Lamborghini Healthcare: Why Billionaires Shouldn't Determine Health Policy

Personally, I'd rather be able to choose between Dr. Hibbert and Dr. Nick based on how good they are and how much confidence I have in their respective abilities, not based on whether or not I am wealthy enough to afford one or the other. I consider the ability to make health care decisions independent of financial status to be a hallmark of a good health care system.

Well @!$%#, lets apply the same logic to Toyotas and Lamborghinis, and this is what we get.

Heh. Amusingly, in the current American health care system, we pay Lamborghini premiums to bloodsucking insurance companies, and they provide us with a Trabant health care system, as a result of the "health care reform" enacted in the 1990's.

I no billionaire (yet) but I do not consider my healthcare to be a Trabant.

Were we talking about your healthcare, or the American health care system? I thought the latter. Or are you assuming that all Americans have the same "healthcare" as you do?

As I recall you stated,

Personally, I'd rather be able to choose between Dr. Hibbert and Dr. Nick ...

That's your call and the market will support it even if we do create a national healthcare program.

That depends on whose program you follow. If you go the Canadian way, then it is illegal to pay for better private care (there actually are quite a few non-rich Canadians who come to the United States for better, timely, health care).

But of course most people who want socialized health care never actually say what plan they want, to avoid any critique. You say you want "Universal Healthcare" and then I say that I don't want what Canada has. But then you of course say that your system is different than Canada's. Then I find another "Universal" system to critique and you claim that yours is different than theirs as well.

The liberal idea of "Universal Healthcare" is perfect because it is a utopia. It doesn't exist. There is no concrete plan for one that actually weighs costs and benefits. The "Universal Healthcare" can be all things to all people because in reality it is nothing.

Until an actual plan is fully proposed by someone, anyone, "Universal Healthcare" is nothing more than a buzz word with little actual meaning.

that would still leave 10 highly profitable hours within the standard 40 hour week. Most doctors work longer hours than that anyway.

Considering that many of the most serious surgeries, where you would want the best of the best, can take 12 to 15 hours alone and your example just fell apart.

......

I'm not a fan of the current system at all. Just because I am against "Universal Healthcare" does not mean I want no change at all. I just believe that the problem in our current system are mainly due to government involvement in the first place and more government involvement will only increase the problems, not help.

Besides, when it comes down to it, who is really responsible for your health, you or the government?

Sure I did. Did that mean that we were talking about your healthcare?

Let me state it another way. I'll try to be extra clear.

I'd like to have a health care system in which I am able to choose between Dr. Hibbert and Dr. Nick based on how competent they are, and how much faith I have in their medical abilities than on whether or not I'm wealthy enough to afford one or the other of them. See - I'm talking about the system. In the system that we have in America, I am free to choose between these two physicians, but if I can't afford the doctor in whom I have the most faith, I might as well be living in a country full of Dr. Nicks.

To be clear, what I'm saying is that an ideal health care system would be one in which medical decisions are made without regard to cost. As you obviously realize, there are many obstacles to such a system. Nonetheless, it is what we should strive for, and health care systems should be graded on how close they come to achieving that goal. In the United States, insurance companies have steadily degraded our health care system by demanding ever-increasing levels of productivity from health care professionals, and by jacking up premiums and refusing to cover more and more Americans. That's what makes our health care system more like a Trabant than like a Lamborghini, notwithstanding your personal satisfaction with the health care that you receive in your personal corner of the system.

Not everyone in America can go see Dr. Hibbert, what method do you propose to use to determine who can see him?

Who is to pay Dr. Hibbert?

Will Dr. Hibbert and Dr. Nick be paid the same?

Is that fair considering that people would rather see Dr. Hibbert?

If they are paid the same, why would Dr. Hibbert work as hard as he does rather than doing the minimum since he gets paid the same anyway?

If they are paid differently, then again, who pays them?

Would Dr. Hibbert make as much in your system as he did before? If he was to make less, why is it fair that his hard work and special gifts are now improperly compensated?

Point taken Brad and very well put, the fact of the matter is that neither of us has any chance of convincing the other, my perfect healthcare system would be me going to the doctor and paying cold hard cash for the service I was provided. Of course being a twenty something with no health care cost in the immediate future it's pretty easy for me to have this view, I'm sure my viewpoint will change with time.

Of course being a twenty something with no health care cost in the immediate future it's pretty easy for me to have this view, I'm sure my viewpoint will change with time.

It will, I assure you.

;-)

It may not ever be the same as mine, but that's OK. Like you, I'd prefer to be able to simply go to the doctor of my choice and to pay her out of my pocket for her help. Truth is, most physicians would definitely be OK with that, too, but their hands are tied by insurance companies when it comes to charges, so even if they want to they can't see me for what I can afford to pay.

As you point out, ajs, many of the best health care professionals on the planet work in the United States, in many of the finest health care facilities. It's not providers that we lack (well, in some areas we do, but that's a whole nother topic), it's a means for all of us to participate. We don't necessarily need a single-payer system to make that happen, but we sure as hell need something that we haven't got yet.

Adam, those are all good questions, and they all deserve answers. The fact that we don't have all the answers at once, though, is not a reason to pretend that there's not a problem. Our health care system has some serious problems, believe it or not. Although I can see you'd like to make this about ideology, and you'd like to use it as a chance to promote libertarianism and market-based solutions, what we're talking about here isn't an ideological problem. We're talking about people not having access to health care, while insurance and pharmaceutical companies rake in money hand over fist by pursuing policies that hurt Americans. If we were talking about a simple matter of relationships between health care providers and patients and how they work out financial arrangements, there are probably a thousand ways we could work it out. Instead, we're talking about a system which has become unwieldy, expensive, and inefficient, not due to the actions of health care providers or their patients, but due to the actions of a whole industry which exists for the express purpose of extracting as much money as possible from providers and patients.

I'm not saying keep this system at all.

Hence I said,

I'm not a fan of the current system at all. Just because I am against "Universal Healthcare" does not mean I want no change at all.

I'm not saying I want a perfect socialized healthcare proposal, I just wanted to see one so I am at least on the same ground as the person I am conversing with. Like I said in my previous comment, often when debating against "universal healthcare" one cannot critique it because it constantly changes.

Brad's plan sounds nice except it is lacking in some of the most basic details. It tells me what I could get, but not what I actually get, and not what I pay.

Your plan tells us what we get and we can at least estimate it's cost.

This years budget calls for $394.5 billion to go to medicare which is a 12.4% increase over last year. Medicare now covers for the most part only those age 65 and over for 42.5 million Americans. Increasing that coverage to all 300 million Americans would cost over 2.7 Trillion Dollars. You are literally doubling the Government's budget. Of course that is just for this year. Medicare is growing at a 12.4% rate. Image doubling the budget, and then increasing that 12.4% each year.

The United States budget would now be $6.3 trillion dollars. Our GDP is slightly over $12 trillion dollars. You are now spending half of all our GDP on the government. Now the average tax rate must be 50% at least. Raising taxes that much will destroy the economy forcing even more taxes to cover the now lower GDP.

This is the cost.

Brad's plan sounds nice except it is lacking in some of the most basic details. It tells me what I could get, but not what I actually get, and not what I pay.

Just to be clear, Adam, I don't have a plan. I just have a yardstick by which to measure a plan. And even that measure, I admit, may be inadequate. I see it as something to strive for. I suspect that, were it not for the incredibly negative effects of insurance companies (and their partners, the lawyers), we would be much closer to such a system than we are now.

but their hands are tied by insurance companies when it comes to charges, so even if they want to they can't see me for what I can afford to pay.

This seems to be an issue with insurance companies. Why not just deal with that issue?

We're talking about people not having access to health care, while insurance and pharmaceutical companies rake in money hand over fist by pursuing policies that hurt Americans.

So again, deal with the insurance and pharmaceutical companies then. Though, I'd be hesitant if I were you with your rhetoric about those companies making money hand over fist. There are actually a few pharmaceutical companies that are very close to bankruptcy for a variety of reasons.

Besides, people have survived for millions of years without health care.

Not that long ago back in just the '50s, the average American could pay their doctor out of pocket, no socialized medicine needed at all. Isn't it a bit peculiar that the most socialized medicine has become the greater the costs have been for the average person and the more red tape is involved?

What we have now is not a free market approach. We have a twisted system where government is involved at every corner.

Brad Farris wrote:

To be clear, what I'm saying is that an ideal health care system would be one in which medical decisions are made without regard to cost. As you obviously realize, there are many obstacles to such a system.

Actually, that's a fair characterization of the system we already have. The US spends more on health care relative to GDP than any other developed nation. All attempts to inject cost consciousness into the system have been met with stiff opposition.

A product can be cheap, quickly delivered or high quality and it can even be two of those things, but never all three. The US health care system is highly skewed towards speed and quality. Other industrialized nations have skewed towards price and quality - with resulting deficiencies in the speed that they receive care. Alas, no industrialized nations allow their citizens to choose their own priorities.

Actually, that's a fair characterization of the system we already have.

I'm not sure what you're getting at, Entelechy, but it's certainly not a characterization of the system we already have in any way, shape, or form. The system that we currently have is characterized by high insurance premiums (both health insurance and provider insurance), highly exclusionary insurance practices, and low availability for patients who are excluded or who are unable to afford premiums. The ideal system that I describe would allow any person to receive any service from any provider at an affordable rate.

A product can be cheap, quickly delivered or high quality...

I've a great deal of respect for your opinion on economic issues, but I don't think you're taking into account the overwhelming reality that the American health care system is fundamentally controlled (and manipulated) by various entities which are neither providers nor patients (insurance and pharmaceutical companies). If we were talking about providers practicing medicine the way they wanted to, and charging for their services the way they wanted to, we could talk about a market that functions like other markets. We're not, though, and the result is a system which is undeniably broken.

This seems to be an issue with insurance companies. Why not just deal with that issue?

Agreed! Have I suggested anything else?

What we have now is not a free market approach. We have a twisted system where government is involved at every corner.

A twisted system, certainly. I would have to say, though, that the bulk of the blame for its twisted nature lies at the feet of the aforementioned insurance companies (did I mention bloodsuckers?), and that the main reason that the government is even interested in the system is due to the terribly harmful effects caused by those entities.

I'll tell you, I couldn't agree more with the idea that if we could deal with the issue of insurance companies, we could go a long way towards achieving an optimal health care system.

Brad, you keep blaming the insurance companies, and they do share some blame, but you do not look at why they even exist in their present form in the first place. Our modern system goes back the '40s and '50s when the government put holes in the tax code that let benefits such as health care be untaxed if provided by your employer. Thus there was a great incentive for your employer to provide your health care to you tax free, rather than you paying for it with your taxed dollars. Obviously employers couldn't directly give health care to employees so they did so through health insurance and similar companies. They paid for your health insurance with untaxed dollars meaning that after taxes you got more than they paid.

This is what created all that red tape and bureaucracy because thanks to employer provided healthcare being tax free, the red tape and lost money to middle men was still cheaper than a system of personal health care paid for by after tax dollars.

The reason that the insurance companies are twisted is because they were given an unfair advantage through the tax code. They have a tax bracket's worth of insulation against the free market.

If the government never let employer given healthcare be tax free, then we would have stuck to paying for healthcare ourselves. There would have never been a need for a middle man in the insurance companies because there would have never been a tax incentive in the first place.

Eventually health insurance companies would have popped up, because people suck at saving for a rainy day and would rather pay insurance companies to do it for them, but they would have done so to cater to individuals where each of us got to choose our own provider and there would have been competition for service and quality rather than just low costs.

Public or private, WE NEED A STANDARD. A standard for cost that doesn't send people to the grave in debt and a standard for care that serves all patients, irrespective of their income.

There is a lot about freedom in your precious Constitution, but nowhere does it guarantee the right to food or basic health care. Nowhere does it guarantee the right to survive.

Nowhere does it guarantee the right to survive.

The Constitution is about the Government's role and power, not our own.

Considering that, you don't have a right to survive off of others, or the government. You are responsible for your own survival.

Why do we need a standard? Healthcare is far from the most basic need for survival. We don't have standards for food. We don't have standards for housing. Why not push for "Universal food" or "Universal shelter"? The government can decide where you live and what you eat.

I'm not sure what you're getting at, Entelechy, but it's certainly not a characterization of the system we already have in any way, shape, or form. The system that we currently have is characterized by high insurance premiums (both health insurance and provider insurance), highly exclusionary insurance practices, and low availability for patients who are excluded or who are unable to afford premiums.

Basically, I'm arguing that given a choice between low quality, high prices and slow service, the US health care system nearly always selects for high prices. Granted, I think a lot of consumers would make the same choice if they had a choice. However, anyone who tries to buy cheap service ends up not getting any at all. As you put it, the system is characterized by high premiums. This is now so systemic that the only way to give a person low premiums is to give them no health care at all.

The ideal system that I describe would allow any person to receive any service from any provider at an affordable rate.

This sounds like a cost and quality optimization (more like most European countries), but this value conflicts with your earlier statement that medical decisions should be made without regard to cost. You can have Lamborghini care (fast, high quality but expensive) or you can have Volvo care (high quality and affordable but rather slow), but there is always going to be some area which suffers depending upon how you prioritize. The problem with the current system as well as most reform plans I've heard, is that it's a one size fits all solution.

I've a great deal of respect for your opinion on economic issues, but I don't think you're taking into account the overwhelming reality that the American health care system is fundamentally controlled (and manipulated) by various entities which are neither providers nor patients (insurance and pharmaceutical companies).

I do see this. The difference is that you see insurance companies as the disease and I see them as a symptom. Precisely because we have forced everyone into a speed/quality optimization, we would expect serious abuses to arise on the cost side of the industry.

If we were talking about providers practicing medicine the way they wanted to, and charging for their services the way they wanted to, we could talk about a market that functions like other markets. We're not, though, and the result is a system which is undeniably broken.

Well, then the first question to be asked is: why is our health care system so heavily skewed the way it is?

It seems to me that the largest contributing factors are 1) subsidizing the purchase of coverage through the tax code and 2) outlawing various insurance practices that allow people of varying risks to be assigned different premiums. This increases the demand for insurance while causing some people to be denied insurance (rather than simply paying more) and many more to be charged far too much to make up for the high risk people who are grouped with them. This raises premiums on those who retain insurance, which in turn encourages people to try to save money by going without coverage entirely. If we ended the insurance deduction and allowed to insurance companies to freely separate people by risk, the situation would improve.

(As a practical matter though, factor 1) is federal, but factor 2) is state level. Laws vary state by state, and average premiums do as well.)

Brad, you keep blaming the insurance companies, and they do share some blame, but you do not look at why they even exist in their present form in the first place.

Of course, Adam. We haven't even talked about the reasons that insurance companies exist. I've got no problem with your characterization whatsoever. Indeed, I thought in the previous comment that we agreed that the problem with the American health care system lies largely in the effect that insurance companies have had on the system. I don't care how they started doing that, I don't care why they do what they do. I happen to feel that they're bloodsuckers. That doesn't affect our agreement, though, that the problem with our system arises from the effect of these companies on the health care "market." I haven't proposed a solution to the problem, because I don't know what to do about it. That doesn't prevent me from knowing where the problem is, though.

To be honest with you, rather than arguing about who is responsible for what portion of the problem, or trying to figure out a way that each of us can blame our favorite villain (me blaming the bloodsucking insurance companies, you blaming the government), I'd be much more interested in thinking about ways to put an end to the problem. I'm pretty sure that I'm not going to convince the decision makers that insurance companies need to be outlawed so that Americans can have a direct relationship with their health care providers, and I'm pretty sure you're not going to convince the decision makers that the government should be drowned in a bathtub. Any realistic solution to this problem is not going to completely satisfy my desire with respect to insurance companies, and is not going to completely satisfy your desire with respect to the government. If you want, I can talk past you all day about how bad the insurance companies (and their partners the lawyers) are, and you can talk past me all day about how bad the government is. Personally, though, I think we already know enough about who we think is to blame. If we can both accept that there's a problem, we might be able to talk about what a solution might be. If only one of us thinks there's a problem, though, we obviously can't get to the solution phase.

However, anyone who tries to buy cheap service ends up not getting any at all.

I'm not sure what service you are referring to, Entelechy. The "service" provided by insurance companies, or the "service" provided by health care providers? They are certainly not the same, which is what I mean when I say that I believe that the American health care system functions differently than a more typical "market," and that it can't be measured the same way. Most Americans buy insurance plans, not health care. If you go to the doctor with the intention of paying a fair price in exchange for a service, you'll find it's quite impossible. Your physician is contractually bound by one or more of the insurance companies with which he or she does business to charge you more than the insurance company is charged. You can't negotiate with a physician for reasonably-priced care. The insurance companies got there before you.

This sounds like a cost and quality optimization (more like most European countries), but this value conflicts with your earlier statement that medical decisions should be made without regard to cost.

It may be possible that I didn't make that earlier statement very clearly. I get the feeling that you are interpreting my statement to mean that I believe that I should be able to pay as much as I want for medical care. What I really meant to say was that I want to be able to make decisions about my health care solely on what is "best" for my health, and that I want to have access to that care regardless of my ability to pay. Further, as I mentioned to Adam - I'm not proposing a system - I'm discussing a means by which to measure a system. If a system allows for health care decisions to be made by patients and providers strictly on the suitability of the care provided, and access to care is available to everyone who needs it at whatever level is needed, the system is functioning ideally. I don't know of a system like that, and I haven't proposed one. Rather, I've proposed a way to determine whether or not a proposal might produce a system which met those goals.

Brad, I began writing a response to your post, but it ended up being an article:

A Look Under the Hood of US Health Care

Entelechy, thanks. I've just taken a quick look, and I'm anxious to get a little more into it. I sincerely appreciate you taking the time, and just from what I've seen so far I'd recommend that anyone interested in this topic read it.

Gold Plated Indifference via truthout.

What's driving all this is the theory, popular in conservative circles but utterly at odds with the evidence, that the big problem with U.S. health care is that people have too much insurance - that there would be large cost savings if people were forced to pay more of their medical expenses out of pocket.

The administration also believes, for some reason, that people should be pushed out of employment-based health insurance - admittedly a deeply flawed system - into the individual insurance market, which is a disaster on all fronts. Insurance companies try to avoid selling policies to people who are likely to use them, so a large fraction of premiums in the individual market goes not to paying medical bills but to bureaucracies dedicated to weeding out "high risk" applicants - and keeping them uninsured.

I'm somewhat skeptical about health care plans, like that proposed by Gov. Arnold Schwarzenegger, that propose covering gaps in the health insurance market with a series of patches, such as requiring that insurers offer policies to everyone at the same rate. But at least the authors of these plans are trying to help those most in need, and recognize that the market needs fixing.

Mr. Bush, on the other hand, is still peddling the fantasy that the free market, with a little help from tax cuts, solves all problems.

What's really striking about Mr. Bush's remarks, however, is the tone. The stuff about providing "incentives" to buy insurance, the sneering description of good coverage as "gold plated," is right-wing think-tank jargon. In the past Mr. Bush's speechwriters might have found less offensive language; now, they're not even trying to hide his fundamental indifference to the plight of less-fortunate Americans.

Wow, a NY Times editorial attacks President Bush and is on the side of socialism. Stop the presses.

Wow, it looks like all of Krugamn's articles appear on this site. I love reading his articles, I think the main reason they added Times Select was so that it was not as easy for conservatives to criticizes him. Just a theory of course. Bookmarked, thanks a Brad.

Wow, it looks like all of Krugamn's articles appear on this site.

Yeah, I think they always get them. It's one of the main reasons I started reading that site. I love reading Krugman, too, although probably for different reasons than you do...

;-)

They don't put all of Krugman's articles there, but a fair number. There are other places where you can find them, though, as well. You can often find them by googling a phrase from the article, which you can often get very easily as the trailer for the article.

You can often find them by googling a phrase from the article, which you can often get very easily as the trailer for the article.

Great tip, ignoblus! Thanks!