Ambiance

27 Comments

1. wj said,

   June 10, 2009 at 8:53 pm

   The only way you can reconcile freedom to behave badly with anything like a universal health care mandate is this. You include some way to hold people responsible for those medical problems which are the result, not of mischance but of their own decisions and choices. You could do that, obviously, financially — but that is not the only possible approach.

   But some such feature has to be included, or we will, as you say, break the bank. Which will not just eliminate medical care for everybody. It will also trash the lives of those who refrained from doing stupid things.
2. amba12 said,

   June 10, 2009 at 9:37 pm

   Problem, though: how do they know you’ve been doing stupid things? (He knows if you’ve been bad or good . . .) First of all, some minority of people really are genetically or metabolically obese, and many others have a predisposition to be. It could be intrusive: what are you going to do, monitor people’s purchases of fast food, or their caloric intake? There are people who can scarf down chips and Big Macs and stay skinny as a rail; and there are people who have a tendency to pack on pounds when they eat relatively normally. (I’m playing devil’s advocate now.)

   The only way not to be unconstitutionally intrusive or drastically unfair is to rely on self-reporting; and some people will lie. So . . . what’s to be done??

   Reduce people’s insurance rates for getting and keeping their weight (if overweight) and cholesterol down and/or quitting smoking? Raise rates for smoking (we already do) or having a body mass index above a generous definition of normal? (In my opinion bars and restaurants for smokers should be allowed.) How do you “incent” exercise, and how do you demonstrate that it’s actually being done? You have fitness clubs and instructors reporting on people’s attendance, the way librarians and booksellers were pressured to reveal what they read?

   Restoring physical activity to schools seems to me a no-brainer. It was just part of the schoolday when we were kids, and it was so refreshing, I’m sure we learned better as a result. Besides, it makes school less discriminatory against boys.

   Nutritious school lunches are also a no-brainer. Kids don’t yet have the adult’s freedom to self-destruct, and since the groundwork is being laid for present learning and a lifetime’s health, I think schools have the right and responsibility to do this (though only for kids who don’t bring lunch from home).
3. Ennui said,

   June 10, 2009 at 10:03 pm

   But some such feature has to be included, or we will, as you say, break the bank. Which will not just eliminate medical care for everybody. It will also trash the lives of those who refrained from doing stupid things.

   I’m not sure such a feature would help at all. Death from a massive heart attack at 64 would seem to be a lot cheaper than, say, requiring constant care from say, 88 to 98 (having avoided the heart attack due to clean living). Everybody dies, the question, as far as expenses are concerned, is how many resources are expended per person over al lifetime. Setting aside any marginal savings from increased organizational efficiencies and so forth, in the long run the only way to save money on health care is for people to receive less care over the course of their lives.

   That sentence ended with a period – for dramatic as well as grammatical reasons.

   By the way, I’m not faulting the elderly for hanging around. It just strikes me as irrefutable that better healthcare for more people = more healthcare for more people = health care as a larger sector of the economy. I doubt that lifestyle changes would affect the bottom line (over the long run) at all.
4. amba12 said,

   June 10, 2009 at 10:44 pm

   I dunno, I think the notion is that people would live longer but also be healthy longer and need less intervention. I don’t know if that has been conclusively demonstrated, though. Genes and luck may have more to do with it than virtue. We all know the stories of the people who smoked, drank, fornicated, and lived to 115 (probably b/c they were having such a good time).

   You hear stories of people who’ve been stented 20 times, had 2 or 3 heart attacks. My father had a quad bypass at age 67, the age both his parents died. He was probably on the verge of having a massive heart attack and may have even started to have it on the table as they were beginning to operate. Now — he’s 91! He’s never had another procedure, though he does use various medications to keep his arteries open. His arteries are crap, but somehow his body has apparently created collateral circulation. He’s lucky in many ways, but probably one big one: naturally low-normal blood pressure.
5. Donna B. said,

   June 10, 2009 at 11:50 pm

   We get these conflicting messages… smokers are now paying $1 a pack for something in the way of taxes. This is supposed to do two things — discourage people from smoking and raise revenue.

   It can’t do both.

   My son, who suffered a traumatic closed head injury at age seven has multiple disabilities. One of them is painful and uncontrollable spasms. All the current medications that are supposed to help control spasms do not work so well with him. Par of the reason is that his problem was cause by an injury — the places his brain doesn’t quite work as specified are not the same as those caused by disease.

   It’s useless trying to explain that nicotine (best delivered by a cigarette) calms his spasms to the point that he can drive safely. He is extremely upset by the huge increase in cigarettes because he has to choose (on his limited income) whether to drive or not smoke. The effect nicotine has on his brain and body is not his imagination — there is scientific evidence.

   There also evidence that a woman who smokes is less likely to suffer pre-eclampsia during pregnancy. In the ’70s when I was pregnant smoking was not frowned upon as it is today and it’s likely that I escaped pre-eclampsia because I smoked. Of course, it was also almost unheard of in those days for a woman to be awake when her child was born. Some things obviously change for the better… some things one wonders about.

   I’m not suggesting pregnant women take up smoking. I’m just saying that the evidence is not clear cut Bad/Good.

   And don’t even get me started on alcohol. Or marijuana….
6. amba12 said,

   June 11, 2009 at 12:11 am

   If medical marijuana, why not medical nicotine?! (That’s not the part of cigarettes that does harm, either.) Heck, where would a lot of us be w/o caffeine??
7. Ennui said,

   June 11, 2009 at 12:33 am

   I think the notion is that people would live longer but also be healthy longer and need less intervention.

   The only way that lifestyle changes could affect healthcare costs over the course of a life is if we were able to say that Lifestyle A reliably results in illnesses (and ultimately causes of death) that are cheaper to treat (or ameliorate) than Lifestyle B. I’m sure that this has been systematically argued somewhere. I’d like to see the analysis. I do remember seeing a study on smokers back in the 90s that suggested that smoking resulted in net social benefit (whatever extra healthcaare costs society incurred was more than covered by smokers not collecting as much in pensions, social security, etc. – and this setting aside the onerous taxes). It may be that we want people to live longer, healthier lives for other reasons, but I don’t buy the cost argument at all, unless …

   … we look at the whole shebang from a social utility standpoint so that,

   Social Utility = (Productivity * Years Working) – (Health Care Costs + Retirement Benefits * Years on the Dole)

   If a lifestyle change would reliably result in more productive years (along with an increased reitrement age), these things might balance out or actually save money over the current system. If not, it could easily (and in my little mind, probably would) be a net loss.

   This is the kind of thinking you get into when you socialize a major segment of the economy. I prefer a mechanism where people judge their own risks, costs and benefits.
8. amba12 said,

   June 11, 2009 at 12:53 am

   yeah, I’m from the “do you want to have your surgery by the post office?” school of thought when it comes to government running things. My family is proudly liberal, in the FDR tradition. They, we, were all taught to see government as good, as “public,” as a commons belonging to the people, an extension of collective, communitarian will. But where is that will?? Can you find it? Or is it somebody’s version of what it *should* be, imposed on everyone? There may be a collective unconscious that’s swept by “memes,” shared ideas and rushes of unifying emotion, but there is no sort of noble collective will, and that seems the most dangerous fiction of the liberalism I was brought up in.
9. Jason (the commenter) said,

   June 11, 2009 at 11:12 am

   Forget the freedom issue, the government can barely function as it is now. How can it find the time to enforce any of these new regulations or deal with the unforeseen consequences? And with all of our other current rules and regulations, how is any of this going to make us more competitive with the rest of the world?
10. amba12 said,

    June 11, 2009 at 11:20 am

    We’re already not competitive with the rest of the world, because we’ve already been too successful and our life has been too easy. We’re not hungry enough (pun intended). Kids sit on their couches and play videogames instead of studying to compete with Indians and Chinese. Or, their parents drive them (pun intended) to buildl fantastic kiddie resumés (presumés?) more out of parental narcissism than interest in American competititveness. A huge (proportionally) percentage of our best science majors are the children of Asian immigrants.
11. Bruce B. (chickenlittle) said,

    June 11, 2009 at 11:50 am

    When faced with the big macro economic question of “what to do about healthcare” I shrug my shoulders. I tweeted some suggestions here , here , and here . At a more personal level, one of the best things I did was to move my family to high deductible plan wherein we pay the first $8 k per year of expenses: everything above that is covered as so-called catastrophic insurance. The transition was relatively painless, because while the premiums decreased dramatically, I put the difference into a tax-deductible healthcare savings plan which rolls over every year and is portable. So instead of putting those premiums into a black hole, we now have a growing chunk of dedicated savings which we manage. I realize that this option wouldn’t work for families who have high fixed costs, but these people can and should have different options.
12. Bruce B. (chickenlittle) said,

    June 11, 2009 at 11:56 am

    Perhaps one “selfish” thing about high deductible plans is that they off-put the costs of caring for the indigent off of the normal insurance rolls. But I justify this by reasoning that if more people would actually pay for shop for quality routine healthcare, the costs should come down across the board.

    None of this addresses the big problem of very costly end-of-life care (I’m filled with stories and anecdotes from my RN wife). Deciding who gets care and who doesn’t is like playing God.
13. amba12 said,

    June 11, 2009 at 12:08 pm

    It’s possible that only a cultural change — becoming more accepting of death when quantity of life has totally trumped quality — will help. The baby boomers talked a good game about this when we were young; now it’s coming to the time to put our money where our mouth is. Will boomers cling to every morsel of miserable life at great expense?

    Taking care of a disabled and demented person makes you think hard about this for yourself. In the past, such people died of pneumonia. J in fact “tried” to do that in December 2006. Now, we don’t let them. And indeed, people who come down with pneumonia may have some fairly good time left, even if it requires intensive care from someone like me. But at some point, a point of diminishing returns is passed. When? Whenever it is, pneumonia becomes God’s own euthanasia. J’s mother died of pneumonia at 84, when she was still healthy in every other way but feared becoming frail and breaking a hip (she had stayed in Romania too long and felt too old to leave). There, they let it happen. Maybe if she’d still had immediate family there they would have treated her. It wasn’t like they didn’t have antibiotics, but they didn’t give them. We got there in time to be with her for the last 3 days and when she died. It wasn’t the worst death in the world. It only lasts a few days and at some point you lose consciousness.

    J’s mother had impressed me some years before by saying about death (in German), “I am curious about this last great experience.” And she let on that she was in fact observing the process when it happened. At one point she said with surprise, “The end comes so hard!” She didn’t seem to mean that she was in agony, but that it was a struggle to die. Her heart was fine and didn’t want to quit.
14. Maxwell said,

    June 11, 2009 at 12:18 pm

    I’m probably biased (my spouse works in public health), but I’ve looked at the data and the return on prevention programs is very good. The fact is that there are a number of widespread health problems in the US which are preventable or manageable with better habits. That may or may not include obesity, but it definitely does include heart disease, lung cancer, and type 2 diabetes.

    But prevention on its own is not nearly enough. For one thing, as Ennui points out, it doesn’t begin to touch end-of-life care, which constitute a huge proportion of Medicare costs. We have an ingrained culture of being willing to pay anything to keep our loved ones alive one more year, month, day. That cultural characteristic is compounded by the fact that our insurance plans are actually payment plans that prevent patients and their families from fully comprehending the costs.

    At the same time, there is no market in health care, nor should there be. The providers in health care – doctors, nurses, hospitals, and insurance providers – all function as cartels. Cartels are fundamentally anti-market forces, and they already get to tell people what their own risks, costs, and benefits are. And that’s a _good_ thing – we don’t want a health care sector where quality and credentials are not governed in a significant way. That would turn our nation into a giant version of the natural foods co-op where I used to work, and while I loved that place, believe me, that would not be an improvement.

    But because they act as cartels, health care providers are also hard-pressed to increase their capacity in response to rising demand. Existing regulations compound that challenge in many, many ways. Doctors leave school in way too much debt and immediately start a grueling, low-paying residency. That leads them to have to make more money later on, which in turn drives them towards specialization and high-priced services. We also have way too few professors of nursing, because a) the pay is poor compared to other academic paths and b) very few practicing nurses bother to get advanced degrees, because there’s no incentive to. So with doctors and nurses bottled up as they are, everyone is praying that some combination of technology and prevention can increase capacity. Both have a role to play, but even combined they’re not nearly enough.
15. Ennui said,

    June 11, 2009 at 1:52 pm

    I’m probably biased (my spouse works in public health), but I’ve looked at the data and the return on prevention programs is very good.

    That may be true at five years out or ten years out, but over a lifetime? For instance, this article makes the case that, over the long term, a complete cessation of smoking would increase health care costs
    Conclusions If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.
    I haven’t checked their methodology
16. Ennui said,

    June 11, 2009 at 1:54 pm

    Hmm. I guess I screwed up the link (I can do hyperlinks here, right?). In any case, this is the article:
    http://content.nejm.org/cgi/content/full/337/15/1052
17. Maxwell said,

    June 11, 2009 at 3:07 pm

    That looks like an interesting paper – I will try to give it a closer look when I have more time. At first glance, it does not seem to account for the likelihood that a healthier, longer-lived population would also be more productive. If that’s so, it’s a serious flaw in the methodology.
18. amba12 said,

    June 11, 2009 at 4:48 pm

    You can do hyperlinks, but having looked at the raw version of your comment I see that you just forgot to put in the URL.
19. Ennui said,

    June 11, 2009 at 7:08 pm

    Ah, thanks Amba.

    it does not seem to account for the likelihood that a healthier, longer-lived population would also be more productive

    Maxwell, I’m not sure that’s a flaw in the methodology. Bear in mind that the “increased years of productivity” does not figure into the question concerning the cost of healthcare (although it does figure into the question of overall social utility). Healthcare costs what it costs. Increased costs associated with a healthier, longer lived population may be more than offset by increases in productivity – but they’re still increased costs.

    On the overall question of healthcare costs, if, as I suspect, the biggest factor input (especially for an aging population) is labor, and domestic labor costs cannot be simply reduced, the only way to reduce healthcare costs in a meaningful way is to reduce the quantity of healthcare delivered. The most effective way to do this, I think, is something like what Bruce B described. Here’s a concrete instance: when I was a TA I had a student who managed to slice the palm side of his fingers with his new knife (which he was proudly showing me – what can I say, it’s Texas). I took him to the emergency room where he was presented with 2 options.

    Option 1: Stitch up the skin and hope that the knicked (but not severed) tendons would heal (he was told that it would probably be fine). Price ~$750
    Option 2: Call in the specialist to stitch up the tendons as well. Price ~$5,000

    He had no insurance. But he wasn’t broke. He mulled it over and chose option 1. As it happens, his hand was fine. This, harsh though it may seem, is cost cutting by means of market economics in the health care field. This is what I am for.
20. Maxwell said,

    June 11, 2009 at 10:34 pm

    Yeah, I slapped that off a little too quickly. Better to simply say that it’s an incomplete picture.
21. Bruce B. (chickenlittle) said,

    June 12, 2009 at 12:12 am

    J’s mother had impressed me some years before by saying about death (in German), “I am curious about this last great experience.”

    Did J’s mother use the word neugierig for curious? Just curious. :) neugierig is such a wonderful concept, literally meaning something like craving the new, or even having a thirst or hunger for the new. Our own word “curious” is so much lamer by comparison, and even had (I just learned this too) sordid connotations: link.
22. amba12 said,

    June 12, 2009 at 12:21 am

    Yep! “Ich bin neugierig über dieses letze grosse Erlebnis.” Literal translation would almost be “new-greedy.”
23. Rod said,

    June 12, 2009 at 1:36 am

    “But Newt recently quoted John Adams as saying only religious people could be trusted with a democratic government.”

    I recall reading that George Washington once said something to the effect that persons who did not believe in God should not be permitted to hold office because an oath would mean nothing to them. Flash forward a couple of hundred years: You can’t trust people who swear an oath whether they believe in God or not. We are the prevarication nation.
24. Bruce B. (chickenlittle) said,

    June 12, 2009 at 2:04 am

    Rod,
    But an oath is still a promise to tell the truth. “So help you God” may no longer instill fear in many, but the outing of truth still catches many off guard. And the means of outing the truth have improved with time, no?
    Wanted to say something about healthcare here but the thread is meandering!
25. Bruce B. (chickenlittle) said,

    June 12, 2009 at 2:26 am

    Will boomers cling to every morsel of miserable life at great expense?

    Yes! That’s the question in a nutshell. So many families (and ailing loved ones) cannot answer that question. It’s almost that simple. The professional caregivers are oriented (even incentivized) to prolong life (it can be written up somewhere!).

    Amba, just wanted to say that what you are doing with J. is a shining example of what needs to be done more. Though it is intensely private, you are not unrecognized by a completely indifferent public.
26. Bruce B. (chickenlittle) said,

    June 12, 2009 at 2:37 am

    One last thought: clinging to life is a completely human impulse for anyone. The disconnect is the chasm between (seemingly infinite) self preservation and the consumption of (seemingly finite) resources. The question circles back on how to increase the supply of finite resources.
27. amba12 said,

    June 12, 2009 at 3:08 am

    What I’m doing with J is what I saw people doing as a matter of course in Romania. They didn’t have any alternatives. But still it just seemed like what you did — so natural. Reciprocal. If it’s your parent, they took care of you when you were defenseless and dependent — how can you do less? If it’s your spouse, well, you’re married, how can one person stash the other and go back to living what amounts to a single life while the other is still alive? It just seemed impossible — didn’t even get to “wrong.”

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