TCS Daily

Minding the Health Gap

By Arnold Kling - June 1, 2006 12:00 AM

'The fact that the English government provides health care to all its citizens while the United States does not may contribute to the disparity, the authors said. "But it is equally important to recognize that health insurance can not be the central reason for the better health outcomes in England because the top socioeconomic tier of the U.S. population have close to universal access but their health outcomes are often worse than those of their English counterparts," the authors said.'
-- Medpage Today, Americans Lag Far Behind English in Overall Health

British health researcher Michael Marmot has produced yet another study suggesting that America's health care system fails to produce outcomes commensurate with the amount that we spend on health care relative to other countries. This issue might be termed the Health Care Cost-Effectiveness Gap, or simply the Gap.

By now, most people who follow health care policy are aware that America spends about twice as much per person on health care as other advanced countries, yet we fare slightly worse than many of them in overall longevity. For this cost-effectiveness Gap, a number of possible explanations have been offered.

(A) Perhaps the Gap does not really exist. Instead, suppose that the United States actually does have a big advantage in health care outcomes, but this is not being measured. Longevity is affected by too many factors unrelated to health care.

(B) Perhaps the problem with the U.S. health care system is that it is inefficient. Although the United States spends more, other countries actually provide more health care services.

(C) Perhaps the problem with the U.S. health care system is that it is inequitable. It is great for the privileged, but not for the underprivileged.

(D) Perhaps the problem with the U.S. health care system is with the way that medicine is practiced. We favor expensive diagnostic procedures, specialist care, and surgeries, where costs are high and benefits tend to be low.

In my book, Crisis of Abundance, I examined each of these four possibilities. I concluded that the most important factor is (D), and that the only way to slow the growth of health care spending in this country is to change our cultural attitudes about what constitutes good medicine.

I use the term "premium medicine" to describe the high-cost procedures that are common in American health care. I use the term "gray-area medicine" to describe the fact that often these procedures are discretionary, with a low likelihood of affecting health care outcomes.

I wanted to believe (A), that American health care actually is more effective than international comparisons of longevity would suggest. It is true that as an indicator of health care quality, longevity is fatally flawed (so to speak). There are a few favorable indicators for the United States, including better survival rates for some forms of cancer. Overall, however, the evidence suggesting wasteful and ineffective health care services is much more compelling. See the work of John Wennberg and his colleagues at Dartmouth, including their recent study of cost-ineffective treatment under Medicare.

Many people would like to believe (B), that Americans could receive the same health care services that they do today, but at a lower cost. They hope that we could enjoy such a "free lunch" by embracing malpractice insurance reform, electronic medical records, single-payer health care, or some other supposed panacea. I am highly skeptical of the "free lunch" theories. For example, when it comes to high expenditures on health care services without commensurate benefits, our taxpayer-funded system of Medicare is very much a part of the problem, not part of the solution.

Explanation (C), that America's disappointing health care outcomes are concentrated in an underprivileged class, also fails to hold up to scrutiny. If there is an underprivileged group in America's health care system, it is not easy to find. For example, I found that in the government's Medical Expenditure Panel Survey for 2002, on a per capita basis people below the poverty line get slightly more health care (as measured in dollars of services consumed) that the average person above the poverty line. At the other end of the scale, the Marmot study, quoted above, found that indicators of health show affluent Americans to be worse off than British citizens of comparable socioeconomic status.

An MD with an Attitude

That leaves (D), with its radical suggestion that America's culture of medical practice is at fault. I arrived at this conclusion as an economist, looking at the data that contradicts the alternative hypotheses and also at a variety of studies, cited in my book, that show little relationship between health care outcomes and the supply of medical services.

Since writing my book, I have come across the work of Nortin Hadler, an MD who, coming from a very different direction, arrived at the same conclusion that I did about America's medical culture. In 2004, Hadler published The Last Well Person: How to Stay Well Despite the Health-care System

Hadler takes on many popular forms of health care in America, from alternative medicine to colonoscopy screening to anti-cholesterol drugs to heart bypass surgery. In his iconoclastic view, all of these therapies have benefits that are too small in terms of either statistical significance or common sense to warrant widespread use (he qualifies this by saying that certain narrow target populations do in fact benefit from these approaches).

Hadler steps on some very sensitive political toes. Americans want to hear that our doctors "save" men with prostate cancer. Hadler sees it is a common, slow-acting ailment that can be left untreated (there is a less-common variant that is more dangerous). We want to believe that talk-show hosts who scold people to get mammograms, watch their cholesterol, and submit to the indignities of colonoscopies are doing the public a service. Hadler argues that we should take a more stoic attitude toward the risks that we face.

Even though many of Hadler's opinions could turn out to be wrong, if enough of them are right then we could cut back on some popular medical procedures with no adverse effect on health. This reinforces my idea that we need a commission, somewhat akin to the UK's NICE (National Institute for Clinical Excellence), to evaluate our medical protocols. However, my worries that such a commission might be politicized also have increased after reading Hadler's book. He shows that political popularity and medical efficacy can be quite different.

I thought that the idea of basing medical practice on hard-headed statistical analysis was the least controversial idea in Crisis of Abundance. It may in fact be the most radical idea in the whole book. But it may be necessary if we really want to close the cost-effectiveness Gap.

Arnold Kling is a TCS Contributing Editor and an adjunct scholar with the Cato Institute.



Unnecessary procedures
There are several factors contributing to the overuse of expensive non-productive medical treatments.
One is defensive medicine. Physicians are rightly scared of malpractice suits, and costs in the US are inflated by high MP premiums and legal fees. The answer is no-fault insurance for the consumer, so unless it is criminal malpractice resulting in revoking a license to practice and possible criminal sanctions, the cost would not devolve onto the physician, and there would be no extra legal fees etc..
The malpractice industry also leads to extra procedures that are costly and serve to protect the physician with no benefit to the patient. For example, I have Meniere's syndrome. I had an MRI to rule out a brain tumor, mainly to insure the physician against a potential malpractice suit.
The second significant factor is the overselling by the pharmaceutical and medical technology sector. If a hospital has MRI equipment, it needs to use it -a lot- to recoup the investment. The more procedures carried ou, the faster one can justify the capital outlay, so physicians, especially staff, are encouraged to schedule these procedures.
The over use of prescription medication has been addressed thoroughly elsewhere, so I defer on that score.

One small difference
I recall a Brit in the US was apalled at the medical service he received here.
In UK he said, you would sit down with your doctor, in his office, on a chair, with your cloths on and have a chat. It may take some time but the doctor would find out who you were.
In the US of course you sit on an uncomfortable examining table waiting for a doctor to rush in, poke, prod, write s script and rush out.
What are the economics behind poor service?

economics of doctor visits
In the U.S., doctors are paid per procedure, under rules set by insurance companies. Sitting down and talking with a patient is only a procedure under certain narrow circumstances.

I am less familiar with the UK, but my impression is that doctors are on straight salary. If so, then it does not matter whether they are chatting with the patient or doing a biopsy--they get paid all the same.

You get what you pay for. Under our system, we pay for procedures.

Porter on malpractice
In Michael Porter's recent book 'Redefining Health Care' he suggests that because we lack useful quality information about providers (i.e. provider experience with a condition, outcomes of treatments at the condition level), the medical community has, in fact, outsourced their quality control to the courts.

If patients were able to make more informed decisions, by knowing a provider's experience and the probabilities of potential outcomes, they would be less likey to litigate when suboptimal outcomes occur. I believe that is Porter's take on malpractice.

Best regards,

Ben Atkinson

while it may be true
that malpractice reform won't completely close the gap, it is still true that malpractice reform would cause the total cost of medicine to drop.

when they do it, such chats in the US are performed by the nurse or some other lower cost screener.

two points
In my book, I propose a commission to provide recommendations for medical practice based on statistical and economic analysis. One advantage of such guidelines is that they might make it easier for doctors who follow reasonable guidelines to ward off malpractice suits. So my solution would work somewhat differently (and I think better).

I would also note that the medical community has the power to take away licenses from fellow practitioners, but it almost never uses that power. That reinforces the notion that the medical community has outsourced quality control to the courts. That seems like a lose-lose.

Item D
I would also add the arrogance/ignorance of the medical community.
Physicians are trained, not educated.
When something outside their experience is discovered, instead of admiting they don't know, they blame the patient, Morgellons is an example. (
Or just today on the radio, an MD wanted to perform surgury, but a chiropracter fixed it.
Also, the MD in Austrailia who discovered most ulcers were caused by bacteria was met with resistance for a very long time.
This all may be tied in with malpractice, but the arrogance of physicians comes from somewhere. Maybe medical schools should be expanded and revised.

The bottom line is YOUR health and the established MD medical community is a part, but not an exclusive part.

unnecessary procedures
One year ago I had a life threatening emergency. On a Saturday evening I was struck by severe pain in my chest. I tried to drive to the hospital but about halfway there i had to stop. My daughter got out of the car and called 911. I was taken to the ER. My pain subsided and I was sent home with none of these frivoilus defensive procedures.

On SUnday evening the pain recurred. This time I could not even get dressed. I again took (a very expensive) ambulance ride this time to another hospital because I was at my home at the time.

To cut the story short I had a viral form of pneuomonia. I firmly believe my life was saved by an English doctor who tried putting me in an MRI machine to look at my lungs and found something the little bedside xray machines in the first hospital didnt see. (too be honest the xray i saw had a big dark patch ehre my lung was but im no expert).

I got drugs. I got well. I am alive still.

I like expensive tests. I like English Doctors, thank you Dr Pickersgill. I think we need doctors that pay attention. and as to the first hospital i went to, the Kaiser facility, well i wont willingly fall into their clutches again.

False premise leading to false conclusions
Antyone with experience with the British medical system must have had a good laugh at the suggestion that the British system delivers better care. We have examples of medical care being denied to patients in Britain because of their political opinions! Can anyone suggest this would happen in the US? There have been cases of people dying because the British system said their conditions didn't warrant immediate attention. So the number of people who die each year because of the syustem's corruption and ineffectiveness are factored into this cost equation in what manner?

There can be little doubt that America's system could provide better care if the government didn't impose a social construct that forces doctors to accept a government designed payment/reimbursement system that forces medical facilities to recoup their losses from private insurers. This is compounded by the government's mandate that hospitals must treat everyone, the true socialist dream, with the subsequent socialist result of bankrupting hospitals and depriving the worker becaus of the leeach.

Finally at the root of all evil is the trial lawyer, who has destroyed the concept of justice by converting the court system into a giant lottery. In NY state there are five counties without full medical staffing; in other states the situation is worse.

If the medical system is to be saved the government must be removed from it along with its destructive medicare and medicaid, which are black holes and contribute to the expensive superstructure that the government has constructed. One need only look at pre-Medicare America to see how government intervention has caused these problems.

Better information
County medical societies prevent this. The same problem prevents the comparison of hospitals.

Actually, all are factors
To say that the poor in the U.S. are covered better than the middle class is bogus. The Author said - "Explanation (C), that America's disappointing health care outcomes are concentrated in an underprivileged class, also fails to hold up to scrutiny. If there is an underprivileged group in America's health care system, it is not easy to find. For example, I found that in the government's Medical Expenditure Panel Survey for 2002, on a per capita basis people below the poverty line get slightly more health care (as measured in dollars of services consumed) that the average person above the poverty line. At the other end of the scale, the Marmot study, quoted above, found that indicators of health show affluent Americans to be worse off than British citizens of comparable socioeconomic status."

A couple of facts are in order:
1. Spending is a poor indicator here. (a) we are acknowledging that America overspends on helathcare and (b) almost all of it is concentrated in two areas; children and serious medical conditions.

2. Poor adults do not get medicaid coverage except in emergency situations, usually after the fact. There may be some coverage for the truely indigent, but the working poor get nothing for the adults. The exception is a female who is an expectant mother. She will get coverage for the duration of the pregnancy and a couple of months post-partem. Because of this, most poor people use emergency rooms for routine proceedures that could be performed in a clinic at a much lower cost; both to the medical community and the taxpayers.

3. This creates a situation where adults, men in particular, do not go to the doctor unless they are in seriously bad shape. And, again, when they do go it will be to the emergency room.

On a lighter note: Americans tend to fall into two categories, those who over-use medical facilities and those who seldom use medical facilities. I fall into the first category. In 2004 I was working on my house and fell. I put a hand down to break the fall and drove a rusty nail through my hand. I pulled the nail out (using the board it was attached to as leverage) and went back to work. A couple of hours later I decided to go and get a tetnous shot as I knew I hadn't had one in a while. The Clinic nurse found my file and the funniest look crossed her face. She then said, "This is the smallest file I've ever seen, there are two sheets in here, one from 1976 and one from 1985, where are your records?"
I told here that was probably about right and I thought she was going to have a heart attack on the spot. It got worse for the poor lady when I showed her my hand and she asked what happened. As I told her and explained how I took it out, she just shook her head and mumbled something about crazy people and sharp objects. I live in a small town where everyone knows just about everyone else and, after giving me the shot and cleaning and bandaging my hand, she said, "I never thought I would see the day when there was someone else worse than your father; but you are definately it!"

Brit appalled at British system
I find this story to be at best laughable. My wife's relatives all have to deal with the British system and all have tales of waiting months to see a doctor for anything serious. They do get to see one fpor the flu, but one doesn't need to see a docxtor for the flu. Its when something serious happens you have to have access. Then you'd better be able to pay for a private doctor in the UK.

Please explain.
Could you expound upon your statement? How do medical societies prevent the revokation of medical licenses?



Medical societies prevent comparison
They ban the publication of cost of services. They do not reveal malpractice suits. In short they serve to conceal rather than promote data transmittal.

No other society on earth has the equivalent of Medicaid. It allows the shiftless to get the same medical treatment as the worker. Even in Scandinava this does not apply.

Legal Value?
I agree that medical practice here in the US is extravagant, but for a reason. The US has more litigous attorneys than anywhere else. Doctors must practice defensive medicine. The attorneys add huge cost to our healthcare. These costs come into the system through defense against lawsuits, settlement costs to lawsuits and defensive medicine. This cost is in the billions with no added value.

Medical costs
I seem to remember a book review in JAMA a few years ago that discussed differences in health care osts between the U.S., Germany, and Canada. Administrative costs and pharmacy accounted for most of the difference.

The issue of longevity as an indicator of medical care quality is interesting. I'm a psychiatrist and don't recall longevity (other than avoidance of suicide)as ever being a goal of treatment for my patients. A couple of studies show that lithium or clozaril may decrease the risk for suicide in some patients and that treatment of depression in myocardial infarction patients may increase survival-but these conclusions are hardly definitive.

Most of the patients I see hope that I'll help to alleviate their suffering. I've stayed fully employed and not had any licensing complaints or malpractice problems-I must be doing something right.I don't know where this fits in on the cost eFfectiveness issue. I suppose you could try to tie my pay to the longevity of my patients, but since almost no one ever dies under my care, the data would be sparse. Maybe this would be a good thing as no one seems to get rich in my field anymore.

I do agree that paying less for procedures might cut costs. Our only real procedure in psychiatry is electroconvulsive therapy, which though very helpful to patients who need it, suffers from an unfortunate image problem. Recent attempts to adapt a fiberoptic scope to psychiatric practice fell short of success-we couldn't figure out where to stick either end!

Experiences with friends and relatives who have had to use the system, as well as medicare, disagree. Perhaps the shiftless non-worker can get medicaid, but the working poor and lower-middle class absolutely cannot, except to cover their children.

I know many social workers and have had the opportunity to discuss this issue. I understand the destitute (and/or shiftless non-worker) cannot get medicaid, unless they can claim a disability. (Then they get medicare or some such related program)

My wife's father is disabled, he gets some kind of medicare (I don't remember the exact term for the program), but his wife doesn't qualify for either and, since she has never worked a day in her life, they live on his disability check. They did qualify for emergency medicaid when she was diagnosed with breast cancer. That, and some other non-medicaid/medicare programs, are the only way they get medical care for her.

Ironically, had she been covered and the cancer found earlier, it would have cost the government 1/4 of the price or less for treatment. It was caught later so a double mastecomy, radiation and chemo were the treatment used. I understand this is a big reason for all of the money spent by Medicaid. I've been told by doctors and social workers that, if the system covered poor adults, it would probably be significantly less expensive in the long run.

There is a solution
There is a solution to the problems you have suggested. The healthcare problem resolution is not in treating the symptoms individually, but taking the whole shebang and resolving it all at once.
If we continue to talk about malpractice or quality or cost or medicare or government policy or..... ad nauseum as individual issues, we will get push back by each of the stakeholders affected.
It is the basic infrastructure that needs to be changed completely.
A group of us have worked on this for the last two years and we have the answer: a new infrastructure that takes care of all of the issues.
Interested in our vision?
"To provide access to affordable health care for every man, woman and child in America, while reducing the overall cost and increasing the quality of the health care system"

You like statistical analysis?
It really is a large part of the answer. Objective data produced by an objective system and presented as an understandable and accessable report set to any patient or analyst (even economics gurus). Add that to a method of financial transactions that ultimately obliterates both the government and private control of the patient.

In the end, the free market will succeed in resolving the issues inherent in both the US and socialist models.

Ricky Dyson

There are different varieties of Medicaid but all are basically Federally funded medical programs for the disabled and people over 65. These are welfare programs.

My problems with them are as follows:
They entitle someone who has never worked to 100% medical care as opposed to Medicare which a worker may pay into for 40 odd years and is faced with deductables and many non-covered items. Is this fair? Why should Mr. and Mrs. Park who just got off the boat from Korea get better healthcare than an American after 40 odd years of work?

The government dictates how much will be reimbursed under both Medicare and Medicaid. If the govt says an MRI costs 100 this is what it will reimburse even if the breakeven cost actually is 600. So where does the 500 odd dollars come from. From cash paying patients, those who have non medicare insurance so their breakeven price of 500 may be 1,100 or less depending on the degree and frequency of government interference in the normal market structure.

Worse is the impact of aliens who impose an heavy burden on hospitals because the Congress mandated no one can be turned away. Exctly who covers these costs? Again the cash payers and those with non federal private insurance.

Now I am confused here by your assertion that there are people who do not have insurance? Are we talking about illegal aliens? WalMart which isn't the greatest employer provides healthcare insurance. So who are we talking about.

Now I will not make fun of those who have no insurance but I wonder how people get into this fix. I mean you are responsible for your actions and I really cannot envision not having healthcare insurance.

But for the sake of argument lets say there are people who fall between the cracks. If our leaders in Washington really cared about the working man they would allow a dollar for dollar tax credit for health insurance and a per centage of your salary for eyeglasses; dental, gyms, drugs etc, say but to 3,000 that could be deducted against taxes due.

The reason we don't see this is that it empowers the individual rather than big government. It does nothing to enrich the special interests or labor unions. It doesn't allow our elites to dictate what is paid for or not.

On the other hand even if such a program was available I doubt this would solve the problem because there are those who do not belief they will be injured or fall ill and wull spend the money on a vacation; new clothes, or otherwise fritter it away until disaster strikes and we will be reminded of the poor who lacked the withwithal, discipline and foresight to prepare. My answer for these is tough. I hope there are charities, professional associations, churches, etc to aid such but they have no claim on my earnings nor my children's. Lack of preparation on their part should not endanger my future.

Health disparity a mystery? How about death?
According to the author and the cited article there is a huge difference in health between the US and our counter parts in Britian by measuring rates of diseases. Maybe, just maybe, there are more folks in the US managing these diseases because THEY ARE ALIVE!!!!!!

Once a person is dead they are not on any list. How about listing mortality rates of folks with these diseases. Or how about measuring how long from diagnosis to death a person may have a disease. Or how about measuring the time age of the disease at diagnosis? Well neither article cites any of this stuff. I wonder why? All of these number will reflect the superior technology delivered by MARGINALLY private healthcare system in the US over those GET IN LINE, WAIT YOUR TURN, See the specialist in 6 months systems.

Get the gummint out o' the way - - - -
Excellent point, bill, I hadn't thot of that. When patients die their illnesses are automatically cured. Modern medicine keeps us around longer, to accumulate more diseases and further spread the infection ones (AIDS?).

Another odd point. 1) We all know that monopolies provide poor products and services at high prices. We also know that bureaucrats do the same. Medicine is a double-whammy. The Docs have a, government enforced, monoploly to ration care and products, and the FDA jealously rations new products coming to market. Are we surprised that we're getting screwed?

The solution? Make all the regulations VOLUNTARY, so that those who like them can obey them. The rest of us will trust and use the free market to buy our care.

There are 2 hospitals in my town
One with a great reputation but it looks like a hospital inside and out the other has not so great a reputation but the rooms look like hotel rooms and exterior is nice also. I will always choose the latter. Length of life is only one measure.

BTW It is also true that many who can aford health insurance choose to not get it. Who can say that they do not get more joy from spending that money on other things than they lose later from not having insurance.

Health Care is 50% Quackery
Arnold, Arnold, Arnold. Stop spouting political correctness. We are talking about the health of our richest people being equal to that of the poorest in England. Do the poor in England know more about good health than the rich in America and its entire health care system. Or is it that the British government, being responsible for all but 10% of those seeking health care, tends to guide its people better in the ways of good health. A rising tide of good health care advice does indeed tend to lift the health of all.

And who are the usual suspects you want to round up?

1. Suppose America does have a big unmeasured advantage in health care outcomes.
2. Longevity is affected by far more than health care.
3. America health care is inefficient: it spends more but provides less health care services.
4. American health care provides more for the privileged, less for others.
5. America favors high cost low benefit procedures.

Without reading any further in your article, I know all of these suspects are guilty. But the bottom line is that our health care system is run by quacks: those who pretend to expertise and knowledge they do not possess, and are almost impervious to learning anything that does not contribute to the bottom line of health care providers. They have to be embarrassed into adopting better health care ways. When the weight of public information becomes so massive that it reaches a tipping point, new ways are adopted on fear of losing even more public confidence.

In the 1970s I had 2 cardiologists in NJ and one in CA who failed to diagnose my dizziness (they took no history), claiming it to be a heart condition. I diagnosed my condition myself upon being given Valium, a drug that immediately banished all my symptoms. And I cured it on my own by gradually reducing the Valium I took when a panic attack seemed to loom, while at the same time walking rapidly to dispel the panic without taking Valium. Dr. Jeffrey Schwartz seems to have adopted a similar method in the 1990s as a cure for compulsive disorder: repeated hand washing and the like.

In the early 1980s, an ultrasound test detected a 30% occluded left carotid artery, and I was told to see a doctor. I had just begun taking the Dr. Rinse breakfast which was supposed to roto-rooter arteries but which within 24 hours surprisingly improved my short term memory. So I thought I would wait and see. Sure enough, the ultrasound a year later showed no signs of occlusion. The following year’s test gave the same negative results.

I remarried at age 59 and had 2 girls and 2 boys, the last at age 65, all 4 very smart and healthy.

The Dr.Rinse breakfast has been published for at lest 45 years, since the 1960s. It is the national breakfast of Holland. Dr. Rinse has a PhD in chemistry, 64 patents to his credit, and fought to defend Holland against the German invasion in WWII. I figured it made sense to take the word of man like Dr. Rinse over a health care system with no answers. How could I lose?

The Dr. Rinse breakfast is not a cure-all. But it does reverse clogged arteries and improve short term memory, if nothing else; though likely not in every case, just most. It will never be researched, not only because it cannot be patented, making it impossible to recoup the $800 million it might cost to get FDA approval, but because it likely would reduce the health care share of GDP from 16% and rising to 10% and going down, leading to massive healthcare related unemployment. The Salk vaccine did so much damage to the bottom line of health care providers in the 1950s that Congress added efficacy to the FDA mandate in 1962 to render another such cure virtually impossible.

The Dr. Budwig omeg-3 Essential Fatty Acid diet, mixing fish and flax oil with nonfat yogurt, is much more like a cure-all because is supplies the EFAs missing in our diets due to the switch from range fed cattle and fowl to feeding with corn and other grains; from linen cloth to cotton cloth, making flax seed as feed for chickens scarce and depriving the flesh of chickens and their eggs of their formerly high omega-3 content; scarcity of fish in the diet, and plenitude of corn fed cattle; avoidance of fresh green vegetables, and the overuse of corn and other omega-6 oils. When the omega-3 EFAs are present, they displace the omega-6 oils in the cells and mitochondria, greatly improving mitochondria energy output and cell function. All of this hornbook chemistry is ignored by mainstream medicine (largely because it is never taught) in pursuit of the bottom line.

The Budwig diet generally results in greatly improved energy and mental and physical function, the performance of which in turn can be greatly enhanced by practice. With practice, you can run, jump, lift weights, etc., better than ever before, while recovery from strenuous exercise is greatly enhanced. Although much of the improved memory and mental function is automatic, it can be multiplied by use, such as reading, memorization, chess, crossword puzzles, study, and the like. Conversations and audio and visual experiences also help, but they are much slower and less efficient than reading in most cases. Steady use of the diet yields constant improvement in all areas.

Again, this is hornbook chemistry in which medicine is completely uninterested because by effecting cures without patented medicines of such diseases as arthritis, diabetes, high blood pressure, heart disease, liver disease, and even cancer, the bottom line may be the reduction of healthcare as a percent of GDP from 16% to maybe as low as 5%.

So you see, in balancing the benefits of greatly improved health of all Americans against the costs of a reduction in income of 70% or more in health related income, bribes to Congress, and ease of mental and physical control of the debilitated population, that control by the corporations, the FDA, Congress, and the health care industry and their bottom lines must govern. So please, no more talk of why our health as a nation is so poor. The final answer is our lawmakers and media are for sale to the highest bidder. And those bidders generally use other people’s money.

A long term solution might be repeal of the estate tax, giving the family the same tax-free eternal life probability as corporations, foundations, churches, and other tax free potentially eternal life organizations. With so many new wealthy family bidders to offset corporate and foundation bidders for lawmaker attention, the cost of influence would go up. Those who use other people’s money would lose influence as the amount of OPM at their disposal was rapidly consumed by higher bidding cost. Yes, the death tax is an anti-competitive device the monopolists will not give up without a fight.

the myth of competition in medicine
a few years ago c. Everett Koop did a program for CBS or other major network. As part of that program he came to Kalamazoo in my home state to study the phenomenon of two major hospitals in a city versus three or more. A curious thing was happening in Kalamazoo. Prices for all medical services were going up much faster in Kalamazoo than they were in other major cities. His point was that competition was actually driving up prices in Kalamazoo and, I think, in medicine in general.

The two hospitals in question, Borgess and Bronson, had a high cost advertising campaign against each other, operating just as any normal business would. However, costs were skyrocketing at both hospitals. I believe the upshot of Koop's study was that the introduction of the third payer system--first, government in the form of Medicare and Medicaid, and then private health insurance--encouraged higher costs. There is a third party between the consumer and the health provider and that third party simply does not watch costs and benefits the way the consumer would.

Sorry, you are wrong on this
The medical welfare system simply doesn't work that way. Working capable adults cannot get medicaid, end of story. They may get emergency assistance if someone is really sick and needs medical attention, but they cannot get covered just because they are broke. There may be ways around this, but I haven't heard of them.

As I said, I know several people who have used or work in the public assistance arena. They do not give medicaid away.

You obviously don't pay much attention to the news; it has been often reported that between 10% and 30% of all Americans do not have health insurance. (30-100 million, depending on which study is used) That is one h ell of a lot of people included in the few who slip through the cracks. Some of them simply choose not to buy insurance, but a majority can't afford it and don't get it through work.

Medicaid is, basically, a pregnant women and children type of program. It is not there for working or non-working poor adults. Aliens, legal or illegal, do not automatically get medicaid. Children of qulaified families do.

This is one of the reasons for the expense of the system, there is no room for preventative medicine in this system. Then there is the extremely high cost of emergency rooms stacked with people that should be going to office visits in clinics. These people don't have insurance and/or can't afford it, but they can get treated in the ER for free; to them (it costs 4 to 10 times the price of a clinic visit to the hospital, regular payees and taxpayer.)

What part of this is stupid? We can agree that the government should get out of this business, but get the facts straight. Medicaid is a problem largely because it doesn't cover everyone and forces bad use of the ER, and a host of other expenses, on to the medical community who then has to re-coup those losses elsewhere. The low level of reimbursement is a problem, but not the biggest one. If Medicaid simply covered everyone who needed it, that alone could drive down healthcare costs.

The "Emergency Only" system is stupid, expensive and self defeating.

Exactly who are these uninsured
Come on lets get real about the numbers of the uninsured. They are recent college graduates who do not think they'll become ill because they're immortal. They are the 20 million illegal aliens who drive our hospitals into bankruptcy. They are those perople who you wouldn't trust to babysit your kiddies much less dog, perhaps three million.

Yes there are some who do not have insurance because the primary wage earner has lost his job, but this is usually temporary. There simply aren't 20 million people without insurance or laughable 100 million you quoted.

People who can work don't get medicaid? Are you real? Tell me what sort of health insurance welfare mothers get? Hint-its medicaid. As for the working poor, an oxymoron if ever there was one in this country, they too get medicaid. So many get it it is driving states like Tennessee into bankruptcy. IN NY there are as many people on medicaid as on medicare.

Who do you think make up the bulk of welfare leeches?

This 100 million would mean about one third of the US population isn't covered. Does this strike you as hysterical. Where are the mass outbreaks of disease; the vast numbers of people dying because of typus; gangrene; etc from induistrial accidents, car accidents, home accidents.

One has to ask how expanding medicaid, essentially a socialization of the medical system would drive down health care costs. If use and costs are divorced people will abuse a system as they do medicaid. The solution is to end free hand outs and allow the medical system to work as it used to.

Nice point
Well stated.

TJ, we usually agree, but you are WRONG
And it is obvious that you have little or no experience with the system; either directly or indirectly. According to the center on policy and budget priorities, 45.8 million Americans are completely uninsured. That is an increase of approximately 800,000 from 2003-2004 and, of those, over 750,000 were working adults age 18-64 (nearly all of the increase).

As I said the numbers vary, but the lowest estimate I've ever seen is 10% (approximately 30 million). I used this reference as it is closer to the low end. Look it up at:

It never fails to amaze me that people who get insurance through their job think everyone does. In fact, less than 60% of Americans have job-based insurance. About 20-25% percent are self-pay, medicaid and medicare. The other 15-20% (again, depending on which numbers you believe) are completely uninsured.

You said - "This 100 million would mean about one third of the US population isn't covered. Does this strike you as hysterical. Where are the mass outbreaks of disease; the vast numbers of people dying because of typus; gangrene; etc from induistrial accidents, car accidents, home accidents."

This is nuts because I answered it already; Breaking the medical system with ER visits.

The alternative for these people, and many illegals, is the ER. The Welfare mothers very often aren't covered a couple of months after they have their children.(some are, depends on the state.)

Then there is this - "Come on lets get real about the numbers of the uninsured. They are recent college graduates who do not think they'll become ill because they're immortal."

This problem has been reported, but it isn't a big issue. Most of this age group is covered by major medical at the least; only a relative few die-hards can afford health insurance and aren't covered.

There are 2 non-profit hospital corporations in my county
Government regulations allow them both the opportunity to challenge each other's expansion plans, raising the costs of both their expansions to meet the needs of our growing population.

45 million uninsured?
Exactly where do these numbers come from? What is your source? Fewer than 60% of Americans have job based insurance! You mean all those people toiling away at those jobs as cops, firemen, airline controllers, teachers lack healthcare?

Again I realize there are gypsies, mimes, cobblers, wrights without health insurance but where do toy get 45 million and then the remarkable 60%figure from?

And your response is the ever favorite the emergency room takes care of 45 million people. Think about what you are saying, the emergency wards cannot give out vaccines because by they're very nature preventative and hence not an emergency measure. If you had 45 million Americans with various diseases this nation would be faced with a disaster that could not be controlled.

As far as welfare mothers go, yes there must be a delay, for their first child, then they procede to build for the National League.

I don't believe you've ever dealt with or seen the number of professionals who do not get health insurance because they believe they can self insure or because they are too arrogant to realize what the consequences of non insured status are.

You know there are 45 million Americans straving every day? They have to live next to 45 millions that are without permanent homes. They live under Starbucks and in carboard containers next to WalMarts. That means at least 135 million people are homeless, starving and without health insurance, right?

TJ, I don't believe this
Are you purposely being ignorant on this or do you simply walk around with blinders on?

Here is a rough estimate: There are approximately 300 million people in the U.S. Of those, about 270-280 million are citizens. Of those citizens, only a bit over half (maybe 60%) are working age (18-64), about half of the remaining 40% are minors and the other half are senior citizens. Medicare covers the seniors and Medicaid, CHIPs and a couple of other programs cover the kids whose parents don't have insurance because of financial inability to get it.

Of the 180 million working age adults, only 60% (about 108 million) of those have insurance offered through their work, not everyone is a teacher, fireman, cop, etc. A whopping 40% (about 72 million) are left to provide their own insurance, many are small business owners or are people who work for small businesses. Nearly half of this number (36 million) have no way to get insured. They don't have a benefits package through work and aren't paid enough to be able to afford it on their own. A percentage of these are just above the government guidelines to get CHIPs and just don't have the income to afford even a low-cost program, so their children go uninsured as well (some 10 million kids are uninsured this way). Of the other 36 million, most are doing quite well and are self insured. The 10 million or so who aren't, are the youngster you talk about, the people to "proud" to even try and get help and others (like the homeless) who are off the grid and simply don't know what they are doing.

Yes, ERs take care of about 45 million nationwide. As for vaccinations, many of those are covered county health grants and other means, and they are pretty inexpensive anyway. ($8 to $20 a vaccination through the County Health Department.) Most of the couple million kids who don't get vaccinated are those whose parents are way-out "Holestic Medicine" nuts who think vaccinations are a baad thing.

As for welfare mothers, it depends on the state. Many states do not provide Medicaid to able-bodied adults. I don't care whether or not you believe it, it is a fact. Google it yourself.

As for those who choose not to get insured, you are right, there are quite a few of the fools. But again, "professionals" make up a pretty small percentage of the working class. (25 to 35%, agian depending on what defination you use) Because of this, they also are a very small percentage of the uninsured.

This is stupid frustration and well beneath you - "You know there are 45 million Americans straving every day? They have to live next to 45 millions that are without permanent homes. They live under Starbucks and in carboard containers next to WalMarts. That means at least 135 million people are homeless, starving and without health insurance, right?"

Health insurance is a seperate issue from hunger and homelessness. To self insure can cost more that the utility bills, and nearly as much as the rent, for a family of four. To get the level of insurance I have would cost me between $700 to $1,100 a month if I self insured. I looked into it and there is no way I could afford that! My co-pay of $150 a month is already a small bit of a burden. On the other hand, I couldn't get major medical only for my family, even with a $10,000 deductable for $150 a month.

We aren't starving, I own my own home, etc. But we aren't doing "well" either. I would call us lower middle class, maybe a step or two above "working poor", but even if we made $10,000 a year more it would be tough to self insure with a real good policy.

Aain TJ, you are simply wrong on this issue. And these are the conservative estimates. Liberal scaremongers double those numbers (but they include all aliens and skew the stats in my opinion).

Like it or not, we do have a medical crisis in this country. We may have the best healthcare system on the planet, but the U.S. spends more than anyone else on healthcare and 10% to 15% of the population receives no benefit from this system; another 20% receive benefit only through government programs. Add to that the massive and unnecessary use of ERs, the expense of an emergency only medicare for many adults, frivilous malpractice lawsuits, etc., and we have an expensive system that is going broke and a medicare/medicaid system that is more expensive than it should be (and going broke as well).

Expanding Medicare could actually make it less expensive and save hospitals a combined Billions in ER expenses they now have to eat because of the poor who use the facility but can't pay. Blaming the government for this is rediculous, I agree that no one should be left to die because they don't have insurance, but some facilities would do that if they could.

Or, maybe there is a better answer yet. Whatever the answer is, we had better find it or risk a meltdown in the not-to-distant future.

People can afrod to get medical insurance. It is not that expensive.

My health Insurance policy for my family cost $300/month

I am 49 years old my wife is 46. I have 2 children one with asthma. My wife has had breast cancer (fine now). And spent 2 weeks in a hospital last year. Health insurance is very afford able. 300/month is $3,600 year. I would say that any family that makes $13,600 or more per year can afford it. They may have to budget though. When I made that little I paid $200/month.

Does not compute
Exactly where does this 45 million come from. Your explanation doesn't even begin to hold water. Take a look at the people working as clerks in small businesses. They older and probably have a job as a way of making some pocket money or getting out of the house. They all ready have insurance.

Let us assume your numbers were true. Where then is the demand for universal healthcare? Even better why isn't there action to allow wage earners to deduct their medical expenses from their taxes. Yeah we see so much concern on the part of politicians. You'll note the Democrats won't even touch the issue, which is strange if there were 45 million people demanding it.

I have not seen medical authorities decry healthcare coverage or the unions demand new coverage? Why is that?

Sorry this falls into the Nessie, global warming, Eric's brains category.

A major medical policy alone, with a big deductable, costs over $150 a month. General health insurance can cost from $400 to $1,200 a month or more. It depends on a number of factors, like how many people in the family, the deductable and how many bells and whistles you want. Group plans are considerably less (thats why businesses can even try and afford this for their employees), but aren't for the self-insured.

Try paying the $150 a month on a $7 an hour job; and there are a lot more people living on that then you and TJ obviously think. Now try paying for a bigger plan, shelter, utilities, clothes, food and other expenses for a family of four on a family income of under $30,000 a year. That is the lower-middle class - working poor.

Just for fun, lets assume that housing, utilities/city services, food, clothing, phone service, health insurance, homeowners/renters insurance and basic supplies (school supplies, toilet paper, cleaners, etc.) are the basic necessities.
Depending on where you live, basic rend is $200 - $500 a month, and a family for four needs extra room, so add a 50% surplus for a mulit-bedroom dwelling. Lets call that average $450 a month. Utilities also vary greatly in different part of the country, depending on the need for heating and the cost of city services. Lets say an average of $200 a month there. Clothing costs, at Walmart and the thrift stores will average you around $15 a month per person, call it $60 a month for a family of four. Food, cleaners and supplies will average this family at least $250 a month and probably closer to $350 if they don't live on mac and cheese dinners. Phone ends up being around $60-$75 a month just about any way you go. Homeowners/renters insurance is around $50 a month or less, depending on the ammount insured. Health insurance for this family, for a decent policy, will be at least $400 a month and probably over $500 if they have to private pay.

Total basic living expenses, at least $1,700 a month. This family must make around $24,000 a year to have enough take-home pay to get by. This is a family with no car, no entertainment budget, no vacations, no extra-curriculars for the kids, no savings, nothing. To make $24,000 a year one person must have a job making more than $11.50/hr equivalent. That may not seem like much to you, but to about half of working age americans that is a pretty decent paying job.

I know a lot of families, where both parents work, that aren't pulling down $30,000 a year. One works full time for $9 an hour, and the other works 30 hrs/week for $7 an hour. One makes just under $20,000 a year and the other makes under $10,000.

Yeah, on the list of basic expenses, which is going to go? Probably phone, homeowners/renters insurnace and then health insurance.

Isn't it obvious that health insurance is so affordable. Tell me another bedtime story!!

Not really
I suggest you look this up for yourself. This is a political issue, but the politicians are ducking it as their answers are all too expensive in this time of growing deficits. Why do you think Healthcare is brought up on this forum quite frequently?

No, I think it is possible you simply don't pay attention to this problem. That isn't meant as a put down, it is just such an obviously bad situation that I find it hard to believe anyone would even try to make the arguements you are making.

I seriously suggest you look this up before you post again. Remember, I'm not suggesting the government get into the universal healthcare game, I'm only saying there is a major problem and it needs to be solved.

I'm all for tort reform as a part of the solution; I'm all for common sense regulation to reduce the burder and the expense to medical facilities; I'm all for booting out the illegals and limiting their access to schools, helathcare and everything else; but these things aren't going to do enough by theirselves. I'm simply advocating a better approach to public assistance helathcare and perhaps a tiered system for public assistance healthcare.

But that is just a suggestion, I'm open to any idea on this one.

The problem is the government
The government has driven health costs through the roof with promises and failed black hole programs. I have recently dealt with the estates of two families that had to obtain health care because their heads, though professionals were loons, who decided they could get health care insurance from professional associations that offered less than comprehensive care. I have never met anyone who didn't have health insurance who wanted it. Not in one of the voluntary associations, not at church, not at the knights, not at the VFW.

I again ask you where this figure you keep waving about comes from. It is no different than the homeless meme or before that the starving children meme.

Why is it that the government doesn't allow a dollar for dollar tax credit for medical expenses if there is such demand? There isn't, there are 20 million illegals who are sucking away our nation's lifeblood and we see the government taking steps to make the situation incredubly more difficult.

Yes there are people who don't have health insurance, just as there are those without a pension, home, or prospects in their old age. Some genuinely merit our compassion. Most dont. But please don't accuse me of being ignorant of the issue because I do not believe your figures based on pure assertion, anymore than I would believe Hampton or Eric. Compassion must never blind people to the prioririties they face in daily life or the solutions that are available. And the first step to a solution is to correctly determine what the problem is.

DR shortage
Obviously Drs and nurses are not earning the money from our overpriced 'health' care system.
Why would there be shortages of nurses and doctors?

"A looming doctor shortage threatens to create a national healthcare crisis by further limiting access to physicians, jeopardizing quality and accelerating cost increases.

Twelve states — including California, Texas and Florida — report some physician shortages now or expect them within a few years. Across the country, patients are experiencing or soon will face shortages in at least a dozen physician specialties, including cardiology and radiology and several pediatric and surgical subspecialties.",0,1528090.story?coll=la-home-headlines

Expand/moderize medical schools and increase the number of medical personnel from overseas.

Laser eye surgury is one area that is not covered by insurance. No guaranteed payment.
Therefore, the industry has had to compete and it has driven costs down and quality up.
Can't say that much about the rest of the medical industry.

My health Insurance policy for my family cost $300/month
My health Insurance policy for my family cost $300/month
I am 49 years old my wife is 46. I have 2 children one with asthma. My wife has had breast cancer (fine now). And spent 2 weeks in a hospital last year. Health insurance is very affordable. 300/month is $3,600 year. I would say that any family that makes $13,600 or more per year can afford health insurance. They may have to budget though. When I made that little I paid $200/month.

Pauled wrote:

‘Try paying the $150 a month on a $7 an hour job; and there are a lot more people living on that then you and TJ obviously think. Now try paying for a bigger plan, shelter, utilities, clothes, food and other expenses for a family of four on a family income of under $30,000 a year. That is the lower-middle class - working poor.’

7 per hour should working 45 hours a week is 1236.25/month – SS tax = 1143.53 – 150 = 993.53 Are there people in this country living on less than 993.53. yes there certainly are so that proves that it can be done. A few years ago my wife an I lived in mobile home that we bought for $3,000 the lot rent $100/month. I bet you that if they needed to the average Middle class America family could live good on that. The poor tend to be less clever and so struggle much more.

A CPA friend of mine who did people taxes used to say some people making $200,000/year (loaded with CC debt) tell him that they cannot live on that and others making $15,000/year are doing fine.

BTW the per capita income in Portugal is not much more that that.

Your Money or Your Life: Transforming Your Relationship with Money and Achieving Financial Independence (Paperback

Good point
Wherever there is competition costs go down. The government conspires with the AMA to restrict competition.

Interesting Floccina
You make interesting points. You say you buy your health insurance. It isn't provided by the firm you work for?

Shortage of medical personnel
The AMA controls the accreditation of medical schools, so its a no brainer to realize reducing supply increases demand. In the 70s when the military couldn't get enough doctors it proposed openning its own school. The AMA realized what a threat this posied to its control and quashed it quickly. Today Guadalajara produces more new American doctors than any other medical school.

Who are the uninsured?
According to the Robert Wood Johnson Foundation’s "State Coverage Initiative" (SCI) statistics for 2004, 9.5 million of the 45.8 million uninsured are not U.S. citizens. I suspect that almost all of the increase of the number of the uninsured in the last few years can be accounted for by the huge influx of legal and illegal immigrants we have sustained.

Uninsured non-citizens are a separate problem, best addressed through immigration policy, not health care policy. World-wide, there are billions of uninsured non-US citizens, and our problem is not that our health care system doesn’t cover them, but that we let too many of them into the country without insisting they are able to provide for their health care.

Then, a sizable number of the remainder of the uninsured are people who are simply practicing "just-in-time" insurance. From the SCI cited above, we also are told that only an estimated 50% of the people who are eligible for Medicaid coverage are enrolled in the program. (This sounds improbable to me, but that's what they claim.)

The number enrolled in Medicaid is 37.5 million (of whom 2.7 are non-citizens), so presumably another 37.5 million people qualify and are not enrolled. But enrollment when no health problem is on the horizon, while it might be the responsible thing to do, is probably not worth the trouble for many of those people.

Overall, it seems that the vast majority of the uninsured are either non-citizens or could be "insured" if they chose to enroll in Medicaid. People in the latter group can obtain coverage when they decide they need it. Allowing for some overlap, this accounts for well over 40 million people.

Although not addressed by the SCI statistics, I seem to recall than 10-15% (or it might even be higher) of the uninsured have annual household incomes over $50,000. While some of those may lack coverage because they deem it "unaffordable," when a household with that kind of income finds something unaffordable what it often means is that its members prefer to spend their money on other things - better housing, newer cars, education, etc. Although somewhat risky, those are not necessarily irrational choices. If I were a healthy young high-income, no-asset (judgment-proof) person, I might choose a new car over health insurance myself. In fact, depending on the condition of my old car (old brakes, no airbag, etc.), that expenditure might be a better health care choice than insurance.

Linking health insurance to employment has encouraged people to forget what insurance is supposed to be for, and led to the expectation that it is supposed to cover all health care costs, even ordinary expenses that should be budgeted for, not insured for. Increasingly that is including even unproven, superstition-based alternative treatments. The greatest increase in my own health insurance premiums came about when regulations imposed by my state’s Insurance Commissioner required coverage for chiropractic, naturopathic and similar faith-based treatments.

(I've been self-employed for 30 years, so have always purchased my health insurance directly. Current premium, in my mid-50s, $166 per month, and could be $50 a month less if I were willing to accept a "gate-keeper" for access to specialists.)

I think the growth in health care expenditures in this country is easily accounted for by three things: first, the aging of the population and the inroads made on early mortality from heart disease and cancer, second, the growth in demand for aggressive treatment of ailments that used to be regarded as inevitable and basically untreatable, such as arthritis and other joint ailments, depression, impotency (now called, as we all know from relentless TV commercials and spam, erectile dysfunction), third, government interference in the marketplace.

To get a sense of what government meddling does to the cost of health care, just compare the cost of treatment, on the one hand, where government involves itself in the financing and on the other hand, to elective procedures that government has largely stayed out of. Procedures such as lasik eye surgery and cosmetic surgery have experienced dramatic advances in technology, methods and availability combined with declining prices.

Largely, I agree
Rising healthcare costs have been driven by a number of a factors. Government mandates, regulations and programs are possibly the biggest followed by uninsured (mainly illegal) aliens.

This rising cost has then caused problems for the working poor and lower-middle class. They can't afford to self pay anymore, even for routine care proceedures (as my parents once did for everything); they can't afford insurance for anything but a major healthcare policy (if that) because the premiums are too much for them; Medicaid will not cover able-bodies males under any conditions.

The numbers can be found in the website I posted. Search the web and you can find several references. The numbers vary a bit, depending on which site you choose. Most of the numbers are government estimates.

Look, some of this also comes from personal experience and the experience of others I've known. Working poor people have to prioritize and health insurance simply can't be a priority above food, shelter and utilities. In some cases a vehicle is necessary to have the job, that means a car, auto insurance and fuel have to be a major priority as well. $400+ a month is simply too much for these people to pay.

Good for you
But that isn't the case for many. I've lived in situations where I've paid less than $150 a month for housing too; but that is a pretty tough thing to find these days and I did not have, and could not afford, health insurance then.

A lot of truth in all of this
But, from my understanding, the illegals are not included in the 45.8 million total. But the most relavent post is what you pay for insurance. As I said, I can get a major medical policy for a bit less than that, but to get a good coverage policy costs triple that. (A policy like the one I had with a company I worked for a few years back would cost me over $1,000 a month to self - pay; but it covered everything and then some!! Only cost me $180/mo.)

Perhaps it has something to do with where I live; maybe it is that I haven't shopped around enough (haven't had too thank goodness) but I have never found a good coverage policy, with a low deductable, that covered my entire family for less than $400. At that it was a pretty "bare bones" policy with a higher deductable than I wanted.

When the comparisons between health costs and benefits are made, are the costs associated with elective, cosmetic procedures included? And, are the pharmaceutical costs associated with erectile disfunction and other arguably elective recreational drugs included? If not, could the answer to the disparity lie in the eagerness of the US population to attain an appearance or activity as opposed to longer lives?

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