

The biggest issue facing America - lmoorman
http://lewmoorman.com/the-biggest-issue-facing-america

======
bokonist
The simplest thing to do is pick out the best healthcare system in the world,
and then replicate it exactly. So bring in the top officials from Singapore,
put them on an independent commission to redesign the healthcare system, and
force Congress to pass exactly the plan they come up with.

Read more about Singapore's healthcare system here:
[http://econlog.econlib.org/archives/2008/01/singapores_heal....](http://econlog.econlib.org/archives/2008/01/singapores_heal.html)
[http://www.american.com/archive/2008/may-june-magazine-
conte...](http://www.american.com/archive/2008/may-june-magazine-contents/the-
singapore-model)

But coming back to Earth, such a plan could never happen. If you approach the
problem from the perspective of a hypothetical policy advisor, there is very
little that is both a) politically possible and b) would actually improve the
system. Raising the caps on medical school enrollment is an obvious fix that
would reduce costs without costing taxpayers anything, but the doctors will
try their hardest to block it. A mandate to buy insurance makes sense in
theory, but in practice the required level of healthcare to buy gets set way,
way, too high, and so a mandate ends up being a huge transfer from citizens to
the healthcare industry. There are dozens of other examples. Our system is f
__*ed up for a reason, and until the political system is reformed, policy
reform is impossible.

In reality, healthcare spending will continue to rise until it simply cannot
rise further. The spending will be distributed according to political power.

~~~
anamax
> The simplest thing to do is pick out the best healthcare system in the
> world, and then replicate it exactly. So bring in the top officials from
> Singapore, put them on an independent commission to redesign the healthcare
> system, and force Congress to pass exactly the plan they come up with.

You'd have to also replicate the covered population and make sure that there's
a "USA" outside paying for drug development and the like.

~~~
ibsulon
As much as people speak of the drug development problem, how many copies of
Viagra do we need? How many more statins? The drugs don't even seem to get
better, they just are finding ways to extend patents!

Past that, most of the competition is not in innovation, but rather in
marketing.

"The researchers’ estimate is based on the systematic collection of data
directly from the industry and doctors during 2004, which shows the U.S.
pharmaceutical industry spent 24.4% of the sales dollar on promotion, versus
13.4% for research and development, as a percentage of US domestic sales of
US$235.4 billion." --
[http://www.sciencedaily.com/releases/2008/01/080105140107.ht...](http://www.sciencedaily.com/releases/2008/01/080105140107.htm)

Finally, the NIH is picking up most of the tab for fundamental research, and
as such, it isn't the drug company that is leading innovation. As such, I find
the drug development argument hollow.

~~~
anamax
> How many more statins?

Are you claiming that the existing statins address all relevant cases?

> which shows the U.S. pharmaceutical industry spent 24.4% of the sales dollar
> on promotion, versus 13.4% for research and development, as a percentage of
> US domestic sales of US$235.4 billion

That's a non sequitor.

> Finally, the NIH is picking up most of the tab for fundamental research

"fundamental research" isn't a significant fraction of the cost of drug
development, aka "getting a drug into the pharmacy".

------
noonespecial
This might actually be a problem that politics just fails monumentally as a
tool for fixing. Like trying to repair an MG with a herring.

There will come a time when technology will make it possible to keep someone
alive indefinitely so long as you spend exponentially more money to do so.
Everyone has been conditioned to think that they deserve the _best_ healthcare
regardless of what choices they've made in their lives. They will not accept
that someone that has more money lives longer.

The only option is rationing. Either the naked market does it or the
government does it. The perceived (and often genuine) inequality of the market
practically guarantees that the voting public will demand the latter. This
means that _someone_ steps in and essentially decides who lives and dies. Some
agency will perform the brutal calculus that decides that a Nobel winning
scientist is a better investment to keep alive than a retired truck driver.
Historically this has a terrible track record. Anyone willing to wield this
power is usually the last person you'd want to actually do so.

Eventually technology will take us through this transitional period into a
better time where healthcare, like food, is cheap enough that everyone can
have as much as is needed and the only shortages will be caused by politics as
is the case for food now.

It seems the best thing we can do as a species is knuckle down and drive
through this transitional period as fast as we can. I'm kind of hoping that
this current recession produces a few more of the "knuckle down and drive
through" types as they seem to be in short supply these days.

~~~
klein_waffle
Can we discuss health care without the science fiction and doomsday scenarios?

I realize that the USA is used to looking inward for solutions, but other
governments are solving these problems, better, _today_.

Every discussion I have with Americans about healthcare leads directly to
these imagined totalitarian futures, as if "everybody" knew that this was what
happens. I don't understand it. Where did you all learn this narrative? Was
there some nursery rhyme about the evils of socialized medicine?

~~~
xiaoma
> _Every discussion I have with Americans about healthcare leads directly to
> these imagined totalitarian futures, as if "everybody" knew that this was
> what happens. I don't understand it. Where did you all learn this
> narrative?_

Pre-WWII footage of Nazi health programs, Aldous Huxley's _Brave New World_ ,
the movie _Soylent Green_ and pretty much everything William Gibson has
written. We've seen just about every distopian outcome imaginable.

Star Trek counters this to some degree, but it's considered "nerdy".

------
patrickg-zill
It is a good start, but he doesn't have the detail at the local level to see
what is going on - the prices are all over the map and there is no way to
rationally determine what is expensive.

I have a weird plan where I pay a percentage of the total cost, but have to
pay for everything first and then get reimbursed; but ultimately a more
expensive operation ends up costing me more, so it always makes sense to shop
around.

As a result, I know all the cash costs for an upcoming outpatient surgery I am
having, and whether they offer cash discounts.

The difference between various hospitals and service centers is HUGE, like 5
to 8 times from one place to another.

Imaging center "A" : CT scan $232 ; Chest Xray: $33; EKG: $21

Hospitals "A" and "B" : CT scan >$1000; Xray $185; EKG: > $100

You end up renting the operating room (the surgeon has privileges at 4
different locations):

(new, shiny, modern) Surgery Center "A": $1200 with cash discount

Hospital "A" : no exact price, "range is $7K to $11K, typical is $9500"

Hospital "B" : no exact price, "range is about $7500, cash discount = $5000"

HOW can it even be reasonable that there is such a discrepancy in pricing? For
one hospital, the CT scan "interpretation charge" was more than the $232 I
spent on the entire scan + interpretation at the imaging place I went to.

(And yes, I used the exact same billing code in discussions with all the
medical billing people I talked to.)

~~~
patrickg-zill
I should add, that I think that part of what is going on with the hospitals,
is to make cash payments so cumbersome, that people are herded into the arms
of the insurance companies.

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cnlwsu
Hmm, no citations, no real references. The graph is 50% "estimated" from 2005
and pre-estimated values doesn't have the exponential growth thats
demonstrated on the graph. Lets also keep in mind the new medicare/medicaid
restrictions that is drastically effects what is being paid for by the state
and what hospitals are now footing the bill for.

"Social security can be solved" sweet, lets get on that. glad he had some
solutions in this article.

why is this on on HN btw?

~~~
lmoorman
The whole point of the post is I don't have solutions.

Try to refute the point that healthcare is the massive piece of our unfunded
liabilities. You can't. Good resource: <http://www.pgpf.org/>

What I am concerned with is I don't think the coming debate will get very far.
We have a visceral fear of change in this arena and it will hurt us.

------
ojbyrne
I just finished "In Defense of Food." Michael Pollan makes a pretty good case
that the health care issue is driven by processed food - causing obesity, type
2 diabetes, high blood pressure and cancer. Essentially if americans ate less
processed food (and less food overall), there wouldn't be a healthcare issue.

~~~
rarrrrrr
Absolutely. One of the best things we could do would be changing our farm
subsidies away from corn and sugar and instead contribute to many forms of
fresh produce.

------
old-gregg
A friend of mine got physically attacked by an old woman in a supermarket
because he was wearing his scrubs. She didn't stop throwing shit at him until
security took her away.

------
lionheart
Why does the bad trend only start in the Estimated part of the graph?

~~~
lmoorman
baby boomers hit the 60-80s. and most healthcare costs are in your later
years.

~~~
lionheart
But if the trend hasn't started yet, how can the graph possibly hope to
extrapolate it with any degree of accuracy?

~~~
david927
It doesn't, but I think you can do the back-of-the-napkin math yourself. Baby
Boomers are the 80 million "pig in the python" and they starting to retire
right about now (2007-2009).

------
furburger
some points:

\- healthcare is not a business. get over it. the law says you cannot decline
emergency care. there is no business model here, any more than there is in
running the navy. its a cost.

\- you care about public health. meaning, you care if other people are
healthy. do you go to the mall or restaurants? if you do, you care if the
person next to you has TB. infectous diseases doesn't care about your fully-
paid premiums...it matters if other people are also healthy. this once again
goes to the fact that healthcare is not a business.

\- single payer is the only model that works. or would you prefer to spend
another century experimenting with craptastic half-baked business/public
hybrids? all health insurance companies must go. the government itself chooses
single payer when it needs to run large healthcare plans. the VA, military,
federal govt...they all go through single-payer.

\- healthcare will be rationed. deal with it. water is rationed. the carpool
lane is rationed. bandwidth is rationed. why would healthcare not be rationed?

~~~
anamax
> water is rationed. ... bandwidth is rationed.

Nope.

I'm pretty sure that I can buy as much water as I want and I know that I can
buy as much bandwidth as I want.

~~~
LogicHoleFlaw
_I can buy as much water as I want_

Try saying that in... Colorado and see how far you get before you get your
lights punched out.

Water rights and rationing are serious business.

~~~
anamax
> Try saying that in... Colorado and see how far you get before you get your
> lights punched out.

I said "buy". Even Coloradans have mastered the fine art of saying "no thanks"
when someone offers to buy something for a price that they don't like. And,
when the price is acceptable, they sell.

Yes, Water rights are for sale in Colorado.

And, most people don't live in Colorado (or the Mojave).

~~~
CalmQuiet
On points 2 & 3: True.

But more and more of the country (and world) are having the same issues that
Colorado (or the Mojave) have.

~~~
anamax
I didn't mention that the fight is over cheap water.

The Mojave isn't that far from an absurdly large source of expensive water.

------
siegler
These aren't the forums you're looking for.

You can go about your business.

Move along, move along.

