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At least you understand it

Let me double check, to be sure we are on the same page. I am suggesting that the current model of paying for health care---employer-sponsored private insurance---is one that you find particularly distasteful, because neither the producer nor the consumer has any incentives to be more efficient.

Edited to add: In other words, you'd be okay with "uncapping the top" only if, at the top, the person consuming the care actually paid for it in some personal way.

Right now, with private insurance, that simply doesn't happen.

Brian Noble said:
Wait.

What's wrong with selfish? We're all selfish. That's the whole idea behind evolution. It is, to put it simply, the entire point of life.

Yeah, I just didn't want to say it. I swear I had something similar typed about selfishness and self-preservation, but backspaced the thought away.

Sometimes I try to put out the fire too. ;)

I'm a pinko commie liberal, so I can say such things. ;)

Brian Noble said:
Let me double check, to be sure we are on the same page. I am suggesting that the current model of paying for health care---employer-sponsored private insurance---is one that you find particularly distasteful, because neither the producer nor the consumer has any incentives to be more efficient.

The current US model is broken. The coverage described in the story djDaemon linked too also seems broken - just in different places. Of the two the current broken US system appears to me to benefit me more - or at least in ways that matter to me. If a better solution came along that kept or improved my current level of care and provided for more overall, then great. It's a step forward. Let's do it.

It's really no more complicated than that as far as my personal interest in the situation goes.

If a better solution came along that kept or improved my current level of care and provided for more overall, then great. It's a step forward. Let's do it.

The problem is, I don't think that's possible unless we simply throw more money at health care. And, I don't think we can afford that as a society.

My personal take: too much of what we spend on health care is at the margins, where it is not cost-effective, because there is no incentive for anyone to ask the question "is this a good use of these health care dollars?" The only question today is "Will I be better off with this procedure, or not?" And no one cares about the costs.

Until someone pays attention to the costs, there is no reason for providers to be more efficient. There is only an incentive to be more effective, no matter what it costs.

Brian Noble said:
The problem is, I don't think that's possible unless we simply throw more money at health care. And, I don't think we can afford that as a society.

Until someone pays attention to the costs, there is no reason for providers to be more efficient. There is only an incentive to be more effective, no matter what it costs.

So you don't believe it's possible to have both - efficiency and effectiveness?

Only if the incentive structures force people to become more efficient. Otherwise, there's no reason to, because becoming efficient is more work.

There are two ways to realign the incentive structures. Make people pay for some fraction of their health care directly, or have a third party make the decisions about which dollars are cost-effective.

Either are tough sells, and neither preserves the same quality of care at the same cost point in the short run. HMOs were supposed to be that third party, but they have mostly failed in the marketplace---providers simply stopped accepting them, and so employers were forced to go with PPOs instead.

I don't understand enough about the health care system to chime in on that one, but I will say that selfishness does not have to a be a foregone conclusion. I think it's drilled into our brains from all directions (advetising being one of the major culprits) but I don't think things have to be that way.

I will also say that regardless of the prevailing societal attitude on selfishness, my decision about my welfare versus the welfare of others is mine alone. To say, "That's just the way the world works" is a cop out. Either I value my welfare over the welfare of others or I don't.

Call me an idealist, but my life goal is to reach a place where I am always willing to help someone, even at my own cost (see Mother Teresa). I'm really really far from that point, but it is my life goal.

Lord Gonchar said:
I'm refusing to improve others' healthcare at the reduction of my own. I'm refusing to do it in that way.

Again, you keep assuming that there's a zero-sum game at play here, and I've not seen any evidence that suggests that's the case now, under Canada's system or anything being proposed right now by the feds.

Philosophically, you have to ask yourself if health care falls under the same general area as other fundamental things our society deems essential, whether that be police, fire, road construction or even military protection (if you can call it that). We already pay various levels of government to provide us for certain things we all take advantage of, so I don't know why this should be any different.

One of the things that turns me on about Canada is the bit about doctors choosing what you need. They can do that here in the states today, sure, but if your insurance company says they won't pay for it, you're screwed. When Diana had her vertigo issues last year, they paid for the doctor visits, but when the doctor prescribed physical therapy for the related muscle issues, you can be they limited the coverage significantly. Not only does that story demonstrate the conflict between doctors and non-doctors, but it also demonstrates that insurers have no interest in preventing health issues.

I for one also grow tired of seeing fund raisers for sick kids of well to do families being bankrupt by six figure medical bills not covered by insurance. That's about as immoral as it gets, in my opinion. It makes no sense.

What makes much of the discussion about these issues non-constructive is that it ultimately degenerates into points of peripheral precedent where unrelated dots get connected. Canada has waiting lists. Some doctors will scam the system. The feds can't be trusted to do anything right. Pick your poison. Complex problems require complex solutions, and we'll never get anywhere invoking soundbite politics (or the use of the term "socialist bastard").

ApolloAndy said:
To say, "That's just the way the world works" is a cop out.

That's not the way the world works, it's the way we work...as humans organisms. It's the exact mentality that allows you and I to be here in the first place.

Like Brian said, it's the entire point of life - to continue to live. Nothing else matters without that. Looking out for your best interest is in your best interest.

Either I value my welfare over the welfare of others or I don't.

I certainly value my own well being over anyone else's. I think there's certainly a pyramid of importance there...and guess what? I'm at the top. I would hope you're at the top of yours as well.

That's not to say I don't value the welfare of others. I'd love for you to be healthy and well, but if the choice is you or I - I win. I value my welfare over yours...it's in my best interest and more important to me. I would hope your answer is exactly the opposite - otherwise you die, I live another day and evolution (again, something Brian mentioned above) has done it's job.

Jeff said:
Again, you keep assuming that there's a zero-sum game at play here, and I've not seen any evidence that suggests that's the case now, under Canada's system or anything being proposed right now by the feds.

As long as the quality, timeliness and cost of my care (and the millions and millions of people in situations like - or similar to - my own) is not reduced, I'm fine with a system that spreads coverage to more people.

I've said it a couple of times now.

If you're reducing any of those things for some in order to provide some level of care for all (the zero-sum thing) then no, it sucks.

I'm not going to pretend to know a whole lot about anything in this thread. I just know that the article linked to says it took 14 months for Aunt Betty to get care and that that's better than nothing.

I think that's a ridiculous approach.

^^Not entirely. There are some very productive species in which the benefit of the group as a whole outweighs the benefit of the invidual (bees and ants for instance). There are many situations in which cooperation is better for everyone than competition (see prisoner's dilemma which I know we brought up before).

Furthermore, the assumption that evolution is the be all and end all of behavior (and implicitly morality) seems flawed to me. There are many things which are "right" which don't benefit the individual. "Do unto others..." and "Love your neighbor..." and all that.

But, Andy, we aren't talking about what's good for you and me. We're talking about what sorts of societal systems and incentives we need to put into place to deal with the costs of health care. It's one thing for a few people to decide to put themselves behind the social good, but as the problem of the commons suggests, that's not going to work unless everyone plays along.

In other words: any solution to this problem has to acknowledge that there are a lot of jagoffs just like Gonch out there. ;)

As long as the quality, timeliness and cost of my care

And, as I've said a couple times now, the "cost" of your care is fundamentally part of the problem---you have no personal incentive to get better value from your health care providers, and you have no incentive to make more healthy choices to reduce the burden you place upon the system, because your costs are almost entirely fixed, no matter what choices you make, modulo a few co-pays here or there.

Either that has to change, or someone else has to make yes/no decisions on your behalf that you are not necessarily going to like. In market-forces terms, it's really that simple.

ApolloAndy said:
There are many things which are "right" which don't benefit the individual. "Do unto others..." and "Love your neighbor..." and all that.

But they aren't detrimental the individual either...and that's the point here.

If my quality of care reamins the same or better and more people get coverage and care, then great. But if my quality of care drops to make an equally insufficient amount of care available to someone else, then no, I don't see the benefit.

There are some very productive species in which the benefit of the group as a whole outweighs the benefit of the invidual (bees and ants for instance). There are many situations in which cooperation is better for everyone than competition...

Not better for everyone, but better for the whole. The wording is important there. Sacrificing myself for the good of the hive may help the hive, but it is certainly better for me to be alive than dead.

Now whether this is the case with a change in heathcare has yet to be seen. There's a million ways to approach it with a million different outcomes.

Going back to Brian's thoughts on change and Jeff's zero-sum thing, I'm not ok with something that ends up lowering the quality of care for some to provide for others. I can't say that enough.

If you can provide care for those without and still maintain the cost, timeliness, effectiveness and overall quality of care for those that already have it (in any degree) then that's great. That's really what it comes down to.

Brian Noble said:
In other words: any solution to this problem has to acknowledge that there are a lot of jagoffs just like Gonch out there. ;)

How 'Pittsburgh' of you.

Jagoffs. :)

My fear that no one ends up getting good enough care. I know it doesn't have to be zero-sum, but the article mentioning that 14 months for care is better than nothing makes it seems that way. (in Canada at least)

To me, one person getting something and another nothing is better than both people not getting enough.

(EDIT - the faster I type the worse my spelling gets)

At least I learned something in the seven years I spent at Carnegie Mellon.

Brian Noble said:
In market-forces terms, it's really that simple.

So it is a zero-sum game?

Something has to give at one end to make the other end work?

Okay. I was talking more about the philosophical construct of selfishness than it's application to this particular problem.

In terms of health care, while the ideal (see philosopical discussion) is that people would be willing to sacrifice for the whole, I agree that it's completely not the case (thanks Gonch) at which point I defer to Prof. Noble.

For some reason the concept Nash equilibrium keeps emerging from the game theory class I took 10 years ago.

Gonch, you need to let go of this 14 month thing. That you can quote one instance in a system that isn't even what has been proposed does not imply anything about the quality of the care. You're drawing the line from socialized care to long wait times for elective surgery. You ignore that the wait time is not likely a symptom of the system itself, but something else entirely, like there aren't enough doctors. There's no rationing go on here, which I assume is what you fear.

Spending considerable time in economics as an undergrad and in public health as a graduate student, there's only one thing I can say with absolute certainty in relation to Professor Noble's cogent argument. When the number of people utilizing ERs for priimary care hits a certain (indefinite?) point, the "game" becomes a lose-lose proposition for everyone. The poor health of a substantial minority becomes a significant burden on the health of society as a whole, and then everyone suffers.