By Dr. Jane Orient, on October 21st, 2011
When I went into solo practice of internal medicine in 1981, it was very easy to get a doctor to see a Medicare patient. All I had to do was make a phone call. A courteous receptionist answered. If the doctor couldn’t come to the phone right away, I could count on a prompt callback.
Consultants saw patients quickly, and generally called me to discuss their findings and advice. And very often there would also be a letter in the mail: “Thank you for referring this delightful patient to me.”
How things have changed! Now a doctor gets the phone menu, just as the patients do, and it often ends in voice mail. It might be a few days before a staff member calls back—usually with the news that “we are not accepting any new Medicare patients.” At best, my patient might be offered an appointment in several months.
One very fine gentleman, who had recently moved to a rural area, found it easier to fly to Tucson to see me than to get in to see a local internist. That was in 2009. Recently, he has become unable to travel, so I needed to find him a local doctor.
I tried to expedite matters by ordering him an immediate diagnostic test: an abdominal CT scan. I don’t think anyone could argue that it wasn’t indicated under the circumstances. One little problem: I am not enrolled in Medicare and don’t have the proper government-issued number to enter into the computer. A license to practice medicine is not enough. This National Provider Identifier (NPI) is supposed to protect the system against being defrauded. Without that number, the imaging facility could not get paid by Medicare.
“Why not use the radiologist’s number?” I asked. After all, he was the one who would get paid. Nope, a referral was required. How about a self-referral from the patient? Nope, we can’t allow patients to decide what tests they need. “The patient is willing to pay for his own test,” I said. Nope, if he’s on Medicare, they aren’t allowed to take his money.
They gave the patient 24 hours to find a properly enumerated doctor to countersign my order. Fortunately, he found a specialist willing to do so, and assume potential criminal liability for committing “waste, fraud, and abuse” by ordering a “medically unnecessary” study. (Fortunately for the patient, he turned out not to have cancer, but that could be bad news for the doctor.)
So this is the status of retired Americans. They can’t just walk into a facility and request a medical test, and pay for it with their very own money.
A man may be qualified to pilot a 747 across the Pacific, but once he’s on Medicare, he is unfit to make an unsupervised decision about his own medical care.
I did find my patient a doctor. None of the internists within a 150-mile radius who “take Medicare” are willing to take on a new Medicare patient. But through the website of the Association of American Physicians and Surgeons (www.aapsonline.org), I found a link to the Medicare carrier’s list of opted out physicians. They don’t “take Medicare,” but many are pleased to see older patients, for a reasonable fee. There was one internist on the list, 150 miles from my patient. She has a courteous and helpful assistant who actually answers the phone, and told me the charge for a new patient visit: $300.
Things could be worse—and already are much worse in Canada. The “soul-destroying search for a family doctor” is described in the Globe and Mail on Aug 21. The Ontario government’s program called Health Care Connect manages to link only 60 percent of patients with a doctor—although you might find a concierge doctor for $3,000 a year.
That’s the cost of medicine when it’s “free”—if you can find it at all. If ObamaCare is implemented, all Americans will be in the same boat. And guess who will get thrown overboard first.
By Simon Grey, on October 14th, 2011
Things are never so simple, of course. The tax has already been received by many Danish firms as a ‘bureaucratic nightmare’, piling on additional costs to firms in an already tough period. Once more, any tax such as this is going to be inherently regressive; those least able to afford any price increases will be hit the hardest. But what does it matter? The French ‘fat tax’ is expected to raise an estimated €120,000,000 p.a.. A nice little earner.
Fat taxes are politically convenient in countries where obesity is a sizeable problem. There is presumably plenty of revenue to be had because fat people aren’t going to change their eating habits overnight, nor are they the type to be particularly cost-conscious, in terms of both direct and indirect costs.
Furthermore, defending fatties is political suicide for most, since fat people are generally reviled. Thus, a fat tax is politically brilliant because it will raise revenue easily and enjoy widespread support (or, at the least, it won’t face much political opposition).
Most are in agreement that obesity is a society-wide problem. The more rotund we become, the more our healthcare costs increase. So what’s the solution? Surely not pricing poor people out of the market for fatty foods. We must seek a solution other than ‘more taxes’ – the default position of any government. Perhaps our BMIs could be helped by making it easier for people to help out at sport clubs without undergoing a raft of CRB checks, or by reforming our health system which currently permits the cost of atrocious health habits to be picked up by someone else.
Sadly the precedent has already been set. When we already allow the government to dictate what we may and may not consume in the form of innumerable drugs, letting them control what we eat is a logical advancement. And it will all be done for our ‘own good’.
Actually, once you expect the government to provide free universal health care for every citizen (and all non-citizen residents), the natural consequence is for the government to enact some sort of cost-cutting measure, like rationing or queuing. Alternatively, the government can enact a tax on unhealthy things in order to make providing health more reasonable. If fat people ignore the increased prices, the government will at least have enough money to defray future health care costs that inevitably arise as a result of unhealthy diet. Alternatively, if fat people decide to respond to the tax rationally, then the government will have to pay less for health care later on, thus negating the effect of less-than-projected revenue.
In many ways, a fat tax mimics the natural workings of the free market. If there were no governmental guarantees of health care, people would more inclined to take care of themselves and eat properly. Thus, the fat tax serves as a replacement market mechanism.
Now, this is not to say that I support a fat tax. I simply view it as the rational response to the current conditions in Europe, with regards to how health care is provided over there. Personally, I think the best solution would be to have the government completely deregulate and desubsidize the entire health industry, and get out of providing and paying for health care in its entirety. But if the government is going to be involved in health care, it is going to have to find a way to manage costs. That much is certain.
By Simon Grey, on June 7th, 2011
The United Kingdom, where, on average, people live longer than in the U.S., spends only about 9 percent of gross domestic product on medicine, compared with our 18 percent. The British control costs in part by having the will to empower a hard-nosed agency, the National Institute for Health and Clinical Excellence, to study treatments and declare some ineffective. Some hope the United States will create a similar agency, but I fear it would be hopelessly politicized and declawed.
My solution: admit we are cost-control wimps, and outsource our treatment evaluation to the U.K. Pass a simple law saying Medicare (and Medicaid) won’t cover treatments considered but not positively appraised by the Britain’s national health institute.
Even better, use clinical evidence evaluations of the British Medical Journal. They’ve classified more than 3,000 treatments as either unknown effectiveness (51 percent), beneficial (11 percent), likely to be beneficial (23 percent), trade-off between benefits and harms (7 percent), unlikely to be beneficial (5 percent) and likely to be ineffective or harmful (3 percent). Let’s at least stop paying for these last two categories of treatments! And to put pressure on doctors to collect evidence, let’s stop paying for “unknown effectiveness” treatments after 10 years of use.
As I’ve said before, and will continue to say until everyone in this world understands, universal health care plans will never work. Resources are limited, and no amount of political posturing will change that fact. As Robin Hanson notes, there will come a point where the government must cut back on providing health care, and that’s because there are simply not enough resources available to make sure that everyone is always in perfect health. Anyone who says otherwise is stupid, ignorant, or lying.
By Winton Bates, on May 31st, 2011
‘The Taskforce says that prevention is everyone’s business – and we call on the state, territory and local governments, on non-government and peak organisations, health professionals and practitioners, communities, families and on individuals to contribute towards making Australia the healthiest country by 2020.’ (Extract from ‘ Taking Preventative Action’, the federal government’s response to the Report of the National Preventative Health Taskforce).
I find the sentiments in the quoted passage objectionable for two reasons. First, preventative health care is not ‘everyone’s business’. Individual adults have primary responsibility for their own preventative health care because no-one is better able to exercise that responsibility than they are. Individuals who are persuaded that preventative health care is a collective responsibility could be expected to look increasingly to the various levels of government, non-government organisations, health professionals and practitioners, communities and families – everyone except themselves – to accept responsibility for what they eat, drink and inhale.
Second, the goal of making Australia the healthiest country by 2020 is being put forward as though it is self-evidently desirable collective good that should be pursued by any and every means available to everyone. The goal is not self-evidently desirable. Individual health is not a collective good. And the end does not justify the means that are being proposed to pursue it.
If you delve behind the spin about making Australia the healthiest country by 2020, the underlying goal seems to be to raise average life expectancy in Australia to the highest level in the world by reducing the incidence of chronic disease. What does this entail? It would be hard to object to the goal of enabling individual Australians to reduce their risk of chronic disease. The problem is that the government’s strategy is more about achieving national goals than providing better opportunities for individuals – more about behaviour modification than about ‘enabling’ individuals to reduce their health risks.
The government claims that analysis of ‘the drivers of preventable chronic disease demonstrates that a small number of modifiable risk factors are responsible for the greatest share of the burden’. The behavioural risk factors led by obesity, tobacco and alcohol apparently account for nearly one-third of Australia’s total burden of disease and injury. The chronic conditions for which some of these factors are implicated include heart disease, stroke, kidney disease, arthritis, osteoporosis, lung cancer, colorectal cancer, depression and oral health problems.
Since these risk factors stem from individual lifestyles it is obviously desirable for individuals to be aware of them. There may be a role for governments in provision of this information. Perhaps governments should also be involved in helping people in various ways to live more healthy lifestyles. It is questionable how far governments should go down this path, but it is difficult to object to modest efforts by governments to improve opportunities for people to live healthier lifestyles.
However, rather than helping people to help themselves the federal government has chosen the path of Skinnerian behaviour modification. It has chosen to drive changes in behaviour through what it describes as the ‘world’s strongest tobacco crackdown’. (This is one instance when I hope the government doesn’t actually mean what it says – some people in Bhutan have apparently been jailed recently for possession of more than small amounts of tobacco products.) The government’s strategy also involves ‘changing the culture of binge drinking’ and ‘tackling obesity’, but in this post I will focus on smoking.
Some of the tactics being used in the tobacco crackdown involve information and persuasion but there is also an element of punishment involved. The tobacco excise has been increased to over $10 for a packet of 30 cigarettes and legislation is proposed to require cigarettes to be sold in plain packaging. It seems to me that this amounts to persecution of smokers and their families. It will reduce the amount of household budgets available to be spent on other products and encourage some to avoid excise by obtaining tobacco from illegal sources.
As a former smoker, I am probably more strongly against smoking than most people who have never smoked. I encourage other people to quit smoking and discourage young people from taking up the habit. But having given up smoking several times, I know how hard this can be. Governments have no basis on which to judge that people are not in their right mind if they consider that the pleasures they might obtain from additional years of life are not worth the pain of giving up smoking.
In my view this question of whether smokers are capable of judging what is in their own best interests is at the crux of the matter. The politicians and bureaucrats who seek to modify the behaviour of smokers may see themselves as enhancing the capability of these people to have lives that they ‘have reason to value’, in accordance with well-being criteria proposed by Amartya Sen. If so, their attitudes highlight a major problem with Sen’s approach. Governments have no business deciding what kinds of lives individuals have reason to value.
Enrolling into a drug rehab program can be the hardest thing to do but it can save a life.
By Simon Grey, on May 13th, 2011
Putting aside, for the moment, the details of the Ryan plan, what many voters refuse to understand is the unpleasant choice they inevitably face. Either cost-control by the consumers or cost-control (aka rationing) by the State. The issue is stark.
Either consumers directly or indirectly will communicate to healthcare providers the need to economize or the State will put limits on what people can get. The thing is Americans don’t want to have to do the former nor allow the latter to happen. The “advantage” of State limits is that they feed fantasies Americans may still have about State magic. Stones into bread, and all that. We can all get the best care regardless of cost. (Keep in mind I want the best care regardless of cost too!)
The underlying problem with government-run health care programs is that they fail to solve the problem of scarcity. Politicians may promise unlimited resources and voters may believe those promises, but the simple fact of the matter is that there are not, in fact, unlimited resources available.
That resources are scarce implies that there MUST be some form of rationing. Democrats and their lapdogs in the mainstream media mocked Republican candidates for claiming that ObamaCare would lead to so-called “death panels.” And the Republicans are right: Government appropriation of health care doesn’t alleviate the need for rationing. Since health care costs are highest for the elderly, and the highest medical costs occur during the last year of one’s life, some sort of “death panel” rationing system is not entirely inconceivable.
Thus, the debate is erroneously framed as unlimited health care versus elitist limited health care. (This is, of course, a hyperbolic simplification. However, the general point remains.) The debate would be more accurately framed if it were described as state-based rationing versus market-based rationing of health care. This way, citizens would more inclined to compare the relative equitability of the competing methods of rationing, and would hopefully be more likely to make the better choice.
By Thomas Knapp, on December 9th, 2009
Simply put, it’s like this: If you’re a member of Generation X or Y or whatever the hell they’re calling the various post-Boomer generations these days, you are to be boiled in hot water until you’re nice and tender and your meat and bones have separated.
The insurance companies receive the meat (“individual mandate”).
The Boomers get the bones (“Medicare buy-in”).
Beautifully efficient as cannibalism schemes go, don’t you think?
Unlike the previously considered “public option” — which might have had loopholes through which a clever youngster could have navigated his or her wallet to some semblance of safety — the “Medicare buy-in” automatically gets the older, higher-risk types out of the insurance companies’ way while pushing the younger, lower-risk population right into their gaping maws with the “individual mandate.” Lower risks! Higher profits!
And watch for ObamaCare’s approval ratings to jump way up since that older, higher-risk group — the over-55 set, which almost certainly constitutes an absolute majority of voters — gets its health care subsidized by the younger, lower-risk group, too (through the payroll tax system, which is already tried, tested and and as escape-proof as anything the government’s ever come up with … just wait, it won’t be long before the younger group’s “insurance premiums” get folded into that scheme as well).
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