans will be a no-brainer. Not only that, it won’t even matter whether any young people sign up or not, because insurance companies are selling insurance, not running a disguised welfare operation – older people are paying the acutal cost of insuring them based on their risk factors, and that cost doesn’t depend on whether any cheaper risks are also being insured (and paying at a lower rate).
And for Heaven’s sake get employers completely out of the picture. Your ability to buy a health plan should depend on who you work for. And there’s no reason on Earth for your employer to select your health plan for you. He’s not being covered by it, so he’s not going to pick the best one for you. Let employers get to the business of whatever business they’re in, and let their employees buy their own plans instead of getting them from the Company Store.
Now what we really need is deregulation of nearly every aspect of the medical care field. What we want is technological advancement similar to that found in the nearly-unregulated computing industry, so that the chances an anti-aging drug will be developed in time to save you and me are maximized. People are dropping like flies long before they reach 100 years of age – only medical research and development, and lots of it, can stop this enormous loss of life.
Ken, you have the right idea! You Get It!
gb_in_ga,
Let me quote to you a signer of the Declaration of independence:
So you would give up the liberty to choose your preferred medicine? You think because you can buy something for a dollar a dose that will do the job I ought to be prevented from growing a plant that will do the same job?
Interesting.
It is people like you that give capitalism a bad name.
more here on the subject with additional links
gb_in_ga,
Cannabis shrinks some kinds of tumors. This benefit has been denied us because of drug prohibition.
Cannabis may help with post combat PTSD. This benefit has been denied us because of drug prohibition.
Cannabis may help with alzheimders. This benefit has been denied us because of drug prohibition.
I could make the list much longer but I’m short of time.
Bottom line. We are being denied additional medicines for hard to treat or impossible to treat conditions because of your philosophy.
How do you feel about denying medicine to those with no alternative?
M Simon, given that GB has already explicitly given three reasons why he’s opposed to the War on Drugs anyway, don’t you think you’re getting just a bit jesuitical here?
Ken:
Well, there is 1 point of issue, though, and that is your first point. I maintain that young adults who forgo health insurance really aren’t thinking straight. Not that that is any reason to coerce them into doing it by governmental force, because it isn’t. The problem with that age group is that since they tend to be in excellent health, they think that they are invulnerable. And this is an understandable point of view. Understandable, but not wise. They still face the prospect of catastrophic illness at that age. I know, I lost my first wife in her prime due to such a thing. It happens. So, what’s to do? Since you and I agree that mandatory health insurance is a bad thing, and since it really isn’t a good thing to be completely uninsured, even at that age, what is to be done about it?
First, we must point out that there are those who will be uninsured by choice, for whatever reason. I maintain that, for whatever reason, all who are uninsured get that way by choice with the exception of those who lose their coverage due to no choice of their own — layoff, provider bankruptcy, etc. Anyway, for those voluntarily uninsured should be coerced into payment in full, out of their own pocket. Will this require modification of current bankruptcy laws? Could be. Anyway, if they choose to be uninsured, they should take responsibility for that choice, even if it paupers them. Too Bad. You Gambled and Lost. It just isn’t right for people to gamble on their healthcare coverage and then stick the community with the tab if they lose.
Second, as for the involuntarily uninsured, well, I’m not quite sure how to handle them. But I’m under the impression that segment of the population will be comparitely small — most will be voluntary and can (or should) pay their own way. But that segment is the one that will receive the most press. I suspect that your insurance reform suggestions will go a long way towards minimizing that segment, as it would make coverage more generally available, and less likely to be involuntarily terminated. Oh, and poverty is not a reason for being uninsured. I know that the following sounds crass and hateful, but it is true: The real poor, in this day and age, have only themselves to blame for being poor. I’ve seen it, and it is a choice. There are ample opportunities out there to obtain gainful employment and escape poverty if they just seek it and are willing to move, even if they — by choice — opted to cripple their life chances by leaving the education system prematurely. Not that I agree with the current education system, but that is another problem entirely. Anyway, there is no reason that one could not obtain high deductible catastrophic health coverage at an affordable price if it were to become generally available under the suggestions you bring forth. Come to think of it, there is a way to provide for the coverage of this class of people (the involuntarily uninsured, that is), and that is how it has been done historically — and that is to allow private charity to handle these cases. Private Charity that is voluntarily funded. For instance, we of the Churches of Christ commonly do this for other members of the Church in times of need. I know, I’ve (well, actually my first wife) been the recipient of such benevolence of the Church, to the tune of $120K for a failed operation that insurance refused to cover. It works.
The next problem is the elderly: and my position remains the same. It is the elderly’s responsibility to set aside for their own retirement and future healthcare needs WHILE THEY ARE STILL WORKING. That means saving and investing. It means acting responsibly long before retirement. Again, there will be times when set aside funds will be insufficient, and that will be time for Private Charity to step in, as above.
Some points that apply to the situation:
A> There is no excuse for irresponsibility.
B> There ain’t no such thing as a free lunch. Somebody, somewhere has to pay for it, even in the current system. If it isn’t you or some other arrangement you have made, then someone else will have to pay your bill involuntarily, and that is STEALING.
C> No Freeloaders. If you run up a bill, you pay the bill.
D> It isn’t the government’s job to be in the healthcare business. Or the benevolence business, for that matter.
E> Stealing is still stealing even if the government does it by coercion under the authority of a majority vote. Just because it is legal and done by the government doesn’t mean it isn’t stealing, neither does that make it right.
F> There already exists a way to provide for the truly needy indigent, and that is by way of Private Charity. We need to cultivate this.
G> There is a place for compassion, but that isn’t in the Government. Government is the ultimate instrument of force, and by it’s nature can never be a truly effective instrument of compassion. Compassion is best wielded voluntarily, typically through Private Charity.
H> Health Care is a BUSINESS. We don’t expect freebies from other businesses, so why do we expect this from the Health Care BUSINESS?
Compassionate Capitalism as a governing policy? BUNK!
If we can’t be serious about those points, then it is all going to boil down to robbing from Peter to pay Paul’s medical bills, and that is fundamentally wrong. There’s no way to paint it as being right. It is still stealing.
M Simon:
Uh, your argument still rings hollow. The profession of the physician, by it’s very nature, will always be an entity that is as feared by the physician who penned that, to a certain extent — there is just too much to learn and too much dicipline required for it to be otherwise. It will always be a high priesthood and a monopoly. I wouldn’t have it any other way, else quality suffers. Oh, yes, and there will be quacks out there, and that is yet another problem, let’s not go there now. And yet, the real monopoly you so fear actually does not exist. There may not be much competition out there for fees (yet), or for insurance rates (yet), but there are all kinds of of options out there for primary care givers, consulting specialists, hospitals, and such. Even medications!!! Want so called alternative medicines and treatments? Sure, that is available, too. Not that I would suggest their use, but if you want ‘em, you can get ‘em. Knock yourself out.
Who says capitalism is dead? It may be running a fever, but it ain’t dead yet.
As for your cannabis argument, well, if it is legalized by way of the reasons I bring forth then you can opt to not go to a physician and treat yourself, thus breaking that monopoly you are so afraid of. Your choice. I mean, nothing’s stopping you from moving to the Netherlands where pot is legal and doing that right now. It’s your life, you know. You can do it, legally, right now if you really wanted to. Just move.
While it may be true that it will be cheaper to grow a plant and consume it than to purchase a quality controlled product, is that really a wise choice? Nope. What sort of variety do you have in actual medications? Very limited, just what you can grow. What if you need something else? Too bad. Can you ACCURATELY control doseage with your home-grown pot? Nope. Can you ACCURATELY assure quality control with your home-grown pot? Nope. I just asked my wife, who is in the health care business, and she says that there haven’t been any double blind tests done on this, hence you really have no verifiable evidence — no actual clinical evidence — to back up your claims, that is. She is a medical professional and she knows what she is talking about, I’ll take her word for it. Ok, so you are convinced about your chosen perfered path to health care. Okie Dokie, nothing I’m going to say is going to change that, seeing as how you have apparently firmly made up your mind on this — as a matter of faith. Not that faith is bad, ’cause it isn’t. But misguided faith can lead to folly. I’ve observed others on this thread attempt to talk sense to you, to no avail, and I realize that nothing I have to say will have a snowball’s chance in Houston of getting through. I’ll not try to keep a fool from his folly, so knock yourself out. Remember, your life is depending on this.
Ok, so I lied, I will put in yet another try:
(it is that compassionate side of me, you know)
Beware: A common saying comes to mind, and it has something to do with the lack of wisdom for physicians who treat themselves. It is a treacherous path to tread, and one that’s been known for a LONG time. Even more perilous is the path taken by the amateur in treating himself. At least the physician knows his business. Ok, if you want to take that path, be my guest. I’ll not stop you. Just don’t expect for me to pay for it, and tell me where to send the flowers.
Oh, your little slur at the end was just that. A slur and an insult. Betcha think you were being cute, right? Well, it gets you nothing but my scorn, for it has ABSOLUTELY NO BASIS IN FACT. You aren’t being cute, you are being infantile. Grow Up.
M Simon:
As Charlie says, I have given 3 excellent reasons to legalize drugs in general, including pot, that have nothing to do with medicine. You do realize, don’t you, that if pot is legalized for reasons other than medicine, then you still can buy it over the counter or grow it yourself and treat yourself to your heart’s content, right?
Put down that joint and engage your brain, man! Think!
Charlie (Colarado),
Actually you are unaware of the drug history at that time. Nixon(yeah that Nixon) created the methadone program to help returning “addicted” vets. There was a lot of truth to the stereo type. Estimates were that 20% or more of returning vets were using heroin regularly. Nixon was frightened. He did something.
What happened is that most vets “got over it”. As you would expect given that for most the PTSD was transient. However the usual 10% or so did not get over it. This happens after every war. In America of course the drug of choice was/is alcohol. It deadens the pain but is particulary hard on the body compared to opiates.
Now how the PTSD drug connection was found was not by studying service men. It was by studying female heroin addicts by Dr. Shavelson. He found that of the 200 female addicts he studied 199 had been sexually abused as children.
I’d put it simply: we do not have a drug abuse problem in America. We have a child abuse problem which is reflected as drug abuse.
In effect what we are doing is persecuting the wounded. Pretty cool, eh?
And of course so many here believe in it.
God have mercy on your souls.
Because now you know better.
=============
Dear Dr. Irons,
I’m Jewish too. So is the guy who wrote “Drug Warriors and Their Prey”. That book shows the absolute parallel between how America treats drug users and how Germany treated the Jews.
The Holocaust was not a Jewish problem. It is a human problem. It has been done many places in many times to many groups. It is just that Jews are our best example.
Please read “Drug Warriors” and get back to me.
or e-mail me. I can give you an education. Both medical and historical. It turns out most of what you know abou the subject of “addictive” drugs is wrong. Sorry. BTW I can give you more than adequate cites from the literature. Including a quote from a representitive of the NAADAC which did a number of seminars with Dr. Shavelson.
Chronic drug use is caused by chronic pain. Even the DEA agrees to that. What is not agreed upon is what constitutes pain. You break a bone and have long lasting consequences – doctors understand that kind of long term pain. What they are not trained in is PTSD because it is a “mental” condition. At least as far as most doctors are concerned.
As usual practicing doctors and society have not kept up with recent studies on the subject.
Please take a look at the B. Lutz study done at the Max Planck Institute in Germany. To start. I have much more. Much, much, more.
Or come over to my url and have a look. I’m putting up my article on genetics in the next few hours. You will enjoy it. If you enjoy studying medicine.
A quote from a piece I wrote: Genetic discrimination.
Did I mention un-Jewish?
Repent. For your time is at hand.
gb_in_ga,
Just because there are valid reasons other than the one’s I have given. Does not make my reasons wrong.
I agree with the Constitutional aspects. However, those arguments have move as many people as they are going to.
What I’m working on is the “medical reasons”. Which have more traction. You know the “drugs are addictive” bit that frightens so many people.
What I’m trying to show is that the whole idea of “addiction” completely misunderstands the drug problem. Which is why the measures taken to limit or cure “addiction” don’t work.
When our undestanding is faulty so are our methods. I’m working on better understanding.
That better understanding will lead to a different concensus.
If drugs do not cause “addiction” then we need not fear drugs. Fear and money is all that is keeping the drug war alive. I’m working on the fear component.
Drugs do not cause addiction. Chronic pain leads to chronic drug use. A lot of people have trouble with that concept.
I had a long discussion with a Sheriff a while back on the subject. Finally he got it. When he saw what his life had been dedicated to he was quite sorry. He shouldn’t have been. When confronted with new information he changed his mind. And he was one of the easy ones. Most people can’t get it. It would mean adjusting to the fact that they have been involved in unwarranted persecutions. Most humans can’t deal with that. Which is why death is so important to human advancement. It wipes the slate clean.
The officers of LEAP have read my work and are in agreement. I’ll post my “Interview with a Police Officer” at my site in a while. Or you can google it if you are in a hurry.
M Simon:
“Chronic drug use is caused by chronic pain.”
Uh, that isn’t necessarily so. Think about what you are saying. While it may be true that some instances of chronic drug use may be in response to pain (like my late sister-in-law, who just passed away about a month ago), it does not mean that all chronic pain leads to chronic drug use. Some people deal with chronic pain using other means. My wife is an example of such, she has RA and uses nothing more than tylenol to control the chronic pain, which is considerable. And it is certainly true that there exists much in the way of chronic drug use that has nothing to do with chronic pain. I’ve seen it in action, in spades — recreational drug use run amok. There was no pain involved, except for maybe the pain of boredom.
What your statement literally says is that chronic pain leads to ALL chronic drug use. I am certain that statement is untrue, for I have witnessed exceptions myself.
gb_in_ga,
Uh, computer designinging at the bare metal level will always be a priesthood because there is so much to learn. Not just programming but Fermi levels, topology, transmission line effects, signal coupling, etc. Did I mention caches, pipelines, pipeline flushes. Wallace tree multipliers. ALU’s. Transmission gates. And how could I leave out transistor behavior? Add in compiler design. Knowledge of instruction use in a particular application. Low power design. Phase Locked Loops etc.
So can I get a government enforced monopoly too?
In any case I do not need to be a physician to know more about my personal conditions and their treatment than any doctor. Especially in this internet age. All I need to do is study. Because my focus in narrow my study can be deep. Much deeper than the average physician.
And therein lies the problem. Most MDs know nothing about the brain chemistry of PTSD. It is not yet taught in medical schools. It exists as an ad hoc discipline at this time. My meta studies on the subject probably make me, even as an amateur, one of the most competent and knowledgeable in the field at this time.
I hope that doesn’t last long (it has been going on for two years with no immediate end in sight). A lot more work needs to be done (so far no new study has contradicted my work, most support it). Fortunately I’m following it avidly and translating it into every day language.
BTW did you know that police officers in some jurisdictions are now being taught that chronic drug use in children is a marker for child abuse? This needs to be expanded. I have written on the subject. It will get reposted. The truth is out there.
I have covered all this and more.
Go to my url to get an education.
As to the grtuitous insults. Persecution of the innocent is a big issue for me. I am not easy on those who prefer to support the status quo in understanding the drug problem. Even constitutionalists who are against prohibition.
I treat them the same way I treat the proKerry moonbats. People devoid of humanity. Get your compassion back coupled with proper understanding and get treated like a human by me. Simple as that.
And I’m not adverse to such treatment when I deserve it. Even though I might not get it at the time. Sometimes I’m a slow learner too.
Let me leave you with this thought. Work on it.
Most addictions are a responses to chronic pain.
Once we get that we can start helping “addicts”. Either by leaving them alone or assisting them in getting the least destructive pain relief possible.
–==–
And yes Jamie,
Persecution of drug users is no more warranted than persecution of Jews.
By making being Jewish a crime Germany forced German Jews into a life of crime. We have done the same to drug users. Read “Drug Warriors” – the parallels are uncanny. Miller (the author) will give you all the sordid details (Jews and drug users alike).
Sorry bout that.
*
gb_in_ga,
Substitute “almost all” in the equation if it will make you happy.
So far I have found no exceptions.
What I have found is that people not in pain don’t like opiates. Which is why most people do not get addicted.
If you look at drug use as a response to pain(in the vast majority of cases) it all begins to make much more sense. Try it.
People in chronic pain chronically take pain relievers.
That is not controversial.
What is controversial is treating PTSD as an internal brain produced pain that can’t be turned off by changing your mind (as far as we know). The connections to the amygdala are mostly out – with respect to conciousness.
It explains why chronic drug use does not respond to market forces (i.e. for addicts higher prices do not lead to much decreased consumption). Why is drug use so inelastic?
Because pain relief has no price if the pain is severe enough.
No other theory explains so much about why drug “addiction” works the way it does.
The current theory is that addicts are addicted and if you are addicted quitting is difficult. Uh? So how do you treat such a condition? Remove the drugs and the addiction will go away. Except such treatment works no better than no treatment. Could there be something missing?
My theory explains over eating and many other “addictions”. What does the addiction theory explain? That people become food addicts because food is addictive?
So are you suggesting food abstinence as the cure?
I will post my article on food addiction at some point. Look for it.
M Simon:
I understand what you you are saying, but I do NOT agree with it. I’ve seen the refutation with my own eyes. I’ve KNOWN the addicts, and know that there was no associated chronic pain. There are physiological changes that occur in the brain that leads to physical addition with several substances. Not all of those substances are illegal. Not all currently illegal drugs are actually addictive at all. And not all of them have anything to do with pain at all.
I was addicted — physically addicted — to tobacco for over 30 years. There was no pain associated. I had an alcoholic roommate many years back. He was addicted — physically addicted — to alcohol, and there was no pain associated. He was just a drunk. Heck, I was a drunk back then, too, just not physically addicted. His alcoholic girlfriend died of dry land drowning. I could never tell if she had any chronic pain, she was too drunk all the time.
I threw off that addiction I had about 10 years ago. It required NO medication to do it — just will and determination. So yes, it is possible to just go “Cold Turkey” and turn your back on it. It ain’t fun, but it can be done. Other drugs are more addictive, I know. But the process is similar, and can likewise be overcome with will and determination, just as mine was. The record shows it.
Oh, and last I heard, that old alcoholic roommate I had was shot down dead in a drug deal gone bad.
I’ve seen people strung out on all kinds of stuff in my time. Mostly from boredom. These were nominally healthy people, from nominally prosperous, well adjusted, middle-class backgrounds. One by one, most of them managed to self destruct. And I never detected any chronic pain in the lot of them. Just boredom. And thrill-seeking. And herd mentality. The depression comes later, after the addictions take hold. And then the downward spiral.
So don’t feed me any more bunk about the real cause of addiction being chronic pain, ’cause I know firsthand that is hooey. People may take addictive drugs to help cope with chronic pain, and then become addicted, but those are not the entire population of addicts by any means. And I am not at all convinced that the presence or absence of pain has anything to do with the addiction. The use of the drugs themselves have everything to do with it.
Now, let’s get on to the real, and only viable reasons to legalize drugs: It is stupid to continue making criminals out of those aren’t harming anyone other than themselves and who would otherwise be lawabiding citizens. It is idiotic and insane to keep on throwing good dollars after bad, year after year, expecting a change in results when the methods haven’t changed. It is worse than stupid to create and nurture a vicious criminal class that is bent on destroying the fabric of society. And it is completely ignorant to assume that people can’t take responsibility for their own actions, and need a nanny-state to look after them.
You make the assertion that people are scared of legalizing drugs because they are addictive, and hence will never agree to their legalization. BUNK. We have historic precedence that this is not so. Alcohol is known to be addictive, and that is a fact. Alcohol was illegal for decades. Alcohol prohibition created the exact same societal problems that drug prohibition creates today. Alcohol was legalized in spite of that. Tobacco is known to be addictive, and that is a fact. Tobacco is is currently legal, but there is much pressure from the left to end that. And yet there is little in the way of societal disruption from either Alcohol or Tobacco, at least as compared to the societal disruption due to drugs that are currently prohibited. Why is that? Merely because they are prohibited and desireable.
There are many prescription drugs that are in fact addictive. Are they illegal? No. At least not when used via the prescription route. People get just as addicted to those medications as they do to illicit ones. I mean, I’ve seen people get REALLY strung out on prescription drugs — like my late sister-in-law. IMHO, that is what eventually did her in — a reaction to the pain meds. Hence, the presence of addicts and the possibility of addiction is not really a concern to the public, and neither is the presence of dangerous drugs in society, since all was done quite legally. IMHO the issue of addicts that are deprived of their drugs due to insufficient finances and resort to other forms of crime to support their addictions is the real issue with the public. People don’t care about legal Methadone users. People don’t care about legal Oxycotin users. People don’t care about Alcoholics. People do care, however, about getting their houses burglarized. People do care about getting robbed. There’s your issue, the public’s real hot button. Ordinary, run of the mill crime against person and property. Legalization changes all of that. Since most of the cost of the illicit drugs comes from smugglers’ profit, transport costs, bribes, and so forth, legalization greatly decreases the cost per unit dose. Not to mention accuracy of dosage and quality. After all, out on the street there is no telling what is being sold, at what quality, and what the cut is. Legal is much safer in other words. If the addict can afford the addiction, the addict can then merge back into society, becoming something like a productive citizen instead of a denizen of the underworld. There are no actual negatives here, in other words.
It is another fact that many of those drugs that are currently prohibited were once widely available, over the counter. Did society collapse back then? Ah, no. It didn’t. Massive addictions? An, no. A few, sure, but not any sort of epidemic of addictions. So what we are facing is a continuing PR campaign at taxpayer expense and a whole lot of FUD due to that. And not much in the way of critical thought.
Sad state of affairs, no?
M Simon:
Tech Monopoly: Well to a certain extent that monopoly is forming of its own accord. Oh, did I tell you that I, too, am a programmer? Well, not down at the board level, but you are edging on my turf now.
The physician monopoly that you speak of, to the extent that it exists, forms and would form irrespective of what the government does. It is just the nature of the beast. Why not talk about the legal profession? Same thing. Engineers? Them, too. Even PR people do this.
Professional organizations come about because of the nature of professions — there is a whole lot of training and dicipline required, and advances happen quickly enough that to remain competent they require frequent contact and communication with their peers. Failure to do this leads to obsolecense in short order. The presence of these monopolic networks have the side benefits of setting industry standards. If you claim to know about the tech industry (I assume so because of your reference to that due to your example), then you must know about the necessity for standards. Employers and clients need to know that the professional being hired — be that an engineer, lawyer, or doctor — is competent to do the job. The job being done is so important that assurance is vital, life or death. Now, just who is competent in any profession to determine the competence of any particular practitioner? Why, those of that profession, of course. Only other doctors can actually tell if a doctor is competent. Only other engineers can determine if an engineer is competent. Only other lawyers can determine if a lawyer is competent.
The government has at least a small ammount of common sense in that they figured this truth out. So they have empowered these professional networks to do their own policing. After all, those networks are the only ones truly competent to make those sorts of determinations. If not them, who?
Now, I don’t particuarly like the fact that the government has put it’s 2 cents in on this. We could do just fine without the government’s input or authority here. Because even without the government’s influence, these professional organizations would form and perform the same sort of policing and standards making. Again, it is just the nature of the beast.
Don’t like it? Tuff. That’s just the way it is. I, for one, think it is not at all a bad thing. Well, except for the government being involved, but in this case it is pretty benign presence.
We have much more pressing issues than perceived doctor monopolies.
Oh, and now you claim to know more about certain facets of medicine then the respective MD’s? And where did you get that material? And where is your clinical data? Double blind checked, mind you. Do I detect that hubris is setting in? Or are you just trumpeting your latest theories just to hear yourself? Dontcha know that most of your MD’s don’t just close the books and quit studying when they leave med school? They have to keep studying CONSTANTLY, just like us techies do, or they find themselves obsolete in short order — just like us techies do. So, if what you are proposing has any basis in fact — backed up with VERIFIED CLINICAL DATA, it will be in the med journals and from there on to the physicians in short order. Since this apparently hasn’t happened — as your cheerleading the cause has shown — then I have much reason to doubt the accuracy of your claims. If it were actually verified it would be in the journals. If it were in the journals, the physicians would know about it. Since it is apparently not common knowledge with the physicians, it appears that it is not a proven thing, since it is not in the journals. A implies B implies C. If you actually do have something earthshattering, then you need to get it published in the journals, and that means you will need to get it past their reviews. And they aren’t going to publish anything bogus. They are going to check you, and they are credible. Get it published in a respectable journal, if you’re so sure of yourself. Then you won’t have to keep on bringing this up. You are, you know, starting to sound like a broken record.
Heck, now I’m starting to sound like a broken record…
Hmm, it is now a quarter to 3, so I’m going to hit the sack.
Actually you are unaware of the drug history at that time.
No, son, I’m not. I remember the drug history of that time.
Some of it, anyway.
Repent. For your time is at hand.
You know, I was beginning to wonder if we weren’t having a religious argument.
Faith can be a wonderful thing, M, but it’s very rarely a good guide to public policy.
gb_in_ga,
I’ve discussed this with lots of Drs. No disagreement.
A professional at the NAADAC (look it up) said that they agree with my work.
Police in some jurisdictions are told to consider drug use in minors a marker for child abuse etc.
I’m having no problem with disagreement.
What I’m having a problem with is general disbelief.
Think: you get paid for persecuting people only you are told you are helping them. What is the incentive to change your mind?
1. You lose your job
2. You have dedicated your life to evil
Now what are the odds of change?
Now what if you are just pro-drug war? The #2 then becomes big.
Change such as I’m proposing will not come easy nor without unwarranted opposition. Who wants to be known to have dedicated even a small part of one’s life to evil?
It is much harder problem than just showing people the truth.
BTW if you want to see the evidence I have collected just google – Simon drugs – or go over to my site where I’m republishing the material.
I have the addiction councilors, the PTSD experts, the genetic markers. Pretty much an overall view of the research.
BTW my research is essentially a meta study. I’ve tied together a lot of different threads. A lot is known by people in the field. It has not reached the point of general knowledge where policy change is possible. Plenty of research. Research is not lacking. Peer reviewed research. What is lacking is an overall view.
It is not hard. Leave me out of the equation. Google – PTSD drugs – or PTSD addiction – . You will get lots of info.
No one has an interest in getting this out.
Think of all the groups that will go out of business including drug reform groups. I’ve been at this for two years with more than adequate evidence for any one willing to put in a few hours of study. You kow where I get the largest agreement? From ex-addicts and current addicts. My second largest group of fans is addiction councilors – it usually hits them like a ton of bricks when they see it. Everything they have seen starts making sense.
Go here read what a drug rehab councilor has to say.
Evidence is not lacking. What is lacking is a willingness to change belief. Nothing new in that. Nothing new at all.
Chronic drug use is caused by chronic pain.
Charlie (Colorado),
Your belief in the rationality of humans is touching. It is also unwarranted.
I have presented you a new idea.
What is your first thought.
“It is so obvious why haven’t the professionals seen it?”
Not “let me look into this and see if it is true”.
The deference to authourity when competing evidence is easy to find astounded me when I first started telling people what I learned. Now I take it as a matter of course.
Your reaction is not unusual. “How can all the learned men be wrong and this no name goof ball be right? Doesn’t stand to reason. Ignore it. It has nothing to do with my life.”
It does happen from time to time that the learned men are wrong and the goof is right. You have to be open to that possibility.
As I have said. Do a little googling on the connection between PTSD and drug “abuse”. The truth is out there. Very few want to look.