
A new report clarifies some misconceptions about the U.S. medical system - austenallred
http://www.theatlantic.com/health/archive/2013/11/obesity-not-old-people-is-making-healthcare-expensive/281444/
======
nostrademons
I've long thought that _the_ most effective action the government could take
to fix health care (and a variety of other problems) would be to eliminate
corn subsidies.

That one government action has ripple effects throughout the economy and
almost all of them are negative. It concentrates economic power in big
agribusiness instead of farmers, because it means that chemical/bioengineering
companies like Monsanto can wield huge economies of scale across the one crop
that is most economically viable in the U.S. (because it's subsidized by the
government). It drives local farmers out of business because they can't
compete with the giant agribusinesses. It makes the U.S. agricultural system
less resilient to drought and blight, and more dependent upon petrochemical
fertilizers.

And then it also makes it far more economical to make food products with high
fructose corn syrup, corn-fed chicken & beef, cornmeal, and corn starch, all
of which are phenomenally unhealthy for you. This is why poor people eat at
McDonalds; because of the subsidies, corn-fed beef & chicken and soda made
from high-fructose corn syrup are much cheaper than healthier alternatives,
and so that is all poor people can afford. Then they get fat, and the rest of
society bears the burden for their medical and lost productivity costs.

~~~
DanBC
Soda made from regular sugar is going to be as cheap as soda made from HFCS.
Obese people will still be able to drink 64 ounce "cups" of sugar water.

Fat people do not need HFCS to become fat. They need calories. Some people
suggest that HFCS may make those calories less satiating than calories from
fat, but they don't mention other types of sugar. Any sugar when eaten in
excess is harmful. Sugar from honey or sugar beets or sugar cane is going to
cause harm if you're drinking six litres of soda a day.

The Economist puts a UK Big Mac as cheaper than a US Big mac. What are our
subsidies that make the burgers so cheap, if we don't have cheap HFCS?

[http://www.economist.com/content/big-mac-
index](http://www.economist.com/content/big-mac-index)

~~~
Chestofdraw
Possibly the beef subsidies? According to the site linked below the price for
a big mac meal is cheaper in the US, so they have a more expensive burger but
cheaper sides.

[http://www.humuch.com/prices/McDonalds-Big-Mac-
Meal/______/5...](http://www.humuch.com/prices/McDonalds-Big-Mac-
Meal/______/518)

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siculars
My brother is a doctor. I work in a university hospital in medical informatics
and I'm friends with literally dozens of doctors across a spectrum of
specialties. Every single one of them will put obesity at the top of the
"what's wrong with healthcare/the population/people" list.

Just stop being fat.

~~~
old-gregg
Successful "healthcare service providers", not obesity is what is making
healthcare expensive. Ask a Porsche salesman who his clients are.

Obesity doesn't explain a $800 knee MRI or $4K ambulance ride. A californian
hospital billed us at $3.7 __per second __for a broken wrist.

Your brother, not fat people, is making healthcare expensive. This is so
freaking obvious I'm starting to veer into conspiracy theories territory
failing to explain this craziness: they'll start suspecting "mongolians and
puerto-ricans" as factors before they'll notice this enormous elephant in the
room. Every US city has a neighborhood where "doctors live". It's sickening.

Also, ask your brother what he thinks. I have a few friends in healthcare and
they're very open about it (it's hard to deny if you know their lifestyles)

~~~
thejteam
$3.70 per second is 222 per hour. In a world where a freelance Javascript
developer can bill 125 or more per hour, that doesn't seem too unreasonable
for doctor plus nurse plus office overhead plus materials. In fact it seems
cheap. My daughter just broke her wrist and I paid the bill. 3.70 per second
is ballpark what I paid as well. I feel the pain, but yes it was worth it.

EDIT: oops, bad math. But 3.70 per minute is closer to the actual cost I paid.
I can't say exactly because I didn't have a stopwatch going.

~~~
eurleif
>$3.70 per second is 222 per hour.

$3.70 per minute is $222 per hour. $3.70 per second is $13320 per hour.

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alexeisadeski3
Is it possible that more than one factor is making healthcare expensive?

The US gov't itself already spends more (per capita) than does the Canadian
gov't. Is the US obesity rate much higher than Canada's? Have a look:
[http://en.wikipedia.org/wiki/Obesity_in_the_United_States](http://en.wikipedia.org/wiki/Obesity_in_the_United_States)

------
transfire
Insurance companies make healthcare expensive.

Pass a law that requires all payers to pay the same rate for the same service,
be it an insurance company or an individual paying out of pocket and the
system would get fixed in short order.

~~~
zdw
This. Middlemen always push the prices up and they exist to get a cut, nothing
more.

In many cases, the insurance agent who sells the policy gets paid the roughly
the same amount as a primary care physician for looking after a patient. Only
one party here is actually doing needed work...

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streptomycin
This says otherwise
[http://www.plosmedicine.org/article/info:doi/10.1371/journal...](http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050029)

Who do I believe, a blogger from The Atlantic who seems to be misinterpreting
the data he cites, or a peer-reviewed scientific publication?

~~~
MaysonL
Well, what that report says is that fat people cost more per year then non-
fat, but since they die quicker, they don't cost as much over their lifetime.
It would be interesting to see what discount rate would equalize the costs.

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__pThrow
What a horrible headline in the original article!

Headline: ___Obesity_ __, not old people, is making healthcare expensive

Article: contains no occurrences of the word ___obesity_ __

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DanBC
> _Actually, chronic diseases, such as heart disease and diabetes, among
> people younger than 65 drives two-thirds of medical spending. About 85
> percent of medical costs are spent on people younger than 65, though people
> do spend more on healthcare as they age._

I thought this might be because the US system has much more support for people
over the age of 65, and thus pushes prices down, but later on in the article
they say

> _Though it often may feel like out-of-pocket expenses are growing
> disproportionately to the cost of healthcare, Medicare, Medicaid, and
> federal employee plans have actually picked up an increasingly larger share
> of the tab._

The article makes some assumptions.

> _The patient wants to see the best doctors and get the best treatments
> available,_

Not necessarily. Many patients don't want the best, they just want protection
from the worst and they want "good" or "excellent", but they'll include other
things. "How convenient is the hospital for people to visit or for me to get
after care?" is one example.

The article title is annoying. The article doesn't explain why obesity is
driving up costs, and doesn't do a good job of showing that obesity is driving
up costs. The abstract doesn't mention obesity, but says:

> Three factors have produced the most change: (1) consolidation, with fewer
> general hospitals and more single-specialty hospitals and physician groups,
> producing financial concentration in health systems, insurers, pharmacies,
> and benefit managers; (2) information technology, in which investment has
> occurred but value is elusive; and (3) the patient as consumer, whereby
> influence is sought outside traditional channels, using social media,
> informal networks, new public sources of information, and self-management
> software.

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ScottBurson
My personal bizarre pet idea for bringing down healthcare costs: mandatory
_minimum_ copays.

The problem, by one analysis, is that patients have no incentive to weigh
costs against benefits. That's a tough task in any case, and pushing it off to
the insurers makes it harder, as the insurer has less information than either
the patient or their doctor about their individual case. The result is that
neither patients nor (often) doctors know what the services cost.

In fact price information has been so effectively removed from the system that
in some cases _nobody_ knows what the service really costs. tptacek posted a
great example:
[http://news.ycombinator.com/item?id=4465845](http://news.ycombinator.com/item?id=4465845)

The purpose of the mandatory minimum copay is to force price information back
into the system. When patients _have_ to pay some part of the price of every
service, they will therefore have to know what those prices are.

All that said, there are obviously some questions and problems to be dealt
with. For starters, what's the formula for how much people have to pay? On the
large end, I would suggest something like (price in dollars) ^ 0.7. This means
for a $10k service, the copay would be about $600; for a $100k service, about
$3000; and for a $1M service, around $16k. Those numbers feel reasonable to
me: big enough to make most people think twice about choosing a six-figure
intervention, but not an absolute barrier if there's a good medical reason.

On the small end, though, that formula produces numbers that are arguably too
large. A $200 service (if there is such a thing? maybe in lower-income rural
areas) would have a $40 copay by that formula. This risks discouraging people
from getting preventative and urgent care that they need. To correct for this
we could simply subtract some fixed number from the result of the above
formula. I'm not sure what the right number is, but somewhere in the $40 - $80
range, I would guess. (This provision could also be subject to means testing.)

Probably when I say "mandatory" what I really mean is "the government provides
incentives to make plans with this property significantly cheaper than those
without". I don't care that rich people will circumvent the rule if they want;
I just care that _most_ people are on plans with this property, so that, as I
say, price information is forced to flow again.

~~~
aantix
Read Maclolm Gladwell's piece, "The Moral Hazard Myth"

[http://www.newyorker.com/archive/2005/08/29/050829fa_fact?cu...](http://www.newyorker.com/archive/2005/08/29/050829fa_fact?currentPage=all)

"For that matter, when you have to pay for your own health care, does your
consumption really become more efficient? In the late nineteen-seventies, the
rand Corporation did an extensive study on the question, randomly assigning
families to health plans with co-payment levels at zero per cent, twenty-five
per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars.
As you might expect, the more that people were asked to chip in for their
health care the less care they used. The problem was that they cut back
equally on both frivolous care and useful care. Poor people in the high-
deductible group with hypertension, for instance, didn’t do nearly as good a
job of controlling their blood pressure as those in other groups, resulting in
a ten-per-cent increase in the likelihood of death."

~~~
ScottBurson
Very interesting column! Thanks! I will think about it.

------
npsimons
As others have pointed out, there are many factors that contribute to high
cost healthcare. And while I think that BMI is almost completely worthless,
and I've never been _really_ fat, I can say that exercise and losing weight
are some of the best things (and best feeling things) I've ever done.

Sure, fix the costs (especially with IT/technology in general, as those on
this board can probably have the biggest effect on that), fix the insurance
industry, and let's have a serious look at the food industry while were at it
- but on an individual level, giving exercise a try will probably reduce our
health costs in the long run and make us feel better in the short run.

------
melling
Gotta wonder if the sedentary lives that many of us have isn't going to lead
to health problems. Throw in the long hours and there has to be a health
downside.

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jes5199
It's NOT a trivial problem, though. There's evidence that other mammal species
are also experiencing obesity epidemics, even though their diets haven't
changed: [http://www.aeonmagazine.com/being-human/david-berreby-
obesit...](http://www.aeonmagazine.com/being-human/david-berreby-obesity-era/)

------
slt555q
Hmmm...I guess all those other academic papers showing that the greatest
percentage of healthcare dollars go to end of life care defined as final 2
years but especially final 6 months. I am also pleased to see this analysis
was in part conducted by, "we'll tell you what you want to hear as long as you
pay us" BCG. Or as I know them BSG. Healthcare costs are skyrocketing because
people are making a lot of money. Look back to '76 or so when the people who
pushed for changes to the laws allowing for the creation of HMOs and promised
enormous savings. That didn't happen. Any time you have a major consulting
company telling you how to reduce healthcare costs the sound your actually
hearing is money dropping in their pockets. It would be fun to skewer the
article point by point but not worth the time.

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ghouse
And by the transitive property, subsidized processed food, including corn
syrup, is making healtcare expensive.

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youngtaff
I'm not even sure the headline actually represents the original article
faithfully
([http://jama.jamanetwork.com/article.aspx?articleID=1769890](http://jama.jamanetwork.com/article.aspx?articleID=1769890))

One thing to note is that there are many organisations who represent the
elderly and they have political power - certainly in the UK, older people vote
so you see laws that benefit them sometimes to the detriment on the young.

------
slt555q
PS Ask my friend in Canada who is waiting 16 months for a hip replacement how
happy he is.

~~~
HarryHirsch
This very issue is known in Britain as the "little old lady problem".
Resources are limited, and society needs to decide who gets care first. There
are many life-threatening conditions, but arthritis in the hips and knees
isn't one of them.

Consequently, if you can pay, you get to the front of the line, and if you
can't you'll get one eventually, but you won't die.

They always roll out the little old ladies in wheelchairs when it comes to
healthcare reform.

~~~
slr555
"Consequently, if you can pay, you get to the front of the line, and if you
can't you'll get one eventually, but you won't die."

That's such a great comfort when you are in excruciating pain and can't walk.
I think that should be the motto of the NHS "at least you won't die". Aim
high.

Actually it's not the little old lady problem. I did a documentary on
healthcare in the UK. One of the patients suffered from severe rheumatoid
arthritis, a serious autoimmune disorder, she was told it would take 6 months
to see a rheumatologist. She had the means to pay for private care and saw the
same doctor within a week. You see arthritis which you probably don't have and
obviously don't understand comes in many for from the less complex
osteoarthritis to forms that have many nasty sequelae such as lupus or
psoriatic arthritis.

I have worked in healthcare for 20 years and my wife about the same but she
has worked more internationally. In countries with state run healthcare many
times newer treatments such as cancer drugs are not available.

Flawed though it may be I will stick with US medicine.

~~~
HarryHirsch
_One of the patients suffered from severe rheumatoid arthritis, a serious
autoimmune disorder, she was told it would take 6 months to see a
rheumatologist_

Again: rheumatoid arthritis does not kill you.

 _many times newer treatments such as cancer drugs are not available_

Good that you say that. In many countries to gain approval the manufacturer
needs to show a benefit over what is already on the market. Whatever was there
was new, but it didn't prolong survival or improve quality of life. Why should
the public pay for something very expensive (because it's still under patent)
when something equally good is available for much less as a generic?

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tpainton
the societal move to destigmatize obesity is the culprit. It's now okay to be
big and beautiful.

~~~
stefan_kendall
I think you may have cause and effect backward here.

Suppose a bunch of people get fat. What are the chances that they, after the
fact, convince themselves that fat is okay?

~~~
npsimons
Not to mention that stigmatizing obesity is not going to solve the problem.
What is this, grade school? "haha, fatty-fatty-fatty!" Maybe some empathy and
support would go much further in helping the obese to conquer their problems.

------
kimonos
True! Many people nowadays are suffering obesity and sometimes are unaware
that their health are at risk.

