20 January 2010

and now I'm asking for it

Obviously, this is all up for debate. Matt asked for my opinion. This is what I shared. Straighten me out!

Honest opinion: we should not provide "death care" or "slob care". That would change everything. Bonus opinion: focus on and reward people for wellness.

I attended a health care forum hosted by Bob Dole at the Dole Institute. It brought people from various parts of the health care industry (except insurance – that guy didn't show up, and apparently they rarely do). All I remember is that somebody – some expert – quoted a stat that something like 80% of health care costs for a patient's last stay (or maybe all stays?) comes in the last 3 weeks. That's death care, and I don't want to put my buck behind it.

If you don't take reasonable measures to be well, then I don't want to pay for your care. I don't know what those measures need to be, but they should probably be few and straight-forward. "Vegetables" comes to mind. "Corn syrup" comes to mind. Most importantly, they need to be auditable; it should be inexpensive and objective to determine if the guidelines have been met. Too many people develop chronic illness from their lifestyle and then that raises my costs. That's slob care, and I'm ag'in' it.

The government should either compete with, strictly regulate, or obsolete insurance companies. My suggestions above apply in the first two options. I don't know how to obsolete it.

Insurance companies manage risk by randomly pooling its subscribers to disperse costs. That's the origin of employer-provided care; the employer is an easy and (usually) effective way to randomly pool people. I think that model is over-simplified. Insurance costs should be hierarchical based on how healthy I am, right now (yearly re-appraisal?), according to my doctor. This appraisal should not include my medical history – just my current health and the results of that audit I mentioned above.

Primary care physicians should be paid more than specialists. Sure, specialists paid more for their education and are favored by supply-and-demand and such, but this is mucking up the system. It's upside down: specialists have the least contribution to a society's health, and yet they are rewarded the most. GPs are the front-line and need to be treated as such. Their clients-per-day are like students in a classroom and need to be minimized so they can receive the attention and advice needed for wellness.

Basically: reward people for a healthy lifestyle, punish them for an unhealthy lifestyle – deal with it libertarians, if you want insurance. Change the payment/appreciation of GPs versus specialists to reflect that emphasis on wellness. Make a regular check-up more viable and less expensive. Most radically: don't spend tons of money treating dying people or people with extremely rare diseases – it's just not as useful for the society, nor fair to the other people in that risk pool.

Also, reform in the insurance and medical services industries will have non-trivial consequences for any intimately related industries, including pharmaceuticals. Someone needs to research drugs, but that business-model is currently as messed up as the RIAA – it's all about intellectual property, baby.


Philip Weaver said...

Yes, we waste resources on people that don't take care of themselves, and therefore don't deserve to have those resources wasted on them. And that's frustrating.

I would prefer that it be more acceptable to terminate a terminally ill patient. At the very least, that patient should be able to make that decision for themselves (themself?). But, if we did it against their will... well, I wouldn't be as upset about that as most people.

But, what I really want to respond to is whether we should intentionally punish people for making poor health decisions.

Two main points: 1) Is it even possible to implement a policy that correctly identifies whether any individual's poor health is their fault? 2) If you punish people for being in poor health, you should punish them for being poor. 3) There's a better solution.

An individual's risk for certain health problems is based on genetics and socio-economic factors, not just their behavior. While I can certainly look at a particular case (so-and-so obviously destroyed his liver by drinking), I don't think you can implement a fair policy to apply to everyone. For example, genetic factors predispose some of us to alcoholism.

It is hard to make a case that being in poor health is your fault but being poor is not. If you deny care to those who don't deserve it because they do not take care of themselves, then you should also deny it to those who cannot pay because they don't work hard enough. I think this argument would sit well with many Americans, who believe -- more than the rest of the world does -- that poverty is your own fault, and blame the poor instead of taking care of them.

Yes, people should be responsible for their health. However, rather than punishing them for making bad decisions (or rewarding them for making good ones), we should enable them to make better decisions. Focus on regulation and education, so that people will have better choices to choose from and will know how to make better decisions.

Philip Weaver said...

Oh, that's three points, not two.

Nicolas Frisby said...

As to the feasibility, I'm not sure. A good start would probably be determining if they smoke or some analysis of their diet. Certainly, choosing these guidelines will be tough – maybe even impossible. But this is my ideal.

With regards to the poor, I recognize the correlation you're concerned about. Hopefully (again) the guidelines will emphasize things independent of financial situations (e.g. smoking again, maybe DUIs?). The "don'ts" on the list seem more likely to fit this category.

"It is hard to make a case that being in poor health is your fault but being poor is not." Agreed. Reliable indicators of unhealthy luxuries is mostly what I have in mind. At least as a place to start. Welfare-based care probably needs to be (remain... I think) separately managed from the rest.

Genetics terrifies me in this context. Do genetic pre-dispositions already affect insurance availability and/or prices?

"However, rather than punishing them for making bad decisions (or rewarding them for making good ones), we should enable them to make better decisions." Pro-education, yes, but I consider that independent from financial motivation. They are both important!

Thanks for sharing.

Philip Weaver said...

Rather than answering "ideally, what solution would be best?", we should answer "pragmatically, what solution will have the best result?".

If we could realize a flawless function for determining whether one's health problems are their own fault, that would be the ideal solution.

As a general rule in any context, I would advocate for teaching and enabling people to make good decisions, and not punishing them or rewarding them based on the decisions they make. I believe this healthcare topic is analogous enough to parenting, that rewards and punishment are ineffective at instilling motivation in someone and teaching them to make good decisions. It's even worse in the case of healthcare; you won't learn from your mistakes if they kill you.

(Ok, that analogy doesn't hold very far).

Philip Weaver said...

Oh, it's also important to identify the end goal. I think your solution targets reducing the cost of medical care for oneself, with the added bonus of reducing everyone's costs, but mine actually attempts to improve the quality of life of others as an end goal, with reduced medical costs as a side effect.

Nicolas Frisby said...

"As a general rule in any context, I would advocate for teaching and enabling people to make good decisions, and not punishing them or rewarding them based on the decisions they make." That emphasized part disturbs me when their actions affect me. I want to be the one responsible for my health care costs, and not subject to the choices of others just because I'm lumped into the same group. Are those people more motivated to "make good decisions" via education? I think many already know better but still drink extreme amounts of soda, for instance, or don't prevent their children from doing so.

I'm sketching my ideal. Maybe once I'm satisfied with it, I'll look for compromises to reach pragmatics. But right now, it's still in development. You've poked a lot of holes in my "guideline" idea, and it's not holding much water. (Especially respecting the circumstances).

I think that framing the issue in terms of individual benefit will garner more support from politically active citizens. That seems pragmatic in a capitalist democracy.

Tyler Harnett said...

I agree with Phil. Sorry Nick.

Worst Case Scenario, you're asking a single income, minimum wage, family of 5 from the inner city to pay out the ass or change their eating and living habits. Generally, changing habits is a luxury.

Look at our house, for instance. If I were on the brink of bankruptcy, I wouldn't value 8-min abs and Tai Chi. I would spend money on the necessities (Easy Mac, and other unhealthy foods) and cheep entertainments (TV, etc).
It may be motivating for me to change in the long run to save costs, but I wouldn't buy-in in the short term. Then, maybe, social medicine would pick up the slack and we would be in the same place we are today or I would die without insurance and with debt and I would pass that debt onto my children thereby creating a cycle.

Cycles of systematic injustice and inequity are the reason that dropping down a system of punishments and rewards wouldn't work. People today are "nature and nurture" effects of positive and negative historical events. This is an educational issue too.

I say that and then I realize that I am just poking holes in your argument w/o proposing a system of my own. *This isn't debate class, it's life*

I think that the First goal of Health Care in the US is to have affordable health care for everyone, without consideration to their present choices or pre-existing conditions. Once that is accomplished (probably by putting the Fed Gov in quadruple the debt), then the Second goal would be to educate and encourage healthy lifestyles.
Hey, why not stop subsidizing cheap corn and subsidize local sustainable farms? Hey, why not tax the FUCK out of the rich - they'll find some loopholes - and pay for public gyms and exercise centers, or other ways to get people healthy?

Final thought, in my pragmatic system, the money is going to have to come from the people who have it in excess and not the people who need it, for a time.

- Robin Hood

Nicolas said...

Tyler, I said, "Welfare-based care probably needs to be (remain... I think) separately managed from the rest." does your cycle of injustice issues apply to non-poor people, too?

I am uncomfortable with redistribution of wealth.

We can't provide affordable universal healthcare without lowering costs, somewhere. "Reform" isn't just cover more people, it's "be more efficent." How would you lower costs – without just subsidizing the leaky system we have?

My original post said, don't prolong terminal patients, even when there's hope, if the costs are disproportianate; don't cover expensive care for extremely rare diseases; encourage preventative care by somehow increasing a GP's salary as compared to specialists and by providing financial motivation to live a healthier lifestyle. Phil inspired me to mention that the financial motivation is inappropriate for the poor and so they should probably receive a different form of motivation.

Motivation is something I think is key, however. That seems to be something you and Phil disagree with me about. For the poor, it obviously shouldn't be financial; maybe it's fewer choices. How do food stamps work? They might already be doing this, but perhaps food stamps could only be exchanged for certain foods, such that it's more difficult to eat crappy food, but doesn't literally cost anything but "change of habit." As your health indicates better choices made, your food stamps could be modified to provide more choice.

Mandatory food stamps for everyone – viola! If you can afford it, opt-out of them and donate them and eat on your own buck. Otherwise, take the financial motivation to eat well, since these food stamps couldn't be redeemed for soda, for instance. (Can today's food stamps?) as your doctor, whom you're seeing more often and spends more time with you, OKs it, your stamps could admit some
luxuries. Liberty be damned, long-term health is basically an externality and should be socially enforced just as much as pollution – especially if someone's health choices affect my finances (as in socialized healthcare).

How would you change things in order to motivate people to make (long-term) healthier choices, such as what they eat?

Nicolas said...

Pay people to exercise at your public workout facilities, or if their doctor says they get enough exercise.

Tyler Harnett said...

1) What makes you uncomfortable with the redistribution of wealth?

Mandatory food stamps is a stranger idea than taking money from people who have outrageous salaries for little reason.

2) So we're only talking about the middle class in this discussion?

If we don't have a universal discussion, then we can't solve the problem. The gap would just continue to widen.

That is why I am talking about prioritizing getting everyone covered before getting the system fixed. If we "fix" the system with an idea that saves money in the short term, we may be punishing people who a) have preexisting conditions or b) have values/priorities different than the new system.

You couldn't say to everyone in the present system, "You made these choices and now you need to die." There would have to be a 'grandfather' clause. Otherwise, the new system would reinforce the same inequalities already present in our system.

Nicolas Frisby said...

1) redistributing wealth – People shouldn't be punished for earning lots of money. The problem with some, maybe most, of the rich is that they don't really earn it – CEOs and such. I'm uncomfortable with redistributing wealth because I don't know how to distinguish those who earned it from those who didn't.

2) middle-class – I don't see inequality as either the problem with our system, or the cause of that problem. I see inaccessibility as the problem, and I assume that is because the system is institutionally flawed with wide-spread inefficiency and profiteering. I think "health" should be recognized as a social good, something that capitalism will not naturally provide. Pooled insurance is just a bad imitation of socialism.

I want to lower costs by first focusing on the larger part of the population that doesn't require special financial consideration. And I think the government is the appropriate entity to manage all of this.

At least 15% of the population is completely uninsured, and a substantial additional portion of the population is "underinsured", or less than fully insured for medical costs they might incur." Wikipedia. Most people are insured, so, to cut costs, we should focus on refining the costs before we focus on expanding coverage – that will be a natural consequence of it being less expensive.

The section on spending has a lot of numbers I need to look at more. On a skim, it supports the idea that spending it mostly disproportionate, and that specialties may be contributing to that significantly.

I agree about pre-existing conditions: "This appraisal should not include my medical history – just my current health and the results of that audit I mentioned above." This is contradictory in terms of cutting costs, but I think it's important in and of itself. There should be a (life-time?) spending cap per person, however. This is partly the point of my criticizing "death care" and disproportionately expensive treatment/research or rare diseases.

Philip Weaver said...

Well, I would say they didn't earn it if the amount is more than X (where X is, say, any more than a few million a year). Nobody needs that much money. That is why I support a very high marginal tax.

You can't just say redistribution of wealth is bad, taxes are bad. There are always taxes. You have to argue how much is ok. Is our current tax rate fair? The marginal tax was huge (>90%) in the early 1900s, and people complain that it's too high now. Again, I support a huge marginal tax.

Philip Weaver said...

And if you respond with support of a flat tax... I will shoot you... in the face.

Nicolas Frisby said...

I'm becoming a little uncomfortable with the growing regularity of your death threats, Phil.

Thought experiment: Say someone invented cold fusion in their garage; perhaps they deserve millions?

Yes, I realize that the vast majority of people currently make millions for bullshit. I would rather they not make those millions in the first place, instead of taxing them on it after the fact. How different is that? I'm not really sure, but it feels like it's addressing the egregiousness more directly. Then again, it probably means less revenue for the government.

Thought experiment 2: Where does the money go, if such income is disallowed? I suggest evenly spreading it throughout the company's entire workforce. That's the kind of solution I would prefer – keepin' it within the people that enabled the company's revenue in the first place. I wonder how much that would change the quality of life of, say, your average factory worker.

How would this apply to less conventional companies? Sports stars? Movie stars? I suppose you could still spread out the money over all employees of the league/broadcasters/venue/production companies/distributors/theaters. Dot com boom and such? That's weirder; disgusting speculation was the problem there, I think. But that's infringing on the separate topic of systematic problems with our financial institutions. When is a company's income completely disproportionate to its work force's size?)

Philip Weaver said...

Ah, that's very simple. There are two logical steps: 1) If you prevent a CEO from making more than X, then the extra will naturally get distributed to others in the company. 2) If you apply a 100% tax to everything over X, you will effectively lower the CEO's salary to X.